ABSTRACT
The decoctions of unprocessed aconite root (uzu) were prepared with the tap water samples collected in Tianjin and Shanghai in China, and the contents of alkaloids in the decoctions were compared to those prepared with purified water or with tap water collected in Niigata, Japan. The contents of aconitine-type diester alkaloids (ADA) in the decoctions prepared with tap water collected in China were significantly lower than those with purified water or tap water in Niigata. It was speculated that this difference appeared by buffering effect of bicarbonic anion in tap water in China to decline pH of the decoction. When uzu was decocted with glycyrrhiza, ginger, or jujube, the contents of ADA in the decoctions exhibited the tendency to have higher levels than those prepared using unprocessed aconite root singly, and also this tendency was observed more remarkably when the decoctions were prepared with tap water collected in China. It was suggested that even the decocting period was fixed, unexpected change of the contents of ADAs might be induced by the differences in the properties of water used for decoction or the crude drugs decocted with aconite root. The physicians in the era when “Songban Shanghanlun” had established may have adjusted the contents of ADA in the decoction by carefully choosing the crude drugs combined to aconite root.
ABSTRACT
A 71-year-old man who had undergone repair of a ruptured abdominal aortic aneurysm with a tube graft 3 months ago was transferred from another hospital with an Aortoenteric Fistula (AEF) for surgical treatment. Computed tomographic (CT) angiography revealed pseudoaneurysm formation at the proximal anastomotic site. Waiting for the elective operation, he developed massive hematemesis with shock. Endovascular stent-graft repair was emergently performed because of high risk for conventional open surgery. Gastrointestinal bleeding was successfully controlled. The psuedoaneurysm disappeared, which was confirmed by postoperative CT angiography. At 1-year follow-up, he has shown no clinical and radiographic evidence of recurrent infection or bleeding. For the case with shock, Endovascular repair could be a bridge to open surgery because it is fast and minimally invasive. Endovascular repair of AEF is technically feasible and may be the definitive treatment in selected patients without signs of infection and gastrointestinal bleeding.
ABSTRACT
We reported a 74-year-old female complicated by ostial obstruction of the left main trunk after aortic valve replacement for severe aortic stenosis. At surgery, the length from the orifice of the left main trunk to the aortic annulus was 3 mm. After a 19 mm Carpentier-Edwards PERIMOUNT MAGNA was implanted in supra-annular position, the orifice of left main trunk was concealed by a sewing cuff of the bioprosthesis. Before aortic declamping, saphenous vein graft was bypassed to the left anterior descending artery. The postoperative course was uneventful. Computed tomography demonstrated the ostial obstruction of the left main trunk by the bioprosthesis.
ABSTRACT
The purpose of this study was to evaluate the efficacy of early rehabilitation starting on the day after cardiac surgery. In the early rehabilitation program, introduced from November 2006, we adopted an original video program about hospitalization and daily multi-specialist conference in the ICU. We divided 179 patients who underwent elective cardiac operation from June 2004 to September 2007 (mean age 65.4 years old, 51 women, 91 CABG, 53 valve procedures and 35 other procedure) into group A (the initial rehabilitation group : <i>n</i>=73) and group B (the early rehabilitation group : <i>n</i>=106). There were no significant differences in patient profile (age, gender, operation time etc.) between the two groups. The mean postoperative day of starting cardiac rehabilitation was 4.3+/-1.6 days in group A and 1.5+/-1.0 days in group B (<i>p</i><0.01). The mean achievement period of all walking distances in group B was significantly shorter than in group A as follows, 50 m : group A 5.4+/-2.2 vs. group B 3.1+/-1.5 days (<i>p</i><0.01), 100 m : group A 6.9+/-3.1 vs. group B 4.9+/-2.2 days (<i>p</i><0.01), 200 m : group A 8.5+/-3.9 vs. group B 6.5+/-2.5 days (<i>p</i><0.01), 300 m : group A 10.2+/-3.9 vs. group B 8.1+/-2.9 days (<i>p</i><0.01), 500 m : group A 14.5+/-6.1 vs. group B 11.9+/-3.8 days (<i>p</i><0.05). Approximately 90 per cent of patients in group B could walk by themselves on leaving the ICU. There were no major complications throughout rehabilitation. The mean hospital stay was 31.0+/-11.2 days for group A and 25.9+/-7.4 days for the group B, with a statistically significant difference (<i>p</i>=0.03). In a questionnaire survey at discharge, 91.0 per cent of patients in group B answered that early rehabilitation was most gratifying. In conclusion, early rehabilitation after cardiac surgery is effective for early recovery of ADL and leads to shorter hospital stay. We think both preoperative education and daily conferences are indispensable for safe and effective early rehabilitation programs.
ABSTRACT
With the progressive aging of the Japanese population, cardiac surgeons are increasingly faced with elderly patients. We have studied 29 consecutive patients, 80 years of age or older, who underwent aortic valve replacement at our institution between January 2000 and December 2003. Mortality, morbidity and late follow-up results were compared to those in 36 patients aged from 64 to 75 years old undergoing the same procedure over the same time period. The older patient group had a significantly higher incidence of calcified aortic stenosis and emergency operations and a higher score of NYHA functional class. Hospital mortality was 2 of 29 (6.9%) in the older patient group and 2 of 36 (5.6%) in the control group (ns). Postoperative renal failure and respiratory failure which needed prolonged ventilator support occured significantly more often in the older patient group. However, there was no significant difference between the 2 groups in terms of hospital stay. Almost all octogenarians showed improved NYHA functional class to class I or II after the operations. The actuarial survival rate was 89% in the older patient group and 78% in the control group at 3 years. The late survival rate and cardiac event-free rate were not significantly different between these 2 groups. Following aortic valve replacement, octogenarians, despite more compromised pre-operative status had good relief of symptoms, a favorable quality of life and a similar late survival to the younger patient groups. These findings support the recommendation that valve replacement should be performed in octogenarians with symptomatic aortic valvular disease.
ABSTRACT
A 62-year-old man, who had been given a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP), was admitted to our hospital for an operation for abdominal aortic aneurysm (AAA). Preoperative coronary angiography revealed severe triple vessel disease, and we chose to treat this first. The platelet count on his first admission was 2.1×10<sup>4</sup>/μl and preoperative immunoglobulin infusion was introduced for 5 days. Off-pump coronary artery bypass grafting (OPCAB) was performed safely with platelet transfusion, and he was discharged on the 14th postoperative day. Thirty-eight days later, graft replacement of AAA was performed with preoperative immunoglobulin infusion and no platelet transfusion, and he was discharged at the 11th postoperative day. Preoperative immunoglobulin infusion therapy and selection of OPCAB were useful to prevent perioperative bleeding complications. This is the first report of staged cardiac and aortic surgery in a patient with ITP.
ABSTRACT
A 74-year-old man was admitted to our hospital to undergo an operation for distal aortic arch aneurysm with chronic aortic dissection. The first operation was attempted through left lateral thoracotomy. Since the aorta had a severely calcified false lumen, conventional aortic replacement was considered to entail greater risk and graft replacement was given up. As an another option, endovascular stent grafting via the aortic arch through median sternotomy was selected as a second operation. Deep hypothermic circulatory arrest with selective cerebral perfusion was used during delivery and deployment of the stented graft through the aortotomy site. The distal stented graft was deployed into the true lumen at the ninth thoracic vertebral level. Neither endoleaks nor complications were observed. Postoperative computed tomography showed complete thrombosis of the distal aortic arch aneurysm and the false lumen. The postoperative course was uneventful. Transaortic endovascular stent grafting is an effective and less invasive treatment for aortic arch aneurysms with severely calcified aorta.
ABSTRACT
A 45-year-old man underwent total arch replacement for acute type A aortic dissection. Vital signs during the operation remained stable, but sinus tachycardia was recognized about 7h postoperatively, followed by a high level of PaCO<sub>2</sub>, low level of PaO<sub>2</sub> and metabolic acidosis. Then, blood pressure decreased, accompanied rapid elevation of body temperature to 39.7°C. Body temperature was decreased gradually by cooling the whole body, however, coma, anuria and hypoxemia persisted. A diagnosis of malignant hyperthermia was made and Dantrolene was administered. However, the patient died of multiple organ failure 7 days postoperatively. The serum level of CPK increased to 12, 446IU/<i>l</i> and serum myoglobin elevated to a very high level (36, 500ng/ml) 2 days postoperatively. Although, it is very rare for malignant hyperthermia to develop after open-heart surgery, physicians must keep this disease in mind if sudden hyperthermia of unknown origin is demonstrated.
ABSTRACT
A 70-year-old-woman was admmitted to receive an operation for aortic arch aneurysm. Total arch replacement was carried out under deep hypothermic circuratory arrest with selective cerebral perfusion. During sternal closure, her blood pressure dropped to 60/30mmHg suddenly, and massive venous bleeding started from the substernal space which turned out to be hemorrhage from the laceration of the pulmonary trunk. Controlling the bleeding by finger compression, rapid introduction of cardiopulmonary bypass was carried out and the laceration was closed by a pericardial patch. The postoperative course was uneventful. In this case, compression of the pulmonary trunk by the aortic arch aneurysm may have caused the fistula formation between them, and decompression of the aneurysm probably induced the rupture of the pulmonary trunk. If the preoperative computed tomogram had showed the compression of the pulmonary artery by the aneurysm, a careful exploration of the main pulmonary artery and a removal of the thrombus should have been performed, even when the preoperative diagnostic evaluation failed to reveal aortopulmonary fistula.
ABSTRACT
An 81-year-old woman developed abdominal pain after off-pump CABG (OPCAB) for unstable angina pectoris. X-ray film and CT scan showed paralytic ileus the day after surgery. A presumptive diagnosis of mesenteric ischemia was made and exploratory laparotomy was performed. During surgery, however, there was no sign of mesenteric ischemia. The patient still complained of abdominal pain after the laparotomy, so selective angiography of the mesenteric artery was performed. The angiography showed remarkable vasospasm of the superior mesenteric artery (SMA) and diagnosis of nonocclusive mesenteric ischemia (NOMI) was made and continuous intra-arterial perfusion of papaverine into the SMA was started. Control angiography during papaverine perfusion showed a clear reduction of vasospasm. Thereafter, the patient developed diffuse peritonitis due to intestinal gangrene on postoperative day 12 and was compelled to undergo extensive resection of the intestine and sigmoidectomy. She could not be weaned from the ventilator due to respiratory insufficiency and died of multiple organ failure about 5 months after OPCAB. NOMI can develop even in OPCAB, in which cardiopulmonary bypass is not required. Therefore maintenance of stable hemodynamics intraoperatively, careful management of the postoperative state and early diagnosis and therapy are essential to prevent NOMI.
ABSTRACT
A 65-year-old-man was admitted with congestive heart failure and septic shock associated with suspected mitral valve infective endocarditis. An echocardiogram revealed vegetation attached to the chordae, high density lesions in both papillary muscles, and severe mitral regurgitation. An emergency operation was performed. Vegetation was been attached to the chordae. Multiple myocardial abscesses were noted in both papillary muscles and surrounding myocardium. However, there were few noticeable lesions on mitral valve leaflets and annulus. The anterior mitral leaflet was resected together with the chordae and the papillary muscles containing the myocardial abscesses. Mitral valve replacement was performed using a 27mm SJM valve after the other myocardial abscesses were drained. <i>Klebsiella pneumoniae</i> was cultured from the vegetation and the myocardial abscesses. Cases of myocardial abscess associated with infective endocarditis at the site of the papillary muscles and in the areas of the myocardium are very rare. It was assumed that the myocardial abscesses were probably due to the septic state from infective endocarditis, since myocardial abscesses was recognized in multiple sites and at a distance from the valve leaflets and annulus.
ABSTRACT
A successfully treated case of a 73-year-old man with mycotic aneurysm of the iliac artery combined with psoas abscess was reported. The operation consisted of débridement of the infected arterial wall with arterial reconstruction using autologous reversed superficial femoral vein and wrapping the graft and filling the defects with omentum. <i>Streptococcus pneumoniae</i> was grown from the psoas abscess culture. He had peritonitis by gangrenous cholecystitis postoperatively and underwent reexploration for correction of the peritonitis. After his second operation, the postoperative course was uneventful. He is doing well 18 months postoperatively. Venous morbidity after superficial femoral vein harvest is minimal. <i>In situ</i> reconstruction with autogenous deep leg veins is a successful option in patients with mycotic aneurysms.
ABSTRACT
We encountered a case of femoro-popliteal bypass using the <i>in situ</i> saphenous vein bypass procedure employing a new valvulotome and technique of angioscopically assisted valvulotomy. The new combined angioscope and valvulotome system for the <i>in situ</i> saphenous vein bypass grafting is safe and effective for resection of valve leaflets and to avoid valvulotome-induced injury in comparison with blind retrograde valvulotomy, and allows minimal skin incision through identification of venous tributaries by angioscopic guidance. Further detailed clinical observation may be needed for the evaluation of the long-term benefits of this maneuver.
ABSTRACT
From January 1982 to August 1993, 23 cues of advanced renal cell carcinoma with tumor thrombus in the inferior vena cava (IVC) were treated surgically. In terms of clinical stage, 12 cases were in stage III and 11 cases were in stage IV. The 23 cases were divided into three groups according to the location of the tumor thrombus in the IVC. In two cases, the tumor thrombus extended to near the right atrium or the hepatic vein, and in six cases, the thrombus extended to the hepatic IVC. All these tumor thrombus with invasion to the IVC wall were removed under partial cardiopulmonary bypass. In 15 cases, tumor thrombus were limited to near the junction of the renal vein, which were removed by balloon catheter or finger after clamping of proximal and distal side of IVC and renal vein. Direct suture of the IVC wall in 12, patch repair with EPTFE in 10 and graft replacement with EPTFE graft in 1 were performed. Eight patients who had distant metastasis, regional lymph node metastasis and extracapsular invasion died within one year, but 4 patients were alive more than four years. Survival rate at three years and five years according to the Kaplan-Meier method was 37.5% and 18.8%, respectively. In conclusion 1) partial cardiopulmonary bypass was useful and could control bleeding when tumor thrombus in the IVC extended to the junction of the hepatic vein or right atrium. 2) long term survival cases were recognized in cases with no distant metastasis, no regional lymph node metastasis and no extracapsular tumor invasion. 3) nephrectomy associated with tumor thrombectomy in the IVC was valuable on the basis of long-term prognosis.
ABSTRACT
Direct observation of the intravascular atherosclerotic change provides many diagnostic information and supports successful vascular surgery. Angioscopic inspections were performed in the 23 patients who underwent laser angioplasty for the peripheral arteries and 7 patients with aorto-coronary bypass surgery in this study. Useful images could be obtained in 19 (83%) of 23 observations in the peripheral arteries, and the successful rates of angioscopic observation were influenced by the diameter and the degree of kinking of each vessel. On the other hand, intraoperative observation of coronary artery with angioscope could be performed easily in all cases. From these findings, intraoperative application of angioscopy was considered to be useful procedure for the cardiovascular surgery.