Susumu Isoda

A successful treatment of cardiac tamponade due to an aortic dissection using open-chest massage.

An 81-year-old woman became unconsciousness after complaining of a backache, and then, an ambulance was called. She was suspected to have an aortic dissection by the emergency medical technicians and was transferred to our department. On arrival, she was in shock. Emergency cardiac ultrasound disclosed good wall motion with cardiac tamponade but no complication of aortic regurgitation. Computed tomography of the trunk revealed a type A aortic dissection with cardiac tamponade. During performance of pericardial drainage, she lapsed into cardiopulmonary arrest. Immediately after sterilization of the patients upper body with compression of the chest wall, we performed a thoracotomy and dissolved the cardiac tamponade by pericardiotomy and obtained her spontaneous circulation. Fortunately, blood discharge was ceased immediately after controlling her blood pressure aggressively. As she complicated pneumonitis, conservative therapy was performed. Her physical condition gradually improved, and she finally could feed herself and communicate. In cases of acute cardiac tamponade, simple pericardiocentesis often is not effective due to the presence of the clot, and a cardiac tamponade by a Stanford type A aortic dissection is highly possible to complicate cardiac arrest, so emergency physicians should be ready to provide immediate open cardiac massage to treat such patients.

Right coronary artery–left ventricle fistula with giant coronary artery aneurysm

A 75-year-old woman was admitted to our hospital because of dyspnoea. She had been diagnosed as a right coronary artery–left ventricle (LV) fistula with a coronary artery aneurysm and moderate mitral regurgitation (MR) 5 years before. Surgical or …

Off-Pump Multilayered Sutureless Repair for a Left Ventricular Blowout Rupture Caused by Myocardial Infarction in the Second Diagonal Branch Territory

A left ventricular (LV) free wall rupture is a highly lethal condition. A 78-year-old female, who collapsed while riding a bike, was admitted to our emergency service 7 days after experiencing chest pain. During admission, she had cardiopulmonary arrest. Though cardiopulmonary resuscitation was successful, computed tomography (CT) showed cardiac tamponade. Emergency surgery was then performed. Pericardiotomy revealed a postinfarction blowout rupture of an aneurysm (2 × 3 × 1 cm) on the anterolateral wall of the LV. The top of the aneurysm had a 2-mm wide blowing blood column. Intra-aortic balloon pumping was initiated. An off-pump multilayered sutureless repair using squares of collagen fleece with fibrinogen-based impregnation (i.e., TachoComb) and gelatin-resorcin-formalin glue (GRF glue) was performed. Postoperative coronary angiography revealed occlusion of the second diagonal branch. The patient was free from re-rupture or aneurysm enlargement. An LV blowout rupture, which was caused by myocardial infarction with a limited tear and necrotic area at the second diagonal branch territory, was successfully treated with an off-pump multilayered sutureless repair by using a TachoComb and GRF glue patch. The thickness of the hemostatic material seemed to help control the bulging of the aneurysm and to prevent further LV aneurysm enlargement and re-rupture.

Occupational true aneurysm of the ulnar artery: a case report of hypothenar hammer syndrome.

A 32-year-old male patient was admitted to the hospital with a pulsing mass of the right palm. He was an electrical construction engineer who frequently used a screwdriver. Computed tomography (CT) examination revealed a 22- × 30-mm saccular aneurysm of the right ulnar artery. The ulnar artery aneurysm was resected, and we could perform direct anastomosis of the ulnar artery. The dilated true aneurysm was compatible with a traumatic origin. A postoperative enhanced CT examination showed smooth reconstruction of the palmar arch. An occupational true aneurysm of the ulnar artery could be treated by resection and direct anastomosis.

Unexpected Lethal Complication of Ventricular Fibrillation in Symptom Free Variant Angina Pectoris

We report an unexpected sudden cardiac death due to variant angina complicated by ventricular fibrillation occurring during routine ambulatory electrocardiographic monitoring. The patient had one previous episode of ventricular fibrillation before the lethal event. He had no significant coronary artery disease and was asymptomatic throughout his illness. In clinical practice, when an episode of ventricular fibrillation is noted, one should be aware of the risk of sudden cardiac death, even if the patients vasospastic angina is relatively stable and asymptomatic.

Off-pump ligation of a coronary arteriovenous fistula

Continuous murmurs (Levine grade III/VI) were heard in the fourth intercostal space at the left sternal border in an asymptomatic 47year-old woman. Transthoracic echocardiography revealed an enlarged right atrium (RA) and a turbulent flow signal from the coronary sinus (CS) into the RA (Fig. 1). Multi-detector computed tomography (MDCT) revealed an ectatic and tortuous right coronary artery draining into the CS at the surface of the base of the heart (Fig. 2). Off-pump ligation of the coronary arteriovenous fistula (CAVF) was performed through a median sternotomy. We used pericardial deep stitches (LIMA stich) and the StarfishTM Heart Positioner (Medtronic, Inc., Minneapolis, MN) to allow clearer visualization of the base of the heart, and placed the patient in the Trendelenburg position (Fig. 3). The drainage site was identified by palpating the thrills and using epicardial echocardiography. Upon manual clamping, the thrills disappeared and mixed venous oxygen saturation decreased from 80% to 60%. Therefore, we ligated the entry vessel using double ligation with #1 silk thread. Postoperative MDCT revealed no persistence of the CAVF (Fig. 2). The patient had a favorable postoperative outcome.

A Case Report of Pulmonary Thromboendarterectomy for Chronic Thromboembolism in a Patient with Protein C Deficiency

The patient was a 41-year-old female with chronic thromboembolism. She was admitted to an affiliated hospital with exertional dyspnea, leg swelling, and hemoptysis, and she was treated medically with tissue plasminogen activator and warfarin therapy. When transferred to our hospital, she was oxygen-dependent with severe dyspnea. A pulmonary arteriogram showed occlusion and stenosis of the pulmonary arteries. Cardiac catheterization revealed marked pulmonary hypertension. The lung perfusion scintigram showedmultiple defects in the right and left lungs. Preoperative laboratory data showed a markedly decreased protein C antigen level. Magnetic resonance angiography showed that a myoma uteri compressed the pelvic vein and that she had deep vein occlusion of the left leg. After the administration of an epoprostenol infusion and the insertion of an inferior vena cava filter, she underwent an operation. Under deep hypothermia, the bilateral pulmonary artery was opened and an endarterectomy was performed during intermittent circulatory arrest. After surgery, her pulmonary vascular resistance was in the normal range. Her New York Heart Association functional classification changed from class IV to class I. She has been in good condition for 7 years since the surgery.

Papillary muscle approximation and relocation with a loop technique for mitral complex repair

Undersized mitral annuloplasty alone is not always sufficient to repair functional mitral regurgitation resulting from left ventricular enlargement; the repair requires a three-dimensional approach to the mitral complex. We introduce a surgical procedure that combines papillary muscle approximation to correct lateral shift and papillary muscle relocation using the loop technique to correct the apical shift with accuracy and technical ease.

Pyogenic vertebral osteomyelitis after surgery for rupture of the aortic arch.

Vertebral osteomyelitis is a very rare and intractable complication after vascular surgery. We describe a case of pyogenic vertebral osteomyelitis induced by methicillin-resistant Staphylococcus Aureus sepsis following surgery for traumatic rupture of the aortic arch, successfully managed with long-term antibiotic therapy for 75 weeks.