Hiraaki Goto

Endovascular approach for an intracranial mycotic aneurysm associated with infective endocarditis.

One of the most serious complications of infective endocarditis is mycotic cerebrovascular aneurysm, which can cause a lethal subarachnoid hemorrhage (SAH). ~ The treatment of mycotic aneurysms in hemodynamically unstable patients is controversial because solid guidelines based on large prospective studies are lacking. Patients show a wide variety in size, number, and location of these intracranial lesions, in addition to varying in basic cardiac function. We report a case of ruptured mycotic aneurysm caused by infective endocarditis in a patient whose cardiac function was too severely compromised to permit an open craniotomy. A 42-year-old man was admitted with a history of general fatigue, dyspnea, fever, and night sweats for a week. He had a high body temperature of 38°C and cardiac murmurs indicative of aortic and mitral regurgitation. A chest radiograph demonstrated cardiomegaly and severe pulmonary edema. An echocardiogram revealed vegetation and severe regurgitation of both the aortic and mitral valves. A diagnosis of infective endocarditis was confirmed by the isolation of Streptococcus viridans in :multiple arterial blood cultures. The patient was treated in the intensive care unit with high doses of antibiotics (ampicillin 10 gm/day and tobramycin 120 mg/day), diuretics, and catecholamines to control bacteremia and acute heart failure. After 6 days of intensive care, the patients body temperature dropped below 37 ° C and further blood cultures were negative for pathogens. The patients pulmonary edema and cardiomegaly also were alleviated. The patient was moved to a general floor, and double valve replacement was scheduled for the following week. Early the next morning, however, the patient became comatose and had a temperature of 38.6 ° C, tachycardia, hypertension, and respiratory distress. Mechanical ventilation under endotracheal intubation was started. Computed t0mography demonstrated a massive SAH. Subsequent cerebral angiography revealed a 5 mm aneurysm arising from the P2 portion of the right posterior cerebral artery (Fig. 1). The patient was transferred to the intensive care unit. Despite conservative therapy, including respiratory support and administration of diuretics and catecholam;mes, the patients condition was considered to be too hCmodynamically unstable to allow him to undergo general anesthesia and an emergency craniotomy for direct clipping of the aneurysm. Emergency double valve

Surgery of hepatoma with intracavitary cardiac extension

SummaryA case of primary liver carcinoma with intracavitary cardiac extension is presented. A 36-year-old female was admitted to our surgical clinic with dyspnea and generalized edema. Echocardiography and superior vena cavography demonstrated a large filling defect in the right atrium. After a diagnosis of acute cardiac failure due to an intracardiac tumor, the patient was operated upon immediately. A right atriotomy exposed a large yellow mass within the right atrium, which was not adherent to the atrial wall. The mass was in continuity with similar material in the inferior vena cava and right hepatic vein. With a suspicion of hepatic malignancy, the atrial tumor was removed, and debulking of the mass in the inferior vena cava and right hepatic vein was performed. A postoperative histological examination of the tumor showed hepatocellular carcinoma. Her postoperative course was uneventful, and she was discharged from the hospital.Intracardiac extension of hepatoma is rarely encountered. In this clinical setting, long-term survival cannot be anticipated from any surgery, but palliative clearing of the atrium and inferior vena cava may be of value in preventing cardiac arrest causing sudden death.

Complement conversion and leukocyte kinetics in open heart surgery

Complement conversions and a pulmonary leukocyte sequestration were observed during cardiopulmonary bypass (CPB) in all of twenty patients who received open heart surgery. A systemic neutropenia was initially observed in the early phase of CPB, and it subsequently turned into a systemic neutrocytosis during the late phase of it. A significant leukocyte sequestration was found in the pulmonary circulation during CPB coincidently with the systemic neutropenia. The contribution of the transpulmonary sequestration to the leukopenia was major, being as high as 80 per cent. Plasma C3, C4, and CH50 levels rapidly decreased following the commencement of CPB. Alterations of the C3 molecule in the patients’ plasma were demonstrated using the immunoblotting method. The appearances of C3a and C3b with the apparent molecular weights of 10,000 and 170,000 respectively, might be evidence of the complement activation during CPB. Another type of alteration in the C3 molecule was observed in the generation of a new fragment with the apparent molecular weight of 14,000. The appearance of this fragment, which did not share common epitopes with C3a, might suggest the consumption of complement components during CPB, unrelated to the activation of the complement systems.

Thoracoabdominal aortic aneurysm combined with aortic occlusion.

The case of a 73-year-old woman with aneurysms of the thoracoabdominal aorta and distal arch, combined with aortic occlusion, is reported. Cannulation from the femoral artery was not possible because of the aortic occlusion. Blood supply to the abdominal viscera and lower extremities was achieved only by selective perfusion from the celiac artery, superior mesenteric artery, and bilateral renal arteries. A unique choice of selective perfusion for distal circulatory support is described.

INFLAMMATORY REACTIONS AFTER VASCULAR PROSTHESIS IMPLANTATION : A COMPARISON OF GELATIN-SEALED AND UNSEALED DACRON PROSTHESES

Despite widespread use of the gelatin-sealed knitted Dacron prosthesis (GDP) in clinical practice owing to its zero porosity, the biological impacts of this graft are still controversial. We conducted a randomized controlled study on 50 patients undergoing abdominal aortic aneurysm repair to evaluate the inflammatory reaction to GDP (n=25) and unsealed knitted Dacron prostheses (UDP, n=25). There were no significant differences in the mean age, size of the aneurysm, operative time, blood loss, or transfusion requirements between the GDP and UDP groups. During the first 7 postoperative days (PODs), slight fever and leukocytosis were noticed in both groups. Significant differences in maximum body temperature, leukocyte count, and plasma C-reactive protein concentration were observed between the GDP and VDP groups on POD 14: 37.2±0.5°C vs 36.9±0.3°C (P=0.019), 8,151±1,788/μl vs 6,914±1,501/μl (P=0.015), and 32.6±27.5mg/l vs 19.0±15.8mg/l (P=0.048), respectively. By POD 21, however, there were no detectable differences in these variables. Thus, we concluded that GDP caused an inflammatory reaction in the 2nd week after implantation, but ultimately there were no significant differences from UDP by the 3rd week.

Anticoagulant effects of argatroban on the pre-DIC state in patients with an aortic aneurysm: A comparative study of heparin

We compared the efficacy of argatroban, a new synthetic thrombin-specific inhibitor, with that of heparin in pre-DIC state patients with abdominal aortic aneurysm (AAA). A pre-DIC state was diagnosed by a detection of soluble fibrin monomer complex (FM) and increased levels of thrombin-antithrombin III complex (TAT) of more than 20 ng/ml. Twelve patients showing a pre-DIC condition were treated with argatroban (40 mg/day, n=6) or heparin (10,000 U/day, n=6) for 5 days. Coagulation and fibrinolytic profiles were analyzed before and after drug administration. FM became negative in two (33%) patients after the argatroban treatment and in all (100%) of the heparin-treated patients. Plasma levels of TAT were significantly decreased after the heparin treatment, however, there was no significant alteration in this parameter after the argatroban treatment. In conclusion, the anticoagulant effects of heparin were superior to those of argatroban in controlling the pre-DIC state associated with AAA.

Neutrophil Producing Capacity of 5-Lipoxygenase Metabolites of Arachidonic Acid After Major Surgery

It is well known that patients who undergo surgical operations have a high risk of infection and sepsis. One explanation for this high risk may be a depression of neutrophil functions at the postoperative period. In the present study, the effects of surgical stresses on neutrophil functions were studied in ten patients who underwent general anesthesia and major surgery. The neutrophil functions especially focused on were the producing capacities of 5-lipoxygenase metabolites of arachidonic acid such as Leukotriene B4 (LTB4), LTC4, LTD4, 6-trans-LTB4, and w-oxidation products of LTB4. Neutrophils were stimulated with calcium-ionophore A23187 (2x10(-5) M) in the presence of arachidonic acid (5x10(-5) M) for 5 minutes at 37 degrees C. The arachidonic acid metabolites were extracted by methanol. After centrifugation, the supernatant of the mixture was concentrated and applied to a C-18 column on reversed phase high performance liquid chromatography (RP-HPLC) system, monitoring the absorbance at 280 nm. In all cases, the LTB4 production significantly increased postoperatively with an increment of 6-trans-LTB4 and w-oxidation products of LTB4. The LTC4 production, by contrast, significantly decreased postoperatively. LTD4 production was observed at neither pre nor postoperative periods. The total amount of LTA4 metabolites at the postoperative period, including LTB4, LTC4, and 6-trans-LTB4, increased 1.2 times compared with that at preoperative period. This indicates the possibility of the alteration of the neutrophil metabolism in 5-lipoxygenase cascade, the increment of LTA4 generation and the change of LTA4 metabolism from LTC4 synthesis to LTB4 generating pathway.

CLINICAL STUDIES ON SOME METABOLISMS AFTER TOTAL PANCREATECTOMY

膵全摘術を4例に施行し, 術後の代謝, 特に糖代謝と消化管ホルモンの変動とについて検討した.糖代謝に関しては, 術後早期のcatabolic phaseでは糖5-6gに1単位の, anabolic phaseになると糖8-10gに1単位のinsulinでcontrolできた.感染時の血糖調節のcontrolは困難であった.消化管ホルモンの動態については30K抗体に対するIRGの存在は認められたが, 血糖上昇作用の有無については不明であつた.経ロブドウ糖負荷ではIRG値は上昇した.arginine負荷ではglucagon分泌は誘発されなかった.食餌負荷によるgastrin分泌反応は全くみられなかった.