Search

Transcatheter device closure has become the first treatment option for atrial septal defects (ASD). Surgical ASD closure, although still implemented, is cosmetically inferior to transcatheter closure. This study aimed to evaluate the feasibility as well as short- and long-term clinical outcomes of the right posterolateral minithoracotomy approach for surgical ASD closure.In total, 102 consecutive patients underwent posterolateral minithoracotomy for ASD between January 2014 and December 2021 at our center. Early surgical outcomes, cosmetic findings, and skin perception were evaluated over 1 year of postoperative follow-up using a self-satisfaction survey (1: very good, 2: good, 3: normal, 4: not good, 5: bad), Cavendish score, and shoulder joint function (angles of flexion, extension, and abduction).No patient required conversion to median sternotomy. Only one patient required reoperation due to bleeding. Postoperative echocardiography revealed no residual shunt at discharge in all patients. The mean follow-up period was 3.7 years (range: 0.3-7.1 years), during which the questionnaire was answered by 69 of 98 patients who were evaluated after more than 1 year. The mean self-satisfaction survey scores for cosmetic findings and skin perception were 1.3 ± 0.6 and 1.2 ± 0.5, respectively. The Cavendish score was under Grade 1 in all patients. Shoulder flexion and abduction were normal at 180° in all patients, except one, while extension was normal at 50° in all patients, except three.Our procedure achieved not only good early surgical outcomes but also excellent long-term cosmetic and shoulder function results.

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.

Left upper lobectomy may be a risk factor for thrombosis in the pulmonary vein stump. We report a case of surgical removal of a left upper pulmonary vein stump thrombus after left upper lobectomy. A 73-year-old man with transit ischemic attack had a history of left upper lobectomy for pulmonary tuberculosis 40 years before. Echocardiography and chest computed tomography (CT) scan revealed a mobile thrombus in the left atrium originating from the left upper pulmonary vein stump. Surgical removal of the thrombus as well as the left upper pulmonary vein stump was performed under extracorporeal circulation and cardioplegic cardiac arrest. Pathological examination of the pulmonary vein stump revealed no growth of tumor nor injury of endothelial cells. Postoperative course was uneventful and no recurrence of the thrombus was observed during 7 years after surgery.

Aortoesophageal fistula (AEF) is relatively rare and usually life-threatening. Lots of strategies have so far been discussed for this entity including the role of endovascular repair. The aim of this study is to review our experiences and reconsider the surgical strategy for aortoesophageal fistula in the endovascular era.This is a retrospective multicenter study. From 1995 to 2011, 10 aortoesophageal fistula cases were identified in four institutions. For all of these cases surgical procedures and results were retrieved from medical records.Six patients underwent open aortic repair and four patients underwent thoracic endovascular aortic repair (TEVAR) as a primary intervention. Three patients who underwent open aortic repair with esophagectomy and omental coverage in early phase, either as a primary intervention or performed after bridging TEVAR, showed 100 % 1-year survival. On the other hand, three patients with TEVAR alone did not survive more than 1 year without recurrence. One patient with bridging TEVAR underwent concomitant esophageal resection and conventional aortic graft replacement 2 days later, and simultaneous gastric tube reconstruction was performed with intact whole omentum covering the aortic prosthesis. This patient is doing well with no sign of infection at 1-year follow-up.For AEF, TEVAR as a primary approach is quite useful to stabilize the patients' condition. However, definitive aortic repair with omental coverage should be performed as early as possible as a next step. It may be one of the strategies for the treatment of AEF that concomitant esophageal resection and aortic graft replacement is performed with simultaneous gastric tube reconstruction with intact whole omentum after removing the stent graft, so far as the patient's physical condition permits.

開心術後周術期の合併症として大動脈解離はまれであるが致死的な合併症の一つとして考えられている.開心術後周術期に新たに弓部大動脈以下より大動脈解離が発生した症例を3例報告する.当科では1994年から2003年までの10年間で開心術は1,647例で,術後大動脈解離の発生率は0.18%であった.3例の術式はannulo aortic ectasiaに対するmodified Bentall手術,虚血性心筋症,陳旧心筋梗塞に対する冠動脈バイパス術およびDor手術,急性II型解離,大動脈弁閉鎖不全症に対する上行置換および大動脈弁置換術で,3例とも術中,術直後の血行動態は安定していた.3例中2例は術後のCT検査およびエコー検査により下行大動脈の解離を指摘され大動脈解離の発症が判明した.ほかの1例は術後10日目に左胸腔内に出血をきたしショックとなり広範囲脳損傷のために失い,死亡後の剖検により大動脈解離の診断を得た.解離のentryは死亡例とほかの1例は下行大動脈近位に,もう1例は左鎖骨下動脈に認めた.生存例はAHAの大動脈解離診療ガイドラインに従い安静と降圧療法を行い,行動拡大,血圧コントロール後に退院,外来followを行っている.術後急性大動脈解離は開心術後の合併症の一つとして考慮し,術中に経食道エコーによる下行大動脈の観察や,症例によっては周術期の血圧コントロールを厳格にすべきである.また,発症例に対しては定期的な経過観察をしていく必要があると考えられる.

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.

The authors report four cases of renal tumors with intracaval and intracardiac extensions that can be removed successfully during cardiopulmonary bypass surgery. The management was relatively simple: mild hypothermia, empty heartbeat, monocaval cannulation, and no circulatory arrest. Bleeding from the hepatic or renal veins was controlled by temporary occlusion of the hepatic artery, the portal vein, and the renal artery for a short duration. The authors also advocate thrombectomy of the hepatic vein using direct observation to relieve hepatic congestion. No complications were experienced postoperatively. One patient died of systemic metastasis 9 months after the operation. Another died of cytomegalovirus infection 3 months postoperatively. The remaining 2 are leading normal lives. Although the surgical indication for these advanced tumors is controversial, the patients' quality of life may be improved by this aggressive yet simple and safe approach.

Disseminated intravascular coagulation (DIC) is one of the complications accompanying aortic aneurysm. We herein report four patients with aortic aneurysm who had DIC preoperatively. In all four cases, DIC was corrected immediately after surgery; however, in two cases, DIC could not be corrected preoperatively. This prompted us to reconsider the importance of correcting DIC before surgery. Of the four cases reported in this paper, DIC existed even at the time of surgery in two cases, in spite of meticulous treatment with heparin and/or protease inhibitor; however, the DIC could be removed postoperatively even in these two cases. Surgeons should not waste time with intensive DIC treatment preoperatively. If the DIC cannot be corrected within more than 2 weeks of meticulous treatment, surgeons should then perform surgery on the patient. In addition, it is also essential to ensure that the DIC is due to the aneurysm itself and that no other disease processes have been overlooked.

Behçet's disease is a systemic process of unknown etiology that features a prolonged, intractable course. Characteristic pathologic findings include recurrent orogenital ulcers and ocular and cutaneous inflammatory lesions. The disease may also involve the articular, neurologic, gastrointestinal, and cardiovascular systems. Vascular lesions reportedly vary from arterial occlusions and aneurysms to thrombophlebitis. Budd-Chiari syndrome due to thrombosis of the inferior vena cava (IVC) has been rarely reported. Here the authors report a thirty-six-year-old Japanese woman with Behçet's disease who developed Budd-Chiari syndrome secondary to inferior vena cava thrombosis. She was treated successfully by cavoatrial bypass. Although the graft was thrombosed, she has been asymptomatic for five years after surgery. Cavoatrial bypass could be considered as a surgical option to immediately relieve hepatic congestion due to caval thrombosis.

慢性腎不全を有し, 血液透析 (以下透析) を受けている52歳男性に対して僧帽弁大動脈弁置換術と冠動脈バイパス術を施行した. 手術前日に透析を行い, 術中, 術直後は過剰な輸液を避けて溢水を回避した. 高カリウム血症に対しては, グルコースインスリン療法で対処した. 血清カリウムが6.0mEq/lを超え, クレアチニンが9.0mg/dlとなった術後2日目から持続的血液透析濾過 (CHDF) を開始した. CHDFにより, 循環動態に影響を及ぼすことなく, 除水, 高カリウム血症の管理が容易にできた. 術後5日目には血液透析に移行, 術後6日目に一般病棟に移った. 開心術後の透析の手段としてCHDFは溶質の除去効率が良い, 循環動態に及ぼす影響が少ないなどの利点を有する優れた方法であると考えられた.

With the resurgence of thoracoscopy, there is renewed interest in less invasive methods of pleurodesis. We wished to compare in an animal model a variety of methods suggested in reports. The purpose of the study was to rank the effectiveness of each procedure against the standard mechanical pleurodesis. Twenty-five mongrel dogs (weight, 25 to 35 kg) underwent bilateral thoracotomy. Each animal was randomly assigned to receive two of the following methods of pleurodesis: tetracycline, talc, mechanical abrasion, neodymium: yttrium-aluminum garnet (Nd:YAG) laser (Hereus Inc, E. Rutherford, NJ) photocoagulation, and argon beam coagulator (ABC) (Beacon Lab, Bloomfield, CO) electrocoagulation of the parietal pleura. At evaluation at 30 +/- 2 days, the efficacy of pleurodesis was graded on a scale of 0 to 4, with 0 representing a complete absence of pleural symphysis and 4 the adhesion of more than one lobe to both the chest wall and mediastinum. Mean grade and standard deviation of each method were: talc, 3.0 +/- 0.67; mechanical, 3.0 +/- 0.82; tetracycline, 2.3 +/- 1.4; ABC, 1.5 +/- 0.97; and Nd:YAG laser, 0.7 +/- 0.95. Both the talc and mechanical methods were superior to either the Nd:YAG laser or the ABC (p0.01). In this study, neither the Nd:YAG laser nor the ABC proved efficacious in producing pleurodesis. Talc poudrage is the only method of pleural symphysis comparable with mechanical abrasion.

Major complications of bronchial anastomoses for either transplantation or sleeve resection include early leak, fistula formation, granulation tissue, and stenosis. To evaluate the impact of technique on these complications, we designed a nonimmunocompromised canine model with a totally ischemic bronchial segment. We wished to discover the prevalence of early and late complications of a telescoping anastomosis and if wrapping techniques modify them. We autotransplanted 25 mm of left main-stem bronchus by telescoping 1 mm of proximal into distal bronchus sutured with interrupted 4-0 polyglactin sutures. The animals were divided into four groups: no wrap; omental pedicle wrap; detached-free omental wrap; and Gelfoam sponge soaked in porcine omental extract. Weekly bronchoscopic studies assessed airway patency. After the animals were put to death at 70 days, the luminal areas of the proximal anastomoses were compared with the origin of the left main bronchus. No air leak, bronchial disruption, or infection occurred in any group at any time. Luminal narrowing occurred in all four groups but was most pronounced in the three groups in which wrapping techniques were used. We conclude that wrapping of a telescoped anastomosis is not necessary to prevent early complications. However, no method completely eliminates stenosis. Further experiments should determine the effects of immunomodulation in this model. (J T horac C ardiovasc S urg 1992;103:763-6)

Reports of a cardiac operation in a patient with idiopathic thrombocytopenic purpura are scarce. Here we present a case of successful mitral valve replacement in a patient with idiopathic thrombocytopenic purpura. Preoperative treatment with high-dosage gamma-globulin successfully increased the platelet count from 50,000/microliter to 80,000/microliter. Twenty units of platelet-rich plasma were administered during and after the operation. No other blood products were used. The postoperative convalescence was uneventful. Perioperative management for patients with idiopathic thrombocytopenic purpura undergoing open-heart surgery is discussed.

A 58-year-old male presented with a diastolic heart murmur was found to have a severe aortic regurgitation on cardiac evaluation. He was transferred to our department, and underwent an aortic valve replacement. During the operation, the aortic valve was recognized quadricuspid, including three equal cusps and one smaller accessory cusp. The finding was consistent with Hurwitz type b quadricuspid aortic valve. It was etiologically thought that the relatively small cusp decreased in size with the aging to produce some space, causing aortic regurgitation. Aortic valve was replaced with Carbomedics 23mm prosthetic valve uneventfully. Thirty-five reported cases are reviewed in terms of clinical features and surgical therapy.

A 61-year-old man presented with consistent hemolytic anemia 15 months after ascending and total arch replacement for DeBakey I type acute aortic dissection. The cause of hemolysis turned out to be mechanical damage of red blood cells at the inverted felt of the proximal anastomosis. Reoperation of resection of the felt and repair of the proximal anastomosis successfully resolved this problem. We report a rare case of hemolytic anemia at the site of inverted felt strip after total arch replacement.

An 87-year-old man underwent aorto-bifemoral bypass using a bifurcated Bionit II knitted Dacron graft for high aortic occlusion in 1987 at another hospital. In November, 2004, he was admitted to our institution because of difficulty in walking due to swelling and tenderness in the right groin. Computed tomography (CT) scan indicated bilateral aneurysms of the grafts in the groins. The size of the right and left aneurysms were 73 mm and 52 mm, respectively. Angiography showed some extravasation in the right thigh. We performed surgical replacement of all the dilated parts with new ringed-Dacron grafts. We report a rare case of late rupture of bifurcated Sauvage Bionit II Dacron graft.

We report a rare case of severe hemolytic anemia accompanied by moderate renal insufficiency after mitral valve repair. Although the degree of the residual mitral regurgitation was less than 1+ during the first three weeks after the operation, the maximum lactate dehydrogenase (LDH) was up to 7,430 U/l and the minimum hemoglobin was 4.9 g/dl. The mitral valve replacement successfully resolved the hemolysis, but the renal function did not completely recover.

An 83-year-old woman was transferred to our hospital because of pacing failure and suspected ventricular perforation by a permanent pacing lead. She had undergone permanent pacemaker implantation 5 months previously. Chest radiography showed the pacing lead running out of the cardiac shadow. Computed tomography and echocardiography confirmed the diagnosis of ventricular perforation by the pacing lead. No evidence of cardiac tamponade was found. The lead was surgically removed through a median sternotomy. Intraoperatively, the lead was found perforating the ventricle and the pericardium, and reaching into the left pleural cavity but not injuring the left lung. A pacing lead may potentially injure the heart or the lung. Regular check-up of lead position and pacing status is recommended.

Background Excellent surgical results have been reported for repair of incomplete atrioventricular septal defect; however, left atrioventricular valve regurgitation (ltAVVR) is a major cause of late morbidity. We reviewed our entire experience with incomplete atrioventricular septal defect in order to investigate long-term results of ltAVVR after repair and determine the factors influencing the progression of ltAVVR in late follow-up. Methods Between 1983 and 2002, 61 patients underwent surgical repair of incomplete atrioventricular septal defect, including 7 patients with intermediate forms. The age of operation ranged from 1 month to 62 years old (median 5.3 years old). Thirteen patients were less than 2 years old, including 7 infants, while there were 15 adult patients. All patients underwent patch closure of the ostium primum defect. Before 1995, the cleft was left open in 7 patients and partial closure of the cleft was done in 41 patients, whereas complete closure of the cleft was performed in 9 patients since 1996. Preoperative and postoperative ltAVVR at hospital discharge and late follow-up were graded 0–IV by echographic evaluation. Results There was 1 early death and 4 late deaths with a 91% 10-year actuarial survival rate. Preoperative ltAVVR grade was I in 25 patients, II in 31 patients, III in 4 patients, and IV in 1 patient. Postoperatively, ltAVVR deteriorated in 3 patients. Left AVVR decreased in 21 patients, whereas in 37 patients it remained the same at hospital discharge. Consequently, ltAVVR remained grade II in 18 patients, grade III in 2, and there was no patient with grade IV. During the long-term follow-up, 24 patients were noted to have increased ltAVVR, including grade III in 8 patients and grade IV in 4. Reoperations for ltAVVR were required in 5 patients (8.3% of hospital survivors); valve replacement in 3 patients and valve repair in 2. Actuarial freedom from reoperation for ltAVVR was 91% at 10 years, whereas actuarial freedom from postoperative ltAVVR grade III or more was 89% at 5 years and 78% at 10 years. Multivariate analysis indicated that postoperative ltAVVR grade II or more at hospital discharge ( p = 0.0032, odds ratio=7.41, 95%CI: 1.95–28.10) was the only independent variable related to late ltAVVR, whereas age at operation, preoperative grade of ltAVVR, and the method of cleft repair were not significant risk factors. Conclusions Left AVVR is still a significant risk in long-term follow-up. Because the postoperative grade of ltAVVR is the only independent risk factor for late ltAVVR, more efforts should be focused on left atrioventricular valve repair so as to minimize residual regurgitation, even mild regurgitation.

We reoperated for diffuse supravalvular aortic stenosis using a modified technique of patch plasty described by Brom. A 36-year-old woman admitted to our hospital with a peak systolic pressure gradient of 92 mmHg across the ascending aorta had previously undergone Doty's operation at another hospital. Aortography showed an ascending aorta diffusely stenotic from the sinotubular junction to the aortic arch. We transected the ascending aorta just above the stenotic portion and incised the proximal wall to the sinus of Valsalva. Three patches were sewn to each sinus to expand them and the ascending aorta. The pressure gradient decreased postoperatively to 11 mmHg, and we conclude that this technique sufficiently relieves diffuse supravalvular aortic stenosis.

We investigated the alterations in the coagulation and fibrinolysis systems after aortic aneurysm surgery under cardiopulmonary bypass (CPB) while using newly developed "molecular markers". Fibrinogen and antithrombin III (AT-III) decreased after surgery but returned to normal values within three days. The thrombin-antithrombin III complex (TAT) and plasmin-alpha-2-plasmin inhibitor complex (PIC) both showed increased values even preoperatively, which indicated that coagulation and fibrinolysis were activated in some patients with an aortic aneurysm. Both markers maintained a high level for at least 14 days after surgery. The fibrin degradation product (FDP) also showed an increased value before and after surgery. These results apparently showed that coagulation/fibrinolysis had already been activated in some patients and maintained such a state for at least 14 days after surgery. The relation of activated system and postoperative organ dysfunction as well as the means to suppress such activation are also discussed.

Maximum preservation times of 4-6 hr continue to plague lung transplantation. The high-potassium colloid University of Wisconsin solution (UWS) has proved superior to the crystalloid modified Eurocollins' solution (ECS) for preservation of the liver, kidney, and pancreas. The purpose of this study was to compare UWS and ECS for extended lung preservation using a technique of combined pulmonary and bronchial artery perfusion. Simultaneous pulmonary artery and bronchial artery (via a closed aortic segment) perfusion was employed to harvest the lungs of ten mongrel dogs (wt 25-35 kg) using either UWS (n = 5) or ECS (n = 5) preservation solutions. Following 17 hr of cold (4 degrees C) pulmoplegic storage, the lungs were placed in an isolated perfused working lung (IPWL) apparatus. Seven freshly harvested lungs served as a control group (CON). Lung aerodynamics and gas exchange were evaluated at standard intervals until failure of the lung on the IPWL apparatus. Time until failure (mean +/- SEM) for each group was: CON = 209 +/- 14 min; UWS = 227 +/- 26 min; and ECS = 123 +/- 29 min. Only one of the ECS lungs lasted longer than 90 min. UWS-preserved lungs displayed a gas exchange efficiency equal to the CON group and better than that in the ECS-preserved lungs (lower A-aDO2, lower intrapulmonary shunt), suggesting better protection of the alveolar capillary membrane. Although the UWS lungs were initially less compliant than the ECS lungs, at no time was there a significant difference in the total work of respiration between the two groups. We conclude that UWS provides superior protection of the alveolar capillary membrane. The aerodynamic disadvantages of UWS preservation did not effect lung survival or total work of respiration.

We describe a modified technique for percutaneous denervation of the thoracic sympathetic chain by laser to treat selected cases of sympathetic causalgia of the upper extremities. The technique involves transpleural ablation with laser under thoracoscopic guidance through the second or third intercostal space-anterior axillary line. We also compare four different modalities of endoscopic denervation: A xenon chloride excimer laser (308 nm, 35 mJ/pulse, 20 pulses/sec, 2.2 mm catheter tip), CO2, laser (14 W, CW, 2 mm spot size), Nd:YAG laser (88 W, CW, 3 mm spot size), and radiofrequency-generated thermocoagulation (3 W, CW, 2.1 mm catheter tip) by performing bilateral thoracic sympathectomy on 12 mongrel dogs (three dogs each). Criteria analyzed included duration of exposure, power density, total energy output, laser penetration and spread, gross morphology, and scanning electron microscopy (SEM) of the destroyed neural tissue. Total ablation of the inferior segment of the stellate ganglion and the T1-T2, nerve roots by excimer laser required 83±1 Joules over an exposure period of 118 seconds. Ablation by CO2, and Nd:YAG laser required 153±13 Joules and 554±47 Joules delivered over 11 and 6 seconds respectively. In contrast, ablation of the same volume of nerve tissue by RF required 810±50 Joules over 270 seconds. SEM evaluation revealed that excimer and CO2, laser lesions were narrower in configuration compared to RF and Nd:YAG lesions which showed more lateral spread. The actual depth of penetration per 1 second exposure was similar for Excimer and CO2, (1.5 mm) and RF (1.3 mm), but deeper for Nd:YAG (3 mm). Our data shows that excimer and CO2, laser produce discrete lesions with minimal damage to surrounding structures. It also demonstrates the safety and reliability of endoscopic denervation, particularly for bilateral denervation which can be performed in one sitting without the added morbidity of a thoracotomy incision.