Naoki Konagai

Left atrial myxoma associated with acute myocardial infarction and multiple cerebral infarctions: Report of a case

We report a case of left atrial myxoma associated with acute myocardial infarction (AMI) in a 63-year-old man. Percutaneous coronary intervention was performed immediately, and we removed white intracoronary particles by using a thrombectomy catheter. The postinterventional course was uneventful; however, on hospital day 5, pathological examination revealed platelet thrombus and myxomatous tissue from the particles aspirated by thrombectomy catheter, and transesophageal echocardiography showed a gelatinous mass in the left atrium. Based on these findings, we diagnosed AMI caused by coronary embolization from a left atrial myxoma, and excision of the myxoma was scheduled. However, preoperative magnetic resonance imaging revealed multiple subacute cerebral infarctions, and the tumor was successfully excised on hospital day 13. Although coronary embolization induced by cardiac myxoma is rare, it should be considered in a young to middle-aged patient presenting with signs of AMI without coronary risk factors.

Six year experience with wrinkled ePTFE vascular prostheses for arteriosclerosis obliterans

From November 1986 to January 1993, 97 wrinkled ePTFE prosthetic vascular grafts were implanted in 90 peripheral arterial reconstructions for 87 patients with arteriosclerosis obliterans (ASO) (79 men and 8 women). Grafts used in this series were 54 Vitagraft and 33 Technograft. Initial results for a period of as long as 6 years are summarized here. Forty-four (45.3%) grafts were implanted anatomically, and the remaining were extra-anatomically routed. The mean age of patients in the anatomic bypass group was 64.7 years, and that of patients in the other group was 71.4 years. Twenty-three (43.3%) grafts in the extra-anatomic group were anastomosed sequentially. Mean follow-up periods for each group were 32.4 months and 30.9 months, respectively. None of nine late deaths during the follow-up period was graft related. There was one primary obstruction in the anatomic group; in the extra-anatomic groups, primary graft occlusion occurred in four grafts. In addition, one perigraft seroma and one pseudoaneurysm requiring surgical repair were seen. Cumulative event free ratio for this group was 80.8% at 72 months. These results reveal that the wrinkled ePTFE graft is clinically applicable to arterial reconstruction for ASO with satisfactory long-term patency, even in extra anatomic sequential bypasses.

Report of Simultaneous Off-Pump CABG and Modified Mastectomy

Abstract  The patient was a 75‐year‐old female who had received medical treatment for effort angina. Recently, she noticed a left breast tumor, which was diagnosed as breast cancer with axillary lymph node swelling. Coronary angiography performed prior to the surgery for the breast cancer showed 90% stenosis in segment 6 of the left anterior descending artery (LAD). Coronary intervention was not possible due to anatomical reasons, so she was admitted for simultaneous surgery for the breast cancer and angina. The chest was opened through a median sternotomy and the full‐skeletonized right internal thoracic artery was grafted on the LAD without cardiopulmonary bypass. A transverse elliptical incision was made after the median sternotomy was closed, and the breast tumor and lymph nodes around the subclavian and axillary vessels were completely dissected. Even in the case of multiple vessel coronary disease, simultaneous surgery may be possible, but indications should be carefully assessed considering the cardiac function and general condition of the patient.

Evaluation of coagulant activity after mechanical heart valve replacement

Long-term oral anticoagulant therapy is required for recipients of mechanical heart valves. In our hospital, the international normalized ratio of prothrombin time (PT-INR) has been set in the range 1.5–2.5 since October 2001. To evaluate whether coagulant activity is fully suppressed by this target range, coagulant activity was evaluated by measuring thrombin–antithrombin III complex (TAT) levels and valve-related complications were investigated retrospectively. Two hundred twenty-three patients who underwent mechanical valve replacement were enrolled in this study. PT-INR and TAT were measured at our outpatient clinic in March 2005 and valve-related complications since October 2001, when we started to control PT-INR in the range 1.5–2.5, were investigated. Under adequate warfarin control, there was no significant correlation between PT-INR and TAT, however nine patients who exhibited a PT-INR of less than 2.0 had high levels of TAT. And in atrial fibrillation (AF) patients after mitral valve replacement (MVR), the level of TAT was significantly high compared with sinus rhythm patients after atrial valve replacement. Valve-related complications were bleeding events at 2.75% per patient year and thromboembolism at 0.32% per patient year. Attention to complications of thromboembolism is necessary when the PT-INR is less than 2.0, especially in AF patients after MVR and in those with a thrombotic past history or high levels of TAT. The monitoring of TAT is useful in detecting potential coagulation factors and to determine the therapeutic range of warfarin that can normalize coagulant activity.

A Case of Hypertrophic Obstructive Cardiomyopathy with Progressive Heart Failure Due toRuptured Mitral Chordae Tendineae.

症例は59歳男性.15年来閉塞性肥大型心筋症(HOCM)で,βブロッカーを投与中であった.本年6月より突然の心不全の進行を認め,経食道心エコーにて僧帽弁腱索断裂と診断した.まず内科的治療にて症状を改善させたのちに,開心術とした.僧帽弁前尖と後尖に腱索断裂を認めたため,人工弁置換術を施行し,腱索の病理組織診断は粘液変性であった.術後経過は良好であり,また心エコーでは,左室流出路圧較差は術前55mmHgから術後0mmHgとなり,狭窄は消失した.HOCMに腱索断裂を合併すると僧帽弁逆流による心不全の急性増悪をきたすため,経食道心エコーなどによる早期診断と時期を逸することなく外科的治療を行うことが必要と考えられた.

A Case of Acute Tuberculous Pericarditis with Transient Constrictive Pericarditis for a Short Time.

症例は32歳男性. 主訴は労作時の息切れと感冒様症状. 胸部CTで縦隔リンパ節腫大, 心膜肥厚, 胸水を認めた. 喀痰, 胸水の抗酸菌培養陰性, アデノシンデアミナーゼ (ADA) 活性正常, ツ反は20t15mm, ウイルス抗体価 (コクサッキーA9, エコー3, インフルエンザB) は陰性であった. 入院後10日目頃より発熱, 心不全症状を呈し, 心臓カテーテル検査で右心室の dip and plateau 波形を認めた. 手術は胸骨正中切開とし, 両側横隔神経間の著明に肥厚した心膜亜全摘術を施行した. 心膜の病理組織診断にてラ氏型巨細胞と乾酪壊死巣を認め結核性と診断した. 術後は, 一過性の胸水貯留を認めたものの良好であり, 退院後も症状の再燃を認めていない.

Internal Felt-reinforced Patch-plasty for Dissecting Aortic Aneurysm.

解離性大動脈瘤11例 (I型4例, II型1例, III型5例および弓部限局解離1例) に対して entry 閉鎖を目的としたフェルト内挿補強パッチ形成術を試案した. 血流遮断時間は平均84±19分で, 解離腔内にもフェルトを挿入した初期の1例を除き entry 部の完全閉鎖が得られた. III型の1例を遠心ポンプ離脱直後の不整脈にて失ったが, 術式に起因した死亡はみられなかった. 術後1か月以上の経過において, 解離腔はI型およびII型で上行部に, III部では下行部に血栓閉鎖が得られ, 弓部解離例は完全閉鎖した. 術後平均16か月の経過で全例良好な社会生活を送っている. 本法は, 解離性大動脈瘤における entry 閉鎖を目的とした簡便かつ確実な術式であり, 症例により試みるべきものと考える.