Socioeconomic effects of surgical site infection after cardiac surgery in Japan.

PURPOSE: Surgical site infection (SSI) increases medical costs and prolongs hospitalization; however, there has been no multicenter study examining the socioeconomic effects of SSI after cardiovascular surgery in Japan. METHODS: A retrospective 1:1 matched, case-controlled study on hospital stay and health care expenditure after cardiovascular surgery was performed in four hospitals. Patients selected for the study had undergone coronary artery bypass grafting and/or valve surgery between April, 2006 and March, 2008. Data were obtained for 30 pairs of patients. RESULTS: The mean postoperative stay for the SSI group was 49.1 days, being 3.7 times longer than that for the non-SSI group. The mean postoperative health care expenditure for the SSI group was ¥ 2,763,000 (US$27,630), being five times higher than that for the non-SSI group. Charges for drug infusion and hospitalization for inpatient care were significantly higher for the SSI group than for the non-SSI group. The increased health care expenditure was mainly attributed to the cost of antibiotics and antimicrobial agents. CONCLUSION: SSI after cardiovascular surgery not only prolonged the length of hospital stay, but also increased medical expenditure. Thus, the prevention of SSI after cardiovascular surgery is of great socioeconomic importance.

[Right ventricular rupture due to blunt trauma diagnosed by MDCT; report of a case].

The survival rate of cardiac rupture due to blunt trauma is generally low. We experienced a case with right ventricular rupture due to blunt trauma. The patient was a 49-year-old man who was crushed in a traffic accident and transported to a local hospital in a shock state. He was diagnosed with cardiac tamponade due to cardiac rupture, and for pericardial drainage was immediately performed. He was then transferred to our hospital for emergency surgery. His hemodynamics was stable, and he was diagnosed with right ventricular rupture by multi-detector row computed tomography (MDCT). The operation was performed successfully without cardiopulmonary bypass, and his postoperative course was uneventful. MDCT is useful for detecting the rupture site of the heart.

[Acute abdominal aortic occlusion in a patient with a giant thrombus in the left atrium and mitral stenosis; report of a case].

The patient was a 69-year-old male who had had percutaneous transvenous mitral commissurotomy (PTMC) 15 years ago, and had stopped taking warfarin after PTMC. He was transferred to our emergency room( ER) because of sudden severe pain in his both lower legs. We recognized pulselessness in his both femoral arteries, and pallor, paresthesia and poikilothermia in his lower extremities. Electorocardiogram(ECG) showed arterial fibrillation, and computed tomography( CT) showed occlusion of the abdominal aorta just below inferior mesenteric artery( IMA) and both common iliac arteries. By echocardiography, a giant thrombus was detected in the left atrium with severe mitral stenosis. Thrombectomy and angioplasty were performed at about 5 hours after the onset of occlusion, and revascularization was successful. Three days after the operation, we excised the giant thrombus in the left atrium and performed mitral valve replacement because we considered that myonephropathic metabolic syndrome (MNMS) had been prevented. The postoperative course was uneventful and he was discharged on the 27th postoperative day.

[Cardiac failure caused by intrapericardial chronic expanding hematoma 18 years after CABG].

Chronic expanding hematoma(CEH)was first recognized by Reid in 1980. It begins to expand chronically more than 1 month after surgery or trauma, which is considered the possible cause of bleeding. It resembles chronic subdural hematoma. Most of the reports on CEH are those in the thoracic cavity or muscles, and few are in the pericardial cavity after open heart surgery. Our case was a 64-year-old male, who had undergone coronary artery bypass grafting (CABG) 18 years before. He presented with symptoms of heart failure such as exertional dyspnea, general fatigue and appetite loss. Computed tomography( CT) scan showed severe compression of the left ventricle by a large mass, and he was diagnosed with intrapericardial CEH. Resection of the severely calcified epicardium as well as removal of the hematoma in the pericardial cavity was performed, and the symptoms of heart failure improved. No recurrence has been noted for 1 year since the operation. A long-term follow-up will be necessary.

[Board of cardiovascular surgery in Japan: past, present, and future].

The Japanese Board of Cardiovascular Surgery (JBCVS) was established in 2003. The criteria for board certification were raised compared with those under the previous system. For the past five years, the JBCVS has continuously made efforts to improve the quality of board-certified surgeons. Their number is expected to decrease considerably due to these reforms. Moreover, from 2010, the JBCVS will limit the number of recognized training hospitals by excluding those with small surgical volume. The work environment for cardiovascular surgeons has remained poor in this country, which will likely be worsened by the future decrease in their number. Therefore, every effort should be made to free them from postoperative care and time-consuming administrative tasks by introducing physician's assistant and medical coordinator systems.

Use of an audible ultrasonic flowmeter to locate deeply buried coronary arteries for off-pump coronary artery bypass grafting.

In patients with coronary arteries that are deeply buried in the myocardium and fat, it is difficult and sometimes risky to expose them for off-pump coronary artery bypass grafting (OPCAB), leading to unavoidable conversion to conventional coronary artery bypass grafting (C-CABG) to ensure their safety. We have developed a new search procedure for these coronary arteries using a dedicated ultrasonic flowmeter with a small tip probe for OPCAB. This technique enables the identification of intramuscular and intra-fat coronary arteries that are less diseased and thus more suited for bypass surgery instead of switching to C-CABG. We believe this procedure will not only improve the quality of OPCAB but also expand its indication.

Surgery for aortic dissection involving an aberrant right subclavian artery.

On diagnosis of Stanford type A acute aortic dissection with an aberrant right subclavian artery, emergency operation was performed. Aortic arch replacement was undertaken with additional 'elephant trunk' procedure to cover the entry site and decrease the blood flow through the false lumen. We consider this technique will become one of the effective procedures for acute aortic dissection involving an aberrant right subclavian artery.

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.

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.

[Acute coronary syndrome].

The first choice of interventional treatment for acute coronary syndrome is percutaneous coronary intervention (PCI), especially when the patient is in cardiogenic shock. In cases of acute myocardial infarction, emergency coronary artery bypass grafting (CABG) is indicated when left main trunk (LMT) lesion or severe triple-vessel disease is left after PCI combined with residual or recurrent ischemic angina and/or ST-T change in electrocardiogram (ECG). Similarly, in cases of unstable angina, emergency CABG is indicated when LMT or LMT equivalent (proximal left anterior descending branch and left circumflex branch) is the culprit lesion or when severe triple-vessel disease exists. Urgency of operation and existence of cardiogenic shock are major operative risk factors of CABG in patients with acute coronary syndrome. The surgical mortality of such cases is much higher than that of elective surgery for chronic angina. As employment of cardiopulmonary bypass (CPB) and achievement of cardioplegic arrest is one of the major causes of surgical mortality, off-pump CABG (OPCAB) using no CPB nor cardioplegic solution has recently become popular. OPCAB, however, is difficult to perform when the hemodynamic state is unstable. On-pump beating heart CABG is an alternative technique of choice because it not only stabilizes the hemodynamic state but also prevents myocardial ischemia/reperfusion injury. These beating heart CABG techniques will improve surgical outcome of acute coronary syndrome.

Conventional surgical repair of traumatic rupture of the thoracic aorta.

OBJECTIVE: Traumatic rupture of the thoracic aorta is a life-threatening injury requiring urgent surgical intervention. Despite recent improvements in resuscitation and emergency operative techniques, the outcomes of patients with multiple injuries are still associated with a high mortality rate. We retrospectively examined the preoperative demographic data, associated complications and mortality rate of these patients. MATERIALS AND METHODS: We analyzed the data (1991-2009) of 18 patients with acute traumatic rupture of the thoracic aorta. Most patients had rupture limited to the aortic isthmus and severe associated injuries in other organs. The aorta was repaired by direct suturing, patch plasty (n = 5; 27.7 %) or graft interposition (n = 9; 50 %). RESULTS: The overall mortality rate was 33.3 %. All six patients who underwent emergency surgery within 2 h died, four intra-operatively and two postoperatively. The causes of the intra-operative mortality were uncontrollable hemorrhage and irreversible cardiac arrest due to penetrating injury of the thoracic aorta and intercostal arteries in three patients, and uncontrollable hemorrhage due to severe liver laceration in one. The surgical complications (42.8 %) were acute lung injury (n = 2), liver insufficiency (n = 2), acute renal failure (n = 1) and cerebral infarction (n = 1). No patients had postsurgical paraplegia. The mean period between arrival and treatment and the mean Injury Severity Score were significantly higher in group D than in group A. CONCLUSION: To improve the outcome of traumatic thoracic aortic injury, the degree of multi-organ damage, the priority of treatment be evaluated accurately is important.

Successful staged operation for acute type A aortic dissection with paraplegia.

A 75-year-old man presented with both paraplegia and acute occlusion of the abdominal aorta at onset. Extraanatomical bypass was performed following spinal drainage. After 3 days, the ascending aorta replaced under cardiopulmonary bypass using the extraanatomical bypass graft for arterial cannulation. The abdominal aorta was replaced after 6 months. A staged operation is one of the options for acute aortic dissection with paraplegia and acute occlusion of the abdominal aorta.

Autoantigenicity of carbonic anhydrase 1 in patients with abdominal aortic aneurysm, revealed by proteomic surveillance.

Abdominal aortic aneurysm (AAA) is sometimes detected in patients with atherosclerosis. One of the histological characteristics of AAA walls is infiltration of inflammatory cells, in which autoimmunity may be involved. Thereby, we here surveyed autoantigens in AAA walls by proteomics. Specifically, we separated proteins extracted from AAA wall samples by 2-dimensional electrophoresis and detected candidate autoantigens by western blotting. One of the detected candidates was carbonic anhydrase 1 (CA1). ELISA confirmed that the autoantibodies to CA1 were detected more frequently in AAA patients (n=13) than in healthy donors (n=25) (p=0.03). Interestingly, some serum samples from the AAA patients reacted to CA1 of the AAA walls stronger than to CA1 of peripheral blood mononuclear cells from healthy donors. Our data indicate that CA1 in the AAA walls would be modified to express neo-epitope(s) and that the autoimmunity to CA1 may be involved in the pathogenesis of AAA.

Left atrial myxoma complicated with an acute upper extremity embolism.

Atrial myxoma is the most common benign tumor of the heart. Patients who have atrial myxoma usually present with cardiac obstruction, arrhythmia, or peripheral embolization. We encountered an unusual case of acute upper extremity ischemia due to a massive atrial myxoma in a young man. A 38-year-old man was admitted to our hospital with an acute onset of severe, right upper extremity pain and paralysis while working. Neurologic examination yielded normal results, but the patient showed no palpable right radial or ulnar artery. Routine sonographic evaluation revealed acute aortic embolism in his right brachial artery. Because of his young age and otherwise healthy condition, we decided to perform transthoracic echocardiography, which showed a huge left atrial tumor, which we suspected to be myxoma. We then performed urgent concurrent open heart surgery and embolectomy to avoid further embolism. The microscopic findings of the resected tumor and embolism specimens were myxoma. He was discharged without complications.

Surgical treatment or conservative therapy for stanford type a acute aortic dissection with a thrombosed false lumen.

OBJECTIVES: Optimum treatment for acute aortic dissection (AAD) with a thrombosed false lumen (thrombosed AAD) remains controversial. We evaluated the outcome of thrombosed AAD according to treatment strategy. MATERIALS AND METHODS: We examined 280 patients with AAD, of which 30 had thrombosed AAD. We compared computed tomography findings, cardiac performance, and clinical course in 28 of these patients. Patients were divided into three groups for the comparison: Group E (emergency surgery), Group C (conservative therapy), and Group S (conservative therapy switched to emergency surgery). RESULTS: In Group E (n = 13), one patient died and 12 survived. In Group C (n = 10), all patients were discharged, of which two died of cancer and two of the remaining eight survivors underwent subsequent elective surgery. In Group S (n = 5), one patient died and four survived following surgery. CONCLUSIONS: It was hard to predict re-dissection or rupture following conservative treatment for thrombosed AAD. Basically, we should perform emergency surgery following the diagnosis of thrombosed AAD, particularly in complicated cases such as those with pericardial effusion, tamponade, and large aorta. Conservative therapy has a very limited application in patients with the initial stages of thrombosed AAD.

Length of stay and cost for surgical site infection after abdominal and cardiac surgery in Japanese hospitals: multi-center surveillance.

PURPOSE: This study evaluated the influence of surgical site infections (SSIs) after abdominal or cardiac surgery on the post-operative duration of hospitalization and cost. METHODS: A retrospective 1:1 matched case-control study of length of stay and healthcare expenditures for patients who were discharged from nine hospitals, between April 1, 2006 and March 31, 2008, after undergoing abdominal or cardiac surgery and who did and did not have a SSI. RESULTS: Information was obtained from 246 pairs of patients who had undergone abdominal surgery and 27 pairs of patients who had undergone cardiac surgery. Overall, the mean post-operative hospitalization was 20.7 days longer and the mean post-operative healthcare expenditure was $8,791 higher in the SSI group than for the SSI-free group. Among the patients who had undergone abdominal surgery, development of SSI extended the average hospitalization by 17.6 days and increased the average healthcare expenditure by $6,624. Among the patients who had undergone cardiac surgery, SSI extended the post-operative hospitalization by an average of 48.9 days and increased the post-operative healthcare expenditure by an average of $28,534. CONCLUSIONS: Under the current healthcare system in Japan, the development of SSI after abdominal surgery necessitates extension of hospitalization two-fold and increases the post-operative healthcare expenditure 2.5-fold. Development of SSI after cardiac surgery necessitates extension of hospitalization fourfold and increases the healthcare expenditure six-fold.

Rupture of a pseudo aneurysm of the abdominal aorta in a patient with human immunodeficiency virus infection.

Human immunodeficiency virus (HIV) infection has an impact on all systems of the body, including the cardiovascular system. A 54-year-old man presented with abdominal pain. Enhanced computed tomography revealed rupture of a pseudoaneurysm of the abdominal aorta. After surgery, the patient tested positive for HIV. Histological examination of the resected aorta showed leukocytoclastic vasculitis, a characteristic feature of HIV-related vasculitis.

Traumatic rupture of the false lumen in a patient with preexisting chronic dissection of the descending thoracic aorta.

A 63-year-old man was transported to the emergency medical center due to blunt chest trauma combined with a fractured left leg caused by a motorcycle accident. He complained of severe dyspnea. Contrast-enhanced computed tomography revealed chronic aortic dissection DeBakey III, mediastinal hematoma of high density just above the diaphragm around the aorta, and an intimal flap-like shadow in the false lumen. Traumatic aortic rupture (TAR) with chronic aortic dissection was suspected. Aortography showed no clear sign of leakage, but a double-contour density was found in the outer wall of the false lumen of the descending aorta just above the diaphragm. He was therefore diagnosed with TAR and underwent an emergency operation. At the operation, rupture in the outer wall of the preexisting false lumen was found and was directly sutured. Acute renal failure developed immediately after surgery, which improved after several hemodialyses. We consider our case rare because no report has been so far made on TAR with chronic dissection.

Cardiac rehabilitation outcome following percutaneous coronary intervention compared to cardiac surgery.

To examine differences in objective and subjective outcomes in outpatients undergoing percutaneous coronary intervention (PCI) performed for acute myocardial infarction versus cardiac surgery (CS) following a phase II cardiac rehabilitation (CR). Longitudinal observational study of 437 consecutive cardiac outpatients after 8 weeks of phase II CR. Patients were divided into the PCI group (n = 281) and CS group (n = 156). Handgrip and knee extensor muscle strength, peak oxygen uptake VO2, upper- and lower-body self-efficacy for physical activity (SEPA), and physical component summary (PCS) and mental component summary (MCS) scores as assessed by Short Form-36 were measured at 1 and 3 months after PCI or CS. All outcomes increased significantly between months 1 and 3 in both groups. However, increases were greater in the CS versus PCI group in handgrip strength (+12.3 % vs. +8.1%, P < 0.01), knee extensor muscle strength (+19.3% vs. +17.5%, P = 0.008), peak VO2 (+20.9% vs. +16.9%, P < 0.01), upper-body SEPA (+27.7% vs. +9.2 vs. , P = 0.001), and PCS score (+6.5% vs. +4.1%, P = 0.001). Although this relatively short-term phase II CR increased all outcomes for both groups, outcomes showed the recovery process was different between the PCI and CS groups, slightly favoring CS patients. Furthermore, patents in the field of CR are presented.