Surgical embolectomy for high-risk acute pulmonary embolism is standard therapy.

OBJECTIVES: Acute massive pulmonary embolism (AMPE) is a life-threatening condition that often induces rapid haemodynamic deterioration. The mortality of surgical embolectomy is still poor in patients with preoperative cardiopulmonary arrest (CPA). We analysed the outcome of surgical pulmonary embolectomy for haemodynamically unstable patients. METHODS: Thirty-one patients underwent surgical embolectomy for haemodynamically unstable AMPE. The indications for surgical embolectomy were (i) <7 days from onset, (ii) haemodynamically unstable, (iii) massive clots in bilateral pulmonary arteries or unilateral pulmonary artery occlusion with a floating clot in the main pulmonary artery or right atrium and (iv) right ventricular dilatation in transthoracic echocardiography. Eight (25.8%) patients had cardiopulmonary arrest. Nine (29.0%) patients received preoperative percutaneous cardiopulmonary support (PCPS). The mean original Pulmonary Embolism Severity Index (PESI) and simplified PESI scores were 158 ± 51 and 2.4 ± 0.9, respectively. RESULTS: The hospital mortality rate was 12.9% (n = 4). Two patients died of hypoxia. Multiorgan failure occurred by sepsis and by right ventricular failure in 1 patient each. No hospital deaths occurred in patients with preoperative PCPS (n = 9). The mean follow-up period was 47.7 ± 35.9 months (range, 3 - 134 months) and the 5-year survival rate was 83.2 ± 6.9%. Postoperative pulmonary artery pressure significantly decreased from 52.7 to 25.8 mmHg. CONCLUSIONS: Surgical embolectomy for high-risk AMPE patients has an excellent operative mortality and long-term outcome. Preoperative PCPS may lead to an immediate stable haemodynamic state and improve surgical embolectomy results, especially in high-risk patients (e.g. those with preoperative CPA). Surgical embolectomy for AMPE is an established operation and considered as the first-line therapy.

[Primary Cardiac Angiosarcoma with Superior Vena Cava Syndrome].

Primary cardiac angiosarcoma is rare and its prognosis very poor. A 34-year-old woman complained of facial edema and dyspnea. Echocardiography, chest computed tomography scan and chest magnetic resonance imaging showed a huge tumor arising in the right atrium. Surgical excision of the tumor was performed for the purpose of relieving superior vena cava syndrome and making diagnosis of the tumor. The right atrial wall, including the tumor, was resected and reconstructed with Gore Tex patch under cardiopulmonary bypass. The tumor was diagnosed as angiosarcoma. Doxorubicin hydrochloride/ifosfamide were used to treat postoperative cardiac recurrence and lung metastasis. These drugs were effective to a certain degree, but she died of brain metastasis of the tumor in the 14th postoperative month.

[Beating mitral valve surgery in patients with poor left ventricular function].

Mitral valve surgery is usually performed under the arrested heart condition. However, cardioplegic arrest techniques will inevitably produce some degree of reperfusion injury. We expected that keeping heart beating decrease the reperfusion injury in patients with poor left ventricular function. The present study compared the results of beating heart technique and conventional mitral valve surgery to demonstrate the merit of this technique. Thirty six patients with low left ventricular function[ ejection fraction (EF)≤35%] who underwent mitral valve surgery between April 2004 and July 2012 were enrolled in this study. On-pump beating mitral valve surgery were performed in 21 patients (beating group). Fifteen patients underwent conventional mitral valve surgery with cardiac arrest using blood cardioplegia (arrest group). Postoperative cardiac events in the beating group were less than that in the arrest group. However, this difference in both groups was not statistically significant. The visual field of the beating heart was equal to that of conventional surgery, and technical accuracy was not compromised. To decrease postoperative cardiac events, beating-heart mitral valve surgery may be suitable surgical option for patients with poor left ventricular function.

[Total aortic arch replacement in Stanford type A aortic dissection using a new method of implanting the stented graft].

In surgery for Stanford type A aortic dissection (SAAD) with intimal tear in the arch or proximal descending aorta, we performed total arch replacement with frozen elephant trunk technique for the purpose of achieving complete exclusion of the entry. To reduce the circulatory arrest time, we developed a quick stent graft placement method in the proximal descending aorta. We reported the early results and assessed the efficacy of our new method. Between March 2006 and February 2010, 52 consecutive patients with SAAD were divided into 2 groups:group A consisted of 17 patients who received total arch replacement with our new method;group B consisted of 35 patients who received ascending aorta or partial arch replacement. The duration of operation and cardiopulmonary bypass were significantly longer in group A. However, the duration of circulatory arrest time and postoperative factors including hospital mortality did not differ in both groups. In group A, thrombus obliteration of the residual false lumen in the descending aorta was observed in 75% at 19.2±13.1 months postoperatively. Shrinkage of false lumen in the aortic arch occurred in 15 patients( 93.8%). There was no reoperation for the residual false lumen and late death. Total aortic arch replacement with our new method for SAAD is technically feasible without increasing the operative risk and might reduce the necessity for further operations.

Kommerell's diverticular rupture complicated by aberrant left subclavian artery and right aortic arch successfully treated surgically.

We report a rare case of a rupture in Kommerell's diverticulum in a 73-year-old woman with Edwards IIIB aberrant left subclavian artery (A-LSA) and right aortic arch. This case was further complicated by an inferior vena cava defect. We performed an emergency operation through a right posterolateral approach. The descending aorta was replaced and the Kommerell's diverticulum was excised, followed by A-LSA reconstruction, performed under deep hypothermia with selective cerebral perfusion. We believe the prognosis was excellent.