RESUMEN
A 39-year-old man was admitted because of cardiac arrest. Emergent coronary angiography revealed a preserved coronary blood flow; however, multiple-row detector computed tomography (MDCT) revealed that the proximal right coronary artery (RCA) was running inside the aortic wall, creating proximal stenosis without atherosclerotic changes. Surgical intervention with unroofing was performed; however, postoperative stenosis of the proximal RCA required additional coronary artery bypass grafting (CABG). Intraoperative findings during CABG did not reveal hematoma or coronary dissection. However, MDCT one year after CABG depicted improvement of the RCA and graft stenoses, suggesting that the post-unroof stenosis may have been caused by an inflammatory reaction after surgical intervention.
Asunto(s)
Enfermedad de la Arteria Coronaria , Anomalías de los Vasos Coronarios , Isquemia Miocárdica , Masculino , Humanos , Adulto , Constricción Patológica/complicaciones , Enfermedad de la Arteria Coronaria/complicaciones , Angiografía Coronaria/efectos adversosRESUMEN
A male patient developed acute type B aortic dissection (AD) extending to the right external iliac artery (EIA) and left common femoral artery at the age of 56 years. Two months after the diagnosis of AD, he developed right renal infarction suggesting embolism, as the right renal artery arose from a false lumen containing a mural thrombus. Seven years later, at the age of 63 years, the patient was readmitted for acute onset of intermittent claudication in the right leg. On admission, arterial pulses distal to the right femoral artery were absent. The right ankle-brachial pressure index (ABI) was 0.66, while the left ABI was 1.06. Computed tomography (CT) confirmed chronic type B AD and revealed a localized occlusion of the right EIA and disappearance of a small protruding thrombus in the false lumen that was found on the previous CT, suggesting a second embolism. Since recovery of antegrade blood flow was insufficient after catheter embolectomy, femorofemoral bypass was performed with resolution of ischemic symptoms. Postoperatively, the ABI recovered to 0.99 in the right and 1.12 in the left, and CT showed a patent bypass graft and restoration of blood flow to the right leg. This case indicates that embolism should be recognized as one of the possible causes of acute organ ischemia in patients with AD, even in patients with chronic AD.
RESUMEN
BACKGROUND: The feasibility of medical management for select patients with acute type A aortic dissection has been reported from a few institutions. In this study, we retrospectively investigated the safety and feasibility of our conservative approach for patients with type A aortic dissection in daily practice. METHODS: From January 2013 to December 2017, 131 consecutive patients were admitted to our institution for acute aortic dissection, including 58 patients of type A. Initial medical management was attempted in select patients who were clinically stable and had a thrombosed false lumen of the ascending aorta without ulcer-like projections in the ascending aorta. RESULTS: Except for nine patients contraindicated for surgery, urgent surgery was performed in 26 patients (SRG group), while 23 patients (MED group) were treated with the initial medical management. The maximum diameter of the ascending aorta was significantly larger in the SRG group than in the MED group. In the MED group, the heart rate and blood pressures were well-controlled at admission to the intensive-care unit, and the systolic blood pressure was further reduced at 24 h after. The in-hospital mortality rates of the MED and SRG groups were 0% and 15%, respectively. During the follow-up period, the survival rate was significantly higher in the MED group than in the SRG group, and the aortic event-free survival at one year was 80%. CONCLUSIONS: The initial medical management for select patients with a thrombosed false lumen in the ascending aorta was a safe and feasible strategy in real-world practice.
Asunto(s)
Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Procedimientos Endovasculares/métodos , Hematoma/cirugía , Trombosis/cirugía , Enfermedad Aguda , Anciano , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/diagnóstico , Femenino , Estudios de Seguimiento , Hematoma/diagnóstico , Hematoma/etiología , Humanos , Masculino , Estudios Retrospectivos , Síndrome , Trombosis/diagnóstico , Trombosis/etiología , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Although chest compression is a standard technique in cardiopulmonary resuscitation, it is well recognized that manual chest compression causes various internal injuries, of which major injuries are often fatal. Similarly, when cardiac tamponade occurs in patients with type A acute aortic dissection, many patients die before reaching the hospital. We report a rare case in which chest compressions caused pericardial laceration that may have inadvertently played a life-saving role in releasing cardiac tamponade induced by acute aortic dissection. CASE PRESENTATION: A 67-year-old woman developed cardiac arrest soon after complaining of epigastric pain, and after successful resuscitation by manual chest compression, she was transferred to our hospital. On arrival, the patient was 14 on the Glasgow Coma Scale. An ECG showed a normal sinus rhythm, and no arrhythmias or signs of myocardial ischemia were observed. A chest X-ray revealed left pleural effusion, while cardiomegaly and pneumothorax were not identified. Computed tomography revealed type A aortic dissection, mild pericardial effusion, and massive left pleural effusion. No pulmonary embolus was found on the CT. After drainage of bloody effusion from the left pleural space, an emergency operation was begun. During surgery, a pericardial laceration with communication to the left pleural space and a hemothorax were found; however, no cardiac injury was identified. No other intra-thoracic injuries or rupture of the aortic dissection causing the hemothorax were detected. Hemiarch replacement was performed without difficulty, but the patient died of multi-organ failure 30 days after surgery. CONCLUSIONS: We report a case of pericardial injury without skeletal fracture caused by chest compression. The pericardial laceration may have inadvertently served to release the cardiac tamponade induced by the acute aortic dissection, resulting in the hemothorax, and provided time to receive surgery.
RESUMEN
We report a case of aortic valve infective endocarditis (IE) in a 24-year-old man with atopic dermatitis (AD). He had a history of balloon valvuloplasty for a stenotic bicuspid aortic valve, and had dental caries but no invasive dental procedure before the onset of IE. On admission, skin lesions of AD with itching and scratches were found on the neck, trunk, and extremities. Echocardiography showed a vegetation on the aortic valve with mild steno-regurgitation, but extension of IE to the annulus was not detected. Magnetic resonance imaging identified fresh cerebral infarction without neurological dysfunction, leading us to suspect an embolism. Blood cultures grew methicillin-sensitive Staphylococcus aureus. During emergency surgery, a vegetation attached to the conjoined cusp was observed, and the aortic valve was replaced with a mechanical valve. The patient recovered uneventfully without any complications such as recurrent IE or mediastinitis. We also review previously reported cases of IE associated with AD.
Asunto(s)
Dermatitis Atópica/complicaciones , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/etiología , Endocarditis Bacteriana/terapia , Humanos , Masculino , Adulto JovenRESUMEN
Although a small number of atrial myxomas are found in association with congenital cardiac defects, ventricular myxomas coexisting with congenital cardiac anomalies are extremely rare. We report a case of right ventricular (RV) myxoma coexistent with atrioventricular septal defect in an adolescent. Echocardiography showed an RV mass, a small ostium primum atrial septal defect, and a cleft of the left atrioventricular valve. Magnetic resonance imaging revealed a mass, suggesting a myxoma. The mass was excised simultaneously with repair of the anomalies and was histologically confirmed as a myxoma.
Asunto(s)
Neoplasias Cardíacas/diagnóstico por imagen , Defectos de los Tabiques Cardíacos/diagnóstico por imagen , Mixoma/diagnóstico por imagen , Adolescente , Ecocardiografía , Neoplasias Cardíacas/cirugía , Defectos de los Tabiques Cardíacos/cirugía , Humanos , Imagen por Resonancia Magnética , Masculino , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/patología , Mixoma/cirugíaRESUMEN
In patients with atrial fibrillation, closure of the left atrial appendage (LAA) is recommended to prevent thromboembolic events, however, conventional exclusion or excision techniques have potential drawbacks such as persistent blood flow into the appendage and a residual stump. We propose a simple and easy technique for LAA closure consisting of intra-atrial excision of the LAA, which is invaginated into the left atrium (LA), and direct suture closure of the orifice from inside the LA. In this technique, complete elimination of the LAA was achieved without leaving a residual stump because the LAA was excised at the orifice and was closed at the base of the LAA.
Asunto(s)
Apéndice Atrial/cirugía , Fibrilación Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Apéndice Atrial/patología , Fibrilación Atrial/patología , Femenino , Humanos , MasculinoRESUMEN
A 73-year-old woman was referred for treatment of left atrial (LA) myxoma. At surgery, a myxoma was attached to the left atrial side of the fossa ovalis in the atrial septum by a stalk and was transmurally excised with a margin of the atrial septum. The atrial septum was closed without any prosthetic materials under mild to moderate tension. Although she was asymptomatic, postoperative transesophageal echocardiography (TEE) revealed an abnormal cavity, containing heterogeneous echogenesity without blood flow, in the posterior LA wall. Magnetic resonance imaging (MRI) demonstrated a mass without significant enhancement. It was considered to be an intramural hematoma, and the diagnosis of LA dissection was made. Follow-up echocardiography showed disappearance of the dissected lumen without surgical intervention. Both TEE and MRI are useful for the correct diagnosis of an LA dissection; and surgical intervention, entry closure or internal drainage, may not always be necessary in the absence of a hemodynamic compromise with an LA dissection.
Asunto(s)
Tabique Interatrial/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Neoplasias Cardíacas/cirugía , Hematoma/etiología , Mixoma/cirugía , Anciano , Tabique Interatrial/diagnóstico por imagen , Tabique Interatrial/patología , Ecocardiografía Transesofágica , Femenino , Neoplasias Cardíacas/diagnóstico , Hematoma/diagnóstico , Humanos , Imagen por Resonancia Magnética , Mixoma/diagnóstico , Remisión Espontánea , Factores de TiempoRESUMEN
The Carpentier-Edwards PERIMOUNT (CEP) Magna (Edwards Lifesciences, Irvine, CA, USA) is a newly developed bioprosthesis with an improved cuff design that allows its implantation into the smaller aortic annulus. We evaluated the hemodynamic performance of the CEP Magna for smaller aortic annulus cases. Patients who underwent aortic valve replacement for aortic stenosis receiving a Magna 19 mm (n = 13), were compared with a standard CEP (n = 19). In the 19-mm series, the real annular size was significantly smaller in the Magna than the standard (21.1 ± 0.8 vs. 19.8 ± 0.8 mm, p = 0.007). The Magna was significantly superior with respect to effective orifice area index (EOAI) at postoperative 3 months; however, no significant difference was seen in other factors (peak pressure gradient, left ventricular mass index, ejection fraction). At postoperative 3 months, despite the lack of statistical significance, the incidence of patient-prosthesis mismatch (PPM) was lower with the Magna. Using the same label size, the Magna can be implanted in a smaller aortic annulus with performance comparable with or better than hemodynamic performance with the standard CEP. The Magna is a useful prosthesis for the small aortic annular patient.
Asunto(s)
Válvula Aórtica , Bioprótesis , Prótesis Valvulares Cardíacas , Anciano , Anciano de 80 o más Años , Femenino , Implantación de Prótesis de Válvulas Cardíacas , Hemodinámica , Humanos , Masculino , Estudios RetrospectivosAsunto(s)
Aneurisma de la Aorta/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Seno Aórtico/diagnóstico por imagen , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/cirugía , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/cirugía , Humanos , Masculino , Persona de Mediana Edad , Seno Aórtico/cirugía , Tomografía Computarizada por Rayos XAsunto(s)
Cardiomiopatías/diagnóstico por imagen , Ecocardiografía Transesofágica , Ecocardiografía , Aneurisma Cardíaco/diagnóstico por imagen , Atrios Cardíacos/diagnóstico por imagen , Tabiques Cardíacos/diagnóstico por imagen , Estenosis de la Válvula Mitral/diagnóstico por imagen , Femenino , Aneurisma Cardíaco/cirugía , Atrios Cardíacos/cirugía , Tabiques Cardíacos/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Persona de Mediana Edad , Estenosis de la Válvula Mitral/cirugíaRESUMEN
We report a case of spontaneous splenic rupture (SSR) caused by a Bacillus species (sp.) infection. A 36-year-old man on warfarin therapy since an aortic valve replacement at the age of 13 was admitted to our hospital with a 3-week history of a high fever. He had been asymptomatic until 4 months previously, when he suffered a cerebral embolism despite adequate oral anticoagulation. Abdominal computed tomography revealed splenic infarctions, which resulted in splenic rupture 2 days later. After embolization of the splenic artery, splenectomy was successfully performed. Pathologic examination revealed splenic infarction, resulting from septic emboli, with associated rupture of the splenic capsule, but no abscess was found. Bacillus sp. was isolated from cultures of arterial blood preoperatively, and the excised splenic specimens, postoperatively. In addition to rupture of the suppurating intrasplenic vessels with hematoma formation, the anticoagulant therapy possibly contributed to distension of the intrasplenic hematoma.
Asunto(s)
Bacillus/aislamiento & purificación , Infecciones Bacterianas/complicaciones , Infarto del Bazo/microbiología , Rotura del Bazo/etiología , Adulto , Anticoagulantes/efectos adversos , Infecciones Bacterianas/cirugía , Prótesis Valvulares Cardíacas , Hematoma/etiología , Humanos , Masculino , Rotura Espontánea , Esplenectomía , Infarto del Bazo/complicaciones , Rotura del Bazo/cirugía , Tomografía Computarizada por Rayos XRESUMEN
Four cases are described of acute subdural hematoma that occurred after valve replacement in patients receiving anticoagulant therapy. All four patients experienced rapid deterioration of consciousness or neurological dysfunction, to varying degrees, between two and 42 days after valve replacement; emergency brain computed tomography scanning demonstrated the presence of subdural hematoma. The neurological problems were completely resolved by removal and drainage of the hematoma in three patients, while conservative management was performed with no aggravation of neurological symptoms in the fourth patient.
Asunto(s)
Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Hematoma Subdural Agudo/etiología , Anciano , Anticoagulantes/efectos adversos , Bioprótesis , Femenino , Prótesis Valvulares Cardíacas , Hematoma Subdural Agudo/diagnóstico , Hematoma Subdural Agudo/terapia , Humanos , Persona de Mediana EdadRESUMEN
BACKGROUND: Leaflet opening angles of ATS valves in vivo tend to be less than those reported by the manufacturer, and there is a wide variation in opening angles even among valves of the same size. METHODS: Leaflet movement of aortic ATS valves was evaluated by cineradiography in 77 patients. The mean period from valve replacement to cineradiography was 40.2 months, and during that period, the ATS valve was replaced due to prosthetic valve obstruction in 1 of the 77 patients. RESULTS: In 76 patients with a normally functioning ATS valve, the mean opening angle of 19-mm valves (66.3 degrees +/- 2.3 degrees) was significantly less (p < 0.0001) than that of ATS valves 21 mm or larger (72.2 degrees +/- 3.8 degrees in 21-mm, 72.4 degrees +/- 2.8 degrees in 23-mm, and 72.8 degrees +/- 2.9 degrees in 25-mm valves). No significant differences were found in the opening angles of ATS valves 21 mm or larger, and the opening angles exceeded 65 degrees in all 69 patients with valves in this category. In one case of obstruction in a 21-mm valve, the opening angle was 57.5 degrees. The closing angle was 24.9 degrees +/- 1.3 degrees, which corresponded well with the manufacturer's in vitro data. CONCLUSIONS: The opening angle in the 19-mm ATS aortic valve is significantly less than that in valves 21 mm or larger, and an opening angle of less than 65 degrees probably indicates prosthetic valve obstruction in aortic ATS valves sized 21 mm or larger.
Asunto(s)
Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas , Falla de Prótesis , Adolescente , Adulto , Anciano , Anticoagulantes/uso terapéutico , Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Aspirina/uso terapéutico , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Cinerradiografía , Comorbilidad , Ecocardiografía Doppler , Diseño de Equipo , Femenino , Hemorreología , Humanos , Masculino , Persona de Mediana Edad , Movimiento (Física) , Inhibidores de Agregación Plaquetaria/uso terapéutico , Complicaciones Posoperatorias/prevención & control , Periodo Posoperatorio , Reoperación , Tromboembolia/prevención & control , Warfarina/uso terapéuticoRESUMEN
We report four long-term survivors after valve replacement with a Starr-Edwards (S-E) mitral caged-disk valve. A model 6520 disk valve, size 3M, had been used in all of the four patients. Of the four patients, three underwent replacement of the disk valves 23, 24, and 26 years after mitral valve replacement (MVR), respectively. A pacemaker was implanted in the remaining patient 33 years after MVR. The S-E disk valves were considered hemodynamically slightly stenotic compared with modern bileaflet valves. No disk wear was detected in any of the three explanted valves, and in the remaining patient, a noninvasive evaluation of the disk showed that it was functioning normally. These results suggest the favorable long-term durability of the S-E disk valve.
Asunto(s)
Enfermedades de las Válvulas Cardíacas/cirugía , Prótesis Valvulares Cardíacas , Válvula Mitral/cirugía , Anciano , Electrocardiografía , Femenino , Estudios de Seguimiento , Humanos , Isoproterenol/farmacología , Masculino , Persona de Mediana Edad , Marcapaso ArtificialRESUMEN
This report describes 3 aged patients undergoing emergent surgery who refused elective operation for a thoracic aortic aneurysm because of freedom from symptoms attributable to the aneurysm at the time of presentation. A 77-year-old woman with a thoracoabdominal aneurysm 57 mm in diameter at presentation had recurrent hemoptysis 12 months later. A 78-year-old man with a saccular type distal arch aneurysm 64 mm in diameter at presentation was transported with shock and hemothorax 27 months later. Another 82-year-old man with a saccular type distal arch aneurysm 60 mm in diameter at presentation was admitted with severe chest and back pain 36 months later. All of them underwent tube graft replacements of the aneurysm urgently and were discharged on foot. Aged patients with life-threatening events should not be denied surgical intervention because of excessive operative mortality and morbidity, even if they had previously refused elective surgery.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Urgencias Médicas , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Masculino , Cooperación del Paciente , Resultado del TratamientoRESUMEN
Surgery for thoracic aortic aneurysm (TAA) in patients 75 years and older is a high risk, but data for their natural history are not available. In the present study the subjects were 62 patients with TAA aged on average 78 years (range, 75-85 years) enrolled between August 1994 and December 2001: 20 operatively treated patients (OPE) and 42 medically managed patients (MED). All of them had been included in the indication for TAA surgery at the time of consultation. Hospital mortality rates and survival rates (Kaplan-Meier method) were compared among emergency OPE, elective OPE, and MED. There were 136 total patient-years of follow-up. Actuarial survival in MED (ie, the natural history) was 83% at 1 year after consultation and 41% at 3 years. Hospital mortality rates in emergency and elective OPE were 27% (3/11) and 0% (0/9), respectively (p=0.22), and the corresponding 3-year survival rates were 44% and 83% (p=0.019). Actuarial survival in elective OPE was higher than that in MED (p=0.022), but that of emergency OPE was similar to that for MED (p=0.17). Patients aged 75 years and older with TAA should undergo an elective operation if the aneurysm diameter is larger than 6 cm and if the patient is asymptomatic and in good anatomicosurgical, physical, and social condition.
Asunto(s)
Aneurisma de la Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/cirugía , Anciano , Anciano de 80 o más Años , Aneurisma Roto/cirugía , Aneurisma de la Aorta Torácica/tratamiento farmacológico , Servicios Médicos de Urgencia , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Masculino , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
Forty octogenarians (OCTO) undergoing a variety of cardiac and thoracic aortic surgeries using cardiopulmonary bypass (CPB) between 1994 and 2002 were retrospectively studied. The results were compared with those of high-risk younger patients aged less than 60 years (YOUNG) (n=89). All patients had an expected operative mortality of EuroSCORE 5 and over. The EuroSCORE score was 9.9+/-3.3 (range, 5-18) in the OCTO group and 6.8+/-2.3 (range, 5-16) in the YOUNG patients (p<0.0001). There were 4 (10%) and 10 (11%) hospital deaths, respectively (p>0.99). Major postoperative complications occurred in 50% of the OCTO and 36% of the YOUNG patients (p=0.17). There were 10 and 7 late deaths, respectively. Actuarial survival including hospital death was significantly lower in the OCTO group than in the YOUNG (p=0.033). Actuarial survival was significantly higher in female octogenarians than in male (p=0.046). The overall 3-year survival rate was 88+/-8% and 64+/-11%, respectively. Multivariate analysis showed that predictors of late death were male gender (p=0.0005) and a high EuroSCORE (p=0.0010). Cardiac and thoracic aortic surgery using CPB can be performed in octogenarians with an acceptable hospital mortality rate and gratifying medium-term survival results.
Asunto(s)
Anciano de 80 o más Años , Aorta Torácica/cirugía , Procedimientos Quirúrgicos Cardíacos , Procedimientos Quirúrgicos Vasculares , Anciano , Procedimientos Quirúrgicos Cardíacos/mortalidad , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Humanos , Japón/epidemiología , Esperanza de Vida , Tablas de Vida , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Análisis de Supervivencia , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/mortalidad , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricosRESUMEN
The risk factors and the outcome of stroke in thoracic aortic surgery were studied in 127 patients (86 males, 41 females), aged 18 to 84 years (mean, 64 years), operated on between September 1994 and December 2000. There were 29 operations on the ascending aorta, 63 arch, 29 descending, 5 thoracoabdominal, and 1 extraanatomical bypass. Perioperative stroke occurred in 15 patients (12%). The risk factors for stroke were identified as preexisting chronic renal failure and femoral arterial cannulation. Hospital death occurred in 4 of the 15 cases (27%) of stroke and 7 of the 112 cases (6%) without stroke (p < 0.05). There were 18 late deaths during a mean follow-up period of 3.2 years (range, 1 month to 7.2 years). The 3-year survival rates were 43 +/- 14% in the stroke patients and 85 +/- 4% in the other patients. Actuarial survival, including during hospitalization, was lower in the stroke patients than in the other patients not only among those 70 years or older but also among all the patients (both p < 0.0001). Stroke occurring in thoracic aortic surgery is thus an important risk factor for early and late mortality, particularly in patients 70 years or older.