Effectiveness and long-term outcomes of surgical intervention for constrictive epicardium in constrictive pericarditis.

OBJECTIVE: Epicardial resection is considered effective in patients with constrictive pericarditis accompanied by epicardial constriction, but few publications have evaluated its long-term outcomes. The study objective was to evaluate early and late results of epicardial resection. METHODS: A total of 22 patients with pericardiectomy for constrictive pericarditis were treated at our institution between 1989 and 2016. They were stratified by the presence or absence of constrictive epicardium and the surgical intervention performed. Group A (n = 7) included those with constrictive epicardium and epicardial resection in addition to pericardiectomy. Group B (n = 5) included those with constrictive epicardium and single pericardiectomy. Group C (n = 10) included those without constrictive epicardium and with a single pericardiectomy. Postsurgical changes were evaluated by echocardiography. RESULTS: No significant differences were found in preoperative baseline characteristics, operative details, and operative mortality among the groups. The median postoperative follow-up was 80 months. Group A patients did not experience cardiac events, and left ventricular end-diastolic volume and stroke volume were significantly improved at late follow-up compared with before and soon after surgery. The early postsurgical parameters were significantly improved in Group C patients, but the improvements were attenuated on late follow-up. Group B patients had the highest occurrence of cardiac events and no improvement in echocardiographic parameters. CONCLUSION: Surgical intervention in constrictive epicardium improved echocardiographic parameters and was free of cardiac events during long-term follow-up.

Surgical Treatment of Coronary to Pulmonary Artery Fistulas in Adults.

Coronary to pulmonary artery fistulas (CPAFs) are abnormal communications between the coronary and pulmonary arteries. They are an uncommon congenital heart disease and usually remain asymptomatic until later in life. However, there is no consensus on their management. We present four adult patients who required surgery for coronary to pulmonary artery fistulas to illuminate this issue. The clinical presentations were variable depending on the anatomical features of coronary to pulmonary artery fistulas and the presence or absence of other cardiac diseases. We successfully performed surgical closure of the coronary to pulmonary artery fistulas in each of the cases. In this report, we describe our experience with these cases and outline the available therapeutic strategies and treatment options for coronary to pulmonary artery fistulas.

[Coronary-pulmonary Artery Fistula in a Hemodialysis Patient].

We report a case of coronary-pulmonary artery fistula in a hemodialysis patient treated surgically. A 47-year-old man was admitted with chest pain and exertional dyspnea that progressively worsened over the previous 2 months. He had a history of end-stage renal disease and has been on hemodialysis for 5 years. Coronary angiography and computed tomography revealed coronary-pulmonary artery fistula that originated from both the left anterior descending coronary artery and the right coronary artery. Under cardiopulmonary bypass, we opened the pulmonary artery and closed the fistula. The symptoms of the patient improved after the surgery, and he was discharged without major complications. Coronary-pulmonary artery fistulas in hemodialysis patients are rare. The presence of additional arteriovenous fistula used for dialysis in these patients increases the left-to-right shunt flow and might cause progression of heart failure. Even if the left-to-right shunt volume is small, surgical treatment is highly recommended at an early stage of the coronary-pulmonary artery fistula in hemodialysis patients.

[Unroofed Coronary Sinus in an Adult; Report of a Case].

Unroofed coronary sinus( UCS) is a rare cardiac anomaly and the most uncommon type of atrial septal defect. It is rarely diagnosed by only echocardiography prior to surgery. We herein report a case of UCS (partially unroofed terminal portion) without persistent left superior vena cava that was precisely diagnosed by cardiac multi-detector low computed tomography (MDCT). A 50-year-old asymptomatic man was admitted for cardiac evaluation. A transesophageal echocardiography showed a left to right shunt at the atrial level. MDCT clearly showed a defect in the coronary sinus and lower part of the interatrial septum. At the time of surgery, the defect was closed using a Gore-Tex patch, such that the coronary sinus drained entirely into the left atrium. The postoperative course was uneventful. Cardiac MDCT provides accurate anatomic details about defects as well as the associated anomalies of the heart and pulmonary vasculature.

[Coronary artery bypass grafting in a patient with chronic bird fancier's lung].

Acute exacerbation is a devastating and fatal event of hypersensitivity pneumonitis. We report an 80-year-old man with chronic bird fancier's lung which acutely exacerbated after off-pump coronary artery bypass grafting. Our perioperative management included avoidance of inhalation of high concentration oxygen, administration of neutrophil elastase inhibitor, and long-term administration of antibiotics. Nevertheless, the patient experienced severe respiratory failure after influenza infection. High-resolution computed tomography (CT) showed new ground-glass opacities overlying fibrosis and traction bronchiectasis. We diagnosed acute exacerbation of hypersensitivity pneumonitis. Immediate steroid pulse therapy with empirical antibiotic administration was effective, and he recovered from critical respiratory failure. High-resolution CT was very helpful in the early detection of acute exacerbation of pneumonitis.

[IgG4-related constrictive pericarditis treated by waffle procedure].

A 59-year-old man was admitted for evaluation of short of breath and bilateral leg edema that had progressively worsened over 3 months. Chest computed tomography revealed marked pericardial thickening. Cardiac echocardiography revealed right heart volume load and diastolic dysfunction. Cardiac catheterization revealed a dip-and-plateau pattern of the pressure curve of right ventricule (RV)without any coronary disease. On a diagnosis of heart failure due to pericardial constriction, he underwent pericardiectomy under cardiopulmonary bypass. Multiple longitudinal and transverse incisions like a waffle were made in the thickened epicardium and improved the hemodynamics. The symptoms improved after surgery. As serum level of immunoglobulin G(IgG)4 was elevated and IgG4-positive plasma cells were recognized in the resected pericardium, diagnosis of constrictive pericarditis of hyper-IgG4 disease was made.

[Quadricuspid aortic valve associated with rapidly progressive aortic stenosis during chronic hemodialysis; report of a case].

A 70-year-old man was referred to our department for surgical treatment for aortic valve stenosis. He was diagnosed with aortic regurgitation 30 years ago, but he was asymptomatic at that time. Ten years ago, chronic hemodialysis was instituted for diabetic nephropathy. In recent years, he became aware of nocturnal dyspnea and echocardiography revealed moderate aortic stenosis. After that, the symptom was getting worse and surgical treatment was indicated. We performed aortic valve replacement. Intraoperatively, we noticed his aortic valve was quadricuspid. The postoperative course was uneventful and he was discharged without complications. Quadricuspid aortic valve is rare congenital anomaly and patients are often operated on for aortic regurgitation. Our case is indicated for valve replacement because of aortic stenosis. In addition, there are a few reports of quadricuspid aortic valve associated with hemodialysis. We consider hemodialysis is one of the cause of rapid progression of aortic stenosis in this patient.

Venous reconstruction with radial artery harvesting: Domino method.

We describe two cases of venous reconstruction after radial artery (RA) harvesting for coronary artery bypass grafting (CABG). Patient 1, a 70-year-old man who underwent CABG 16 years earlier, presented with acute posterolateral myocardial infarction caused by total occlusion of the saphenous vein graft (SVG). RA grafting was considered ideal, but he had bilateral hypoplastic ulnar arteries. Venous reconstruction with RA harvesting using SVG was performed, and surgery was successful. Patient 2, a 57-year-old-man with chronic renal failure caused by polycystic kidney disease, presented with angina pectoris. Off-pump CABG was recommended. We used a right internal thoracic artery and the RA as an I-composite graft. However, RA preservation was essential for future hemodialysis. The RA was harvested and reconstructed as described for patient 1. Ischemia had not developed in the hands and forearms as of 5 years after the surgery. We believe that the method may be an alternative graft choice in CABG.

Characteristics of revascularization treatment for arteriosclerosis obliterans in patients with and without hemodialysis.

BACKGROUND: Limb ischemia is a major complication in patients who are receiving hemodialysis (HD). In this study, distinctive features and factors affecting the outcome of HD patients with limb ischemia are identified. METHODS AND RESULTS: One hundred and eighty consecutive symptomatic limb ischemic patients who were or were not receiving HD and who successfully underwent surgical bypass grafting (bypass, n=75) or endovascular angioplasty (percutaneous transluminal angioplasty (PTA), n=105) were retrospectively compared at our hospital. The endpoint of this study was amputation of the ischemic leg or death. Median follow up was 2.25 years. The amputation-free survival of HD patients was significantly lower than that of non-HD patients (P<0.0001). In the bypass group, the amputation-free survival of HD patients was significantly lower than that of non-HD patients (P=0.0002), even if the graft was patented or not (P=0.77). In contrast, in the PTA group, the amputation-free survival of HD patients was lower than that of non-HD patients (P=0.03), and with a significantly lower patency rate (P=0.0004). Predictors of amputation-free survival differed between HD and non-HD patients; predictors were diabetes mellitus and gender in HD patients, while they were Fontaine classification and hyperlipidemia in non-HD patients. The infectious death rate was higher in HD patients than in non-HD patients (53% vs 22%, P<0.05). CONCLUSIONS: This study clearly showed a poorer prognosis in HD patients than in non-HD patients especially after bypass surgery, even if the the graft was patented or not.

Infective endocarditis complicated with splenic abscess successfully treated with splenectomy followed by double valve replacement.

Splenic abscess (SA) is a rare complication of infective endocarditis (IE). A successful outcome lies with a choice between medical and surgical treatments. However, there is still insufficient evidence in the decision-making process. Our patient was a 73-year-old male who complained mainly of fever and general fatigue. An echocardiography showed vegetation of 10 mm in diameter and severe mitral and aortic regurgitation and a diagnosis was made of IE. Because of a recent brain embolism, we decided to treat him initially with medical therapy. Antibiotics were effective, but on the 28th day after starting treatment, he complained of left upper abdominal pain. An abdominal computed tomography scan showed SA. The administration of vancomycin did not improve the condition. We decided that he should undergo surgical treatment. A splenectomy was performed and 9 days after the splenectomy, the mitral and aortic valves were successfully replaced. There is still no clear-cut evidence to support the order of surgical interventions. Indeed, the current guidelines, which recommend that splenectomy is to be performed first, are not supported by strong evidence. The present case report showed that splenectomy before valve surgery successfully treated the patient.

[Long-term prognosis after coronary revascularization in patients with end-stage renal disease on dialysis: comparison of percutaneous coronary intervention and coronary artery bypass grafting].

OBJECTIVES: To investigate the optimal method of coronary revascularization in patients on dialysis. METHODS: We retrospectively analyzed 145 patients on dialysis who underwent percutaneous coronary intervention (PCI) (81 patients) or coronary artery bypass grafting (CABG) (64 patients). Survival and non-fatal cardiac event-free rates were compared between the two groups by the Kaplan-Meier method. The impact of independent predictors on survival and non-fatal cardiac event-free rates were examined by the Cox regression model. RESULTS: The number of diseased vessels was smaller and ejection fraction was greater in the PCI group compared with the CABG group (1.74 +/- 0.67 vs 2.56 +/- 0.61, p < 0.0001 and 61.1 +/- 14.3% vs 50.6 +/- 17.4%, p = 0.001). The 1-year and 5-year survival rates of the PCI group were significantly higher than those of the CABG group (93.8 +/- 2.7% and 66.6 +/- 5.7% vs 76.0 +/- 5.4% and 44.8 +/- 6.5%, p = 0.0065). However, CABG was not an independent predictor of death by multivariate analysis (p = 0.06). The 1-year and 5-year non-fatal cardiac event-free rates of the PCI group were significantly lower than those of the CABG group (63.7 +/- 5.4% and 34.7 +/- 5.8% vs 83.2 +/- 4.9% and 66.8 +/- 7.4%, p = 0.0003). PCI was an independent predictor of non-fatal cardiac event by multivariate analysis (p = 0.007). CONCLUSIONS: PCI was associated with a higher incidence of non-fatal cardiac events, but survival rate was better after PCI than after CABG. PCI is very important and acceptable as a method of coronary revascularization in patients on dialysis.

Left pneumonectomy for lung cancer after correction of contralateral partial anomalous pulmonary venous return.

We report the successful treatment of a 48-year-old man with left lung cancer and contralateral partial anomalous pulmonary venous return (PAPVR). He was found to have an abnormal shadow on a regular checkup. Sputum cytology revealed squamous cell carcinoma. Chest computed tomography showed not only a left hilar mass but also showed that his right superior pulmonary vein was draining into the high portion of the superior vena cava. In the presence of the right partial anomalous pulmonary venous return, it was believed that left pneumonectomy would cause serious postoperative heart failure due to an increase in the left-to-right shunt. Therefore his partial anomalous pulmonary venous return was corrected first under cardiopulmonary bypass, and 3 weeks later he underwent successful radical left pneumonectomy.

[Acute infective endocarditis].

Between January 1987 and June 2004, 65 patients with infective endocarditis underwent aortic and/or mitral surgery. Nine of these patients with active native valve endocarditis required emergency surgery. Indications for emergency operation were progressive congestive heart failure in 5 patients, systemic emboli in 2 patients and uncontrolled infection in 2 patients. The aortic valve was affected in 3 patients, the mitral valve in 4 patients and both the aortic and mitral valve in 2 patients. All of these patients were treated with radical excision of infected tissue and implantation of mechanical or stented bioprosthetic valves. There was no hospital death and no patients required reoperation for recurrent endocarditis. Although medical therapy for acute infective endocarditis is effective in most instances, some patients still require early surgical intervention. These data demonstrate excellent results in patients who underwent emergency surgery for acute infective endocarditis.

Multiple atherosclerotic aneurysms of the bilateral subclavian artery, aortic arch and abdominal aorta.

Subclavian artery aneurysms are relatively rare in comparison with other peripheral aneurysms. We report a 65-year-old woman with multiple atherosclerotic aneurysms of the subclavian artery, aortic arch saccular aneurysm and abdominal aortic aneurysm. Two-staged operations by which the infrarenal abdominal aorta was replaced first and median sternotomy extending to the supraclavicular space for the concomitant resection of bilateral subclavian as well as aortic arch aneurysm resulted in good results.

Resection of paraaortic lymph node metastasis of colon cancer with graft replacement.

The metastasis sites of colon cancer are the liver, lungs, bones, peritoneum, and lymph nodes. Lymph node recurrences, however, are seldom resected metachronously. We report here a case of en-bloc resection of paraaortic lymph node recurrence together with the invaded abdominal aorta, left kidney and ureter 4 years after curative resection of sigmoid colon cancer. Combined resection of the metastatic lymph nodes and the abdominal aorta would be an even more radical procedure and treatment for cancer because of lymphatic spread around the aorta. The slow growth of the cancer might justify this aggressive resection. This is the first report of resection of late paraaortic lymph node metastasis and simultaneous abdominal aortic graft replacement.

False aneurysm due to suture loosening after aortic arch replacement.

We describe a case of false aneurysm due to loosening of the anastomotic sutures 5 years after graft replacement for subacute type A aortic dissection. Leakage from the graft was controlled by tightening the suture slack indicating that suture loosening was the cause of the aneurysm. The mechanism was probably the progressive thinning of the edematous swollen aortic wall over the years causing the sutures to loosen.