[A Thrombus in the Right Atrium Associated with Pyogenic Liver Abscess].

Hepatic abscesses are divided into bacterial and amoebic types. Although the prognosis of bacterial liver abscesses has improved owing to progress in drainage techniques and antimicrobial agents, poor outcomes remain common. While there have been some reports of amoebic liver abscesses complicated by thrombosis, bacterial liver abscesses and subsequent thrombus in the right atrium are very rare. We herein report the case of an 82-year-old man. He had suffered acute obstructive suppurative cholangitis 10 months previously, and bile culture yielded Enterococcus faecalis. In the present case, a right atrial thrombus caused by a bacterial liver abscess was observed and the causative organism was thought to be Enterococcus faecalis, for which was detected in a blood culture was positive. The patient was successfully treated with hepatic abscess drainage and surgical right atrial thrombectomy under cardiopulmonary bypass with a beating heart.

[Acute Pulmonary Thromboembolism with Chiari Network:Report of a Case].

A 60-year-old woman was admitted to our hospital for dyspnea. Contrast-enhanced computed tomography( CT) revealed acute pulmonary artery thromboembolism. An echocardiogram showed a movable structure in the right atrium. Emergency surgery was performed under general anesthesia. The movable structure in the right atrium looked like a Chiari network with a diameter of over 5 cm, and no obvious thrombus was found. The patient had a good postoperative course and was discharged home on postoperative day 17. The Chiari network is a remnant structure of the fetal venous sinus valve, and its diagnosis was important for determining the appropriate treatment plan for this case.

[Thrombus in the Right Atrial Appendage Detected Incidentally during Coronary Artery Bypass Grafting;Report of a Case].

A 71-year-old male was admitted to our hospital for treatment of complete atrioventricular block. By cardiac catheterization, chronic occlusion was confirmed in the right coronary artery and circumflex branch, and coronary artery bypass grafting was planned. Although atrioventricular block disappeared by discontinuance of ß-blocker, paroxysmal atrial flutter had been confirmed before surgery. After an incision into the pericardium, changes in the color of the right atrial appendage were observed, and a thrombus was detected at the site by epicardial echography. The right atrial appendage was removed together with the thrombus, and coronary artery bypass grafting was performed as scheduled. Pathological findings suggested myocardial tissues with ischemic changes and an organized thrombus exhibiting granulomatous changes. This case suggested the need to observe the right atrial appendage carefully during cardiac surgery in patients with risk factors for atrial thrombus.

[Rupture of Tuberculous Infective Abdominal Aortic Aneurysm after Intravesical Bacillus Calmette-Guérin Instillation Therapy].

The patient was a 74-year-old male who had undergone intravesical Bacillus Calmette-Guérin(BCG) instillation therapy for bladder cancer. He visited our hospital with chief complaints of fever and abdominal pain. Abdominal aortic aneurysmal rupture and iliopsoas muscle abscess were confirmed by computed tomography( CT). We performed semi-emergency surgery, including replacement of the abdominal aorta with a synthetic graft, iliopsoas abscess debridement, and omentopexy. A rifampicin-bonded synthetic graft was used because of the possibility of tuberculous involvement after BCG instillation therapy. Examination of the tissues collected during surgery were positive for tuberculosis deoxyribonucleic acid (DNA) in a polymerase chain reaction (PCR), and showed multiple giant cell granulomas with caseous necrosis, which both strongly suggested involvement of tuberculosis. Therefore, 4 types of antituberculous drugs were administered for 40 days. This case shows that an infective aneurysm should be suspected when fever and abdominal pain develop after intravesical BCG instillation therapy.

Use of the Dorsal Vein of the Hand for Arteriovenous Fistula Creation.

A radiocephalic arteriovenous fistula (AVF) in the anatomical snuffbox is the most distal site of AVF in the upper limb. When the cephalic vein distal to the wrist is in poor condition or thrombosed, creating the typical radiocephalic AVF in the distal forearm just proximal to the wrist will likely be considered. However, we have adopted an operative technique for creating a transposed radial artery-dorsal metacarpal vein AVF (RDAVF) in the anatomical snuffbox when possible in such cases. RDAVF is AVF using the most peripheral autologous vein in the upper limb. To our knowledge, the creation of an RDAVF has not been previously reported. We herein describe the steps of the technique and report the successful treatment of a hemodialysis patient who developed occlusion of a radiocephalic AVF in the anatomical snuffbox.

[Treatment of Right Atrial Myxoma Complicated with Pulmonary Embolism;Report of a Case].

Myxomas are account for approximately half of primary cardiac tumors, 75% of which originate in the left atrium. We report a case of a right atrial myxoma complicated with bilateral pulmonary embolism. A 54-year-old woman was admitted to the hospital with a complaint of dyspnea. Echocardiography and computed tomography angiography showed a right atrial tumor and bilateral pulmonary embolism. We performed an emergency surgery to remove both the right atrial tumor and the pulmonary emboli. Histopathologically, the tumor was revealed to be myxoma. The postoperative course was uneventful. She is now doing well without any symptoms.

[Mycotic aneurysm of the descending thoracic aorta].

A 55-year-old man was admitted with severe back pain and saccular aneurysm of the descending aorta on computed tomography. Laboratory examinations showed elevated serum C-reactive protein of 16.98 mg/dl. Graft replacement of the descending thoracic aorta was performed on an emergency basis, and a latissimus dorsi muscle flap was wrapped around the implanted graft. Because Streptococcus pneumoniae was detected in the resected tissue, proper antibiotic therapy was administrated. The patient recovered uneventfully, without any sign of infection.

Utilization of the autologous vein on the ulnar side of the dorsal hand for arteriovenous fistula creation.

We previously described the success and usefulness of two operative techniques for creating a radial artery-first or second dorsal metacarpal vein arteriovenous fistula (AVF) in the first interdigital space of the dorsal hand using the most distal site and autologous veins in the upper limb. These techniques utilize the dorsal metacarpal veins on the radial side of the dorsal hand. Developing these ideas, we devised a novel operative technique for creating a transposed radial artery-third metacarpal vein AVF in the first interdigital space of the dorsal hand using the most distal vein on the ulnar side of the upper limb and most distal site in the upper limb. The distinctive advantage of this technique is that it can be applied to patients whose cephalic vein in the forearm and the dorsal metacarpal veins on the radial side of the dorsal hand are of a poor quality. We herein report the steps of this technique and describe its successful performance in a patient who has been on hemodialysis for 14 months without any additional vascular access interventions or postoperative complications. We consider this technique to be a valuable option in select patients who meet the applicable conditions. The creation of the first AVF as distally as possible is ideal, and it offers a further viable option of distal native vascular access that may be overlooked.

Brachio-brachial arteriovenous fistula combined with superficialization of the brachial artery using a short skin incision for hemodialysis.

A brachio-brachial arteriovenous fistula with superficialization of the brachial vein and superficialization of the brachial artery are useful vascular access techniques for hemodialysis patients. However, both typically require a long skin incision from the antecubital fossa toward the axillary fossa. In addition, the brachio-brachial arteriovenous fistula in particular, which is created with not a one-stage but a two-stage procedure, requires a relatively long time of 2-3 months before it can be used for hemodialysis. Furthermore, superficialization of the brachial artery usually requires nonarterialized superficial veins for blood return. In cases where patients have no adequate superficial veins for creating an arteriovenous fistula, we have adopted a one-stage operative technique to create a brachio-brachial arteriovenous fistula with superficialization of not only the brachial vein but also the brachial artery using a short skin incision. This technique of a brachio-brachial arteriovenous fistula with superficialization of the brachial artery has several advantages over traditional approaches, including a minimally invasive procedure and early use for vascular access. To our knowledge, the presently described technique and the related data have not been previously reported in the English literature. We herein report the steps of this technique and the midterm follow-up outcomes.

Radial artery-first dorsal metacarpal vein arteriovenous fistula in the first interdigital space of the dorsal hand for hemodialysis.

A radiocephalic arteriovenous fistula in the anatomical snuffbox (tabatière region) was first described in 1969 as the most peripheral site for arteriovenous fistula in the upper limb. In cases in which the internal diameter of the first dorsal metacarpal vein under avascularization is ⩾2.0 mm, we have adopted a new operative technique for creating a radial artery-first dorsal metacarpal vein arteriovenous fistula in the first interdigital space of the dorsal hand, which lies between the thumb and the index finger. This technique is the creation of the arteriovenous fistula using the first dorsal metacarpal vein and the most peripheral site in the upper limb. To our knowledge, no previous report has described the creation of a radial artery-first dorsal metacarpal vein arteriovenous fistula. We herein describe the steps of the technique and report its successful performance in a patient with chronic renal failure.

Radial artery-second dorsal metacarpal vein arteriovenous fistula in the first interdigital space for hemodialysis: Utilization of the most peripheral site and autologous vein in the upper limb - A case report.

INTRODUCTION: The creation of the first arteriovenous fistula (AVF) as far distally in the upper limb as possible is ideal. We developed a new operative technique for creating a radial artery-second dorsal metacarpal vein AVF in the first interdigital space. This technique involves the creation of the AVF using the most peripheral site and autologous vein in the upper limb. CASE PRESENTATION: We herein describe the steps of this technique and its successful performance in a 71-year-old man with end-stage renal disease. DISCUSSION: This technique has several advantages including preserving many future vascular access options and providing a long segment of arterialized vein for cannulation. CONCLUSION: We consider this technique to be a worthwhile option and recommend the use in patients with the proper vessels for the creation of the AVF.

Surgical results of hemiarch replacement for acute type A dissection.

BACKGROUND: The appropriate surgical strategy for patients with an arch tear in acute type A dissection remains controversial. We retrospectively compared surgical results after hemiarch as compared with transverse aortic arch replacement in patients with an arch tear in acute type A dissection. METHODS: The records of 88 patients who consecutively underwent graft replacement for acute type A dissection between 1989 and 2001 were reviewed. The patients were divided into three groups: patients with ascending aortic replacement (group AS, n = 41), those with hemiarch replacement (group HA, n = 23), and those with transverse arch replacement (group AR, n = 24). Operative mortality and morbidity and late outcome were compared among the three groups. RESULTS: The overall early (30 day) mortality was 11.3% (10/88), and in-hospital mortality was 14.7% (13/88). In-hospital mortality in groups AS, HA, and AR were 7.3%, 8.6%, and 33.3%, respectively (p = 0.011). Cardiopulmonary bypass, circulatory arrest, and operation times were significantly shorter in group HA than in group AR (p < 0.001). A smaller amount of intraoperative transfusion of red blood cells (p = 0.0006) and fresh-frozen plasma (p = 0.0003) was needed in group HA than in group AR, and postoperative bleeding during the first 24 hours postoperatively was significantly less in group HA than in group AR (p = 0.0028). The incidence of postoperative coma did not differ among the three groups (p = 0.89), nor did the incidence of postoperative patent false channel in the descending thoracic aorta (p = 0.57). Actuarial survival rates after 5 years were significantly better in group HA (91.3% +/- 5.9%) than in group AR (44.4% +/- 14.3%, p = 0.018). Freedom from reoperation on the distal aorta within 5 years did not differ among the groups (p = 0.46). CONCLUSIONS: Hemiarch replacement for acute type A dissection demonstrated favorable early and late outcome. The extent of graft replacement influenced surgical mortality and morbidity. Whenever the intimal tear is located in the lesser curvature of the transverse arch, hemiarch replacement is recommended to improve overall operative mortality and morbidity.

Distensibility of the pulmonary autograft under systemic pressure.

BACKGROUND AND AIMS OF THE STUDY: Although the Ross procedure has recently been recognized as one of the best replacements of the aortic valve, regurgitation has occasionally been observed with dilatation of the sinotubular junction (STJ) and/or basal ring (BR). This study was designed to evaluate the native distensibility of the free pulmonary root under systemic pressure. METHODS: Pulmonary arterial grafts (n = 7) were taken from pig hearts and pressurized (20-100 cmH2O) with crystal sensors attached around the STJ and BR. Dimensions of the STJ and BR were measured using a digital 3-D ultrasonic sonomicrometer at different pressures (20-100 cmH2O) with and without the STJ and/or BR plicated with felt-strip to prevent overdistension. Valve insufficiency was evaluated macroscopically and endoscopically. RESULTS: All grafts showed no obvious valve insufficiency at 20 cmH2O. Grafts pressurized at 100 cmH2O showed 125+/-6% and 113+/-5% enlargement of dimensions compared with baseline (20 cmH2O) data at the STJ and BR respectively, with recognizable insufficiency. When the STJ was plicated to prevent overdistension at 100 cmH2O with less dilated BR (106%), mild excentric insufficiency was observed. In case of the BR plicated at 100 cmH2O with a less dilated STJ (112%), central slight regurgitation was observed. Both the STJ and BR plications resulted in no recognizable regurgitation. CONCLUSION: Free pulmonary arterial grafts were remarkably enlarged under systemic pressure with recognizable valve insufficiency; this could be prevented by maintaining the original dimensions of the graft STJ and BR.

Complete resection of recurrent thymic carcinoid using cardiopulmonary bypass.

We report a case of recurrent thymic carcinoid (multiple episodes of recurrence over a 14-year period) invading the right atrium and superior vena cava, which was resected using cardiopulmonary bypass. In our case with dense adhesion between the great vessels and the sternum as a result of repeated operations and therapeutic irradiation, the innominate artery was injured while re-sternotomy, which was successfully repaired under deep hypothermic circulatory arrest. Repeated aggressive surgical resection might improve prognosis of the recurrent thymic carcinoid even in patients with extended lesions, which could be completely resected only on cardiopulmonary bypass.

Heparinless cardiopulmonary bypass with argatroban in dogs.

OBJECTIVES: Systemic heparinization is usually required for cardiopulmonary bypass (CPB). However, problems such as heparin-induced thrombocytopenia, protamine shock, and antithrombin III deficiency exist related to CPB with heparinization. The aim of this study was to evaluate argatroban (ARG) as a substitute for heparin during CPB. METHODS: In the pilot study, blood samples were sequentially obtained from dogs with continuous infusion of ARG at a dose of 10 (n = 6), 20 (n = 6), or 30 (n = 6) microg/kg per min for 2 h without CPB. In the main study, dogs underwent CPB for 2 h with 10 (n = 6) or 30 (n = 6) microg/kg per min of ARG or with heparin with blood samples obtained sequentially. Thrombogenicity in each group was evaluated by observation of the blood-contacting surfaces of the CPB circuits with scanning electron microscopy (SEM). Evidence of thromboembolism in the dogs was also investigated in histological specimens of the kidney and spleen in addition to microscopic observation at autopsy. RESULTS: In the pilot study, the activated coagulation time (ACT) reached a maximum level dose-dependently after continuous infusion of ARG for 30 min. ACT returned to the baseline value within 60 min after the termination of continuous infusion. In the main study, CPB with 30 microg/kg per min of ARG achieved thrombin-antithrombin III complex (TAT) level similar to that achieved by CPB with heparin. Platelet count with 30 microg/kg per min of ARG tended to be higher than that with heparin or 10 microg/kg per min of ARG. The SEM appearance of blood-contacting surfaces of the CPB circuits after infusion with 30 microg/kg per min of ARG appeared to be similar to that after infusion with heparin. Depositions on the blood-contacting surfaces of the CPB circuits were also frequently observed with 10 microg/kg per min of ARG. CONCLUSIONS: Coagulability related to CPB was controlled by the appropriate ARG dosage without the use of heparin in dogs. ARG may be a substitute for heparin in CPB.

Successful management of acute pulmonary embolism after surgery for lung cancer.

OBJECTIVE: Although many case reports of acute pulmonary embolism (APE) have been published, the literature dealing with the management of APE after resection of lung cancer is limited. This report describes seven cases of successful management of APE after surgery for lung cancer and discusses how to manage this problematic complication. METHODS: The medical charts of seven patients with APE after lobectomy and complete mediastinal lymphnode dissection were retrospectively reviewed. RESULTS: Six patients collapsed during their first attempt at walking after surgery in conjunction with a dramatic respiratory change. All these patients promptly underwent enhanced spiral computed tomography (CT) scanning. Bilateral clots were detected in all patients and one patient with a deep venous thrombus (DVT) in the femoral vein had a temporary inferior vena cava filter implanted. Non-surgical therapy was used for six patients: thrombolysis (systemic urokinase) and anticoagulant (heparin or argatroban) for four patients and only anticoagulant therapy started on the day after the operation using argatroban for two. There were no bleeding problems with these thrombolysis and/or anticoagulant therapies except in one case of hemorrhage induced by heparin usage on the day after the operation. None of the cases required allotransfusion in connection with these therapies. Thromboembolectomy was performed for one patient who was hemodynamically unstable due to massive embolism and primary atrial fibrillation. All patients were discharged from our hospital without major complications. CONCLUSIONS: Patients with pulmonary embolism after surgery for lung cancer can be treated aggressively with anticoagulants with/without fibrinolitics or even with pulmonary embolectomy on cardiopulmonary bypass, without excessive risk of bleeding complications. Enhanced spiral CT scanning was very helpful for making a simultaneous diagnosis of APE and DVT. The use of argatroban in conjunction with activated clotting time monitoring should be effective without causing bleeding problems during the early stages after pulmonary resection for lung cancer.

Geometrical difference between an ascending aneurysm and a root aneurysm in valve-sparing operations.

OBJECTIVE: The aortic root geometry of the leaflet size and coaptation in an ascending aortic aneurysm, and in a root aneurysm, may predict the early and late outcomes from valve-sparing surgery. METHODS: The aortic root was investigated using intraoperative endoscopy before and after valve-sparing root reconstruction. The definition of 'root aneurysm' was marked sinus dilatation proximal to the sinotubular junction. 'Ascending aneurysm' was defined as dominant dilatation distal from the sinotubular junction. Fifteen cases were examined and classified into two groups; Group A with an ascending aneurysm (four patients), and Group R with a root aneurysm (eleven patients). RESULTS: Cusp prolapse was seen in 10 (90.9%) patients of Group R, and in only one (25%) patient of Group A. The length of the free margin of all cusps in Group R was significantly longer than those in Group A. In Group R, the lengths of the free margin of an individual cusp were significantly different, indicating asymmetric cusps. In Group A, the length of the free margin were similar, indicating symmetric cusps. There was no significant difference in the degree of immediate postoperative aortic insufficiency, between the two groups. At the most recent follow-up, progressive aortic insufficiency was present in two patients of Group R. CONCLUSIONS: A root aneurysm had asymmetric, elongated and prolapsed aortic cusps, while an ascending aneurysm had symmetric cusps without prolapse. The mechanism of aortic insufficiency in a root aneurysm was more complex, suggesting a difficulty in achieving long-term valve competence. Such geometrical difference should be considered in the indication for the surgical technique of valve-sparing operations.

Improved survival of surgery for acute type A aortic dissection: impact of noninvasive diagnosis and hemostatic surgical management.

OBJECTIVES: In the past decade, progress in cardiovascular technology has been incorporated into the surgical treatment of acute type A dissection resulting in remarkable improvement. Factors in this progress encompass rapid noninvasive diagnosis, intraoperative introduction of aprotinine, surgical glue, sealed grafts, and refined surgical technique. The objective of this study is to identify which factors contributed to the improvement of the surgical outcome of acute type A dissections. METHODS: Between January 1989 and February 2001, 78 consecutive patients had emergency surgeries for acute type A dissection. The initial 31 patients (group I) received preoperative angiography, when possible. Since 1996, the next 47 patients (group II) have received noninvasive rapid diagnosis with hemostatic surgical management. This included aggressive proximal resection and judicious use of gelatin resorcine formol glue and felt strips. Between the two groups, in-hospital mortality and morbidity, incidence of neurological complications, late survival and cardiovascular events were compared. Risk factors for in-hospital death were investigated with univariate and multivariate analysis. RESULTS: The in-hospital mortality was significantly improved in group II (4.3%) compared with group I (29.0%). Overall mortality was 14.1%. Multivariate analysis revealed preoperative limb ischemia and delayed timing of operation (> 3 hours after arrival) as independent risk factors for in-hospital death. Late survival at 5 years was 61.5+/-7.5%. Between the two groups there was no significant difference in late survival or cardiovascular events. CONCLUSIONS: Immediate surgical intervention, using rapid noninvasive diagnosis with hemostatic management, substantially improves the surgical outcome of acute aortic dissection.

Coronary occlusion using bi-directionally stretched elastic sutures during off-pump coronary artery bypass grafting.

OBJECTIVE: Off-pump coronary artery bypass grafting may be partly invasive, particularly to the coronary endothelium that is snared. Efficacy of a simple technique to occlude a coronary artery with elastic sutures bi-directionally stretched just beneath the artery was evaluated. METHODS: Test subjects were eighteen adult mongrel dogs weighing 20-30 kg. After systemic heparinization (150 U/kg), the mid-left anterior descending artery (mid-LAD) was exposed with a stabilizer applied and snared using non-elastic sutures (n = 6) or elastic sutures (n = 6), or occluded with elastic sutures bi-directionally stretched (n = 6). The left internal thoracic artery (LITA) was anastomosed to the mid-LAD with humidified gas insufflation. After completion of the anastomosis, the mid-LAD was observed endoscopically through the LITA. The coronary endothelium was also observed by a scanning electron microscope (SEM) after perfusion fixation. RESULTS: Bleeding at the anastomotic site with the coronary artery occluded by bi-directionally stretched elastic sutures was observed. However, all anastomoses were done successfully with the aid of humidified gas insufflation. Coronary endoscope showed that the lumens snared with non-elastic sutures were collapsed with folds and often with clots. Coronary arteries snared with elastic sutures appeared similar to the arteries snared with non-elastic sutures endoscopically, but with less clots. In the case of coronary occlusion with bi-directionally stretched elastic sutures, the lumens were occluded in a flattened linear fashion without clots. SEM showed endothelial injuries with blood cells deposited when non-elastic sutures were used. When elastic sutures were used for snaring, endothelial injuries were ameliorated with less blood cells deposited, which were further decreased when elastic sutures were bi-directionally stretched. CONCLUSION: The coronary artery can be effectively occluded by bi-directionally stretched elastic sutures with minimal endothelial damage.