[Acute Aortic Dissection Complicated by IgA Deficiency].

Immunoglobulin A (IgA) deficiency is the most common type of primary immunodeficiency. When a patient receives a blood product transfusion, anti-IgA antibodies are formed. Second transfusion may sometimes cause an anaphylactic reaction, thus caution is necessary. Reported here is a case of Stanford type A acute aortic dissection performed in the patient with IgA deficiency with a history of blood transfusion. Red blood cells and platelet were washed and prepared, and flesh frozen plasma from IgA deficient donors was obtained. Thereafter, the surgery was safely performed.

[Lipomatous Hypertrophy of Interatrial Septum in Patient with Venous Thrombus:Report of a Case].

A 64-year-old female underwent a computed tomography (CT) examination of the chest because of pneumonia, which revealed lipomatous hypertrophy of the atrial septum. During medical treatment for pneumonia, venous thrombus of the superior vena cava occurred and then disappeared following apixaban administration. The patient refused surgery at that time, thus follow-up examinations include CT scans were conducted at the outpatient clinic. Two years later, the tumor became larger, and this time she accepted surgery. Under total cardiopulmonary bypass with beating heart a 5.0×3.5 cm tumor was resected. Because of its location very close to superior vena cava, upper area of the right atrium was augmented using a bovine pericardium. Following surgery, sick sinus syndrome developed and pacemaker implantation was performed. Thereafter, the patient had a smooth recovery and no recurrence is noted one year since.

[Off-pump Coronary Artery Bypass Grafting in Jehovah's Witness Patient on Hemodialysis;Report of a Case].

Cardiac surgery in Jehovah's witnesses is challenging due to their refusal of blood transfusion. Furthermore, dialysis patients often suffer from anemia and are also prone to bleeding. We performed offpump coronary artery bypass grafting (CABG) [OPCAB] on a Jehovah's witness male patient on hemodialysis. His preoperative hemoglobin level was around 10.0 g/dl. We used cell saver-collected blood as much as possible during operation. His postoperative course was uneventful with the lowest hemoglobin level of 7.2 g/dl using iron supplements and erythropoietin. This case indicates that intraoperative blood salvage and perioperative management of anemia make OPCAB without blood transfusion possible even in Jehovah's witness hemodialysis patients, when their preoperative hemoglobin levels are maintained greater than 10.0 g/dl.

[Acute Type B Aortic Dissection Complicated with Malperfusion of Celiac Artery Alone;Report of a Case].

Malperfusion of the superior mesenteric artery(SMA) in acute type B aortic dissection is potentially fatal. Revascularization should therefore be aggressively considered in a proactive way. However, this is not the case with the celiac artery malperfusion. We present a case of malperfusion of isolated malperfusion of the celiac artery due to acute type B aortic dissection. Although the collateral blood flow from the SMA via the pancreatic arcade was identified, ischemic gastric ulcer and pancreatitis developed later on. At present, there is a general agreement that catheter intervention is the 1st treatment of choice for complicated acute type B aortic dissection. In the present case, however, even a guide wire did not pass through the orifice of the celiac artery and revascularization was not successful.

[Emergency Mitral Valvoplasty for Papillary Muscle Rupture].

We experienced 2 emergency surgical cases of severe mitral valve regurgitation due to papillary muscle rupture. Case 1:a 69-year-old man presented with respiratory and cardiac failure due to mitral regurgitation. He had no history of myocardial infarction. Mitral valve repair with artificial cords was performed. The papillary muscle of the anterior leaflet was ruptured. The postoperative course was uneventful. Case 2:a 80-year-old man came to our hospital with cardiac arrest. Emergency coronary intervention was performed to the right coronary and intraaortic balloon pumping was inserted. However his condition remained unstable. Severe mitral regurgitation was found by teansesophageal echo cardiography, and he underwent emergency mitral valve repair and single coronary bypass grafting. His cardiac function recovered quickly, but severe brain damage remained.

Urgent simultaneous revascularization of the carotid artery and ascending aortic replacement for type A acute aortic dissection with cerebral malperfusion.

We report a case of successful urgent surgical therapy for a Stanford type A acute aortic dissection with cerebral malperfusion. A woman with a sudden severe chest pain consulted the emergency department. Computed tomography results showed a Stanford type A acute aortic dissection. She had repeating left paralysis, so a cerebrovascular study was performed. It showed that the collateral left carotid and vertebral arteries perfused only the right cerebral hemisphere. Hence, it was thought that the left paralysis was caused by cerebral malperfusion due to the dissection. Simple aortic replacement endangered the right cerebral hemisphere, so we performed urgent revascularization of the right carotid artery, followed by an ascending aortic replacement procedure.

Thoracoscopic sympathetic surgery for hand sweating.

Recently, thoracoscopic surgery has been shown to be effective for the relief of hand sweating. Although it is not fatal if left untreated, the treatment aim is to improve the quality of daily life. Therefore, it is important to understand the complaints of the patient, and provide an adequate explanation regarding postoperative sequelae. Surgeons should also recognize that thoracoscopic surgery might cause problems when performed, as the general risk of surgery remains. Many patients have been helped by the procedure, as their choices in life have expanded, and satisfactory results can be obtained when indication is determined by a full examination of the patients condition. Between December 1999 and September 2002, we performed thoracoscopic sympathetic surgery in 556 consecutive patients. Five-hundred seventeen (93%) of these complained of profuse hand sweating. Based on the new concept presented, we consider that this method of operation is an effective treatment.

Late patency of the left internal thoracic artery graft in patients with and without previous successful percutaneous transluminal coronary angioplasty.

The aim of this study was to compare early and late graft patency in patients with and without previous successful PTCA. Of the 70 patients who received both early and late follow-up angiography, 13 patients who had received successful PTCA at the left anterior descending coronary artery (LAD) before CABG (group I) and 31 patients who had not received preoperative PTCA in any vessel (group II) were retrospectively reviewed. There were no significant differences in patient characteristics including major coronary risk factors. The mean duration between the operation and control angiography was 35+/-23 months in group I and 36+/-19 months in group II (P=0.90). Occlusions of the LITA graft were observed in four patients of group I and in four patients of group II. Cumulative patencies of the LITA graft were 54% in group I and 83% in group II (P=0.12). The late patency rate of the LITA graft bypassed to the LAD in patients that received previous successful PTCA in the coronary artery tended to be lower than in patients without previous PTCA. This result should be confirmed by further prospective studies.

Use of the radial artery graft after transradial catheterization: is it suitable as a bypass conduit?

BACKGROUND: The suitability of the radial artery after transradial catheterization as a bypass conduit has been of great concern to surgeons. METHODS: A total of 67 patients underwent isolated coronary artery bypass grafting using the radial artery: 22 patients received preoperative transradial catheterization (group 1) and 45 patients did not receive transradial catheterization (group 2). Those patients were retrospectively reviewed. RESULTS: Patient characteristics, operative procedures, and early clinical outcome were not different between groups. The stenosis-free graft patency rates in groups 1 and 2 were 88% (16 of 18 patients) and 90% (38 of 42 patients) in the left internal thoracic artery (p = 0.87); 77% (17 of 22 patients) and 98% (48 of 49 patients) in the radial artery (p = 0.017); and 87% (13 of 15 patients) and 84% (21 of 25 patients) in the saphenous vein (p = 0.42), respectively. Intimal hyperplasia of the radial artery was observed in 68% (11 of 16 patients) in group 1 and in 39% (14 of 34 patients) in group 2 (p = 0.046). CONCLUSIONS: Transradial catheterization reduced early graft patency and caused intimal hyperplasia, although it did not affect early clinical outcomes. We suggest that the use of the radial artery as a bypass conduit after transradial catheterization should be undertaken cautiously.

Aortic valve replacement by limited sternotomy for infective endocarditis in a patient with a tracheostomy.

Active infection in the area of the tracheostomy during cardiac surgery presents a high risk. We successfully performed urgent aortic valve replacement for an endocarditis patient with active infection of methicillin resistance staphylococcus aureus in the tracheostoma. To avoid wound infection, a 2nd J-limited sternotomy was used during the operation. Despite malnutrition, the patient showed no wound infection after surgery and recovered smoothly.

Long-term follow-up of cardiac valve replacement using bioprosthesis in patients 70 years old and older.

Good long-term results with the bioprosthetic valves for patients 70 years old and older have been reported. However, because the average lifespan is increasing, we aimed to clarify whether patients older than 70 may still be candidates for valve re-replacement. Seventy-one patients 70 years old and older, who received a total of 81 bioprosthetic valve replacements during 73 procedures between 1988 and 2000, were reviewed. There were 8 hospital and 7 late deaths. Ten-year actual survival after valve replacement was 73.5%, and 82.8% when hospital deaths were excluded. During the follow-up period, 2 patients received mitral valve re-replacement. Ten years of freedom from reoperation were found in 66.7% for all valves and in 50.0% for mitral valves. The average lifespan in Japan is currently 77.64 years for men and 84.62 years for women; therefore, valve degeneration in patients who receive bioprosthesis replacement in their early 70s should be anticipated.

Primary pulmonary leiomyosarcoma. Report of a case diagnosed by fine needle aspiration cytology.

BACKGROUND: Primary pulmonary leiomyosarcoma is a rare but important entity. We report a case diagnosed by fine needle aspiration cytology. CASE: A 73-year-old male presented with an asymptomatic, right, pulmonary, subpleural nodule detected by computed tomography during follow-up for chronic obstructive pulmonary disease. Fine needle aspiration cytology showed cellular smears with numerous single or loosely cohesive groups of spindle-shaped to round cells. The tumor cell nuclei were blunt ended (cigar shaped), with fine to fine-granular chromatin, prominent nucleoli and an irregular nuclear rim. The tumor cells were positive for desmin and negative for cytokeratin and S-100 protein by immunocytochemistry. Right upper lobectomy with lymph node dissection was performed. Pathologic diagnosis after microscopic, immunohistochemical and electron microscopic studies was leiomyosarcoma. CONCLUSION: To our knowledge, this is the first reported case of primary pulmonary leiomyosarcoma arising in the subpleural region diagnosed by fine needle aspiration cytology. Immunocytochemistry was useful in establishing the diagnosis in this case.

[Scrotal emphysema: a case report].

We report a case of scrotal emphysema following the placement of a chest tube and an endotrachial catheter for traumatic pneumothorax. Scrotal emphysema is a rare condition and is considered as a type of pneumoscrotum, for which 4 possible mechanisms have been discussed. It is important to promptly determine the origin of air because this condition may be caused by a life-threatening disease.