Aortic Dissection Associated with Autosomal Dominant Polycystic Kidney Disease

A 78-year-old man who had been diagnosed with autosomal dominant polycystic kidney disease (ADPKD) and hypertension presented with chest pain. His family history was positive for ADPKD. Chest computed tomography (CT) revealed a type A aortic dissection with thrombotic occlusion of a false lumen and an ulcer-like projection in the ascending aorta, an aneurysm of the ascending aorta, and pericardial effusion. Abdominal CT showed multiple renal and hepatic cysts. At surgery, aortic dissection with thrombotic occlusion of the false lumen and an intimal tear in the distal ascending aorta were observed. Hemiarch replacement including the intimal tear was performed. The patient is doing well without requiring dialysis and without recurrence of aortic dissection or aneurysm under strict antihypertensive therapy 3 years after the operation. Pathological examination of aortic wall specimens revealed no degenerative abnormality. ADPKD should be kept in mind as one of the causative disorders of aortic dissection.

Infective Endocarditis Associated with Atopic Dermatitis.

We report a case of aortic valve infective endocarditis (IE) in a 24-year-old man with atopic dermatitis (AD). He had a history of balloon valvuloplasty for a stenotic bicuspid aortic valve, and had dental caries but no invasive dental procedure before the onset of IE. On admission, skin lesions of AD with itching and scratches were found on the neck, trunk, and extremities. Echocardiography showed a vegetation on the aortic valve with mild steno-regurgitation, but extension of IE to the annulus was not detected. Magnetic resonance imaging identified fresh cerebral infarction without neurological dysfunction, leading us to suspect an embolism. Blood cultures grew methicillin-sensitive Staphylococcus aureus. During emergency surgery, a vegetation attached to the conjoined cusp was observed, and the aortic valve was replaced with a mechanical valve. The patient recovered uneventfully without any complications such as recurrent IE or mediastinitis. We also review previously reported cases of IE associated with AD.

Intra-Atrial Excision of the Left Atrial Appendage: A Simple and Easy Technique.

In patients with atrial fibrillation, closure of the left atrial appendage (LAA) is recommended to prevent thromboembolic events, however, conventional exclusion or excision techniques have potential drawbacks such as persistent blood flow into the appendage and a residual stump. We propose a simple and easy technique for LAA closure consisting of intra-atrial excision of the LAA, which is invaginated into the left atrium (LA), and direct suture closure of the orifice from inside the LA. In this technique, complete elimination of the LAA was achieved without leaving a residual stump because the LAA was excised at the orifice and was closed at the base of the LAA.

Displacement of Amplatzer septal occluder in a patient with atrial septal defects and an atrial septal aneurysm.

Transcatheter closure of atrial septal defects has become more common because of its high success rate and low morbidity; however, this treatment for patients with atrial septal aneurysms is still challenging.

Precision CT­guided marking with India ink and microcoils for laparoscopic resection of a lateral lymph node recurrence of rectal cancer: A case report.

Although rarely used in laparoscopic surgery, computed tomography (CT)-guided marking is useful for targeting small lesions. The present study describes the performance of laparoscopic resection with preoperative CT-guided marking for lateral lymph node recurrence of rectal cancer. A 48-year-old man underwent laparoscopic low anterior resection with D3 lymph node dissection for rectal cancer (postoperative diagnosis, stage IIIb). Postoperative adjuvant chemotherapy was then administered. Solitary lymph node recurrence was observed in the left lateral region after 6 months. Systemic chemotherapy reduced the size of the metastatic lymph nodes; however, 3.5 years after the surgery, the diameter increased by 10 mm, and laparoscopic resection was thus planned. Because the target lesion was small and located deep in the pelvis, preoperative CT-guided marking was performed with India ink injection and embolization microcoil implantation. The markers were clearly identified and the lesion was successfully resected with adequate margins. The approach described in the present study is thus considered potentially useful for the detection of small lesions.

Left atrial myxoma mimicking papillary fibroelastoma.

A 67-year-old woman was referred to our hospital with a diagnosis of deep vein thrombosis due to surgery for left patellar fracture. Deep vein thrombosis resolved with thrombolytic therapy. Transthoracic echocardiogram revealed a mobile left atrial tumor. Transesophageal echocardiography showed a fragile tumor with multiple fronds, implying a papillary fibroelastoma. Because this patient had a history of cerebral embolism, urgent surgery was scheduled. The excised tumor showed a sea anemone-like appearance in saline, which was similar to that of a papillary fibroelastoma. However, histological examination revealed the features of a myxoma and not papillary fibroelastoma. Herein, we illustrate a very rare case of left atrial myxoma with papillary fibroelastoma-like features in terms of both echocardiographic and gross findings.

Effectiveness of near-infrared spectroscopy during surgical repair of tracheo-innominate artery fistula.

Monitoring regional cerebral oxygen saturation (rSO(2)) by use of near-infrared spectroscopy (NIRS) is a useful method for detecting cerebral ischemia. Tracheo-innominate artery fistula is a rare but life-threatening complication of tracheostomy. The surgical procedures for management of tracheo-innominate artery fistula include direct or patch closure of the fistula, ligation or division of the innominate artery, and anatomical or extra-anatomical reconstruction of the flow of the innominate artery. Division of the innominate artery is the best method to prevent postoperative recurrence of bleeding and infection. However, cutting off the innominate artery flow may cause brain ischemia. We present the case of a patient with tracheo-innominate artery fistula successfully treated by dividing the innominate artery while the rSO(2) was monitored. In this case report, we have shown that NIRS is a useful method for deciding the surgical maneuver for tracheo-innominate artery fistula.

Alveolar soft part sarcoma of the orbit: A case report.

Alveolar soft part sarcoma is a rare soft tissue neoplasm that accounts for approximately 1% of all sarcomas and is usually identified in the extremities in adults. The occurrence of alveolar soft part sarcoma in the orbit is extremely rare, estimated at approximately 5% - 15% among all cases of alveolar soft part sarcoma . Here, we present a case of 29-year-old woman with orbital alveolar soft part sarcoma. We describe the magnetic resonance and F-18 2-fluoro-2-deoxy-D-glucose-position emission tomography/computed tomography findings of this case. This young woman had a spindle-shaped mass. A higher signal compared to the extraocular muscle on T1-weighted images, numerous flow voids on T2-weighted images, and intense enhancement could be key findings of this disease.

Mitral stenosis due to pannus overgrowth after rigid ring annuloplasty.

Although mitral stenosis (MS) due to pannus overgrowth after mitral valve repair for rheumatic mitral regurgitation (MR) is not uncommon, it is extremely rare in relation to non-rheumatic mitral regurgitation. Whilst it has been suggested that the rigid annuloplasty ring induces pannus overgrowth in the same manner as the flexible ring, to date only in cases using the flexible ring has pannus formation been confirmed by a pathological examination after redo surgery. The case is described of a woman who had undergone mitral valve repair using a 28 mm rigid ring three years previously because of non-rheumatic MR, and subsequently suffered from MS due to pannus formation over the annuloplasty ring. To the present authors' knowledge, this is the first report of MS due to pannus formation after mitral valve repair using a rigid annuloplasty ring to treat non-rheumatic MR documented at reoperation.

A child with influenza A (H1N1)-associated myocarditis rescued by extracorporeal membrane oxygenation.

A 6-year-old boy had cold-like symptoms and was diagnosed with influenza A at a clinic. Administration of oseltamivir and azithromycin did not improve the symptoms. He was referred to our hospital and was diagnosed with H1N1 pneumonia. The patient required ventilator support. However, hypoxia and hypercapnia were uncontrollable. To oxygenate and reduce the carbon dioxide concentration, veno-venous extracorporeal membrane oxygenation (ECMO) was applied 24 h after admission. We established outflow via the right internal jugular vein and inflow via the right femoral vein. Six hours later, an electrical storm of ventricular fibrillation occurred, probably due to influenza myocarditis. Chest compression was started immediately. Both cardioversion and medication were ineffective in treating the electrical storm. Therefore, we decided to switch the veno-venous ECMO to veno-arterial ECMO to maintain systemic flow. During chest compression, a 6-mm graft was anastomosed to the left common femoral artery, and an outflow tube was connected to the graft. Consequently, veno-arterial ECMO was established via outflow through the left common femoral artery and inflow through both the right jugular vein and right femoral vein. Veno-arterial ECMO terminated the electrical storm, and cardiac output improved. Veno-arterial ECMO was provided for 107 h, and was then replaced by veno-venous ECMO. Forty-three hours later, veno-venous ECMO was discontinued. The patient was successfully weaned from the mechanical ventilator on the 9th day after admission. Unfortunately, spinal infarction appeared as a complication. The patient was discharged from the hospital on the 86th day, and has now returned to primary school.

Remission of Palmoplantar Pustulosis after On-Pump Coronary Artery Bypass Grafting in a Patient with Titanium Allergy.

Metal allergy is an uncommon problem during surgery. Among them, titanium allergy is said to be rare, but can lead to serious complications, such as palmoplantar pustulosis (PPP). A 69-year-old woman was admitted to our hospital with a chief complaint of chest pain. Coronary angiography showed severe coronary artery disease that required coronary artery bypass grafting (CABG). The patient had a history of orthopedic surgery for left distal radius fracture 2 years previously, which resulted in inflammation on the left arm and PPP. We suspected titanium allergy based on results of skin patch tests and use of titanium alloy in the previous orthopedic operation. The patient underwent CABG without use of permanent metallic material. As a result, her PPP disappeared. In this rare case, it is difficult to identify the exact cause of the improvement in PPP; thus, further studies are required to clarify the mechanism of remission.

Pannus overgrowth after mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis.

A Carpentier-Edwards pericardial (CEP) bioprosthesis was explanted from an 81-year-old woman due to nonstructural dysfunction 9 years after mitral valve replacement. The nonstructural dysfunction produced severe regurgitation in the mitral position. During the surgery, excessive pannus overgrowth was seen on the left ventricular side of the CEP bioprosthesis. Pannus overgrowth was prominent on one leaflet. That leaflet was stiff and shortened due to the excessive overgrowth of pannus. In this patient, the distortion of one leaflet was the main reason for transvalvular leakage of the CEP bioprosthesis in the mitral position. A new CEP bioprosthesis was implanted in the mitral position. Pathological analysis revealed fibrotic pannus with a small amount of cellular material over the leaflets of the resected CEP valve. This change was marked on the distorted leaflet.

A new hydrocolloid dressing prevents surgical site infection of median sternotomy wounds.

PURPOSE: This prospective and semi-randomized study was conducted to clarify the effectiveness of a new hydrocolloid dressing placed over median sternotomy wounds using an occlusive dressing technique. METHODS: The subjects were 253 patients undergoing coronary artery bypass grafting (CABG), who were randomized to receive either the new hydrocolloid dressing (Karayahesive, n = 117) or a polyurethane foam dressing (Tegaderm plus Pad, n = 136) immediately after sternal wound closure. Karayahesive was left in place for 7 days, whereas the Tegaderm plus Pad was removed on postoperative day (POD) 2 and replaced with an adhesive wound dressing until POD 7. RESULTS: In the Karayahesive group, complete integrity of the wound was achieved in 91% of the patients, with an infection developing in 3.4%: as a superficial surgical site infection (SSI) in three and as a deep SSI in one. On the other hand, in the Tegaderm plus Pad group, an infection developed in 10.3% (14 patients) of the patients: as a superficial SSI in nine and as a deep SSI in five (P < 0.05). The total treatment costs from the application of the dressing until completion of treatment was 699 yen for the Karayahesive and 910 yen for the Tegaderm plus Pad (P < 0.001). CONCLUSIONS: The new hydrocolloid dressing, applied with an occlusive dressing technique to median sternotomy wounds, prevented SSI and was cost effective.

Edge-to-edge repair for mitral regurgitation associated with isolated double-orifice mitral valve.

We report the case of a patient with severe mitral regurgitation who was diagnosed with double-orifice mitral valve by preoperative transthoracic and transoesophageal echocardiography. During surgery, it was revealed that the mitral valve was divided into 2 orifices, anterolateral and posteromedial, by a fibrous bridging tissue that was supported by the chordae tendineae originating from an accessory middle papillary muscle. The posterior scallop of the anterolateral orifice was prolapsed due to chordal elongation. Six interrupted sutures were made between the anterior leaflet and the posterior leaflet at the prolapsed site. Additional interrupted sutures were made at the sites of 2 clefts, and a ring annuloplasty was added. Residual mitral regurgitation was trivial, and the mean postoperative pressure gradient through each orifice was approximately 6 mmHg. To the best of our knowledge, this is the first case report of an edge-to-edge mitral repair for mitral regurgitation associated with a double-orifice mitral valve.

Surgical Repair of Subacute Right Ventricular Perforation after Pacemaker Implantation.

We report an 84-year-old woman who presented with right ventricular perforation 4 days after pacemaker implantation for syncope due to sick sinus syndrome. Median sternotomy revealed no pericardial effusion, but the pacing lead had penetrated the right ventricle and pericardium. When the pleura was opened, the tip of the lead was seen in the visceral pleura. The lead was cut in the pericardial cavity and extracted from the left subclavian wound together with the generator. The right ventricular perforation was sutured and a temporary pacing lead was placed on the right ventricular wall intraoperatively. Ten days after the surgery, a new pacemaker lead was placed in the ventricular septum via the right axillary vein. Right ventricular perforation is a rare complication after pacemaker implantation. Typically, it occurs at the time of implantation or within 24 hours after implantation. In the present case, the perforation of the right ventricle which needed urgent surgery occurred 4 days after implanting the pacing lead at the right ventricular apex. Great care should have been taken not to overlook this life-threatening complication even more than 24 hours after pacemaker implantation.

A case of a quadricuspid aortic valve identified preoperatively using transthoracic echocardiography.

Quadricuspid aortic valve is an extremely rare congenital heart anomaly that often causes valve incompetence, requiring surgical intervention. Care must be taken to avoid surgical complications in patients with quadricuspid aortic valve; thus, preoperative diagnosis is important. A 76-year-old man presented with exertional dyspnea due to aortic regurgitation. Transthoracic and transesophageal echocardiography revealed severe aortic regurgitation caused by quadricuspid aortic valve. To avoid interference with the cardiac conduction system, we performed aortic valve replacement using an ingenious technique, in which pledgeted sutures on the accessory leaflet were placed from outside the sinus of Valsalva to above the aortic annulus. The patient recovered uneventfully and was discharged from the hospital without any complications. While preoperative diagnosis of quadricuspid aortic valve is considered difficult, we identified it preoperatively using transthoracic echocardiography; we were, thus, able to properly prepare for complete atrioventricular block.

Usefulness of three-dimensional transesophageal echocardiography for diagnosis of hemolytic anemia due to inverted internal felt strip after surgery for aortic dissection.

Felt strips are widely used for reinforcement of the aortic stump in surgery for aortic dissection (AD). Postoperative hemolytic anemia (HA) due to an inverted internal felt strip at the aortic stump fixation for AD is extremely rare. A 70-year-old woman underwent ascending aorta replacement for acute type A AD, where both proximal and distal anastomotic sites were reinforced with Teflon felt strips. A week later, macroscopic hematuria and HA emerged. Three-dimensional transesophageal echocardiography (3D-TEE) demonstrated that the proximal inner felt strip turned up and protruded into the aortic inner lumen. At redo surgery, which was performed 2 weeks after the initial surgery, the findings of 3D-TEE were confirmed, and the inverted internal felt strip was replaced with a bovine pericardial strip. The findings of HA disappeared immediately after the second surgery. 3D-TEE is a very informative, valuable modality for accurate diagnosis that leads to a safe surgery.

Ten-year NEDO BVAD development program: moving forward to the clinical arena.

Since 1995, the Baylor Group has been developing a totally implantable NEDO BVAD system. This 10-year program was completed in March 2005, and preparation for clinical trials is underway. This article summarizes the entire 10-year NEDO program and describes the strategy for clinical trials. The project aimed to achieve: (1) dual centrifugal pumps with the ability of full biventricular support, (2) a compact system implantable into small adults, (3) a totally implantable system with transcutaneous energy transmission system (TETS), (4) a durable system with a lifetime of over 5 years, and (5) a system free of thrombus and with minimal hemolysis. The final goals are to complete preclinical system evaluations and commence the clinical trials in the near future. In vitro studies have demonstrated a pump capacity of over 8.5 l/min and an Index of Hemolysis of <0.004 g/100 l. The pump-bearing life expectancy was over 5 years. To date, eight pumps endured in vivo studies of over 3 months without complications, including thromboembolic events. The in vitro endurance studies of eight pumps are longer than 1 year. There were no mechanical malfunctions or pump failure. A stepwise clinical trial is being planned: Step1, a wearable BVAD/VAD will be clinically studied; Step 2, the BVAD/VAD will be implanted intracorporeally without TETS; and, Step 3, a totally implantable system will be clinically evaluated. The NEDO BVAD system has completed preclinical testing. Clinical trial preparation is underway.

Indirect flow rate estimation of the NEDO PI Gyro pump for chronic BVAD experiments.

In totally implantable ventricular assist device systems, measuring flow rate of the pump is necessary to ensure proper operation of the pump in response to the recipient's condition or pump malfunction. To avoid problems associated with the use of flow probes, several methods for estimating flow rate of a rotary blood pump used as a ventricular assist device have been studied. In the present study, we have performed a chronic animal experiment with two NEDO PI gyro pumps as the biventricular assist device for 63 days to evaluate our estimation method by comparing the estimated flow rate with the measured one every 2 days. Up to 15 days after identification of the parameters, our estimations were accurate. Errors increased during postoperation days 20 to 30. Meanwhile, their correlation coefficient r was higher than 0.9 in all the acquired data, and estimated flow rate could simulate the profile of the measured one.

Development of a clipped single-bag with bicarbonate replacement fluid to ensure proper mixing.

A clipped single-bag for bicarbonate replacement fluid was developed to ensure proper mixing before administering to the patient. Nonmixture can cause imbalances of electrolytes and pH, which is a key problem for the current double-bag type bicarbonate replacement fluid sets. To resolve this problem, this single bag properly mixes the solutions before use. The new bag consists of a clip that is placed in the middle to keep the two solutions separated and sealed. When the caregiver is ready to administer treatment, the bag is simply unfolded and the clip automatically detaches, releasing the fluids. Thereby, the bicarbonate fluids are effectively mixed. An optimal clip size with an outer diameter of 16 mm and thickness of 2 mm was determined using compression tests and drop tests. This bag may be a safer and more effective way to provide proper replacement fluid supply for both hemofiltration and hemodiafiltration.