Off-pump reimplantation of anomalous origin of the right coronary artery.

A 30-year-old man was diagnosed to have an anomalous origin of the right coronary from the pulmonary artery. Through a mini-sternotomy, without extracorporeal circulation, reimplantation of the anomalous origin of the right coronary artery from the pulmonary artery to the aorta was successfully performed. This is a successful case of off-pump cardiac correction of this type of isolated anomaly, using a minimally invasive approach.

Surgically treated Swyer-James syndrome.

Because patients with Swyer-James syndrome have almost always been treated conservatively, few reports exist of pathological findings of the lung in this syndrome. We report a case of this rare disease treated surgically and discuss pathological findings. A 36-year-old woman repeatedly contracted bronchitis and pneumothorax since adolescence, until April 26, 1997, when she reported chest pain and dyspnea. Chest X-ray on admission showed left pulmonary collapse with a slight deviation of the mediastinum toward the right. Chest computed tomography showed an apical bulla and emphysematous change in the left upper lobe. Pulmonary arteriography at age 17 showed hypoplasia of left pulmonary artery branches in the left upper lobe. Based on a diagnosis of Swyer-James syndrome, we conducted left upper lobectomy on May 2, 1997. Pathological examination of the resected left upper lobe showed marked emphysematous change, including an emphysematous bulla with destruction of alveolar structure and peribronchiolar fibrosis. No vascular abnormality was recognized in histology. Emphysematous change secondary to repeated bronchiolitis is believed to have led to her repeated pneumothorax.

Recurrent cardiac tamponade treated using a pericardio-venous shunt.

A 49-year-old woman was admitted because of recurrent cardiac tamponade. She had undergone radical mastectomy and radiotherapy for left breast cancer four years previously. In the following two years, she felt short of breath on exertion due to cardiac tamponade. Repeated conservative therapy with diuretics and pericardial drainage were ineffective in terminating pericardial effusion. The therapeutic procedure of a pericardio-venous shunt was then employed and was effective for improving the recurrent symptoms.

[A case of progressive saccular aneurysm caused by localized dissection of descending aorta].

A fifty-three-year-old man was admitted because of chest pain. CT scan showed the localized dissection of the descending aorta which was partially thrombosed. The patient was followed by controlling of essential hypertension. He, however, complained of the second attack of chest pain after a year and 5 months. CT scan showed the increased dilatation of the false lumen as compared to that of previous examination. MR angiogram showed a saccular aneurysm localized in the middle portion of the descending aorta. An operation was performed through posterolateral thoracotomy in the 4th intercostal space with the aid of normothermic femoro-femoral bypass circulation. The aneurysm was located at the level of 5th thoracic vertebra with the size of 70 mm in length and 45 mm in diameter. Entry was observed in the posterior wall of the aorta, and the terminal end of the false lumen was occluded with the organized thrombus. The aneurysm was successfully replaced with a prosthetic graft. To the extent of our knowledge, only limited surgical cases of saccular aneurysm caused by localized dissection of the middle portion of the descending aorta have been reported.

[Surgical treatment of type A aortic dissection combined with aortic root lesions].

From January 1980 to December 1992, 36 patients with type A aortic dissection were operated on at the St. Marianna University Hospital. Hospital mortality and 10-year survival rate in 26 patients (Group I and II) undergoing replacement of the ascending aorta with or without hemi-arch resection (including one case of aortic wrapping for the closing dissection) were 19.2% and 88.0%, respectively. Among the patients having aortic root destructions due to acute aortic dissection or preexisting annuloaortic ectasia (Group III), 8 patients underwent aortic root reconstruction with a valved conduit and 2 patients supra-coronary aortic resection and graft replacement with concomitant coronary artery bypass grafting with 20.0% of hospital mortality and 55.6% of 10-year cumulative survival rate. Modified Bentall operation using Carrel patch method seems to be preferable to avoid postoperative complications for the case with intimal tear extending to the aortic sinuses, ruptured outer layer of the aortic root or preexisting AAE. If the disrupted coronary artery is concerned, coronary artery bypass grafting is mandatory. In the case of replacement of the ascending aorta for the dissection extending to the aortic sinuses, complete obliteration of the proximal false lumen must be required to avoid uncontrollable bleeding and compromised coronary blood flow.

[Pseudocoarctation associated with dissecting aneurysm of the aorta: a case report].

A case of pseudocoarctation with dissecting aneurysm of the ascending aorta and arch is reported. A 49-year-old man was admitted with chest pain and loss of consciousness. Angiogram showed kinking of the aortic isthmus and dissecting aneurysm of the ascending aorta. There was no pressure gradient between arms and legs. Prosthetic graft replacement of the ascending aorta was successfully performed by the use of total cardiopulmonary bypass with moderate hypothermia. Etiology of the development of pseudocoarctation is unknown, however, hypothesis that embryological abnormality of the aortic arch is one of the contributing factors has been widely accepted. This case was accompanied by bicuspid aortic valve. It is suggested that the developmental etiology of this case seems to be similar to that of classical coarctation of the aorta. Development of the dissecting aneurysm is supposed to be due to hypertension of the upper body during exercise, even though there is no pressure gradient at rest.

[Subarachnoid hemorrhage following commencement of danazol treatment in a patient well controlled on warfarin anticoagulation].

A 45-year-old woman with prosthetic valves replacement, was admitted with severe headache and vomiting one month after starting danazol treatment at 300 mg per day. She was receiving long-term anticoagulation with warfarin and dipyridamole, taking 3.5 mg and 300 mg per day respectively. The patient's thrombotest value was less than 6% at the time of admission. Cranial CT revealed subarachnoid hemorrhage. Warfarin and danazol treatment ware discontinued with replenishment of vitamin K. Recovery was uneventful. Danazol is 2, 3 isoxazol derivative of 17-alpha-ethinyl testosterone. As such, it shares the property of C 17 alkylated steroids in potentiating the action of coumarin. It is suggested that danazol affects the turnover of vitamin-K-dependent clotting factors, an impairment of synthesis being a likely mechanism. The possible hazard of the potentiating effect of danazol on warfarin should be widely appreciated.

Surgical experience with traumatic rupture of the thoracic aorta.

Nine cases of traumatic thoracic aortic rupture (TAR), operated on at St. Marianna University Hospital between July 1980 and December 1988, were reviewed in order to evaluate the role of contrast-enhanced CT in the early diagnosis of TAR. The absence of mediastinal hematoma on CT eliminated the need for aortography in 30 (38.5%) of the 78 patients suspected of having TAR on the basis of chest roentgenograms. The presence of mediastinal hematoma necessitated aortography in 48 patients. However, operative treatment was carried out without aortography in 3 patients who had specific signs of rupture on CT. CT proved to be a reliable indicator for the selection of the patients who need aortography. As a rule, emergency operations were performed in these patients. Simple aortic crossclamping was employed in 4 patients, and heparinless left heart bypass with the BioPump was performed for spinal cord protection in 2 recent patients without complication of embolization. Use of the BioPump as an adjunct in the repair of TAR appears to be promising.