Risk Factors Associated with Difficult Reversal of Heparin by Protamine Sulfate in Cardiopulmonary Bypass: An Ignored Issue.

BACKGROUND: The aim of this study was to evaluate risk factors associated with difficult heparin reversal by protamine after cardiopulmonary bypass. METHODS: Data from 120 consecutive patients who underwent open heart surgery from 2009 to 2017 were retrospectively reviewed. Patients were divided into 2 groups: (1) those in whom complete heparin reversal was achieved after a single infusion of protamine (group A, n=89); and (2) those who required more protamine for heparin reversal (group B, n=31). RESULTS: Female sex, prolonged bypass time (>200 min), long aortic cross-clamping time (>120 min), and a lowest rectal temperature <26°C were significant predictors of difficult heparin reversal. Larger amounts of fresh frozen plasma and platelet concentrate were transfused in group B than in group A. CONCLUSION: Surgeons' efforts to reduce operative time and avoid deep hypothermia may be helpful for increasing the likelihood of easy heparin reversal, especially in female patients.

Clinical Value of Intraoperative Flow Measurements of Brachiocephalic Arteriovenous Fistulas for Hemodialysis.

BACKGROUND: The aim of this study was to analyze the clinical outcomes of autogenous brachiocephalic arteriovenous fistulas and to investigate the factors associated with 1-year patency after initiation of hemodialysis. METHODS: We retrospectively reviewed the medical records of 41 patients who underwent surgery to create an autogenous brachiocephalic arteriovenous fistula between January 2015 and December 2017, received hemodialysis at the same hospital for longer than 1 year, and were monitored for their vascular access status. Intraoperative flow was measured using transit-time ultrasonography. RESULTS: The 1-year primary and secondary patency rates were 61% (n=25) and 87.8% (n=36), respectively. The functional group (subjects who required no intervention to maintain patency within the first year after hemodialysis initiation) displayed a significantly higher median intraoperative flow rate (450 mL/min) than the non-functional group (subjects who required intervention at least once regardless of 1-year patency) (275 mL/min) (p=0.038). Based on a receiver operating characteristic curve analysis, all patients were additionally subdivided into a high-flow group (>240 mL/min) and a low-flow group (≤240 mL/min). The high-flow group included a significantly greater number of functional brachiocephalic arteriovenous fistulas than the low-flow group (74.2% vs. 20%, respectively; p=0.007). CONCLUSION: Transit-time flow, as measured with intraoperative transit-time ultrasonography, was associated with patency without the need for intervention at 1 year after initiation of hemodialysis.

Cardiac Autotransplantation with Concurrent Pneumonectomy for Complete Resection of Primary Cardiac Intimal Sarcoma.

Primary cardiac sarcoma is rare, and intimal sarcoma is an extremely rare and highly lethal disease. We report a case of a 62-year-old woman who was incidentally diagnosed with a primary cardiac sarcoma originating from the left atrial appendage and extending to the left superior pulmonary vein. The location of the tumor was very complicated, posing a major challenge for complete resection. We successfully performed complete resection of the cardiac sarcoma via cardiac autotransplantation with left pneumonectomy. The patient recovered uneventfully, without any adjuvant therapy as of 6 months postoperatively. Autotransplantation of the heart may be suggested as a reasonable surgical option for extensive left atrial tumors.

Selective Shunting Based on Dual Monitoring with Electroencephalography and Stump Pressure for Carotid Endarterectomy.

PURPOSE: The aim of this study is to analyze postoperative outcomes for carotid endarterectomy (CEA) in addition to the preoperative clinical characteristics related to selective shunting based on dual monitoring with stump pressure (SP) and electroencephalography (EEG). MATERIALS AND METHODS: We retrospectively reviewed medical records of 70 patients who underwent CEA from March 2010 to December 2017. CEA was performed under general anesthesia and selective shunting was done if the SP was lower than 35 mmHg regardless of EEG or if intraoperative EEG showed any changes different from preoperative one regardless of SP. RESULTS: There was no postoperative 30-day adjusted mortality or adverse cardiac events. Three patients (4.3%) had postoperative minor stroke finally reaching pre-operative neurologic status at the time of discharge. Twenty-six patients (37.1%) used shunting and severe contralateral internal carotid stenosis or occlusion was related to shunting (P<0.010). There were larger number of symptomatic patients in shunt group in spite of no statistical significance (P=0.116). CONCLUSION: Perioperative stroke rate was 4.3% for CEA under general anesthesia based on dual intraoperative monitoring with SP and EEG. There was no 30-day adjusted mortality and adverse cardiac event. Severe stenosis or occlusion of contralateral internal carotid artery is related to shunting (P<0.010).

Dual Monitoring with Stump Pressure and Electroencephalography During Carotid Endarterectomy.

BACKGROUND: Intraoperative monitoring during carotid endarterectomy is crucial for cerebral protection. We investigated the results of carotid endarterectomy under dual monitoring with stump pressure and electroencephalography. METHODS: We retrospectively reviewed the medical records of 50 patients who underwent carotid endarterectomy between March 2010 and February 2016. We inserted a temporary shunt if the stump pressure was lower than 35 mm Hg or if any intraoperative change was observed on electroencephalography. RESULTS: Seventeen (34%) patients used a temporary shunt, and the mean stump pressure was 26.8 mm Hg in the shunt group and 46.5 mm Hg in the non-shunt group. No postoperative mortality or bleeding occurred. Postoperatively, there were 3 cases (6%) of minor stroke, all of which took place in the shunt group. A comparison of the preoperative and the intraoperative characteristics of the shunt group with those of the non-shunt group revealed no statistically significant difference between the 2 groups (p <0.01). CONCLUSION: Dual monitoring with stump pressure and electroencephalography was found to be a safe and reliable monitoring method with results comparable to those obtained using single monitoring. Further study should be performed to investigate the precise role of each monitoring method.

Delayed aortic rupture resulting from postoperative superficial sternal wound infection.

While deep sternal wound infection (DSWI) after cardiac surgery is a significant contributor to patient morbidity and mortality, superficial sternal wound infection (SSWI) mostly has a benign course. We report a mortality case of aortic rupture resulting from SSWI after cardiac surgery. A 50-year-old male underwent an aortic valve replacement (AVR). Three months after the valve operation, he presented with severe dyspnea, which had never before been observed, and chest computed tomography revealed an ascending aortic rupture with large hematoma compressing the main pulmonary artery. We performed an emergent operation for aortic rupture that possibly originated from the SSWI. Postoperatively, the patient died of hypovolemic shock due to recurrent aortic rupture despite efforts to resuscitate him.

Bilateral chylothorax after transsternal total thymectomy: resolution with short period of fasting and total parenteral nutrition.

Bilateral chylothorax after transsternal total thymectomy is very rare, but can be a serious complication. Disruption of minor lymphatic channels in the anterior mediastinum which is remote from thoracic duct is considered to be the cause of chylothorax. We report the case of bilateral chylothorax followed by thymectomy which was treated with pleural drainage, total parenteral nutrition, and fasting without octreotide injection.

Unusual Presentation of a Cervical Mass Revealed as External Jugular Venous Aneurysm.

Venous aneurysms of the jugular vein are one of the rare causes of neck swelling, and primary venous aneurysms of the external jugular vein are extremely rare. A 46-year-old woman presented with a painless and suddenly growing mass in the left neck. A computed tomography angiography revealed a fusiform venous aneurysm of the external jugular vein containing intraluminal thrombus. We performed resection of the aneurysm and ligation of the external jugular vein. Removal of the aneurysm of the neck vein was necessary because venous aneurysms with thrombosis may lead to serious thrombotic complications such as pulmonary embolism.

The effects of climate change and globalization on mosquito vectors: evidence from Jeju Island, South Korea on the potential for Asian tiger mosquito (Aedes albopictus) influxes and survival from Vietnam rather than Japan.

BACKGROUND: Climate change affects the survival and transmission of arthropod vectors as well as the development rates of vector-borne pathogens. Increased international travel is also an important factor in the spread of vector-borne diseases (VBDs) such as dengue, West Nile, yellow fever, chikungunya, and malaria. Dengue is the most important vector-borne viral disease. An estimated 2.5 billion people are at risk of infection in the world and there are approximately 50 million dengue infections and an estimated 500,000 individuals are hospitalized with dengue haemorrhagic fever annually. The Asian tiger mosquito (Aedes albopictus) is one of the vectors of dengue virus, and populations already exist on Jeju Island, South Korea. Currently, colder winter temperatures kill off Asian tiger mosquito populations and there is no evidence of the mosquitos being vectors for the dengue virus in this location. However, dengue virus-bearing mosquito vectors can inflow to Jeju Island from endemic area such as Vietnam by increased international travel, and this mosquito vector's survival during colder winter months will likely occur due to the effects of climate change. METHODS AND RESULTS: In this section, we show the geographical distribution of medically important mosquito vectors such as Ae. albopictus, a vector of both dengue and chikungunya viruses; Culex pipiens, a vector of West Nile virus; and Anopheles sinensis, a vector of Plasmodium vivax, within Jeju Island, South Korea. We found a significant association between the mean temperature, amount of precipitation, and density of mosquitoes. The phylogenetic analyses show that an Ae. albopictus, collected in southern area of Jeju Island, was identical to specimens found in Ho Chi Minh, Vietnam, and not Nagasaki, Japan. CONCLUSION: Our results suggest that mosquito vectors or virus-bearing vectors can transmit from epidemic regions of Southeast Asia to Jeju Island and can survive during colder winter months. Therefore, Jeju Island is no longer safe from vector borne diseases (VBDs) due to the effects of globalization and climate change, and we should immediately monitor regional climate change to identify newly emerging VBDs.

Massive spontaneous diaphragmatic rupture induced by a squatting position.

While a diaphragmatic rupture commonly results from trauma to the abdomen and chest, a spontaneous diaphragmatic rupture is very rare. A 68-year-old male presented with chest pain that had originated while doing farm work in a squatting position. Images revealed a 5 cm defect of the left diaphragmatic dome, and the entire stomach was displaced into the thorax. The diaphragmatic defect was round and half had a well-demarcated margin. The remaining fragile tissue was completely excised and was closed primarily. The patient was uneventfully discharged and resumed with a normal diet 10 days after the operation.

Pepsin-solubilised collagen (PSC) from Red Sea cucumber (Stichopus japonicus) regulates cell cycle and the fibronectin synthesis in HaCaT cell migration.

Pepsin-solubilised collagen (PSC) from Red Sea cucumber (Stichopus japonicus) was studied with respect to its wound-healing effects on a human keratinocyte (HaCaT) cell line. Disaggregated collagen fibres were treated with 0.1M NaOH for 24h and digested with pepsin for 72h to reach maximum yield of 26.6%. The results of an in vitro wound-healing test showed that migration of HaCaT cells was 1.5-fold faster on PSC-coated plates than on untreated plates. The migration rate of sea cucumber PSC was similar to that of rat PSC, but five times higher than that of bovine gelatin. HaCaT cells grown on PSC-coated plates revealed increased fibronectin synthesis (6-fold and 3-fold compared to gelatin and rat PSC, respectively). Additionally, sea cucumber PSCs induced HaCaT cell proliferation by decreasing the G1 phase by 5% and maintaining a larger population (8%) of cells in mitosis. Collagen from Red Sea cucumber might be useful as an alternative to mammalian collagen in the nutraceutical and pharmaceutical industries.

Main pulmonary artery stenosis caused by fibrocalcified mass in a young infant.

We present a rare case of main pulmonary artery stenosis secondary to protruding fibrous material in the main pulmonary artery associated with patent ductus arteriosus. A 1-month-old baby boy manifested cardiac murmur. Echocardiogram showed circumferential high echogenic mass inside the main pulmonary artery with pressure gradient of 49 mmHg and patent ductus arteriosus. The mass did not regress during 3 months' follow-up period. Angiographic images showed that the circular filling defect was located at the main pulmonary artery distal to pulmonary valve, and pulmonary valve and both pulmonary arteries were normal. After surgical removal of the circumferential material and ductus ligation, the pressure gradient became negligible. The material was consisted of scarcely cellular fibrous tissue, abundant coagulum of fibrinous material and dense calcification.