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A 43-year-old man was referred to our hospital in June 2014 because of severe heart failure. He was diagnosed with familial dilated cardiomyopathy and was administered oral tolvaptan and amiodarone for atrial and ventricular tachycardia. Since up-titration of carvedilol had failed and he was dependent on dobutamine, a left ventricular assist device (LVAD) was implanted. Tolvaptan and furosemide were both discontinued after LVAD implantation and he was discharged from the hospital. Thirteen months later, he was hospitalized for lethargy and hyponatremia of 108 mEq/L, with an antidiuretic hormone level of 2.5 pg/mL, which suggested syndrome of inappropriate antidiuretic hormone secretion (SIADH). We discontinued amiodarone and administered fludrocortisones. However, hyponatremia persisted for a few more days, eventually resulting in delirium and damage to the LVAD driveline. He received an urgent pump exchange and hyponatremia was gradually improved. We considered the possibility that amiodarone-induced SIADH was masked by tolvaptan therapy before LVAD implantation.

We report a case of concomitant carotid endarterectomy(CEA)and aortic valve replacement(AVR)for symptomatic severe carotid artery and aortic valve stenosis(AS). A 77-year-old man, presented to our hospital with AS complicated by right internal carotid artery(ICA)stenosis and left ICA occlusion, seeking treatment for AS. He suffered from left hemiparesis, and diffusion-weighted magnetic resonance imaging(MRI)showed multiple ischemic lesions in the right cerebral hemisphere. He was admitted to our neurosurgical department and received treatment for acute cerebral infarction caused by severe right ICA stenosis. The symptomatic severe right ICA stenosis was an indication for surgical treatment, but simple carotid revascularization of the stenosed ICA was considered to be deteriorated the cardiac function due to untreated AS. Thus, we decided to perform concomitant carotid and valvular surgery. The patient underwent a combined CEA and AVR procedure with the introduction of an intraoperative intra-aortic balloon pump. His postoperative course was uneventful even 12 months after the surgery. Management and surgical strategies for patients with concomitant ICA stenosis and AS continue to be controversial subjects. Combined carotid and cardiac valve surgery is considered to be effective in such cases, and we discuss its implications and review of literature.

Transcatheter aortic valve implantation is a recent innovation in the treatment of severe aortic stenosis. On the other hand, several reports suggested that minimally invasive aortic valve replacement (MICS-AVR) is likely to be associated with reduced postoperative discomfort and faster recovery. Of note, an upper partial sternotomy for isolated aortic valve replacement( L-shaped MICS-AVR) has been accepted as the most common approach to the MICS-AVR. Since October 2013, we have preformed L-shaped MICS-AVR at our hospital. In L-shaped MICS-AVR group(16 patients, 74.4±8.7 years),there was no operative mortality and any other complication including reexploration for postoperative bleeding, wound infection, peri-valvular leakage, pulmonary complication like re-intubation or minitracheostomy. To demonstrate the benefits of this approach, over-octogenarian subgroup( n=7)was analyzed and compared with the isolated AVR using a conventional sternotomy (C-AVR, n=10)in the same period. A trend was seen toward better postoperative course in the L-shaped MICS-AVR group than in the C-AVR group;however, this difference was not statistically significant. The mean duration of cardiopulmonary bypass(120±29 min vs 93±24 min, p=0.005)and cross clamp time(151±36 min vs 124±32 min, p=0.038)were significantly longer than C-AVR. We believe that more clinical experience is required to clarify the benefits of this approach and we must more consider the preoperative images for the attainment of the excellent exposure. Moreover, the concomitant use of this new device and L-shaped MICS-AVR may enable a big improvement in the future.

Background A traumatic sternal fracture with extensive mediastinal abscess and concomitant native valve endocarditis is an extremely rare but catastrophic situation. Case presentation For 2 weeks, the co-infected patient was treated with aggressive debridement for the mediastinitis, change of vacuum-assisted closure therapy dressings, vegetectomy and valve repair through lower partial sternotomy, and delayed primary wound closure. Conclusions To the best of our knowledge, this successful staged strategy has not been previously reported. We believe that our quick decision about repeated surgical interventions and preservation of the manubrium led to a favorable result.

We describe a case of a 41-year-old woman with acute exacerbation of chronic thromboembolic pulmonary hypertension (CTEPH) complicated by rapidly progressive respiratory failure and right heart failure with cardiogenic shock. A computed tomography (CT) showed thrombi in the right main pulmonary artery and bilateral peripheral pulmonary arteries, and echocardiography showed right ventricular dilatation and tricuspid regurgitation, with an estimated pressure gradient of 80 mmHg. The patient was initially diagnosed with acute pulmonary thromboembolism, and thrombolytic therapy was administered. Her condition subsequently deteriorated, however, necessitating mechanical ventilation and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We performed emergency catheter-directed thrombectomy and thrombus aspiration. Pulmonary hypertension (PH) temporarily improved, but subsequently worsened, and the patient was diagnosed with CTEPH. Pulmonary endarterectomy (PEA) was performed. After PEA, we were unable to wean the patient off VA-ECMO, and rescue balloon pulmonary angioplasty (BPA) to the middle and inferior lobe branches of the right lung was performed. Five days after BPA, the patient was removed from VA-ECMO and on the 57th day of hospitalization, she was weaned off the ventilator. The patient was discharged after 139 days of hospitalization. Rescue BPA represents a useful intervention for improving PH and weaning off VA-ECMO in a patient with acute exacerbation of CTEPH.

Treatment of infective endocarditis (IE) associated with aortic annular destruction remains a formidable surgical challenge. Discussions about the optimum modality for reconstruction are still continuing. In such severe endocarditis, we have performed aortic root replacement using the Freestyle stentless bioprosthesis with the full root technique. From 2005 through 2012, 11 patients who had aortic valve endocarditis with annular destruction underwent aortic root replacement at our institute. All of them were treated with the Freestyle stentless bioprosthesis. Their mean age was 69.9 years, and 8 patients were men. Two patients had native valve endocarditis and 9 patients had prosthetic valve endocarditis. Despite appropriate antibiotic therapy, 3 patients required emergency surgery because of hemodynamic deterioration. In-hospital death occurred in 1 patient due to progressive hemodynamic failure. The 10 hospital survivors were followed up for a mean of 27.7±23.1 months (range 5 to 82). Although late death occurred in 2 patients, recurrent IE was not observed in any patients during the follow-up. The results of our study suggest that the Freestyle stentless bioprosthesis could be an excellent alternative to a homograft in the treatment of infective endocarditis associated with aortic annular destruction.

Primary cardiac angiosarcoma is very rare with an incidence of 0.0017∼0.19% in collected autopsy series, and its prognosis has been reported as being extremely poor( average survival of 6∼9 months). A 56-year-old man was referred to our hospital with cardiac tamponade caused by right atrial angiosarcoma, after initially being misdiagnosed as acute type A dissection. Echocardiography and chest computed tomography (CT) revealed a pedunculated tumor with a broad base which was originating from the right atrial wall and extended into atrio-ventricular (AV) groove. The tumor was completely resected, and a bovine pericardium patch was used for cardiac reconstruction. Histological examination showed angiosarcoma and a sign of radical excision. The patient, who made an uneventful recovery,was given postoperative radiotherapy and chemotherapy. He died of multiple systemic metastases 14 months postoperatively despite of multidisciplinary treatment. We discuss the therapeutic strategies available for this highly malignant cardiac tumor.

A 51-year-old man, who had undergone aortic valve replacement with a mechanical valve 30 years ago, was referred to our hospital due to acute type A aortic dissection. Pre- and intra-operative echocardiographic evaluation showed no evidence of valve dysfunction or paravalvular leak. Intraoperative inspection revealed a thin pannus covering the leaflet housing of the mechanical valve, which we easily removed. We performed aortic root replacement while leaving the valve in situ, and total aortic arch replacement using elephant trunk technique under hypothermic circulatory arrest. He was discharged from the hospital 31 days after operation and retains normal valve function. For patients with aneurysms and acute type A aortic dissection having aortic valve prosthesis that does not require replacement, the completion Bentall procedure is a more secure and safer repair than complete aortic root reconstruction.

The successful surgical repair of an uncommon case of blunt chest trauma is described. A 28-year-old man was involved in a motorcycle accident during which the victim struck a pole at high speed. Extracorporeal membrane oxygenation was required with a tentative diagnosis of traumatic respiratory distress syndrome, but he nevertheless continued to show progressive deterioration. In the preoperative evaluation, transesophageal echocardiography clearly demonstrated an injury involving of mitral regurgitation secondary to total rupture of a papillary muscle. Mitral valve replacement was performed seven days after the accident. The importance of the diagnostic process and surgical treatment are emphasised.

This paper presents two cases of mediastinal schwannoma originating from the intrathoracic vagal nerve together with a review of 65 cases given detailed explanations in the Japanese literature. The first case: A 48-year-old man was admitted to the hospital because of an abnormal shadow in a chest X-ray film. Under a diagnosis of left mediastinal tumor, an operation was carried out. The tumor and string attached to the tumor were resected en bloc through a thoracotomy. Pathological diagnosis was schwannoma. Left recurrent nerve paralysis was evident by postoperative horseness. We thought that the tumor was a schwannoma arising from the vagal nerve proximal to the origin of the recurrent nerve. The second case: A 51-year-old woman was admitted to the hospital because of an abnormal shadow in a chest X-ray film. From a CT scan and a MRI we diagnosed preoperatively that the tumor arose from the vagal nerve distal to the origin of the recurrent nerve. Thoracoscopic surgery was performed. The tumor was resected with transection of the vagal nerve. Pathological diagnosis was schwannoma. The postoperative course was uneventful. Mediastinal schwannoma originating from the intrathoracic vagal nerve presents difficulty in preoperative diagnosis. Although it uncommonly appears, some malignant cases have been reported and hence complete resection is desirable. However, we have to consider treatments which differ from case to case in terms of postoperative complications.

症例は52歳, 男性である. 左内胸動脈瘤を合併した狭心症に対し, 動脈瘤の切除と内胸動脈再建, 前下行枝に右内胸動脈にて一枝バイパスを行った. 瘤は動脈硬化性であった. 内胸動脈瘤の発生はまれで, これまでの7例の文献報告によると von Recklinghausen 病や川崎病などが病因となり, 若年女性に多く発生している. また, 破裂が2例ある. 手術は瘤切除が主体で, 血行再建の報告はない. 本症例は非常に興味あるもので, 症例を呈示するとともに文献を集計して考察する.

症例は38歳, 男性である. TAPVR (Darling Ia 型) による急性心不全で緊急入院した. 肺静脈レベル (垂直静脈は短頸, 肺静脈閉塞なし), 心房レベル (ASDは28×24mm) に還流障害はなく肺血流増多であった. 根治手術は上方経路で行い, 術後3カ月目の心臓カテーテル検査で吻合部狭窄の所見はなかった. 心臓の脱転や両心房切開を行わない上方経路は視野も良く, 自然な位置での左房・総肺静脈吻合が可能である. また, 長期生存の最大の要因として肺血管抵抗の上昇がなかったことが考えられた.

90歳以上の開心術を2例経験したので報告する.症例1は90歳8ヵ月の男性で,大動脈閉鎖不全症(AR)III度を伴う60mmのroot aneurysmに対して,Bentall変法(Carrel patch法)による大動脈基部置換術を行った.症例2は91歳7ヵ月の男性で,大動脈弁狭窄症(AS)とSeg.12の90%狭窄に対して大動脈弁置換術(AVR)(CEP® 21mm)と冠動脈バイパス術(CABG)(LITA-Seg.12)を行った.2症例とも術後経過良好で術後3～4週目に退院,術前同様の日常生活に復帰した.90歳以上の超高齢者に対しても暦年齢のみでなく,生活状態,活動性の高さ,本人の意思,家族の希望に留意して手術適応を判断すれば心臓手術は有効であり,術後もQOLを維持できる.

生後5日目の女児,アプガー8点,34週,体重3,460gで出生した.生後2日目より多呼吸,心室性期外収縮,発熱のため当院に紹介入院となった.心エコーと胸部CTにて巨大な腫瘍と多量の心嚢液が心臓を圧迫し,心タンポナーデを呈していた.人工心肺stand-by下で腫瘍を完全に摘出した.腫瘍は上行大動脈から発生し,骨,気管上皮,唾液腺,中枢神経などを有するmature teratomaであった.AFPは術前25,910ng/mlから退院時630ng/ml,さらに現在1.5歳で6.7ng/mlと正常化し,再発傾向もない.心嚢内奇形腫は新生児心臓腫瘍のなかでもまれなもので,かつ進行性の呼吸循環不全に陥るため,救命には早期診断と早期手術が重要である.

We designed a study to evaluate three factors (siphon gradient [PH], the right atrial pressure [RAP], and the inferior vena caval flow [IVCF]) to be optimized to maximize the venous drainage flow (DF) during partial cardiopulmonary bypass using eight venous cannulas of three different types and an original model circuit. The relationship between venous DF and the three factors is indicated by the multiple regression equation DF2 = alpha PH + beta RAP + gamma IVCF2 + C, where alpha, beta, and gamma are regression estimates and C is a constant. Multiple regression analysis results showed that DF was positively correlated with PH and RAP and negatively correlated with IVCF. A long cannula with 12 side holes and 60 cm long was considered to be useful to yield the optimal venous drainage flow under the condition of maintenance of the flow balance (DF and ICVF) and the pressure balance (RAP and IVCP) at the zero point. Moreover, this model may allow extensive research in flow dynamics of venous cannula without involving human subjects.

冠動静脈瘻の中枢側の動脈は, 瘤状に拡大し破裂予防のため手術が行われることがあるが, その破裂例の報告は少ない. 今回, 冠動静脈瘻破裂により心タンポナーデをきたした症例に対し, 緊急手術を施行し救命しえた一例を経験したので報告する. 瘤状拡大を示す冠動静脈瘻は, 破裂の予防のためにも積極的に手術をすすめるべきである.

症例1は29歳, 男性. MVR5カ月後に, 心筋保護針の留置部から仮性動脈瘤が発生した. 超低体温循環停止下に自作のダブルバルンを用いて人工血管で閉鎖した. 症例2は79歳, 男性. 右大動脈弓を合併した遠位弓部大動脈瘤破裂で遠位弓部置換を行った. 術後4カ月, 中枢吻合部に仮性動脈瘤が発生した. ハイリスクのためコイル塞栓を試みたが, entry が大きく血栓化は不成功で, 破裂死亡した. 2例とも胸骨正中創のMRSA感染が関連していた. 上行大動脈の仮性瘤は手術が最良であるが, 手術不能例に対するコイル塞栓は課題を残した. Entry が拡大しない時期に早急に行うべきであると思われる.

In a 56-year-old man under the treatment of gastric ulcer with anemia, a submucosal tumor in the posterior wall of the middle portion of gastric corpus was accidentally found by upper gastrointestinal series and gastroendoscopy. Abdominal CT and unltrasonography revealed a solid mass about 7 cm in diameter, locating in front of the pancreas and presenting as extragastrical growth. An extragastrically growing leiomyosarcoma was strongly suspected preoperatively. On laparotomy, an egg-size tumor was found to be arising from the posterior wall of the corpus of the stomach. The mass was pedunculated and encapsulated with no evidence of invasion into the surrounding organs. No hepatic metastasis nor peritoneal dissemination was found. Subtotal gastrectomy with dissection of regional lymphnodes (R1) was performed. The resected mass measured 7.5×6.2×4.2 cm in size and lobulated with partial cystic degeneration.Pedunculated gastric leiomyomas growing extragastrically behave specifically and differently from those presenting as other growth patterns. Here we describe a case and discuss its clinicopathological features and some problems in the surgical treatment.

肺全摘後の食道胸腔瘻はきわめて稀な合併症であり, いったん発症すれば難治性で死亡率が高い.われわれは左肺全摘後2ヵ月後に食道胸腔瘻を生じた72歳の男性肺癌患者に対し, 有茎大網を用いた一期的手術を行なった.しかし, 瘻孔の再発を認め, 満足すべき結果が得られなかった。胸部外科手術領域における難治性部位の被覆充填材料として有茎大網の利用頻度が増加しているが, 肺全摘後の食道胸腔瘻に対する外科的治療法としては今後十分な検討が必要と思われた.

Pure red cell aplaisa (PRCA) is a rare, refractory atuo-immune disease, and produces chronic progressive anemia because of a failure of erythropoiesis. Half the patients with PRCA are associated with thymoma. Thymomectomy or thymectomy is not sufficient to restore the hemopoiesis in this disease. Steroid therapy is thought to be the most useful treatment for PRCA, but the effective dosage of steroids is controversial. We reviewed cases of PRCA from the viewpoint of sterioid therapy, including these 2 cases (one died of post-trasfusion hepatitis, and the another died of penumonia due to massive steroid dosage). As a result, conventional steroid dosage (

Open heart surgery in nonagenarians is not common. We reported a successful Bentall operation in a 90-year-old man with aortic root aneurysm and aortic regurgitation. He has lived healthfully and independently without a big problem. He was referred to our hospital for acute heart failure. The aortic root enlarged as a diameter of 60 mm and moderate aortic regurgitation were recognized by echocardiography and aortogram. We excised the aneurysm, implanted a composite graft, directly attached the coronary arteries to the aortic graft (Carrel patch technique), and made the distal anastomosis to the divided aorta. Postoperative course was uneventful. To our knowledge, this is the first successful case of Bentall operation for nonagenarians in Japan. If selective criteria identifying risks and benefits for individual patients is applied, the nonagenarian can safely undergo cardiac surgery.

The vasodilating and anti-platelet actions of OP-41483 was studied to determine the effective dose of this drug for the treatment of ischemic lower limbs. The compound was given to 11 patients intravenously at rates of 2.5, 5.0 and 10.0 ng/kg/min. Infusion at a rate of 10 ng/kg/min increased the mean flow rate of the tibial arteries from 3.15 +/- 1.77 ml/min before the infusion, to 7.89 +/- 2.51 ml/min (p less than 0.001) and to 6.38 +/- 3.19 ml/min (p less than 0.001), at the time of, and 60 minutes after the cessation of the infusion, respectively. The peripheral flow resistance of the tibial arteries was reduced from 2.1 +/- 1.12 X 10(5) dyne.sec/cm5 before the infusion to 0.9 +/- 0.33 X 10(5) dyne.sec/cm5 (p less than 0.001) and to 1.2 +/- 0.78 X 10(5) dyne.sec/cm5 (p less than 0.05), at the time of, and 60 minutes after the cessation of the infusion. ADP-induced platelet aggregation was reduced from 73.3 +/- 17.6% before the infusion to 50.7 +/- 24.5% (p less than 0.01) and to 64.0 +/- 23.5% (p less than 0.05), at the time of, and 60 minutes after the cessation of the infusion, respectively. Collagen-induced platelet aggregation was also reduced from 71.4 +/- 24.0% to 66.6 +/- 21.5% before and after the infusion (p less than 0.05).