[Direct True Lumen Cannulation in the Ascending Aorta During Stanford Type A Acute Aortic Dissection Repair:Report of a Case].

A 51 years-old male with sudden onset of chest and back pain was referred to our hospital from another hospital. Contrast-enhanced computed tomography( CT) revealed the presence of Stanford type A acute aortic dissection with critically narrow true lumen in the ascending aorta. Then, emergency surgery was performed. One umbilical tape tourniquet was placed around the ascending aorta. A vent tube was inserted into the main pulmonary artery. A venous drainage cannula was inserted into the right atrium. In the head-down position, pulmonary artery venting and venous drainage were initiated. As the blood puressure fell down around 40 mmHg, the ascending aorta was incised. A cannula (DLP 24 Fr) was placed in the true lumen and the aorta was snared. Cardiopulmonary bypass was established followed by selective antegrade cardioplegia, and systemic cooling. An entry was found in the ascending aorta, so ascending aorta graft replacement was performed under selective antegrade cerebral perfusion. There were no perioperative complications, and he was discharged home on 24th postoperative day. There is still remain controversies as to the optimal arterial cannulation site for cardiopulmonary bypass in patients with Stanford type A aortic dissection. We think the ascending aorta is most simply, rapidly and reliably available. In this case, direct true lumen cannulation in the ascending aorta was useful.

[Metastatic Right Atrial Tumor of Renal Cell Carcinoma:Report of a Case].

Metastatic cardiac tumors are known to be more common than primary cardiac tumors, and most patients are asymptomatic. In patients with renal cell carcinoma (RCC) with cardiac metastases, total tumor resection is known to improve the prognosis. We report a case of a successfully resected RCC with right atrial metastasis under cardiopulmonary bypass. A 71-year-old female with abdominal distention was diagnosed with right RCC and extension to the right atrium. After neoadjuvant chemotherapy, she underwent right nephrectomy and neiection of intraocular tumor extention with partial right atrium under cardiopulmonary bypass, because the tumor tightly adhered to the right atrium. She had a good postoperative course and was discharged home on the 22nd postoperative day. Nine months after surgery, she shows no sign of recurrence.

[Stanford Type A Acute Aortic Dissection Complicated with Intestinal Ischemia Preceded by Superior Mesenteric Artery Bypass:Report of a Case].

A 78-year-old male with sudden onset of chest and back pain was transported to our institution by ambulance. Upon arrival at our hospital, he also complained of abdominal pain. Contrast-enhanced computed tomography (CT) revealed the presence of Stanford type A acute aortic dissection complicated with intestinal ischemia;because of the effects of aortic dissection, the superior mesenteric artery 378 Vol.76 No.5(2023-5) (SMA) was obstructed, leading to the complication of intestinal ischemia. An arterial blood gas test showed elevated lactate and metabolic acidosis. We immediately performed resection of the necrotic portion of the intestine and bypass of the common iliac artery to the SMA. Subsequently, after confirmation of the improvement of acidosis, ascending aortic replacement was performed on the same day. Although the patient's condition was complicated by acute kidney injury and pneumonia, he was discharged home on the 55th postoperative day. Acute aortic dissection complicated by intestinal ischemia has a poor prognosis;however, here we reported a life-saving surgical procedure in a patient with this presentation.

[Stanford Type A Acute Aortic Dissection in a Patient with a Single Coronary Artery:Report of a Case].

A single coronary artery is a very rare anomaly and is usually asymptomatic. Here we report a case of a single coronary artery complicated with Stanford type A acute aortic dissection. A 58-year-old male with chest pain was transported to our institution by ambulance. He was diagnosed with a single coronary artery accompanied by acute coronary syndrome. The single coronary artery originated from the left sinus of Valsalva and the right coronary branch coursed between the aorta and the pulmonary artery. It was, therefore considered difficult to perform catheter intervention, and urgent coronary artery bypass surgery was planned. Enhanced computed tomography, however, revealed Stanford type A acute aortic dissection, and aortic root replacement combined with coronary artery bypass grafting was performed by emergency. The postoperative course was uneventful.

[The Apical Left Ventricle Aneurysm, Eighteen Years After the Fulminant Myocarditis:Report of a Case].

Ventricular aneurysm after myocarditis is a rare complication. It has been reported that scarred areas of the myocardium may become aneurysm. Here, we report a case of apical left ventricle aneurysm at 18 years after the fulminant myocarditis. The patient is a 36-year-old female with a history of fulminant myocarditis at the age of 18. Eighteen years after the onset of the disease, she was referred to our hospital because of an apex ventricular aneurysm. Her computed tomography scan showed an apex ventricular aneurysm sized 45×40 mm with a wall width of 1.8 mm. We performed resection of ventricular aneurysm and reconstruction using Linear technique. The postoperative course was uneventful and discharged on the 17th post operative day.

Spontaneous splenic rupture, mesenteric ischemia and spinal infarction after aortic repair for acute type A dissection in a patient with sickle cell trait.

Sickle cell trait (SCT), a benign hematological condition affecting approximately 300 million individuals globally, is associated with an increased risk of vaso-occlusive disease. However, the risks related to surgery employing cardiopulmonary bypass in patients with SCT are not well established. Herein, we report the case of a 27-year-old African American man with SCT who underwent an emergency aortic repair for acute Stanford type A aortic dissection using hypothermic circulatory arrest. The patient developed a sickle cell crisis, which was followed by spontaneous splenic infarction and rupture, nonocclusive mesenteric ischemia, and spinal infarction.

[Rhabdomyolysis during Perioperative Period after Cardiac Surgery].

We report a case of rhabdomyolysis during a perioperative period after cardiac surgery. A 47-yearold man underwent aortic root replacement for annuloaortic ectasia under general anesthesia using sevoflurane, fentanyl, remifentanil, rocronium bromide and midazolam. On the 1st postoperative day (1 POD), his body temperature rose over 38 ℃, which continued for 3 days despite our attempt to stabilize the fever. On 4 POD, his laboratory data and hemodynamics dramatically worsened, and we commenced continuous hemodialysis filtration (CHDF) and percutaneous cardiopulmonary support system (PCPS). In addition, balloon pumping (IABP) was started on 5 POD. At the same time, we initiated dantrolene sodium hydrate infusion according to a clinical grading scale to predict malignant hyperthermia (MH) susceptibility. Serum creatine phosphokinase (CPK) increased over 350,000 U/l on the 7 POD, and dantrolene sodium hydrate was continuously infused until 9 POD. Despite dantrolene sodium infusion, CHDF, IABP and PCPS, his condition did not improve, and he died of disseminated intravascular coagulation syndrome (DIC) and sepsis on 28 POD. Computed tomography on 21 POD disclosed scattered low-density areas in the erector spinal, lliopsoas and femoral muscles, which indicated rhabdomyolysis. Histopathological examination using hematoxylin and eosin stain revealed destroyed striated-muscle fibers and swelling rhabdomyocytes. It remained unclear which drug triggered rhabdomyolysis. When MH is suspected, we should consider the use of the clinical grading scale to predict its susceptibility and start dantrolene sodium hydrate infusion.

Direct True Lumen Cannulation ("Samurai" Cannulation) for Acute Stanford Type A Aortic Dissection.

In operations for acute Stanford type A aortic dissection, several cannulation options are available for cardiopulmonary bypass arterial perfusion. These are femoral, axillary, Seldinger ascending aortic, transapical, and transatrial, each of which has advantages and drawbacks. We describe our surgical technique of direct true lumen cannulation ("Samurai" cannulation), which represents an easy, safe, and practical option in operations for acute type A aortic dissection.

Energy dynamics of the intraventricular vortex after mitral valve surgery.

Mitral valve morphology after mitral valve surgery affects postoperative intraventricular flow patterns and long-term cardiac performance. We visualized ventricular flow by echocardiography vector flow mapping (VFM) to reveal the impact of different mitral valve procedures. Eleven cases of mechanical mitral valve replacement (nine in the anti-anatomical and two in the anatomical position), three bioprosthetic mitral valve replacements, and four mitral valve repairs were evaluated. The mean age at the procedure was 57.4 ± 17.8 year, and the echocardiography VFM in the apical long-axis view was performed 119.9 ± 126.7 months later. Flow energy loss (EL), kinetic pressure (KP), and the flow energy efficiency ratio (EL/KP) were measured. The cases with MVR in the anatomical position and with valve repair had normal vortex directionality ("Clockwise"; N = 6), whereas those with MVR in the anti-anatomical position and with a bioprosthetic mitral valve had the vortex in the opposite direction ("Counterclockwise"; N = 12). During diastole, vortex direction had no effect on EL ("Clockwise": 0.080 ± 0.025 W/m; "Counterclockwise": 0.083 ± 0.048 W/m; P = 0.31) or KP ("Clockwise": 0.117 ± 0.021 N; "Counterclockwise": 0.099 ± 0.057 N; P = 0.023). However, during systole, the EL/KP ratio was significantly higher in the "Counterclockwise" vortex than that in the "Clockwise" vortex (1.056 ± 0.463 vs. 0.617 ± 0.158; P = 0.009). MVP and MVR with a mechanical valve in the anatomical position preserve the physiological vortex, whereas MVR with a mechanical valve in the anti-anatomical position and a bioprosthetic mitral valve generate inefficient vortex flow patterns, resulting in a potential increase in excessive cardiac workload.

Zero Contrast Coronary Intervention Using Intravascular Ultrasound Guidance in a Patient with Allergy to Contrast Medium.

The occurrence of allergy to iodinated contrast in certain patients may prevent the use of percutaneous coronary intervention (PCI) in such cases. We present a 53-year-old male with a history of allergic reaction to iodinated contrast who successfully underwent intravascular ultrasound (IVUS) guided PCI. Stent size was determined based on IVUS. After PCI, stent expansion and a lack of edge dissection or incomplete apposition were confirmed by IVUS. Thus, PCI without contrast injection under IVUS may be feasible in selected patients with allergy to iodinated contrast.

[Perioperative Multiple Pulmonary Embolism in a Patient with Giant Right Atrial Myxoma: Report of a Case].

It is reported that 20% of cardiac myxomas are located in the right atrium. An 81-year-old man presented with dyspnea, general fatigue and leg edema lasting for a year. Echocardiography revealed an 80 mm tumor occupying the right atrium and the right ventricle. At surgery, the tumor attached to the atrial septum was removed with the surrounding septal wall. As the tricuspid annulus was dilated, tricuspid annuloplasty with an artificial ring was also carried out. After coming off cardiopulmonary bypass, the patient developed pulmonary hypertension with the pulmonary arterial pressure being 80% of the systemic pressure, which subsided gradually day by day. Histopathological diagnosis was cardiac myxoma. Postoperative lung perfusion scintigraphy revealed postoperative multiple defects. It was considered that multiple tumor embolisms in the distal pulmonary artery caused postoperative pulmonary hypertension. Careful follow-up for remote recurrence would be essential.

[Emergency Surgery for Acute Pulmonary Embolism].

According to the current guidelines for acute pulmonary embolism in Japan, it is standard to perform surgical thrombectomy only after introducing percutaneous cardiopulmonary support (PCPS) for circulatory collapse. We experienced 2 cases of surgical thrombectomy without using PCPS. The 1st patient was a 49-year-old man. Computed tomography (CT) on admission revealed a thrombus in the main trunk of the pulmonary artery. He developed severe dyspnea and drop of consciousness after admission, and underwent emergency surgical thrombectomy. The 2nd patient was a 52-year-old man whose levels of consciousness and arterial oxygenation rapidly declined after admission. His CT revealed thrombi in the main trunk of the pulmonary artery, and he underwent emergency thrombectomy. Both patients had a history of diabetes and obesity. At our institute, we actively choose surgical thrombectomy for cases in which a thrombus is revealed in the main trunk of the pulmonary artery on CT and for cases in which abnormal symptoms and/or signs such as impaired consciousness and oxygenation develop.

Mechanical Endovascular Recanalization in a Patient with Middle Cerebral Artery Occlusion by Tumorous Emboli Originating from Cardiac Myxoma.

Cardiac tumor is a rare cause of cerebral embolic infarction which has no established therapeutic strategies. Although some cases were successfully treated by recombinant tissue-plasminogen activator (rt-PA), this article indicates the effectiveness of emergency mechanical thrombectomy for tumorous type of emboli which do not respond to rt-PA. A 34-year-old man presented with ischemic stroke and right middle cerebral artery (MCA) occlusion by cardiac tumor originating emboli. Intravenous rt-PA therapy was ineffective, but mechanical endovascular thrombectomy using Merci Retriever was successful. His neurological deficit began to improve and good outcome was obtained at discharge. The embolus was histologically identical to a cardiac myxoma, confirmed and treated successfully by surgery later. We report the first successfully treated tumorous embolic stroke case with cardiac tumor by using Merci Retriever. Emergency mechanical thrombectomy would be an option for elastic hard myxoma emboli.

A selection of cases of direct cannulation in surgery for type A dissection.

BACKGROUND: We use antegrade cannulation, circulatory arrest, and selective antegrade cerebral perfusion in patients with acute aortic dissection. While blood is generally supplied via the ascending aorta, this route can be difficult, depending on the features of dissection and the form of the true lumen. In such cases, we incise the ascending aorta and insert the cannula directly into the true lumen of the ascending aorta to secure the blood supply. METHODS: Between April 2005 and April 2012, direct true lumen cannulation of the ascending aorta was performed in 12 patients; 5 had total arch replacement, and 7 had ascending aorta and hemiarch replacement. RESULTS: Total arch replacement involved circulatory arrest for 62 ± 16 min, aortic crossclamping for 174 ± 13 min, cardiopulmonary bypass for 211 ± 11 min, and a minimal rectal temperature of 28.4 ± 1.8. Ascending aorta and hemiarch replacement involved arrest of the circulation for 40 ± 9 min, aortic crossclamping for 111 ± 29 min, cardiopulmonary bypass for 131 ± 34 min, and a minimal rectal temperature of 27.8 ± 0.9. One patient died from cerebral infarction during hospitalization. CONCLUSION: In these cases, direct true lumen cannulation of the ascending aorta was effective.

Death due to undetected heparin-induced thrombocytopenia after cardiac surgery.

A 41-year-old male patient was diagnosed acute myocardial infarction. An intra-aortic balloon pump was inserted to treat heart failure, and off-pump coronary artery bypass surgery was performed. Postoperative cardiac catheterization revealed occlusion of all the 3 bypass grafts, and percutaneous coronary intervention (PCI) was performed. Thrombosis due to heparin-induced thrombocytopenia (HIT) occurred during PCI, which was completed after switching to argatroban based on the possible HIT. Cardiopulmonary arrest occurred suddenly after PCI, and the patient died. Undetected HIT may have caused the sudden change. HIT should be suspected and aggressively treated when thrombocytopenia occurs even during assisted circulation.

Double-patch closure using gelatin resorcine formol glue of a ventricular septal perforation following acute myocardial infarction.

Complete closure is most important when attempting acute-phase closure of a ventricular septal perforation following acute myocardial infarction. Here, we present a case of a 76-year-old male with a ventricular septal perforation following acute myocardial infarction. The ventricular septal perforation was repaired by stitching small and large bovine pericardial patches onto the affected septum from the side of the left ventricle, then cementing the two patches together with gelatin resorcine formol glue injected into the space between them. Complete closure of the ventricular septal perforation was accomplished. Simultaneously, right coronary artery bypass grafting was performed using a saphenous vein. The postoperative course was uneventful, and the patient was discharged, with a favorable post-discharge course for 24 months to date after surgery.

New surgical technique of left ventricular free wall rupture: double patch sealing method.

We experienced two cases of left ventricular free wall rupture (LVFWR) following acute myocardial infarction (AMI). Case 1, with the blowout type of LVFWR was initially closed by direct suture, followed by hemostasis using a double patch sealing method (DPS) by which the tear was doubly sealed with large and small bovine pericardium patches to which GRF glue was applied. Case 2 with the oozing type of LVFWR was treated only using DPS. Complete hemostasis was achieved in both cases, and aneurysmal dilatation or constrictive heart failure were not detected by postoperative left ventriculography. Therefore, DPS may be useful for treating LVFWR following AMI.