Tatsuo Magara

Interruption of multiple accessory conduction pathways in the Wolff-Parkinson-White syndrome

Of 35 patients with Wolff-Parkinson-White syndrome operated on, 5 were seen with two accesory conduction pathways each; all of these were successfully interrupted. In one patient, one accessory conduction pathway each was located in the right and left side of the heart; in the other 4, both pathways were confined to the right side. In 2 patients with unilateral (right side) multiple accessory conduction pathways, Ebsteins anomaly was also present. In 1 patient with Ebsteins anomaly, the second unilateral accessory conduction pathway was discovered intraoperatively and was successfully interrupted. The remaining 4 patients required a second operation to interrupt the other pathway. A delta wave completely different from the preoperative one appeared 4 to 10 days after interruption of the first major pathway, and the second operation was performed 14 days, 42 days, four months, or five years after the first operation. All 5 patients survived, and long-term follow-up revealed no signs of morbidity.

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.

Massive mediastinal bleeding due to spontaneous rupture of the vertebral artery in von Recklinghausen disease

In Von Recklinghausen disease, patients rarely demonstrate vascular abnormalities, but several reports have noted massive bleeding from vascular rupture. A 28-year-old man with Von Recklinghausen disease was admitted to our hospital because of swelling on the left neck accompanied by dyspnea. Neck and thoracic CT revealed a high density shadow on the mediastinum and left upper thorax which was suspected to indicate hemomediastinum. Under suspicion of bleeding from the intrathoracic artery, the patient underwent on surgery. Massive hematoma disrupted visual recognition of bleeding point, but under anatomical consideration, we concluded that the bleeding was from the ruptured left vertebral artery (VA) which branched independently from the aorta. The left VA was ligated distally and proximally. Left subclavian artery, injured unexpectedly, was not reconstructed but sutured carefully because of its fragility. Thus massive bleeding was controlled. Histology of the neighboring subclavian artery revealed involvement with neurofibrinomatosis. Although the patients left arm demonstrated a slightly low blood pressure, he was discharged without complaint on the 56th postoperative day.

Cardiac operation for a patient with autoimmune hemolytic anemia with warm-reactive antibodies

We present a case of a patient with autoimmune hemolytic anemia with warm-reactive antibodies who underwent successful coronary artery bypass grafting. We discuss some of the important problematic issues related to perioperative management.

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.

Surgical treatment of the Wolff-Parkinson-White syndrome in infants and children.

Eleven pediatric Wolff-Parkinson-White (WPW) syndrome patients underwent surgery. Four had left, 5 right cardiac type and 2 had right septal type WPW syndrome. Two patients had 2 accessory conduction pathways (ACP). Ebsteins anomaly and secundum type atrial septal defect were the associated congenital cardiac diseases in one patient each. Indications for surgery included repeated and/or long-lasting paroxysmal supraventricular tachycardia (PSVT), ineffective drug therapy, cardiac failure due to frequent tachycardia, short effective refractory period of the ACP, and simultaneous surgery for associated congenital cardiac diseases. Pre- and intra-operative examinations, including ECG, VCG, UCG, body surface mapping, intracavitary recording by catheter electrodes, computerized epicardial mapping, and endocardial mapping, were performed for the precise localization of the ACP. The surgical method was basically the same as is used for adults. Anterior median stermotomy was used primarily in right cardiac and right septal type and left anterior thoracotomy was used in 3 of 4 cases of the left cardiac type. Eight of 11 cases, two of which had 2 ACPs, were completely cured and in 3 there was evidence of postoperative pre-excitation. However, the PSVT attacks disappeared almost completely and drug therapy is not required at present.

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.