Aortic injury repair in a patient with situs inversus totalis and dextrocardia.

Situs inversus totalis (SIT) with dextrocardia is a rare autosomal recessive disorder. We herein describe a blunt thoracic aortic injury (BTAI) in a patient with SIT and dextrocardia. An 18-year-old girl who was injured by a fall presented to our hospital. Computed tomography (CT) revealed a traumatic pseudoaneurysm at the aortic isthmus. Open aortic repair was performed through a right thoracotomy. No abnormal findings were observed on CT 1 year after the surgery. Open aortic repair of BTAI can be safely performed through a right thoracotomy in patients with SIT and dextrocardia.

Laparoscopic subtotal cholecystectomy after percutaneous transhepatic gallbladder drainage for grade II or III acute cholecystitis.

BACKGROUND: Severe adhesions and fibrosis between the posterior wall of the gallbladder and liver bed often render total cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) difficult, leading to high open conversion rates. Since the publication of Tokyo Guidelines 2018 (TG18), our policy has shifted from open conversion to subtotal cholecystectomy (SC) when total laparoscopic cholecystectomy for difficult cases of cholecystitis is not feasible. Recently, SC has been frequently applied as bailout surgery for complicated cholecystitis. Nonetheless, the efficacy and validity of laparoscopic SC after PTGBD remain unclear. This study aimed to evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC) by comparing two periods of altered surgical strategies. METHODS: This retrospective cohort study was conducted between January 2013 and December 2020. A total of 44 eligible patients with grade II or III AC were divided according to the time of cholecystitis onset into the pre-TG18 group (2013-2017, n = 17) and post-TG18 group (2018-2020, n = 27). Patients' background demographics, surgical method, surgical results, and postoperative complications were compared. RESULTS: The interval between PTGBD and surgery was significantly longer in the post-TG18 group than in the pre-TG18 group (15 [interquartile range: 9-42] days vs. 8 [4-11] days; P = 0.010). The frequency of laparoscopic cholecystectomy significantly increased from 52.9% in the pre-TG18 group to 88.9% in the post-TG18 group (P = 0.007), whereas the frequency of SC was 23.5% and 40.7%, respectively, which showed no statistically significant difference (P = 0.241). However, the rate of laparoscopic SC significantly increased from 0 to 90.9% among 15 SC cases, whereas the rate of open SC significantly plummeted from 100 to 9.1% (P = 0.001). Significant differences in the operative time, amount of intraoperative bleeding, and incidence of postoperative complications (wound infection and subhepatic abscess) were not observed. Mortality, bile leakage, and bile duct injury did not occur in either group. CONCLUSIONS: For grade II or III AC after PTGBD, aggressive adoption of SC increased the completion rate of laparoscopic surgery. Laparoscopic SC is a safe and feasible treatment option.

Early onset bioprosthetic tricuspid valve stenosis in a case with cardiac sarcoidosis: Pathological findings based on autopsy.

A 60-year-old woman with cardiac sarcoidosis developed recurrent and refractory right heart failure 26 months after tricuspid valve replacement. Echocardiography revealed thickened and immobile cusp with increased diastolic tricuspid gradient of 8-10 mmHg, consistent with bioprosthetic tricuspid stenosis (TS). Prolonged intravenous injection of dobutamine and carperitide, with intermittent intravenous furosemide, was necessary at multiple times. Despite treatment, the patient died of refractory right heart failure. The explanted tricuspid bioprosthesis on autopsy revealed marked pannus formation, resulting in stiff and immobile cusps while the same mitral bioprosthesis, which was implanted on the same day, was normal. Sarcoid granulomas were not present either in tricuspid or mitral bioprostheses. Chronic valve inflammation associated with prolonged use of intravenous drugs and multiple episodes of line-associated bacteremia may have caused early onset bioprosthetic TS. Learning objectives:1Early onset bioprosthetic tricuspid stenosis (TS) is rare.2Elevated jugular venous pulse and pan-diastolic rumble with the Rivero-Carvallo sign are keys to the diagnosis of TS which is confirmed using echocardiography.3Repeated episodes of bacteremia associated with prolonged infusion of intravenous drugs might have contributed to the development of early onset bioprosthetic TS.

The use of warm fresh whole blood transfusion in the austere setting: A civilian trauma experience.

BACKGROUND: Hemostatic resuscitation strategy using blood components with a balanced ratio is adopted in the civilian trauma setting. However, there is usually limited availability of blood components in the austere setting. Warm fresh whole blood (WFWB) has been used for trauma patients with life-threatening hemorrhage necessitating massive transfusions in the Okinawa Islands, Japan. The purpose of this study was to evaluate the safety and feasibility of WFWB use in the austere civilian trauma setting. METHODS: We conducted a retrospective cohort study between January 1999 and June 2019, including trauma patients who received WFWB within 24 hours of admission. Immediately after WFWB was collected from blood donors, the sample was typed and screened for transmissible infectious diseases. Approximately half of the study population received irradiated WFWB to prevent graft versus host disease. We evaluated the incidence of transfusion-associated adverse events. Transfusion requirements and patient outcomes were compared between early and late WFWB use. RESULTS: A total of 28 patients from three civilian institutions were eligible. Of those, 93% sustained blunt trauma. The median Injury Severity Score was 37 (interquartile range, 32-49). All patients required operative hemostatic intervention, and half of the patients required both operative and endovascular hemostatic interventions. Patients received a median of 1,800 mL WFWB transfusions from seven volunteer blood donors. None of our subjects developed hemolytic reactions, transmissible infectious diseases, or graft versus host disease. Early WFWB use (within 4 hours of admission) was associated with a significant reduction in platelet transfusion requirement compared with the late WFWB group in univariate analysis (16 units vs. 47 units, p = 0.002). CONCLUSION: Warm fresh whole blood use is safe and feasible in an austere civilian trauma setting. Prospective studies with larger cohorts are necessary to determine whether early WFWB use will affect patient outcomes, transfusion requirement, and treatment cost. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Acute Aortic Dissection Masquerading as Acute Pericarditis.

We herein report 3 cases of acute aortic dissection (AAD) in which the initial 12-lead electrocardiogram showed typical ST elevation consistent with acute pericarditis. All patients exhibited small pericardial effusion but did not suffer from rupture into the pericardium or clinical tamponade. Slow leakage or exudate stemming from the dissecting hematoma appeared to have caused inflammation, resulting in pericarditis. Therefore, we highlight the fact that AAD may masquerade as acute pericarditis. Physicians should be aware of the possibility of type A AAD as an important underlying condition, since the early diagnosis and subsequent surgical treatment may save patients' lives.

Association between contrast extravasation on computed tomography scans and pseudoaneurysm formation in pediatric blunt splenic and hepatic injury: A multi-institutional observational study.

PURPOSE: We aimed to examine the association between contrast extravasation (CE) on initial computed tomography (CT) scan and pseudoaneurysm (PSA) development in pediatric blunt splenic and/or liver injury. METHODS: We conducted a multi-institutional retrospective study in cases of blunt splenic and/or hepatic injury who underwent an initial attempt of nonoperative management. A logistic regression model was used to compare PSA formation and CE on initial CT scan, and the area under the receiver operating characteristic curve (AUC) with and without CE was used to assess the predictive performance of CE for PSA formation. RESULTS: Of 236 cases enrolled from 10 institutions, PSA formation was observed in 17 (7.2%). Multivariate analysis showed a significant association between CE on initial CT scan and increased incidence of PSA formation (odds ratio, 4.96; 95% confidence interval, 1.37-18.0). There was no statistically significant association between the grade of injury and PSA formation. The AUC improved from 0.75 (0.64-0.87) to 0.80 (0.70-0.91) with CE. CONCLUSION: Active CE on initial CT scan was an independent predictor of PSA formation. Selective use of follow-up CT in children who showed CE on initial CT may provide early identification of PSA formation, regardless of injury grade. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Bioprosthetic tricuspid valve stenosis: a case series.

BACKGROUND: Bioprosthetic tricuspid valve stenosis is a late sequela of tricuspid valve replacement (TVR); however, detailed information regarding its clinical picture is lacking. CASE SUMMARY: Thirty-one patients with bioprosthetic TVR (mean age: 60.5 ± 16.6 years, male/female: 11/20) were followed-up for 79.5 ± 49.1 months (14-188 months). Eleven patients developed bioprosthetic tricuspid valve stenosis (mean tricuspid gradient >5 mmHg) at a median interval of 96 months (interquartile range: 61-114 months). The mean tricuspid gradient at the time of tricuspid valve stenosis diagnosis was 10.9 ± 3.9 mmHg. Although the mid-term tricuspid valve stenosis-free survival was favourable (92.4% at 60 and 78.7% at 84 months), it had declined steeply to 31.5% by 120 months. Ten out of 11 tricuspid valve stenosis patients showed signs of right heart failure (RHF) as manifested by oedema and elevated jugular venous pressure, requiring moderate-to-high doses of diuretics. Diastolic rumble was audible in 10 patients. Five of the 11 tricuspid valve stenosis patients required redo TVR as a result of refractory RHF. Examination of the five excised bioprostheses showed pannus in four, fusion of the commissure in three, native valve attachment in two, and sclerosis in one. Detailed clinical pictures and pathology of the explanted valves in three cases that underwent surgery are presented in this case series. DISCUSSION: Bioprosthetic tricuspid valve stenosis is not uncommon after 8 years. Tricuspid valve replacement performed at the second surgery was associated with a higher incidence of bioprosthetic tricuspid valve stenosis.

Primary aortoduodenal fistula: A case report and review of literature.

BACKGROUND: Primary aortoduodenal fistula (PADF) is an abnormal connection between the aorta and the duodenum and is a life-threatening condition. It is a very rare cause of gastrointestinal bleeding, which often leads to delay in its diagnosis. Prompt diagnosis and surgical treatment are crucial to improve the outcome of patients with PADF. PRESENTATION OF CASE: An 82-year-old man with a history of untreated abdominal aortic aneurysm (AAA) presented to the emergency department with hematemesis. Computed tomography (CT) revealed an AAA with air within the thrombus wall and disruption of the fat layer between the AAA and duodenum, indicating PADF. Emergent surgery, in situ aortic reconstruction using a Dacron graft, and omental coverage were performed. Although the patient needed another surgery for postoperative chylous ascites, he made good recovery and was discharged 86 days after initial surgery. DISCUSSION: In our case, the patient presented with hematemesis and a pulsatile abdominal mass on physical examination and had a history of untreated AAA, which helped in prompt diagnosis of PADF. CT findings suggesting PADF include disappearance of the fat plane between the aneurysm and duodenum, air in the retroperitoneum or within the aortic wall, and contrast enhancement within the duodenum. The recommended surgical approach for PADF consists of aortic reconstruction (in situ aortic reconstruction or extra-anatomical bypass) and duodenal repair. CONCLUSION: Our report affirms that CT and open surgery are effective diagnostic and treatment options, respectively, for PADFs.

Mitral valve replacement for Libman-Sacks endocarditis in a patient with antiphospholipid syndrome secondary to systemic lupus erythematosus.

Libman-Sacks endocarditis is a relatively rare sterile verrucous vegetative lesion observed in systemic lupus erythematosus (SLE)/antiphospholipid syndrome (APLS) patients. Most patients with this condition are asymptomatic. Here we report a case of a 46-year-old woman with APLS secondary to SLE complicated with frequent thromboembolic events due to a mitral valve mass. We performed minimally invasive mitral valve replacement with a mechanical prosthetic valve, and she was successfully discharged 14 days after surgery. Thus, Libman-Sacks endocarditis may be an indication for mitral valve replacement.

Dynamic left ventricular outflow obstruction in situs inversus with levocardia.

A 69-year-old man with situs inversus, levocardia and inverted great arteries developed severe dynamic left ventricular outflow tract (LVOT) obstruction with systolic anterior motion of the anterior mitral leaflet. There was no asymmetric septal hypertrophy. A possible mechanism of the LOVT obstruction in the present case may have been related to an abnormally long and bent outflow tract resulting from overriding of the right ventricle over the LVOT due to a congenital malposition of the heart. Mitral valve replacement with septal myectomy was performed in order to eliminate systolic anterior motion. The postoperative course has been excellent.

Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room.

BACKGROUND: Initial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD. METHODS: We conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test. RESULTS: An IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01-6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14-36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39-9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001). CONCLUSIONS: WI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.

Left ventricular pseudoaneurysm as a complication of prosthetic mitral valve infective endocarditis.

We report a case of infective endocarditis complicated with left ventricular pseudoaneurysm originating from the posterior annulus of the prosthetic mitral valve in a 56-year-old woman. Despite prolonged antibiotic treatment, transesophageal echocardiography (TEE) showed partial detachment of the prosthesis from the posterior mitral annulus. Three-dimensional rotational computed tomography clearly demonstrated a pseudoaneurysm toward the posterolateral portion of the mitral prosthetic valve, which was not evident by TEE. Valve replacement and repair of the pseudoaneurysm were performed 83 days after initiation of antibiotic therapy. Left ventricular pseudoaneurysm is a rare but serious complication of mitral prosthetic valve endocarditis. It requires prompt diagnosis and early surgical intervention. .

Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review.

BACKGROUND AND METHOD: The aim of this study was to assess retrospectively the clinical presentation, management and outcome of three patients with isolated SMA dissection encountered at Okinawa Prefectural Chubu Hospital, Japan from 2005 to 2006, along with a review of the literature. We follow up the patient's clinical symptoms and the image by using enhanced dynamic CT at 1 week, 1 or 2 months, 6 months, and yearly after onset. CASE PRESENTATION: We present three patients with acute abdominal pain due to spontaneous dissection of the superior mesenteric artery (SMA), who were treated by surgical revascularization or conservative management. Two patients underwent surgery because of signs or symptoms of intestinal ischemia and one patient elected conservative management. The SMA was repaired by bypass graft in two cases, and in one of these, the graft was occluded because of prominent native flow from the SMA. All patients were symptom free and there was no evidence of disease recurrence after a median follow-up of 4.3 years. CONCLUSION: Although the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia. A non-operative approach for SMA dissection requires close follow-up abdominal CT, with a focus on the clinical signs of mesenteric ischemia and the vascular supply of the SMA, including collateral flow from the celiac artery and inferior mesenteric artery.

Primary chylopericardium treated by surgery: Report of two cases.

Primary chylopericardium is a rare condition. The etiology and the treatment remain unclear. We report two cases of primary chylopericardium successfully treated by surgery. Both cases were asymptomatic young women and were found to have cardiomegaly on chest X-ray at a routine annual health examination. An echocardiography demonstrated massive pericardial effusion and chylous fluid was obtained with pericardiocentesis. Lymphoscintigraphy demonstrated abnormal communication between the pericardial sac and the thoracic duct. Because of reaccumulation of chylous pericardial effusion after conservative treatment, we performed surgical ligation of thoracic duct and partial pericardectomy by video-assisted thoracic surgery (VATS) in one case and by thoracotomy in another case. After surgery, both patients are doing well without recurrence of pericardial effusion. Surgical treatment including VATS is effective and should be performed in case of primary chylopericardium.

True aneurysm of the pancreaticoduodenal arteries: a single institution experience.

BACKGROUND: True pancreaticoduodenal artery (PDA) aneurysm is a rare but potentially fatal disease. The aim of this study was to make recommendations for management of true PDA aneurysm. METHODS: True aneurysms of the PDA were diagnosed at our institution between 1996 and 2007 and analyzed retrospectively, for clinical presentation, management, and outcome. RESULTS: Eight patients were admitted to our institution for true aneurysms of the PDA. Five patients had aneurysmal rupture, and three were asymptomatic. In the rupture group, computed tomography (CT) showed the retroperitoneal hematoma around the pancreas and aneurysm, ranging from 5 to 25 mm (median, 12 mm). In the non-rupture group, CT revealed saccular aneurysm, ranging from 10 to 20 mm (median, 16 mm). The celiac axis was occluded in two patients, stenotic in four, and normal in two. Two patients underwent laparotomy, and we finally performed transcatheter arterial embolization in seven. All patients are alive, and there is no evidence of recurrence after median follow-up of 6 years. CONCLUSIONS: We recommend treatment of all true PDA aneurysms at the time of diagnosis. True PDA aneurysm with celiac artery stenosis or occlusion requires precise techniques for embolization to preserve blood flow in the celiac artery territory.

Electrocardiographic changes in patients with type A acute aortic dissection. Incidence, patterns and underlying mechanisms in 159 cases.

BACKGROUND: Not only symptoms but electrocardiographic (ECG) changes mimicking acute coronary syndrome as well have been known to develop in acute aortic dissection (AAD). However, detailed information is lacking. OBJECTIVE: We sought to evaluate incidence, patterns, and underlying mechanisms for acute ECG changes in type A AAD. METHODS: Retrospective study in a single tertiary care hospital. A total of 159 cases (mean age 65.1±14.8 years, male/female=67/92) that presented within 12 h from the onset were included. Shift of the ST segment ≥0.1 mV or changes of the T wave were considered acute ECG changes. RESULTS: Acute and chronic ECG changes were observed in 49.7% and 36.5% cases, respectively. ECG was normal only in 27.0% cases. ST elevation was observed in 8.2% cases and was closely related to direct coronary involvement. ST depression and T wave changes were observed in 34.0% and 21.4% cases, respectively. Cases with ST depression or T wave changes had higher incidence of shock (65.2% vs. 28.8%, p<0.001) and cardiac tamponade (51.2% vs. 15.0%, p<0.001) compared with those without changes. CONCLUSION: Acute ECG changes were common in type A AAD. Physicians taking care of patients with chest pain and acute ECG changes should consider the possibility of AAD before performing thrombolysis or percutaneous catheter intervention.