Nobuaki Kaki

Multiple papillary fibroelastoma of the left ventricle.

treatment of a brain infarction. The transesophageal echocardiography (TEE) showed a mobile, solitary, intracavitary tumor with a short pedicle arising from the left ventricular outfl ow just below the right coronary cusp (Figure 1). It was considered to be the cause of the brain infarction. To avoid any further embolization, the patient was transferred to our hospital for urgent operation. At surgery, the aortotomy was performed under cardiopulmonary bypass and a 5 mm in diameter video-assisted thoracoscope (Olympus, Japan) was introduced through the aortic valve for inspecting the left ventricular cavity. A tumor measuring IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY

Surgical embolectomy for high-risk acute pulmonary embolism is standard therapy

OBJECTIVES Acute massive pulmonary embolism (AMPE) is a life-threatening condition that often induces rapid haemodynamic deterioration. The mortality of surgical embolectomy is still poor in patients with preoperative cardiopulmonary arrest (CPA). We analysed the outcome of surgical pulmonary embolectomy for haemodynamically unstable patients. METHODS Thirty-one patients underwent surgical embolectomy for haemodynamically unstable AMPE. The indications for surgical embolectomy were (i) <7 days from onset, (ii) haemodynamically unstable, (iii) massive clots in bilateral pulmonary arteries or unilateral pulmonary artery occlusion with a floating clot in the main pulmonary artery or right atrium and (iv) right ventricular dilatation in transthoracic echocardiography. Eight (25.8%) patients had cardiopulmonary arrest. Nine (29.0%) patients received preoperative percutaneous cardiopulmonary support (PCPS). The mean original Pulmonary Embolism Severity Index (PESI) and simplified PESI scores were 158 ± 51 and 2.4 ± 0.9, respectively. RESULTS The hospital mortality rate was 12.9% (n = 4). Two patients died of hypoxia. Multiorgan failure occurred by sepsis and by right ventricular failure in 1 patient each. No hospital deaths occurred in patients with preoperative PCPS (n = 9). The mean follow-up period was 47.7 ± 35.9 months (range, 3 - 134 months) and the 5-year survival rate was 83.2 ± 6.9%. Postoperative pulmonary artery pressure significantly decreased from 52.7 to 25.8 mmHg. CONCLUSIONS Surgical embolectomy for high-risk AMPE patients has an excellent operative mortality and long-term outcome. Preoperative PCPS may lead to an immediate stable haemodynamic state and improve surgical embolectomy results, especially in high-risk patients (e.g. those with preoperative CPA). Surgical embolectomy for AMPE is an established operation and considered as the first-line therapy.

Usefulness of Lower Ministernotomy in Aortic Valve Replacement (AVR) by Minimary Invasive Cardiac Surgery (MICS)

Minimary invasive cardiac surgery (MICS)による大動脈弁置換術(AVR)においては一般的にupper ministernotomyが選択されることが多い.しかし,retograde cardioplegia cannulaが挿入できないことなどがある.当科でCTをもとに検討したところ日本人の大動脈弁の位置はlower ministernotomyでも手術可能な場合が多いことがわかった.そこでこの2種のアプローチの有用性について検討した.1997年1月から2002年3月までに大動脈弁疾患に対しMICSによるAVRを施行した68症例を対象としupper ministernotomy施行症例をU群,lower ministernotomy施行症例をL群とした.Retrograde cardioplegiaは一般にAVRでの心筋保護法として頻用されている.L群は心筋保護および術野確保の点でもfull sternotomyへの移行した症例はなく有効であった.L群ではMAZE手術も施行でき大動脈遮断時間,人工心肺時間,手術時間,出血量,そのほかの因子でも有意差を認めなかった.Lower ministernotomyはupper ministernotomyと比較しMICS AVRにおいてretrograde cardioplegiaによる心筋保護および術野確保に有効であった.

Ruptured Aneurysm of the Sinus of Valsalva with a Double Chambered Right Ventricle in a Jehovah's Witness Patient.

症例はエホバの証人信者の45歳の女性で, 動悸および息切れを主訴とした. 右室流出路狭窄を伴うバルサルバ洞動脈瘤破裂の診断のもとに, 手術を施行した. 術中所見からは, 右室二腔症と心室中隔欠損症を合併したバルサルバ洞動脈瘤破裂であった. 無輸血下にバルサルバ洞動脈瘤切除およびパッチ閉鎖, 異常筋束切除および右室流出路パッチ拡大, 心室中隔欠損直接閉鎖を行った. 先天性心疾患の中でバルサルバ洞動脈瘤破裂と成人の右室二腔症はおのおの頻度が少なく, 両者の合併はさらに稀である. 両者を合併したエホバの証人信者の手術症例を経験したので, 若干の文献的考察を加えて報告した.