[Metastatic Right Atrial Tumor of Renal Cell Carcinoma:Report of a Case].

Metastatic cardiac tumors are known to be more common than primary cardiac tumors, and most patients are asymptomatic. In patients with renal cell carcinoma (RCC) with cardiac metastases, total tumor resection is known to improve the prognosis. We report a case of a successfully resected RCC with right atrial metastasis under cardiopulmonary bypass. A 71-year-old female with abdominal distention was diagnosed with right RCC and extension to the right atrium. After neoadjuvant chemotherapy, she underwent right nephrectomy and neiection of intraocular tumor extention with partial right atrium under cardiopulmonary bypass, because the tumor tightly adhered to the right atrium. She had a good postoperative course and was discharged home on the 22nd postoperative day. Nine months after surgery, she shows no sign of recurrence.

[Stanford Type A Acute Aortic Dissection Complicated with Intestinal Ischemia Preceded by Superior Mesenteric Artery Bypass:Report of a Case].

A 78-year-old male with sudden onset of chest and back pain was transported to our institution by ambulance. Upon arrival at our hospital, he also complained of abdominal pain. Contrast-enhanced computed tomography (CT) revealed the presence of Stanford type A acute aortic dissection complicated with intestinal ischemia;because of the effects of aortic dissection, the superior mesenteric artery 378 Vol.76 No.5(2023-5) (SMA) was obstructed, leading to the complication of intestinal ischemia. An arterial blood gas test showed elevated lactate and metabolic acidosis. We immediately performed resection of the necrotic portion of the intestine and bypass of the common iliac artery to the SMA. Subsequently, after confirmation of the improvement of acidosis, ascending aortic replacement was performed on the same day. Although the patient's condition was complicated by acute kidney injury and pneumonia, he was discharged home on the 55th postoperative day. Acute aortic dissection complicated by intestinal ischemia has a poor prognosis;however, here we reported a life-saving surgical procedure in a patient with this presentation.

[Comparison of Two Minimally Invasive Aortic Valve Replacement Approaches;Right Infra-axillary Thoracotomy versus Partial Sternotomy].

OBJECTIVES: Minimally invasive aortic valve replacement(AVR) is reported to show better postoperative outcomes than those associated with conventional AVR. We compared 2 minimally invasive approaches;right infra-axillary thoracotomy( TAX) and partial sternotomy( PS). METHODS: From January 2013 to December 2017, 54 patients underwent isolated AVR, of whom 14 were in TAX group and 28 were in PS group. Operative outcomes were compared between the 2 groups. RESULTS: Preoperative characteristics were similar between the groups. Cardiopulmonary bypass time and cross-clamp time were significantly longer in TAX group. Blood transfusion rates, however, were lower[ 5( 35.7%) versus 22 ( 78.6%):p=0.006] and ventilation time was shorter( median 4.0 versus 6.0 hours:p<0.001) in the TAX group. No mortality or stroke occurred in either group. CONCLUSIONS: Both TAX and PS AVR could be performed safely, with low mortality and morbidity. TAX was associated with a lower transfusion rate and a shorter ventilation time, and was supposed to be less invasive than PS.

Evaluation of longitudinal and radial left ventricular functions on 2-D and 3-D echocardiography before and after intravenous immunoglobulin in acute Kawasaki disease.

BACKGROUND: The relationship between left ventricular (LV) function and longitudinal or radial contraction has not yet been elucidated in acute Kawasaki disease (KD), especially before and after treatment with intravenous immunoglobulin (IVIG). METHODS: We studied 28 KD patients without coronary aneurysms (average age, 3.2 years). The LV end-diastolic volume (LVEDV), end-systolic volume (LVESV), stroke volume (LVSV), and ejection fraction (LVEF) were assessed on 3-D echocardiography before IVIG, after IVIG, and in the convalescent phase. LV fractional shortening (LVFS) and the mitral annular plane systolic excursion (MAPSE) z-score were measured as surrogates for radial and longitudinal LV wall motions, respectively. Serum brain natriuretic peptide (BNP) was also assessed as a heart failure indicator in acute KD patients. RESULTS: In all KD patients, LVEDV decreased in the acute phase with preservation of LVESV. Both LVSV and MAPSE z-score were lowest before IVIG and increased after IVIG. MAPSE z-score was highly correlated with LVEF before and after IVIG treatment. Although there was a good correlation between logBNP and LVEF before IVIG, it was lost after IVIG. CONCLUSIONS: LVEDV decreased longitudinally during the acute phase of KD with preservation of LVESV, reducing both LVSV and LVEF. Serum BNP is a useful marker for evaluating LV function only prior to IVIG treatment.

Increased systemic cardiac output improves arterial oxygen saturation in bidirectional cavopulmonary shunt.

The low arterial oxygen saturation (SaO2) after bidirectional cavopulmonary shunt (BCPS) predicts poor prognosis. The venous oxygen saturation of inferior vena cava (SivcO2), as well as the pulmonary blood flow/systemic blood flow ratio (Q p/Q s) affects the SaO2. The purpose of this study is to determine whether SivcO2 or Q p/Q s should be increased to achieve better outcomes after BCPS. Forty-eight patients undergoing BCPS were included. Data of patients' age and body weight, SivcO2, Q p/Q s, pulmonary artery (PA) pressure and resistance, PA area index, morphology of ventricle, atrioventricular valve regurgitation, and history of PA plasty were collected. Stepwise multiple logistic regression analyses were used to investigate which of the factors most affected the SaO2 after BCPS. There was a significant correlation between SivcO2 and SaO2 (r = 0.771, P < 0.00001). There was no strong correlation between Q p/Q s and SaO2 (r = 0.358, P < 0.05). Stepwise multiple logistic regression analyses revealed that both SivcO2 (r = 0.49, 95 % confidence interval (CI) 0.37-0.62, P < 0.0001) and Q p/Q s (r = 11.1, 95 % CI 3.3-18.9, P = 0.007) most affected SaO2 after BCPS. Since the SivcO2 has a stronger correlation than Q p/Q s with SaO2, despite the fact that both raising Q p/Q s and raising cardiac output can increase SaO2, raising cardiac output should be considered prior to Q p/Q s to raise the SaO2 after BCPS.

Neutrophil elastase inhibitor sivelestat attenuates perioperative inflammatory response in pediatric heart surgery with cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) evokes activation of a systemic inflammatory response. Sivelestat has been used clinically to treat acute lung injury associated with systemic inflammatory response syndrome. This prospective, doubleblind, randomized study was designed to evaluate the effects of sivelestat in the perioperative period of elective pediatric open-heart surgery with CPB. Twenty-six consecutive pediatric patients weighing between 5 and 10 kg and undergoing open-heart surgery with CPB were divided into a sivelestat group (n = 13) and a control group (n = 13). The patients in the sivelestat group were administered a continuous intravenous infusion of 0.2 mg/kg/hour of sivelestat, and the patients in the control group were administered the same volume of 0.9% saline from the initiation of CPB to 24 hours after surgery. Blood samples were drawn for the measurement of cytokines, polymorphonuclear elastase (PMN-E), white blood cell count (WBC), neutrophil count (NC), and C-reactive protein (CRP). There were no significant differences in cytokine data between the two groups. The peak PMN-E and WBC levels were significantly increased in the control group (P = 0.049, P = 0.039). The WBC and NC levels immediately after surgery in the control group were significantly greater than those in the sivelestat group (P = 0.049, P = 0.044). The peak CRP level in the control group was significantly greater than the sivelestat group (P = 0.04), and the CRP level on postoperative day 4 in the control group was significantly greater than in the sivelestat group (P = 0.014). This study showed that sivelestat attenuates the perioperative inflammatory response in pediatric heart surgery with CPB.

Complete coverage of in situ aortograft by total omental pedicle flap as the most reliable treatment of aortoesophageal fistula.

Aortoesophageal fistula secondary to a thoracic aortic aneurysm is usually a fatal disease with few survivors reported previously. We encountered 2 consecutive patients who were treated successfully with esophagectomy and in situ aorta reconstruction using cryopreserved homograft that was wrapped completely with omental pedicle flap. For the construction of omental flap, the right gastroepiploic artery was resected at the root and all the vessels entering the greater curvature and the transverse colon were resected at the adherent edges. Because the gastroepiploic arcade is totally preserved, large amounts of omental tissue could be obtained, with an excellent blood supply mainly from the left gastroepiploic artery. This type of omental flap is highly mobile, easily transferred to the left hemithorax, and has enough volume to cover the in situ aortic graft completely including anastomosis lines. Thus, our omental coverage appears to be the most reliable method to prevent postoperative graft infection.

Effectiveness of combined blood conservation measures in thoracic aortic operations with deep hypothermic circulatory arrest.

BACKGROUND: The effectiveness of blood conservation measures for thoracic aortic operations with deep hypothermic circulatory arrest has not yet been documented. METHODS: From July 1997 to December 2000, 148 thoracic aortic operations were performed in our department. Sixty-one cases involving patients who underwent elective thoracic aortic operation with deep hypothermic circulatory arrest were reviewed retrospectively. RESULTS: Seventeen patients did not meet the criteria for the blood conservation program and were excluded from the present study. Therefore, 44 patients were analyzed in this study. Overall, 50% of patients did not require operative homologous blood transfusion (HBT) and 43% did not require in-hospital HBT. Smaller amounts of autologous donation, greater blood loss, and a longer operation time were independent risk factors for HBT requirement. Among 16 patients who had made an autologous donation of 1,600 mL or greater, 75% did not require intraoperative HBT and 69% did not require in-hospital HBT. The overall perioperative mortality rate was 4.5%. As for postoperative complications, prolonged intubation and postoperative infection were significantly more frequent among patients who required in-hospital HBT. CONCLUSIONS: Our combined blood conservation measures were effective in avoiding HBT during major thoracic aortic operations with deep hypothermic circulatory arrest and may have reduced postoperative complications. The amount of the autologous donation was a strong predictor for avoiding HBT.

Open stent-grafting for aortic arch aneurysm is associated with increased risk of paraplegia.

BACKGROUND: Open surgery using the endovascular stent-graft is a novel technique that lessens the invasiveness of surgery for the aortic arch. However, the outcome of this procedure remains uncertain. METHODS: Between November 1996 and July 2000, a total of 19 patients underwent open surgery using an endovascular stent-graft for thoracic aortic aneurysms. There were 15 men (78.9%) and 4 women (21.1%). Patient age ranged from 29 to 82 years (mean 69.3 years, median 74 years). Atherosclerotic thoracic aortic aneurysms were present in 17 patients (89.4%) and aortic dissection in 2 patients (10.5%). RESULTS: Two patients (10.5%) died in the hospital and 4 patients (21.1%) presented with paraplegia postoperatively. Among the 4 patients with postoperative paraplegia, 1 case was complicated with intraoperative aortic dissection. The other 3 patients with paraplegia had spinal cord ischemic time of more than 60 minutes and intraoperative body weight gain of more than 4 kg. Of these 3 patients, hemodynamic instability after cardiopulmonary bypass was observed in 1 patient and cholesterin embolus in the anterior spinal artery was found at autopsy in another. On univariate analysis, age greater than 75 years was the only risk factor associated with paraplegia (p < 0.05). Autopsy findings for the 2 patients showed that the Adamkiewicz arteries were not blocked by the stent-graft in either patient. CONCLUSIONS: Intraoperative aortic dissection, embolization of the intercostal arteries, long ischemic time of the spinal cord, and excessive weight gain during operation may have been associated with the high incidence of paraplegia after open surgery using the endovascular stent-graft.

Cerebral metabolism of nitric oxide during retrograde cerebral perfusion.

The aim of this study was to determine whether alpha- or pH-stat protects the brain during deep hypothermic retrograde cerebral perfusion. Fifteen anesthetized dogs on cardiopulmonary bypass were cooled to 18 degrees C under alpha-stat and underwent retrograde cerebral perfusion for 90 minutes under alpha-stat or pH-stat, or underwent antegrade cardiopulmonary bypass under alpha-stat as the control. Cerebral blood flow of the cortex was monitored and serial analyses of blood gases and total nitric oxide oxidation products made. Cerebral blood flow and cerebral metabolic rate for oxygen were significantly higher and plasma levels of nitric oxide oxidation products in the outflow from the brain were significantly lower in retrograde cerebral perfusion under pH-stat than under alpha-stat. This study shows that reduced levels of nitric oxide oxidation products may protect against neuronal damage induced by nitric oxide and that increased cerebral blood flow under pH-stat may lead to a reduction of nitric oxide oxidation products. Under retrograde cerebral perfusion, pH-stat is thus better than alpha-stat for protecting the brain.

Thrombus originating from frayed distal edge of an aortic stent-graft.

An 87-year-old woman who had undergone a stent-graft repair of a descending aortic aneurysm had additional stent-graft implantation for endoleak. The postoperative course was eventful reflecting her preexisting multiple organ disorder, and despite intensive treatment over a span of 2 months, she died of disseminated intravascular coagulation due to intestinal ischemia. Autopsy revealed a thrombus originating from the frayed distal edge of the graft. Although the relation between intestinal ischemia and the thrombus remains to be proven, this is considered a vital finding.

Successful repair of graft failure and abdominal aortic aneurysm following thoraco-abdominal bypass for atypical aortic coarctation.

A 54-year-old woman, who underwent descendo-abdominal aortic bypass grafting for atypical aortic coarctation complicated with Takayasu's arteritis 37 years previously, was referred to our hospital for treatment of a pseudoaneurysm due to rupture of the graft. Preoperative computed tomography scan also demonstrated an abdominal aortic aneurysm. First, an endovascular stent-graft repair of the pseudoaneurysm was performed, then the abdominal aortic aneurysm was repaired with the aid of cardiopulmonary bypass. Proper surgical planning was important to treat this rare development accompanied by aberrant circulation.

Pseudoaneurysm developed after aortic root homograft implantation.

A 55-year-old man with severe infective endocarditis underwent aortic root replacement using a homograft concomitant with saphenous vein grafting to the left anterior descending artery. The patient developed angina due to stenosis of the proximal anastomosis of the vein graft accompanied by a 2-cm pseudoaneurysm. This complex lesion was successfully managed with urgent coronary artery bypass surgery through a left thoracotomy, followed by a redo replacement of the old aortic homograft. The mechanism and the basis of the treatment strategy adopted for this case are described.

Elephant trunk in a small-calibre true lumen for chronic aortic dissection: cause of haemolytic anaemia?

OBJECTIVES: The elephant trunk technique for aortic dissection is useful for reducing false lumen pressure; however, a folded vascular prosthesis inside the aorta can cause haemolysis. The purpose of this study was to investigate whether an elephant trunk in a small-calibre lumen can cause haemolysis. METHODS: Inpatient and outpatient records were retrospectively reviewed. RESULTS: Two cases of haemolytic anaemia after aortic surgery using the elephant trunk technique were identified from 2011 to 2013. A 64-year-old man, who underwent graft replacement of the ascending aorta for acute Stanford type A aortic dissection, presented with enlargement of the chronic dissection of the descending aorta and moderate aortic regurgitation. A two-stage surgery was scheduled. Total arch replacement with an elephant trunk in the true lumen and concomitant aortic valve replacement were performed. Postoperatively, he developed severe haemolytic anaemia because of the folded elephant trunk. The anaemia improved after the second surgery, including graft replacement of the descending aorta. Similarly, a 61-year-old man, who underwent total arch replacement for acute Stanford type A aortic dissection, presented with enlargement of the chronic dissection of the descending aorta. Graft replacement of the descending aorta with an elephant trunk inserted into the true lumen was performed. The patient postoperatively developed haemolytic anaemia because of the folded elephant trunk, which improved after additional stent grafting into the elephant trunk. CONCLUSIONS: A folded elephant trunk in a small-calibre lumen can cause haemolysis. Therefore, inserting an elephant trunk in a small-calibre true lumen during surgery for chronic aortic dissection should be avoided.

Management of infected grafts and aneurysms of the aorta.

Seventeen patients treated for infected grafts (11/17) or aneurysms (6/17) of the aorta between 1998 and 2003 were reviewed to evaluate our experience with aortic infection. The causative organisms were identified in 12 patients (71%), with 5 (29%) having methicillin-resistant Staphylococcus aureus. A periaortic abscess occurred in eight patients, and all of them were associated with infected grafts. Surgical treatment included cryopreserved allograft replacement in eight patients, prosthetic graft replacement in four patients, and drainage with or without omental wrapping in five patients. One patient was still hospitalized at the end of the study period. Five patients with infected grafts died after the operation during the initial hospitalization. No early mortality occurred in the aneurysm group. The early mortality rate was 31% for all patients, 50% for the graft group, and 63% for patients with a periaortie abscess. Another patient with an infected aneurysm died of arrhythmia after discharge from the initial hospitalization, Ten patients are still alive without evidence of reinfection. The early mortality rate for patients with infected aortic grafts is higher than that for those with infected aneurysms, especially when a periaortic abscess accompanies them. However, the late outcome is favorable, with no reinfection or late treatment-related deaths.

Multichannel monitoring of cerebral circulatory and oxygenation status using optical topography during deep hypothermic retrograde cerebral perfusion.

In this study, we evaluated changes in the cerebral circulatory and oxygenation status during deep hypothermic total circulatory arrest (TCA) and retrograde cerebral perfusion (RCP) using optical topography, a form of multichannel near-infrared spectrophotometry, to monitor the broad area perfused by the middle cerebral artery. Seven patients underwent thoracic aortic surgery with TCA and RCP via the superior vena cava. Pressure-regulated RCP was performed under pH-stat. No postoperative neurologic complications occurred. Using optical topography, the relative changes in oxy-, deoxy-, and total hemoglobin (oxy-Hb, deoxy-Hb, total Hb) were simultaneously measured from 24 points in both hemispheres. Deoxy-Hb was used for evaluating the regional oxygenation status under RCR The values of deoxy-Hb at the beginning of RCP were regarded as the basal values, and the rate of increase in deoxy-Hb per minute (deoxy-Hb/min) was calculated at each site. Deoxy-Hb/min during TCA was also calculated. In every case, both oxy-Hb and total Hb decreased and deoxy-Hb increased during TCA. When RCP was initiated, the decrease in oxy-Hb and the increase in deoxy-Hb were attenuated. Deoxy-Hb/min was significantly lower under RCP than during TCA in all portions. There was no significant difference of deoxy-Hb/min between any portions during RCP Our results showed that the status of circulation and oxygenation might be uniform in the brain during RCP and better than that under TCA.