Hiromichi Fujii

Rectus abdominis myocutaneous flap after unsuccessful delayed sternal closure

Open chest management is one of the best options for severely impaired hearts after open-heart surgery. Reapproximation of sternal edges compresses the heart, so a less compressive method of chest wall reconstruction should be considered when sternal closure must be delayed. We applied a rectus abdominis myocutaneous flap approach in 3 patients after difficulties with delayed sternal closures. Two patients were weaned off intraaortic balloon pumping and survived without respiratory troubles or wound complications. This alternative method of chest reconstruction is useful in patients after an unsuccessful delayed sternal closure.

Serous cystadenoma of the pancreas with atypical cells. Case report.

SummaryConclusion. Serous cystadenomas of the pancreas may have the biologic ability to undergo malignant transformation.Background. It is generally recognized that: serous cystadenomas of the pancreas are benign and that their malignant potential is low.Methods. A serous cystadenoma of the pancreas was resected from a 53-yr-old woman. In the central portion of the tumor, papillary structures were found on the cyst wall. Immunohistologic studies using antibodies to carbohydrate antigen 19-9, carcinoembryonic antigen, and proliferating cell nuclear antigen were performed to determine the malignant potential of this tumor.Results. On histology, most tumor cells were positive for periodic acid-Schiff but were negative for periodic acid-Schiff after diastase digestion and Alcian blue, a staining pattern typical of serous cystadenomas. The cells found in the papillary structure of the cyst wall were mildly atypical. These cells were stained with antibodies to carbohydrate antigen 19-9, carcinoembryonic antigen, and proliferating cell nuclear antigen, indicating that the cells comprising the papillary structure were proliferating more rapidly than cells in other parts of the tumor and strongly suggesting that the cells are premalignant.

A Case of Adventitial Cystic Disease of the Popliteal Artery Progressing Rapidly after Percutaneous Ultrasound-guided Aspiration

Adventitial cystic disease is a rare non-atherosclerotic vascular disease. We report a 36-year-old man with right intermittent claudication by adventitial cystic disease. computed tomography (CT) and magnetic resonance imaging (MRI) revealed an ovoid cystic mass compressing the right popliteal artery and causing severe stenosis of the lumen. Percutaneous aspiration was performed, which improved his symptoms. However, he complained of identical intermittent claudication two weeks later. Radiographic findings revealed that the cystic lesion had progressed rapidly. The cystic lesion was resected and the affected arterial segment was interposed. We consider that conventional surgical intervention remains the favored treatment option in the management of adventitial cystic disease.

Impact of non-di-(2-ethylhexyl)phthalate cardiopulmonary bypass tubes on inflammatory cytokines and coagulation-fibrinolysis systems during cardiopulmonary bypass

Di-(2-ethylhexyl)phthalate (DEHP), an excellent plasticizer for poly(vinyl chloride) (PVC), is a known endocrine-disrupting chemical. This study was designed to investigate whether a new non-DEHP bilayer tube reduced the release of DEHP, suppressed inflammatory cytokines, and altered coagulation-fibrinolysis systems. Sixteen patients undergoing coronary artery bypass grafting (CABG) were randomly assigned to the non-DEHP bilayer group (group B, n = 8), or the noncoated PVC group (group N, n = 8). The level of DEHP in the blood was measured before and after cardiopulmonary bypass (CPB). The levels of interleukin-6 (IL-6), D-dimer, and thrombin-antithrombin complex (TAT) were also measured at six points during and after CPB. DEHP was significantly lower in group B (472 ± 141 ng/ml) after CPB compared with group N (2094 ± 1046 ng/ml). The IL-6 level was significantly lower in group B (151 ± 131 pg/ml) than group N (206 ± 224 pg/ml) 180 min after protamine administration. The D-dimer level was significantly lower in group B 60 min after protamine administration (6.2 ± 2.4 μg/ml in group B vs 10.4 ± 4.5 μg/ml in group N) and 180 min after protamine administration (4.4 ± 0.7 μg/ml in group B vs 7.3 ± 2.7 μg/ml in group N). Group B had a tendency toward reduced postoperative bleeding compared with group N at any time. The bilayer tube was superior to the noncoated tube in terms of the inhibition of DEHP release, inflammatory cytokines, and the fibrinolysis system.

Di(2-Ethylhexyl) Phthalate Exposure during Cardiopulmonary Bypass

Di(2-ethylhexyl) phthalate is an excellent plasticizer for polyvinyl chloride but a known endocrine disrupting chemical. To investigate whether tubing containing no diethylhexyl phthalate reduces the overall extraction of this plasticizer during cardiopulmonary bypass, 16 patients undergoing coronary artery bypass grafting were randomly divided into 2 groups of 8 each. Group A had tubing containing diethylhexyl phthalate in the circuit, and group B had no diethylhexyl phthalate in the tubing. The plasma diethylhexyl phthalate level at the end of cardiopulmonary bypass was significantly increased compared to before anesthesia in both groups (group A: 103 ± 60 to 2,094 ± 1,046 ng·mL−1; group B: 135 ± 60 to 472 ± 141 ng·mL−1), and it was significantly higher in group A than group B. This study demonstrates that using tubing free from diethylhexyl phthalate significantly reduces the release of this agent during cardiopulmonary bypass, which may minimize exposure to diethylhexyl phthalate.

Sonoclot analysis in cardiac surgery in dialysis-dependent patients

BACKGROUND Dialysis-dependent patients have multiple disorders of hemostasis; however, there are no reports of viscoelastic changes during cardiac surgery in such patients. METHODS Hemostasis in dialysis-dependent patients during cardiac operations was evaluated. Thirty patients who underwent cardiopulmonary bypass (CPB) were studied: 6 with chronic renal failure undergoing dialysis (HD group), and 24 without hemodialysis. Blood samples were obtained at four points: before sternotomy, 30 and 90 minutes after the start of CPB, and after protamine administration. RESULTS Activated clotting time (ACT) measured with Sonoclot analyzer was significantly correlated with ACT measured traditionally (r = 0.92; p < 0.001; y = 36.1 + 0.95x). Values for ACT measured with Sonoclot analyzer as well as traditional ACT increased significantly during CPB. Values for ACT measured with Sonoclot analyzer in the HD group were significantly longer than those in the control group. Before CPB, both ACT measured with Sonoclot analyzer and traditional ACT in the HD group were significantly longer than those in the control group; however, there were no significant differences in ACT measured with Sonoclot analyzer between the groups after CPB. Clot rates and peak signal values were significantly decreased during CPB in both groups, and returned to preoperative values after protamine administration. There were no significant differences in clot rate and peak signal values between the two groups. There were no differences between the two groups in changes of time to peak. Platelet counts in the HD group were significantly higher (p < 0.05) than those in the control group. There were no differences in platelet counts after CPB between the two groups. Antithrombin III levels decreased below 50% during and after CPB. Antithrombin III in the HD group was significantly lower (p < 0.01) than those in the control group. A significant time-group interaction was observed in antithrombin III levels. CONCLUSIONS Sonoclot signatures in HD patients showed no significant differences in viscoelastic changes compared with non-HD patients.

Open heart surgery for posttraumatic inferior vena caval thrombosis

A 40-year-old woman was diagnosed as intrahepatic hematoma after blunt abdominal trauma. One month later computed tomography (CT) revealed the inferior vena caval thrombus extending into the right atrium. Emergency thrombectomy was performed under cardiopulmonary bypass. We believe that the thrombus, which was derived from laceration of the hepatic vein, extended through the inferior vena cava into the right atrium, and was the eve of pulmonary embolization. CT study should be repeated, once the intrahepatic hematoma was recognized. We emphasize that we should recognize the existence of such complication to prevent the catastrophic result.

Early and long-term results of coronary artery bypass grafting in dialysis patients

OBJECTIVE We evaluated the surgical outcome of coronary artery bypass grafting in dialysis patients. METHODS We retrospectively analyzed 25 consecutive dialysis patients requiring isolated coronary artery bypass grafting. Their mean age was 61.6 years and average dialysis duration 80.4 months. RESULTS Eight patients (32%) had emergency or urgent surgery. The mean number of bypassed vessels was 3.3 +/- 1.2. Internal thoracic artery grafts were used in 19 patients and gastroepiploic artery grafts in 5. Two (8%) died during hospitalization and complications occurred in 11 (44%). No cerebral complications were observed. All survivors showed ameliorated symptoms and improved overall function. Of 14 late deaths, 5 were cardiac-related, with 2 involving obvious myocardial ischemic events. Actuarial survival, including hospital deaths, at 1 year was 70.9%, at 3 years was 43.5%, and at 5 years was 34.8%. Cardiac-death-free survival was 70.2% at 3 years and 70.2% at 5 years. CONCLUSION Coronary artery bypass grafting in dialysis patients is associated with a higher incidence of complications but has acceptable surgical mortality and effectively relieves angina symptoms.

Early surgery for active infective endocarditis

OBJECTIVE The timing of surgery for active infective endocarditis remains controversial. In this report, we have reviewed 26 patients who underwent surgery for active infective native-valve endocarditis between April 1992 and December 1998. PATIENTS AND METHOD There were 19 male and 7 female patients (mean age 45 years). The aortic valve was involved in 8 patients, the mitral valve in 6 patients, tricuspid valve in 2 patients, both aortic and mitral valves in 7 patients, both aortic and tricuspid valve in 2 patients, and both mitral and tricuspid valve in one patient. The most common microorganisms were streptococcal species. Preoperative high New York Heart Association functional class (III and IV) was presented in 20 patients (77%). Progressive heart failure and the echocardiographic findings of vegetation (larger than 1 cm) were the main operative indications. Emergency or urgent surgery was required in 18 patients (70%). All patients underwent valve replacement, involving 25 mechanical prosthesis and 8 bioprosthesis. RESULTS The operative mortality was 7.8% (n = 2). In the two patients who died, the infection had extended to the deep cardiac tissue and to the cerebral artery. The mean follow-up of the 24 survivors was 33 months (range from 6 to 82 months). There was no late death and no recurrence of infective endocarditis. CONCLUSION In case of active infective endocarditis, early surgical intervention is recommended in patients with rapidly progressive cardiac deterioration or vegetation seen on echocardiography.

Cardiac calcified amorphous tumor in a hemodialysis patient

We present a case of cardiac calcified amorphous tumor, a rare intracardiac non-neoplastic tumor, in a hemodialysis patient. A 72-year-old woman with no history of thromboembolic, malignant, or inflammatory disease presented with dyspnea. Echocardiography revealed a highly echoic, slightly mobile mass with an acoustic shadow originating from the mitral subvalvular apparatus, extending to the left ventricular outflow tract. She underwent surgical resection of the mass through the aortic valve, which was easily excised from the papillary muscle and chordae tendineae. Histopathologic examination revealed nodular calcium deposits on a background of amorphous degenerated fibrin material, consistent with calcified amorphous tumor.