Surgical outcomes of mitral valve replacement with concomitant mitral annular reconstruction.

BACKGROUND AND AIM OF THE STUDY: We evaluated the early and long-term outcomes of mitral annular reconstruction (MAR) with pericardium during mitral valve replacement (MVR), and analyzed the risk factors associated with post-operative mortality. METHODS: Between May 1997 and April 2013, 78 consecutive patients underwent MVR with MAR. The indications for MAR were treatment for annular infection in native valve endocarditis (n = 23, 29.5%) or prosthetic valve endocarditis (n = 26, 33.3%), reinforcement of damaged annulus resulting from a previous operation (n = 17, 21.8%), complete excision of extensive calcification (n = 9, 11.5%), and left ventricular or left atrial rupture (n = 3, 3.8%). Patients were classified into infective endocarditis (n = 49) and non-endocarditis groups (n = 29). The mean follow-up period was 59.4 ± 47.3 months. RESULTS: There were two operative deaths and 11 cases of late mortality in the endocarditis group and five cases in the non-endocarditis group. Late prosthetic valve endocarditis occurred in four patients. The overall survival rate at 1 and 10 years was 94.8% and 65.1%, respectively. There was no statistical difference in the overall survival, freedom from reoperation, and freedom from endocarditis rates between the groups (P = 0.565, P = 0.635, and P = 0.449, respectively). Univariable and multivariable analyses revealed that pre-operative left ventricular dysfunction (ejection fraction <40%) was an independent predictor of overall mortality. CONCLUSIONS: The early and long-term results of MAR with pericardium during MVR are acceptable in both endocarditis and non-endocarditis patients.

Hyperglycemia and Hypoglycemia Are Associated with In-Hospital Mortality among Patients with Coronavirus Disease 2019 Supported with Extracorporeal Membrane Oxygenation.

Metabolic abnormalities, such as preexisting diabetes or hyperglycemia or hypoglycemia during hospitalization aggravated the severity of COVID-19. We evaluated whether diabetes history, hyperglycemia before and during extracorporeal membrane oxygenation (ECMO) support, and hypoglycemia were risk factors for mortality in patients with COVID-19. This study included data on 195 patients with COVID-19, who were aged ≥19 years and were treated with ECMO. The proportion of patients with diabetes history among nonsurvivors was higher than that among survivors. Univariate Cox regression analysis showed that in-hospital mortality after ECMO support was associated with diabetes history, renal replacement therapy (RRT), and body mass index (BMI) < 18.5 kg/m2. Glucose at admission >200 mg/dL and glucose levels before ventilator >200 mg/dL were not associated with in-hospital mortality. However, glucose levels before ECMO >200 mg/dL and minimal glucose levels during hospitalization <70 mg/dL were associated with in-hospital mortality. Multivariable Cox regression analysis showed that glucose >200 mg/dL before ECMO and minimal glucose <70 mg/dL during hospitalization remained risk factors for in-hospital mortality after adjustment for age, BMI, and RRT. In conclusion, glucose >200 mg/dL before ECMO and minimal glucose level <70 mg/dL during hospitalization were risk factors for in-hospital mortality among COVID-19 patients who underwent ECMO.

Omission of a prior Glenn anastomosis is a risk factor for prolonged pleural drainage after the fenestrated extracardiac conduit Fontan procedure.

OBJECTIVE: Factors related to prolonged pleural drainage after the Fontan operation have not been clearly defined. We investigated perioperative variables to establish factors predicting operative morbidity including prolonged chest tube drainage. Also, we pursued the fate of the fenestration during the follow-up period. METHODS: We retrospectively reviewed 52 patients who had undergone a fenestrated extracardiac Fontan procedure between August 1998 and June 2008. The median age at the time of surgery was 34.8 (range: 18.5 ∼ 156) months and the median body weight 13.2 kg (range: 9.5 ∼ 33). A multivariable logistic regression model was used to compare demographic, anatomic, and physiological variables for postoperative morbidity. RESULTS: Operative mortality occurred in one patient (1.9%). The mean duration of respiratory support, chest tube drainage, and hospital stay was 13 hours (range: 4 to 328 hours), six days (range: 2 to 45 days), and 16 days (range: 7 to 444 days), respectively. Statistically, an operation without previous bidirectional cavopulmonary shunt (OR 30, 95% CI 3.1 to 289) was the only independent risk factor for prolonged pleural drainage. Aortic cross-clamp time was identified as a risk factor for prolonged mechanical ventilatory support. During a median follow-up at 62 months (range: 17 to 137 months), there was one late death (1.9%). Twenty-two patients (43%) underwent intervention for fenestration closure. CONCLUSIONS: Previous bidirectional cavopulmonary shunt and shortened aortic cross-clamp time may reduce postoperative morbidity including prolonged chest tube drainage and mechanical ventilator support after the fenestrated extracardiac conduit Fontan procedure.

A successfully treated case of primary purulent pericarditis complicated by cardiac tamponade and pneumopericardium.

Acute pericarditis is caused by various factors, but purulent pericarditis is rare. Primary purulent pericarditis in immunocompetent hosts is very rare in the modern antibiotics era. We report a successfully treated case of primary purulent pericarditis complicated with cardiac tamponade and pneumopericardium in an immunocompetent host. A 69-year-old female was referred from another hospital because of pleuritic chest pain with a large amount of pericardial effusion. She was diagnosed with acute pericarditis accompanied by cardiac tamponade. We performed emergency pericardiocentesis, with drainage of 360 ml of bloody pericardial fluid. The culture grew Streptococcus anginosus, confirming the diagnosis of acute purulent pericarditis. We performed pericardiostomy because cardiomegaly and pneumopericardium were aggravated after removal of the pericardial drainage catheter. The patient received antibiotics for a total of 23 days intravenously and was discharged with oral antibiotic therapy. Purulent pericarditis is one of the rare forms of pericarditis and is lifethreatening. A multimodality approach is required for proper diagnosis and treatment of this disease.

Aortic false lumen patency following the adventitial inversion technique for acute DeBakey type I aortic dissection.

BACKGROUND: We determined the beneficial effect of the adventitial inversion technique on reducing the patency rate of false lumens in acute aortic dissection (AAD) compared with the sandwich technique using Teflon felts. METHODS: Between 2003 and 2008, 65 consecutive patients with DeBakey type I AAD underwent emergent surgery. To obliterate a false lumen, the sandwich technique was used in 35 patients (group TS) before October 2006 and the adventitial inversion technique was used in 30 patients (group AIT) subsequent to October 2006. The false lumen patency was evaluated with computerized tomo-angiography (CTA). RESULTS: There were three operative deaths (AIT [n = 1]; TS [n = 2]). The operative morbidity rate was not different (AIT = 17.2%, TS = 21.2%). Follow-up was completed in 56 patients (90.3%) with a mean duration of 12.2 ± 4.9 months in the group AIT and 31.8 ± 19.8 months in the group TS. During the follow-up period, there were no deaths or aortic events. In 53 patients (AIT [n = 26]; TS [n = 27]), a postoperative one-year CTA was obtained and compared with that of immediate postoperative one. The patency rate in the immediate postoperative period was 30.8% in group AIT and 63.0% in group TS (p = 0.019). On the follow-up CTA, it was 15.4% in group AIT and 48.1% in group TS (p = 0.018), respectively. CONCLUSIONS: The adventitial inversion technique can be performed safely and obliterate the false lumen more effectively than the sandwich technique. The adventitial inversion technique might decrease the incidence of reoperations related to aneurysmal changes and improve survival or event-free survival.

The role of percutaneous cardiopulmonary support in the treatment of native coronary spasm after coronary artery bypass grafting.

Postoperative coronary artery spasm following off-pump coronary artery bypass is a rare and unpredictable complication. The clinical manifestations following spasm vary, depending on the severity or the affected vessels. In serious cases, it can proceed to circulatory collapse and cardiac arrest. Coronary angiography with infusion of coronary vasodilators has been a well-established diagnostic and therapeutic tool. We present a patient who was successfully resuscitated with an intra-aortic balloon pump (IABP) and percutaneous cardiopulmonary support (PCPS) as initial stabilization because of an inability to proceed to angiography. Furthermore, we demonstrated the effectiveness of IABP and PCPS for restoring cardiac function.

Risk Factors Associated with Difficult Reversal of Heparin by Protamine Sulfate in Cardiopulmonary Bypass: An Ignored Issue.

BACKGROUND: The aim of this study was to evaluate risk factors associated with difficult heparin reversal by protamine after cardiopulmonary bypass. METHODS: Data from 120 consecutive patients who underwent open heart surgery from 2009 to 2017 were retrospectively reviewed. Patients were divided into 2 groups: (1) those in whom complete heparin reversal was achieved after a single infusion of protamine (group A, n=89); and (2) those who required more protamine for heparin reversal (group B, n=31). RESULTS: Female sex, prolonged bypass time (>200 min), long aortic cross-clamping time (>120 min), and a lowest rectal temperature <26°C were significant predictors of difficult heparin reversal. Larger amounts of fresh frozen plasma and platelet concentrate were transfused in group B than in group A. CONCLUSION: Surgeons' efforts to reduce operative time and avoid deep hypothermia may be helpful for increasing the likelihood of easy heparin reversal, especially in female patients.

Clinical Value of Intraoperative Flow Measurements of Brachiocephalic Arteriovenous Fistulas for Hemodialysis.

BACKGROUND: The aim of this study was to analyze the clinical outcomes of autogenous brachiocephalic arteriovenous fistulas and to investigate the factors associated with 1-year patency after initiation of hemodialysis. METHODS: We retrospectively reviewed the medical records of 41 patients who underwent surgery to create an autogenous brachiocephalic arteriovenous fistula between January 2015 and December 2017, received hemodialysis at the same hospital for longer than 1 year, and were monitored for their vascular access status. Intraoperative flow was measured using transit-time ultrasonography. RESULTS: The 1-year primary and secondary patency rates were 61% (n=25) and 87.8% (n=36), respectively. The functional group (subjects who required no intervention to maintain patency within the first year after hemodialysis initiation) displayed a significantly higher median intraoperative flow rate (450 mL/min) than the non-functional group (subjects who required intervention at least once regardless of 1-year patency) (275 mL/min) (p=0.038). Based on a receiver operating characteristic curve analysis, all patients were additionally subdivided into a high-flow group (>240 mL/min) and a low-flow group (≤240 mL/min). The high-flow group included a significantly greater number of functional brachiocephalic arteriovenous fistulas than the low-flow group (74.2% vs. 20%, respectively; p=0.007). CONCLUSION: Transit-time flow, as measured with intraoperative transit-time ultrasonography, was associated with patency without the need for intervention at 1 year after initiation of hemodialysis.

Cardiac Autotransplantation with Concurrent Pneumonectomy for Complete Resection of Primary Cardiac Intimal Sarcoma.

Primary cardiac sarcoma is rare, and intimal sarcoma is an extremely rare and highly lethal disease. We report a case of a 62-year-old woman who was incidentally diagnosed with a primary cardiac sarcoma originating from the left atrial appendage and extending to the left superior pulmonary vein. The location of the tumor was very complicated, posing a major challenge for complete resection. We successfully performed complete resection of the cardiac sarcoma via cardiac autotransplantation with left pneumonectomy. The patient recovered uneventfully, without any adjuvant therapy as of 6 months postoperatively. Autotransplantation of the heart may be suggested as a reasonable surgical option for extensive left atrial tumors.

Chemical Pleurodesis Using Viscum album Extract in Gorham Disease Complicated with Chylothorax.

Gorham disease, also known as massive osteolysis, is characterized by unregulated proliferation of lymphatic or vascular capillaries within bone, resulting in destruction and replacement with angiomatous tissue. This disease can lead to chylothorax that can be lethal. Viscum album extract from European mistletoe is a complementary anti-cancer drug which is commonly prescribed in many European countries and is considered as a new generation of chemical agent for pleurodesis. A 14-year-old girl presented with dyspnea and chest pain. She was diagnosed as Gorham disease who was definitively treated with V. album extract for chylothorax that was refractory to standard conservative management.

Successful extracorporeal cardiopulmonary resuscitation in a postpartum patient with amniotic fluid embolism.

Amniotic fluid embolism (AFE) is a rare but fatal obstetric emergency, which is characterized by a sudden cardiovascular collapse, respiratory failure, and disseminated intravascular coagulation (DIC). We report a case of sudden cardiac arrest due to an amniotic-fluid embolism which was successfully treated with veno-arterial extracorporeal membrane oxygenation (ECMO). A 32-year-old female at 39.1 weeks of gestation was scheduled for induction labor. During labor, a sudden generalized tonic-clonic seizure was developed followed by dyspnea and hypotension. An immediate vaginal delivery was performed, and the baby was healthy. Despite the appropriate cardiopulmonary resuscitation, she became hypoxemic and experienced recurrent cardiovascular collapse. ECMO was applied promptly, and the patient became stable rapidly and was discharged without any complications. ECMO seems to be a proper treatment option for catastrophic amniotic-fluid embolism.

Massive air embolism while removing a central venous catheter.

Air embolism is a rare but mostly iatrogenic complication of medical or surgical procedures and may have a serious outcome. On the removal of a central venous catheter (CVC), minor carelessness can lead to a venous air embolism sometimes accompanied by arterial embolism. We experienced the case of a 61-year-old male who suffered from a paradoxical systemic air embolism while we removed a CVC. Immediate resuscitation and venovenous extracorporeal membrane oxygenation support saved his life. Multiple end-organ damage related to the systemic air embolism was noted, including the kidney, liver, and brain. In echocardiography, multiple air bubbles and an atrial septal defect were observed. An air embolism is preventable with appropriate precautions and techniques. Therefore, it is important to identify errors and prevent occurrence.

Selective Shunting Based on Dual Monitoring with Electroencephalography and Stump Pressure for Carotid Endarterectomy.

PURPOSE: The aim of this study is to analyze postoperative outcomes for carotid endarterectomy (CEA) in addition to the preoperative clinical characteristics related to selective shunting based on dual monitoring with stump pressure (SP) and electroencephalography (EEG). MATERIALS AND METHODS: We retrospectively reviewed medical records of 70 patients who underwent CEA from March 2010 to December 2017. CEA was performed under general anesthesia and selective shunting was done if the SP was lower than 35 mmHg regardless of EEG or if intraoperative EEG showed any changes different from preoperative one regardless of SP. RESULTS: There was no postoperative 30-day adjusted mortality or adverse cardiac events. Three patients (4.3%) had postoperative minor stroke finally reaching pre-operative neurologic status at the time of discharge. Twenty-six patients (37.1%) used shunting and severe contralateral internal carotid stenosis or occlusion was related to shunting (P<0.010). There were larger number of symptomatic patients in shunt group in spite of no statistical significance (P=0.116). CONCLUSION: Perioperative stroke rate was 4.3% for CEA under general anesthesia based on dual intraoperative monitoring with SP and EEG. There was no 30-day adjusted mortality and adverse cardiac event. Severe stenosis or occlusion of contralateral internal carotid artery is related to shunting (P<0.010).

Multimodal Imaging in Klippel-Trénaunay-Weber Syndrome: Clinical Photography, Computed Tomoangiography, Infrared Thermography, and 99mTc-Phytate Lymphoscintigraphy.

We report the case of a 19-year-old man who presented with a 12-year history of progressive fatigue, feeling hot, excessive sweating, and numbness in the left arm. He had undergone multimodal imaging and was diagnosed as having Klippel-Trénaunay-Weber syndrome (KTWS). This is a rare congenital disease, defined by combinations of nevus flammeus, venous and lymphatic malformation, and hypertrophy of the affected limbs. Lower extremities are affected mostly. Conventional modalities for evaluating KTWS are ultrasonography, CT, MRI, lymphoscintigraphy, and angiography. There are few reports on multimodal imaging of upper extremities of KTWS patients, and this is the first report of an infrared thermography in KTWS.

Dual Monitoring with Stump Pressure and Electroencephalography During Carotid Endarterectomy.

BACKGROUND: Intraoperative monitoring during carotid endarterectomy is crucial for cerebral protection. We investigated the results of carotid endarterectomy under dual monitoring with stump pressure and electroencephalography. METHODS: We retrospectively reviewed the medical records of 50 patients who underwent carotid endarterectomy between March 2010 and February 2016. We inserted a temporary shunt if the stump pressure was lower than 35 mm Hg or if any intraoperative change was observed on electroencephalography. RESULTS: Seventeen (34%) patients used a temporary shunt, and the mean stump pressure was 26.8 mm Hg in the shunt group and 46.5 mm Hg in the non-shunt group. No postoperative mortality or bleeding occurred. Postoperatively, there were 3 cases (6%) of minor stroke, all of which took place in the shunt group. A comparison of the preoperative and the intraoperative characteristics of the shunt group with those of the non-shunt group revealed no statistically significant difference between the 2 groups (p <0.01). CONCLUSION: Dual monitoring with stump pressure and electroencephalography was found to be a safe and reliable monitoring method with results comparable to those obtained using single monitoring. Further study should be performed to investigate the precise role of each monitoring method.

Unusual Presentation of a Cervical Mass Revealed as External Jugular Venous Aneurysm.

Venous aneurysms of the jugular vein are one of the rare causes of neck swelling, and primary venous aneurysms of the external jugular vein are extremely rare. A 46-year-old woman presented with a painless and suddenly growing mass in the left neck. A computed tomography angiography revealed a fusiform venous aneurysm of the external jugular vein containing intraluminal thrombus. We performed resection of the aneurysm and ligation of the external jugular vein. Removal of the aneurysm of the neck vein was necessary because venous aneurysms with thrombosis may lead to serious thrombotic complications such as pulmonary embolism.

Delayed aortic rupture resulting from postoperative superficial sternal wound infection.

While deep sternal wound infection (DSWI) after cardiac surgery is a significant contributor to patient morbidity and mortality, superficial sternal wound infection (SSWI) mostly has a benign course. We report a mortality case of aortic rupture resulting from SSWI after cardiac surgery. A 50-year-old male underwent an aortic valve replacement (AVR). Three months after the valve operation, he presented with severe dyspnea, which had never before been observed, and chest computed tomography revealed an ascending aortic rupture with large hematoma compressing the main pulmonary artery. We performed an emergent operation for aortic rupture that possibly originated from the SSWI. Postoperatively, the patient died of hypovolemic shock due to recurrent aortic rupture despite efforts to resuscitate him.

Bilateral chylothorax after transsternal total thymectomy: resolution with short period of fasting and total parenteral nutrition.

Bilateral chylothorax after transsternal total thymectomy is very rare, but can be a serious complication. Disruption of minor lymphatic channels in the anterior mediastinum which is remote from thoracic duct is considered to be the cause of chylothorax. We report the case of bilateral chylothorax followed by thymectomy which was treated with pleural drainage, total parenteral nutrition, and fasting without octreotide injection.

Acute pneumonitis consequent on pleurodesis with Viscum album extract: severe chest images but benign clinical course.

Chemical pleurodesis is widely recommended in the treatment of pulmonary air leak of different etiologies as well as malignant pleural effusions and chylothorax. Conventional chemical pleurodesis using erythromycin, tetracycline, hydrophilic fumed silica, autologous blood and talc slurry has been standardized, and its complications, including high fever, intractable chest pain, and acute lung injury, seem to be frequent. Viscum album extract is a new chemical agent for pleurodesis, and only a few studies have reported outcomes of such chemical pleurodesis in the treatment of malignant pleural effusion. Moreover, the complications resulting from pleurodesis using Viscum album extract are very rare, and acute pneumonitis has not been reported. in this paper we report the first case of acute pneumonitis after pleurodesis using Viscum album extract in a 58-year-old man who had prolonged air leaks after a left upper lingularsegmentectomy for metastatic lung cancer. We performed repeated pleurodesis four times with 2 to 4 days intervals. While the patient had no symptoms of pneumonia, such as cough, sputum, chilling, and fatigue, a follow-up chest X-ray revealed increasing peribronchial consolidations and infiltrations in the left upper lobe. A chest tomography showed extensive parenchymal consolidations and ground-glass appearances in the left lungs, representing pneumonia with acute lung injury. The acute pneumonitis was spontaneously resolved with supportive care, and the patient was discharged ten days after the development of pneumonitis. We think that pleurodesis with Viscum album extract is effective, but repeated pleurodesis should be avoided for possible onset of acute pneumonitis.