Cardiac surgery for a right atrial myxoma with traumatic intracranial hemorrhage: a case report.

BACKGROUND: The timing of cardiac surgery with cardiopulmonary bypass (CPB) for intracranial hemorrhage is controversial. CASE PRESENTATION: We report the case of an 82-year-old woman who was transferred to our hospital because of a head injury. Brain computed tomography (CT) revealed traumatic intracranial hemorrhage, and transthoracic echocardiography revealed a giant right atrial myxoma. After confirming the disappearance of intracranial hemorrhage on brain CT, cardiac surgery with CPB was performed, which was uneventful. CONCLUSIONS: For an uneventful surgery, the optimal timing of cardiac surgery with CPB in patients with giant right atrial myxoma and intracranial hemorrhage should be based on brain CT.

Renal Vein Thrombosis Occurring in Association with Oral Contraceptives: A Case Report.

Peripheral venous thromboembolism is a well-known complication of hormonal contraception, but reports on its association with visceral vein thrombosis is limited. We report the case of left renal vein thrombosis (RVT) associated with oral contraceptives (OCs) and concurrent smoking. The clinical presentation of this patient was acute left flank pain. Computed tomography revealed left RVT. The OC was discontinued, and we initiated anticoagulation with heparin and switched to edoxaban. Computed tomography 6 months later showed complete resolution of the thrombosis. This report alerts us regarding the importance of OCs as a risk factor for RVT.

Fatal pulmonary thromboembolism caused by idiopathic ovarian vein thrombosis.

Ovarian vein thrombosis (OVT) is observed in the field of obstetrics and gynaecology. It is occasionally diagnosed during the postpartum period or in patients with ovarian malignancy. Few cases of pulmonary thromboembolism (PTE) caused by OVT have been reported previously. We report the case of a 67-year-old woman who presented with fatal PTE due to left OVT during hospitalization for cerebral infarction. The left ovary of the postmenopausal elderly patient showed no tumorous appearance. This case of OVT is extremely rare because of its idiopathic nature and fatal result.

A case of plastic bronchitis after mitral valve surgery in an adult.

Plastic bronchitis is a rare and fatal disease that is characterized by the presence of long dendritic bronchial casts in the airway. It is encountered most frequently in children with congenital heart disease after correction surgery. We reported a case of plastic bronchitis after mitral valve surgery in a 70-year-old woman.

Efficacy of Preoperative Antibiotic Therapy for the Treatment of Vascular Graft Infection.

Objective: We aimed to assess the efficacy of preoperative antibiotic therapy for the treatment of prosthetic graft infection. Materials and Methods: We retrospectively analyzed the treatment strategies used for managing patients with prosthetic vascular graft infections between 2000 and 2016. The patients were divided into two groups: early antibiotic (EA) group, those who were administered with antibiotics ≥2 weeks preoperatively and late antibiotic (LA) group, those who were administered with antibiotics <2 weeks preoperatively. We evaluated the outcomes including surgical procedures, length of hospital stay, and surgical revision. Results: All the surgical procedures performed in the EA group were elective surgeries. Three of the 11 surgeries performed in the LA group were emergency surgeries (P=0.16). No significant differences were observed in the operative procedure (P=0.64), operation time (P=0.37), and blood loss (P=0.63) of the two groups. Although the length of postoperative hospital stay did not significantly differ (P=0.61), the total length of hospital stay was longer in the EA group (P=0.02). Surgical revisions were performed for five patients in the LA group and for none in the EA group (P=0.04). Conclusion: Preoperative antibiotic therapy provided excellent outcomes in terms of avoiding surgical revisions in the treatment of vascular graft infection.

Multiple recurrent sinus of valsalva aneurysms.

We report a case of multiple unruptured sinus of Valsalva aneurysms in an adult patient over nine years.

Atypically located pericardial cyst in a patient who underwent off-pump myocardial revascularization.

Pericardial cysts are rare benign mediastinal lesions and most commonly located at the cardiophrenic angle. We present a case of an atypically located pericardial cyst in a patient who underwent myocardial revascularization. A 61-year-old man with acute myocardial infarction was scheduled for coronary artery bypass grafting (CABG). Preoperative chest computed tomography revealed a homogenous cystic lesion in the superior mediastinum. The mass was located between the ascending aorta, the superior vena cava, and the left innominate vein. It was growing to the anterior of the aorta and to the right anterior paratracheal area. The density of the mass was close to that of water; thus, the contrast medium failed to enhance its visualization. A concomitant resection of the mass and the CABG was scheduled. After a medial sternotomy and bypass graft harvest, a median pericardectomy was performed. The surgeon found the cystic mass along the roof of the pericardium and located between the ascending aorta and superior vena cava. There was no adhesion between the mass and cardiovascular components. The mass was resected en bloc; therefore, off-pump CABG was completed. Histopathological examination of the resected specimen confirmed diagnosis of a pericardial cyst.

Active cerebral perfusion during carotid endarterectomy.

A patient with critical stenoses in the bilateral internal carotid arteries (ICA) required multivessel coronary revascularization. The diameter of the left ICA was far greater than the right, which strongly suggested that the cerebral circulation was highly dependent on the left. During left ICA endarterectomy, active cerebral perfusion of 300 mL x min(-1) at 23 degrees C using an extracorporeal circulation was employed through the ICA under repair. Subsequently, coronary bypass was performed on-pump with the heart beating. The postoperative course was very good.

[Successful salvage of a patient with cardiac arrest caused by multiple pulmonary emboli and lung abscesses due to infective endocarditis of the tricuspid valve: a case report].

A 28-year-old female developed infective endocarditis in the tricuspid valve and multiple lung abscesses due to septic pulmonary emboli early after intensive therapy for ulcerative colitis. The pathogen was methicillin-resistant Staphylococcus aureus. Usual antibiotic agents and linezolid were administered. Three weeks later, she fell into cardiopulmonary arrest due to further pulmonary emboli and required mechanical circulatory assist. Fatal brain damage was suggested at first. Two days later, she fully regained consciousness and underwent tricuspid valve replacement using mechanical valve and extirpation of septic pulmonary embolus. Mechanical circulatory assist was discontinued on the next day. After strenuous administration of linezolid and other drugs for 9 weeks, she was discharged from hospital on foot. We believe that early surgical intervention should be considered in patients with infective endocarditis in the right heart and subsequent septic pulmonary emboli. Linezolid was very useful in this patient.

Off-pump coronary artery bypass grafting for a patient with anomalous origin of the right coronary artery from the pulmonary artery.

We report on a case of a 70-year-old chronic hemodialysis patient. He presented with anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) and severe left anterior descending coronary artery (LAD) stenosis, which supplied collateral flow to the right coronary artery (RCA). The patient complained of myocardial ischemic symptoms during routine hemodialysis. We performed off-pump coronary artery bypass grafting (OPCABG) surgery and ligation of the origin of the ARCAPA. Previous reports described that the myocardial ischemia was a rare complication with the ARCAPA patients. However, this case required coronary revascularization because of the atherosclerotic LAD stenosis as a collateral source of the RCA.

Successful bridge to resynchronization therapy with a left ventricular assist system in a patient with idiopathic dilated cardiomyopathy.

Implantation of a left ventricular assist system (LVAS) in patients with idiopathic dilated cardiomyopathy (DCM) may improve cardiac function and allow explantation of the device. Generally, an ejection fraction of more than 40% is considered necessary for successful weaning from an LVAS, but less than 10% of DCM patients with an LVAS can achieve such a significant recovery of cardiac function. Cardiac resynchronization therapy, or atrial-synchronized biventricular pacing, has been found to treat congestive heart failure and ventricular dyssynchrony effectively. Here we report on a patient with an LVAS, in whom enough functional recovery could be obtained with resynchronization therapy for the device to be explanted successfully. A 32-year-old man was implanted with a Toyobo-NCVC paracorporeal LVAS to treat his intractable heart failure caused by idiopathic dilated cardiomyopathy. While on the LVAS for 8 months, his cardiac function recovered to some extent. The ejection fraction of his left ventricle (LVEF) improved from 9% to 41%. He chose explantation of the device rather than heart transplantation. Because he occasionally showed a wide QRS pattern on his ECG, epicardial biventricular pacing leads as well as a biventricular pacemaker were implanted on LVAS explantation surgery. An echocardiogram 2 weeks after explantation showed a marked difference in his LVEF by switching his biventricular pacing on and off (40% with biventricular pacing on and 29% with it off). Biventricular pacing may help recovery of cardiac function in selected LVAS patients and contribute to the increase in bridge to recovery cases.

[Coronary artery bypass grafting in patients undergoing chronic hemodialysis: importance of wound healing and hypoproteinemia].

OBJECTIVES: Outcome of coronary artery bypass grafting (CABG) in patients undergoing chronic hemodialysis was studied. METHODS: Between January 1996 and August 2004, 49 consecutive hemodialysis patients [38 males and 11 females, mean age 60.0 years (range 47-74 years)] underwent CABG using cardiopulmonary bypass. Duration of hemodialysis was 5.2 years (range 1 month-21 years), and 32 patients were diabetics. Surgery was conducted on the emergency/urgency basis in 12 patients, and intraaortic balloon pumping was placed in 7. Left ventricular ejection fraction was 57.7 +/- 16.3% (range 27-84%). Nine patients underwent concomitant valve surgery. CABG was performed under hypothermic cardiopulmonary bypass and ventricular fibrillation except in one patient, and intraoperative hemodialysis was also performed. Continuous hemodiafiltration was used in the early period after surgery. RESULTS: Number of bypass grafts was 3.0 +/- 1.0 (range 1-6), and the unilateral internal thoracic artery was used in 29 patients. Operation time, cardiopulmonary bypass time, and aorta clamp time were 313 +/- 87, 145 +/- 63, and 49 +/- 43 min, respectively. Diffuse pericardial adhesion was present in five patients. Severely atheromatous ascending aorta precluded manipulation in seven patients. Although the 30-day mortality was 2.0% (one case), all in-hospital mortality over 9 months was 14.3% (seven cases). The morbid events were mediastinitis in seven cases, reexploration for hemorrhage in seven, pneumonia in two, abdominal complication in three, and stroke in one. Delayed onset mediastinitis was common. Risk factors for death were mediastinitis and serum albumin levels < 3.5 g/dl (both p < 0.05), both of which were wound healing-related factors. CONCLUSIONS: CABG in hemodialysis patients carries a high risk. Patients with hypoalbuminemia appear to require special consideration.

[Active infective endocarditis remaining latent for six weeks after discontinuation of antibiotic therapy: a case report].

A 75-year-old man was treated for 4 weeks with penicillin administration for infective endocarditis in the mitral valve caused by Enterococcus faecalis. The infection recurred, so he received penicillin administration for a further 6 weeks. He remained afebrile and all laboratory examinations were within normal limits for 6 weeks after the antibiotic treatment was discontinued, but the vegetation remained large and highly mobile. Since the onset, possible embolic episodes had occurred three times. He underwent mitral valve repair with annuloplasty. Although the infection appeared to have healed by antibiotic therapy, resected tissue was strongly positive for Enterococcus faecalis. This case suggests that surgery should be aggressively considered if the vegetation does not shrink markedly.

[Long survival with chronic ventricular fibrillation under support of uni-left-ventricular assist system].

Few minutes of suspended malignant ventricular arrhythmia may be permitted for the patient with left ventricular assist system (LVAS). However, longer and continuous ventricular arrhythmia, especially ventricular fibrillation (Vf), may induce the low output of LVAS, which leads circulatory collapse immediately. Our presenting case is a female dilated cardiomyopathy patient who has been supported with LVAS. Four months after the LVAS installation, her electrocardiogram has changed to Vf without any symptoms. Her ventricular function has never recovered, even ventricular tachycardia. She has been a candidate of heart transplantation for more than 19 months with this rare hemodynamic condition (LVAS+Vf), like the Fontan circulation. Her performance status is limited due to deceasing of the LVAS flow, which caused by the change of her position: 2.5-2.9 l/min (lie down) to 2.0 l/min (rise). Her peak VO2/W is 6.9 ml/min/kg measured by the cardio-pulmonary exercise test. However, she has developed her general status by doing rehabilitation program and is able to walk for more than 100-150 meters.

[Aortic root replacement using an allograft for active infective endocarditis with periannular abscess: single center experience].

OBJECTIVES: Results of aortic root replacement using an allograft for active infective endocarditis in the aortic position and periannular abscess were studied. METHODS: Aortic root replacement using a cryopreserved aortic allograft was performed 13 times in 12 patients (9 men, 3 women, mean age 52.8 years) at Saitama Medical School. Allografts were obtained from the Tokyo University Tissue Bank. Infection affected the prosthetic valve in 6 patients and the native valve in 7. Causative organisms were Staphylococci in 7 patients, Streptococci in 2, and unknown in 4. New York Heart Association functional class was II in 2 patients, III in 3, and IV in 8. Six patients required inotropic support. Four were mechanically ventilated. Two were in a state of profound shock. Four had multiple organ failure. Surgery was conducted under hypothermic cardiopulmonary bypass and cardioplegic arrest. Allograft was sewn into place by monofilament continuous sutures. Carrel patch technique was used for coronary artery reconstruction. Five patients underwent concomitant procedures (replacement of the ascending aorta in 2 patients, coronary artery bypass grafting in 1, mitral valve repair in 1, pulmonary artery reconstruction in 1). RESULTS: Duration of surgery, cardiopulmonary bypass, and aortic clamping were 507 +/- 154, 307 +/- 111, and 189 +/- 49 min, respectively. Two patients required intraaortic balloon pumping, and one required percutaneous cardiopulmonary support. Two patients in a state of shock died(hospital mortality: 15.4%). Duration of mechanical ventilation was 2.9 +/- 3.7 days. Intensive care unit stay was 4.6 +/- 5.5 days, and hospital stay was 61 +/- 26 days. One patient died of cancer 18 months later. One patient required reoperation 11 months later. Including operative death cases, cumulative survival at 2 years was 66.5% and freedom from cardiac events was 72.7%. CONCLUSIONS: Aortic root replacement with an allograft yielded acceptable clinical results.

Lethal thrombus in the carotid artery during operation for acute aortic dissection with cerebral malperfusion.

A drowsy patient with acute type A aortic dissection and cerebral malperfusion required emergency operation. Because the right carotid artery was totally obstructed, cerebral perfusion was first restored by cannulating it and the left femoral artery before midline sternotomy. However, a long fresh thrombus was found flowing backward from the obstructed carotid artery. This thrombus was removed, and both arteries were connected through a Y-shaped extracorporeal circulation circuit to reperfuse the brain. During the subsequent aortic procedure, both arteries were used for arterial inflow. Such thrombi can cause grave postoperative neurologic dysfunction. Carotid artery cannulation is mandatory in such cases.