Takane Hiraiwa

Rupture of a benign mediastinal teratoma into the right pleural cavity

A 27-year-old woman with a ruptured mediastinal cystic teratoma had high levels of amylase and carcinoembryonic antigen in cystic fluid. The activity of the amylase is thought to be the most likely cause of the rupture. High levels of carcinoembryonic antigen in pleural fluid are not necessarily indicative of a malignant lesion but may suggest the presence of a ruptured teratoma in patients with mediastinal tumors.

Effects of Nafamostat Mesilate on Coagulopathy With Chronic Aortic Dissection

A 65-year-old man with chronic aortic dissection experienced two massive subcutaneous hemorrhages. Laboratory data indicated disseminated intravascular coagulation, whereas a contrast computed tomographic scan revealed a dilatated aortic arch with a partial thrombosis at the false lumen. Because disseminated intravascular coagulation can be caused by chronic aortic dissection, and the aortic arch was 6 cm in diameter, we performed graft replacement from the ascending to the descending aorta in a single stage. Before graft replacement, nafamostat mesilate, a protease inhibitor, was administered and the disseminated intravascular coagulation improved. Nafamostat mesilate may be useful for managing disseminated intravascular coagulation associated with chronic aortic dissection.

Nafamostat Mesilate, as a Treatment for Heparin Resistance, Is Not Associated With Perioperative Ischemic Stroke in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass

OBJECTIVE Nafamostat mesilate, a short-acting protease inhibitor, treats heparin resistance during cardiopulmonary bypass. This study tested whether nafamostat mesilate is associated with perioperative ischemic stroke. DESIGN A retrospective observational study. PARTICIPANTS A total of 870 adult cardiac surgery patients. INTERVENTION The authors retrospectively identified the patients who received nafamostat mesilate and who suffered symptomatic ischemic stroke within 30 postoperative days. MEASUREMENTS AND MAIN RESULTS The authors evaluated perioperative patient characteristics in association with perioperative ischemic stroke and death. The patients were identified as heparin resistant if they had an activated coagulation time of <480 seconds after the administration of heparin at 400 to 500 U/kg. Heparin-resistant patients received a 10- to 20-mg bolus plus 25 to 50 mg/h of nafamostat mesilate and heparin at 100 U/kg intravenously every 1.5 to 2.0 hours to maintain an activated coagulation time over 480 seconds. Of the 870 patients, 11 (1.3%) suffered a perioperative ischemic stroke. Of the 190 (21.8%) patients who received nafamostat mesilate, 1 (0.5%) suffered ischemic stroke compared with 10 (1.5%) in 680 patients without nafamostat mesilate (Fisher exact test; p = 0.47; regression analysis; odds ratio, 0.35; 95% confidence interval, 0.45-2.8; p = 0.32); 3 (1.6%) patients with nafamostat mesilate died postoperatively within 30 days compared with 11 (1.6%) without nafamostat mesilate (Fisher exact test; p > 0.99, regression analysis; odds ratio, 0.98; 95% confidence interval, 0.27-3.5; p = 0.97). CONCLUSIONS No evidence was found that nafamostat mesilate was associated with perioperative ischemic stroke in heparin-resistant patients undergoing cardiac surgery with cardiopulmonary bypass.

Perforation of a Tricuspid Pouch Caused by Infective Endocarditis

A 61-year-old man was admitted because of infective endocarditis. Echocardiography revealed the bicuspid aortic valve and a tricuspid pouch bulging into the right ventricle. Color Doppler demonstrated mild aortic regurgitation and left-to-right ventricular shunt through the lower part of the pouch. We successfully performed an aortic valve replacement and closed the interventricular communication. Infective endocarditis of the bicuspid aortic valve appeared to have caused left-to-right ventricular communication at the lower part of the tricuspid pouch.

A Case of External Compression of Femoral Vein by the Enlarged Iliopsoas Bursa with Long Term Edema

The iliopsoas bursa is the largest bursa in the region of hip joint. It is unusual that these bursa become symptomatic. However the bursa can compress femoral vein, leading to lower extremity edema. A 58-year-old man was referred to our department for his unilateral leg edema which had been treated as deep vein thrombosis without any favorable response. Magnetic resonance angiography was performed, which demonstrated enlarged iliopsoas bursa compressing his femoral vein. Surgical removal of the bursa was performed. The postoperative course was uneventful, and the patient is free from symptoms with no evidence of recurrence.

Successful Surgical Exclusion of Rapidly Expanding Kommerell Diverticulum Following a Total Arch Replacement for an Acute Type A Aortic Dissection

A 50-year-old man presented with an acute type A aortic dissection with an aberrant right subclavian artery. Emergent total arch replacement with an elephant trunk was performed. Intraoperatively, the origin of the aberrant right subclavian artery could not be resected because it was located too far from the distal arch. After two weeks, the patient became aware of dysphagia. Postoperative computed tomography showed the esophagus was compressed anteriorly by the aneurismal origin of this aberrant vessel (Kommerell diverticulum) with a patent false lumen. Additional replacement of the descending aorta via left thoracotomy was performed immediately to exclude a Kommerell diverticulum.

Combined coronary and femoral revascularization for the treatment of hypoplastic aortoiliac syndrome: Report of a case

The coronary artery and aortoiliac occlusive disease frequently coexist and in relatively rare instances, a complication of hypoplastic aortoiliac syndrome (HAIS) may occur. We herein present our experience with a 51-year-old female patient with HAIS and concomitant coronary artery disease. She underwent a successful simultaneous coronary and femoral revascularization. The left anterior descending artery was bypassed with the in situ gastroepiploic artery and a biaorto-external iliac artery bypass was performed with expanded polytetrafluoroethylene precuffed grafts. She had a good postoperative course, with no angina or intermittent claudication. The importance of the technical aspects of reconstructive surgery in patients with HAIS has been emphasized in many reports in the literature, and the surgical options for combined coronary and femoral revascularization are also discussed herein.

One-Stage Operation for Ruptured Abdominal Aortic Aneurysm and Acute Myocardial Infarction.

症例は65歳男性. 腹痛を主訴に来院. また来院直後より胸痛が出現しECG所見では, V1-3誘導でST上昇が認められた. 緊急CTおよびCAG施行した結果, 急性心筋梗塞を合併した腹部大動脈瘤 (AAA) 破裂と診断し緊急手術を施行した. 手術は体外循環下に冠状動脈バイパス術 (CABG) を行った後, 補助循環中にAAA切除, 人工血管 (Yグラフト) 置換を行った. また慢性腎不全患者であったため術中透析を行った. 本術式は体外循環中にAAA手術を行うため大動脈周囲の操作は極めて容易であり, また心配された出血のコントロールも容易であったため本症例のように心機能低下を伴う虚血性心疾患 (IHD) とAAA合併例には有用な術式と考えられた.

Postoperative Thrombus Formation in the False Lumen Following Surgical Repair of Aortic Dissection

During the period 1980 to 1990, 65 patients with aortic dissection underwent surgical treatment. The authors have mainly been using the entry closure proce dures to enclose the false lumen with thrombus for dissecting aortic aneurysm. The survival rate was 75%. In 36 long-surviving patients who have been able to be followed up postoperatively, angiography and/or computed tomography (CT) with contrast enhancement was used to evaluate the aortic and any resid ual false lumen during a mean follow-up of sixty months. Complete thrombotic closure of the false lumen was obtained in only 5 cases; 18 of the remaining 31 patients have developed almost complete thrombus for mation, and only local remaining false lumens were noted. In the other 13 pa tients (36%), an extensive residual false lumen was observed, mainly in the patients with an aneurysm of larger diameter where the preoperative CT im ages showed the false lumen to be larger than the true lumen, indicating the requirement for extensive aortic graft replacement or secondary operation.