Rare Clinical Course of Immunoglobulin G4-Related Inflammatory Abdominal Aortic Aneurysm with Multiple Rare Complications.

Immunoglobulin G4- (IgG4-) related inflammatory abdominal aortic aneurysm (AAA) has been recognized as a manifestation of IgG4-related disease (IgG4-RD). We experienced one patient with multiple consecutive manifestations before and after endovascular stent grafting for IgG4-related inflammatory AAA (IAAA). A 71-year-old man was diagnosed with IgG4-RD due to increased IgG4 serum concentration, typical findings of parotid gland biopsy, and periaortitis in another hospital 2 years and 7 months before visiting our hospital. He came to our hospital because of abdominal pain and IAAA. He developed paraplegia after hospitalization and underwent endovascular stent grafting for the IAAA. About one month after stent grafting, he developed perforation of the sigmoid colon due to enteritis. He also had myocardial infarction. Finally, he died of intestinal bleeding. Here, we describe this case with rare, multiple, consecutive manifestations of IgG4-RD, some of which might be caused by IgG4-related IAAA or side effects of treatments rather than by IgG4-RD itself. We report this case because the clinical course seemed rare for IgG4-RD or IgG4-related IAAA. For treating IgG4-RD with IgG4-related IAAA, we should consider factors causing the symptoms and carefully select the proper treatment.

[Mycobacterium Mageritense Bacteremia after Implantation of Pacemaker;Report of a Case].

An octogenarian female patient underwent implantation of pacemaker for sick sinus syndrome. Seventeen days after implantation, she came back to our hospital with pain and redness of the skin around the pacemaker generator. It was difficult to differentiate the infection from a subcutaneous hemorrhage. She did not have high fever. The blood test showed only a slight elevation of C-reactive protein(CRP). Cefazolin was administered after readmission. Five days after readmission, the report of the blood culture showed nontuberculous Mycobacterium positive. We immediately removed the generator and the leads completely. Antibiotics were changed to clarithromycin and ciprofloxacin. The culture reports of blood, generator, leads, and subcutaneous tissue were first Mycobacterium peregrinum( M. peregrinum) but was later corrected to be Mycobacterium mageritense (M. mageritense). Twenty-seven days after the removal of the device, she was transferred to another hospital near her family and antibiotics were ceased due to allergic reaction the day after transfer. Ten days after transfer, a new device was implanted, and she does not have any signs of infection now. The possibility of mycobacterial infection, including nontuberculous mycobacterial infection, should be considered for device contamination, especially for the aging population, and quick and proper treatments are required.

[Use of Flash Glucose Monitoring during the Perioperative Period of Cardiac Surgery in a Patient with Type 1 Diabetes Mellitus].

FreeStyle Libre (flash glucose monitoring) is useful to control the blood sugar levels of outpatients with diabetes. We used FreeStyle Libre for a patient with type 1 diabetes mellitus during the perioperative period of cardiac surgery except during and just after surgery. We adjusted the insulin amount according to the glucose level of the device before surgery and prevented prolonged hypoglycemia. After surgery, we could also adjust the blood sugar levels using the device until discharge. All data were within zones A and B of the Clarke error grid analysis when referred to as arterial blood sugar levels in the intensive care unit. In the general ward after surgery, 95% of the data referred to as venous blood sugar levels were within zones A and B. FreeStyle Libre was useful for adjusting the amount of insulin for a patient with type 1 diabetes mellitus during the perioperative period of cardiac surgery in the ward and also might be useful for decreasing the frequency of arterial blood collection in the intensive care unit.

[Endoscopic saphenous vein harvesting with non-disposable device].

Endoscopic vein harvesting (EVH) for coronary artery bypass grafting has been proved to be effective in reduced wound complications, without compromising long-term mortality or composite of death, myocardial infarction and repeat revascularization. However, only disposable devices that are costly and raise environmental problems, have been obtained on the market in Japan. Now, a non-disposable device for EVH is available. With this equipment, a 50 cm-long great saphenous vein can be obtained with a single 3 cm-long incision. We demonstrate how to use this device and show its tips and pitfall.

Apicoaortic valved conduit for a patient with porcelain aorta.

A 69-year-old woman had severe aortic stenosis with a circumferentially calcified aorta from the ascending aorta to the aortic arch, and moderately impaired left ventricular function. Implantation of an apicoaortic valved conduit was performed as aortic clamping was not feasible. The early results were excellent.

Cardiac surgery for a patient with familial lecithin: cholesterol acyltransferase deficiency.

A 62-year-old female with familial lecithin: cholesterol acyltransferase (LCAT) deficiency was subjected to cardiac surgery consisting of mitral valve repair, tricuspid valve annuloplasty, and left atrium plication, under cardiopulmonary bypass. Familial LCAT deficiency is a very rare disease with clinical features including corneal opacity, hemolytic anemia, and renal failure. Our patient manifests partial LCAT activity and no renal failure. Patients with LCAT deficiency have fragile red blood cells, renal dysfunction, and disturbed metabolism of platelet-activating factor. To date, no record of cardiac surgery on patients with LCAT deficiency has been reported. Thus, we present the result of this experience to share what we learned about this complicated and rare disease.

Abdominal compartment syndrome causing respiratory failure during surgery for a ruptured descending thoracic aneurysm: report of a case.

Elevated intra-abdominal pressure causing widespread organ dysfunction is known as abdominal compartment syndrome (ACS). The subject of our case report is a 64-year-old man who underwent repair of a ruptured descending thoracic aortic aneurysm (TAA) under deep hypothermic circulatory arrest. During the operation, decompression laparotomy was required to relieve intra-abdominal hypertension causing respiratory failure, before the patient could be weaned off cardiopulmonary bypass. We report this case to alert surgeons to the fact that ACS can occur during surgery on the thoracic aorta, especially if massive fluid resuscitation is required and venous drainage for extracorporeal circulation is less than optimal. Early recognition and prompt decompression by laparotomy is essential to save the life of the patient.

Tau protein in the cerebrospinal fluid is a marker of brain injury after aortic surgery.

BACKGROUND: Tau is a protein localized primarily in neurons, especially in the axonal compartment. Cerebrospinal fluid tau levels are elevated in acute stroke and head traumas. The purpose of this study is to elucidate the alterations of cerebrospinal fluid tau levels in patients with or without neurologic complication after aortic surgery. METHODS: Twenty-eight patients undergoing descending thoracic (n = 8) or thoracoabdominal (n = 20) aortic surgery were enrolled. Cerebrospinal fluid tau levels were measured before operation and at seven time points up to the 72nd postoperative hour, and were compared with cerebrospinal fluid S100B levels. RESULTS: Two patients developed brain infarction, including the one with paraplegia. In these patients, 20-fold to 100-fold tau elevation was observed, but S100B elevation was less evident in the patient without paraplegia. Three other patients developed spinal cord injury. Additional three patients suffered from temporary neurologic dysfunction of the brain. Tau levels in the latter three patients showed tenfold elevation and were higher than those in the three patients with spinal cord injury or those in the patients without neurologic complication up to 24 postoperative hours. The S100B levels were also higher in the three patients with temporary neurologic dysfunction of the brain than in the patients without neurologic complication at the conclusion of surgery. From 6 to 24 postoperative hours, they were higher in the three patients with spinal cord injury than in the patients without neurologic complication. CONCLUSIONS: These preliminary results suggest that cerebrospinal fluid tau levels reflect brain injury. Because tau levels may separate the patients with temporary neurologic dysfunction, they may serve as a useful marker of brain injury.

Outcome of the perioperative use of percutaneous cardiopulmonary support for adult cardiac surgery: factors affecting hospital mortality.

Percutaneous cardiopulmonary bypass support (PCPS) has become a widespread standard modality for the treatment of circulatory collapse; however, its clinical use for postcardiotomy low cardiac output syndrome (LOS) has been reported to be unsatisfactory. We reviewed the clinical outcomes of twenty-three patients undergoing cardiac surgery and treated with PCPS. Solitary coronary artery grafting was undertaken for nine patients, while three had concomitant procedures. The remaining patients underwent valvular surgery. The indications for PCPS were preoperative shock in two patients and postcardiotomy LOS or shock in twenty-one patients. All patients except one underwent an intraaortic balloon pump. Sixteen of the twenty-three patients (69.6%) were weaned from PCPS and twelve patients (52.2%) reached hospital discharge. A univariate analysis revealed that risk factors for hospital mortality were age older than seventy years (P = 0.05), PCPS running time (P = 0.017), low cardiac function at the institution of PCPS (P = 0.004), and urine output within the initial 24 h (P = 0.041). The cardiac index (CI) in survivors was improved within 24 h, and eleven of the twelve survivors were weaned off PCPS within 48 h, whereas ten of the twelve nonsurvivors required PCPS for more than 48 h (P = 0.0006). There is little possibility of weaning patients from PCPS who do not show any signs of hemodynamic recovery within 48 h after its institution. Limited use of PCPS within 48 h may be applicable for postcardiotomy patients, but other cardiopulmonary support, such as a left ventricular assist device, may be required when hemodynamic recovery is not obtained within 48 h.