Combination therapy of modified electroconvulsive therapy and long-acting injectable aripiprazole for dopamine supersensitivity psychosis: a case report.

In the treatment of schizophrenia, long-term pharmacotherapy with D2-receptor antagonists can induce dopamine supersensitivity psychosis (DSP). We report a male patient with schizophrenia with suspected DSP due to excessive polypharmacy. He was hospitalized for several years. Most psychotropic drugs were reduced and subsequently stopped without the exacerbation of symptoms by administering modified electroconvulsive therapy (mECT). Aripiprazole was then selected as the main drug for treatment, which was subsequently changed to the long-acting injection formulation. He was eventually discharged and returned home. Combination therapy with mECT and aripiprazole, especially the long-acting injectable formulation, may help improve and prevent DSP.

Aortic valve replacement with 17-mm St. Jude Medical Regent prosthetic valves for a small calcified aortic annulus in elderly patients.

PURPOSE: The aim of this study was to investigate the outcome of aortic valve replacement (AVR) performed with a 17-mm St. Jude Medical Regent prosthetic valve (17SJMR) for an aortic annulus ≤19 mm in elderly patients aged ≥65 years. METHODS: Six female patients (age 73.0 ± 5.1 years, body surface area 1.43 ± 0.07 m²) underwent AVR between October 2005 and February 2008. RESULTS: Peak transaortic pressure gradient, which was 80.8 ± 31.0 mmHg preoperatively, decreased to 31.0 ± 4.2 mmHg postoperatively (P < 0.01) and to 21.7 ± 1.5 mmHg long term (P < 0.01). The left ventricular mass index, which was 112.1 ± 10.6 g/m² preoperatively, also significantly decreased to 101.4 ± 15.0 g/m² postoperatively and to 88.3 ± 14.8 g/m² long term (P < 0.01). Subjective symptoms diminished in all patients, and neither mortality nor hemorrhagic complications occurred. The postoperative mean effective orifice area index was 0.91 ± 0.04 cm²/m². CONCLUSION: A favorable outcome was obtained by aortic valve replacement with the 17SJMR. Patients showed improved postoperative hemodynamic performance without valve-related complications.

Posterior mitral annuloplasty using autologous pericardium in the repair of posterior leaflet prolapse.

OBJECTIVE: Mitral valve repair is frequently performed now because it produces a favorable postoperative quality of life, as well as improved cardiac function. For the treatment of posterior leaflet prolapse, we perform a posterior mitral annuloplasty using an autologous pericardium. The present study assessed the efficacy of this operation. METHODS: From April 1999 to October 2003, 42 patients underwent a posterior mitral annuloplasty using autologous pericardium for the treatment of posterior leaflet prolapse. There were 15 men and 27 women with an average age of 63.9 +/- 11.8 years. The length of the autologous pericardium matched the length of the posterior leaflet annulus as measured with Carpentier-Edwards ring sizer that was chosen based on the area of the anterior leaflet. RESULTS: The average size of the Carpentier-Edwards ring sizer that was used to determine the length of the autologous pericardium was 27.7 +/- 13 mm, and the absolute length of the pericardium was 50.9 +/- 1.8 mm, and the average intraoperative jet area, as assessed by transesophageal echocardiography, was 0.36 +/- 0.47 cm2. The five-year freedom from reoperation was 97.1%, while the freedom from significant residual mitral regurgitation (> or = 3+/4+) was 92.0%. Two patients (4.8%) developed systolic anterior motion, and one patient (2.4%) had a cerebral infarction. None of the patients died after surgery, and no patients developed complications such as hemolysis or ring detachment. CONCLUSIONS: Posterior mitral annuloplasty using an autologous pericardium was shown to be a superior technique because it allows a sufficient annular repair with no complications such as hemolysis or ring detachment.

Three cases of ischemic ulcer due to arteriosclerosis obliterans responding to basic fibroblast growth factor spray.

The management of the chronically ischemic leg with ulcer formation that is not suitable for either surgical or interventional treatment is still a matter of controversy. We describe three cases of ischemic ulcer treated with basic fibroblast growth factor spray. Ulcer healing was accelerated and complete epithelialization was achieved in all cases. Basic fibroblast growth factor spray is useful in the treatment of the ischemic ulcer in patients with arteriosclerosis obliterans, especially in high-risk surgical patients.

Prosthetic valve endocarditis due to Candida albicans treated successfully with medical treatment alone.

Prosthetic valve endocarditis (PVE) caused by Candida species is associated with high morbidity and mortality. A combination of surgical resection and antifungal drug therapy is the golden standard for treatment, yet surgical intervention is not possible in all cases of Candida PVE. We report a case of PVE due to Candida albicans cured by medical treatment alone. This case suggests that, in some instances, Candida PVE can be managed medically with antifungal therapy. Such a conservative approach should be applied with caution and necessitates very close follow-up on a long-term basis.

Inflammatory response after coronary revascularization: off-pump versus on-pump (heparin-coated circuits and poly2methoxyethylacrylate-coated circuits).

OBJECTIVE: Off-pump coronary artery bypass grafting (OPCAB) may reduce the inflammatory response associated with cardiopulmonary bypass (CPB) and contribute to minimizing postoperative complications. Heparin-coated circuits and poly2methoxyethylacrylate (PMEA)-coated circuits were developed to reduce such complications. We compared the postoperative inflammatory response with or without CPB. METHODS: Eighteen consecutive patients undergoing isolated coronary artery bypass grafting (CABG) were divided into three groups: OPCAB group (n=6), heparin-coated circuits group (n=6), PMEA-coated circuits group (n=6). The plasma concentrations of the following inflammatory markers were measured: cytokines [interleukin (IL-10)], polymorphonuclear elastase (PMNE), coagulofibrinolytic factor [thrombin-antithrombin III complex (TAT)], complement factor (C3a). RESULTS: At the end of CPB, IL-10 and TAT concentrations were significantly different among the three groups (OPCAB group < PMEA-coated group < heparin-coated group). The PMNE concentration was significantly lower in the OPCAB group and the heparin-coated group as compared to the PMEA-coated group both at the end of CPB and 4 hours after CPB. C3a concentration was significantly lower in the OPCAB group than in the CPB groups at the end of CPB. Clinical variables did not differ significantly among the three groups. CONCLUSION: Off-pump CABG is associated with a reduction in the inflammatory response when compared with on-pump CABG, using either PMEA-coated or heparin-coated circuits.

Iatrogenic pseudoaneurysm in a hemodialysis patient: the hidden hazard of a high radial artery origin.

High origin of the radial artery is the most common variation in the arterial network of the upper extremities in humans. A 36-year-old Japanese woman undergoing chronic hemodialysis presented with a pseudoaneurysm originating from the brachial portion of the radial artery and associated with a high radial artery origin. Recognition of variants of the arterial network in the upper extremities is crucial for clinicians because their superficial position at the elbow joint may make these vessels vulnerable to injury.

Chronic aortic dissection complicated by disseminated intravascular coagulation: successful treatment with endovascular stent-grafting.

PURPOSE: To report endovascular repair of a chronic aortic dissection complicated by disseminated intravascular coagulation (DIC). CASE REPORT: A 61-year-old man developed DIC associated with a chronic Stanford type B aortic dissection that occurred during cardiac catheterization 12 years earlier. At the current admission, computed tomography showed a partially thrombosed false lumen extending from the aortic arch to the left common iliac artery. On angiography, entry and re-entry tears were identified at the right subclavian and left common iliac arteries, respectively. After stent-graft implantation at the entry and re-entry sites, not only was the false lumen completely thrombosed but the DIC also resolved. The patient is doing well with no complication at 16 months after treatment. CONCLUSIONS: Endovascular stent-grafting is an acceptable alternative to surgical repair for aortic dissection accompanied by DIC.

Thrombus removal with a temporary vena caval filter in patients with acute proximal deep vein thrombosis.

Between September 1999 and January 2001 we performed thrombus removal with the use of a temporary vena caval filter in 11 patients who had acute iliofemoral venous thrombosis. To facilitate thrombus removal, 5 patients initially received catheter-directed thrombolytic therapy (thrombolysis group), and the other 6 received surgical thrombectomy (thrombectomy group). Residual thrombus was confirmed after initial catheter-directed thrombolysis in all patients in the thrombolysis group, and thrombolysis was continued in the ward. Bleeding complications subsequently occurred in 2 patients. In the thrombectomy group, 1 patient had residual thrombus just below the temporary filter, and a permanent vena caval filter was deployed for removal. Another patient had a residual thrombus in the superficial femoral vein, and rethrombectomy was performed. One patient in the thrombectomy group died of pneumonia. All other patients were discharged. There were no deaths from pulmonary thromboembolism in this series. Post-thrombotic syndrome occurred in 2 of the 5 patients in the thrombolysis group (40%) and in 3 of the 6 patients (50%) in the thrombectomy group. We conclude that a temporary vena caval filter is useful for the management of acute proximal deep vein thrombosis, especially when aggressive treatment is required.

Surgical treatment for cervical aortic arch with aneurysm formation.

Cervical aortic arch is an unusual malformation. Cervical aortic arch with aneurysm formation is very rare. We report a case of cervical aortic arch associated with a saccular aneurysm in a 59-year-old Japanese man. The aneurysm protruded caudally and was located between the left common carotid and left subclavian arteries. Cardiopulmonary bypass and deep hypothermic circulatory arrest was applied as adjunct methods. A Dacron graft was sutured just distal to the left common carotid artery, with the patient in the Trendelenburg position. The proximal site was left open while oxygen-saturated venous blood was supplied in a retrograde manner to perfuse the lower body during occlusion of the descending aorta. Distal anastomosis to the descending aorta was performed during rewarming. The left subclavian artery was reconstructed by using a branch of the graft. This procedure is simple and useful for distal arch operations, especially in patients with Haughton D type aneurysms.

Biocompatibility of poly2methoxyethylacrylate coating for cardiopulmonary bypass.

The systemic inflammatory response to cardiopulmonary bypass (CPB) may contribute to the development of postoperative complications. Heparin-coated circuits and poly2methoxyethylacrylate (PMEA)-coated circuits have been developed to reduce the risk of such complications. We compared the biocompatibility of these circuits. Twelve patients scheduled to undergo elective coronary artery bypass grafting (CABG) with CPB were assigned to CPB with a PMEA-coated circuit (PMEA-coated group, n=6) or a heparin-coated circuit (heparin-coated group, n=6). The plasma concentrations of the following inflammatory markers were measured before CPB and just after, 4 hours after, and 24 hours after the termination of CPB: cytokines (interleukin [IL]-6, IL-8, IL-10), complement factor (C3a), polymorphonuclear elastase (PMNE), and coagulofibrinolytic factors (thrombin-antithrombin III complex [TAT], D-dimer). Postoperative clinical response was evaluated on the basis of respiratory index, blood loss, and the postoperative and preoperative body-weight percent ratio. There were no significant differences between the groups in the plasma concentrations of IL-6, IL-10, C3a, PMNE, TAT, or D-dimer. Plasma IL-8 concentrations were below the assay detection limits at all time points in both groups. Clinical variables did not differ significantly between the groups. In conclusion, PMEA-coated CPB circuits are as biocompatible as heparin-coated CPB circuits and prevent postoperative organ dysfunction in patients undergoing elective CABG with CPB.