Takehisa Nojima

Modified ultrafiltration removes serum interleukin-8 in adult cardiac surgery

Cardiopulmonary bypass (CPB) causes an increase in serum cytokine levels and systemic inflamatory responses, which may trigger the onset of various types of postoperative organ failure. In the present study, modified ultrafiltration (MUF) was applied in cases of adult cardiac surgery and an attempt was made to determine whether MUF reduces serum interleukin-8 (IL-8) levels. Nine patients who underwent cardiovascular surgery with CPB and MUF between June 1996 and June 1997 were compared with nine control patients who underwent cardiovascular surgery without MUF in the same period. Modified ultrafiltration was performed, based on a method proposed elsewhere. Serum IL-8 was measured by enzyme immunoassay at the start of CPB, immediately after CPB, immediately after MUF and 3 h after MUF. The mean filtrated volume was 1550.0 ± 173.2 ml. In the MUF group, haematocrit increased significantly from 21.2 ± 2.0 to 24.9 ± 3.3% (p = 0.0008), while systolic blood pressure increased from 97.5 ± 16.7 to 116.5 ± 23.9 mmHg (p = 0.0024) after MUF. In contrast, there were no changes in either haematocrit or blood pressure in the control group. In the MUF group, serum IL-8 was reduced from 69.5 ± 33.5 to 58.9 ± 32.4 pg/ml after MUF (p = 0.0029), whereas it was not reduced in the control group. The results of the present study suggest that MUF has beneficial effects on postoperative haemodynamics, and can reduce serum IL-8 levels in adult cardiac surgery.

Myxoma of the aortic valve

Myxoma of the aortic valve is exceedingly uncommon. In this article, we report a 58-year-old man with myxoma arising from the aortic valve. Aortic valve replacement was performed, and postoperative histologic examination showed myxoma of aortic valve.

Clinical significance of reverse redistribution phenomenon after coronary artery bypass grafting

The reverse redistribution (RR) phenomenon is a decrease in thallium 201 uptake during redistribution compared with 201Tl uptake immediately after exercise. We evaluated RR in 23 patients after coronary artery bypass grafting. Postoperative RR was present in 48% and was significantly more common in patients with a history of myocardial infarction (62%). The patients were classified according to the presence (+) or absence (-) of RR. An analysis of left ventricular wall motion showed significant improvement after coronary artery bypass grafting in the RR+ group (n = 12) but not in the RR- group (n = 11). Quantitative myocardial viability was evaluated using the defect volume ratio, mean defect severity, and defect severity index. The preoperative defect volume ratio was higher in the RR+ group than in the RR- group (p < 0.05). In the RR- group, no improvement in these indices was observed after operation. In contrast, the RR+ group showed significant improvement in all three indices (p < 0.05). These results indicate that after coronary artery bypass grafting, an adequate blood supply to the remaining myocardium may induce RR. This phenomenon, therefore, may be a significant indicator of postoperative myocardial viability.

Combined catheter embolization and femorofemoral bypass for pseudoaneurysm of the right external iliac artery: Report of a case

Performing direct surgery for postoperative hemorrhage caused by intraperitoneal arterial injury is very difficult. We report herein the case of a 52-year-old woman who developed sudden right lower abdominal pain after numerous laparotomies and radiotherapy for advanced uterine cancer. A diagnosis of pseudoaneurysm of the right external iliac artery was made, and an emergency catheter embolization and femorofemoral bypass was successfully performed under local anesthesia. The patient was able to walk the next day. To the best of our knowledge, this is the first report of such a combined procedure in the literature.

Bilateral main bronchial compression caused by the ductal ligament

Several authors have reported cases of respiratory distress resulting from bronchial compression due to a hypertensive pulmonary artery in the setting of a large left-to-right shunt. However, respiratory distress due to bilateral main bronchial compression due to an enlarged pulmonary artery suspended posteriorly by the ductal ligament following repair of a ventricular septal defect is extremely rare. In this report, we advocate the necessity of dividing the ductal ligament in some patients with large left-to-right shunts when there are episodes of idiopathic respiratory distress before operation.

Surgical Treatment for Ruptured Abdominal Aortic Aneurysms.

破裂性腹部大動脈瘤19例を対象とし手術成績を検討した. 男性18例女性1例, 平均年齢は69.2歳で, 70歳以上の高齢者を9例含んでいた. 19例中15例 (79%) でショックを呈しており, 4例に心臓マッサージを要した. 術中心停止で1例, 術後多臓器不全, 呼吸不全等で3例を失ったが, 残りの15例は軽快退院し死亡率は21%であった. 術後血液透析ないし持続血液濾過透析を4例, 再開腹止血術を2例, 創し開での再閉腹術を1例, 術中イレウスチューブ留置を3例に行った. 平均瘤径82mm, 平均手術時間は251分, 平均総出血量は5,139ml, 平均同種血輸血量は3,683mlを要した. 術後平均挿管期間は6.4日, 平均禁食期間は7.6日であった. 手術死亡4例中3例が70歳以上の高齢者で, 死亡率は70歳未満群 (10%) と比較して70歳以上群 (33%) が有意に高値であった. 高齢者の破裂症例でも迅速な対応によって救命が可能で, 積極的な手術が必要と考えられた. 今後手術成績の向上にはとくに高齢者における術後多臓器不全の克服が重要であると考えられ, 術中のイレウスチューブ留置や持続血液濾過透析はその一助になるものと考えている.

Cardiac Rupture after Acute Myocardial Infarction in 6 Cases.

急性心筋梗塞 (AMI) の重篤なる合併症として心破裂は現在のところ予後不良な疾患の一つである. 当院における6例の心破裂症例について検討し, 心破裂の分類について文献的検討を加え報告した. 1995年3月までに6例のAMI後心破裂に対する手術を経験した. 6例はすべて男性であり, 年齢は59～76歳 (平均65.2歳) であった. AMI発症～心破裂まで8時間から4日 (平均2.6日), 破裂～緊急手術まで1時間から24時間 (平均11時間) であった. 6例のうち2例は術前ショック状態で, このうち1例はIABP, PCPSを使用下に手術室へ搬送した. 2例とも破裂孔は blowout type で Felt Sandwich 法で閉鎖したが出血をコントロールできず死亡した. 残りの4例は心嚢ドレナージ後, 循環動態の改善がみられ, その後手術を施行した. Blowout type の1例は出血にて死亡したが, 出血解離型の2例は Felt Sandwich 法で縫合し, oozing type の1例はフィブリン糊とコラーゲンシートにて止血を行い救命しえた. 出血解離型や oozing type の成績は良好であったが blowout type は不良であり, とくに出血のコントロールや愛護的操作など今後もその対策を検討する必要があると考えられた. 肉眼的病理所見と臨床経過の対応を検討すると blowout 型や Becker のI型は急性型に属し, 出血解離型と oozing type の一部が亜急性期に, oozing type の一部と仮性左室瘤形成型および左室瘤形成型が慢性期症例にあたるものと考えられた.

Spinal Cord Damage after Aorto-bifemoral Bypass Operation.

腹部大動脈手術時の脊髄障害は希だが, 患者の quality of life の上からも重大な合併症である. 今回, われわれは腹部大動脈・腸骨動脈領域の閉塞性動脈硬化症術後に右下肢麻痺を発症した1例を経験した. 症例は59歳の男性. 左総腸骨動脈, 右外腸骨動脈の閉塞性動脈硬化症に対する腹部大動脈・両側大腿動脈バイパス術後に右側の第2腰髄 (L2) から第1仙髄 (S1) にかけての運動および痛覚麻痺が出現した. 脊髄障害は内科的治療などによりS1は改善したもののL2-L5は改善せず, 患者は術後3か月目に退院した. 腹部大動脈-大腿動脈バイパス術において, 粥状硬化の強い腹部大動脈に対する side clamp は腰動脈の開口部を閉塞させる可能性があり, 脊髄障害発症の危険性を高めると考えられる.