Jun'ichi Oba

Alterations in coagulation and fibrinolysis after surgery for aortic aneurysm

We investigated the alterations in the coagulation and fibrinolysis systems after aortic aneurysm surgery under cardiopulmonary bypass (CPB) while using newly developed “molecular markers”. Fibrinogen and antithrombin III (AT-III) decreased after surgery but returned to normal values within three days. The thrombin-antithrombin III complex (TAT) and plasmin-alpha-2-plasmin inhibitor complex (PIC) both showed increased values even preoperatively, which indicated that coagulation and fibrinolysis were activated in some patients with an aortic aneurysm. Both markers maintained a high level for at least 14 days after surgery. The fibrin degradation product (FDP) also showed an increased value before and after surgery. These results apparently showed that coagulation/fibrinolysis had already been activated in some patients and maintained such a state for at least 14 days after surgery. The relation of activated system and postoperative organ dysfunction as well as the means to suppress such activation are also discussed.

Preoperative disseminated intravascular coagulation (DIC) associated with aortic aneurysm — does it need to be corrected before surgery?

Disseminated intravascular coagulation (DIC) is one of the complications accompanying aortic aneurysm. We herein report four patients with aortic aneurysm who had DIC preoperatively. In all four cases, DIC was corrected immediately after surgery; however, in two cases, DIC could not be corrected preoperatively. This prompted us to reconsider the importance of correcting DIC before surgery. Of the four cases reported in this paper, DIC existed even at the time of surgery in two cases, in spite of meticulous treatment with heparin and/or protease inhibitor; however, the DIC could be removed postoperatively even in these two cases. Surgeons should not waste time with intensive DIC treatment preoperatively. If the DIC cannot be corrected within more than 2 weeks of meticulous treatment, surgeons should then perform surgery on the patient. In addition, it is also essential to ensure that the DIC is due to the aneurysm itself and that no other disease processes have been overlooked.

Perioperative Acute Aortic Dissection Complicating Open Heart Surgery: Report of Three Cases

開心術後周術期の合併症として大動脈解離はまれであるが致死的な合併症の一つとして考えられている.開心術後周術期に新たに弓部大動脈以下より大動脈解離が発生した症例を3例報告する.当科では1994年から2003年までの10年間で開心術は1,647例で,術後大動脈解離の発生率は0.18%であった.3例の術式はannulo aortic ectasiaに対するmodified Bentall手術,虚血性心筋症,陳旧心筋梗塞に対する冠動脈バイパス術およびDor手術,急性II型解離,大動脈弁閉鎖不全症に対する上行置換および大動脈弁置換術で,3例とも術中,術直後の血行動態は安定していた.3例中2例は術後のCT検査およびエコー検査により下行大動脈の解離を指摘され大動脈解離の発症が判明した.ほかの1例は術後10日目に左胸腔内に出血をきたしショックとなり広範囲脳損傷のために失い,死亡後の剖検により大動脈解離の診断を得た.解離のentryは死亡例とほかの1例は下行大動脈近位に,もう1例は左鎖骨下動脈に認めた.生存例はAHAの大動脈解離診療ガイドラインに従い安静と降圧療法を行い,行動拡大,血圧コントロール後に退院,外来followを行っている.術後急性大動脈解離は開心術後の合併症の一つとして考慮し,術中に経食道エコーによる下行大動脈の観察や,症例によっては周術期の血圧コントロールを厳格にすべきである.また,発症例に対しては定期的な経過観察をしていく必要があると考えられる.

Successful Cavoatrial Bypass for Inferior Vena Caval Occlusion in A Patient with Behçqet's Disease A Case Report

Behçets disease is a systemic process of unknown etiology that features a prolonged, intractable course. Characteristic pathologic findings include recurrent orogenital ulcers and ocular and cutaneous inflammatory lesions. The disease may also involve the articular, neurologic, gastrointestinal, and cardiovascular systems. Vascular lesions reportedly vary from arterial occlusions and aneurysms to thrombophlebitis. Budd-Chiari syndrome due to thrombosis of the inferior vena cava (IVC) has been rarely reported. Here the authors report a thirty-six-year-old Japanese woman with Behçets disease who developed Budd-Chiari syndrome secondary to inferior vena cava thrombosis. She was treated successfully by cavoatrial bypass. Although the graft was thrombosed, she has been asymptomatic for five years after surgery. Cavoatrial bypass could be considered as a surgical option to immediately relieve hepatic congestion due to caval thrombosis.

The Usefulness of Continuous Hemodialofiltration (CHDF) after Concomitant Mitral and Aortic Valve Replacement and Coronary Artery Bypass Grafting in a Patient with Chronic Renal Failure

慢性腎不全を有し, 血液透析 (以下透析) を受けている52歳男性に対して僧帽弁大動脈弁置換術と冠動脈バイパス術を施行した. 手術前日に透析を行い, 術中, 術直後は過剰な輸液を避けて溢水を回避した. 高カリウム血症に対しては, グルコースインスリン療法で対処した. 血清カリウムが6.0mEq/lを超え, クレアチニンが9.0mg/dlとなった術後2日目から持続的血液透析濾過 (CHDF) を開始した. CHDFにより, 循環動態に影響を及ぼすことなく, 除水, 高カリウム血症の管理が容易にできた. 術後5日目には血液透析に移行, 術後6日目に一般病棟に移った. 開心術後の透析の手段としてCHDFは溶質の除去効率が良い, 循環動態に及ぼす影響が少ないなどの利点を有する優れた方法であると考えられた.