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Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by persistent elevation of platelet count due to abnormal proliferation of megakaryocytes. While some cases may be asymptomatic, the condition is associated with an increased risk of complications such as thrombosis and bleeding tendencies, necessitating appropriate management tailored to individual cases. Hemostasis analyzer systems are automated analytical devices designed for comprehensive evaluation of blood coagulation function. These systems enable rapid and accurate measurement of multiple parameters, including coagulation time, platelet function, and fibrin formation, thus facilitating a holistic assessment of hemostatic function. A 76-year-old male patient presented to our hospital. At the age of 65, he received treatment for promyelocytic leukemia and achieved remission. At 75 years, he developed leukocytosis, thrombocytosis, and progressive anemia. A comprehensive examination, including bone marrow biopsy and genetic testing, revealed a JAK2 mutation, leading to the diagnosis of ET. At the age of 76 years, he complained of chest discomfort during exertion. Further investigation revealed severe aortic valve stenosis and two-vessel coronary artery disease. The patient underwent aortic valve replacement and three-vessel coronary artery bypass grafting. A hemostasis analyzer system was used to monitor coagulation function throughout the procedure. Compared with the normal range, his coagulation profile showed a tendency toward hypercoagulability. Intraoperative and postoperative transfusions were performed as required. The patient's postoperative course was uneventful without any complications related to bleeding or thrombosis.
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OBJECTIVES: The relationship between cooling status during aortic surgery with hypothermic circulatory arrest and postoperative neurologic dysfunction remains unknown. In the present study, we evaluated the effect of cooling status on transient neurologic dysfunction after total arch replacement. METHODS: We studied patients who underwent elective total arch replacement with hypothermic circulatory arrest and antegrade selective cerebral perfusion from December 2011 to January 2021. Changes in tympanic temperature trends recorded during surgery were plotted. Several parameters, including the nadir temperature, cooling speed, and degree of cooling (cooling area, or the area under the curve of inverted temperature trends from cooling to rewarming as calculated by the integral method), were analyzed. The relationships between these variables and transient neurologic dysfunction were evaluated. RESULTS: Transient neurologic dysfunction was observed in 33 (14.5%) of the 228 included patients. In the transient neurologic dysfunction group, the cooling area was larger (2417.3 vs. 1920.8 °C min; P < 0.001) and the cooling speed was higher (0.68 vs. 0.51 °C/min; P < 0.001) than in the non-transient neurologic dysfunction group. A multivariate logistic model revealed that both the cooling area (odds ratio = 1.13 per 100 °C min; P < 0.001) and cooling speed (odds ratio = 3.69 per °C/min; P = 0.041) were independent risk factors for transient neurologic dysfunction. CONCLUSIONS: Both the cooling area, which indicates the degree of cooling, and cooling speed had significant relationships with transient neurologic dysfunction after total arch replacement. Together, these findings indicate that overcooling and rapid cooling may contribute to brain injury.
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A 79-year-old man underwent bioprosthetic valve replacement for aortic regurgitation 10 years previously (Carpentier-Edwards PERIMOUNT Magna Ease, 21 mm; Edwards Lifesciences, Irvine, CA, USA). The indexed effective orifice area decreased to 0.422 cm2/m2, and heart failure symptoms appeared. The patient underwent aortic valve replacement through a redo median sternotomy. A perivalvular leak was observed on transesophageal echocardiography at the time of weaning from cardiopulmonary bypass. The patient was judged to have a leak characteristic of bioprosthetic valves and was monitored closely. Postoperative echocardiography showed that the perivalvular leak had decreased to a trivial level, indicating that the intraoperative decision had been correct. We report this case because such intraoperative judgments are difficult to make.
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An 85-year-old man underwent hemiarthroplasty for a left intertrochanteric femoral fracture at another hospital two years prior. While under outpatient monitoring, the left femur displacement occurred. Therefore, total hip arthroplasty of the left hip was scheduled. However, during acetabular cup insertion damage to the inner plate led to a sudden decrease in blood pressure from 120 to 60 mmHg. The physicians suspected a pelvic vascular injury and promptly stopped the procedure. In case of adhesion between the acetabular cup and the left iliac vein, intraoperative vascular damage would be repaired via endovascular intervention. Subsequently, orthopedic surgery was cautiously performed, taking into account the potential of a vascular injury. The surgery proceeded as planned without vascular intervention. This case involved a patient with suspected injury to the iliac vein and artery during acetabular cup placement. Following comprehensive enhanced CT and angiography tests, orthopedic surgery was performed in preparation for potential vascular damage, demonstrating the multidisciplinary approach to managing such cases.
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OBJECTIVES: Endoleaks are important complications of endovascular aortic repair. Usually, endoleaks are judged indirectly by aortography or postoperative computed tomography. However, findings from these modalities are difficult to distinguish because of the divergency of endoleaks. Few studies have reported direct visualization of endoleaks. Herein, we introduce a direct procedure for intraoperatively evaluating endoleaks using angioscopy. METHODS: From April 2023, consecutive patients with an abdominal aortic aneurysm, except emergency cases and those of narrow access, seen at Sunagawa City Medical Center were enrolled in our study. Endoleaks were detected by intraoperative angioscopy using a novel endovascular procedure. RESULTS: Seven patients underwent endovascular aortic repair of an abdominal aortic aneurysm with intraoperative angioscopy. None of the enrolled patients experienced complications. The procedure revealed types 2, 3a, and 4 endoleaks. CONCLUSIONS: This is the first study to demonstrate intraoperative visualization of endoleaks using angioscopy. Direct findings observed by this novel procedure might provide information on the velocity and volume of the endoleak, providing comprehensive insights into the intra-sac hemodynamics after the endovascular aortic repair.
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BACKGROUND: Perforation by pacemaker leads, although rare, is a complication reported since the introduction of pacemaker therapy. Although historically reported frequencies were as high as 5%, recent reports have cited frequencies ranging from 1 to 2%. We report a case where a screw-type atrial lead slightly penetrated the right atrial wall, causing chronic abrasion of the ascending aorta, resulting in shock. CASE PRESENTATION: A 54-year-old male presented with dilated cardiomyopathy diagnosed at 40 years of age when he developed decompensated heart failure. Despite ongoing treatment, his heart failure worsened, leading to hospitalization at the age of 54. During his hospital stay, he experienced cardiac arrest that required cardiopulmonary resuscitation, followed by a return of spontaneous circulation. He was subsequently transferred to our institution after initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and an intra-aortic balloon pump (IABP). Echocardiography revealed an ejection fraction of 25%, left ventricular end-diastolic diameter of 60 mm, and severe mitral regurgitation (MR). Transcatheter mitral valve repair was performed to treat severe MR, followed by implantation of a cardiac resynchronization therapy defibrillator (CRT-D). Three months later, the patient was brought to our emergency department by ambulance because of hypotension. Contrast-enhanced computed tomography revealed pericardial effusion causing cardiac tamponade, necessitating emergency pericardial decompression via left fourth intercostal mini-thoracotomy and drain placement. Upon transfer to the intensive care unit, 1200 mL of blood was drained from the chest tube, prompting a return to the operating room for a median sternotomy. It was discovered that the pacemaker lead on the left side of the right atrium had slowly eroded into the aorta, leading to perforation. The ascending aorta was repaired and hemostasis was achieved; the patient recovered uneventfully and was discharged on postoperative day 18. CONCLUSIONS: The pacemaker lead perforated the right atrium; chronic abrasion of the lead against the ascending aorta resulted in bleeding from the ascending aorta 3 months later.
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The case involves a 37-year-old female who was diagnosed with undifferentiated immunodeficiency and protein-losing gastroenteropathy at the age of 26 and was under outpatient care in the gastroenterology department while taking Prednisolone 15mg. At the age of 37, she experienced loss of consciousness and was diagnosed with a right occipital lobe arteriovenous malformation upon investigation. Although initially managed conservatively, she presented the following month with a right-sided headache and vomiting and was urgently transported to our hospital. Imaging with contrast-enhanced CT revealed bleeding from the arteriovenous malformation. Emergency craniotomy was performed, followed by ventricular drainage. Two weeks later, she underwent transcatheter arterial embolization of the main feeder via the right femoral artery approach, followed by excision of the arteriovenous malformation the next day. Subsequently, she had an uneventful recovery. A confirmation CT angiography before discharge revealed severe stenosis of the right common femoral artery, leading to a referral to the cardiovascular surgery department. The stenosis was attributed to the Pro-Glide used for hemostasis during the embolization procedure. Repair surgery was performed, during which CT angiography revealed arteriovenous malformations in both the popliteal fossae and the foot.
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BACKGROUND: Experimental animal models of ischemic spinal cord injury (iSCI) are essential for studying its pathogenesis and for developing new therapeutic strategies to improve functional recovery in humans. Many existing models, however, exhibit high variability or early lethality. A reliable experimental iSCI model would significantly advance novel treatment approaches for these severe neurological disorders. To this end, we have established a rat model of persistent iSCI with an extended lifespan. METHODS: We have developed a novel iSCI model that induces localized ischemic lesions in the spinal cord of male Sprague-Dawley rats. This is achieved by cross clamping the descending aorta just rostral the azygos vein using an atraumatic bulldog clamp. RESULTS: The experimental iSCI model consistently demonstrated symptoms specific to spinal cord ischemia at the lumbar level. The procedure takes approximately 50 min and does not require specialized surgical equipment. It has a survival rate of 84%, a recovery rate of 40%, and a complication rate of 16%. CONCLUSIONS: We have successfully developed a rat model of persistent iSCI. This protocol proves to be highly reliable and holds promise for evaluating new therapeutic strategies aimed at promoting functional recovery in patients suffering from spinal cord ischemia.
Subject(s)
Disease Models, Animal , Rats, Sprague-Dawley , Spinal Cord Ischemia , Animals , Spinal Cord Ischemia/etiology , Male , Rats , Postoperative Complications/etiology , Spinal Cord/surgery , Spinal Cord/blood supplyABSTRACT
A 77-year-old male patient with immunoglobulin (Ig)G4-related disease was diagnosed with a 60-mm aortic arch aneurysm and atherosclerosis of the aorta advanced throughout the body. Aortic arch replacement surgery was performed with circulatory arrest at 28°C. One week later, the patient developed acute pancreatitis, followed by encapsulated necrosis in the chronic phase. After debridement surgery, the patient's condition improved.
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A 66-year-old man with a history of type 2 diabetes mellitus who was undergoing hemodialysis presented with angina. Coronary angiography revealed triple-vessel coronary artery disease. He underwent multiple percutaneous coronary interventions due to recurrent restenosis and was referred for coronary artery bypass grafting (CABG). The left internal thoracic artery and bilateral saphenous veins were harvested under general anesthesia. Four CABGs were performed: left internal thoracic artery to the left anterior descending artery; saphenous vein graft to the obtuse marginal branch of the circumflex artery; and saphenous vein graft to two sites in the right coronary artery. Intraoperative assessment with transit-time flow measurements showed no abnormalities, and the surgery was completed. On postoperative day seven, coronary and graft angiography revealed dissection of the left internal thoracic artery at its midportion with restricted flow. On postoperative day eight, a surgical intervention was performed to excise the dissected segment of the left internal thoracic artery. The dissection site was identified by fluorescence imaging. The dissected segment was excised, and the artery was re-anastomosed. The postoperative course was uneventful, and graft angiography performed on postoperative day 22 confirmed good blood flow. Fluorescence imaging was valuable in identifying the dissection site in the left internal thoracic artery.
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OBJECTIVES: Our goal was to evaluate early and mid-term outcomes of physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms from 10 Japanese aortic centres. METHODS: From January 2012 to March 2022, a total of 121 consecutive adult patients who underwent physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms were enrolled. We analysed early and mid-term postoperative outcomes, including postoperative complications and mortality. RESULTS: The pararenal and thoraco-abdominal aortic aneurysm groups included 62 (51.2%) and 59 (48.8%) patients, respectively. The overall in-hospital mortality rate was 5.8% (n = 7), with mortality rates of 3.2% (n = 2) and 8.5% (n = 5) in pararenal and thoraco-abdominal aortic aneurysm groups, respectively (P = 0.225). Type IIIc endoleaks occurred postoperatively in 18 patients (14.9%), with a significantly higher incidence (P = 0.033) in the thoraco-abdominal aortic aneurysm group (22.0%, n = 13) than in the other group (8.1%, n = 5). Major adverse events occurred in 7 (11.3%) and 14 (23.7%) patients in pararenal and thoraco-abdominal aortic aneurysm groups (P = 0.074), respectively. The mean follow-up period was 24.2 months. At the 3-year mark, both groups differed significantly in freedom from all-cause mortality (83.3% and 54.1%, P = 0.004), target aneurysm-related mortality (96.8% and 82.7%, P = 0.013) and any reintervention (89.3% and 65.6%, P = 0.002). Univariate and multivariate regression analyses demonstrated that ruptures, thoraco-abdominal aortic aneurysms and postoperative type IIIc endoleaks were associated with an increased risk of all-cause mortality. CONCLUSIONS: The mid-term outcomes of physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms were clinically acceptable and comparable with those in other recently published studies. Notably, pararenal and thoraco-abdominal aortic aneurysms represent distinct pathological entities with different postoperative outcomes.
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BACKGROUND: In patients with retrosternal neo-esophageal conduit after right thoracotomy, the approach to cardiac surgery could be challenging. Particularly, in patients with infective endocarditis, there is a risk of injury to the conduit through standard median sternotomy. Moreover, right lung adhesions could be predicted. Herein, we present a case of successful mitral valve repair in a patient with infective endocarditis through a redo right thoracotomy after esophageal reconstruction. CASE PRESENTATION: A 66-year-old male patient was diagnosed with infective endocarditis and a large anterior mitral leaflet vegetation after a previous esophageal reconstruction via right thoracotomy for esophageal cancer. Due to the retrosternal esophageal reconstruction, we performed a mitral valve repair through a redo right thoracotomy. After resecting the vegetation, the defect was closed with a fresh autologous pericardial patch. Mitral valve annuloplasty was performed. Postoperatively, antibiotics controlled the infection. The patient was discharged on postoperative day 30. CONCLUSIONS: Successful mitral valve repair was performed for infective endocarditis through a redo right thoracotomy after esophageal reconstruction.
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OBJECTIVES: Treatment of thoracoabdominal aortic aneurysms in high surgical risk patients can be challenging. Reports of physician-modified inner-branched endovascular repair (PMiBEVAR) are increasing. Despite low morbidity and mortality rates, re-interventions for endoleaks with these grafts are serious. There are no reports of additional treatment for PMiBEVAR failure. METHODS/RESULTS: A 75-year-old man presented to our hospital with a Crawford's type IV thoracoabdominal aortic aneurysm. A PMiBEVAR was performed. Postoperative computed tomographic angiography revealed an endoleak from the inner branch of the right renal artery. A re-intervention was performed with coil embolization of the endoleak. Imaging after re-intervention showed successful obliteration of the endoleak. CONCLUSIONS: We thereby report a successful case of re-intervention for PMiBEVAR failure.
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OBJECTIVE: The aim of this study was to evaluate midterm outcomes of our novel strategy of postoperative initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the prevention of subsequent type II endoleak (T2EL) in a single-center series. METHODS: Between 2008 and 2014, 137 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from 2013, the mean blood pressure was maintained between 75 and 90 mmHg for the initial 24 hours after EVAR followed by systolic pressure controlled below 120 mmHg during the next 24 hours in the treatment group (n = 76). The incidence of T2EL detected at 7 days, reintervention, and AAA sac diameter up to 5 years after EVAR were compared with those of the control group comprising of 60 consecutive patients who underwent standard EVAR without BPM prior to 2013. RESULTS: Between the treatment group and the control group, significant differences were achieved in the incidence of T2EL at 7 days (19.7% vs 40.0%; P = .009), a mean decrease of AAA sac diameter at 1-year (-5.1 ± 4.9 vs -2.2 ± 6.7 mm; P = .013) and 2-year (-5.4 ± 7.7 vs -1.7 ± 10.8 mm; P = .045). In addition, there was a significant decrease in the incidence of T2EL detected at 7 days with the use of the Gore Excluder with 22.7% in the treatment group vs 80.0% in the control group (P < .001), which resulted in a significant decrease in the aneurysm sac diameter up to 4 years after EVAR. Survival rate without AAA sac enlargement at 5 years after EVAR (83.0% vs 70.0%; P = .021) in the treatment group was significantly higher than that of the control group, whereas no significant differences were observed in the freedom rates of reintervention, T2EL-related reintervention, and all-cause mortality between the groups. CONCLUSIONS: Postoperative initial 2-day BPM had a preventive effect on AAA sac enlargement until midterm periods, by reducing the incidence of T2EL at 7 days after EVAR. The usage of Gore Excluder under BPM was especially associated with sustained positive effects until the midterm follow-up.
Subject(s)
Aortic Aneurysm, Abdominal , Blood Vessel Prosthesis Implantation , Endovascular Procedures , Humans , Aortic Aneurysm, Abdominal/diagnostic imaging , Aortic Aneurysm, Abdominal/surgery , Aortic Aneurysm, Abdominal/complications , Endoleak/epidemiology , Endoleak/etiology , Endoleak/prevention & control , Blood Pressure , Endovascular Aneurysm Repair , Blood Vessel Prosthesis Implantation/adverse effects , Treatment Outcome , Incidence , Endovascular Procedures/adverse effects , Retrospective Studies , Risk FactorsSubject(s)
Thoracic Surgery , Thoracic Surgical Procedures , Humans , Japan/epidemiology , Databases, FactualABSTRACT
OBJECTIVE: The purpose of this study was to statistically analyze the factors that influence cardiovascular surgery recruitment. METHODS: Fifth- and sixth-year medical students and first-year residents who participated in cardiovascular surgery-related events at our university over a 10-year period from April 2013 to August 2022 were included. The primary endpoint was admission to the department of cardiovascular surgery. Gender, participation in sixth-year elective clinical training, participation in national academic conferences, participation in cardiovascular surgery summer school, and the cost of participation in these events (airfares and lodging) were included as analytic factors. RESULTS: Fifty-three participants attended cardiovascular surgery events during the study period. The sample included 48 males (84%) and 9 females (16%), and 3 fifth-year medical students (5%), 45 sixth-year students (79%), and 9 students in their first year of clinical training (16%). Eighteen (32%) of the participants eventually joined the department. Gender, participation in national academic conferences, cardiovascular surgery summer school, and cost of participation were not significantly related to the decision to join the department, but participation in elective clinical training was significantly positively related to the decision to join the department for sixth-year students (p < 0.01). CONCLUSIONS: We statistically analyzed the factors involved in the recruitment of students and initial clinical residents to the department of cardiovascular surgery. The results showed that participation in elective clinical training was significantly positively associated with the decision to join the department, suggesting that efforts to encourage participation in elective clinical training are important.
Subject(s)
Cardiovascular Surgical Procedures , Career Choice , Students, Medical , Humans , Male , Female , Students, Medical/statistics & numerical data , Cardiovascular Surgical Procedures/education , Cardiovascular Surgical Procedures/statistics & numerical data , Internship and Residency , Multivariate Analysis , Decision Making , AdultABSTRACT
A 74-year-old man with pemphigoid, for which he was on a daily regimen of 14 mg of prednisolone and immunosuppressive drugs, was admitted to the orthopedic surgery department with a fever of 38 °C. An MRI scan of his head revealed multiple bilateral cerebral infarcts, and echocardiography showed a 30-mm structure attached to the anterior apex of the mitral valve. The patient was diagnosed with infective endocarditis and administered antibiotic therapy. Five days after the diagnosis, the patient underwent mitral valve surgery, during which the mitral valve was observed to be severely deteriorated and hence replaced with a bioprosthetic valve. Blood flow disturbance was observed in the right lower extremity, and a thrombectomy was performed. A dispersed vegetation around the heart was observed and removed. After the surgery, the patient progressed without mediastinitis and had a good postoperative course. He was discharged from the hospital on the 56th postoperative day after continued antibiotic therapy.