Acute Pulmonary Thromboembolism: 14 Years of Surgical Experience.

BACKGROUND: Pulmonary thromboembolism (PTE) is a life-threatening disease with high mortality. This study aimed to assess the outcomes of surgical embolectomy and to clarify the sustained long-term effects of surgery by comparing preoperative, postoperative, and long-term follow-up echocardiography outcomes. Of 22 survivors, 21 were followed up for a mean (median) period of 6.8±5.4 years (4.2 years). METHODS: We retrospectively reviewed 27 surgical embolectomy cases for massive or submassive acute PTE from 2003 to 2016. Immediate and long-term follow-up outcomes of surgical embolectomy were assessed on the basis of 30-day mortality, long-term mortality, postoperative complications, right ventricular systolic pressure, and tricuspid regurgitation grade. RESULTS: The 30-day and long-term mortality rates were 14.8% (4 of 27) and 4.3% (1 of 23), respectively. Three patients had major postoperative complications, including hypoxic brain damage, acute kidney injury, and endobronchial bleeding, respectively (3.7% each). Right ventricular systolic pressure (median [range], mm Hg) decreased from 62.0 (45.5-78.5) to 31.0 (25.7-37.0, p<0.001). The tricuspid valve regurgitation grade (median [range]) decreased from 1.5 (0.63-2.00) to 0.50 (0.50-1.00, p<0.05). The improvement lasted until the last echocardiographic follow-up. CONCLUSION: Surgical embolectomy revealed favorable mortality and morbidity rates in patients with acute massive or submassive PTE, with sustained long-term improvements in cardiac function.

Vanishing Venous Coronary Artery Bypass Grafts after Sepsis.

The dehiscence of saphenous vein grafts (SVGs) is a rare, often fatal, complication of coronary artery bypass grafting (CABG). We present the case of a 57-year-old man who underwent hemiarch graft interposition and CABG for a Stanford type A aortic dissection. Five months after discharge, the patient developed streptococcal sepsis caused by a hemodialysis catheter. Complete rupture of the proximal anastomoses of the saphenous veins and containment by the obliterated pericardial cavity was observed 25 months after the initial operation. The patient was successfully treated surgically. This report describes a patient who developed potentially fatal dehiscence of SVGs secondary to infection and outlines preventive and management strategies for this complication.

Use of a valved-conduit for exclusion of the infected portion in the prosthetic pulmonary valve endocarditis.

A 51-year-old male was admitted to the hospital with complaints of fever and hemoptysis. After evaluation of the fever focus, he was diagnosed with pulmonary valve infective endocarditis. Thus pulmonary valve replacement and antibiotics therapy were performed and discharged. He was brought to the emergency unit presenting with a high fever (>39℃) and general weakness 6 months after the initial operation. The echocardiography revealed prosthetic pulmonary valve endocarditis. Therefore, redo-pulmonary valve replacement using valved conduit was performed in the Rastelli fashion because of the risk of pulmonary arterial wall injury and recurrent endocarditis from the remnant inflammatory tissue. We report here on the successful surgical treatment of prosthetic pulmonary valve endocarditis with an alternative surgical method.

Successful surgical treatment of a right atrial myxoma complicated by pulmonary embolism.

A 76-year-old woman with hypertension was admitted to the hospital with complaints of chest pain and dyspnea. An echocardiogram and pulmonary computed tomography angiography showed right atrial myxoma complicated with pulmonary thromboembolism. An operation to resect the right atrial myxoma and pulmonary embolism was recommended; however, the patient refused and was discharged with anticoagulation therapy. Two years later, she developed dyspnea. Radiological studies and echocardiography showed similar results with the previous findings. The patient underwent mediastinotomy with resection of the right atrial myxoma and pulmonary embolectomy. As there are few reports on right atrial myxoma complicated with pulmonary embolism, we report a successful case of surgical removal of right atrial myxoma and pulmonary embolism.

Efficacy of veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock.

AIM: We analyzed the results of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) necessitating extracorporeal membrane oxygenation (ECMO), and investigated for the associated risk factors for poor clinical outcomes. METHODS: We retrospectively reviewed the medical records of 27 patients who required ECMO for AMI associated with CS between April 2006 and July 2010. Mean age was 63.7 ± 11.0 (range: 45-81) years, and there were 16 males (59.3%). RESULTS: The mean duration of ECMO support was 30.2 ± 30.1 (range: 1-141)h. Cardiopulmonary resuscitations (CPR) were performed in 21 patients (77.8%) before ECMO initiation. Twenty-two patients (81.5%) were successfully weaned off ECMO, and 16 patients (59.3%) survived to discharge. The 30-day mortality was 37.0% (10/27 patients). Complications developed in 17 patients (63.0%: pneumonia in 10 patients, acute renal failure in 10 patients, massive bleeding in 4 patients, and thromboembolic event in 1 patient). The period between CPR initiation and ECMO commencement was a significant risk factor for ECMO weaning failure. High pre-ECMO serum lactate level was identified as a significant risk factor for poor survival on univariated and multivariated analysis. CONCLUSION: ECMO support could improve survival in patients who suffer AMI associated with CS, and early ECMO initiation yields better outcomes (successful ECMO weaning).

The effects of barrier materials on reduction of pericardial adhesion formation in rabbits: a comparative study of a hyaluronan-based solution and a temperature sensitive poloxamer solution/gel material.

OBJECTIVE: This study was performed to examine the efficacy and safety of a hyaluronan solution (Guardix-SL) and a temperature sensitive poloxamer solution/gel material (Guardix-SG) on the prevention of pericardial adhesion in rabbits. METHODS: A total of 60 rabbits were divided into three groups according to material applied after epicardial abrasion: the control group (group CO), the Guardix SL group (group SL), and the Guardix SG group (group SG). The ejection fraction and the presence of pericardial effusion were evaluated by echocardiograms at the immediate postoperative period and 2 wk after the surgery. The adhesion was evaluated macroscopically and microscopically 2 wk after the surgery. RESULTS: In the group SG, mild pericardial effusions were observed only at the immediate postoperative period in 10 out of 20 rabbits with an insignificant reduction of the ejection fraction. Group CO had a significantly higher macroscopic adhesion and fibrosis score than did groups SL and SG (P < 0.001), and group SL had a significantly higher adhesion score than did group SG (P = 0.045). Inflammation score and the expression of anti-macrophage antibody in group CO were higher than those in groups SL and SG, although the differences were not significant. CONCLUSIONS: Guardix-SL and Guardix-SG effectively reduced the adhesion formation, and Guardix-SG is more effective than Guardix-SL for preventing adhesion. However, Guardix-SG showed a potential disadvantage of decreasing the ejection fraction, although this was statistically insignificant. Further study to verify the appropriate dosage to maximize the therapeutic effect without decreasing the heart function is needed.

Characterization of human monoclonal autoantibody Fab fragments against oxidized LDL.

Oxidized low-density lipoprotein (oxLDL) is a key autoantigen in atherosclerosis. The genetic structures and pathogenic roles of autoantibodies against this protein remain to be established. In this study, we cloned several monoclonal IgG autoantibody Fab fragments specific for oxLDL from peripheral blood lymphocytes of atherosclerosis patients, using phage display technology. The sequences of their variable regions were determined at the cDNA level. The closest germline counterparts for the heavy chains belonged to the V(H)3 or V(H)1 family. The sequences and lengths of complementarity-determining regions (CDR)3-V(H) were diverse, and frequent mutations of positively charged amino acids (particularly arginine) over entire V(H) and V(L) sequences were observed. It is proposed that anti-oxLDL autoantibody formation is driven by antigens. Among the Fabs, P2-8 and P3-175 bound to both MDA-LDL and Cu-oxLDL, and inhibited the uptake of oxLDL by macrophages, suggesting the epitope(s) recognized by the Fabs is a part of ligands on oxLDL that is involved in uptake by macrophage scavenger receptor. These human autoantibody Fabs require detailed investigation to ascertain their potential as agents for clinical applications.

Molecular properties of excitation-contraction coupling proteins in infant and adult human heart tissues.

Excitation-contraction coupling (ECC) proteins in the human heart were characterized using human atrial tissues from different age groups. The samples were classified into one infant group (Group A: 0.2-7 years old) and three adult groups (Group B: 21-30; Group C: 41-49; Group D: 60-66). Whole homogenates (WH) of atrial tissues were assayed for ligand binding, 45Ca2+ uptake and content of ECC proteins by Western blotting. Equilibrium [3H]ryanodine binding to characterize the ryanodine receptor (RyR) of the sarcoplasmic reticulum (SR) showed that the maximal [3H]ryanodine binding (Bmax) to RyR was similar in all the age groups, but the dissociation constant (kd) of ryanodine was higher in the infant group than the adult groups. Oxalate-supported 45Ca2+ uptake into the SR, a function of the SR SERCA2a activity, was lower in the infant group than in the adult groups. Similarly, [3H]PN200-110 binding, an index of dihydropyridine receptor (DHPR) density, was lower in the infant group. Expression of calsequestrin and triadin assessed by Western blotting was similar in the infant and adult groups, but junctin expression was considerably higher in the adult groups. These differences in key ECC proteins could underlie the different Ca2+ handling properties and contractility of infant hearts.