Coronary artery bypass grafting in a patient with polyarteritis nodosa presenting with acute myocardial infarction and multiple coronary aneurysms.

Polyarteritis nodosa (PAN) is a necrotizing form of vasculitis that affects small- and medium- sized vessels. Cases of ischemic heart disease involving coronary aneurysms in patients with PAN have been reported previously, but there have only been a few reports of coronary artery surgery for PAN-related coronary disease. A 46-year-old female with a history of PAN arrived at our emergency room due to cardiopulmonary arrest. After cardiopulmonary resuscitation, emergent coronary angiography was performed, because an electrocardiogram demonstrated ST segment elevation in leads V1 to V5. Coronary angiography revealed occlusion of the proximal right coronary artery and left anterior descending coronary artery as well as multiple coronary aneurysms. We performed emergent two-vessel coronary artery bypass grafting (the left anterior descending coronary artery and posterolateral branch of the circumflex system were treated with grafts from the left internal mammary artery and saphenous vein graft, respectively) under percutaneous cardiopulmonary support without cardiac arrest. The patient's postoperative course was uneventful, and postoperative coronary angiography revealed that the bypass grafts were patent. A review of the literature and a discussion of this case are also presented.

[Infective endocarditis with destruction of the mitral valve annulus and the left atrial posterior wall after cancer chemotherapy].

The case is reported of a 48-year-old man who underwent distal pancreatectomy, splenectomy, and 4 cycles of postoperative chemotherapy for stage I pancreatic cancer, at the age of 47. Four days after completion of chemotherapy, the patient developed high-grade fever (40 degrees C). In addition, on day 10, he developed disturbance of consciousness, followed by symptoms of shock, which led to emergency hospitalization. On day 4 of admission, the patient was diagnosed as having infective endocarditis and severe mitral valve insufficiency, and was started on antibiotic and heart failure therapy. Surgery was performed on day 16 of admission; the mitral valve infection had spread to the valve cusp and ring, and thence to the posterior wall of the left atrium. After excision of the lesions, the patient underwent mitral valve replacement with a collared prosthesis valve and a translocation procedure. The postoperative course was uneventful, and there has been no recurrence of inflammation or paraprosthetic leakage over the year and 6 months since the operation.

[Marfan-like aortic aneurysm syndrome; A surgical experience with Loeys-Dietz syndrome].

A 17-year-old female patient complaining of chest pain was transferred to our hospital to treat annuloaortic ectasia associated with severe aortic valve insufficiency. She underwent a valve sparing operation with graft replacement of the ascending aorta and the proximal portion of the aortic arch. After the 1st operation, she was diagnosed with Loeys-Dietz syndrome (LDS), which is recently described as an autosomal dominant aortic aneurysm syndrome caused by heterozygous mutations in the transforming growth factor-beta receptor type 1 and 2 genes. Only 2 months after the 1st operation, she developed heart failure due to recurrence of aortic regurgitation. Computed tomography (CT) scan showed an expansion of the aortic arch. Total arch replacement using the elephant trunk technique and aortic valve replacement were performed successfully 4 months after the 1st operation. The rapidly progressive nature of the aortic disease in patients with LDS underscores the importance of meticulous surveillance of the entire aorta and the need for early surgical management.

Which patients can be weaned from inotropic support within 24 hours after cardiac surgery?

Inotropic support after cardiac surgery is sometimes employed for a long period without any definite criteria to wean patients from it. There are few reports describing factors influencing the inotropic support period. This study was undertaken to clarify the proper inotropic support period, especially to judge which patients can be weaned from it within 24 h. From January 2000 to December 2001, 151 patients, 88 (58.2%) with ischemic heart disease, 51 (33.8%) with valvular disease, 7 (4.6%) with congenital heart disease, and 5 (3.4%) with other heart disease, underwent cardiac surgery. The mean age was 66.2 +/- 10.1 years (range 30-95); 98 patients (65%) were male. The data were analyzed retrospectively. Eighty patients (53%) were weaned from inotropic support within 24 h after cardiac surgery. Univariate analysis showed that intra-aortic balloon pumping, blood transfusion, operation time, cardiopulmonary bypass time, and aortic cross-clamping time significantly influenced the inotropic support period. Multivariate analysis indicated that intra-aortic balloon pumping, blood transfusion, and cardiopulmonary bypass time significantly influenced the inotropic support period. Intra-aortic balloon pumping, blood transfusion, and cardiopulmonary bypass time might determine the inotropic support period. Appropriate surgical procedure and methods both reducing cardiopulmonary bypass time (<75 min) and minimizing blood loss are the keys to weaning patients from inotropic support within 24 h.