Successful Percutaneous Thoracic Duct Embolization for Chylothorax After Total Arch Replacement.

Chylothorax after cardiac surgery is a rare complication associated with severe morbidity and mortality. This report documents successful treatment with percutaneous thoracic duct embolization for chylothorax after total arch replacement. A 69-year-old man underwent replacement of the aortic arch to treat a ruptured aortic aneurysm. After surgery, the left thoracic drain discharged 2,000 to 3,000 mL serosanguineous fluid per day, even though the patient took nothing orally and was administered subcutaneous octreotide therapy. On postoperative day 9, percutaneous thoracic duct embolization was performed, and the drain could be removed. The chylothorax did not recur, and the patient was discharged on postoperative day 17.

Intraoperative Type B Aortic Dissection during Total Arch Replacement.

BACKGROUND: Intraoperative aortic dissection is an extremely serious complication that should be prevented whenever possible. When it does occur, it requires urgent clinical management. CASE PRESENTATION: We report the case of a 78-year-old man with Marfan syndrome who developed an intraoperative complicated type B aortic dissection with a distal anastomosis entry site during total arch replacement for a chronic dissection. CONCLUSION: Performing immediate thoracic endovascular aortic repair, we were able to improve malperfusion to the lower extremities occurred during total arch replacement.

A case of right ventricular infarction due to acute type A aortic dissection with anomalous aortic origin of the right coronary artery from the left sinus of Valsalva.

Anomalous aortic origin of a coronary artery from the opposite sinus is a rare congenital condition that can cause sudden death in young people. When it is associated with acute aortic dissection, acute myocardial infarction can occur due to enlargement of the sinus of Valsalva. We report the case of a 71-year-old man with anomalous origin of the right coronary artery from the left sinus of Valsalva, who developed right ventricular infarction due to the compression of the right coronary artery between the aorta and pulmonary artery trunk.

[Mitral Valve Repair via Right Thoracotomy Thirty-seven Years after Right Pneumonectomy:Report of a Case].

A 57-year-old man was referred to our hospital due to dyspnea on exertion with severe mitral regurgitation. Because he had underdone right pneumonectomy 37 years earlier due to congenital defect of the right pulmonary artery, his mediastinum was severely shifted to the right, and his pulmonary function was poor. Mitral valve repair was successfully performed with right thoracotomy approach, which made excellent exposure of the mitral valve. The patient was extubated three hours after the surgery. He was discharged on the 30th postoperative day without postoperative respiratory complications. With an appropriate plan of the surgery and postoperative optimal management, cardiac surgery can be performed on patients with a single lung.

[Further Surgery for Mitral Stenosis 12-years after Mitral Valve Repair;Report of a Case].

A rare case of mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation is presented. An 81-year-old woman who had undergone mitral valve repair using an annuloplasty ring 12 years earlier, was referred to our hospital because of dyspnea during exertion. As echocardiography revealed severe mitral stenosis, and redo surgery was carried out. During the surgery, fibrous tissue covered the annuloplasty ring and extended onto both leaflets of the mitral valve, which narrowed its orifice, by rendering the leaflets stiff and immobile. It was not possible to remove the fibrous tissue covering the mitral valve without damaging the leaflets. Hence, the annuloplasty ring and both leaflets were excised. The mitral valve was replaced with a 27 mm Magna Mitral Ease, and subsequently, postoperative course was uneventful.

Surgical embolectomy for high-risk acute pulmonary embolism is standard therapy.

OBJECTIVES: Acute massive pulmonary embolism (AMPE) is a life-threatening condition that often induces rapid haemodynamic deterioration. The mortality of surgical embolectomy is still poor in patients with preoperative cardiopulmonary arrest (CPA). We analysed the outcome of surgical pulmonary embolectomy for haemodynamically unstable patients. METHODS: Thirty-one patients underwent surgical embolectomy for haemodynamically unstable AMPE. The indications for surgical embolectomy were (i) <7 days from onset, (ii) haemodynamically unstable, (iii) massive clots in bilateral pulmonary arteries or unilateral pulmonary artery occlusion with a floating clot in the main pulmonary artery or right atrium and (iv) right ventricular dilatation in transthoracic echocardiography. Eight (25.8%) patients had cardiopulmonary arrest. Nine (29.0%) patients received preoperative percutaneous cardiopulmonary support (PCPS). The mean original Pulmonary Embolism Severity Index (PESI) and simplified PESI scores were 158 ± 51 and 2.4 ± 0.9, respectively. RESULTS: The hospital mortality rate was 12.9% (n = 4). Two patients died of hypoxia. Multiorgan failure occurred by sepsis and by right ventricular failure in 1 patient each. No hospital deaths occurred in patients with preoperative PCPS (n = 9). The mean follow-up period was 47.7 ± 35.9 months (range, 3 - 134 months) and the 5-year survival rate was 83.2 ± 6.9%. Postoperative pulmonary artery pressure significantly decreased from 52.7 to 25.8 mmHg. CONCLUSIONS: Surgical embolectomy for high-risk AMPE patients has an excellent operative mortality and long-term outcome. Preoperative PCPS may lead to an immediate stable haemodynamic state and improve surgical embolectomy results, especially in high-risk patients (e.g. those with preoperative CPA). Surgical embolectomy for AMPE is an established operation and considered as the first-line therapy.

[Primary Cardiac Angiosarcoma with Superior Vena Cava Syndrome].

Primary cardiac angiosarcoma is rare and its prognosis very poor. A 34-year-old woman complained of facial edema and dyspnea. Echocardiography, chest computed tomography scan and chest magnetic resonance imaging showed a huge tumor arising in the right atrium. Surgical excision of the tumor was performed for the purpose of relieving superior vena cava syndrome and making diagnosis of the tumor. The right atrial wall, including the tumor, was resected and reconstructed with Gore Tex patch under cardiopulmonary bypass. The tumor was diagnosed as angiosarcoma. Doxorubicin hydrochloride/ifosfamide were used to treat postoperative cardiac recurrence and lung metastasis. These drugs were effective to a certain degree, but she died of brain metastasis of the tumor in the 14th postoperative month.

[Ascending aorta-abdominal aorta bypass for atypical coarctation with intractable hypertension due to aortitis syndrome; report of a case].

A 63-year-old woman was admitted to our hospital. Aortitis syndrome was diagnosed 12 years ago. She developed intractable hypertension and a computed tomography scan showed coarctation of descending aorta with severe calcificaiton. Her ankle brachial pressure index (ABI) was 0.74 on the right side and was 0.70 on the left side. She underwent a bypass operation with 14 mm-diameter prosthetic graft from ascending aorta to the infrarenal abdominal aorta without using cardiopulmonary bypass. Postoperatively, ABI was 1.22 on the right side and was 1.21 on the left side, and hypertension was well controlled.

[Beating mitral valve surgery in patients with poor left ventricular function].

Mitral valve surgery is usually performed under the arrested heart condition. However, cardioplegic arrest techniques will inevitably produce some degree of reperfusion injury. We expected that keeping heart beating decrease the reperfusion injury in patients with poor left ventricular function. The present study compared the results of beating heart technique and conventional mitral valve surgery to demonstrate the merit of this technique. Thirty six patients with low left ventricular function[ ejection fraction (EF)≤35%] who underwent mitral valve surgery between April 2004 and July 2012 were enrolled in this study. On-pump beating mitral valve surgery were performed in 21 patients (beating group). Fifteen patients underwent conventional mitral valve surgery with cardiac arrest using blood cardioplegia (arrest group). Postoperative cardiac events in the beating group were less than that in the arrest group. However, this difference in both groups was not statistically significant. The visual field of the beating heart was equal to that of conventional surgery, and technical accuracy was not compromised. To decrease postoperative cardiac events, beating-heart mitral valve surgery may be suitable surgical option for patients with poor left ventricular function.

[Two-staged hybrid surgery for an extended thoracic aortic aneurysm with Komerell's diverticulum].

We have successfully performed 2 staged hybrid operation for an extended thoracic aortic aneurysm with Komerell diverticulum, which lessened surgical stress of the patient with avoidance of postoperative complications. An 82-year-old man who had been under observation for thoracic aortic aneurysm was admitted to the hospital with continuous chest discomfort. The patient initially underwent graft replacement for an ascending and arch aneurysm by using the elephant trunk technique. Thirty-five days later, he underwent endovascular repair for the residual descending thoracic aneurysm. The postoperative course was uneventful, and postoperative computed tomography (CT) revealed no stent migration and just a little type II endoleak. This 2 staged hybrid approach might be less invasive than the conventional approach, and be a potential therapeutic option for high risk patients with an extended thoracic aortic aneurysm.

[Total aortic arch replacement in Stanford type A aortic dissection using a new method of implanting the stented graft].

In surgery for Stanford type A aortic dissection (SAAD) with intimal tear in the arch or proximal descending aorta, we performed total arch replacement with frozen elephant trunk technique for the purpose of achieving complete exclusion of the entry. To reduce the circulatory arrest time, we developed a quick stent graft placement method in the proximal descending aorta. We reported the early results and assessed the efficacy of our new method. Between March 2006 and February 2010, 52 consecutive patients with SAAD were divided into 2 groups:group A consisted of 17 patients who received total arch replacement with our new method;group B consisted of 35 patients who received ascending aorta or partial arch replacement. The duration of operation and cardiopulmonary bypass were significantly longer in group A. However, the duration of circulatory arrest time and postoperative factors including hospital mortality did not differ in both groups. In group A, thrombus obliteration of the residual false lumen in the descending aorta was observed in 75% at 19.2±13.1 months postoperatively. Shrinkage of false lumen in the aortic arch occurred in 15 patients( 93.8%). There was no reoperation for the residual false lumen and late death. Total aortic arch replacement with our new method for SAAD is technically feasible without increasing the operative risk and might reduce the necessity for further operations.

Adult patent ductus arteriosus: successful surgery with mitral valvuloplasty.

The development of left ventricular dysfunction is a serious complication of longstanding patent ductus arteriosus. An 80-year-old woman who underwent patent ductus arteriosus ligation 13 years previously developed congestive heart failure and mitral regurgitation. She underwent surgical repair with transpulmonary ductus closure and mitral valve annuloplasty under cardiopulmonary bypass. She made a full recovery with improved left ventricular function.