[Asymptomatic Chronic Expanding Hematoma Following Previous Cardiac Surgery Diagnosed by Computed Tomography-guided Biopsy:Report of a Case].

A 48-year-old man was referred to our hospital with an intrapericardial mass, which was incidentally found by computed tomography( CT) in a health check-up. He had undergone surgical closure of atrial septal defect 23 years ago. Although echocardiography and CT revealed compression of the right ventricle by a mass, he had no symptoms and echocardiography revealed no significant right ventricular overload. Magnetic resonance imaging revealed a mosaic pattern of various signal intensities. We performed a CT-guided biopsy, and the histological result was a hematoma. This was the first reported case of chronic expanding hematoma following previous cardiac surgery diagnosed by CT-guided biopsy.

Salvage of severe ischemic lower limb having peak creatine phosphokinase level exceeding 200,000 IU/L treated by continuous hemodiafiltration.

We performed revascularization by an anti-anatomical bypass in a 40-year-old man with extended ischemia of both legs beyond 12 hr after onset because of traumatic aortic dissection. This patient developed myonephropathic metabolic syndrome, including renal and circulatory failure accompanied by a creatine phosphokinase level above 200,000 IU/L. Nevertheless, his bilateral affected limbs were salvaged by intensive care based on aggressive hemocatharsis with continuous hemodiafiltration with treatment for poor hemodynamics and respiratory distress.

Prophylactic use of intra-aortic balloon pumps in open heart surgery.

During a 1-year period, intra-aortic balloon pumps (IABPs) were used in open heart surgery on 57 patients. Indications were prophylactic usage for coronary artery bypass grafting (CABG) in 52 patients, prophylactic usage for valve replacement in three patients, and cardiopulmonary bypass (CPB) weaning during valve replacement in two patients. The 52 CABG patients comprised 94.5% of all CABG procedures during the period. Sheathless 8 Fr IABPs were used in all cases. The 57 patients using IABPs were analyzed. The mean duration of IABP use was 41.7 h. Morbidity was not associated with using IABPs. There was one case of balloon rupture. Hemostasis was performed easily after removing IABP catheters by compressing the groin for approximately 15 min. The lowest blood pressure during anastomosis or cardiac arrest was also assessed. The lowest peak pressure was 55.9 ± 17.3 mm Hg for patients with IABP still turned on, and the lowest mean pressure was 34.7 ± 6.5 mm Hg for patients with IABP temporarily turned off. Peak blood pressure after CPB was 73.8 ± 17.8 mm Hg. During open heart surgery under anesthesia with the low blood pressure presented by this series, use of IABPs enabled patients to tolerate the procedure. In conclusion, aggressive use of IABPs is easy, safe, and effective with no related morbidity.

The endoscopic no-touch saphenous vein harvesting technique.

The no-touch saphenous vein harvesting technique is being increasingly used; however, this technique causes more leg wound complications than conventional techniques. Endoscopic saphenous vein harvesting is considered a safe and effective approach for reducing leg complications, despite the fact that experience with this technique remains limited, because leg CO2 insufflation and dissection with a tip cannula to isolate the vein enables the graft to naturally skeletonize.  In this video tutorial, we demonstrate our endoscopic no-touch saphenous vein harvesting technique using a reusable saphenous vein retractor system without CO2 insufflation and an electrothermal bipolar vessel sealing device.

Use of the No-Touch Saphenous Vein Harvesting Technique via Small Incisions.

There are substantial data in support of improved patency using the no-touch (NT) saphenous vein (SV) harvesting technique. However, wound complications correlated with such are more significant than those associated with the skeletonized technique. To solve this, we introduced the use of the electrothermal bipolar vessel sealing device via small incisions. In this study, a cordless retractor with a built-in LED light source was utilized. The NT-SV graft was harvested with a pedicle of surrounding tissue approximately 5 mm in size and attached to the main trunk. The intima, tunica media, adventitia, and vasa vasorum appeared normal by histological analysis. Our technique combines the potential advantages of a minimally invasive endoscope approach using bipolar electrothermy and the improved patency of a NT-SV.

Insecticide resistance in potential vector mosquitoes for West Nile virus in Japan.

Culex pipiens complex is the significant vector mosquito of West Nile virus. To take stock of the current situation of insecticide susceptibilities and design an ideal mosquito control strategy, we collected Culex pipiens pallens Coquillet, Culex pipiens form molestus Forskal, and Culex quinquefasciatus Say from fields in Japan and conducted bioassays for five larvicides (fenitrothion, temephos, etofenprox, diflubenzuron, and pyriproxyfen) by using a larval dipping method. Among five insecticides tested, obvious reduced susceptibilities were observed for etofenprox, which is the only pyrethroid compound registered as a larvicide in Japan. Twenty-two of 56 colonies exhibited a >10% survival rate at the etofenprox concentration of 5.7 microg/ml, which is a 10 times higher concentration of the working solution. The LC50 of a colony collected from Fukuoka prefecture for etofenprox exceeded 60 microg/ml (resistance ratio >2,307), and this colony also exhibited cross-resistance to other pyrethroids, permethrin (299-fold) and phenothrin (1,200-fold). The insect growth regulators diflubenzuron and pyriproxyfen were found to be sufficiently effective enough to control Culex larvae present, but decreased sensitivities to these insecticides were slightly detected in some colonies of Cx. p. form molestus collected from urban areas. Several etofenprox-resistant colonies of Cx. p. form molestus exhibited simultaneously decreased susceptibilities to other insecticides, including temephos, diflubenzuron, and pyriproxyfen.

Ascending aorta cannulation in acute type A aortic dissection.

OBJECTIVE: Antegrade perfusion for type A acute aortic dissection prevents malperfusion and retrograde cerebral embolism during cardiopulmonary bypass. Prompt establishment of antegrade perfusion via ascending aorta may improve the surgical results of type A dissections, especially in the situations of hemodynamic instability. Thus, we evaluated the efficacy of use of the dissected ascending aorta as an alternative arterial inflow. METHODS: Between 2002 and 2006, 32 patients underwent prosthetic graft replacement of the ascending aorta or hemiarch for acute type A aortic dissection. The ascending aorta was routinely cannulated, in addition to the femoral artery, with a heparin-coating flexible cannula for arterial inflow, using Seldinger technique, and by epiaortic ultrasonographic guidance (n=6). Antegrade systemic perfusion via ascending aorta was performed. RESULTS: Ascending aorta cannulation was safely performed in all cases. There was no malperfusion or thromboembolism due to ascending aorta cannulation. Cardiopulmonary bypass was established within 30 min after skin incision. There was one in-hospital death due to duodenal bleeding (1/32=3.1%), two cases of cerebral infarction (2/32=6.3%), and one case of pulmonary embolism. Twenty-nine patients (29/32=90.6%) were discharged in New York Heart Association class I and have been followed up uneventfully for a mean of 17 months. CONCLUSIONS: Antegrade perfusion via the ascending aorta was successfully performed with low mortality and morbidity. With ultrasound-guided Seldinger technique, ascending aorta cannulation has a potential to be a simple and safe option that enables rapid establishment of antegrade systemic perfusion in patients with acute type A aortic dissection.

Recurrent discrete subaortic stenosis and small aortic annulus successfully repaired by the Konno procedure in a young woman.

A 24-year-old woman who had undergone excision of the membrane for discrete subaortic stenosis when 6 years old displayed recurrent subaortic stenosis and had a small aortic annulus, with a peak pressure gradient of 60mmHg. We chose to perform the Konno operation with a mechanical valve. This released the left ventricular outflow tract obstruction adequately, and she recovered uneventfully with New York Heart Association functional class I. In our experience, an aggressive strategy such as myectomy is an appropriate initial procedure for preventing recurrence when the geometry of the problem may lead to recurrence in the left ventricular outflow tract. The Konno operation is a good option for recurrent subaortic stenosis with small aortic annulus.

Heterotopic transplantation of a decellularized and recellularized whole porcine heart.

OBJECTIVES: One of the final treatments for end-stage heart failure is heart transplantation. However, a shortage of donor hearts has created a long waiting list and limited benefits. Our ultimate goal is to create a whole beating heart fabricated on an organ scaffold for human heart transplantation. Here, we successfully performed the first transplantation using a decellularized whole porcine heart with mesenchymal stem cells. METHODS: A porcine heart was harvested following cardiac arrest induced by a high-potassium solution and stored at -80°C for 24 h. The porcine heart was completely decellularized with 1% sodium dodecyl sulphate and 1% Triton X-100 under the control of perfusion pressure (100 mmHg) and maintained at 37°C. A decellularized whole-heart scaffold was sterilized with gamma irradiation. Cultured mesenchymal stem cells were collected and either infused into the ascending aorta or injected directly into the left ventricular wall. Finally, recellularized whole-heart scaffolds were transplanted into pigs under systemic anticoagulation treatment with heparin. Coronary artery angiography of the transplanted heart graft was performed. RESULTS: In our decellularization method, all cellular components were removed, preserving the heart extracellular matrix. Heterotopic transplantations were successfully performed using a decellularized heart and a recellularized heart. The scaffolds were well perfused, without bleeding from the surface or anastomosis site. Coronary angiography revealed a patent coronary artery in both scaffolds. The transplanted decellularized heart was harvested on Day 3. Haematoxylin and eosin staining showed thrombosis in the coronary arteries and migrated inflammatory cells. Haematoxylin and eosin staining of the transplanted recellularized heart showed similar findings, with the exception of injected mesenchymal stem cells. CONCLUSIONS: To the best of our knowledge, this is the first report of heterotopic transplantation of a decellularized whole porcine heart with mesenchymal stem cells. The scaffolds endured surgical procedures. We detected short-term coronary artery perfusion in the transplanted scaffolds by angiography. Future studies should analyse the histological features of transplanted decellularized scaffolds and optimize the system for recellularization to apply this unique technology clinically.

Shallow stitching close to the rim of the ventricular septal defect eliminates injury to the right bundle branch.

BACKGROUND: Complete right bundle branch block carries a deleterious effect on the long-term outcome of patients who undergo surgical treatment of the perimembranous ventricular septal defect. We describe a novel suturing method to reduce the prevalence of complete right bundle branch block. METHODS: From March 1996 through December 2000, 48 consecutive patients with perimembranous ventricular septal defect underwent patch closure using shallow stitches placed close to the rim (group 1). The same number of patients was randomly selected from those who had previously undergone surgery using deep stitches placed distant from the rim (group 2). Postoperative electrocardiograms were reviewed to compare the prevalence of complete right bundle branch block between groups. A morphologic study of the conduction system was performed to identify the vulnerable segment of the right bundle branch where the surgical damage tended to occur. Additional analyses were made to determine whether younger age and right ventriculotomy increased the prevalence of complete right bundle branch block. RESULTS: The prevalence of complete right bundle branch block in group 1 (6.3%) was significantly (p < 0.0001) lower than in group 2 (43.8%). The result was consistent with the morphologic finding that stitches of group 2 tended to damage the right bundle branch and those of group 1 did not. The younger age and right ventriculotomy did not increase the prevalence of complete right bundle branch block. CONCLUSIONS: Shallow stitches placed close to the rim of the perimembranus ventricular septal defect eliminate injury to the right bundle branch.

Successful surgical repair of a ventricular septal defect and high take-off of the right coronary artery in an infant.

A 6-month-old boy was admitted in acute distress because of severe dyspnea and intractable congestive heart failure. With a diagnosis of the ventricular septal defect, pulmonary hypertension and deteriorated lung function due to the respiratory syncytial virus infection, he was taken to the operating room to undergo banding of the pulmonary artery. However, an intraoperative finding of the anomalous high take-off from the right coronary artery made us to discontinue the banding procedure. After intensive medical management, he underwent a successful surgical repair of the defect with no ischemic injury to the myocardium. Congenital cardiac defects having this particular subset of anomalies of the coronary artery need to be repaired primarily since the palliative procedure near the anomalous coronary artery has a potential hazard to compromise the flow of blood through this artery.

Repair of lacerated intrapericardial inferior vena cava after cardiac massage.

We successfully undertook surgical treatment of intrapericardial laceration of the inferior vena cava caused by external cardiac massage in a patient with acute coronary syndrome. Injury to the inferior vena cava without blunt trauma is very rare, and diagnostic imaging does not show it clearly, making it difficult to diagnose. Rapid and accurate judgment and management are necessary, because the mortality due to this injury is very high.

Novel single-stage operation and inflow source: for thoracic aortic aneurysm and limb ischemia.

Patients with thoracic aortic aneurysms sometimes also have peripheral vascular disease. In such cases, staged operations are usually performed in order to avoid additional morbidity. We have achieved good long-term outcomes in 2 patients with use of a single-stage surgical technique. Our novel procedure uses a pre-sewn side branch with a Dacron graft as the inflow source for the aortofemoral bypass during thoracic aortic aneurysm repair. As of 25 and 52 months' follow-up, these grafts were patent in our 2 patients. We believe that this procedure is a safe and easy single-stage operation that achieves favorable patency. To our knowledge, this is the first report to document the use of a pre-sewn perfusion branch of a Dacron graft as an inflow source for aortofemoral bypass.

Mediastinal hematoma: another lethal sign of aortic dissection.

Acute compressive hemomediastinum due to type A acute aortic dissection in a 70-year-old man caused acute simultaneous obstruction of pulmonary artery and superior vena cava, leading to sudden death, presenting acute progressive bruising of the upper half of the body and subsequent massive hemoptysis. Computed tomography scanning revealed acute severe stenosis of the superior vena cava and right pulmonary artery by mediastinal hematoma. Mediastinal hematoma combined with simultaneous obstruction of pulmonary artery and superior vena cava is a rare entity and should be recognized as one of the acutely fatal signs of type A dissection.

The use of intra-aortic balloon pump as cerebral protection in a patient with moyamoya disease undergoing coronary artery bypass grafting.

We performed coronary artery bypass grafting in an urgent and rare case of acute coronary syndrome with moyamoya disease in a 75-year-old female. Because of collateral dependent severe cerebrovascular obstruction, additional support for brain protection was necessary; we used high pressure pulsatile perfusion assist to maintain cerebral circulation with an intra-aortic balloon pump support throughout the cardiopulmonary bypass, giving a successful outcome.

Hypothermic circulatory arrest through a left thoracotomy in a 12-year-old child with aortic coarctation.

Surgical correction of adult complex aortic coarctation using hypothermic circulatory arrest often requires central cannulation to secure cerebral perfusion. It is not easy to place the cannula in the ascending aorta, however, especially in children undergoing surgery through a left thoracotomy. In a 12-year-old male with hypoplastic distal aortic arch, we placed an arterial cannula in the ascending aorta using the Seldinger puncture technique through the stenotic segment of the distal aortic arch. Replacement of the stenotic segment with a 20 mm-size Dacron graft was then routine. The ascending aorta was exposed only for the proximal anastomosis. The left subclavian artery was also reconstructed. This central cannulation technique is simple and is useful in repairing complex aortic coarctation.

Traumatic aortic regurgitation caused by a detached commissure.

Case reports of traumatic aortic regurgitation caused by detached commissures are rare. We report a case of a 56-year-old man involved in a traffic accident. During his hospitalization for subdural hematoma and pulmonary contusion, he began to suffer from heart failure. He was operated on under diagnosis of severe aortic regurgitaion. The commissure between the left and the noncoronary cusps was largely detached from the aortic wall, which was easily estimated to be the cause of the prediagnosed left cusp prolapse. His aortic valve was replaced, and his postoperative course was uneventful.

Teflon felt wrapping repair for coronary perforation after failed angioplasty.

Acute type III perforation caused by failed angioplasty is a lethal complication that often requires emergency operation. However, the presence of multiple rigid stents beneath the subepicardial hematoma disturbs optimal revascularization and hemostasis. Teflon felt (Meadox Medical Inc, Oakland, NJ) wrapping repair is a simple salvage technique that allows stable hemostasis and the rescue of the entire blood flow of the coronary artery. This procedure was successfully performed with type III perforation of the left anterior descending coronary artery on 2 patients subjected to multiple stenting.