Kei Aizawa

Spontaneous rupture of an intercostal artery in a patient with neurofibromatosis type 1

A 48-year-old man with neurofibromatosis type 1 (NF1) presented with a right pleural effusion. A 3D computed tomography (CT) angiogram showed an aneurysm of the right 11th intercostal artery. He had no history of chest trauma so we diagnosed a spontaneous rupture of the aneurysm causing a massive effusion. We opened his pleural cavity and found lacerated pleura and active bleeding in the posterior 11th intercostal space. After controlling the active bleeding, we treated a persistent oozing from the region of the 10th-12th vertebrae with pressure hemostasis by absorbable oxidized cellulose packing. The next day, the patient gradually developed a paraplegia affecting both lower limbs. Magnetic resonance imaging (MRI) showed spinal cord compression at the level of the 9th and 10th vertebrae. We evacuated the cellulose and coagulum. The patients paraplegia improved and within six months he was walking without a crutch.

Uterine Intravenous Leiomyomatosis with Right Ventricular Extension

Intravenous leiomyomatosis is a rare neoplastic condition characterized by the benign intravascular proliferation of smooth muscle cells originating from either the uterine venous wall or a uterine leiomyoma. In the present report, we describe the case of a 45-year-old woman without a history of gynaecological surgeries, who was referred to our institution due to repeated syncopal attacks. Computed tomography indicated the presence of an intravenous leiomyoma originating from the uterus and extending to the inferior vena cava, right atrium, and right ventricle. The patient was successfully treated by cardiotomy, which was performed under hypothermic circulatory arrest, and laparotomy in a single-stage operation. She continued to recover and did not exhibit any recurrence at the 10-month follow-up.

Clinical experience with the Bicarbon heart valve prosthesis.

BacgroundWe have previously reported mid-term results of a study, which ended in January 2000, on the Bicarbon valve. The study concluded that the valve showed excellent clinical results, associated with a low incidence of valve-related complications. In the present study, the same patients were prospectively followed for an additional 5 years.MethodsForty-four patients had aortic valve replacement (AVR), 48 had mitral valve replacement (MVR), and 13 had both aortic and mitral valve replacement (DVR). The mean age of the 105 patients was 61.2 ± 11.3 years. The mean follow-up was 6.1 ± 1.9 years with a cumulative follow-up of 616 patient-years.ResultsThere were 5 early deaths (4.7%: 4 in the AVR group and 1 in the MVR group) and 21 late deaths (3.4%/patient-year: 5 valve related deaths and 16 valve unrelated deaths). Survival at 8 years was 75.2 ± 7.0% in the AVR group, 76.6 ± 6.2% in the MVR group, and 55.4 ± 16.1% in the DVR group. The linearized incidence of thrombo-embolic complications, hemorrhagic complications, and paravalvular leaks in all patients was 0.65 ± 1.48%, 0.81 ± 1.69%, and 0.16 ± 0.54%/patient-year respectively. No other complications were observed.ConclusionThe Bicarbon prosthetic heart valve has shown excellent long-term clinical results, associated with a low incidence of valve-related complications.

Modified Bentall operation in a patient with hemophilia A.

We detail a successful modified Bentall operation in a patient with hemophilia A. A 53-year-old man with mild hemophilia A and a history of few bleeding episodes was diagnosed with annuloaortic ectasia. Surgical repair was planned. Simple bolus infusions of factor VIII concentrate were given before and after cardiopulmonary bypass to achieve 100% blood levels and postoperatively every 12 hours for 7 days to maintain 50% levels. The patient received no transfusion other than 10 units of platelet concentrate. We used routine operative and cardiopulmonary bypass techniques. The patient recovered well postoperatively with no excessive bleeding despite warfarin therapy.

Starr-Edwards valves at the aortic and mitral positions implanted for 39 years.

Cloth-covered Starr-Edwards caged ball valves implanted in the aortic and mitral valve positions for 39 years were extracted. Both showed valve dysfunction resulting from pannus overgrowth. The metal cages of the Starr-Edwards valves were covered with worn cloth. This case indicates the extended durability of Starr-Edwards valves and the importance of the design and materials of prosthetic heart valves to avoid pannus overgrowth and prosthetic valve abrasion.

Extraanatomical ascending-abdominal aorta bypass with stump closure for aortic graft infection

A 42-year-old man, who 25 years previously underwent grafting of the descending aorta because of traumatic rupture after a traffic accident, was admitted to our hospital complaining of fever and hemoptysis. Computed tomography (CT) scans showed a low density area around the prosthetic graft. We diagnosed a graft infection. We undertook extraanatomical ascending-abdominal aorta bypass with stump closure of the descending aorta, with omentopexy around the stump. Postoperative course was uneventful and he has been free from infection for one year. Extraanatomical bypass was an effective strategy for treatment of a graft infection.

Twenty-two year experience with the omniscience prosthetic heart valve.

This study was designed to evaluate the long-term clinical results of the Omniscience tilting disc valve. Omniscience valves were implanted in 51 patients (mean age, 50 ± 10 years); 18 had aortic valve, 24 had mitral valve, and 9 had both aortic and mitral valve replacements. Oral warfarin potassium and dipyridamole were prescribed as our anticoagulant therapy. Preoperatively, 42 patients were in New York Heart Association class III or IV, and 23 of 25 surviving patients were in class I or II after operation. There were 2 (3.9%) early deaths and 23 late deaths (3.5 ± 0.7% per patient-year). Cardiac related mortality including congestive heart failure, sudden death, and thromboembolism, and hemorrhagic complications were seen in 16 patients. Overall survival at 10, 15, and 20 years was 77 ± 6%, 62 ± 7%, and 46 ±7%, respectively. Thromboembolic complications were seen in 5 patients, for a rate of 0.8 ± 0.3% per patient-year; similarly, hemorrhagic complications were also seen in 5 patients. Nonstructural prosthetic valve dysfunction was seen in 4 patients, for a rate of 0.6 ± 0.3% per patient-year, and sudden death was seen in 2, a rate of 0.3 ± 0.2% per patient-year. The Omniscience prosthesis demonstrated excellent postoperative clinical status with low rates of valve related complications.

Clinical features of third open-heart valve surgery at the same valve position.

OBJECTIVE Recently, there has been an increase in case of repeated open-heart valve surgery and the clinical results of the second surgery are only slightly worse than those of the first surgery. However, clinical results of the third open-heart valve surgery at the same position are rarely reported. Clinical features of third open-heart valve surgery at the same position are discussed in this study. METHODS Between 1995 and 2004, 16 patients underwent third open-heart valve surgery at the same valve position under cardiopulmonary bypass. The average age of the 16 patients, 12 females and 4 males, was 56 +/- 15 years. Clinical features of the 16 cases were retrospectively analyzed. RESULTS Mechanical valve nonstructural dysfunction was the most common valve malady, followed by bioprosthetic valve dysfunction. The duration of surgery from skin incision to establishment of the cardiopulmonary bypass was 94 +/- 42 minutes. Myocardial ischemia time was 137 +/- 38 minutes and extracorporeal circulation time was 212 +/- 82 minutes. Early mortality was seen in 1 patient (6.25%) and late mortality was seen in 1 patient. CONCLUSION Mechanical valve nonstructural valve dysfunction leads to repeated valve surgery. The clinical results of the third open-heart valve surgery at the same valve position are acceptable, and the mid-term survival is excellent.

Transection of left common pulmonary vein during left upper lobectomy: how should it be reconstructed?

A common trunk of the left pulmonary vein is an anatomical variation in the pulmonary vessels and may be incidentally transected during left upper lobectomy. Difficulty in reconstruction of the left inferior vein often requires completion pneumonectomy. We herein describe a patient with lung cancer in the left upper lobe of the lung. His common trunk of the left pulmonary vein was incidentally transected with a mechanical stapler during a thoracoscopic left upper lobectomy. The concomitantly transected inferior pulmonary vein was augmented with a cuff technique using an orifice of the superior vein followed by end-to-end anastomosis. The postoperative course was uneventful. This technique should also be considered in patients with lung cancer when a right upper lobe tumor is invading the right superior trunk branching pulmonary veins to the upper and middle lobes.

Aortogenic cerebrovascular accident

A 59-year-old man was transferred to our hospital because of mural thrombus in the ascending aorta. He had suffered some neurological dysfunctions such as transient dysorientation. Electrocardiogram showed normal sinus rhythm without premature beats. Trans-thoracic echocardiogram and three-dimensional CT showed a mobile mural mass sticking to the ascending aortic wall. No coagulopathy was detected in the patient. The mural masses were thought to be a possible cause of the repeated cerebro-vascular symptoms. Under cardiopulmonary bypass and cardiac arrest, the masses were removed including the mass sticking to the aortic wall. Postoperative pathological findings showed the masses were organizing thrombi that had originated from the atherosclerotic aortic wall. Postoperative course was uneventful, and the patient was doing well one year after the operation without neurological dysfunction.