[Metastatic Right Atrial Tumor of Renal Cell Carcinoma:Report of a Case].

Metastatic cardiac tumors are known to be more common than primary cardiac tumors, and most patients are asymptomatic. In patients with renal cell carcinoma (RCC) with cardiac metastases, total tumor resection is known to improve the prognosis. We report a case of a successfully resected RCC with right atrial metastasis under cardiopulmonary bypass. A 71-year-old female with abdominal distention was diagnosed with right RCC and extension to the right atrium. After neoadjuvant chemotherapy, she underwent right nephrectomy and neiection of intraocular tumor extention with partial right atrium under cardiopulmonary bypass, because the tumor tightly adhered to the right atrium. She had a good postoperative course and was discharged home on the 22nd postoperative day. Nine months after surgery, she shows no sign of recurrence.

[Stanford Type A Acute Aortic Dissection Complicated with Intestinal Ischemia Preceded by Superior Mesenteric Artery Bypass:Report of a Case].

A 78-year-old male with sudden onset of chest and back pain was transported to our institution by ambulance. Upon arrival at our hospital, he also complained of abdominal pain. Contrast-enhanced computed tomography (CT) revealed the presence of Stanford type A acute aortic dissection complicated with intestinal ischemia;because of the effects of aortic dissection, the superior mesenteric artery 378 Vol.76 No.5(2023-5) (SMA) was obstructed, leading to the complication of intestinal ischemia. An arterial blood gas test showed elevated lactate and metabolic acidosis. We immediately performed resection of the necrotic portion of the intestine and bypass of the common iliac artery to the SMA. Subsequently, after confirmation of the improvement of acidosis, ascending aortic replacement was performed on the same day. Although the patient's condition was complicated by acute kidney injury and pneumonia, he was discharged home on the 55th postoperative day. Acute aortic dissection complicated by intestinal ischemia has a poor prognosis;however, here we reported a life-saving surgical procedure in a patient with this presentation.

[Stanford Type A Acute Aortic Dissection in a Patient with a Single Coronary Artery:Report of a Case].

A single coronary artery is a very rare anomaly and is usually asymptomatic. Here we report a case of a single coronary artery complicated with Stanford type A acute aortic dissection. A 58-year-old male with chest pain was transported to our institution by ambulance. He was diagnosed with a single coronary artery accompanied by acute coronary syndrome. The single coronary artery originated from the left sinus of Valsalva and the right coronary branch coursed between the aorta and the pulmonary artery. It was, therefore considered difficult to perform catheter intervention, and urgent coronary artery bypass surgery was planned. Enhanced computed tomography, however, revealed Stanford type A acute aortic dissection, and aortic root replacement combined with coronary artery bypass grafting was performed by emergency. The postoperative course was uneventful.

[The Apical Left Ventricle Aneurysm, Eighteen Years After the Fulminant Myocarditis:Report of a Case].

Ventricular aneurysm after myocarditis is a rare complication. It has been reported that scarred areas of the myocardium may become aneurysm. Here, we report a case of apical left ventricle aneurysm at 18 years after the fulminant myocarditis. The patient is a 36-year-old female with a history of fulminant myocarditis at the age of 18. Eighteen years after the onset of the disease, she was referred to our hospital because of an apex ventricular aneurysm. Her computed tomography scan showed an apex ventricular aneurysm sized 45×40 mm with a wall width of 1.8 mm. We performed resection of ventricular aneurysm and reconstruction using Linear technique. The postoperative course was uneventful and discharged on the 17th post operative day.

[Rhabdomyolysis during Perioperative Period after Cardiac Surgery].

We report a case of rhabdomyolysis during a perioperative period after cardiac surgery. A 47-yearold man underwent aortic root replacement for annuloaortic ectasia under general anesthesia using sevoflurane, fentanyl, remifentanil, rocronium bromide and midazolam. On the 1st postoperative day (1 POD), his body temperature rose over 38 ℃, which continued for 3 days despite our attempt to stabilize the fever. On 4 POD, his laboratory data and hemodynamics dramatically worsened, and we commenced continuous hemodialysis filtration (CHDF) and percutaneous cardiopulmonary support system (PCPS). In addition, balloon pumping (IABP) was started on 5 POD. At the same time, we initiated dantrolene sodium hydrate infusion according to a clinical grading scale to predict malignant hyperthermia (MH) susceptibility. Serum creatine phosphokinase (CPK) increased over 350,000 U/l on the 7 POD, and dantrolene sodium hydrate was continuously infused until 9 POD. Despite dantrolene sodium infusion, CHDF, IABP and PCPS, his condition did not improve, and he died of disseminated intravascular coagulation syndrome (DIC) and sepsis on 28 POD. Computed tomography on 21 POD disclosed scattered low-density areas in the erector spinal, lliopsoas and femoral muscles, which indicated rhabdomyolysis. Histopathological examination using hematoxylin and eosin stain revealed destroyed striated-muscle fibers and swelling rhabdomyocytes. It remained unclear which drug triggered rhabdomyolysis. When MH is suspected, we should consider the use of the clinical grading scale to predict its susceptibility and start dantrolene sodium hydrate infusion.

[Emergency Surgery for Acute Pulmonary Embolism].

According to the current guidelines for acute pulmonary embolism in Japan, it is standard to perform surgical thrombectomy only after introducing percutaneous cardiopulmonary support (PCPS) for circulatory collapse. We experienced 2 cases of surgical thrombectomy without using PCPS. The 1st patient was a 49-year-old man. Computed tomography (CT) on admission revealed a thrombus in the main trunk of the pulmonary artery. He developed severe dyspnea and drop of consciousness after admission, and underwent emergency surgical thrombectomy. The 2nd patient was a 52-year-old man whose levels of consciousness and arterial oxygenation rapidly declined after admission. His CT revealed thrombi in the main trunk of the pulmonary artery, and he underwent emergency thrombectomy. Both patients had a history of diabetes and obesity. At our institute, we actively choose surgical thrombectomy for cases in which a thrombus is revealed in the main trunk of the pulmonary artery on CT and for cases in which abnormal symptoms and/or signs such as impaired consciousness and oxygenation develop.

Surgical management of left ventricular thrombus following severe dehydration.

We experienced a case involving a left ventricular ball-like thrombus caused by severe following a 150 mile cycling road race. The patient had lower-limb arterial obstruction due to systemic thromboembolism on admission with no significant embolism, including the cerebral arteries, were detected. Left ventricular wall motion was good with no evidence of left and right coronary artery occlusion; therefore, we performed emergency left ventricular thrombectomy. Although there are many reports of left ventricular thrombus following acute myocardial infarction, dehydration is a very rare cause. Herein, we describe the surgical and management approaches to the treatment of left ventricular thrombectomy in this case.

A selection of cases of direct cannulation in surgery for type A dissection.

BACKGROUND: We use antegrade cannulation, circulatory arrest, and selective antegrade cerebral perfusion in patients with acute aortic dissection. While blood is generally supplied via the ascending aorta, this route can be difficult, depending on the features of dissection and the form of the true lumen. In such cases, we incise the ascending aorta and insert the cannula directly into the true lumen of the ascending aorta to secure the blood supply. METHODS: Between April 2005 and April 2012, direct true lumen cannulation of the ascending aorta was performed in 12 patients; 5 had total arch replacement, and 7 had ascending aorta and hemiarch replacement. RESULTS: Total arch replacement involved circulatory arrest for 62 ± 16 min, aortic crossclamping for 174 ± 13 min, cardiopulmonary bypass for 211 ± 11 min, and a minimal rectal temperature of 28.4 ± 1.8. Ascending aorta and hemiarch replacement involved arrest of the circulation for 40 ± 9 min, aortic crossclamping for 111 ± 29 min, cardiopulmonary bypass for 131 ± 34 min, and a minimal rectal temperature of 27.8 ± 0.9. One patient died from cerebral infarction during hospitalization. CONCLUSION: In these cases, direct true lumen cannulation of the ascending aorta was effective.

Death due to undetected heparin-induced thrombocytopenia after cardiac surgery.

A 41-year-old male patient was diagnosed acute myocardial infarction. An intra-aortic balloon pump was inserted to treat heart failure, and off-pump coronary artery bypass surgery was performed. Postoperative cardiac catheterization revealed occlusion of all the 3 bypass grafts, and percutaneous coronary intervention (PCI) was performed. Thrombosis due to heparin-induced thrombocytopenia (HIT) occurred during PCI, which was completed after switching to argatroban based on the possible HIT. Cardiopulmonary arrest occurred suddenly after PCI, and the patient died. Undetected HIT may have caused the sudden change. HIT should be suspected and aggressively treated when thrombocytopenia occurs even during assisted circulation.

For what type of constrictive pericarditis is the waffle procedure effective?

The waffle procedure is performed in patients with marked thickening and calcification of the epicardium and no substantial improvement in hemodynamic parameters after pericardiectomy. We retrospectively investigated the efficacy of the waffle procedure in 6 of 11 patients who underwent pericardiectomy. These 6 patients showed no improvement in central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, or cardiac index after pericardiectomy. After the waffle procedure, all hemodynamic parameters improved, and there were no significant differences compared to those of the 5 patients who did not require the waffle procedure, despite higher pulmonary capillary wedge pressure and lower cardiac index values preoperatively in the waffle group. The waffle procedure was considered effective in patients with persistent epicardial constriction.

The lower limit of the pulmonary artery index for the extracardiac Fontan circulation.

OBJECTIVE: In the era of the staged Fontan operation, small pulmonary artery index (<250 mm(2)/m(2)) has not affected the early or midterm results. The lower limit of pulmonary artery index, however, has not yet been determined. We created numeric models of the Fontan circulation to investigate the lower limit of the pulmonary artery size. METHODS: The extracardiac Fontan geometries with pulmonary artery index, ranging from 50 to 200 mm(2)/m(2) with every 10-mm(2)/m(2) increase, were created from the postoperative angiographic data of 17 patients. The superior and inferior vena caval flow rates at rest and on 2 exercise levels (0.5 and 1.0 W/kg) were given by magnetic resonance imaging flow studies. Respiration-driven transient flow analysis was performed with a finite element solver. Energy loss and mean inferior vena caval pressure were obtained from the results. RESULTS: Energy loss and mean inferior vena caval pressure were prominently increased in small pulmonary artery index models, especially during exercise. The pulmonary artery indices sufficient for mean inferior vena caval pressure less than 17 mm Hg were 80 mm(2)/m(2) at rest, 100 mm(2)/m(2) during 0.5-W/kg exercise, and 110 mm(2)/m(2) during 1.0-W/kg exercise. With the increase of pulmonary arterial resistance, mean inferior vena caval pressure increased, but the flow pattern did not change. CONCLUSIONS: A small pulmonary artery causes a high pressure gradient and a high energy loss. The lower limit of pulmonary artery index, considering the exercise tolerance, was 110 mm(2)/m(2).

Miniaturized biocompatible cardiopulmonary bypass for the Fontan procedure.

PURPOSE: Postoperative inflammatory response and perioperative systemic edema are the risks of failed Fontan circulation. We evaluated the efficiency of the miniaturized, poly-2-methoxyethylacrylate (PMEA)-coated cardiopulmonary bypass (CPB) circuit, which we devised in 2003, in the Fontan circulation. METHODS: Thirty-seven patients who underwent the Fontan procedure between March 1996 and December 2006 were divided into two groups: one consisting of patients with a priming-volume >250 m on uncoated conventional bypass (group C; n = 20), and one consisting of those with miniaturized (<200 ml) and PMEA-coated circuits (group M; n = 17). We compared the body weight gain (%BWG), minimum platelet count, maximum postoperative C-reactive protein (CRP), and minimum hematocrit (Hct) levels during the operation, maximum white blood cell (WBC) count, and postoperative pleural effusion, between the two groups. Stepwise multiple logistic regression analyses were used to investigate the most affecting factors. RESULTS: The %BWG and CRP levels were significantly lower in group M (P = 0.047 and P = 0.012, respectively). The minimum platelet count was significantly higher in group M (P = 0.012). There were no significant differences in postoperative pleural effusion, minimum Hct, or maximum WBC. CONCLUSION: The miniaturized biocompatible CPB system reduced perioperative inflammatory responses.

Regional high-flow cerebral perfusion improves both cerebral and somatic tissue oxygenation in aortic arch repair.

BACKGROUND: Regional cerebral perfusion provides cerebral circulatory support during aortic arch reconstruction. We report the effectiveness of high-flow regional cerebral perfusion (HFRCP) from the right innominate artery to maintain sufficient cerebral and somatic oxygen delivery through collateral vessels. METHODS: Frontal cerebral and thoracolumbar probes to measure somatic regional oxygen saturation (rSo(2)) were used to continuously measure oxygenation during cardiopulmonary bypass in 18 patients (weight, 2.1 to 4.3 kg) who underwent arch reconstruction using HFRCP (mean flow, 82; range, 43 to 108 ml/kg/min). Procedures included 9 Norwood procedures, 5 coarctation of aorta/interruption of aorta complex repairs, and 4 aortic arch repairs for a single ventricle. Mean HFRCP duration was 51 + or - 17 minutes under moderate hypothermia. Mean radial arterial pressure was kept at less than 50 mm Hg during HFRCP, and chlorpromazine (mean dose, 2.8 mg/kg) was given to all patients before and during HFRCP to increase regional cerebral perfusion flow. Plasma lactate concentration was measured before and after HFRCP. RESULTS: During HFRCP, mean cerebral rSo(2) was 78.8% + or - 9.5%, somatic rSo(2) was 65.4% + or - 12.1%, and lactate concentration increased from 3.8 + or - 2.2 to 5.5 + or - 2.1 mmol/L. There was significant correlation between regional cerebral perfusion flow and somatic rSo(2). Significant inverse correlations were noted between regional cerebral perfusion flow and the increase of lactate concentration and between somatic rSo(2) and the increase of lactate concentration. CONCLUSIONS: High-flow regional cerebral perfusion preserved sufficient cerebral and somatic tissue oxygenation during aortic arch repair. The reduction of vascular resistance of collateral vessels increased both cerebral and somatic blood flow, resulting in improved tissue oxygen delivery.

Repair of ventricular septal perforation after inferior myocardial infarction.

Various techniques have been used for repair of ventricular septal perforation complicating inferior myocardial infarction, but no standard method has been established. An effective technique for closing ventricular septal perforation using double patches via a right atrial approach is described. In our experience, no residual shunt was observed after repair using this procedure.

The effectiveness of prestorage leukocyte-reduced red blood cell transfusion on perioperative inflammatory response with a miniaturized biocompatible bypass system.

OBJECTIVE: Since 2007, the Japanese Red Cross Blood Center has provided prestorage leukocyte-reduced red blood cell concentrates in which the leukocytes were reduced soon after collection. We have established a miniaturized bypass system (140 mL) to reduce the perioperative inflammatory responses. This study was designed to reveal the effectiveness of leukocyte-reduced red blood cell concentrate transfusion on perioperative inflammatory responses in pediatric cardiac surgery. METHODS: Between May 2006 and June 2008, 50 consecutive patients weighing less than 5 kg who underwent a surgical procedure with red blood cell concentrate transfusion using a miniaturized bypass system were reviewed retrospectively. Twenty-five patients before 2007 received stored red blood cell concentrate in which leukocytes were reduced with a filter just before transfusion (group A). After 2007, 25 patients received the prestorage leukocyte-reduced red blood cell concentrate transfusion (group B). The postoperative peak C-reactive protein level, peak white blood cell count, peak neutrophil count, percentage body weight gain, inotrope score, plasma lactate concentration, postoperative mechanical ventilation time, and length of intensive care unit stay were compared as the perioperative inflammatory response and morbidity for both groups. RESULTS: There were no significant differences in peak white blood cell count, peak neutrophil count, percentage body weight gain, and inotrope score between the groups. The peak C-reactive protein level in group A was significantly greater than that in group B (6.7 +/- 4.7 vs 4.2 +/- 3.6 mg/dL, P < .05). The lactate concentration at 12 and 24 hours after surgical intervention in group A was significantly greater than that in group B (3.1 +/- 2.5 vs 1.9 +/- 1.1 mmol/L [P < .05] and 2.2 +/- 0.2 vs 1.4 +/- 0.2 mmol/L [P < .05], respectively). The postoperative mechanical ventilation time and intensive care unit stay in group A were significantly greater than those in group B (5.9 +/- 7.4 vs 2.1 +/- 2.0 days [P < .05] and 9.8 +/- 7.9 vs 5.0 +/- 2.1 days [P < 0.05], respectively). Multivariate analyses showed that the leukocyte-reduced red blood cell concentrate transfusion reduced the peak C-reactive protein level (in milligrams per deciliter; coefficient, -2.95; 95% confidence interval [CI], -4.66 to -0.93; P = .003), postoperative mechanical ventilation time (in days; coefficient, -3.41; 95% CI, -6.07 to -0.74; P = .013), and intensive care unit stay (in days; coefficient, -4.51; 95% CI, -7.37 to -1.64; P = .003). CONCLUSIONS: Our study revealed that in neonates and small infants, compared with transfusions with stored red blood cell concentrate, transfusion of leukocyte-reduced red blood cell concentrates was associated with reduced perioperative inflammatory responses and improved clinical outcomes.

The influences of red blood cell transfusion on perioperative inflammatory responses using a miniaturized biocompatible bypass with an asanguineous prime.

Whole blood transfusion generates an inflammatory response and may contribute to organ dysfunction following cardiopulmonary bypass. We established a miniaturized (minimum 140 mL) and biocompatible bypass system to reduce perioperative inflammatory responses and avoid blood transfusions. This study was designed to reveal the influences of stored red blood cell (RBC) transfusions on perioperative inflammatory responses in infants. Fifty-four consecutive patients weighing 4-10 kg who underwent surgical procedures for complex heart anomalies with asanguineous prime were retrospectively reviewed. Twenty-two patients (40.7%) received RBC transfusions during CPB. The postoperative peak white blood cell count (p-WBC), peak neutrophil count (p-NC), and peak C-reactive protein (p-CRP) were compared for both patient groups. Stepwise multiple logistic regression analyses were used to investigate which of the factors most affected the perioperative inflammatory responses. The p-CRP and p-NC in patients with transfusion was significantly greater than those in patients without transfusion (CRP 8.1 +/- 5.1 versus 5.5 +/- 3.0 mg/dL, P < 0.05, p-NC 14.6 +/- 4.5 versus 12.0 +/- 4.0 x 1000/mm3, P < 0.05). Multivariate analyses showed that RBC transfusion most affected p-WBC (coefficient: 3.89, 95% confidence interval [CI] 0.79-6.99, P = 0.015) and p-NC (coefficient: 3.64, 95% CI 0.87-6.40, P = 0.011). The RBC transfusions increased the perioperative inflammatory responses, compared to transfusion-free procedures, even when using a miniaturized biocompatible bypass with an asanguineous prime.

Optimal conduit size of the extracardiac Fontan operation based on energy loss and flow stagnation.

BACKGROUND: In the extracardiac Fontan operation, larger conduits are used when considering the patients' growth rate. However, larger conduits may cause inefficient flow due to turbulence or stagnation, resulting in late problems such as thrombosis or stenosis. Our objective was to reveal the physiologic effects of respiration and exercise using numerical models, based on the energy loss and flow stagnation, and to determine optimal conduit size. METHODS: For the Fontan operation, a conduit from 14 to 22 mm was created based on angiographic data from 17 Fontan patients (mean age, 36.0 months; mean body surface area, 0.53 m(2)). Respiratory-driven flow of the superior and inferior vena cava was determined at rest and during exercise on two levels (0.5 and 1.0 W/kg) by magnetic resonance imaging flow studies. Flow stagnation was defined as the volume of the region where flow velocity was less than 0.01 m/second at both the expiratory and inspiratory phases. RESULTS: In larger conduits, backward flow at the expiratory phase was prominent. Energy loss was small even during exercise, but the change was slightly larger between 14 and 16 mm than other conduit sizes (14 mm, 5.759 mW; 16 mm, 4.881 mW; and 22 mm, 4.199 mW during 1.0 W/kg exercise). Stagnation volume at the expiratory phase increased with an increase of conduit size (14 mm, 9.20% vs 22 mm, 33.9% conduit volume at rest). CONCLUSIONS: Fontan circulation is a low-energy system even during exercise. Larger conduits were proven to have redundant spaces, thus 16 and 18 mm conduits were optimal.

Higher cerebral oxygen saturation may provide higher urinary output during continuous regional cerebral perfusion.

OBJECTIVE: We examined the hypothesis that higher cerebral oxygen saturation (rSO2) during RCP is correlated with urinary output. METHODS: Between December 2002 and August 2006, 12 patients aged 3 to 61 days and weighing 2.6 to 3.4 kg underwent aortic arch repair with RCP. Urinary output and rSO2 were analyzed retrospectively. Data were assigned to either of 2 groups according to their corresponding rSO2: Group A (rSO2 < or = 75%) and Group B (rSO2 < 75%). RESULTS: Seven and 5 patients were assigned to Group A and Group B, respectively.Group A was characterized by mean radial arterial pressure (37.9 +/- 9.6 vs 45.8 +/- 7.8 mmHg; P = 0.14) and femoral arterial pressure (6.7 +/- 6.1 vs 20.8 +/- 14.6 mmHg; P = 0.09) compared to Group B. However, higher urinary output during CPB (1.03 +/- 1.18 vs 0.10 +/- 0.15 ml.kg-1.h-1; P = 0.03). Furthermore our results indicate that a higher dose of Chlorpromazine was used in Group A (2.9 +/- 1.4 vs 1.7 +/- 1.0 mg/kg; P = 0.03). CONCLUSION: Higher cerebral oxygenation may provide higher urinary output due to higher renal blood flow through collateral circulation.