Total arch replacement in a patient with a tracheostoma through a reverse L-shaped partial sternotomy.

A conventional median sternotomy in a patient with a tracheostoma is susceptible to postoperative mediastinitis or graft infection after total arch replacement (TAR). An optimal surgical procedure has still not been established to circumvent these complications in such patients. We report a successful case of a 74-year-old man with a tracheostoma who received TAR through a reverse L-shaped partial sternotomy. This incision was simple and enabled us to secure an adequate operative field similar to that of a conventional median sternotomy. The patient was discharged without any evidence of infection or any other complications.

Two-stage surgery to repair a dissecting abdominal aortic aneurysm in a severely obese patient: Open bifurcated graft replacement after laparoscopic sleeve gastrectomy.

With the increasing prevalence of severe obesity worldwide, surgical treatment for severely obese patients is becoming more popular. Bariatric surgery has occasionally been performed as a precursor to major operations for serious diseases to make these difficult surgeries safer for severely obese patients. We present the case of a severely obese patient with a dissected abdominal aortic aneurysm and left iliac artery aneurysm. Initially, we performed bariatric surgery on this patient to reduce perioperative risk and then subsequently performed bifurcated graft replacement. A 54-year-old man presented at our hospital for bariatric surgery before open abdominal aortic aneurysm repair. Laparoscopic sleeve gastrectomy was performed; 15 months later, the patient's weight and BMI had decreased from 139.0 kg to 97.6 kg and from 48.7 kg/m(2) to 34.2 kg/m(2) , respectively. Bifurcated graft replacement was performed safely without postoperative complications. Bariatric surgery was also effective in controlling the patient's blood pressure during the interval between surgeries.

Strategy for thoracic endovascular aortic repair based on collateral circulation to the artery of Adamkiewicz.

PURPOSE: Spinal cord ischemia (SCI) is a serious complication of thoracic endovascular aortic repair (TEVAR). The purpose of this study was to establish if preoperative identification of the artery of Adamkiewicz (AKA) can help prevent post-TEVAR SCI. METHODS: Of 74 post-TEVAR patients, 51 had the critical segmental artery (CSA) to the AKA pre-identified to help the surgeon deploy stent grafts. RESULTS: None of these 51 patients suffered permanent paraplegia postoperatively, but 5 (23.8 %) of the remaining 23 patients (2 of whom had pre-existing paraplegia) did suffer permanent SCI. The CSA/AKA was preserved in 43 patients with pre-identification of the CSA/AKA; however, in 8 patients, the CSA was completely or partially occluded by a stent graft. Transient SCI developed in one patient from each group, but both of these patients recovered fully before discharge. No change in the anatomical route was identified in 29 of the patients who had postoperative evaluation of the CSA/AKA. Five of eight patients whose CSA was completely occluded had new collateral circulation to the AKA. CONCLUSIONS: None of the 51 patients with the CSA/AKA identified before TEVAR suffered permanent paraplegia, whereas 5 of the 23 without pre-identification did suffer permanent SCI. Thus, careful identification of the CSA/AKA may prove useful for preventing postoperative SCI. Preservation of potential collateral circulation may also reduce the risk of postoperative SCI.

Spontaneous spinal epidural hematoma presenting as paraplegia after cardiac surgery.

An 86-year-old woman was scheduled to undergo aortic valve replacement and coronary artery bypass graft. On postoperative day 3, she developed sudden-onset neck pain followed by weakness in the right arm. Her symptoms worsened with time, and she developed paraplegia. At 60 h after the first complaint, spontaneous spinal epidural hematoma (SSEH) from C2 to C6 with spinal cord compression was diagnosed from a magnetic resonance image of the cervical region. We decided on conservative therapy because operative recovery was impossible. Delayed diagnosis led to grievous results in the present case. When neurological abnormalities follow neck or back pain after open heart surgery, SSEH must be considered in the differential diagnosis. Further, if it is suspected, early cervical computed tomography/magnetic resonance imaging and surgery should be considered.

Management of infectious endocarditis with mycotic aneurysm evaluated by brain magnetic resonance imaging.

OBJECTIVES: Cerebral complications of infective endocarditis (IE) [particularly, mycotic aneurysm, visualized as a hypointense spot on T2*-weighted brain magnetic resonance imaging (MRI)] are associated with a high incidence of postoperative cerebral or subarachnoid hemorrhage. We have adopted a policy of performing elective open heart surgery after performing a MRI enhanced by gadolinium in such patients whenever possible after improvement in inflammatory findings around a cerebral aneurysm. METHODS: Fifty-six patients (35 men and 21 women, mean age 56 years) diagnosed with active-phase IE between January 2000 and December 2010 were analysed retrospectively. RESULTS: Six patients who had not undergone MRI were excluded. The remaining patients were classified into four groups according to preoperative brain MRI findings-Group A (n = 13): cerebral haemorrhage, cerebral infarction, abscess and encephalitis; Group B (n = 7): simple or multiple black dots ( = hypointensive spots) with cerebral haemorrhage or cerebral infarction; Group C (n = 15): simple or multiple black dots alone; Group D (n = 15): no abnormal MRI findings. None of the 12 patients who successfully underwent elective surgery in Groups B and C developed postoperative cerebral complications. CONCLUSIONS: Brain MRI is an important tool for the detection of asymptomatic intracranial abnormalities associated with IE and evaluation of the preoperative bleeding risk of patients. Patients with contrast enhancement around black dots are at high risk for bleeding, and performing open heart surgery in such patients whenever possible after the improvement of inflammatory findings reduces the potential risk of cerebral haemorrhage.

Aortic translocation using the hemi-mustard procedure for corrected transposition.

The management of congenitally corrected transposition of the great arteries and associated lesions is frequently challenging. Restrictive ventricular septal defect and mild pulmonary stenosis are contraindications to the double switch procedure, including the atrial-Rastelli switch procedure, due to the production of postoperative left ventricular outflow tract obstruction. We describe a case of aortic translocation using the hemi-Mustard procedure after left ventricular training in order to prevent postoperative left ventricular outflow obstruction.

Successful valve repair in traumatic aortic valve regurgitation.

Case 1 was a 20-year-old male who had been involved in a traffic accident and developed aortic regurgitation (AR) eight months later. He was admitted with dilatation of the left ventricle. Transesophageal echocardiography (TEE) showed severe AR with perforation of the right coronary cusp. Case 2 was a 50-year-old male who had fallen from a height four months previously, and was admitted with congestive heart failure due to severe AR. TEE showed severe AR due to rupture of the right coronary cusp. In the former patient, valve repair was performed with a patch of autologous pericardium. In the latter patient, cusp reconstruction was performed with autologous pericardium and the commissural plication technique, achieving successful aortic valve repair.

[Off-pump coronary artery bypass grafting in an early-teen patient with aortitis syndrome].

A 14-year-old girl was admitted to our hospital with a history of syncope and chest pain on exercise. Multi-slice coronary computed tomography (CT) demonstrated ostial stenosis of the left main trunk as well as wall thickening in the ascending aorta. Magnetic resonance imaging (MRI) also showed occlusion of the left carotid artery. She was diagnosed as having angina pectoris caused by aortitis syndrome. We performed off-pump coronary artery bypass grafting (OPCAB) with the left internal thoracic artery to the left anterior descending artery. The postoperative course was uneventful and coronary CT demonstrated good graft patency. We herein report successful OPCAB in a patient with left coronary main trunk ostial stenosis with aortitis syndrome.

One- and multi-photon cycloreversion reaction dynamics of diarylethene derivative with asymmetrical structure, as revealed by ultrafast laser spectroscopy.

A cycloreversion reaction of a photochromic diarylethene derivative, 1-(2-methyl-3-benzothienyl)-2-(2,4-dimethyl-5-phenyl-3-thienyl)perfluorocyclopentene, with asymmetrical structure, in n-hexane solution, was investigated by means of picosecond and femtosecond laser spectroscopic methods. Femtosecond laser spectroscopy revealed that the excited state (S(1)) of the closed form with a lifetime of 1.3 ps undergoes the cycloreversion reaction in competition with the internal conversion and the apparent reaction yield was independent of the excitation intensity. On the other hand, picosecond laser excitation at 532 nm led to the drastic enhancement of the cycloreversion reaction yield by a successive two-photon absorption process via the S(1) state, leading to higher excited states with a large cycloreversion yield of 0.60 +/- 0.1. For the multiphoton-enhanced cycloreversion reaction, we reported that the efficient cycloreversion reaction of a diarylethene derivative with C(2v) symmetry could occur by stepwise, visible two-photon excitation but did not take place by UV one-photon absorption to a higher excited state. In the present asymmetrical system, both UV one-photon and visible two-photon absorption opened the efficient cycloreversion reaction. Similarities and differences of the reaction profiles in higher excited states between diarylethene derivatives with symmetrical and asymmetrical structures are discussed from the viewpoint of the selection rule of optical transition and its dependence on molecular structures.

Single-stage transmedial approach to a Stanford type B dissection in a patient with Marfan's syndrome.

We report the case of a patient with Marfan's syndrome and a Stanford type B chronic aortic dissection in which replacement of the ascending aorta, aortic arch and descending aorta was accomplished in a single stage via median sternotomy. The patient was a 51-year-old woman with a 70 mm Stanford type B chronic aortic dissection and Marfan's syndrome. Median sternotomy and replacement of the ascending aorta, aortic arch, and descending aorta were performed under deep hypothermic circulatory arrest. Postoperatively, the patient developed paraplegia. However, after immediate placement of an intrathecal catheter and drainage of cerebrospinal fluid for 72 hours, the neurologic deficit fully resolved. Despite concerns related to the complexity of the procedure and neurological protection during the procedure, we believe that single-stage replacement of the ascending aorta, aortic arch, and descending aorta is possible and is one of several surgical choices for patients such as ours.

Severe stenosis of the true lumen in the abdominal aorta after an ascending aorta reconstruction for an acute type a dissection: report of a case.

We encountered a case of severe symptomatic stenosis of the abdominal aorta after a surgical repair of an ascending aortic dissection. A 75-year-old woman underwent a reconstruction of the ascending aorta to treat a Stanford type A acute aortic dissection and cardiac tamponade. Eight hours postoperatively, the patient was anuric. An abdominal computed tomography scan revealed severe stenosis of the true lumen of the suprarenal abdominal aorta due to a dilatation of the false lumen. The patient's ischemic symptoms progressed to include a weakening femoral pulse and, as a result, an emergency right axillofemoral artery bypass was performed. We hypothesize that the stenosis of the true lumen of the abdominal aorta was secondary to the mechanical obstruction due to a false lumen, which already existed because of the thoracic dissection, and its size increased postoperatively as a consequence of uncontrolled postoperative hypertension.