Multidisciplinary surgical approach for renal cell carcinoma with inferior vena cava tumor thrombus.

PURPOSES: The optimal surgical management of renal cell carcinoma with tumor thrombus within the inferior vena cava (IVC) remains to be clarified. METHODS: Sixteen consecutive cases were reviewed. Incision, the IVC clamping position, and the venous drainage procedure were modified according to the tumor thrombus extension level: level I or II (below the hepatic vein, n = 8), level III (above the hepatic vein but below the right atrium, n = 5), and level IV (extending into the right atrium, n = 3). RESULTS: For level I or II, resection could be simply achieved by clamping the IVC below the hepatic vein, without hemodynamic collapse. For level III, clamping the IVC above the hepatic vein and the hepatoduodenal ligament was required. Venous drainage from the lower body (cannulation to distal IVC) and portal system (cannulation to ileocolic vein) were applied. When opening the IVC, the significant backflow was controlled using cardiopulmonary bypass with drop-in suckers. For level IV, median sternotomy, exposure of the right atrium, and cardiopulmonary bypass were mandatory. With the combination of these approaches, the perioperative mortality rate was 0% and the 5-year overall survival rate was 52%. CONCLUSIONS: A multidisciplinary surgical approach is essential, especially for level III and IV cases.

[Intractable Atrial Arrhythmia after Maze Procedure].

Maze procedure has achieved high cure rates and become the surgical golden standard for the treatment of atrial fibrillation. But, atrial arrhythmia after maze procedure is often persistent and drug-resistant. In these cases, diagnosis by electrophysiological study (EPS) and treatment by catheter ablation (ABL) are useful. In our hospital, maze procedure has been actively performed for mitral valve surgery with atrial arrhythmia. We examined the cases that required ABL after maze procedure in our hospital. We reported 2 such typical cases where ablation of cavo-tricuspid isthmus line (CTI) in the right atrium and left superior pulmonary vein-left atrial appendage space( LSPV-LAA ridge) in the left atrium was effective.

Correction to: Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients: predictors of in­hospital mortality and failure to be weaned from extracorporeal membrane oxygenation.

In the original publication of the article, author group affiliation was published incorrectly.

Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients: predictors of in-hospital mortality and failure to be weaned from extracorporeal membrane oxygenation.

Postcardiotomy cardiogenic shock (PCCS) is a rare clinical entity associated with substantial morbidity and mortality. It is characterized by heart failure that results in an inability to be weaned from cardiopulmonary bypass (CPB). The aim of this study was to analyze the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with PCCS and to identify predictors of in-hospital mortality and failure to be weaned from ECMO. From January 2002 to August 2016, 3248 patients underwent cardiac surgery in our hospital. Of these, 29 patients (0.89%) required ECMO because of an inability to be weaned from cardiopulmonary bypass. The median duration of ECMO support was 144 h (340-52 h) (range 17-818 h). Sixteen patients (55.2%) were weaned from ECMO, and 6 (20.7%) survived to hospital discharge. The multivariate analysis revealed that reoperation [odds ratio (OR): 13.667, 95% confidence interval (CI): 0.999-187.056, p = 0.05] and ECMO support duration > 130 h (OR: 17.688, 95% CI: 1.324-236.233, p = 0.03) were independent predictors of failure to be weaned from ECMO. Temporarily being weaned from CPB > 15 min (OR: 0.027, 95% CI: 0.001-0.586, p = 0.02) was found to be a protective factor. The multivariate analysis revealed that CPB time > 270 min (OR: 12.503, 95% CI: 1.058-147.718, p = 0.05) and ECMO support duration > 60 h (OR: 12.503, 95% CI: 1.058-147.718, p = 0.05) were independent predictors of in-hospital mortality. ECMO is an acceptable technique for treating PCCS in patients undergoing cardiac surgery. Our data suggest a reevaluation of therapeutic strategies after 60 h and again after 130 h of ECMO support.

[Pericardiocentesis and Pericardial Drainage].

Peicardiocentesis and surgical pericardial drainage are essential treatment and diagnostic modality for pericardial effusion. Though it theoretically is a simple therapeutic method, accurate diagnosis, correct decision, and safe procedure are not always easy. Thoracic and cardiovascular surgeons are required to have high level of expertise in pericardial drainage as surgeons who specialize this anatomical part of the body. The presence of pericardial effusion does not always require drainage. Accurate diagnosis is essential to determine correct indication. Echocardiography and computed tomography are useful tools for accurate diagnosis. The percutaneous drainage has become much safer in these 2 decades with the aid of imaging technology, especially echocardiography and fluoroscopy. Surgical pericardial window still has its role and is considered one of the standard treatment methods with minimal chance to require repeat procedure compared to percutaneous drainage.

Midterm results of the "sandwich technique" via a right ventricle incision to repair post-infarction ventricular septal defect.

BACKGROUND: Residual shunting and mortality are problems associated with current surgical repair techniques for post-infarction ventricular septal defects. METHODS: We describe the mid-term results of the "sandwich technique" to repair a post-infarction ventricular septal defect (VSD), performed via a right ventricle incision. Application of direct ultrasonography to the right ventricular wall enables a surgeon to visualize the region, perform an appropriate incision into the right ventricle, and perform a trabecula resection. One patch is placed on the left ventricular (LV) side and the other on the right ventricular (RV) side of the VSD. The VSD is sealed with gelatin-resorcin-formalin (GRF) glue between the two patches. RESULTS: We had seven consecutive patients. The sandwich technique resulted in geometric preservation of the LV shape. There were no significant leaks, no mortality within a thirty-day postoperative period, and no bleeding problems. Hospital mortality was 14.3% (1/7 cases). Late survival longer than a year was obtained in five cases (71%). The longest patient survival time was nine years. No tissue degeneration was noted. CONCLUSION: This technique may be useful for repairing a post-infarction VSD.

The "loop with anchor" technique to repair mitral valve prolapse.

The current surgical technique of using an artificial chord (composed of expanded polytetrafluoroethylene [ePTFE] sutures) to repair mitral prolapse is technically difficult to perform. Slippery knot tying and the difficulty of changing the chordae length after the hydrostatic test are frustrating problems. The loop technique solves the problem of slippery knot tying but not the problem of changing the chordae length. Our "loop with anchor" technique consists of the following elements: construction of an anchor at the papillary muscle; determining the loop length; tying the loop to the anchor; suturing the loop to the mitral valve; the hydrostatic test; and re-suturing or changing the loop, if needed. Adjustments can be made for the entire procedure or for a portion of the procedure.

Coronary malperfusion due to flap suffocation after acute type A dissection surgery.

A 24-year-old man presented with chest pain. He was diagnosed as having a type A acute aortic dissection and an annulo-aortic aneurysm. After emergency surgery for an aortic root replacement, his electrocardiogram showed ST-segment depression and T-wave inversion. Echocardiography showed asynergy of the left ventricle without coronary ostial pathology. Heart catheterization revealed no coronary stenosis, but the true lumen of the residual ascending aorta had extreme diastolic narrowing due to flap suffocation. This resulted in coronary malperfusion. The pullback pressure curve confirmed the mechanism. The patient underwent a surgical re-intervention for a total arch repair, which diminished the coronary malperfusion. At a follow-up appointment four years and four months later, the patient was doing well.

In vitro study of the optimum volume ratio of activator to adhesive in gelatin-resorcin-formalin glue.

OBJECTIVE: Excessive use of activator (formaldehyde + glutaraldehyde) may cause late complications after use of gelatin-resorcin-formalin (GRF) glue during surgery. The goal of the study was to define the appropriate ratio of activator to adhesive and to establish an approach for accurate control of this ratio. METHODS: The relation between adhesive force and the activator/adhesive ratio was studied by attaching two sheets of equine pericardium using GRF glue, with ratios from 1: 50 to 1: 2. The amount of activator was measured per drip from the needle in the GRF glue kit and other needles (27, 25, 23, 22, and 21 gauge). RESULTS: The adhesive force was about 400 gram-weight (gw) for activator/adhesive ratios from 1: 50 to 1: 20. This force showed a significant increase to 1317 ± 462 gw for a ratio of 1: 10 compared to the force at a ratio 1: 20 (P = 0.0069) but did not increase significantly for ratios above 1: 10. The activator volume was 12.5 µl in one drip from the needle in the GRF glue kit and 4.3 µl in one drip from the 27-gauge needle. Therefore, the 27-gauge needle is suitable for measuring the activator volume. CONCLUSION: In vitro, an activator at a ratio of one-tenth the volume of the adhesive provides approximately maximum force; any more activator is residual and potentially harmful. Measurement of the activator volume using a 27-gauge needle and the adhesive volume using a syringe is recommended to control the ratio accurately.