RESUMO
An 85-year-old man being treated for idiopathic interstitial pneumonia underwent chest CT 6 months prior to the current admission and was diagnosed as having an expanding saccular aneurysm of the aortic arch. Due to the patient's advanced age and the anatomical position of the aneurysm, it was difficult to perform total aortic arch replacement or hybrid arch repair with a commercially available device. After ethical approval had been obtained from the institutional review board, a commercially available stent graft (Relay Plus®) was fenestrated with a 12-mm hole. Under general anesthesia, bypass grafting was performed between the bilateral axillary arteries and the right common carotid artery with a T-shaped ring-supported e-PTFE prosthesis. The fenestrated stent graft was advanced through the left femoral artery and deployed with the device fenestration located at the bifurcation of the brachiocephalic artery. Then, a branched stent graft was deployed through the right common carotid artery in a retrograde manner between the brachiocephalic artery and the ascending aorta through the fenestration to complete the procedure. The patient had an uneventful postoperative course, with no detectable endoleak on postoperative digital subtraction angiography. The current technique, involving the use of an easy-to-make device，is effective for endovascular aneurysm repair, especially when a proximal neck needs to be created in the ascending aorta.
RESUMO
A 45-year-old man underwent total arch replacement for acute type A aortic dissection. Vital signs during the operation remained stable, but sinus tachycardia was recognized about 7h postoperatively, followed by a high level of PaCO<sub>2</sub>, low level of PaO<sub>2</sub> and metabolic acidosis. Then, blood pressure decreased, accompanied rapid elevation of body temperature to 39.7°C. Body temperature was decreased gradually by cooling the whole body, however, coma, anuria and hypoxemia persisted. A diagnosis of malignant hyperthermia was made and Dantrolene was administered. However, the patient died of multiple organ failure 7 days postoperatively. The serum level of CPK increased to 12, 446IU/<i>l</i> and serum myoglobin elevated to a very high level (36, 500ng/ml) 2 days postoperatively. Although, it is very rare for malignant hyperthermia to develop after open-heart surgery, physicians must keep this disease in mind if sudden hyperthermia of unknown origin is demonstrated.
RESUMO
A 70-year-old-woman was admmitted to receive an operation for aortic arch aneurysm. Total arch replacement was carried out under deep hypothermic circuratory arrest with selective cerebral perfusion. During sternal closure, her blood pressure dropped to 60/30mmHg suddenly, and massive venous bleeding started from the substernal space which turned out to be hemorrhage from the laceration of the pulmonary trunk. Controlling the bleeding by finger compression, rapid introduction of cardiopulmonary bypass was carried out and the laceration was closed by a pericardial patch. The postoperative course was uneventful. In this case, compression of the pulmonary trunk by the aortic arch aneurysm may have caused the fistula formation between them, and decompression of the aneurysm probably induced the rupture of the pulmonary trunk. If the preoperative computed tomogram had showed the compression of the pulmonary artery by the aneurysm, a careful exploration of the main pulmonary artery and a removal of the thrombus should have been performed, even when the preoperative diagnostic evaluation failed to reveal aortopulmonary fistula.
RESUMO
An 81-year-old woman developed abdominal pain after off-pump CABG (OPCAB) for unstable angina pectoris. X-ray film and CT scan showed paralytic ileus the day after surgery. A presumptive diagnosis of mesenteric ischemia was made and exploratory laparotomy was performed. During surgery, however, there was no sign of mesenteric ischemia. The patient still complained of abdominal pain after the laparotomy, so selective angiography of the mesenteric artery was performed. The angiography showed remarkable vasospasm of the superior mesenteric artery (SMA) and diagnosis of nonocclusive mesenteric ischemia (NOMI) was made and continuous intra-arterial perfusion of papaverine into the SMA was started. Control angiography during papaverine perfusion showed a clear reduction of vasospasm. Thereafter, the patient developed diffuse peritonitis due to intestinal gangrene on postoperative day 12 and was compelled to undergo extensive resection of the intestine and sigmoidectomy. She could not be weaned from the ventilator due to respiratory insufficiency and died of multiple organ failure about 5 months after OPCAB. NOMI can develop even in OPCAB, in which cardiopulmonary bypass is not required. Therefore maintenance of stable hemodynamics intraoperatively, careful management of the postoperative state and early diagnosis and therapy are essential to prevent NOMI.
RESUMO
A 65-year-old-man was admitted with congestive heart failure and septic shock associated with suspected mitral valve infective endocarditis. An echocardiogram revealed vegetation attached to the chordae, high density lesions in both papillary muscles, and severe mitral regurgitation. An emergency operation was performed. Vegetation was been attached to the chordae. Multiple myocardial abscesses were noted in both papillary muscles and surrounding myocardium. However, there were few noticeable lesions on mitral valve leaflets and annulus. The anterior mitral leaflet was resected together with the chordae and the papillary muscles containing the myocardial abscesses. Mitral valve replacement was performed using a 27mm SJM valve after the other myocardial abscesses were drained. <i>Klebsiella pneumoniae</i> was cultured from the vegetation and the myocardial abscesses. Cases of myocardial abscess associated with infective endocarditis at the site of the papillary muscles and in the areas of the myocardium are very rare. It was assumed that the myocardial abscesses were probably due to the septic state from infective endocarditis, since myocardial abscesses was recognized in multiple sites and at a distance from the valve leaflets and annulus.
RESUMO
A 42-year-old man noted a left hypothenar mass about one week after hitting the palm of his left hand. Although he did not seek treatment, numbness and cyanosis of the left 2nd, 3rd, 4th, and 5th digits appeared suddenly about one year later. A computed tomography scan revealed an ulnar artery aneurysm with a mural thrombus, with a maximal diameter of 20mm, at the site where the ulnar artery passed near the hamate bone. The aneurysm was excised, and the ulnar artery was reconstructed with direct end-to-end anastomosis. Traumatic ulnar artery aneurysm is commonly seen in workers who use the hypothenar eminence of their hands as a hammer, and is usually accompanied by finger ischemia.
RESUMO
We report here a case of pseudo-false aneurysm of the left ventricle with ventricular septal perforation following myocardial infarction. An 85-year-old man was treated for acute inferior myocardial infarction three months previously. He was admitted due to an acute posterior myocardial infarction. Since a cardiac catheter study showed three diseased coronary arteries, a left ventricular aneurysm and a ventricular septal perforation, he underwent emergency surgery. The ventricular aneurysm was located on the right side along the posterior descending branch, and was 4×1.5cm in size. We ruled out a false aneurysm because there was no adhesion between the epicardium and the pericardium. The communication between the aneurysm and the left ventricle was then closed with a Gore-Tex patch, and the perforation of the right ventricle was closed directly. CABG was performed for the left anterior descending artery using a vein graft. The postoperative course was uneventful, and he was discharged on the 27th postoperative day. The pathological findings showed a pseudo-false aneurysm of the ventricle.
RESUMO
We present a case of solitary arteriosclerotic aneurysm of the profunda femoris artery (PFA), which is very rare among peripheral aneurysms and a reviewed the 19 cases reported in the Japanese literature. A 78-year-old man had a chief complaint of a painful pulsatile mass in the left thigh. Enhanced CT showed the ruptured solitary aneurysm of the PFA. The aneurysm was 6.8cm in diameter. It was removed after ligation of the the PFA. In the Japanese literature, the mean age of patients with solitary arteriosclerotic aneurysm of the PFA was 73 (64-84), all patients were males, the rate of rupture of PFA aneurysm was 47%, and the mean diameter was 8.9cm. In our case, we simply ligated the aneurysm because the patient did not have any evidence of peripheral artery occlusive disease and the distal artery of the aneurysm was very small. However, there is a need to reconstruct the PFA whenever possible because the surgical importance of PFA in occlusive arterial disease has been recognized.
RESUMO
A 6-year-old girl who had undergone repair of an endocardial cushion defect 4.5 years previously, developed discrete subaortic stenosis requiring surgical intervention. On two-dimensional echocardiography a membrane was visualized below the aortic valve. A pressure gradient of 97mmHg was recorded across the left ventricular outflow tract by cardiac catheterization. Operative findings showed a fibrous ring tissue just below the aortic valve, which was peeled away by sharp dissection. Postoperative cardiac catheterization revealed a 25mmHg pressure gradient across the left ventricular outflow tract. Two years later, she continues to do well and the pressure gradient remains unchanged on Doppler echocardiography.
