Extracorporeal membrane oxygenation for takotsubo cardiomyopathy that developed after mitral valve replacement.

Takotsubo cardiomyopathy is a transient systolic and diastolic left ventricular dysfunction that presents several wall-motion abnormalities, while the coronary artery shows normal findings. Because patients with Takotsubo cardiomyopathy present with symptoms similar to acute coronary syndrome, the initial diagnosis and treatment are often difficult. The condition is often precipitated by acute emotional or physical stress and frequently occurs in postmenopausal women. Takotsubo cardiomyopathy may also occur in the perioperative period after cardiac and noncardiac surgery; surgery-associated Takotsubo cardiomyopathy reportedly accounts for 3%-23% of all cases. Of these perioperative cases, cardiothoracic surgery accounted for 16%. However, few cases have been reported in patients undergoing cardiac surgery and managed with extracorporeal membrane oxygenation (ECMO). We report a case of Takotsubo cardiomyopathy managed with ECMO in a patient in the intensive care unit after mitral valve replacement.

Differences between the Molecular Mechanisms Underlying Ruptured and Non-Ruptured Carotid Plaques, and the Significance of ABCA1.

BACKGROUND AND PURPOSE: Carotid plaques are a strong risk factor for ischemic stroke, and plaque rupture poses an even higher risk. Although many studies have investigated the pathogenic mechanisms of carotid plaque formation, few have studied the differences in molecular mechanisms underlying the rupture and non-rupture of carotid plaques. In addition, since early diagnosis and treatment of carotid plaque rupture are critical for the prevention of ischemic stroke, many studies have sought to identify the important target molecules involved in the rupture. However, a target molecule critical in symptomatic ruptured plaques is yet to be identified. METHODS: A total of 79 carotid plaques were consecutively collected, and microscopically divided into ruptured and non-ruptured groups. Quantitative polymerase chain reaction array, proteomics, and immunohistochemistry were performed to compare the differences in molecular mechanisms between ruptured and non-ruptured plaques. Enzyme-linked immunosorbent assay was used to measure the differences in ATP-binding cassette subfamily A member 1 (ABCA1) levels in the serum. RESULTS: The expression of several mRNAs and proteins, including ABCA1, was higher in ruptured plaques than non-ruptured plaques. In contrast, the expression of other proteins, including ß-actin, was lower in ruptured plaques than non-ruptured plaques. The increased expression of ABCA1 was consistent across several experiments, ABCA1 was positive only in the serum of patients with symptomatic ruptured plaques. CONCLUSIONS: This study introduces a plausible molecular mechanism underlying carotid plaque rupture, suggesting that ABCA1 plays a role in symptomatic rupture. Further study of ABCA1 is needed to confirm this hypothesis.

Long-Term Outcome After Carotid Endarterectomy in Patients with Ischemic Heart Disease.

BACKGROUND: The long-term outcome after carotid endarterectomy (CEA) is determined by many confounding factors. Ischemic heart disease (IHD) is linked to atherosclerotic stroke, and it is an important cause of death during the perioperative and follow-up periods after CEA. We aimed to investigate mortality and long-term major adverse cardiovascular events (MACEs) in patients with IHD compared with patients who do not have IHD. METHODS: We consecutively enrolled 229 patients who underwent CEA procedures from 2000 to 2011. Of these patients, 45 had known or probable IHD defined by history or medical record of myocardial infarction, stable/unstable angina, previous coronary revascularization such as percutaneous coronary intervention or coronary artery bypass graft, or positive stress test. Long-term outcome was identified by using death certificates from the Korean National Statistical Office and telephone interviews by June 2013. We investigated predictors of early (≤30 days) and long-term mortality and MACEs (stroke, myocardial infarction, and death). RESULTS: Mean follow-up period was 49 months. Cox proportional analysis adjusted for potent predictors revealed symptomatic stenosis (hazard ratio, 1.72; 95% confidence interval, 1.02-2.88; P = 0.042) and presence of IHD (hazard ratio, 1.93; 95% confidence interval, 1.09-3.42; P = 0.025) as significant predictors of long-term MACEs. Kaplan-Meier analysis showed a significantly lower rate of survival (P = 0.030) and MACE-free survival (P = 0.003) in the IHD group. CONCLUSIONS: In this study, a poor long-term outcome was observed in patients with IHD and symptomatic stenosis but not in patients with conventional high-risk factors for surgery. Therefore, appropriate evaluation and treatment of IHD before and after CEA might be helpful for better outcome.

Pericardial synovial sarcoma presenting with large recurrent pericardial effusion.

Primary pericardial synovial sarcoma is an extremely rare disease with a dismal prognosis. Its main presenting symptoms are a large pericardial effusion, signs of cardiac tamponade, and visualization of a pericardial mass on echocardiography. However, the systemic symptoms of fever, cough, and night sweats may present a clinical picture without any apparent pericardial mass on diagnostic imaging, potentially impeding the diagnosis. We report the case of a 34-year-old patient with fever and recurrent pericardial effusion for 2 years, who was diagnosed with primary pericardial synovial sarcoma after 2-year follow-up echocardiography.

Endoscopic Vacuum-Assisted Closure (E-VAC) Treatment in a Patient with Delayed Anastomotic Perforation following a Perforated Gastric Conduit Repair after an Ivor-Lewis Esophagectomy.

It has been reported that intrathoracic esophageal leakages occur at a rate of 4%-17% after Ivor-Lewis esophagectomy. There has been no consensus on a specific treatment for the post-operative anastomotic leakage. Recently, endoscopic vacuum-assisted closure (E-VAC) has been introduced as a novel treatment for the post-operative anastomotic leakage. We herein report the case of a patient with early perforation of the gastric conduit followed by late esophagogastric anastomotic leakage who was successfully treated with early surgical repair and subsequent E-VAC. The patient had been previously diagnosed with achalasia and squamous cell carcinoma of the esophagus and undergone an Ivor-Lewis esophagectomy.

Aortic arch calcification on chest X-ray combined with coronary calcium score show additional benefit for diagnosis and outcome in patients with angina.

BACKGROUND: The coronary artery calcium (CAC) and aortic arch calcification (AoAC) are individually associated with cardiovascular disease and outcome. This study investigated the predictive value of AoAC combined with CAC for cardiovascular diagnosis and outcome in patients with angina. METHODS: A total of 2018 stable angina patients who underwent chest X-ray and cardiac multi-detector computed tomography were followed up for four years to assess adverse events, which were categorized as cardiac death, stroke, myocardial infarction, or repeated revascularization. The extent of AoAC on chest X-ray was graded on a scale from 0 to 3. RESULTS: During the four years of follow-up, 620 patients were treated by coronary stenting and 153 (7%) adverse events occurred. A higher grade of AoAC was associated with a higher CAC score. Cox regression showed that the CAC score, but not AoAC, were associated with adverse events. In patients with CAC score < 400, AoAC showed an additive predictive value in detecting significant coronary artery disease (CAD). A gradual increases in the risk of adverse events were noted if AoAC was present in patients with similar CAC score. CONCLUSIONS: As AoAC is strongly correlated with the CAC score regardless of age or gender, careful evaluation of CAD would be required in patients with AoAC on conventional chest X-rays.

A primary malignant melanoma of the mediastinum with gross surgical view.

Primary malignant mediastinal melanomas are rare. Few studies have reported on the chest computed tomography (CT) scan and histopathological features. We report a case of a primary malignant mediastinal melanoma in a 32-year-old man and provide a gross surgical view of the tumour.

Preoperative Coronary Stenosis Is a Determinant of Early Vascular Outcome after Carotid Endarterectomy.

BACKGROUND AND PURPOSE: The benefit of carotid endarterectomy (CEA) is directly influenced by the risk of perioperative adverse outcomes. However, patient-level risks and predictors including coronary stenosis are rarely evaluated, especially in Asian patients. The aim of this study was to determine the relationship between the vascular risk factors underlying CEA, including coronary stenosis, and postoperative outcome. METHODS: One hundred and fifty-three consecutive CEAs from our hospital records were included in this analysis. All patients underwent coronary computed tomography angiography before CEA. Data were analyzed to determine the vascular outcomes in patients with mild-to-moderate vs. severe coronary stenosis and high vs. standard operative risk, based on the criteria for high operative risk defined in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial. The vascular outcome was defined as the occurrence of postoperative (≤30 days) stroke, myocardial infarction (MI), or death. RESULTS: An adverse vascular outcome occurred in 8 of the 153 CEAs, with 6 strokes, 2 MIs, and 3 deaths. The vascular outcome differed significantly between the groups with mild-to-moderate and severe coronary stenosis (p=0.024), but not between the high- and standard-operative-risk groups (stratified according to operative risk as defined in the SAPPHIRE trial). Multivariable analysis adjusting for potent predictors revealed that severe coronary stenosis (odds ratio, 6.87; 95% confidence interval, 1.20-39.22) was a significant predictor of the early vascular outcome. CONCLUSIONS: Severe coronary stenosis was identified herein as an independent predictor of an adverse early vascular outcome.

Pleomorphic adenoma presenting with a mediastinal mass.

Pleomorphic adenoma is the most common type of salivary gland tumor. Although it rarely affects the trachea and bronchus, it usually grows in the airway and presents as an endobronchial mass. We recently experienced a case of pleomorphic adenoma originating in the bronchus and growing outward into the mediastinum. We present this case with review of the computed tomography (CT) scan of the patient's chest, the endoscopic ultrasound (EUS), and the histopathology report.

Multiple endotracheal and endobronchial metastases after pneumonectomy for a primary lung cancer: A case report.

Endotracheal metastasis of primary lung cancer is extremely rare. We report the case of a 51-year-old male patient who had undergone right pneumonectomy for squamous cell carcinoma one year earlier. The post-operative chest computed tomography (CT) image revealed a very small endotracheal nodule with contrast enhancement. This finding was erroneously regarded as endotracheal phlegm because of the nodular size and the rarity of endotracheal metastases from primary lung cancer. This case indicates that a thorough evaluation should be performed with a high level of suspicion for malignancy when a nodule-like lesion with contrast enhancement or tracheal thickening is detected on follow-up CT scan, in patients who undergo surgery for lung cancer.

Surgical treatment for intra-thoracic migration of acupuncture needles.

The aim of this study was to introduce the experience of diagnosis and treatment for patients with migrated acupuncture needle to pleural cavity and or lung parenchyma. We had treated 5 patients who had acupuncture needles in their thoracic cavity from January 2000 to September 2009. The mean age was 55.8 yr old. All patients suffered from the sequelae of the cerebrovascular accident and had been treated with acupuncture. They had drowsiness and hemiplegic or quadriplegic motor activity. Fever and dyspnea were main symptoms when referred to us. Diagnosis was made by the chest radiography and chest computed tomography which revealed straight metallic materials in their thoracic cavity. The needles were removed via thoracotomy or thoracoscopic procedures. Pleural decortications were also needed in four patients. Thoracoscopic surgery was successfully performed in two patients. After the removal all patients became symptomless. Although we experienced only five patients who have migrated acupuncture needles in thoracic cavity, we suggest that thoracoscopic removal of the needle with or without pleural decortication is the most optimal modality of treatment in those patients.

Pulmonary thromboembolectomy for acute pulmonary thromboembolism.

BACKGROUND: Acute pulmonary thromboembolism is fatal because of abruptly occurring hypoxemia and right ventricular failure. There are several treatment modalities, including anticoagulation, thrombolytics, ECMO (extracorporeal membrane oxygenator), and thromboembolectomy, for managing acute pulmonary thromboembolism. MATERIALS AND METHODS: Medical records from January 1999 to December 2004 at our institution were retrospectively reviewed for pulmonary thromboembolectomy. There were 7 patients (4 men and 3 women), who underwent a total of 8 operations because one patient had post-operative recurrent emboli and underwent reoperation. Surgery was indicatedfor mild hypoxemia and performed with CPB (cardiopulmonary bypass) in a beating heart state. RESULTS: The patients had several symptoms, such as dyspnea, chest discomfort, and palpitation. Four patients had deep vein thromboembolisms and 3 had psychotic problems, specifically schizophrenia. Post-operative complications included hemothorax, pleural effusion, and pericardial effusion. There were two hospital deaths, one each by brain death and right heart failure. CONCLUSION: Emergency operation should be performed when medical treatments are no longer effective.

Surgical outcomes of the modified single-patch technique in complete atrioventricular septal defect.

We examined the usefulness of the modified single-patch technique for the surgical management of complete atrioventricular septal defect (AVSD). Sixty-one patients undergoing total correction for complete AVSD from January 1997 to December 2006 were classified to the modified single-patch technique group (18 patients) and the classical one-/two-patch technique group (43 patients). The surgical outcomes of the modified single-patch technique were compared with those of the classical-patch technique. Aortic cross-clamp time was shorter in the modified single-patch technique group (110.8+/-27.5 min vs. 134.4+/-42.5 min, P=0.03). During the follow-up period, two patients required reoperation for atrioventricular valve dysfunction in the modified single-patch technique group vs. three patients in the classical-patch technique group (P=0.63). One late death occurred in the modified single-patch technique and two late deaths in the classical-patch technique group (P=0.90). There was no significant difference in surgical outcomes between the two groups. And the modified single-patch technique has the advantage of relative simplicity and shorter ischemic time, and thus it is thought to be a feasible surgical option for the repair of complete AVSD.