Outcome of massive pulmonary embolism treated only with extracorporeal membrane oxygenation and anticoagulation without thrombolytic therapy or surgical embolectomy.

INTRODUCTION: Although thrombolytic therapy is the standard treatment for massive pulmonary thromboembolism (PTE), it is often ineffective in patients with circulatory collapse. Surgical embolectomy is another treatment option, but whether it is absolutely necessary is controversial. We sought to evaluate the outcomes of patients with massive PTE treated with intensive critical care including extracorporeal membrane oxygenation (ECMO) without thrombolytic therapy or surgical embolectomy. METHODS: We analyzed 39 patients who were treated for massive PTE from January 2011 to June 2019. Massive PTE was treated with anticoagulation and hemodynamic support at an intensive care unit. ECMO was applied in patients with circulatory collapse. The computed tomography (CT) obstruction index and the ratio of the right ventricle to left ventricle short-axis diameters (RV/LV) were measured using serial CT angiography to confirm changes in pulmonary emboli and RV strain. RESULTS: Twenty-one patients were in cardiogenic shock, and 15 of them needed cardiopulmonary resuscitation (CPR). Fifteen patients were treated with ECMO and nine of them were weaned successfully. The overall in-hospital mortality was 23% (9/39). On the follow-up CT scan after 6 months, residual PTE was observed in 10 patients and their median CT obstruction index was 6.25 % (range 2.5-35). The initial mean RV/LV ratio was 1.8 ± 0.47 and the value measured at follow-up CT decreased to less than 1 (0.9 ± 0.1). CONCLUSIONS: Intensive critical care with heparin alone and timely ECMO support without thrombolytic therapy could be an effective treatment option in patients with acute massive PTE.

Thoracoscopic Bilateral Bullectomy for Simultaneously Developed Bilateral Primary Spontaneous Pneumothorax: Ipsilateral Transmediastinal versus Bilateral Sequential Approach.

Background Simultaneously developed bilateral primary spontaneous pneumothorax (BPSP) is an indication for thoracic surgery of both sides. Recently, we have reported a new technique for BPSP, which is ipsilateral apicoposterior transmediastinal (TM) bullectomy of both sides using video-assisted thoracoscopic surgery (VATS), and we compared this TM VATS with bilateral sequential (BS) VATS for BPSP. Materials and Methods From June 2003 to May 2014, 11 and 14 patients were performed VATS TM and BS bullectomy for BPSP, respectively. We reviewed the medical records and compared the clinical data between the two groups. For TM group, we first performed the right VATS bullectomy and approached through the apicoposterior mediastinal region for contralateral VATS. In the other group, conventional BS VATS bullectomy was performed in the lateral decubitus position change. Results The mean follow-up was 62.0 ± 32.6 months. No mortality and major complications were observed. The operative time (68.18 ± 24.93 vs. 96.07 ± 37.73, p = 0.046), duration of left pleural drainage (1.00 ± 0.45 vs. 3.21 ± 1.37, p = 0.000), and length of hospital stay (3.82 ± 1.54 vs. 4.93 ± 1.07, p = 0.044) were significantly shorter in the TM group than in the BS group. No significant differences were seen in duration of general anesthesia, total number of wedge resections and endostaplers used in both lungs, duration of right drainage, and postoperative recurrence. Conclusion The TM VATS approach may be a safe and feasible modality for BPSP. It may decrease the operative time, patients inconvenience such as bilateral multiple wounds and longstanding placement of chest tubes, and decrease the hospital stay compared with the BS VATS approach.

Delayed Sternal Closure Using a Vacuum-Assisted Closure System in Adult Cardiac Surgery.

Background: Delayed sternal closure (DSC) is a useful option for patients with intractable bleeding and hemodynamic instability due to prolonged cardiopulmonary bypass and a preoperative bleeding tendency. Vacuum-assisted closure (VAC) has been widely used for sternal wound problems, but only rarely for DSC, and its efficacy for mediastinal drainage immediately after cardiac surgery has not been well established. Therefore, we evaluated the usefulness of DSC using VAC in adult cardiac surgery. Methods: We analyzed 33 patients who underwent DSC using VAC from January 2017 to July 2022. After packing sterile gauze around the heart surface and great vessels, VAC was applied directly without sternal self-retaining retractors and mediastinal drain tubes. Results: Twenty-one patients (63.6%) underwent emergency surgery for conditions including type A acute aortic dissection (n=13), and 8 patients (24.2%) received postoperative extracorporeal membrane oxygenation support. Intractable bleeding (n=25) was the most common reason for an open sternum. The median duration of open sternum was 2 days (interquartile range [25th-75th pertentiles], 2-3.25 days) and 9 patients underwent VAC application more than once. The overall in-hospital mortality rate was 27.3%. Superficial wound problems occurred in 10 patients (30.3%), and there were no deep sternal wound infections. Conclusion: For patients with an open sternum, VAC alone, which is effective for mediastinal drainage and cardiac decompression, had an acceptable superficial wound infection rate and no deep sternal wound infections. In adult cardiac surgery, DSC using VAC may be useful in patients with intractable bleeding or unstable hemodynamics with myocardial edema.

Long-Term Survival after Wide Resection of Malignant Fibrous Histiocytoma of the Chest Wall.

Primary malignant fibrous histiocytoma (MFH) of the chest wall is extremely rare and is characterized by aggressive features, including a high incidence of local recurrence and distant metastasis. Surgical resection of the chest wall is the primary modality of management. However, surgical treatment is not generally recommended in patients with evidence of distant metastasis. Here, we present a case of chest wall MFH along with a schwannoma mimicking distant metastasis in the right upper arm. The patient was treated by radical en bloc resection and survived for more than 9 years without recurrence.

A laceration of left internal mammary artery caused by an amateur golfer's swing.

We report the rare case of a patient presenting with a spontaneous laceration of left internal mammary artery (LIMA) after playing golf. The patient had no specific history except for cardiac surgery, and there were no results that caused bleeding on preoperative examination. A computed tomography (CT) scan of the chest demonstrated an anterior mediastinal hematoma and a left hemothorax with active extravasation close to LIMA. Through thoracotomy, hematoma evacuation and clipping for lacerated artery were performed. The patient was discharged in stable condition on the sixteenth postoperative day. This is the first reported case of a spontaneous laceration of internal mammary artery (IMA) after playing golf.

Collaborative treatment of huge intrathoracic meningoceles associated with neurofibromatosis type 1: a case report.

BACKGROUND: An intrathoracic meningocele is a relatively rare disease, and it commonly accompanies neurofibromatosis type 1. Patients tend to have no symptom but if its size is too large and compresses a lung and neighboring organs, it needs shunt drainage or surgical resection. CASE PRESENTATION: Herein, we present the case of a 52 year-old female patient with huge intrathoracic meningoceles associated with neurofibromatosis type 1, who has complained about chest discomfort and dyspnea at rest. As for a preliminary treatment, a neurosurgeon had performed a cystoperitoneal shunt, but the symptoms continued and the size of mass and the amount of pleural effusion did not change significantly. Therefore, the huge thoracic meningoceles were successfully treated through the thoracotomic approach in combination with lumbar puncture and cerebrospinal fluid drainage. CONCLUSIONS: It is reported that double huge intrathoracic meningoceles associated with neurofibromatosis type 1 was successfully treated by a shunting procedure followed by thoracotomic resection with collaboration of a neurosurgeon.

Gene encoding prolactin in cinnamon clownfish Amphiprion melanopus and its expression upon acclimation to low salinities.

BACKGROUND: Prolactin (PRL) is a key hormone for osmoregulation in fish. Levels of PRL in the pituitary gland and plasma ion composition of clownfish seem to change to regulate their hydromineral balance during adaptation to waters of different salinities. In order to understand osmoregulatory mechanism and its association with growth performance and PRL in fish, the gene encoding PRL and its expression level in cinnamon clownfish Amphiprion melanopus upon acclimation to low salinity was analyzed. RESULTS: The PRL gene of A. melanopus encoded a protein of 212 amino acid residues comprised of a putative signal peptide of 24 amino acids and a mature protein of 188 amino acids. Analysis of growth performance under different salinities of 34, 25, 15, and 10 ppt indicated that cinnamon clownfish could survive under salinities as low as 10 ppt. A higher rate of growth was observed at the lower salinities as compared to that of 34 ppt. Upon shifting the salinity of the surrounding water from 34 ppt to 15 ppt, the level of the PRL transcripts gradually increased to reach the peak level until 24 h of acclimation at 15 ppt, but decreased back as adaptation continued to 144 h. In contrast, levels of plasma Na+, Cl-, and osmolality decreased at the initial stage (4-8 h) of acclimation at 15 pt but increased back as adaptation continued till 144 h. CONCLUSION: Cinnamon clownfish could survive under salinities as low as 10 ppt. Upon shifting the salinity of the surrounding water from 34 ppt to 15 ppt, the level of the PRL transcripts gradually increased during the initial stage of acclimation but decreased back to the normal level as adaptation continued. An opposite pattern of changes - decrease at the beginning followed by an increase - in the levels of plasma Na+, Cl-, and osmolality was found upon acclimation to low salinity. The results suggest an involvement of PRL in the processes of osmoregulation and homeostasis in A. melanopus.

Prediction of postoperative lung function in patients undergoing lung resection: dual-energy perfusion computed tomography versus perfusion scintigraphy.

OBJECTIVES: The purpose of this study was to assess the usefulness of dual-energy perfusion computed tomography (CT) for predicting postoperative lung function in patients undergoing lung resection. METHODS: Fifty-one patients (38 men, 13 women; mean age, 63.8 years) were prospectively enrolled and subsequently underwent dual-energy CT, perfusion scintigraphy, a pulmonary function test before surgery, and a pulmonary function test 6 months after surgery. Computed tomography was performed using dual-source CT with the dual-energy technique. Using weighted average images, each lobe was segmented and using perfusion images, the iodine value was quantitatively measured. Lobar perfusion was calculated by multiplying the volume of the lobe by the iodine value. The ratio of lobar perfusion per whole-lung perfusion was then calculated. The predicted postoperative forced expiratory volume during 1 second (post-FEV1) was calculated by multiplying the preoperative FEV1 by the fractional contribution of perfusion of the remaining lung. The agreement between the predicted post-FEV1 and the actual post-FEV1 was then evaluated. The percentage of error of the predicted post-FEV1 to that of the actual post-FEV1 was then calculated. RESULTS: Using the Bland-Altman method, the limits of agreement between the actual post-FEV1 and the predicted post-FEV1 were -29.3% and 26.9% for scintigraphy and -28.9% and 17.3% for CT. The percentage of error of CT (15.4%) was comparable with that of scintigraphy (17.8%). CONCLUSIONS: Dual-energy perfusion CT was more accurate than perfusion scintigraphy was for predicting postoperative lung function.

Effects of pneumoperitoneum and position changes on blood pressure variability and heart rate variability during laparoscopy-assisted vaginal hysterectomy.

BACKGROUND: This study was designed to assess the effects of pneumoperitoneum and positional changes on the autonomic nervous system (ANS) in laparoscopy-assisted vaginal hysterectomy (LAVH) patients. METHODS: Systolic blood pressures and R-R interval were recorded for 5 minutes in 22 patients, and then power spectral analyses were conducted to evaluate the ANS. The following variables were measured at various positions: preinduction (BASE), prepneumoperitoneum (PREPP), pneumoperitoneum at head-down (PP), normoperitoneum at supine (POSTPP). RESULTS: High frequency of heart rate variability (HRVHF), Low frequency of heart rate variability (HRVLF), Low frequency of blood pressure variability (BPVLF), LF/HF ratios of HRV (LFHFr) were significantly lower than that of BASE at PREPP. HRVHF, HRVLF, BPVLF were significantly lower than that of BASE at PP. At PP, normalized HF of HRV (nuHF) is significantly lower than that of BASE and normalized LF of HRV (nuLF) is significantly higher than that of BASE and PREPP (P < 0.05). LFHFr was significantly lower than that of BASE and significantly higher than that of PREPP at PP. At POSTPP, HRVHF, HRVLF, BPVLF were significantly lower than that of BASE. But, BPVLF at POSTPP was higher than that of PP. CONCLUSIONS: We conclude that the pneumoperitoneum and trendelenburg positions caused sympathetic activation in LAVH patients.

Hybrid palliation for right atrial isomerism associated with obstructive total anomalous pulmonary venous drainage.

A twenty-four-day-old girl, who was prematurely born at 36 weeks of gestation, and weighed 2.2 kg, and diagnosed with right atrial isomerism, functionally single ventricle, bilateral superior vena cava (SVC) and obstructive supracardiac total anomalous pulmonary venous drainage (TAPVD) draining to the junction between the right SVC and the right atrium, underwent a hybrid procedure in the operating room, which consisted of pulmonary artery banding, ductus ligation and stenting of the draining vein of TAPVD. Obstruction at the drainage site of TAPVD was initially relieved after stenting, but, one month after the procedure, the distal end of the stent became stenotic and she received bilateral sutureless repair of TAPVD. At postoperative seven months, she underwent bidirectional cavopulmonary shunt uneventfully, and she has been followed-up for two months in a stable state without any problem in the pulmonary venous pathway.