Fifteen-year survival of a hepatocellular carcinoma extending into the right atrium treated by surgical resection with the heart-first approach under cardiopulmonary bypass: a case report and review of the literature.

Hepatocellular carcinoma with tumor thrombus in the inferior vena cava extending into the right atrium is rare and associated with poor prognosis in most cases. Although liver resection with thrombectomy is the only curative treatment, there is no consensus on the therapeutic options for managing these rare cases. The patient was a 67-year-old man with hepatocellular carcinoma with tumor thrombus in the right atrium. In February 2003, cavo-atrial thrombectomy was first performed using cardiopulmonary bypass with heparinization and cardiac arrest. After thrombectomy, right hepatectomy was performed. The total operative time was 10 h 48 min. Moreover, the total blood loss was 7267 mL. The patient recovered uneventfully except for right pleural effusion. He was cancer-free for approximately 9 years. A new lesion in the remnant liver was detected in March 2012. He underwent transcatheter arterial chemoembolization, followed by sequential administration of sorafenib and sunitinib. Radiation therapy was also administered. Eventually, the patient expired 6 years after recurrence. Cavo-atrial thrombectomy under cardiopulmonary bypass prior to hepatectomy for hepatocellular carcinoma with tumor thrombus in the right atrium could be performed safely. Aggressive surgery with the heart-first approach and multidisciplinary treatments even after recurrence led to long-term survival.

[Coronary-pulmonary Artery Fistula Manifested by Cardiac Tamponade;Report of a Case].

Coronary-pulmonary artery fistula( CPAF) is a relatively rare congenital malformation. We successfully treated a patient who presented with cardiac tamponade due to ruptured CPAF. A 58-year-old woman was admitted to our hospital due to consciousness disorder. Enhanced computed tomography revealed hemopericardium, and she was diagnosed with cardiac tamponade due to a ruptured coronary artery aneurysm with fistula arising from the right coronary and entering the main pulmonary artery. Therefore, emergency operation was performed. Under cardiopulmonary bypass, the aneurysm was opened and the ostium of the fistula was closed with pledgetted mattress sutures. After ligating the tortuous CPAF, the aneurysmal wall was sutured. Postoperative course was uneventful, and she was discharged on postoperative day 16.

[Early and Mid-term Outcomes of Surgical Treatment with Conservative Approach Using Adventitial Inversion Technique for an Acute Type A Aortic Dissection].

OBJECTIVE: This study was performed to assess the early and mid-term outcomes of surgical treatment with adventitial inversion technique for an acute type A aortic dissection. METHODS: From June 2008 to June 2015, 48 patients underwent emergent surgery for acute type A aortic dissection. Ascending aorta/hemiarch replacement was performed in 44/48(91.7%)patients, and total arch replacement in 4/48(8.3%)patients. The adventitial inversion technique was used for both proximal and distal stump constructions of the dissected aortic wall without the reinforcement of Teflon felt. Aortic regurgitation was treated with resuspention of aortic commissures. RESULTS: The operative mortality was 8.3%(4/48). There was no re-exploration in all patients. Postoperative computed tomography showed the obliteration of false lumen in aortic root in all of patients, and aortic arch and/or descending thoracic aorta in 80.9%(38/47)of patients. The actuarial survival rates at 5 years were 74.7%.The freedom from aortic or aortic valve event rate and reoperation rate at 5 year were 90.9% and 95.2%, respectively. CONCLUSION: The adventitial inversion technique provides excellent early and mid-term outcomes for the repair of acute type A aortic dissection.

A Case of External Compression of Femoral Vein by the Enlarged Iliopsoas Bursa with Long Term Edema.

The iliopsoas bursa is the largest bursa in the region of hip joint. It is unusual that these bursa become symptomatic. However the bursa can compress femoral vein, leading to lower extremity edema. A 58-year-old man was referred to our department for his unilateral leg edema which had been treated as deep vein thrombosis without any favorable response. Magnetic resonance angiography was performed, which demonstrated enlarged iliopsoas bursa compressing his femoral vein. Surgical removal of the bursa was performed. The postoperative course was uneventful, and the patient is free from symptoms with no evidence of recurrence.

Successful surgical exclusion of rapidly expanding kommerell diverticulum following a total arch replacement for an acute type a aortic dissection.

A 50-year-old man presented with an acute type A aortic dissection with an aberrant right subclavian artery. Emergent total arch replacement with an elephant trunk was performed. Intraoperatively, the origin of the aberrant right subclavian artery could not be resected because it was located too far from the distal arch. After two weeks, the patient became aware of dysphagia. Postoperative computed tomography showed the esophagus was compressed anteriorly by the aneurismal origin of this aberrant vessel (Kommerell diverticulum) with a patent false lumen. Additional replacement of the descending aorta via left thoracotomy was performed immediately to exclude a Kommerell diverticulum.

Nafamostat mesilate, as a treatment for heparin resistance, is not associated with perioperative ischemic stroke in patients undergoing cardiac surgery with cardiopulmonary bypass.

OBJECTIVE: Nafamostat mesilate, a short-acting protease inhibitor, treats heparin resistance during cardiopulmonary bypass. This study tested whether nafamostat mesilate is associated with perioperative ischemic stroke. DESIGN: A retrospective observational study. PARTICIPANTS: A total of 870 adult cardiac surgery patients. INTERVENTION: The authors retrospectively identified the patients who received nafamostat mesilate and who suffered symptomatic ischemic stroke within 30 postoperative days. MEASUREMENTS AND MAIN RESULTS: The authors evaluated perioperative patient characteristics in association with perioperative ischemic stroke and death. The patients were identified as heparin resistant if they had an activated coagulation time of <480 seconds after the administration of heparin at 400 to 500 U/kg. Heparin-resistant patients received a 10- to 20-mg bolus plus 25 to 50 mg/h of nafamostat mesilate and heparin at 100 U/kg intravenously every 1.5 to 2.0 hours to maintain an activated coagulation time over 480 seconds. Of the 870 patients, 11 (1.3%) suffered a perioperative ischemic stroke. Of the 190 (21.8%) patients who received nafamostat mesilate, 1 (0.5%) suffered ischemic stroke compared with 10 (1.5%) in 680 patients without nafamostat mesilate (Fisher exact test; p = 0.47; regression analysis; odds ratio, 0.35; 95% confidence interval, 0.45-2.8; p = 0.32); 3 (1.6%) patients with nafamostat mesilate died postoperatively within 30 days compared with 11 (1.6%) without nafamostat mesilate (Fisher exact test; p > 0.99, regression analysis; odds ratio, 0.98; 95% confidence interval, 0.27-3.5; p = 0.97). CONCLUSIONS: No evidence was found that nafamostat mesilate was associated with perioperative ischemic stroke in heparin-resistant patients undergoing cardiac surgery with cardiopulmonary bypass.

Effects of nafamostat mesilate on coagulopathy with chronic aortic dissection.

A 65-year-old man with chronic aortic dissection experienced two massive subcutaneous hemorrhages. Laboratory data indicated disseminated intravascular coagulation, whereas a contrast computed tomographic scan revealed a dilatated aortic arch with a partial thrombosis at the false lumen. Because disseminated intravascular coagulation can be caused by chronic aortic dissection, and the aortic arch was 6 cm in diameter, we performed graft replacement from the ascending to the descending aorta in a single stage. Before graft replacement, nafamostat mesilate, a protease inhibitor, was administered and the disseminated intravascular coagulation improved. Nafamostat mesilate may be useful for managing disseminated intravascular coagulation associated with chronic aortic dissection.

Perforation of a tricuspid pouch caused by infective endocarditis.

A 61-year-old man was admitted because of infective endocarditis. Echocardiography revealed the bicuspid aortic valve and a tricuspid pouch bulging into the right ventricle. Color Doppler demonstrated mild aortic regurgitation and left-to-right ventricular shunt through the lower part of the pouch. We successfully performed an aortic valve replacement and closed the interventricular communication. Infective endocarditis of the bicuspid aortic valve appeared to have caused left-to-right ventricular communication at the lower part of the tricuspid pouch.

Combined coronary and femoral revascularization for the treatment of hypoplastic aortoiliac syndrome: report of a case.

The coronary artery and aortoiliac occlusive disease frequently coexist and in relatively rare instances, a complication of hypoplastic aortoiliac syndrome (HAIS) may occur. We herein present our experience with a 51-year-old female patient with HAIS and concomitant coronary artery disease. She underwent a successful simultaneous coronary and femoral revascularization. The left anterior descending artery was bypassed with the in situ gastroepiploic artery and a biaorto-external iliac artery bypass was performed with expanded polytetrafluoroethylene precuffed grafts. She had a good postoperative course, with no angina or intermittent claudication. The importance of the technical aspects of reconstructive surgery in patients with HAIS has been emphasized in many reports in the literature, and the surgical options for combined coronary and femoral revascularization are also discussed herein.

Papillary muscle sling and overlapping cardiac volume reduction with aortic valve replacement for valvular cardiomyopathy.

A 63-year-old male was admitted to our hospital because of severe aortic regurgitation. The left ventricle was extremely dilated and mild functional mitral regurgitation was detected because of outward displacement of papillary muscles. We used a papillary muscle sling with aortic valve replacement to correct the widened distance between the papillary muscles. A papillary muscle sling when used for reducing tethering at the mitral valve also reduces the posterior left ventricular volume. As well, a transmural longitudinal incision along the left anterior descending artery in the left ventricular free wall was sutured by an overlapping method to reduce the anterior left ventricular volume. The combination of papillary muscle sling and the overlapping method does not need any resection of the cardiac muscle and so would be beneficial for end-stage valvular cardiomyopathy.

Mitral valve repair with papillary muscle sling for functional mitral regurgitation: application of double mitral ring concept in a case of ischemic cardiomyopathy and a case of idiopathic dilated cardiomyopathy.

Functional mitral regurgitation (FMR) is a common complication in patients with ischemic heart disease or idiopathic dilated cardiomyopathy (DCM). We report successful application of a papillary muscle sling (PMS) to maintain the efficacy of undersized mitral annuloplasty (MAP) in two patients with FMR. A 5-mm expanded polytetrafluoroethylene tube was placed around the trabecular base of the papillary muscles and then tightened to make a sling that banded the two papillary muscles together. In case 1, a 57-year-old woman who had experienced anterolateral myocardial infarction underwent mitral valve reconstruction with undersized MAP and PMS in addititon to coronary revascularization for chronic ischemic mitral regurgitation. In case 2, we applied the same mitral valve procedure in a 65-year-old woman with idiopathic DCM. Neither had mitral insufficiency at an intermediate follow-up.

Spontaneous innominate artery perforation presenting as hemoptysis.

An 86-year-old man with a history of asthma and hypertension suddenly developed hemoptysis. A computed tomographic (CT) scan demonstrated a right-sided paratracheal mass adjacent to the aortic arch that had not been recognized on a CT scan 5 months before. Angiography revealed extravasation of the contrast agent from the innominate artery. These findings suggested innominate artery perforation resulting in a pseudoaneurysm. At the time of operation, an approximately 3-cm defect was noted at the right side of the innominate artery. The aneurysmal cavity was inspected through the tear of the innominate artery, and there was no purulent fluid or thrombus. A prosthetic graft interposition between the origin of the innominate artery and the bifurcation of the common carotid artery and subclavian artery was performed under cardiopulmonary bypass. Histologic study of the innominate artery revealed only atherosclerotic changes. There was no evidence of infection or malignancy. The hemoptysis disappeared postoperatively.

Aortic valvular insufficiency and postductal aortic coarctation with small aorta syndrome: one-stage surgical management using extra anatomic bypass through median sternotomy.

A 30-year-old man who had undergone repair for coarctation of the thoracic aorta at age 7 and mitral valve annuloplasty at age 9 was admitted for shortness of breath and claudication of both lower legs. The pre-operative angiogram showed severe aortic regurgitation, moderate coarctation of the thoracic aorta beyond the left subclavian artery, a degree of hypoplasia of the infrarenal abdominal aorta, and total occlusion of both external iliac arteries. Aortic valve replacement, ascending-to-bilateral femoral arterial bypass, and end expanded polytetra fluoro ethylene (ePTFE) graft-to-descending aorta bypass was performed via a median sternotomy. Ascending-to-descending aortic bypass via the posterior pericardium allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.

Surgical repair of a pseudoaneurysm derived from a nine-year-old saphenous vein graft after coronary artery bypass.

A 57-year-old male presented intermittent pain between the left shoulder and neck. He had undergone coronary artery bypass twice and all grafts had been confirmed to be angiographically intact at three and a half years prior. Coronary angiography revealed that a pseudoaneurysm derived from around the proximal ascending aortic anastomosis of the saphenous vein graft that connected to the left anterior descending branch and #4-atrioventricular branch sequentially. The pseudoaneurysm compressed the saphenous vein graft itself. He underwent repair of the pseudoaneurysm through median sternotomy after left subclavian artery-saphenous vein graft bypass utilizing a free left radial artery without cardiopulmonary bypass through left anterolateral thoracotomy. A 7 mm length longitudinal tear in the saphenous vein graft near the proximal anastomosis had caused the pseudoaneurysm. This tear had likely been caused by perforation by a catheter during coronary arteriography three and a half years ago.