A rare case of positional vertebrobasilar ischemia with the retrograde flow of the vertebral artery.

Positional vertebrobasilar ischemia, also known as Bow hunter stroke, is typically caused by mechanical compression of the vertebral artery (VA). On the other hand, subclavian steal syndrome is incidentally detected by vertigo, syncope or loss of consciousness due to the steal phenomenon. A 61-year-old man suffered from near syncope when he turned his head to the left side. Although asymmetric arm blood pressure of the right dominant was observed, arm claudication was not detected. Computed tomographic angiography and magnetic resonance imaging revealed total occlusion of the left subclavian artery, hypoplasia of the right VA and an incomplete circle of Willis. Furthermore, carotid Doppler ultrasonic echography revealed retrograde blood flow of the left VA. It means that head rotation might occur in the left VA ischemia. An axillary-axillary bypass surgery was performed and ultrasonic echography showed anterograde effective blood flow of the left VA after the procedure.

Rare case of ruptured muscular ventricular septal aneurysm due to silent myocardial ischemia in adult.

Interventricular septal aneurysm of muscular type is uncommon in adult, to say nothing of membranous type. Acute or subacute left-to-right shunt (LR shunt) in a ventricular septum is mostly critical and usually shows severe symptoms. Therefore, ruptured muscular ventricular septal aneurysm (VSA) with LR shunt of unknown onset in adult is highly rare. A 70-year-old man was suffered from mild dyspnea and chest oppression. A muscular VSA was detected at the center of the ventricular septum and LR shunt of unknown onset in it had induced congestive heart failure. The sandwich patch technique through a right ventricular approach was simultaneously performed with coronary artery bypass grafting and the postoperative course was uneventful. In addition, concomitant myocardial biopsy of VSA wall during the surgery could reveal histopathologic evidence of acute or subacute myocardial infarction with old myocardial infarction as silent myocardial ischemia.

[Vascular Behçet disease presenting large right coronary artery pseudoaneurysm after percutaneous coronary intervention( PCI): report of a case].

A 37-year-old man was diagnosed with angina pectoris and underwent percutaneous coronary intervention(PCI) procedure for right coronary artery in other hospital. Five months after PCI procedure, he was admitted to the hospital because of fever, chest pain and respiratory discomfort. He was diagnosed as having a large right coronary artery pseudoaneurysm which was about 40 mm in diameter. He was transfered to our hospital. We did coronary artery bypass grafting(CABG)[ saphenous vein graft (SVG)-#3] and pseudoaneurysm closure, and he left our hospital on 37 post-operative day. After discharge from our hospital, he developed iliocecal ulcer, oral aphtha, folliculitis and arthralgia and was diagnosed with Behçet disease. Seven months after the 1st surgery, proximal anastomosis site of SVG was ruptured and presented huge ascending aorta pseudoaneurysm. We performed autologous pericardial patch plasty on ascending aorta, and covered there with omentum flap. He uneventfully left our hospital on 19 post-operative day.

[Thoracic and cardiovascular surgery in Jehovah's Witness].

A Jehovah's Witness who requires thoracic and cardiovascular surgery represents a challenge to both the surgeon and the patient because of the patient's refusal to accept blood transfusion. We reported 15 cases of Jehovah's Witness patients from 43 to 80 years of age who underwent cardiac operations or thoracic vascular operations. There was 1 emergency operation case and 2 re-do operation cases. Erythropoietin and serum albumin injections were allowed to be used in some cases. The mean pre-operative haemoglobin level in these patients was 12.3 g/dl. The mean postoperative lowest haemoglobin level was 9.2 g/dl. The mean haemoglobin level at the point of leaving hospital was 11.4 g/dl. There were no postoperative complications and no operative deaths. We successfully performed the thoracic and cardiovascular operations on Jehovah's Witnesses, including emergency cases, safely without blood transfusion. The most important thing is a careful and safe operative technique which reduces perioperative bleeding as much as possible.

Neurological outcomes after immediate aortic repair for acute type A aortic dissection complicated by coma.

BACKGROUND: Management of acute type A aortic dissection (AADA) complicated by coma remains controversial. We analyzed our experience in managing AADA complicated by coma to determine the relationship of duration of preoperative coma to postoperative neurological recovery. METHODS AND RESULTS: Between September 2003 and October 2010, 181 patients with AADA were treated, including 27 presenting with coma (Glasgow Coma Scale <11) on arrival. Twenty-one patients were repaired immediately (immediate group); time from onset of symptoms to operating room was <5 hours. For brain protection, deep hypothermia with antegrade cerebral perfusion was used, and postoperative therapeutic hypothermia with magnesium treatment was performed. Six patients initially were managed medically, and 3 of them were followed by eventual repair because time from onset was >5 hours (delayed group). The preoperative National Institutes of Health Stroke Scale score was 31.4 ± 6.6 in the immediate group and 28.3 ± 9.5 in the delayed group. Hospital mortality was 14% in the immediate group and 67% in the delayed group. Full recovery of consciousness was achieved in 86% of patients in the immediate group and in 17% in the delayed group. In immediate group, the postoperative National Institutes of Health Stroke Scale score significantly improved to 6.4 ± 8.4, cumulative survival rate was 71.8% in 3 years, and independence in daily activities was achieved in 52% (11/21). CONCLUSIONS: Aortic repair, if performed immediately from the onset of symptoms, showed satisfactory recovery of consciousness and neurological function in patients with AADA complicated by coma. In this patient population, immediate aortic repair is warranted.

Aortocavitary fistula without aneurysm and transient incomplete atrioventricular block due to infective endocarditis.

A 67-year-old man with persistent fever and moderate aortic valve regurgitation was transferred. He suffered from incomplete atrioventricular block (AVB), and temporary pacing was needed. Left-to-right shunt flow from the aorta to the right atrium was found without an aneurysm. Operative findings indicated that the aortic valve was highly calcified. The orifice of an aortocavitary fistula (ACF) was detected in the sinus of Valsalva and the right atrium. Patch repair of the aortic annulus with complete débridement of the abscess cavity was performed, a procedure that consisted of aortic valve replacement directly to the Gore-Tex patch and aortic root replacement. His postoperative course was uneventful, but a pacemaker was implanted owing to complete AVB. To our knowledge, this is a rare case in which infective endocarditis was complicated by ACF without an aneurysm of the sinus of valsalva (SV) on the noncoronary cusp to the right atrium and transient incomplete AVB (Mobitz type II) occurring simultaneously.

Coronary artery bypass grafting with bilateral internal thoracic arteries for Bland-White-Garland syndrome in an adult.

A 46-year-old man with anomalous origin of the left coronary artery from the pulmonary artery (Bland-White-Garland syndrome) is reported. We successfully performed coronary artery bypass grafting with the use of bilateral internal thoracic arteries and ligation of the anomalous left coronary artery. The patient was discharged from the hospital after an uneventful postoperative course and postoperative coronary angiography, which revealed patent internal thoracic arteries and no leakage of blood flow from the anomalous left coronary artery to the pulmonary artery. This surgical procedure is technically simple and useful for adult patients with Bland-White-Garland syndrome. To our knowledge, this is one of only a few reports on coronary artery bypass grafting with bilateral internal thoracic arteries as a treatment of Bland-White-Garland syndrome.

Curved nitinol stent-graft placement for treating blunt thoracic aortic injury: an early experience.

BACKGROUND: Blunt trauma-induced aortic injury traditionally has been treated with early open surgical repair. However, recently endovascular stent-graft technology is considered a less-invasive therapeutic alternative, and flexible stent-grafts, such as the Matsui-Kitamura stent-graft (MKSG), are being used widely. We report our experience with the curved MKSG in treating thoracic aortic injuries. METHODS: Nine patients with traumatic thoracic aortic injury underwent endovascular surgery (8, emergency; 1, elective) with curved MKSG. The study variables were Injury Severity Score, endovascular surgery duration, aortic and stent-graft diameter, stay in the intensive care unit, follow-up period, and mortality. An MKSG was constructed using the Matsui-Kitamura stent and a polyester fabric graft. The stent-graft was placed using the transfemoral approach and the wire-tug technique. RESULTS: The mean Injury Severity Score was 42.3; 5 patients required 6 emergency procedures before the endovascular procedure (pneumothorax or hemothorax drainage, 5; transarterial embolization, 1). In 8 patients (88.9%), we achieved complete pseudoaneurysm exclusion or hemostasis in the injured portion. There were no postoperative complications; blood loss was minimal, and the intensive care unit stay was 13.4 days. The overall hospital mortality was 22.2% (n = 2; causes of death were unrelated to MKSG placement). Neither intervention-related mortality during follow-up (mean, 237.7 days) nor late endovascular graft-related complications (endoleak or graft migration) were noted. CONCLUSIONS: Although this study is limited by a small sample size and short follow-up period, no collapse or stent-graft fractures were noted. Thus, MKSG placement for traumatic thoracic aortic injury appears a safe and effective therapy.

Lymphatic cardiac tamponade after open-heart surgery with liver dysfunction.

A 46-year-old female with alcoholic liver dysfunction was admitted for mitral regurgitation due to infective endocarditis. She underwent mitral valvuloplasty and resection of the vegetation without complication. After removal of the chest tube, late cardiac tamponade occurred and subsequently recurred. On the 64th day after mitral valvuloplasty, we performed redo median sternotomy with small laparotomy trying to reveal and repair injured lymphatic vessels in the pericardial space and successfully cured the leakage of lymph. The post reoperative course was uneventful and the patient was discharged 20 days after reoperation. We review a rare complication of recurrent cardiac tamponade of lymphatic leakage associated with liver dysfunction.