Mikiko Murakami

Severe hemolysis due to cloth wear 23 years after aortic valve replacement on a Starr–Edwards ball valve model 2320

Despite iron substitution therapy, a patient developed severe hemolytic anemia 23 yr after insertion of a cloth-covered Starr-Edwards model 2320 aortic valve prosthesis. The prosthesis showed no sign of significant dysfunction. Upon removal, it showed extensive cloth wear on the inner surface of all three struts; one strut was completely denuded of its cloth covering. Hemolysis immediately resolved after replacement with a St Jude aortic prosthesis.

A prominent Chiari network.

Fig 1. A prominent Chiari network. The two upper panels show the excised structure. The upper right panel is a photograph of the Chiari network floated in water. (*) indicates attachment to the coronary sinus and (**) indicates attachment to the crista terminalis. The two lower left photographs show the operative view through the right atriotomy. The lower right panel is a transesophageal echocardiographic image of the Chiari network. (Ao aorta; CS coronary sinus; LA left atrium; RA right atrium; RV right ventricle.)

End-tidal carbon dioxide monitoring indicates recovery from cardiogenic shock in patients receiving percutaneous cardiopulmonary support.

The aim of this study was to examine the prognostic value of monitoring end-tidal carbon dioxide (ETCO2) levels for patients in cardiogenic shock undergoing percutaneous cardiopulmonary support (PCPS). Fifteen patients in whom PCPS was used to treat cardiogenic shock were enrolled in this study. For hemodynamic measurements, a thermodilution catheter was inserted into the pulmonary artery and an infrared absorption sensor was placed in the main stream of exhaled air between the respiration tube and the respirator to measure ETCO2 levels. Nine patients (group II, 60%) died of multiple organ failure. In the six survivors (group I), there was a significant increase in average ETCO2 level from 8.8 ± 3.9 mmHg before treatment to 20.5 ± 2.1 mmHg 24 h after the start of PCPS compared with values in group II patients (8.8 ± 3.9 mmHg, P = 0.0411). Also, serum lactate concentrations fell significantly in group I patients (group I 2.8 ± 0.47 mmol/l, group II 9.0 ± 2.31 mmol/l, P = 0.0435). The mean ETCO2 level in group I patients gradually returned to 23 mmHg, which was within the normal healthy range; these patients were successfully weaned from PCPS. These results suggest that, in cardiogenic shock patients, ETCO2 level is a possible index of cardiac recovery during PCPS support.

Sealed Rupture of an Internal Iliac Artery Aneurysm in a 92-Year-Old Woman Surgically Treated with Success

症例は92歳,女性.下腹部痛と腰痛を主訴に前医を受診し,腹部大動脈瘤の疑いのため救急紹介された.CT検査で最大径85×73mmの右内腸骨動脈瘤を認め,切迫破裂が疑われた.腹部正中切開,経腹膜的アプローチで,緊急手術を施行した.後腹膜腔と腸間膜に血腫が認められ,sealed ruptureと考えられた.分岐型グラフト(Intergard 16×8mm)を用いて腹部大動脈人工血管置換術を行った.術当日に抜管し,術後2日目にICUを退室した.その後の経過も良好で,十分なリハビリののち,術後13日目に独歩で退院した.本症例は,検索しえた範囲内で,最高齢の内腸骨動脈瘤手術例であった.

Acute Aortic Dissection Occurring on the Day after Coronary Artery Bypass Operation

冠動脈バイパス術(CABG)術後の急性大動脈解離は希であるが重篤な合併症である.今回われわれは,CABGを施行した翌日に急性大動脈解離を発症し,緊急手術を行い救命しえた1例を経験したので報告する.症例は73歳,女性.狭心症のため,オフポンプCABG(3枝:RITA-LAD,LITA-OM,SV-PDA)を施行した.静脈グラフトの中枢側は上行大動脈に吻合した.術翌日,呼吸リハビリを行っていたときに,突然,著明な高血圧(200mmHg前後)となり,ほぼ同時に背部痛を訴えた.造影CT検査を行い,大動脈解離(Type A)と診断した.ただちに緊急手術で上行大動脈置換術を施行した.解離のエントリーは静脈グラフトの中枢側吻合部であった.術後経過は良好で,術後24日目に独歩で前医に転院となった.CABGのさいには,グラフトの中枢側吻合が大動脈解離の原因となり,かつ術後超急性期に発生しうることを知っておくべきである.

Biventricular pacing in a patient with severe congestive heart failure

We report a case of dilated cardiomyopathy with severe congestive heart failure (ejection fraction: 19%) and complete left bundle branch block (QRS duration: 240 ms) 13 years after aortic valve replacement. Permanent biventricular pacing was implanted by inserting a left ventricular lead thorough a small left thoracotomy following intravenous insertion of right atrial and ventricular endocardial leads. Biventricular pacing increased hemodynamic parameters such as blood pressure, cardiac output and decreased mitral regurgitation. Symptoms and exercise tolerance improved dramatically. Left ventricular epicardial lead insertion via a small thoracotomy is thus useful in selected patients.