Tomomi Hirata

Endovascular approach for an intracranial mycotic aneurysm associated with infective endocarditis.

One of the most serious complications of infective endocarditis is mycotic cerebrovascular aneurysm, which can cause a lethal subarachnoid hemorrhage (SAH). ~ The treatment of mycotic aneurysms in hemodynamically unstable patients is controversial because solid guidelines based on large prospective studies are lacking. Patients show a wide variety in size, number, and location of these intracranial lesions, in addition to varying in basic cardiac function. We report a case of ruptured mycotic aneurysm caused by infective endocarditis in a patient whose cardiac function was too severely compromised to permit an open craniotomy. A 42-year-old man was admitted with a history of general fatigue, dyspnea, fever, and night sweats for a week. He had a high body temperature of 38°C and cardiac murmurs indicative of aortic and mitral regurgitation. A chest radiograph demonstrated cardiomegaly and severe pulmonary edema. An echocardiogram revealed vegetation and severe regurgitation of both the aortic and mitral valves. A diagnosis of infective endocarditis was confirmed by the isolation of Streptococcus viridans in :multiple arterial blood cultures. The patient was treated in the intensive care unit with high doses of antibiotics (ampicillin 10 gm/day and tobramycin 120 mg/day), diuretics, and catecholamines to control bacteremia and acute heart failure. After 6 days of intensive care, the patients body temperature dropped below 37 ° C and further blood cultures were negative for pathogens. The patients pulmonary edema and cardiomegaly also were alleviated. The patient was moved to a general floor, and double valve replacement was scheduled for the following week. Early the next morning, however, the patient became comatose and had a temperature of 38.6 ° C, tachycardia, hypertension, and respiratory distress. Mechanical ventilation under endotracheal intubation was started. Computed t0mography demonstrated a massive SAH. Subsequent cerebral angiography revealed a 5 mm aneurysm arising from the P2 portion of the right posterior cerebral artery (Fig. 1). The patient was transferred to the intensive care unit. Despite conservative therapy, including respiratory support and administration of diuretics and catecholam;mes, the patients condition was considered to be too hCmodynamically unstable to allow him to undergo general anesthesia and an emergency craniotomy for direct clipping of the aneurysm. Emergency double valve

Altered plasma antigen levels of tissue factor pathway inhibitor during open-heart surgery

r = 0.96, P < 0.0001) which increased significantly after heparin injection (P < 0.0001), and increased further during the bypass period (P < 0.005). The increased free TFPI antigen level during CPB correlated with the duration of bypass (r = 0.65, P = 0.02). When heparin was neutralized by protamine, the free TFPI antigen level decreased immediately, but remained higher than the preoperative level (P < 0.005). These results suggest that plasma TFPI antigen levels increase during CPB.

INFLAMMATORY REACTIONS AFTER VASCULAR PROSTHESIS IMPLANTATION : A COMPARISON OF GELATIN-SEALED AND UNSEALED DACRON PROSTHESES

Despite widespread use of the gelatin-sealed knitted Dacron prosthesis (GDP) in clinical practice owing to its zero porosity, the biological impacts of this graft are still controversial. We conducted a randomized controlled study on 50 patients undergoing abdominal aortic aneurysm repair to evaluate the inflammatory reaction to GDP (n=25) and unsealed knitted Dacron prostheses (UDP, n=25). There were no significant differences in the mean age, size of the aneurysm, operative time, blood loss, or transfusion requirements between the GDP and UDP groups. During the first 7 postoperative days (PODs), slight fever and leukocytosis were noticed in both groups. Significant differences in maximum body temperature, leukocyte count, and plasma C-reactive protein concentration were observed between the GDP and VDP groups on POD 14: 37.2±0.5°C vs 36.9±0.3°C (P=0.019), 8,151±1,788/μl vs 6,914±1,501/μl (P=0.015), and 32.6±27.5mg/l vs 19.0±15.8mg/l (P=0.048), respectively. By POD 21, however, there were no detectable differences in these variables. Thus, we concluded that GDP caused an inflammatory reaction in the 2nd week after implantation, but ultimately there were no significant differences from UDP by the 3rd week.

Anticoagulant effects of argatroban on the pre-DIC state in patients with an aortic aneurysm: A comparative study of heparin

We compared the efficacy of argatroban, a new synthetic thrombin-specific inhibitor, with that of heparin in pre-DIC state patients with abdominal aortic aneurysm (AAA). A pre-DIC state was diagnosed by a detection of soluble fibrin monomer complex (FM) and increased levels of thrombin-antithrombin III complex (TAT) of more than 20 ng/ml. Twelve patients showing a pre-DIC condition were treated with argatroban (40 mg/day, n=6) or heparin (10,000 U/day, n=6) for 5 days. Coagulation and fibrinolytic profiles were analyzed before and after drug administration. FM became negative in two (33%) patients after the argatroban treatment and in all (100%) of the heparin-treated patients. Plasma levels of TAT were significantly decreased after the heparin treatment, however, there was no significant alteration in this parameter after the argatroban treatment. In conclusion, the anticoagulant effects of heparin were superior to those of argatroban in controlling the pre-DIC state associated with AAA.

Cardiac hemangioma of the right ventricle —Report of a case—

A 74-year-old male was admitted to our hospital with a diagnosis of intra-cardiac tumor on echochardiography, CT, and MRI. The tumor was located on the free wall of the right ventricle and protruded into the outflow tract. The surgical excision of the tumor was performed under cardiopulmonary bypass. The size of the tumor was 5 x 5 x 4 cm. Histological examination disclosed cavenous hemangioma. The post opertive course was uneventful. This is the forth case reported in Japan and the fifteenth case in the world.

A surgical case for concomitant coronary artery disease and ASO with advanced colon cancer

We report a successful surgical case of concomitant severe coronary artery disease and ASO with advanced sigmoid colon cancer. This patient underwent two-stage operation. Resection of the sigmoid colon was carried out first, then CABG and aortofemoral bypass was carried out simultaneously. The surgical strategy of a patient with coronary artery disease and malignant neoplasm is still controvertial, however, it should be decided considering the severity and the symptoms of both disease. In this case, ascending aorta was used as a donor artery for aortofemoral bypass. This technique will bring those benefits, i.e., consecutive operation procedures in same operating field, obtaining abundant blood flow to lower limb and safe IABP catheter insertion from subcutaneously tunneled bypass graft.

Clinical benefits of normothermic cardiopulmonary bypass on postoperative systemic metabolism

To evaluate the influence of body temperature during cardiopulmonary bypass (CPB) on postoperative systemic metabolism, 32 patients undergoing elective cardiac surgery were randomly assigned to either hypothermia (n = 16) or normothermia (n = 16). Serial hemodynamic parameters and blood samples were obtained after surgery. CPB and operation times were significantly shorter and the platelet reduction ratio during CPB [ = (platelets before CPB-platelets after CPB)/platelets before CPB] was significantly lower in normothermic patients than in hypothermic patients. The platelet reduction ratio was dependent on the minimum rectal temperature during CPB, the operation time, and the CPB time. In the early postoperative period, hypothermic patients had abnormally high systemic vascular resistance and a reduced cardiac index compared with the normothermic patients. There were no differences between 2 groups in postoperative hepatic and renal functions, changes in oxygen consumption, arterial-venous PCO2 or arterial-venous pH gradient. This study suggested a beneficial influence of normothermic CPB on postoperative hemodynamics. Normothermic CPB was not associated with adverse effects on postoperative metabolic recovery.

Cardiovascular effects of bolus-administered vasodilators in elderly patients with atherosclerotic disease: A comparative study of nitroglycerin and prostaglandin E1

To evaluate the hemodynamic effects of vasodilators in elderly patients with atherosclerotic disease, systemic hemodynamics were examined during cardiac catheterization study. After the intravenous bolus injection of nitroglycerin (NTG, 5 µg/kg, n=20) or prostaglandin E1 (PGE1, 0.2 µg/kg, n=20), significant reduction of mean arterial pressure, pulmonary capillary wedge pressure (PCWP), systemic vascular resistance index (SVRI), and rate-pressure product (RPP) was observed. In contrast, cardiac index and stroke index were not significantly deteriorated in either group. In conclusion, bolus-administered NTG and PGE1 had beneficial vasodilating effects without harmful impact on cardiac functions in elder patients with atherosclerotic disease.

Analysis of reticuloendothelial phagocytic function and plasma fibronectin following digestive surgery.

消化器手術43例を対象とし, 細網内皮系貪食率, 血中fibronectinを測定し, 手術前後の変動を検討した. 細網内皮系貪食率は術後早期に低下し, 大手術侵襲群, 高齢者群に低下が顕著であった. 術後の血中丘bronectinは, 手術侵襲が大きい程低下し, 大手術侵襲群では術前値への回復が遅延し, 貪食率と血中fibronectinの術後変動に解離があった. 術後合併症発生例では貪食率の低下があり, また, 術後の血中fibronectin値は低値で推移した. 新鮮凍結血漿の投与は術後の血中fibronectinの低下を軽減した. 細網内皮系機能の評価には血中fibronectinとともに, 直接, 貪食率を測定すべきであり, 貪食率の評価には年齢も考慮し, 血中fibronectinの評価にはその推移をみるべきと考えられる.