Two Cases of Valsalva Sinus Aneurysm with Rupture into the Right Atrium / 日本心臓血管外科学会雑誌

Valsalva sinus aneurysm (VSA) is a rare disease, especially that of Konno classification Type IV. When VSA ruptures, the patient has uncontrollable congestive heart failure because of massive left-right shunt. We encountered two cases with ruptured VSA of the right atrium. Case 1 : A 71-years-old man with a ruptured noncoronary VAS complained of dyspnea on effort. He underwent surgical treatment consisting of aneurysm resection and patch closure with Hemashield after medical treatment for congestive heart failure. He progressed well after operation and was discharged on the 14th postoperative day in stable condition. Case 2 : A 41-year-old man had heard systolic murmur. We diagnosed VSA rupture with echocardiography. He was symptomless but his left ventricle diastolic diameter was dilatated and Qp/Qs was 2.0 by blood gas sampling. He underwent elective surgical treatment consisting of aneurysm resection and patch closure with Hemashield. He was discharged on the 14th postoperative day in stable condition.

Successful Open-Surgical Treatment for a Secondary Aorto-esophageal Fistula and Broncho-mediastinal Fistula / 日本心臓血管外科学会雑誌

Patient: A 74-year-old man. Previous history: Total arch replacement for thoracic aortic aneurysm at 72 years old. History of current condition: The patient presented at a local otolaryngology clinic complaining of hoarseness of the voice. Left vocal cord paralysis was present, and as he had previously undergone thoracic vascular graft replacement, he was referred to our department. Further investigation with computed tomography (CT) revealed air in the mediastinum, and he was admitted for treatment of mediastinitis. Post-admission course: Upper gastrointestinal endoscopy revealed esophageal ulceration. After antibiotic treatment, thoracic subtotal esophagectomy via right thoracotomy, esophagostomy, and gastrostomy were performed on admission day 39. Vascular graft infection was also suspected, and antibiotic treatment was therefore continued. As some improvement in inflammatory response was evident, antibiotic treatment was discontinued and the patient's condition was monitored, but fever developed on day 107, and CT again revealed air in the mediastinum. Bronchoscopy revealed a broncho-mediastinal fistula in the left main bronchus. On day 110, repeated total arch replacement using a vascular graft, omentoplasty, and left main bronchus repair were performed via left thoracotomy. Esophageal reconstruction was left for later surgery, but follow-up CT on day 160 again revealed air in the mediastinum. Bronchoscopy was performed the same day and revealed a broncho-mediastinal fistula in the left main bronchus, located on distally from the previous fistula. This fistula was surgically closed on day 173. The subsequent course was favorable, and antethoracic esophageal reconstruction by jejunal elevation was performed on day 233. The patient was able to start eating on day 244, and was discharged in an improved condition on day 250.

Feasibility of metronomic chemotherapy with tegafur-uracil, cisplatin, and dexamethasone for docetaxel-refractory prostate cancer / Journal of Rural Medicine

<p><b>Objectives:</b> To evaluate the efficacy of tegafur–uracil (UFT), a prodrug of 5-fluorouracil, plus cisplatin and dexamethasone in patients with docetaxel-refractory prostate cancers.</p><p><b>Methods:</b> Twenty-five patients with docetaxel-refractory prostate cancer were administered oral UFT plus intravenous cisplatin (UFT-P therapy) and dexamethasone. Treatment responses were assessed monthly via prostate-specific antigen (PSA) level measurements. Treatment-related adverse events and overall survival were also assessed.</p><p><b>Results:</b> UFT-P therapy resulted in decreased PSA levels in 14 (56%) patients and increased PSA levels in 11 (44%). In patients with increased PSA levels, 7 (64%) of the 11 patients displayed decreased PSA doubling times. The UFT-P therapy response rate was 84% (21/25 patients). Imaging studies revealed that tumor shrinkage during UFT-P therapy occurred in 1 patient in whom bilateral hydronephrosis caused by lymph node metastasis improved. The median survival time from docetaxel initiation was 36 months. In UFT-P-treated patients, the median PSA progression and overall survival times were 6 and 14 months, respectively. UFT-P treatment-related adverse events were mild diarrhea, general fatigue, and anorexia. Treatment was not discontinued for any of the patients. UFT-P therapy did not cause serious hepatic or renal dysfunction or pancytopenia.</p><p><b>Conclusions:</b> UFT-P therapy is a safe and effective treatment for patients with docetaxel-refractory prostate cancer, although large-scale, multicenter, prospective studies are needed to validate these findings.</p>

Cardiovascular Surgery in Patients 85 or Older / 日本心臓血管外科学会雑誌

<b>Background</b> : This study was performed to evaluate surgical outcomes after cardiovascular surgery (including urgent surgery) in patients 85 or older. <b>Methods</b> : A retrospective analysis was performed on 39 patients (mean age, 86.3 years ; age range, 85-90 years) who underwent total arch replacement (<i>n</i>=4), ascending aorta replacement (<i>n</i>=4), descending aorta replacement (<i>n</i>=1), aortic valve replacement (AVR ; <i>n</i>=13), mitral valve replacement or valvuloplasty (<i>n</i>=3), coronary artery bypass grafting (CABG ; <i>n</i>=9), CABG+AVR (<i>n</i>=4), tumor resection (<i>n</i>=1) between June 2008 and December 2012 at Dokkyo Medical University Hospital. <b>Results</b> : Six hospital deaths occurred. One patient died due to bleeding from a ruptured descending thoracic aortic aneurysm, and another patient died due to gastrointestinal perforation from non-occlusive mesenteric ischemia (NOMI) after urgent AVR. The other deaths were related to various complications, including lung cancer, cholecystitis, myocardial infarction, and Takotsubo cardiomyopathy, during the postoperative period. Overall 30-day mortality was 2.6%, hospital mortality was 12.8%, duration of hospital stay after surgery was 41.3 days, duration of intensive care unit (ICU) stay was 3.8 days and ventilator time was 49.1 h. Twenty patients underwent elective surgery, and 19 patients underwent urgent surgery. The two groups had similar preoperative characteristics, except for the number of patients with aortic disease. No significant difference was evident in hospital mortality (26.3% vs. 5%, <i>p</i>=0.065) or 30-day mortality (0% vs. 5.3%, <i>p</i>=0.3) when comparing the two groups. However, the duration of hospital stay (58.9 days vs. 27.5 days, <i>p</i>=0.049), ICU stay (6.74 days vs. 1.05 days, <i>p</i>=0.002) and ventilator time (89.9 h vs. 8.2 h, <i>p</i>=0.006) was significantly longer in the urgent surgery group than in the elective surgery group. Fourteen patients (70%) in the elective surgery group and four patients (21.1%) in the urgent surgery group were able to be discharged from the hospital to their homes within 30 days after surgery. These data demonstrated that cardiovascular surgery in patients 85 years of age or older was associated with satisfactory outcomes, and outcomes associated with elective surgery were even better than those associated with urgent surgery. <b>Conclusions</b> : Therefore, advanced age does not represent a contraindication of conventional cardiovascular surgery. Rather, the decision for surgery should take the patient's preoperative condition, the severity of concurrent medical disease, the wishes of the patient, and the predicted functional outcomes into account.

A Left Ventricular Pseudoaneurysm Related to Infective Endocarditis in the Mitral Valve / 日本心臓血管外科学会雑誌

A 78-year-old woman who had undergone an axillobifemoral artery bypass with a prosthetic graft for Leriche syndrome presented 1 month later with cough and fever. A clinical examination revealed obvious redness in the right groin. Routine laboratory tests uncovered inflammation and methicillin-sensitive-<i>Staphylococcus aureus </i>was cultured from blood samples. Mitral valve vegetations were identified by echocardiography, and after a diagnosis of infective endocarditis, specific intravenous antibiotics were immediately administered. One month later, CT revealed a large pseudoaneurysm of the posterior left ventricular wall that had not been present at the time of admission. Transesophageal echocardiography and magnetic resonance imaging showed an aneurysmal cavity arising from the wall just below the posterior mitral valve leaflet. The patient agreed to undergo cardiac surgery due to the high likelihood that the pseudoaneurysm would rupture. The mitral annulus and leaflet were normal at surgery. We resected the posterior leaflet, closed the cavity using a Xenomedica patch, and reconstructed the leaflet. We did not remove the pseudoaneurysm using an extracardiac approach because the likelihood of damaging the coronary arteries and the coronary sinus was quite high. The postoperative course was uneventful. At follow-up 1 year later, the patient was afebrile and both CT and echocardiography showed that the cavity was completely filled by the thrombus. The imaging findings were useful in determining the surgical approach.

An Elderly Case of Ruptured Aortic Arch Aneurysm with Hemorrhagic Cardiac Tamponade / 日本心臓血管外科学会雑誌

An 82-year-old man was taken to a local clinic following the occurrence of syncope. Chest roentgenography and computed tomography (CT) findings led to a suspicion of a ruptured aortic aneurysm, and the patient was immediately transferred to our hospital. Upon admission, his consciousness was clear and blood pressure was 74/47mmHg. Enhanced chest CT images demonstrated pericardial effusion and a saccular aneurysm with a maximum diameter of 5cm, which was associated with a thrombus in the distal aortic arch. An emergency operation was performed under a diagnosis of a ruptured distal aortic arch aneurysm and hemorrhagic cardiac tamponade. During the procedure, a hole was found in the lesser curvature of the aneurysm, which had directly ruptured into the pericardial space, and a graft replacement of the aortic arch was performed using selective cerebral perfusion. The patient was discharged 19 days after surgery without any postoperative complications.

Clear Cell Sarcoma of the Kidney: A Case Report of an 11-year-old Boy and A Review of 11 Cases in Japan / Journal of Rural Medicine

An 11-year-old boy experienced right flank pain on October 12, 2005. The pain was once alleviated but recurred on the following day, and the patient visited our hospital on October 13, 2005. An imaging study revealed a tumor, sized approximately 12.0 × 7.5 × 8.0 cm, in the right kidney without metastases, for which right nephrectomy was performed. The tumor was solid, although degenerative necrosis and hemorrhage were partially observed inside the tumor. A histopathological study revealed poorly-defined, almost round tumor cells which were strongly stained with vimentin but not with cytokeratin or epithelial membrane antigen (EMA). Based on these findings, a diagnosis of clear cell sarcoma of the kidney in Stage II was made. A review of 10 previous cases reported in Japan during the past 10 years revealed that the affected patients were mostly aged 1 month to 4 years, while our case, occurring in an 11-year-old patient, was uncommon in respect to age.

A Case of Traumatic Tricuspid Regurgitation with Cyanosis Caused by Patent Formen Ovale / 日本心臓血管外科学会雑誌

A 47-year-old man was referred to our hospital for multiple rib fractures and pneumohemothorax due to a traffic accident. After admission, tricuspid valve regurgitation and hypoxemia were also diagnosed. Although fixation of the fractured ribs with plates and removal of hematoma in the pleural cavity were performed, hypoxemia did not improve. He was discharged on home oxygen therapy. Ten months and 3 years after the traffic accident, pulmonary perfusion scintigraphy suggested a right-to-left shunt. Transesophageal echocardiography demonstrated an opening of the foramen ovale and a right-to-left interatrial shunt. Direct closure of the patent foramen ovale and tricuspid valve replacement with the Carpentier-Edwards bioprosthesis were performed and hypoxemia disappeared after the second operation. Traumatic tricuspid valve regurgitation with cyanosis is extremely rare. However, it is important to take the possibility of patent foramen ovale into consideration in patients with traumatic tricuspid valve regurgitation and cyanosis.

Effect of Neoadjuvant Hormonal Therapy of Surgical Margin Status in Patients with Prostate Cancer Treated by Radical Prostatectomy / Journal of Rural Medicine

(Objective) Neoadjuvant hormonal therapy (NHT) before radical prostatectomy promotes the downstaging of primary lesions. A retrospective analysis was conducted of the relationship between NHT durations and positive surgical margin rates, as well as between positive surgical margin rates and three types of prostatectomy (antegrade radical prostatectomy, retrograde radical prostatectomy, and laparoscopic radical prostatectomy (LRP)).;(Materials and Methods) This study was a retrospective analysis of 257 patients treated with radical prostatectomy during the three years between April 2002 and March 2005. Of the 257 patients, 190 were treated by NHT. NHT durations were classified into “not conducted,” “<1 month,” “1-3 month,” “3-6 month” and “>6 month,” and the relationship between positive surgical margin rates and NHT durations was investigated. Seventy-four patients underwent antegrade radical prostatectomy, 131 were treated with retrograde radical prostatectomy, and 52 underwent LRP. Positive surgical margin rates were investigated according to the types of prostatectomy, as well as according to prostate-specific antigen (PSA) levels upon diagnosis.;(Results) Positive surgical margin rates were 53.8% in the “not conducted” and “<1 month” groups, 38.8% in the “1-3 month” group, 32.4% in the “3-6 month” group, and 10.7% in the >6 month” group. Positive surgical margin rates after open surgery (antegrade and retrograde) tended to decrease when NHT durations were longer, while those after LRP tended to increase inversely. No correlation was observed between PSA levels upon diagnosis and positive surgical margin rates or between presurgical PSA levels and NHT durations.;(Conclusion) Positive surgical margin rates were not significantly different when patients were treated with NHT for 1-3 months, but they tended to decrease when NHT was for >6 months. However, positive surgical margin rates after LRP increased when NHT continued for longer periods of time. This may the result of fibrous adhesion in the vicinity of the prostate due to long-term NHT which made the surgical margins unclear.

A Case of Successful Transcatheter Arterial Embolization of Ruptured Celiac Artery Aneurysm / 日本心臓血管外科学会雑誌

Celiac artery aneurysm is very uncommon. We report an even more rare case in which a life threatening ruptured aneurysm was treated successfully by an emergency interventional procedure. A 72-year-old man was transferred to our hospital with a chief complaint of severe epigastralgia. In the emergency room, the patient was already in shock and emergency CT scan suggested severe intraperitoneal bleeding. The diagnosis of ruptured celiac artery aneurysm was confirmed by subsequent angiographic examinations and immediate hemostasis was successfully achieved by transcatheter arterial embolization. One year after the embolization, the patient remains asymptomatic and follow-up CT scans revealed reduction in size and thrombotic occlusion of the aneurysm.

A Case of Isolated Interruption of the Aortic Arch without Any Complications of Other Cardiovascular Malformations / 日本心臓血管外科学会雑誌

A 7-year-old boy suffered from isolated interruption of the aortic arch without any other complications or cardiovascular malformations. Cardiac murmur, which had been apparent since one month of age, had been left untreated because of the absence of any symptoms of heart failure. Isolated interruption of the aortic arch was noted during a routine physical examination at school and the patient was referred to our hospital for a complete medical evaluation. Blood-pressure difference was recognized not only between the right side and the left side of the upper extremities but also between the upper and lower extremities. On the basis of the results obtained via magnetic resonance angiography (MRA) and aortography, a definitive diagnosis of isolated interruption of the aortic arch was made. Reconstruction of the aortic arch by synthetic implant was indicated. The blood-pressure difference disappeared and the postoperative course was satisfactory.