Shigeki Funaki

Surgically treated Swyer-James syndrome

Because patients with Swyer-James syndrome have almost always been treated conservatively, few reports exist of pathological findings of the lung in this syndrome. We report a case of this rare disease treated surgically and discuss pathological findings. A 36-year-old woman repeatedly contracted bronchitis and pneumothorax since adolescence, until April 26, 1997, when she reported chest pain and dyspnea. Chest X-ray on admission showed left pulmonary collapse with a slight deviation of the mediastinum toward the right. Chest computed tomography showed an apical bulla and emphysematous change in the left upper lobe. Pulmonary arteriography at age 17 showed hypoplasia of left pulmonary artery branches in the left upper lobe. Based on a diagnosis of Swyer-James syndrome, we conducted left upper lobectomy on May 2, 1997. Pathological examination of the resected left upper lobe showed marked emphysematous change, including an emphysematous bulla with destruction of alveolar structure and peribronchiolar fibrosis. No vascular abnormality was recognized in histology. Emphysematous change secondary to repeated bronchiolitis is believed to have led to her repeated pneumothorax.

Changing predictors of postoperative mortality in acute type A aortic dissection. Is only coronary artery compromise significant

OBJECTIVES Rapid emergency transport and early diagnosis and surgical treatment for acute type A aortic dissection have improved postoperative survival, which has, however, plateaued at about 80%. End-organ malperfusion is regarded as a strong predictor of postoperative mortality, replacing factors such as cardiac tamponade complications, aortic rupture, and left ventricular dysfunction due to aortic insufficiency. It is thus important to reevaluate risk factors for surgical death to assess current therapeutic strategies. METHODS We statistically analyzed potential risk factors for perioperative death in 88 patients undergoing surgical repair for type A aortic dissection between January 1990 and December 1999. RESULTS Univariate analysis showed that cardiopulmonary arrest (adjusted odds ratio: 13.78; p < 0.01) and malperfusion of more than 1 vital organ (adjusted odds ratio 4.97, p < 0.01), especially myocardial ischemia due to coronary artery dissection (adjusted odds ratio 3.21, p < 0.05), significantly increased the likelihood of operative death. Multivariate logistic regression analysis showed only cardiopulmonary arrest (p < 0.01) and concomitant coronary artery bypass grafting necessitated in cases complicated by evolving myocardial infarction (p < 0.05) to be independent predictors of postoperative mortality. CONCLUSION Preoperative complication from coronary dissection was the most important predictor of early postoperative mortality in this series. In such cases, rapid surgical intervention before myocardial infarction develops is vital to saving lives.

Continuous Monitoring of Short-Latency Somatosensory Evoked Potentials During Cardiac and Aortic Surgery

The effectiveness of monitoring somatosensory evoked potentials (SEPs) intraoperatively to detect brain damage early remains controversial. To assess the diagnostic accuracy of this modality, a study was conducted between 1991 and 1994, recording SEPs in 287 consecutive patients undergoing cardiac and aortic surgery using cardiopulmonary bypass (CPB) with moderate hypothermia or deep hypothermic circulatory arrest. From P1 to N2 of the SEPs occurring within 50 ms latency in response to electrical stimulation of the median nerve were recorded over the contralateral postcentral cortex at 5-min intervals using a Neuropack-2 (Nihon Koden, Tokyo, Japan). Normal SEPs were recovered in 247 patients postoperatively; however, 2 of these patients had suffered a cerebral infarction and 1, a transient stroke intraoperatively, demonstrating a false-negative incidence of 1.2%. On the other hand, three different types of abnormal SEPs were recorded postoperatively. P1 and N1 absence, probably caused by a subcortical lesion, was observed in 4 patients; P2 and N2 absence, probably caused by a cortical lesion, was observed in 8 patients; and a flat SEP, representing diffuse damage, was observed in 2 patients. Among these 14 patients with abnormal SEPs, 7 showed no neurologic disturbance at all, demonstrating a false-positive incidence of 50%. Thus, we concluded that when normal SEPs are recovered during weaning from CPB, the incidence of brain damage could be predicted at below 5%. Conversely, when abnormal SEPs are demonstrated, the incidence of brain dysfunction impeding a return to active life is estimated to be about 70%.

Traumatic rupture of the false lumen in a patient with preexisting chronic dissection of the descending thoracic aorta

A 63-year-old man was transported to the emergency medical center due to blunt chest trauma combined with a fractured left leg caused by a motorcycle accident. He complained of severe dyspnea. Contrast-enhanced computed tomography revealed chronic aortic dissection DeBakey III, mediastinal hematoma of high density just above the diaphragm around the aorta, and an intimal flap-like shadow in the false lumen. Traumatic aortic rupture (TAR) with chronic aortic dissection was suspected. Aortography showed no clear sign of leakage, but a double-contour density was found in the outer wall of the false lumen of the descending aorta just above the diaphragm. He was therefore diagnosed with TAR and underwent an emergency operation. At the operation, rupture in the outer wall of the preexisting false lumen was found and was directly sutured. Acute renal failure developed immediately after surgery, which improved after several hemodialyses. We consider our case rare because no report has been so far made on TAR with chronic dissection.

Traumatic left ventricular free-wall laceration by a gunshot: report of a case.

This report describes the case of a 47-year-old man who shot himself in the left side of the chest in an attempted suicide, and was transferred to the hospital. Two gunshot wounds were found in the left side of the chest and the back. CT scans revealed left hemopneumothorax, the accumulation of pericardial blood, and lacerations of the heart and the spleen. Emergency thoracotomy and laparotomy were performed. There was a contusion of the left lung and lacerations of the left ventricular free wall, the diaphragm, and the spleen. The laceration of the heart was repaired by 3 pairs of mattress sutures with felt strips, and covered with fibrin glue and a TachoComb® tissue sealing sheet without the use of cardiopulmonary bypass. The patient was discharged on foot on the 18th postoperative day. Such patients can only be saved with an efficient emergency medical-care system including quick transportation, and close cooperation of the hospital staff.

A case of progressive saccular aneurysm caused by localized dissection of descending aorta

A fifty-three-year-old man was admitted because of chest pain. CT scan showed the localized dissection of the descending aorta which was partially thrombosed. The patient was followed by controlling of essential hypertension. He, however, complained of the second attack of chest pain after a year and 5 months. CT scan showed the increased dilatation of the false lumen as compared to that of previous examination. MR angiogram showed a saccular aneurysm localized in the middle portion of the descending aorta. An operation was performed through posterolateral thoracotomy in the 4th intercostal space with the aid of normothermic femoro-femoral bypass circulation. The aneurysm was located at the level of 5th thoracic vertebra with the size of 70 mm in length and 45 mm in diameter. Entry was observed in the posterior wall of the aorta, and the terminal end of the false lumen was occluded with the organized thrombus. The aneurysm was successfully replaced with a prosthetic graft. To the extent of our knowledge, only limited surgical cases of saccular aneurysm caused by localized dissection of the middle portion of the descending aorta have been reported.

Arterial Reconstruction with Prosthetic Grafts in the Bilateral External Iliac Artery of Infant.

幼児の医原性両側外腸骨動脈閉塞の症例を経験した. 症例は6歳女児で, 主訴は間歇性跛行と寒冷時下肢痛であった. 既往歴として, 大動脈縮窄複合に対して生後1カ月と1歳3カ月時にそれぞれ右および左大腿動脈穿刺によるカテーテル検査を施行した. 4歳時に縮窄部切除端々吻合術と心室中隔欠損直接縫合閉鎖術を二期的に施行した. 今回血管造影検査時, 大腿動脈を穿刺したところ, 両側外腸骨動脈が閉塞しており, 内腸骨動脈の分枝を側副血行路として大腿動脈が造影された. 成長期に下肢虚血があり, 寒冷時下肢痛があるため, 下肢血行再建の適応とした. 手術は開腹し, 両側とも外腸骨動脈に伴走して, 6mmの expanded polytetrafluoroethylene (ePTFE) グラフトを用いて, 内腸骨動脈と総大腿動脈間に端側吻合によりバイパスを作成した. 術後, 両側とも足背動脈触知可能となり, 自覚症状は消失した. MR-angiogram でもグラフトはよく開存していた.