Aortic subannular left ventricular aneurysm in a patient of Asian ancestry.

An asymptomatic 50-year-old Japanese man was diagnosed with an aortic subannular left ventricular aneurysm during a routine physical checkup. Operative findings showed the subaortic aneurysm had developed beneath the noncoronary cusp of the aortic valve and expanded into the epicardium between the aortic root and left atrium. The operation involved patch closure of the orifice of the annular subaortic aneurysm, aortic valvuloplasty, and plication of the dilated ascending aorta.

[A case of pyoderma gangrenosum after mitral valve replacement].

A 48-year-old male with treated hypothyroidism underwent mechanical valve replacement for mitral valve regurgitation. After the operation, the patient developed progressive median chest wound ulceration. The wound did not heal with conventional therapies for mediastinitis such as administration of antibiotics, debridement of necrotic tissue or continuous irrigation. The entire surgical wound opened spontaneously. Bacterial cultures yielded negative and the wound biopsy specimen revealed non-specific inflammatory change. The anti-TSH receptor antigen level was high. Pyoderma gangrenosum based on auto-immune deficiency was diagnosed and high dose corticosteroid therapy was started. The wound healed completely in 5 months.

Redo cardiac surgery for atrial septal defect in a patient with idiopathic thrombocytopenic purpura. Preoperative management with high-dose intravenous gamma-globulin.

A 58-year-old woman with idiopathic thrombocytopenic purpura required redo cardiac surgery of atrial septal defect closure, mitral annuloplasty, and tricuspid annuloplasty. Preoperative high-dose intravenous gamma-globulin and platelet transfusion after termination of cardiopulmonary bypass allowed successful redo cardiac surgery. Management of a patient with idiopathic thrombocytopenic purpura undergoing open heart surgery are discussed.

[A case of surgical treatment for giant pseudoaneurysm of the left ventricle after myocardial infarction].

A 70-year-old male was admitted for acute postero-inferior myocardial infarction. In cardiac catheterization one month later, there was narrowing of the distal left circumflex artery and the aneurysm of the postero-inferior wall of the left ventricle. The echocardiogram strongly suggested the pseudoaneurysm of the left ventricle. At operation, a large postero-inferior aneurysm was densely adherent to the pericardium. After cardiopulmonary bypass was established, the aorta was cross-clamped and cold cardioplegia was infused, the aneurysm was opened without excision of it. There was a 4 cm by 5 cm defect in the postero-inferior wall of the left ventricle, which communicated with the cavity of the aneurysm. The defect was closed with a patch. Pseudoaneurysm of the left ventricle was diagnosed by histological examination. The postoperative course was uneventful and he discharged on 29th day after surgery.

Left atrial ball thrombus in a patient without mitral valve disease.

We experienced a large left atrial ball thrombus in a patient without mitral valve disease. By transthoracic echocardiography the mass was appeared to be free-floating and swinging randomly in the left atrium. An urgent operation was performed successfully. Operative findings revealed the mass to be a large ball thrombus loosely attached to atrial wall. We suggest that surgical removal is indicated as soon as possible, because of a very high risk of embolism or circulatory collapse.

Cardiac extension of intravenous leiomyomatosis with successful resection.

A case of intravenous leiomyomatosis spreading to the right ventricle is described. A 28-year-old woman had been previously diagnosed as having a smooth muscle tumor of borderline malignancy after hysterectomy for a large uterine tumor, because of its unusual invasive character. Based on the above diagnosis, the patient had been managed clinically as having a uterine sarcoma. One year after her hysterectomy, a local recurrence in the pelvic cavity was detected. Two years later, the tumor appeared as a cardiac tumor causing syncope. The tumor was totally resected in two surgical stages, and the correct diagnosis of an intravenous leiomyomatosis was made. The diagnostic and operative considerations are reviewed and the preferred surgical procedure is discussed.

[Effect of autologous platelet rich plasma on adult open heart surgery].

To reduce the rate and the volume of homologous blood transfusion, we have used autologous platelet rich plasma (PRP) in adult open heart surgery. From Jan. 1988 to Jun 1992, 191 patients have underwent open heart surgery of coronary artery disease or valvular heart disease in our institution. We divided these patients into two groups: (1) PRP group; autologous PRP was used in 99 cases, (2) C (Control) group; autologous PRP was not used in 92 cases. Patient characteristics of age, sex, body weight, preoperative hematocrit values, preoperative platelet counts, and CPB time were same in these groups. Intraoperative and postoperative blood loss in PRP group were significantly less than those in C group (376 ml and 458 ml vs 511 ml and 568 ml; p < 0.01). Homologous blood transfusion rate (number of patients receiving homologous blood transfusion/all patients) was lower in PRP group (11.1% vs 32.6%; p < 0.01). The volume of homologous blood transfusion in the patients receiving transfusion were smaller in PRP group (7.5 U vs 13.3 U; p < 0.05). We conclude autologous PRP is useful in adult open heart surgery to reduce the perioperative blood loss, the rate, and the volume of homologous blood transfusion.

Invasive thymoma with intracaval growth into the right atrium.

We report an unusual case of invasive thymoma with intracaval growth into the right atrium. Computed tomography and venacavography demonstrated this manner of extension of thymoma. The tumor was completely removed by means of cardiopulmonary bypass after four courses of chemotherapy. Multidisciplinary treatment for invasive thymoma with this growth pattern is thought to be useful.

[A case of ruptured aortic arch aneurysm into the lung].

Successful surgical treatment of aortic arch aneurysm ruptured into the left lung was reported. The patient was a 74-year-old man suffering from recurrent hemoptysis. Computed tomography and aortic angiography demonstrated a giant aortic arch aneurysm. Emergency operation was performed. Arch reconstruction by a Dacron graft was performed with hypothermic circulatory arrest. The post operative course was uneventful and there was no evidence of cerebral complication. In the emergency operation for ruptured aortic arch aneurysm, hypothermic circulatory is very useful method for cerebral protection.

[A case report of ball variance of Smeloff-Cutter prosthetic valve].

A 37-year-old woman had undergone aortic valve replacement with Smeloff-Cutter prosthetic valve in 1967. She visited our hospital because of dyspnea and chest pain about 22 years after the operation. Severe aortic regurgitant murmur was audible and a chest X-ray demonstrated lung edema. A diagnosis was made of acute left heart failure due to prosthetic valve dysfunction, and emergency operation was performed. The Silastic ball was severely deformed and shrunken. Therefore, the ball was easily put off outside the cage. A St. Jude medical prosthetic valve was implanted. The postoperative course was uneventful.

[Intrathoracic pacemaker implantation in children].

In order to minimize the complications, we introduced the intrathoracic implantation method since 1976. Until 1988, 12 children underwent this method. A pacemaker generator was exchanged in 8 patients, 12 times, because of battery exhaust. Compared with the conventional method (abdominal wall implantation), the complications such as electrode fracture, which was related to the implantation sites, were reduced. Furthermore it was very useful from the cosmetic viewpoint. Although an exchange of generator was very easily done at the first time, it was very difficult at the second time, due to rib fusion accompanying with children's growth.

[A case of pulmonary infarction secondary to subacute bacterial endocarditis with subpulmonary VSD].

A case of pulmonary infarction secondary to subacute bacterial endocarditis of pulmonary valve which is associated with subpulmonary VSD is presented. The jet stream of blood through the subpulmonary VSD made damage to the pulmonary valve, which may be one of the reasons why subacute bacterial endocarditis was associated with the subpulmonary VSD. Echocardiography of the right-sided valves will be very useful in order to detect the pulmonary valve endocarditis in congenital heart disease presenting with fever.

[Surgical consideration of ruptured abdominal aortic aneurysms].

During the recent 18 and a half years, 30 cases of ruptured abdominal aortic aneurysm (including four cases of A-V fistula) were operated at Saiseikai Utsunomiya Hospital. In 26 cases, a conventional graft replacement was performed. In other four cases, axillo-bifemoral bypass (in the cases ruptured into the colon) or other methods were used. Overall operative mortality rate was 26.7%. However, during the last 9 years, operative results were improved (21.7%, 5 deaths out of 23 cases). Amount of intraoperative blood loss influenced the operative results greatly. Other operative risk factors included preoperative shock, preoperative severe cerebrovascular or cardiovascular complications, and postoperative thromboembolism. Factors of recent improvement in mortality included; establishment of emergency system which resulted in earlier operation after the patient's arrival at the hospital, use of occlusive balloon for bleeding control, heparin administration before the aortic clamp for preventing peripheral thromboembolism and introduction of autotransfusion system for reducing the amount of blood transfusion.

Bilateral ovarian hemangiomas associated with diffuse hemangioendotheliomatosis: a case report.

A patient who had disseminated vascular tumors involving the bilateral ovaries, bilateral lungs and pleura, pericardium, and mediastinum is reported. The tumors were histologically of the capillary, and partly the cavernous, type of hemangioma. However, endothelial cell growth was prominent in some areas, especially in the lung, and the histology of the lung tumor resembled epithelioid hemangioendothelioma or intravascular bronchiolo-alveolar tumor (IVBAT). In the endocardium of the right atrium, an endothelial tumorous projection was observed, and there were tiny foci of tumor cell nests in the abdominal venous wall. Small lymphangiomas were also found in the subcapsular region of the spleen. These findings suggest that there had been an abnormal proliferation of systemic endothelial cells and that tumors of endothelial cell origin with diverse histological patterns developed with this condition as a background. The autopsy finding of fibrin thrombi in multiple organs as well as laboratory data including thrombocytopenia suggest that this case belongs to the "Kasabach-Merritt syndrome."