Surgical Treatment of Primary Pulmonary Artery Sarcoma / 日本心臓血管外科学会雑誌

We present a 62-year-old woman who was diagnosed with primary pulmonary arterial sarcoma with pulmonary hypertension. CT showed a large defect inside both main pulmonary arteries in accordance with the accumulation of FDG-PET. To relieve the symptom and to prevent sudden death, removal of a massive pulmonary tumor and postoperative chemotherapy were planned. Utilizing the intermittent systemic circulatory arrest under deep hypothermia (18°C), the pulmonary artery trunk and both main pulmonary arteries were opened. The tumor stacking inside the pulmonary artery was removed and its origin at the commissure of the pulmonary artery valve was resected. The defect was repaired with a pulmonary valve replacement. Histopathological examination revealed high grade sarcoma. Her postoperative course was uneventful ; however, she died of cerebral hemorrhage during chemotherapy six months after surgery.

Utility of the Isolation Technique for Total Arch Replacement in Patients with a Shaggy Aorta / 日本心臓血管外科学会雑誌

Introduction : Prevention of embolic stroke is the key issue to perform aortic arch replacement in patients with a shaggy aorta. The aim of this study is to report the utility of the isolation technique for total arch replacement in patients with a shaggy aorta. Methods : Clinical results of seven patients (71.7 years old, all men) with a shaggy aorta who underwent total arch replacement between January 2017 and November 2018 were retrospectively reviewed. The operative indications were a distal arch or proximal descending aortic aneurysm in 6 patients and a thrombus inside brachiocephalic artery in one. A cerebral perfusion was established by inserting a cannula directly into all supra-aortic branches before starting systemic perfusion. Result : Utilizing the isolation technique with clamping of all branches in 4 patients and the functional isolation technique with clamping of two branches in 3, total arch replacement was performed in all patients (operation time : 513 min, selective cerebral perfusion time : 162 min). No operative death was observed and no newly developed stroke was encountered. Conclusion : The isolation technique is a useful method to prevent stroke during total arch replacement in patients with a shaggy aorta.

Cerebral Infarction after Hybrid Arch TEVAR / 日本心臓血管外科学会雑誌

Among 62 patients who underwent hybrid arch TEVAR, which is a combination of supra-aortic bypass and TEVAR to treat arch aneurysm, 5 patients encountered postoperative cerebral infarction. In 2 patients, whose thoracic aorta were extremely shaggy, cerebral infarction were multiple and fatal. Other 3 patients, whose aorta were not shaggy, developed visual disturbance after TEVAR and minor cerebral infarction were detected in the area of vertebral artery. To prevent cerebral infarction after hybrid arch TEVAR, the blood flow from the left subclavian to vertebral artery is considered to be significant.

A Case of Transfusion-Related Acute Lung Injury after Total Arch Replacement for a Thoracic Aortic Aneurysm / 日本心臓血管外科学会雑誌

An 84-year-old man with a thoracic aortic aneurysm underwent total arch replacement with selective antegrade cerebral perfusion. Immediately after the operation, respiratory distress and hypotension developed and Chest X-ray films and computed tomography showed bilateral lung edema. Echocardiography showed a small, underfilled left ventricle, but with preserved systolic function. We suspected transfusion-related acute lung injury (TRALI), and started sivelestat and steroid pulse therapy. His respiratory condition gradually improved, and he was discharged on postoperative day 78. The diagnosis of TRALI was confirmed by positive test results of an HLA class I antibody in the transfused fresh frozen plasma and T- and B-cells of the patient. TRALI should be considered as a cause of acute lung injury after surgery with blood transfusion.

A Ruptured Abdominal Aortic Aneurysm with Cardiopulmonary Arrest Survived from MOF following Bowel Necrosis / 日本心臓血管外科学会雑誌

A 61-year-old man fell into out-of hospital cardiopulmonary arrest due to rupture of an abdominal aortic aneurysm, and was resuscitated onsite. On arrival at the emergency room, a fusiform type abdominal aortic aneurysm and massive hematoma in the retro-peritoneal space were detected by ultrasonography. Quickly, an aortic occlusion balloon catheter was placed at the proximal site of abdominal aorta through the left brachial artery, and then graft replacement of the aneurysm was carried out. The inferior mesenteric artery was occluded, and was not reconstructed. Five hours after the operation, left hemi-colectomy was carried out for ischemic necrosis of the descending to sigmoid colon. Although he was complicated by multiple organ failure; renal failure, liver dysfunction, severe infection, and brain infarction, he survived without a fatal disability. A rare case with ruptured abdominal aortic aneurysm who fell into cardiopulmonary arrest outside the hospital but survived after bowel necrosis and multiple organ failure is reported.

A Case of Embolectomy for Acute Pulmonary Embolism without Shock / 日本心臓血管外科学会雑誌

A 73-year-old woman complaining of increased dyspnea, but no shock, was admitted under an echographic diagnosis of right atrial tumor. Echo-cardiogram at the time of admission did not reveal the right atrial tumor, and a massive pulmonary embolus was detected a pulmonary arteriography. After the infusion of tissue plasminogen activator and heparin, pulmonary arterial systolic pressure was decreased from 66 to 43mmHg, and dyspnea was improved. However, repeated pulmonary arteriograms showed no change of the pulmonary embolus, thus emergency pulmonary embolectomy was indicated. Massive thrombi, which were suspected to have moved from the lower extremities, were successfully removed. During operation, the following critical events were encountered; shock during IVC taping and severe hypoxia immediately after the pulmonary revascularization. These problems were successfully controlled by partial extracorporeal circulation. Pulmonary pressure decreased to 25mmHg postoperatively and she is doing well with anticoagulant therapy.

A Case of Blue Toe Syndrome and Myonephropathic Metabolic Syndrome with Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 49-year-old man presented in emergency center with complaints of severe lumbago and severe pain of the right lower limb. Symptoms were suggestive of hernia nuclei pulposi and he was referred to orthopedic department of our hospital. His pain was not relieved by analgesics and the right lower leg was cyanotic with a swollen, hard, and tender calf. On palpation a pulsating mass was revealed in the mid-abdomen. He was transferred to the cardiovascular floor. CT and IA-DSA revealed an abdominal aortic aneurysm and no occlusion of the major arteries of the right lower leg. The serum glutamic oxaloacetic, lactic dehydrogenase levels all increased especially the creatinine phosphokinase increased to 46, 460IU/<i>l</i>, and the urine myoglobin level was 4, 200ng/ml. Myonephropathic metabolic syndrome (MNMS) was suspected. Urine volume was maintained with fluid infusion and diuretics. The blood urea nitrogen and potassium levels remained within normal limits throughout the course. The immediate recognition of MNMS and treatment of the condition were successful in preventing serious complications. But all the toes of the right foot became necrotic and they were amputated. Two months after admission, replacement of the abdominal aortic aneurysm was performed successfully. The patient was discharged in good condition one month after the operation.

Coronary Artery Bypass Grafting in Two Chronic Hemodialysis Patients / 日本心臓血管外科学会雑誌

Two hemodialysis patients underwent coronary artery bypass grafting. Emergency coronary artery bypass grafting was performed in one patient with unstable angina and acute left ventricular failure. The other patient underwent a combined operation of coronary artery bypass grafting and replacement of abdominal aortic aneurysm. In both patients, hemofiltration was used during cardiopulmonary bypass. In the early postoperative periods, peritoneal dialysis and extracorporeal ultrafiltration method (ECUM) were used in Case 1, while Case 2 was treated by hemofiltration and ECUM. Postoperative coronary angiography showed that all grafts of both patients were patent, and both patients weve discharged from hospital without angina.