ABSTRACT
BACKGROUND: A team approach is essential for effective trauma management. Close collaboration between interventional radiologists and surgeons during the initial management of trauma patients is important for prompt and accurate trauma care. This study aimed to determine whether trauma patients benefit from close collaboration between interventional radiology (IR) and surgical teams during the primary trauma survey. METHODS: A retrospective observational study was conducted between 2014 and 2021 at a single institution. Patients were assigned to an embolization group (EG), a surgery group (SG), or a combination group (CG) according to their treatment. The primary and secondary outcomes were survival at hospital discharge compared with the probability of survival (Ps) and the time course of treatment. RESULTS: The analysis included 197 patients, consisting of 135 men and 62 women, with a median age of 56 [IQR, 38-72] years and an injury severity score of 20 [10-29]. The EG, SG, and CG included 114, 48, and 35 patients, respectively. Differences in organ injury patterns were observed between the three groups. In-hospital survival rates in all three groups were higher than the Ps. In particular, the survival rate in the CG was 15.5% higher than the Ps (95% CI: 7.5-23.6%; p < 0.001). In the CG, the median time for starting the initial procedure was 53 [37-79] min and the procedure times for IR and surgery were 48 [29-72] min and 63 [35-94] min, respectively. Those times were significantly shorter among three groups. CONCLUSION: Close collaboration between IR and surgical teams, including the primary survey, improves the survival of severe trauma patients who require both IR procedures and surgeries by improving appropriate treatment selection and reducing the time process.
Subject(s)
Embolization, Therapeutic , Radiology, Interventional , Male , Humans , Female , Adult , Middle Aged , Aged , Retrospective Studies , Embolization, Therapeutic/methods , Injury Severity ScoreABSTRACT
BACKGROUND: The prevalence of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) has been increasing rapidly worldwide. However, guidelines or clinical studies do not provide sufficient data on ECPR practice. The aim of this study was to provide real-world data on ECPR for patients with OHCA, including details of complications. METHODS: We did a retrospective database analysis of observational multicenter cohort study in Japan. Adult patients with OHCA of presumed cardiac etiology who received ECPR between 2013 and 2018 were included. The primary outcome was favorable neurological outcome at hospital discharge, defined as a cerebral performance category of 1 or 2. RESULTS: A total of 1644 patients with OHCA were included in this study. The patient age was 18-93 years (median: 60 years). Shockable rhythm in the initial cardiac rhythm at the scene was 69.4%. The median estimated low flow time was 55 min (interquartile range: 45-66 min). Favorable neurological outcome at hospital discharge was observed in 14.1% of patients, and the rate of survival to hospital discharge was 27.2%. The proportions of favorable neurological outcome at hospital discharge in terms of shockable rhythm, pulseless electrical activity, and asystole were 16.7%, 9.2%, and 3.9%, respectively. Complications were observed during ECPR in 32.7% of patients, and the most common complication was bleeding, with the rates of cannulation site bleeding and other types of hemorrhage at 16.4% and 8.5%, respectively. CONCLUSIONS: In this large cohort, data on the ECPR of 1644 patients with OHCA show that the proportion of favorable neurological outcomes at hospital discharge was 14.1%, survival rate at hospital discharge was 27.2%, and complications were observed during ECPR in 32.7%.
Subject(s)
Cardiopulmonary Resuscitation , Extracorporeal Membrane Oxygenation , Out-of-Hospital Cardiac Arrest , Adolescent , Adult , Aged , Aged, 80 and over , Cohort Studies , Humans , Japan/epidemiology , Middle Aged , Out-of-Hospital Cardiac Arrest/therapy , Retrospective Studies , Young AdultABSTRACT
A 62-year-old Japanese male presented with graft infection by Staphylococcus schleiferi 50 days after debranching of the left subclavian artery and frozen elephant trunk repair for the entry closure of a Stanford type B aortic dissection. The graft was removed, and the patient was successfully treated using in situ reconstruction of the arch with omental flap coverage, removal of the debranching graft, autologous iliac artery grafting, and longterm antibiotics. Domino reconstruction of the infected debranching graft using autologous external iliac artery and a Dacron graft can thus be a good option in similar cases.
Subject(s)
Aorta, Thoracic/surgery , Blood Vessel Prosthesis/adverse effects , Staphylococcal Infections/diagnosis , Surgical Wound Infection/microbiology , Vascular Grafting/adverse effects , Anti-Bacterial Agents/therapeutic use , Humans , Iliac Artery/transplantation , Male , Middle Aged , Reoperation , Staphylococcus/isolation & purification , Surgical Wound Infection/diagnostic imaging , Surgical Wound Infection/drug therapy , Vascular Grafting/methodsABSTRACT
Congenital quadricuspid aortic valve is a rare cardiac malformation with an unknown risk of infective endocarditis. We report a case of quadricuspid aortic valve complicated with infective endocarditis. A 53-year-old Japanese woman was hospitalized with leg edema and a fever of unknown origin. Corynebacterium striatum was detected in the blood culture. Echocardiography demonstrated a quadricuspid aortic valve with vegetation and severe functional regurgitation. The condition was diagnosed as a quadricuspid aortic valve with infective endocarditis, for which surgery was performed. The quadricuspid aortic valve had three equal-sized cusps and one smaller cusp (type B according to Hurwitz classification). We dissected the vegetation and infectious focus and implanted a mechanical valve. Following the case report, we review the literature.
Subject(s)
Aortic Valve Insufficiency/surgery , Aortic Valve/abnormalities , Aortic Valve/surgery , Endocarditis/etiology , Endocarditis/surgery , Heart Valve Prosthesis Implantation , Aortic Valve Insufficiency/etiology , Corynebacterium Infections , Endocarditis/diagnosis , Endocarditis/microbiology , Female , Heart Valve Prosthesis , Humans , Middle Aged , Risk , Severity of Illness Index , Treatment OutcomeABSTRACT
A 74-year-old male was referred to our department due to a mobile solid mass of 10 mm in diameter on the left ventricular interior wall just below the posterior leaflet of the mitral valve. Mild mitral regurgitation and moderate tricuspid regurgitation were also detected. A high serum level of IL-6 was detected(33.0 pg/ml), and myxoma was suspected. The tumor, which was bright yellowish brown with a partly jelly-like surface, was successfully removed surgically through the mitral valve under cardiopulmonary bypass. Pathological findings of the mass was papillary fibroelastoma. Papillary fibroelastoma derived from the left ventricular wall is very rare.
Subject(s)
Fibroma/pathology , Heart Neoplasms/pathology , Aged , Fibroma/surgery , Heart Neoplasms/surgery , Heart Ventricles , Humans , Male , Mitral ValveABSTRACT
Prosthesis-patient mismatch (PPM) is always of concern when performing aortic valve replacement (AVR) in patients with a small aortic annulus. Although bioprosthetic AVR is preferred in patients older than 65 years, we have experienced cases in elderly patients with a small aortic annulus whereby we could not implant small-sized bioprosthetic valves. We have implanted St. Jude Medical Regent (SJMR) mechanical valves (St. Jude Medical, St. Paul, MN, USA) as necessary, even in elderly patients with no aortic annulus enlargement. We investigated our experiences of AVR with SJMR mechanical valves of 21 mm or less in size. Between January 2006 and December 2009, 40 patients underwent AVR with SJMR mechanical valves ≤21 mm in size: 9 patients received 21-mm valves, 19 received 19-mm valves, and 12 received 17-mm valves. The mean age was 65.9 ± 9.5 years, and 25 patients (62.5 %) were 65 years or older. We evaluated the clinical outcome and the echocardiographic data for each valve size. There was no operative or hospital mortality. The mean duration of clinical follow-up was 31.2 ± 17.6 months. During follow-up, there were no hospitalizations due to heart failure. The cumulative valve-related event-free survival was 93 % at 33 months, and the cumulative hemorrhagic event-free survival was 93 % at 33 months and 84 % at 43 months, using the Kaplan-Meier method. At follow-up, the mean values of the measured effective orifice area (EOA) for the 21-, 19-, and 17-mm prostheses were 2.00 ± 0.22, 1.74 ± 0.37, and 1.25 ± 0.26 cm(2), and the mean measured EOA index (EOAI) were 1.17 ± 0.12, 1.11 ± 0.21 and 0.90 ± 0.22 cm(2)/m(2), respectively. A PPM (EOAI ≤0.85) was documented in 5 patients, all of whom had received a 17-mm SJMR valve. AVR with SJMR valves of 21 mm or less in size appears to show satisfactory clinical and hemodynamic results.
Subject(s)
Aortic Valve/surgery , Heart Valve Diseases/surgery , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis , Adult , Aged , Aged, 80 and over , Aortic Valve/diagnostic imaging , Aortic Valve/physiopathology , Disease-Free Survival , Female , Heart Valve Diseases/diagnosis , Heart Valve Diseases/physiopathology , Heart Valve Prosthesis Implantation/adverse effects , Hemodynamics , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Prosthesis Design , Retrospective Studies , Time Factors , Treatment Outcome , UltrasonographyABSTRACT
Vascular complications after the intravesical instillation of Bacillus Calmette-Guérin (BCG) therapy are extremely rare. We experienced a case of abdominal aortic aneurysmal infection excluded by a stent graft with an iliopsoas abscess after intravesical instillation of BCG therapy that required reoperation. Five years ago, an 81-year-old man was diagnosed with transitional cell carcinoma of the bladder. After transurethral resection of the bladder tumor and intravesical BCG therapy, a radical cystectomy was performed. Twenty-four months after intravesical BCG therapy, follow-up an abdominal computed tomographic (CT) scan revealed an aortic abdominal aneurysm. Endovascular aneurysm repair was performed, and the aneurysm was excluded postoperatively. Thirty months after the endovascular aneurysm repair (and 54 months after intravesical BCG therapy), a follow-up abdominal CT revealed a low-density area in the right iliopsoas muscle that formed a fistula to the excluded aneurysm. We performed CT-guided iliopsoas abscess drainage and collected yellow pus. Polymerase chain reaction analysis revealed that the pus was positive for Mycobacterium tuberculosis complex. The patient was diagnosed with abdominal aortic aneurysmal infection associated with iliopsoas abscess caused by Mycobacterium bovis, and surgery was performed. We performed an extra-anatomical bypass and removed the stent graft with debridement. When the aneurysmal wall was incised and resected, yellow pus surrounded the stent graft. In addition, a large fistula was present between the right posterolateral aortic aneurysmal wall and the iliopsoas abscess cavity. After the operation, the histopathological examination of excised abdominal aortic aneurysmal wall tissue revealed an epithelioid granuloma with caseous necrosis involving multinucleated giant cells, indicating M tuberculosis complex infection. Although the intravesical instillation of BCG therapy is considered safe, complications resulting from vascular infections can arise in extremely rare cases. The complication described in this case report emphasizes the need to cautiously select treatment for a mycotic aortic aneurysm after intravesical instillation of BCG therapy.
Subject(s)
Antineoplastic Agents/adverse effects , Aortic Aneurysm, Abdominal/surgery , BCG Vaccine/adverse effects , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis/adverse effects , Endovascular Procedures/adverse effects , Mycobacterium tuberculosis/pathogenicity , Prosthesis-Related Infections/microbiology , Psoas Abscess/microbiology , Tuberculosis, Cardiovascular/microbiology , Administration, Intravesical , Aged, 80 and over , Antineoplastic Agents/administration & dosage , Antitubercular Agents/therapeutic use , Aortography/methods , BCG Vaccine/administration & dosage , Blood Vessel Prosthesis Implantation/instrumentation , Carcinoma, Transitional Cell/drug therapy , Chemotherapy, Adjuvant , Debridement , Device Removal , Drainage , Endovascular Procedures/instrumentation , Fistula/microbiology , Humans , Male , Mycobacterium tuberculosis/isolation & purification , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/surgery , Psoas Abscess/diagnosis , Psoas Abscess/surgery , Reoperation , Tomography, X-Ray Computed , Treatment Outcome , Tuberculosis, Cardiovascular/diagnosis , Tuberculosis, Cardiovascular/surgery , Urinary Bladder Neoplasms/drug therapySubject(s)
Blood Coagulation Disorders/etiology , Hemophilia A/classification , Multiple Trauma/complications , Shock, Hemorrhagic/etiology , Wounds, Nonpenetrating/complications , Accidents, Traffic , Adolescent , Blood Component Transfusion , Blood Loss, Surgical , Contusions/complications , Erythrocyte Transfusion , Humans , Lacerations/complications , Lung Injury/complications , Male , Motorcycles , Plasma , Platelet Transfusion , Spleen/injuries , SplenectomyABSTRACT
PURPOSE: The aim of this study was to investigate the primary echocardiographic results of aortic valve replacement using 21- and 19-mm Carpentier-Edwards Perimount Magna bioprosthesis aortic xenografts in patients with small aortic annulus. METHODS: Twenty patients (mean body surface area 1.63 ± 0.16 m(2)) underwent aortic valve replacement between June 2008 and December 2009. Eight and 12 patients received 21- and 19-mm Magna bioprostheses, respectively. After 12 months, hemodynamic data were obtained by echocardiography to estimate the prosthesis-patient mismatch. RESULTS: At follow-up, significant decreases in peak and mean left ventricular aortic pressure gradients were observed in the 12 patients with aortic stenosis (P < 0.05). Regression of the left ventricular mass was observed in all the patients (P < 0.05). The mean measured effective orifice area (EOA) and EOA index (EOAI) were 1.61 ± 0.28 cm(2) and 0.99 ± 0.16 cm(2)/m(2), respectively. Prosthesis-patient mismatch (EOAI ≤0.85) was documented in three patients. CONCLUSION: The primary echocardiographic findings suggested that the hemodynamic performance of the 19- and 21-mm Carpentier-Edwards Perimount Magna bioprostheses was satisfactory in the patients with a small aortic annulus.
ABSTRACT
PURPOSE: The purpose of this study was to examine the survival benefits of a workflow in which an interventional radiology (IR) team participates in a primary trauma survey on patients with hemodynamically unstable trauma. MATERIALS AND METHODS: A retrospective observational study was conducted between 2012 and 2019 at a single institution. Patients who underwent an IR procedure as the initial hemostasis were assigned to the hemodynamically stable group (HSG) or hemodynamically unstable group (HUG). The primary and secondary outcomes were survival at hospital discharge compared with the probability of survival (Ps) and the time course. RESULTS: A total of 160 patients (100 men, 60 women; median age, 57.5 years [interquartile range (IQR): 31.5-72 years]) with an injury severity score of 24 (IQR: 13.75-34) were included. A total of 125 patients were included in the HSG group and 35 patients in the HUG group. The observational survival rate was significantly greater than the Ps rate by 4.9% (95% confidence interval [CI]: 1.6-8.4%; P = 0.005) in HSG and by 24.6% in HUG (95% CI: 16.9-32.3%; P < 0.001). The observational survival rate was significantly greater than Ps in HUG than in HSG (P < 0.001). The median time to initiate IR procedures and the median procedure time in HUG were 54 min [IQR: 45-66 min] and 48 min [IQR: 30-85 min], respectively; both were significantly shorter than those in the HSG. CONCLUSION: A trauma workflow utilizing an IR team in a primary survey is associated with improved survival of patients with hemodynamically unstable trauma when compared with Ps with a shorter time course.
Subject(s)
Embolization, Therapeutic , Radiology, Interventional , Embolization, Therapeutic/methods , Female , Humans , Injury Severity Score , Male , Middle Aged , Retrospective Studies , Survival RateABSTRACT
BACKGROUND AND AIM OF THE STUDY: Mitral annular calcification (MAC) occurs mainly at the posterior half of the annulus, and is often seen in dialysis-dependent patients who have a high risk for cardiac surgery. A simple supra-annular prosthesis insertion ('half-and-half') technique was applied to five dialysis patients with extensive MAC to prevent catastrophic complications. METHODS: Five dialysis patients with extensive MAC underwent mitral valve replacement (MVR) using the 'half-and-half' technique. In all patients, everted mattress sutures were anchored to the left atrial wall just around the posterior half of the calcified annulus with minimum debridement, while horizontal mattress sutures were placed from the left ventricular side to the left atrial side on the non-calcified anterior half of the annulus. In one patient with an entirely calcified annulus who underwent double valve replacement, the anterior MAC was removed through the aorta to enable mitral valve sutures to be placed on the annulus. St. Jude Medical (SJM) valves were secured in the supra-annular position in all patients. RESULTS: No valve dysfunction was observed in any patient. Among the four hospital survivors, there were no valve-related events, except for a trivial paravalvular leak in one patient, during follow up periods ranging from 11 to 33 months. CONCLUSION: This simple supra-annular prosthesis insertion technique was safely and easily performed with minimum debridement of the calcified annulus in five dialysis patients. The technique may represent an alternative approach for high-risk patients with extensive MAC. The SJM valve, with its hinge protruding into the atrial side, is suitable for use in this technique.
Subject(s)
Calcinosis/surgery , Heart Valve Diseases/surgery , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis , Kidney Diseases/therapy , Mitral Valve/surgery , Renal Dialysis , Aged , Calcinosis/complications , Calcinosis/diagnostic imaging , Debridement , Female , Heart Valve Diseases/complications , Heart Valve Diseases/diagnostic imaging , Heart Valve Prosthesis Implantation/adverse effects , Humans , Japan , Kidney Diseases/complications , Male , Middle Aged , Mitral Valve/diagnostic imaging , Prosthesis Design , Risk Assessment , Suture Techniques , Time Factors , Treatment Outcome , UltrasonographyABSTRACT
A persistent sciatic artery (PSA) is a rare congenital malformation, frequently complicated by atherosclerotic changes such as aneurysmal formation. Optimal treatment is dependent on the individual situation. We report a case of a PSA aneurysm complicated by lower limb ischemia. Graft interposition with distal balloon angioplasty and thrombectomy from the posterior transgluteal approach was performed successfully, without any complications.
Subject(s)
Aneurysm/complications , Iliac Artery/abnormalities , Ischemia/etiology , Leg/blood supply , Sciatic Nerve/blood supply , Vascular Malformations/complications , Vascular Surgical Procedures/methods , Aneurysm/diagnosis , Diagnosis, Differential , Female , Humans , Iliac Artery/surgery , Ischemia/diagnosis , Ischemia/surgery , Middle Aged , Stents , Tomography, X-Ray Computed , Vascular Malformations/diagnosis , Vascular Malformations/surgeryABSTRACT
AIM: The mortality rates among elderly patients with open abdomen (OA) are high, and pre-existing comorbidities could affect the outcomes. However, long-term prognosis remains uncertain. We examined long-term outcomes in elderly patients with OA, focusing on physical functional status. METHODS: We undertook a retrospective cohort study between 2007 and 2017 at a single institution. Patients with OA who were aged ≥65 years were categorized into two groups: "good preoperative functional status" group (GFG) and "poor preoperative functional status" group (PFG). The GFG was defined as Eastern Cooperative Oncology Group/World Health Organization performance status (PS) 0-1, whereas PFG was defined as PS 2-4. The primary outcomes were survival and PS 2 years following the initial surgery. RESULTS: Of the 53 participants, 38 and 15 were assigned to the GFG and PFG, respectively. The PFG (median age, 81 years) was older than the GFG (median age, 75.5 years; P = 0.040). The 2-year survival rate was 39.5% in GFG and 6.7% in PFG, and Kaplan-Meier analysis showed significant difference (P = 0.022). Among all patients, the PS at 2 years was worse than that at discharge (P = 0.007). Preoperative PS was correlated with 2-year survival (P = 0.003), whereas age and pre-existing comorbidities were not. CONCLUSION: The long-term outcomes of elderly patients with OA are affected by the preoperative physical functional status. Functional status deteriorates in a time-dependent manner. Therefore, surgery requiring OA must be carefully considered for elderly patients with PS 2 or higher.
ABSTRACT
A 72-year-old woman presented with a post-infarction ventricular septal defect, presumably within 10 days after the onset of acute myocardial infarction. An emergency surgery was performed because of hemodynamic instability. Using the sandwich patch technique, we approached the posteriorly oriented defect through a right atriotomy and detached tricuspid valve. By avoiding either left or right ventriculotomy, additional damage to the already infarcted ventricle and risk of bleeding were avoided. The patient showed an uneventful postoperative recovery, with no residual shunt detected. A transatrial approach combined with a sandwich patch technique is a good alternative in cases where the pathological anatomy is suitable.
Subject(s)
Heart Atria/surgery , Heart Septal Defects, Ventricular/surgery , Myocardial Infarction/complications , Postoperative Complications , Acute Disease , Aged , Female , Heart Septal Defects, Ventricular/etiology , Heart Ventricles/surgery , Humans , Postoperative Period , Tricuspid Valve/surgeryABSTRACT
Two cases of infective endocarditis after pacemaker implantation were reported. Complete removal of infected devices was performed under cardiopulmonary bypass, and simultaneous implantation of new devices was performed using epicardial leads and generator on the abdominal wall. The postoperative course was uneventful and recurrence was not recognized. These procedures may be suitable for the patients who depend on the pacemaker or who have repeat bacteremia with other infectious disease or conditions.
Subject(s)
Device Removal/methods , Endocarditis, Bacterial/surgery , Pacemaker, Artificial/adverse effects , Staphylococcal Infections/surgery , Staphylococcus aureus/isolation & purification , Aged , Atrioventricular Block/therapy , Echocardiography , Endocarditis, Bacterial/diagnosis , Endocarditis, Bacterial/microbiology , Female , Humans , Male , Pacemaker, Artificial/microbiology , Staphylococcal Infections/diagnosis , Staphylococcal Infections/microbiologyABSTRACT
There is good evidence for the effectiveness of exposure-based cognitive-behavioral therapy (CBT) in the treatment of social anxiety disorder (SAD). In this article, the Clark's cognitive model of SAD is presented, followed by the description of general CBT strategies, such as the shift from internal to external attention and the correction of anticipatory/postevent processing. Typical schemata in SAD and comorbid avoidant personality disorder are then illustrated, along with schema-focused approaches. Finally, a four-step CBT for SAD is suggested.
Subject(s)
Anxiety Disorders/therapy , Cognitive Behavioral Therapy/methods , Phobic Disorders/therapy , Anxiety Disorders/psychology , Cognition , Female , Humans , Male , Models, Psychological , Phobic Disorders/psychology , Social EnvironmentABSTRACT
A 66-year-old man presented with a one month history of hoarseness. Left recurrent nerve palsy and a left upper mediastinal mass were observed by an otorhinolaryngologist who referred the patient to our department. Chest computed tomography showed a superior mediastinal mass, which seemed to involve the left common carotid and left subclavian arteries from the greater curvature of the aortic arch. The innominate vein was compressed, and collateral circulation was well developed. The left upper lobe of the lung was also seemed involved. A mediastinal biopsy conducted via left thoracoscopy revealed a malignant spindle cell tumor. The mediastinum was irradiated (40 Gy), and surgical extirpation was subsequently undertaken 3 weeks later. The tumor was successfully removed without the use of extracorporeal circulation. Because only smooth muscle actin was focally but strongly expressed immunohistochemically, leiomyosarcoma was confirmed. The patient was discharged on day 14. A solitary left pleural metastasis was observed and resected 12 months after the surgery and the patient is well without further recurrence 16 months after the initial surgery.
Subject(s)
Aorta, Thoracic/pathology , Carotid Artery, Common/pathology , Leiomyosarcoma/pathology , Mediastinal Neoplasms/pathology , Subclavian Artery/pathology , Aged , Biomarkers, Tumor/analysis , Biopsy , Hoarseness/etiology , Humans , Immunohistochemistry , Leiomyosarcoma/chemistry , Leiomyosarcoma/complications , Leiomyosarcoma/secondary , Leiomyosarcoma/therapy , Male , Mediastinal Neoplasms/chemistry , Mediastinal Neoplasms/complications , Mediastinal Neoplasms/therapy , Neoadjuvant Therapy , Neoplasm Invasiveness , Pleural Neoplasms/secondary , Pleural Neoplasms/surgery , Radiotherapy, Adjuvant , Reoperation , Thoracic Surgical Procedures , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
Subclavian artery aneurysms are comparatively rare in peripheral aneurysms. We experienced a case of intrathoracic aneurysm originating from the proximal part of the right subclavian artery. A 78 year-old man was referred to our hospital with the diagnosis of a right subclavian artery aneurysm. Enhanced computed tomography demonstrated an intrathoracic aneurysm, originating from the right subclavian artery just proximal of its origin. Through a median sternotomy and supra-infraclavicular incision, we reconstructed the brachiocephalic and right common carotid arteries and bypassed to the distal part of the right subclavian artery by using a T-shaped vascular graft and the aneurysm was excluded.
ABSTRACT
Early diagnosis and treatment of prosthetic valve endocarditis (PVE) is important because it has a high mortality rate. We report a case of PVE which was difficult to diagnose. A 36-year-old man, who had undergone an aortic valve replacement (AVR) 7 years prior, was hospitalized with a high fever of unknown origin. We could not detect a stuck valve, vegetations or abscesses using echocardiography, and the peak aortic transvalvular pressure gradient had increased to 81 mmHg. We suspected PVE and initiated intravenous antibiotic therapy immediately. On day 5, echocardiography demonstrated an abnormal shadow directly under the prosthesis, and we definitively diagnosed PVE and performed an operation. Intraoperatively, the prosthesis was not vegetative, but the left ventricular outflow tract was filled with vegetation that was nearly obstructing it. After dissecting the infectious focus, we performed a re-AVR. Postoperative echocardiography showed that the peak left ventricular aortic pressure gradient decreased to 30 mmHg. Obstructive vegetation is difficult to diagnose by preoperative echocardiography.
Subject(s)
Aortic Valve/surgery , Endocarditis/diagnosis , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis/adverse effects , Prosthesis-Related Infections/diagnosis , Adult , Anti-Bacterial Agents/therapeutic use , Device Removal , Endocarditis/diagnostic imaging , Endocarditis/etiology , Endocarditis/surgery , Fever of Unknown Origin/etiology , Heart Valve Prosthesis Implantation/instrumentation , Humans , Male , Prosthesis-Related Infections/diagnostic imaging , Prosthesis-Related Infections/etiology , Prosthesis-Related Infections/surgery , Reoperation , Treatment Outcome , UltrasonographyABSTRACT
A 73-year-old man who had undergone surgery for lingual cancer, followed by radiation therapy and chemotherapy, presented with severe dyspnea. A chest radiograph revealed a left tension pneumothorax. An immediate tube thoracostomy alleviated his dyspnea. A chest computed tomography scan showed multiple large cystic tumors in both lungs. Squamous cell carcinoma was cytologically proven in the pleural effusion. A malignant bronchopleural fistula due to a metastatic pulmonary tumor was diagnosed. Surgical interventions were tried twice. However, air leakage occurred when the rapidly recurring tumor caused bilateral pneumothoraces. Thus, bronchoscopic closure was conducted. A flexible video bronchoscope and a thin catheter were inserted into the targeted left bronchiolus. The lumen of the catheter was filled with water. Cyanoacrylate glue and lipiodol were mixed in 2 syringes, and the mixture was slowly injected and then flushed with water. As soon as the lipiodol accumulation was visualized by radiograph fluoroscopy, the air leakage stopped. Pleurodesis with the intrathoracic administration of OK-432 was added to both pleural cavities, and the left and right chest tubes were removed on the third and fifth days, respectively. The patient was discharged the following day. However, he died of the disease a month later.