[Intravenous Ablation for Lower Extremity Varices to Prevent Recurrent Pulmonary Embolism in Klippel-Trenaunay Syndrome;Report of a Case].

Klippel-Trenaunay syndrome( KTS) is a complex congenital anomaly characterized by lower extremity varix and venous malformations, port-wine stains, and soft tissue and bone hypertrophy. We present a case of a 35-year-old man of KTS with pulmonary embolism (PE). The patient was referred to our hospital complaining of the leg pain and sudden onset of dyspnea. Enhanced computed tomography (CT) showed lower extremity varices, superficial thrombophlebitis and bilateral pulmonary thrombi. No venous malformations except for varicose veins were revealed in the limbs or pelvis. The patient received adequate anticoagulant therapy with edoxaban, followed by intravenous radiofrequency ablation for lower extremity varices. Two months after the operation, the patient suffered from thrombophlebitis in the leg again, however, CT showed no pulmonary thrombus. This case report suggests that intravenous ablation for lower extremity varices in KTS prevented recurrent PE.

Coronary artery spasm following off-pump coronary artery bypass surgery.

Coronary artery spasm after coronary artery bypass surgery may result in life-threatening arrhythmias, circulatory collapse, or death. We report two cases of coronary artery spasm after coronary artery bypass surgery, one of which developed ventricular fibrillation requiring extracorporeal membrane oxygenation support. Both patients were discharged in good condition and are currently followed as outpatients. Unexpected sudden hemodynamic compromise could be due to coronary vasospasm, and this should be considered as one of the possible differential diagnoses. We were able to prevent the lethal consequences seen with coronary artery spasm by early diagnosis and management.

Long term results with the Cabrol aortic root replacement.

Cabrol aortic root replacement is rarely performed in recent years because of potential coronary complications. The purpose of this study was to investigate its early and late results, including coronary complications, by evaluating our experience thus far. A retrospective lookup of patients who underwent Cabrol aortic root replacement between 1988 and 2001 found a total of 36 patients (24 men and 12 women) with a mean age of 45 years. Annuloaortic ectasia was the most frequent cause (n = 22), followed by chronic dissection (n = 5), acute dissection (n = 5), and aneurysm with prior aortic operation (n = 4). Early mortality occurred in one patient (2.8%). The mean follow-up period was 104 months. There were 7 late deaths, 4 of which were disease-related. The actuarial survival was 83.3% at 5 years and 72.9% at 10 years, and the freedom from reoperation was 87.9% at 5 years and 76.6% at 10 years. There were no reoperations on the ascending aorta. Coronary ostia were examined by angiography or 64-row multidetector computed tomography in 18 patients 43 to 189 months after the operation. Two patients developed stenosis or occlusion of the right coronary ostium. The early and late results of the Cabrol operation were favorable with the exception of coronary complications. The importance of careful follow-up for late coronary complications cannot be overemphasized.

[Acute forearm compartment syndrome after total arch replacement].

A 61-year-old female presented with shortness of breath and was found to have moderate aortic regurgitation with annulo-aortic ectasia and an aneurysm involving the aortic arch. She underwent Bentall operation and total arch replacement with a branched prosthesis. The patient developed hypesthesia and paresis of the left forearm one day after the surgery. Computed tomography revealed complete occlusion of the left subclavian artery (LSA). An emergency operation was performed 15 hours after the initial operation. A new bypass graft to the axillary artery was placed since the LSA was occluded by the wide arterial dissection. However, her left forearm showed rapid swelling within a few hours. Under the diagnosis of acute compartment syndrome (ACS) of the forearm, emergency decompression fasciotomy was performed. She was discharged with a mild dysfunction of her forearm and hand 40 days after the operation. The rapid progression of ACS was thought to have been associated with not only the severe and prolonged ischemia but also the venous obstruction caused by the ligation of left brachiocephalic vein during the initial operation. Immediate and complete decompression, including the deep compartment of the forearm, was essential to achieve a full functional recovery from ACS.

[Heparin-induced thrombocytopenia after on-pump coronary artery bypass grafting].

We report herein a case of a patient who suffered heparin-induced thrombocytopenia (HIT) after on-pump coronary bypass grafting (CABG). A 62-year-old woman had received coronary angiography with heparin 4 months before CABG. She had been given heparin for 7 days before CABG, and underwent the operation under cardiopulmonary bypass uneventfully. She experienced thrombosis of multiple vein grafts without deep venous thrombosis or pulmonary embolism postoperatively. During percutaneous coronary intervention for residual coronary stenoses, acute multiple thromboses in coronary stents developed. We suspected HIT and administered argatroban instead of heparin. She recovered from shock after intra-aortic balloon pump insertion and balloon angioplasty for in-stent thromboses. HIT should be suspected whenever a thrombosis suddenly occurs in perioperative cardiac patients. Early diagnosis and treatment for HIT is essential to prevent subsequent thromboembolic events.

Long-Term Survival in a Case of Primary Leiomyosarcoma of the Inferior Vena Cava in Which PET-CT Follow-up Was Useful.

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignancy, but has been found more frequently with recent advances in diagnostic imaging. Local recurrence and metastases are frequent with this pathology, and prognosis is poor. We report a case of a patient with leiomyosarcoma of the IVC surviving for >10 years after the first resection despite local recurrence and two metastatic recurrences to the pancreas and liver, with successful excisions following early detection on positron emission tomography-computed tomography.

Evaluation of coronary artery bypass grafts and native coronary arteries using 64-slice multidetector computed tomography.

BACKGROUND: The conventional use of 16-slice multidetector computed tomography (MDCT) remains somewhat limited for evaluating stenoses in vein graft distal anastomotic sites and in coronary arteries. We investigated the diagnostic accuracy of 64-slice MDCT for assessment of both grafts and coronary arteries in patients with coronary artery bypass grafts. METHOD: The study group included 54 consecutive patients. One patient had to be excluded from the study because of arrhythmia. The remaining 53 patients with coronary artery bypass grafts underwent both 64-slice MDCT angiography and invasive coronary angiography. The MDCTs were analyzed for presence of significant stenosis (>50%) or occlusion in grafts and coronary arteries. The results were compared with those of invasive coronary angiography. RESULTS: Overall, 138 of 146 (94.5%) grafts including distal anastomoses were evaluable with MDCT. Evaluability of arterial grafts, venous grafts, distal runoff arteries, and nongrafted arteries was 90.3%, 98.6%, 84.0%, and 97.3%, respectively. After censoring nonevaluable grafts or arteries and considering them to be positive, the sensitivity to detect significant stenosis or occlusion in arterial grafts was 100% and specificity was 91.4%. In venous graft, sensitivity was 100% and specificity was 98.1%. In distal runoff arteries, sensitivity to detect significant stenoses was 83.3% and specificity was 80.2%. In nongrafted arteries, sensitivity was 100% and specificity was 87.5%. CONCLUSIONS: Sixty-four-slice MDCT showed improved ability to assess bypass grafts and coronary arteries. However, there were still difficulties in assessment of distal runoff arteries in which relatively low diagnostic accuracy was observed that might limit clinical implementation of MDCT.

Large aneurysm in saphenous vein coronary artery graft with fistula: case report and review.

Aneurysms developing in a saphenous vein graft (SVG) after coronary artery bypass grafting (CABG) are an unusual complication and fistulae forming between an SVG aneurysm and a cardiac chamber are even rarer. A 71-year-old man had undergone a triple CABG with the left internal thoracic artery and double SVGs. Twenty years later, he was admitted with repeated congestive heart failure. A large true aneurysm (99 × 60 mm) developed in the mid portion of a saphenous vein graft to the right coronary artery together with a fistula with a diameter of 8 mm in the right atrium. The aneurysm was surgically resected and the fistula was closed.

Repeated mitral valve replacement in a patient with extensive annular calcification.

BACKGROUND: Mitral valve replacement in the presence of severe annular calcification is a technical challenge. CASE REPORT: A 47-year-old lady who had undergone mitral and aortic valve replacement for rheumatic disease 27 years before presented with dyspnea. At reoperation, extensive mitral annular calcification was hindering the disc motion of the Starr-Edwards mitral prosthesis. The old prosthesis was removed and a St Jude Medical mechanical valve was implanted after thorough annular debridement. Postoperatively the patient developed paravalvular leak and hemolytic anemia, subsequently undergoing reoperation three days later. The mitral valve was replaced with an Edwards MIRA valve, with a bulkier sewing cuff, after more aggressive annular debridement. Although initially there was no paravalvular leak, it recurred five days later. The patient also developed a small cerebral hemorrhage. As the paravalvular leak and hemolytic anemia gradually worsened, the patient underwent reoperation 14 days later. A Carpentier-Edwards bioprosthetic valve with equine pericardial patches, one to cover the debrided calcified annulus, another as a collar around the prosthesis, was used to eliminate paravalvular leak. At 7 years postoperatively the patient is doing well without any evidence of paravalvular leak or structural valve deterioration. CONCLUSION: Mitral valve replacement using a bioprosthesis with equine pericardial patches was useful to overcome recurrent paravalvular leak due to severe mitral annular calcification.

Arteriovenous access closure in hemodialysis patients with refractory heart failure: a single center experience.

Arteriovenous dialysis access may impose a burden on the cardiac system. The objective of this study is to examine the usefulness of access closure in hemodialysis patients with refractory heart failure and to identify possible factors associated with symptomatic improvements. The study population comprised 33 hemodialysis patients with symptomatic heart failure (New York Heart Association [NYHA] class ≥ II), who underwent arteriovenous access closure (30 fistulas and three grafts) between 1991 and 2008. In all patients, heart failure was refractory to all possible medical and surgical treatments, and persisted after optimal dry weight control. First, short-term changes in hemodynamics, clinical symptoms and echocardiographic morphology were examined. Second, clinical and echocardiographic parameters were compared between responders (N=23), who demonstrated NYHA class improvement after access closure, and non-responders (N=10). After access closure, systolic blood pressure rose and the heart rate decreased significantly. Body weight and echocardiographic parameters did not change significantly. Twenty-three patients (70%) demonstrated NYHA class improvement and were designated as responders. In responders, the duration from access creation to closure was significantly shorter and fewer had ischemic heart disease, compared with non-responders. Access flow, cardiac output and ejection fraction were comparable between the two groups. Although the five-year survival was 20.2% in all patients, responders showed better early survival than non-responders. Arteriovenous access closure improved clinical symptoms in 70% of patients with refractory heart failure. This improvement was especially likely to be achieved in patients without ischemic heart disease and those who developed heart failure within a relatively short time after access creation.

Concomitant aortic valve-sparing operation and closed biatrial radiofrequency ablation for annuloaortic ectasia and paroxysmal atrial fibrillation.

A 53-year-old woman was admitted for annuloaortic ectasia with moderate aortic valve insufficiency (AI) and paroxysmal atrial fibrillation. Concomitant aortic root replacement with a valve-sparing technique and closed biatrial procedure using bipolar radiofrequency ablation was performed successfully. Postoperative echocardiography showed trivial AI with regular sinus rhythm, which meant she could avoid anticoagulation therapy.

Mid-term results of a closed biatrial procedure using bipolar radiofrequency ablation concomitantly performed with non-mitral cardiac operations.

The long-term success rate of the Cox maze III procedure is excellent, although it has not been widely adopted because of the need for extensive incisions of the atria. In this study, we report our experience with a closed biatrial procedure using bipolar radiofrequency (RF) ablation for treating atrial fibrillation (AF) during non-mitral cardiac operations. Beginning in December 2004, a total of 19 patients underwent a closed biatrial procedure with bipolar RF energy. All the patients had a maze procedure plus a concomitant non-mitral operation. Except for several stabs to introduce the bipolar device, no incisions were made in either atrium. The first six patients were investigated with 64-slice multidetector computed tomography (MDCT), six months after the operation. Patients were followed-up monthly with a clinical examination and electrocardiography. There were no operative deaths. MDCT showed no evidence of coronary sinus stenosis. At one year of follow-up, 93% of the patients (14/15) were in sinus rhythm. The closed biatrial procedure using bipolar RF ablation is safe and effective in treating AF during open-heart surgery. This could be particularly beneficial for patients with AF who are undergoing a cardiac surgical procedure without opening the left atrium.

Off-pump coronary artery bypass grafting in a patient with Werner's syndrome.

Werner's syndrome is a rare hereditary disorder that is characterized by premature aging. We report a case of off-pump coronary artery bypass grafting (OPCAB) in a 56-year-old man with Werner's syndrome. We used an endoscopic vessel-harvesting system to harvest great saphenous vein grafts (SVGs) because this system helps minimize surgical wounds. This is important because poor wound healing is a prominent feature of Werner's syndrome. Revascularization of the coronary arteries in this case was thought to improve his prognosis, although he had already outlived the average life-span of Werner's syndrome. A detailed examination of the cardiovascular system should be performed in patients with this disorder.

Papillary fibroelastoma of the left ventricle: report of two cases.

Papillary fibroelastoma is a relatively rare cardiac tumor. We report two cases of papillary fibroelastoma. The first case involved a 45-year-old woman who presented with rheumatic valves and three tumors developing from the papillary muscle and left ventricle. The second case involved a 68-year-old man who was asymptomatic and whose tumor was detected incidentally on echocardiogram. Both cases were treated surgically. An additional 71 cases of papillary fibroelastoma reported in the medical literature in Japan are reviewed.

Rapid diagnosis and management of intraoperative myocardial infarction during valvular surgery: using intraoperative transesophageal echocardiography followed by emergency coronary artery bypass grafting without coronary angiography.

A 68-year-old man was admitted to undergo elective mitral valve surgery. Although the preoperative coronary angiography was normal, the patient suffered a myocardial infarction that resulted in untreatable collapsed hemodynamics. After inferring the responsible occluded coronary artery from the segmental wall motion abnormality detected in intraoperative transesophageal echocardiography, together with the anatomy found in preoperative coronary angiography, we performed an emergency coronary artery bypass graft surgery without a new angiography. This procedure resulted in survival of a potentially life-threatening situation. In selected cases, this therapeutic strategy may lead to reduction of mortality as a result of the intraoperative myocardial infarction.