A Case of Deaf-mute Patient Requiring Ingenuity in Communication Who Complicated Advanced Stage Lung Cancer to Chronic Myeloid Leukemia

Those involved in end-of-life care need to understand the patient’s view of life and values, and support them so that they can approach the end of their lives in a way that suits them, and this requires sufficient communication. We report a deaf-mute patient who developed advanced lung cancer during treatment of chronic myeloid leukemia. The communication with him was difficult for those who did not use sigh language routinely, but through trial and error, we tried to build a good relationship through nonverbal communication as well as sign language and written communication. It was necessary to recognize and understand that deaf-mute people have different living environments and communities and have their own language and culture. These experiences can be utilized for the treatment of cancer patients in daily clinical practice, and it is considered that the attitude of the medical worker to approach the patient is necessary for mutual understanding.

Risk Assessment for a Learning Curve in Endovascular Abdominal Aortic Aneurysm Repair with the Zenith Stent-Graft: The First Year in Japan / 日本心臓血管外科学会雑誌

In Japan, doctors inexperienced stent-graft new devices are required to secure agreement on criteria and choice of the device size in endovascular aneurysm repair (EVAR) from experienced doctors. It was hoped that strict patient selection might reduce the learning curve for initial successes in given procedures. In a leading center in Japan, a number of cases which were scheduled for operation at other institutes were evaluated anatomically. We surveyed the initial success of Zenith AAA system implantation in the remaining cases by inexperienced doctors and evaluated the results. This study aimed to verify the validity of strict patient selection in improving the success rate of inexperienced doctors. We enrolled 112 consecutive patients from 19 institutes, who were scheduled for repair between January and October in 2007. All patients were evaluated on the basis of a less-than-3mm reconstructed CT image. Mean patient age was 76±5.7 years. All cases satisfied the Zenith's anatomic prerequisites. Fifteen cases were excluded for various reasons, the major reason being insufficiency of the proximal landing zone (LZ) length, angle and contour. The second reason was difficulty to approach via the iliac artery. Ninety seven cases were included, of which 17 cases were low-risk candidates for EVAR. Medium-risk seventy two cases requiring some advice to avoid problems with device size, technique of implantation and choice of main-body side. Eight cases were high-risk, requiring the presence of an experienced surgeon. Excluded cases had significantly shorter proximal LZ, larger aortic diameters 15mm below the renal artery and tortuous access routes on preliminary measurement by inexperienced doctor. Perioperative mortality was 0%, while the major complications were injury to the iliac artery in one high-risk case and thromboembolism of the superficial femoral artery in another. Perioperative proximal type I endoleak occurred in 5 cases. In 3 of these cases, the endoleak was eliminated by implantation of a Palmatz stent. In the other 2 cases, it disappeared within a month without additional procedures. These cases had a significantly greater angle between the proximal LZ and the suprarenal aorta and significant amount of mural thromboses in the proximal LZ. Perioperative type III endoleak occurred in 3 cases. In all cases the endoleak was eliminated by additional procedure. Perioperative type II endoleak occurred 8 cases. In 3 of these cases, the endoleak disappeared within a month. In the 5 other cases, the endoleak did not disappear. Mid-term results showed iliac leg thromboembolism in one case and new type II endoleaks in 3 cases. Type II endoleak occurred in cases which had significantly greater angles between the proximal LZ and the aneurysm. The results which were evaluated in our center had excellent perioperative and mid-term outcomes. We think this evaluation system is effective for risk assessment and reduces the learning curve in EVAR. In anatomically marginal cases, it is possible for proximal type I endoleak and injury of the iliac artery to occur. It is impossible to exclude these marginal cases if treatment need for EVAR is a priority. In these cases, lessexperienced operators should be trained in troubleshooting techniques in advance.

A Case of Mitral Valve Regurgitation due to Infective Endocarditis with Mycotic Aneurysms of the Intracranial Artery and Superior Mesenteric Artery / 日本心臓血管外科学会雑誌

A 31-year-old man underwent mitral valve replacement because of mitral regurgitation due to continued active infective endocarditis despite antibiotic therapy. Because cerebral mycotic aneurysm was suggested by preoperative IVDSA (Intravenous Digital Subtraction Angiography), cerebral angiography was performed on the first postoperative day. Cerebral mycotic aneurysm was detected in the middle cerebral artery and emergency aneurysm trapping was successfully performed. Although the patient had no neurologic deficit and postoperative cardiac function was stable, impending rupture of the mycotic aneurysm of the superior mesenteric artery occurred suddenly on the twelfth postoperative day. Endovascular treatment using the coil-embolization technique was immediately performed, and the postoperative course was uneventful.

A Case of Aortic Valve Regurgitation due to Infective Endocarditis Associated with Multiple Organ Failure / 日本心臓血管外科学会雑誌

A 40-year-old man was admitted because of prolonged fever after extraction of teeth. Infective endocarditis, congestive heart failure and hepatorenal failure were diagnosed in a series of examinations. Electrocardiograms showed complete atrio-ventricular block and QT prolongation. After continuous hemodiafiltration (CHDF) and high doses of antimicrobials promptly initiated for the treatment of multiple organ failure, the aortic valve with regurgitation and vegetation was replaced with an artificial valve. Serious arrhythmias occurred after the operation, which disappeared by the administration of antiarrhythmic agents. In cases of infective endocarditis with multiple organ failure, preoperative intensive treatment such as CHDF in combination with high doses of antimicrobials and surgical intervention represent a good strategy for successful outcome.

A Case of Acute Tuberculous Pericarditis with Transient Constrictive Pericarditis for a Short Time / 日本心臓血管外科学会雑誌

A 32-year-old man was admitted with dyspnea on exertion and a prolonged common cold. Swelling of mediastinal lymph nodes, pericardial thickening and pleural effusion were detected by chest CT. Mycobacterial culture of sputa and pleural effusion were negative. Serum adenosine deaminase (ADA) activity was normal. A tuberculin test showed a positive reaction (20×15mm). Viral antibody titers (Coxsackie A9, echo 3, influenza B) were negative. Ten days after admission, the patient had pyrexia and low cardiac output symptoms. Right ventricular pressure curve cardiac catherterization showed a“dip and plateau”pattern which indicated constrictive pericarditis. We performed subtotal pericardiectomy (from the right phrenic nerve to the left phrenic nerve). Pathological examination of pericardium showed Langerhans' giant cell infiltration and caseous necrosis which could be diagnosed as tuberculosis. Although the patient had transient pleural effusion, symptoms disappeared postoperatively. At present there are no signs of recurrent infection.