Aberrant mediastinal mediobasal segmental pulmonary artery in a patient with lung cancer undergoing right lower lobectomy: a case report.

BACKGROUND: A mediastinal mediobasal segmental pulmonary artery (A7) from the right main pulmonary artery is extremely rare. CASE PRESENTATION: We report the case of a 71-year-old woman with an aberrant mediastinal A7 who underwent right lower lobectomy for lung cancer (cT1bN0M0, stage IA2). Preoperative three-dimensional computed tomography (CT) angiography revealed an aberrant mediastinal A7 in the right main pulmonary artery. Right lower lobectomy and mediastinal lymph node dissection were performed. Intraoperatively, A7 was observed between the superior and inferior pulmonary veins and in the front of the lower bronchus near the anterior hilum. The artery was carefully dissected from the caudal side after inferior pulmonary vein dissection. The lung parenchyma, which was within the fissure due to poor lobulation between the middle and lower lobes, was safely divided. CONCLUSIONS: Thoracic surgeons need to carefully evaluate CT angiography or enhanced multidetector CT findings at preoperative conferences and always keep this anomaly in mind.

Successful salvage surgery followed by second ALK-TKI after alectinib failure in a patient with ALK-positive NSCLC.

BACKGROUND: Anaplastic lymphoma kinase (ALK)-tyrosine kinase inhibitors (TKIs) have been approved for the therapy of locally advanced non-small cell lung cancer (NSCLC) caused by ALK rearrangement. However, its treatment after failure of initial ALK-TKI therapy remains controversial. CASE PRESENTATION: A 47-year-old woman with a hemosputum was diagnosed with adenocarcinoma of the left lung (cT2bN3M0, stage IIIB). Gene mutation analysis indicated positive ALK translocation. Alectinib was selected as the first-line treatment. Although the treatment effect was determined as a partial response, the main tumor regrew. Alectinib was discontinued, and salvage surgery was performed without causing morbidity. The pathological diagnosis was pleomorphic carcinoma without lymph node metastasis (yp-T2bN0). After surgery, lorlatinib was administered as the second-line treatment for 8 months until the patient could not tolerate continuation. Computed tomography scan revealed no lung cancer recurrence 14 months after discontinuation. CONCLUSIONS: Our experience with this case suggests that salvage surgery after alectinib treatment followed by lorlatinib therapy may be effective for initially unresectable ALK-positive NSCLC.

[Typical Carcinoid of the Lung with Abnormal Elevation of Serum Pro-gastrin-releasing Peptide (ProGRP)].

A 40-year-old male was referred to our hospital because of a nodular shadow detected in the left lower lobe with the tendency to increase gently. Because fluoro-2-deoxy-D-glucose (FDG) uptake was extremely low on a FDG positron emission tomography (PET-CT), the tumor was highly suspected of the benign tumor. Five years later, a follow-up computed tomography (CT) showed the shadow to be enlarged. FDG uptake was changed to be high, and serum level of pro-gastrin-releasing peptide (Pro-GRP) was extremely elevated. Surgical treatment was chosen under suspicious diagnosis of neuroendocrine tumor, such as small cell carcinoma, large cell neuroendocrine carcinoma, and carcinoid. By the intraoperative aspiration cytology, a small cell carcinoma or a carcinoid was suspected and left lower lobectomy with systemic lymph node dissection was performed. The final histological diagnosis was a typical carcinoid. The elevated serum ProGRP immediately decreased to normal postoperatively.

Comprehensive review of the epidemiology and treatments for malignant adult cardiac tumors.

Carcinomas rarely occur in the heart, and cardiac surgeons are generally not familiar with cardiac tumors. Some characteristics of cardiac and intrapericardial tumors are reviewed to understand the features of cardiac tumors. Cardiac tumors are discussed separately from intrapericardial tumors. Primary cardiac tumors are predominantly benign whereas primary intrapericardial tumors are usually malignant. The prevalence of each tumor types is presented in this review. In both cardiac and intrapericardial tumors, the incidences of metastatic tumors from cancers outside of the heart are high with carcinomas occupying more than half of the cases. Generally, the prognosis of primary malignant cardiac tumors is very poor. Cardiac tumors metastasize to other organs as hematogenous metastases. Surgery must be performed based on all the above-mentioned features of both cardiac and intrapericardial tumors.

Primary cardiac solitary fibrous tumors.

Primary cardiac solitary fibrous tumors were reviewed. They are classified as pericardial tumors. Their incidences are very rare. Only 16 cases were reported in the literature. Basically, surgical treatments are performed. Their prognoses are generally good, although malignant cases are also reported.

Mediastinal schwannoma diagnosed preoperatively as a cyst.

Mediastinal schwannomas are sometimes diagnosed as pericardial or bronchogenic cysts, if cystic degeneration is extensive. When mediastinal schwannomas are not diagnosed as primary cardiac tumors, the use of cardiopulmonary bypass in their resection appears to be infrequent. We report the case of a 48-year-old woman who presented with symptoms from a suspected intrapericardial cyst. Multiple diagnostic images revealed a large mass, potentially a proteinaceous or hemorrhagic cyst, in the transverse sinus behind the ascending aorta and against the left main trunk. After complete resection with the use of cardiopulmonary bypass, the mass was identified as a benign extracardiac schwannoma. More than 3 years postoperatively, the patient had no relevant symptoms. We discuss the preoperative diagnosis, the method of resection, and our broad strategy for dealing with such a case.

Technique for using pedicled latissimus dorsi muscle flaps to wrap prosthetic grafts in an infected thoracic aorta.

In this report we describe a special method of using a pedicled latissimus dorsi muscle flap for a mycotic aneurysm. The method involves wrapping the flap around a prosthetic graft. Using this method, an in situ graft, which replaces an aneurysm, can help to avoid recurrence of local infection.

Surgery for primary intrapericardial tumors in adults.

Primary intrapericardial tumors in adults, whether benign or malignant are rare. Surgical treatment for these tumors are reviewed together with their incidence, classification, clinical features, and diagnosis.

Simplicity, skills, and pitfalls of ascending aortic cannulation for type A aortic dissection.

BACKGROUND: Ascending aortic cannulation for an antegrade central perfusion during surgery for type A aortic dissection is simple and can be performed within median sternotomy. This cannulation is performed routinely without problems in our hospital. Using our experience, the skills and pitfalls were clarified to make this challenging procedure successful. METHODS: 29 cases of ascending aortic cannulation using the Seldinger technique for insertion were studied. All insertions were performed with the guidance of transesophageal echocardiography alone. The cannulas were inserted after decompressing the aorta by initiating cardiopulmonary bypass with femoral artery cannulation. From our experience, the skills required for this procedure are the abilities to carefully assess the needle insertion site preoperatively, sense resistance to needle insertion twice, and ensure the guide wire is in the descending aorta and distal arch. The pitfalls are entrance of the guide wire into the false lumen and dilatation of the false lumen during the insertion procedure. RESULTS: There were no complications associated with ascending aortic cannulation. Regarding morbidity, 2 cases of brain infarction occurred. There were 3 hospital deaths unrelated to the procedure. CONCLUSIONS: In surgery for type A aortic dissection, ascending aortic cannulation using the Seldinger technique is simple to perform. We found that some practical skills and precautions were required to make this procedure successful.

Intravenous Lobular Capillary Hemangioma Occurring after Needle Insertion during Routine Health Checkup.

Surgery was performed on a 53-year-old male patient with a painful mass in front of the elbow. The mass originally occurred after needle insertion during a routine health checkup and grew in size during a 1-year period. Intravenous tumor with arterio-venous fistula was diagnosed, and it was resected. Histopathological diagnosis of intravenous lobular capillary hemangioma was made. Occurrence of this tumor after a routine health checkup is rare. The etiology of this tumor occurring simultaneously with arteriovenous fistula is discussed.

Using a double-plicated posterior leaflet as an anchor for mitral valve replacement: a case of mitral annular calcification.

We present a 62-year-old man with mitral regurgitation whose posterior annulus had severe calcification. Mitral valve replacement was performed by anchoring the cuff on a double-plicated posterior leaflet, and reinforcing with an equine pericardium. The patient is doing well 13 years after surgery with echocardiography showing no problems.

Malignant solitary fibrous tumor of the left ventricular epicardium.

Reports describing solitary fibrous tumors of the pericardium are rare. Surgical treatment was performed on a 49-year-old woman with a large pericardial mass. The mass was attached to the left ventricular wall with a broad stalk and was free of the parietal pericardium. It was apparent macroscopically that the tumor had invaded the left ventricular muscle. On histopathology, the tumor was diagnosed as a solitary fibrous tumor with low-grade malignancy.

Resection of an intrapericardial lipoma with nonsustained ventricular tachycardia.

A 35-year-old female presented with nonsustained ventricular tachycardia (NSVT) and a large intrapericardial mass. The mass was attached to the left ventricular wall with a broad stalk. On histopathology, the tumor was diagnosed as a lipoma. Postoperatively, the NSVT disappeared.

Prophylactic use of intra-aortic balloon pumps in open heart surgery.

During a 1-year period, intra-aortic balloon pumps (IABPs) were used in open heart surgery on 57 patients. Indications were prophylactic usage for coronary artery bypass grafting (CABG) in 52 patients, prophylactic usage for valve replacement in three patients, and cardiopulmonary bypass (CPB) weaning during valve replacement in two patients. The 52 CABG patients comprised 94.5% of all CABG procedures during the period. Sheathless 8 Fr IABPs were used in all cases. The 57 patients using IABPs were analyzed. The mean duration of IABP use was 41.7 h. Morbidity was not associated with using IABPs. There was one case of balloon rupture. Hemostasis was performed easily after removing IABP catheters by compressing the groin for approximately 15 min. The lowest blood pressure during anastomosis or cardiac arrest was also assessed. The lowest peak pressure was 55.9 ± 17.3 mm Hg for patients with IABP still turned on, and the lowest mean pressure was 34.7 ± 6.5 mm Hg for patients with IABP temporarily turned off. Peak blood pressure after CPB was 73.8 ± 17.8 mm Hg. During open heart surgery under anesthesia with the low blood pressure presented by this series, use of IABPs enabled patients to tolerate the procedure. In conclusion, aggressive use of IABPs is easy, safe, and effective with no related morbidity.

Hypothermic circulatory arrest through a left thoracotomy in a 12-year-old child with aortic coarctation.

Surgical correction of adult complex aortic coarctation using hypothermic circulatory arrest often requires central cannulation to secure cerebral perfusion. It is not easy to place the cannula in the ascending aorta, however, especially in children undergoing surgery through a left thoracotomy. In a 12-year-old male with hypoplastic distal aortic arch, we placed an arterial cannula in the ascending aorta using the Seldinger puncture technique through the stenotic segment of the distal aortic arch. Replacement of the stenotic segment with a 20 mm-size Dacron graft was then routine. The ascending aorta was exposed only for the proximal anastomosis. The left subclavian artery was also reconstructed. This central cannulation technique is simple and is useful in repairing complex aortic coarctation.

Traumatic aortic regurgitation caused by a detached commissure.

Case reports of traumatic aortic regurgitation caused by detached commissures are rare. We report a case of a 56-year-old man involved in a traffic accident. During his hospitalization for subdural hematoma and pulmonary contusion, he began to suffer from heart failure. He was operated on under diagnosis of severe aortic regurgitaion. The commissure between the left and the noncoronary cusps was largely detached from the aortic wall, which was easily estimated to be the cause of the prediagnosed left cusp prolapse. His aortic valve was replaced, and his postoperative course was uneventful.

Ascending aorta cannulation in acute type A aortic dissection.

OBJECTIVE: Antegrade perfusion for type A acute aortic dissection prevents malperfusion and retrograde cerebral embolism during cardiopulmonary bypass. Prompt establishment of antegrade perfusion via ascending aorta may improve the surgical results of type A dissections, especially in the situations of hemodynamic instability. Thus, we evaluated the efficacy of use of the dissected ascending aorta as an alternative arterial inflow. METHODS: Between 2002 and 2006, 32 patients underwent prosthetic graft replacement of the ascending aorta or hemiarch for acute type A aortic dissection. The ascending aorta was routinely cannulated, in addition to the femoral artery, with a heparin-coating flexible cannula for arterial inflow, using Seldinger technique, and by epiaortic ultrasonographic guidance (n=6). Antegrade systemic perfusion via ascending aorta was performed. RESULTS: Ascending aorta cannulation was safely performed in all cases. There was no malperfusion or thromboembolism due to ascending aorta cannulation. Cardiopulmonary bypass was established within 30 min after skin incision. There was one in-hospital death due to duodenal bleeding (1/32=3.1%), two cases of cerebral infarction (2/32=6.3%), and one case of pulmonary embolism. Twenty-nine patients (29/32=90.6%) were discharged in New York Heart Association class I and have been followed up uneventfully for a mean of 17 months. CONCLUSIONS: Antegrade perfusion via the ascending aorta was successfully performed with low mortality and morbidity. With ultrasound-guided Seldinger technique, ascending aorta cannulation has a potential to be a simple and safe option that enables rapid establishment of antegrade systemic perfusion in patients with acute type A aortic dissection.

Teflon felt wrapping repair for coronary perforation after failed angioplasty.

Acute type III perforation caused by failed angioplasty is a lethal complication that often requires emergency operation. However, the presence of multiple rigid stents beneath the subepicardial hematoma disturbs optimal revascularization and hemostasis. Teflon felt (Meadox Medical Inc, Oakland, NJ) wrapping repair is a simple salvage technique that allows stable hemostasis and the rescue of the entire blood flow of the coronary artery. This procedure was successfully performed with type III perforation of the left anterior descending coronary artery on 2 patients subjected to multiple stenting.

Recurrent discrete subaortic stenosis and small aortic annulus successfully repaired by the Konno procedure in a young woman.

A 24-year-old woman who had undergone excision of the membrane for discrete subaortic stenosis when 6 years old displayed recurrent subaortic stenosis and had a small aortic annulus, with a peak pressure gradient of 60mmHg. We chose to perform the Konno operation with a mechanical valve. This released the left ventricular outflow tract obstruction adequately, and she recovered uneventfully with New York Heart Association functional class I. In our experience, an aggressive strategy such as myectomy is an appropriate initial procedure for preventing recurrence when the geometry of the problem may lead to recurrence in the left ventricular outflow tract. The Konno operation is a good option for recurrent subaortic stenosis with small aortic annulus.