Endoscopic-assisted Surgical Removal of Infected Interosseous Wires 40 Years After Mandibular Surgery.

We demonstrate a highly reliable minimally invasive treatment for removal of residual wire from the mandible. The patient was a 55-year-old Japanese man who was referred to our department for a fistula in his submental area. The patient had undergone open reduction and fixation with wires for mandibular fractures (left parasymphysis, right angle fracture) more than 40 years prior and mandibular tooth extraction and drainage 6 months prior. Minimally invasive endoscopy-assisted wire removal surgery was performed under general anesthesia with good visualization in a narrow surgical field. Bone resection was minimized using an ultrasonic cutting instrument with a wide choice of tip shapes. The use of endoscopy with ultrasonic cutting tools makes it possible to effectively utilize narrow surgical fields with a small skin incision and minimal bone cutting. The advantages and disadvantages of the newer endoscopic systems in oral and maxillofacial surgical units are discussed.

Proposal of a new classification: "sealed type" postinfarction left ventricular free wall rupture.

OBJECTIVE: Postinfarction left ventricular free wall rupture (FWR) has been classified into blow-out type and oozing type. However, considering past papers, oozing type included the cases in which the bleeding had spontaneously stopped or sealed, and the distinction between blow-out type and oozing type was not always clear. We classified FWR into the BO type (combination of blow-out type and oozing type) with continuous bleeding and sealed type and clarified the pathophysiology of the sealed type. METHODS: Thirty-five patients who underwent surgical treatment for FWR during the past 21 years were retrospectively evaluated. RESULTS: Twenty-one patients (60%) were sealed. Comparing the sealed type with the BO type, the incidence of sudden collapse with acute onset was significantly lower (sealed type; 62%, BO type; 100%, P = 0.0118), and there were more cases of transport from outside the hospital (76%, 43%, P = 0.0453). Significantly few cases had electro-mechanical dissociation immediately before surgery (10%, 71%, P = 0.0001). In the sealed type, median sternotomy was performed in 9 patients (43%), and subxiphoid drainage was performed in 12 (57%). Fifteen patients (71%) were supported by IABP postoperatively, and re-rupture occurred in 3 patients without IABP. Long-term outcomes were significantly better in the sealed type than in the BO type. CONCLUSION: Sixty percent of postinfarction ventricular free wall rupture was the sealed type. Median sternotomy and sutureless repair with postoperative IABP support were reliable treatments. Subxiphoid drainage and strict blood pressure control with IABP may be acceptable surgical strategies in elderly, frail patients.

Brachiocephalic artery dissection is a marker of stroke after acute type A aortic dissection repair.

OBJECTIVE: Postoperative stroke is a serious unsolved complication after acute type A aortic dissection (ATAAD) repair. We investigated the incidence and risk factors of stroke, and hypothesized that dissection of supra-aortic vessels is an important risk factor of this morbidity. METHODS: Between 2012 and 2019, 202 (56% men, median age 68 years) patients with ATAAD underwent surgical repair. Clinical data, image findings, method of circulatory support, and repair technique were retrospectively investigated to explore the risk factor of postoperative stroke. RESULTS: Of the 202 patients, operative mortality was 6% and the incidence of postoperative stroke was 12% (n = 25). Brachiocephalic artery (BCA) dissection was associated with a higher risk of stroke (odds ratio, 3.89; 95% confidence interval, 1.104-13.780; p = .035) having no relation to the presence or absence of left common carotid artery dissection. Preoperative malperfusion syndrome, circulatory arrest time, isolated cerebral perfusion time, repair technique (total arch replacement), and femoral artery perfusion alone were not related to the incident rate of postoperative stroke. Stroke occurred in both hemispheres, regardless of the laterality of carotid artery dissection. CONCLUSION: BCA dissection was an independent risk factor of stroke after ATAAD repair.

Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation in descending aortic surgery.

Hypoxia during one-lung ventilation is a significant problem in descending aortic surgery via left thoracotomy. Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation (VAPa-ECMO), which consists of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and an additional arterial branch to perfuse a pulmonary artery (Pa), is useful.

Efficacy of Glutaraldehyde-Treated Leaflets for Mitral Valve Repair to Treat Active Infective Endocarditis: A Case Report.

We report the use of glutaraldehyde (GA) in a case of valve repair for mitral valve prolapse associated with active infective endocarditis. GA scrubbed at the site of infection decontaminates and reinforces infected fragile tissue, avoids excessive debridement, and strengthens the edges of valve leaflets to facilitate suturing.

Treatment of coronary malperfusion in type A acute aortic dissection.

Coronary malperfusion is one of the most dreadful complications of acute aortic dissection because it causes catastrophic acute myocardial infarction in patients who are already severely ill. Our strategy was as follows. After the administration of heparin, emergency percutaneous coronary intervention (PCI) was urgently performed at the same time as starting to prepare the operating room. A stent was then placed to cover the full length of dissected coronary artery. Patients whose cardiac function improved after successful coronary artery reperfusion were transferred to the operating room to undergo central repair surgery. If the cardiac function did not recover even after coronary reperfusion, and the patient required extracorporeal membrane oxygenation, we considered the best supportive care without performing central repair surgery. In patients with left coronary malperfusion, we believe that preoperative PCI must be performed immediately. Preoperative PCI might delay central repair surgery and potentially increase the risk of catastrophic cardiac tamponade. However, the benefit of PCI in preserving cardiac function exceeds the risk of cardiac tamponade. The indications of PCI before central repair in patients with right coronary malperfusion should be considered after assessing each patient's condition, including the presence or absence of cardiac tamponade and right ventricular infarction, left ventricular function, the immediate availability of cardiologists or cardiac surgeons, and the speed of preparing the operating room.

Pitfalls for the "Sandwich technique" via a right ventricular incision to repair post-infarction ventricular septal defects.

BACKGROUND: We have reported "sandwich technique," via a right ventricular incision, to treat a post-infarction ventricular septal defect (VSD). This technique involves the placement of patches on both the left and right sides of the septum, pinching the VSD sealed with surgical adhesive between the two patches. In this study, we analyzed factors influencing 1-year mortality to determine the pitfalls in our procedure. METHODS: We evaluated 24 consecutive patients with post-infarction VSD who underwent the "sandwich technique" via a right ventricular incision. One-year survival and major residual leak were used as the criteria for the analysis of survival and technical success, respectively. In protocol 1, clinical variables were evaluated as predictors of one-year mortality. In protocol 2, surgical techniques were evaluated as predictors of major residual leak, which was found to be related to one-year mortality in protocol 1. RESULTS: In protocol 1, the one-year mortality was higher in patients with major residual leak (75 %, 3/4) than in those without (15 %, 3/20) (p = 0.035). In protocol 2, the patients with major residual leak had smaller patches than those without (41.9 ± 3.8 vs. 47.8 ± 4.8 mm, p = 0.031) and a smaller size difference between the patches and the VSD (22.5 ± 6.5 vs. 30.0 ± 5.7 mm, p = 0.028). CONCLUSION: For the "sandwich technique" via a right ventricular approach to treat post-infarction VSD, the choice of patch size according to VSD size is an important variable for reducing major residual leak.

Heparin-Induced-Thrombocytopenia Causing Massive Aortic Thrombosis after Ascending Aortic Replacement for Type A Acute Aortic Dissection.

A 77-year-old woman underwent emergency ascending aortic replacement for type A acute aortic dissection. Fifteen days after the operation, she had motor and sensory disturbances in the lower limbs. Computed tomography revealed multiple aortic thrombi and disrupted blood flow in the right external iliac and left common iliac arteries. She underwent an emergency thrombectomy for acute limb ischemia. Because heparin-induced-thrombocytopenia (HIT) was suspected to have caused the multiple aortic thrombi, we postoperatively changed the anticoagulant therapy from heparin to argatroban. Seventeen days after the first operation, gastrointestinal bleeding developed, and the patient died of mesenteric ischemia caused by HIT. Arterial embolization caused by HIT after cardiovascular surgery is a rare, but fatal event. To avoid fatal complications, early diagnosis and early treatment are essential. Use of a scoring system would probably facilitate early diagnosis.

[A re-do case of recurrent constrictive pericarditis 35 years after pericardiectomy; report of a case].

Reports of recurrent constrictive pericarditis are scarce. We report a re-do case of recurrent constrictive pericarditis 35 years after pericardiectomy. The calcified pericardium was thick and severely adhesive. We performed pericardiectomy on pump, using Harmonic Scalpel and rib scissors for a safe and secure operation. The calcified pericardium looked like a crab's shell. The patient was discharged on 14th post-operative day. Long-term follow-up is necessary for this patient.

Left atrium ball thrombus in a patient with hemorrhagic cerebral infarction.

The patient was a 72-year-old man with left hemiparesis. Multiple hemorrhagic cerebral infarctions were recognized on a computed tomographic (CT) scan. A transesophageal echocardiogram showed a huge left atrial mass, which was floating and nearly obstructed the mitral orifice in the diastolic phase. Emergency left atrial mass removal was performed. To reduce the risk of critical brain hemorrhage, the dose of heparin was reduced (100 U/kg) and 1 mg/kg/h of nafamostat mesilate was administered into the venous circuit during extracorporeal circulation. A postoperative brain CT scan showed no evidence of deterioration of cerebral hemorrhage. Pathologic examination showed a ball thrombus.

Partial translocation mitral valve replacement with autologous pericardial patch reinforcement of ventricularized left atrial wall for severe annular calcification extending to the left ventricle.

We describe a technique of partial translocation with an autologous pericardial patch reinforcement of the left atrial wall in patients with extensive mitral annular calcification (MAC) who require mitral valve replacement.

In situ graft replacement and rectus abdominis muscle flap transfer for infected thoracoabdominal aortic aneurysm after gastrectomy.

An infected thoracoabdominal aneurysm is a rare, life-threatening condition with high mortality. We performed an in situ graft replacement and applied a rectus abdominis muscle flap transfer technique in a case of infected thoracoabdominal aortic aneurysm after distal gastrectomy. A rectus abdominis muscle flap transfer might be a good alternative when the omental flap technique is not feasible.

[Usefulness of photo dynamic eye system for detection of graft spasm in off-pump coronary artery bypass grafting].

A 54-year-old-man on hemodialysis was admitted to the hospital because of effort angina. A coronary angiography revealed multiple stenoses including 90% stenosis in the left main trunk. Coronary artery bypass grafting (CABG) was performed with Y-composite grafts constructed by the right internal thoracic artery (RITA) and the free gastroepiploic artery (GEA) which were anastomosed to left anterior descending artery (LAD) and the diagonal branch (D1) using the off-pump technique. After completion of anastomosis, Photo Dynamic Eye (PDE) system showed fluorescence not in the free GEA but at the anastomotic site of GEA to D1. Because the graft spasm of GEA was diagnosed by PDE, papaverine solution was sprayed to the graft, which resolved the spasm and re-anastomosis was avoided. PDE system is a useful tool for the diagnosis of graft spasm, and may contribute to improvement of quality of CABG.