Toshiyuki Yuda

Surgical repair of a solitary deep femoral arterial aneurysm: report of two cases.

We report herein two cases of a solitary deep femoral arterial aneurysm that were successfully treated by aneurysmectomy and ligation of the deep femoral artery. The patients were a 69-year-old man and a 73-year-old man, both of whom presented with localized pain and a pulsatile mass in the femoral area showing rapid enlargement. Ultrasonography and arteriography confirmed the diagnosis and revealed no evidence of aneurysm or occlusive disease in the other arteries. Aneurysmectomy and ligation of the deep femoral artery were performed, and no ischemic symptoms or thrombus developed postoperatively in either patient. Preoperative arteriography is essential to delineate not only the state of the aneurysm, but also that of the distal arterial tree. An emergency operation is also mandatory due to the rapid enlargement of this type of aneurysm, even if rupture occurs.

Fatal hemolysis due to unidentified causes following mitral valve replacement with bileaflet tilting disc valve prosthesis

SummaryFatal hemolysis after mitral valve replacement with the St. Jude bileaflet tilting prosthesis is reported in two patients. Although one underwent re-replacement of the valve, both died from multiple organ failure and acute renal failure, respectively. Scanning electron microscopy revealed microthrombi adherent to a leaflet in one and irregular leaflet surfaces in the other. Such defects are rare but are possible causes of hemolysis in patients with the St. Jude mitral valve prosthesis.

Surgical treatment of abdominal aortic aneurysm in the high-risk patient

In an attempt to define the preoperative risk factors that predictably influence mortality after aneurysmectomy, this study reviews the surgical management of abdominal aortic aneurysms in a series of 110 consecutive patients who underwent elective resection. The preoperative risks to be added to the present study included pulmonary insufficiency, renal dysfunction, advanced age of over 80 years, ischemic heart disease, and associated other diseases such as thoracic aneurysms, atherosclerosis of the limbs and malignant tumors. Forty-six patients had one of these risk factors (one-risk group), 17 had two (two-risk group), and 9 had three (three-risk group). The operative mortality rates were 4.2 per cent for the high-risk patients and 0 per cent for the patients at no risk. As the number of risk factors increased, aneurysm repair was associated with an increased operative mortality; being 2.2 per cent in the one-risk group, 5.9 per cent in the two-risk group and 11.1 per cent in the three-risk group. The common risk factor in patients who died after aneurysmectomy was pulmonary insufficiency which induced prolonged periods of assisted ventilation. Thus, the optimal management of high-risk patients, particularly those with pulmonary insufficiency, may reduce the mortality after aneurysmectomy.

Right atrial mural thrombus associated with pericarditis

A 33-year-old man was hospitalized with right heart failure. He was diagnosed as having right atrial mural thrombus complicated with pericarditis on echocardiography, thoracic computed tomography, and cardiac catheterization. Pericardiectomy and thrombectomy with a partial resection of the right atrial wall were performed under extracorporeal circulation. It was suggested that the cause of right atrial thrombus was congestion, atrial fibrillation, and pericarditis. The cause of pericarditis could not be determined by pathologic examination and laboratory data. Surgical treatment should be performed as soon as possible to prevent pulmonary embolism.

The necessity of reoperation for patients with Bjork-Shiley, St Jude Medical, Hancock and Carpentier-Edwards prostheses.

The purpose of this study was to determine the criteria of valve selection from the long-term results of Hancock, Carpentier-Edwards, St Jude Medical and Bjork-Shiley prostheses, taking into special account the frequency of reoperation. Reoperations on the Hancock bioprosthesis were performed on six patients for tissue leaflet disruption with an incidence of 2.2 per cent/patient-year. Reoperations on the Carpentier-Edwards bioprosthesis were performed on 24 patients for tissue leaflet disruption in 23 patients and prosthetic valve endocarditis (PVE) in one, with an incidence of 3.8 per cent/patient-year. Reoperations on the Bjork-Shiley prosthesis were performed in two patients for severe hemolysis, with an incidence of 0.32 per cent/patient-year. Reoperations on the St Jude Medical prosthesis were performed on 3 patients, for valve thrombosis in one patient, PVE in one, and hemolysis in one, with an incidence of 0.23 per cent/patient-year. The overall mortality rate was 20 per cent, or 7 patients, and the indications for reoperation affected this. Patients with primary tissue failure had a mortality rate of 10.3 per cent; those with a thrombosed valve, 0 per cent; those with hemolysis, 66.7 per cent; and those with valve infection, 100 per cent. A good chance of survival may be achieved in patients facing prosthetic valve complications by performing reoperation as soon as possible after early detection, since mortality is high following emergency reoperation and in patients with severe symptoms. Currently, we recommend mechanical prostheses for valve replacement except in patients over 70 years old and in younger patients with absolute contraindications to anticoagulative therapy.

Acute ventricular septal perforation in a patient with autoimmune hemolytic anemia

A 71-year-old woman with autoimmune hemolytic anemia underwent an emergency endocardial patch repair for ventricular septal perforation after acute myocardial infarction. Use of washed red blood cells was effective in averting hemolytic crisis throughout perioperative period. In spite of improvement of her hemodynamics, liver dysfunction which had been present preoperatively deteriorated after the operation. Finally she died of hepatic failure on the 21st postoperative day. Deterioration of liver function could not be associated with autoimmune hemolytic anemia. To date, little information is available concerning the influence of cardiopulmonary bypass on hemolysis in patients with autoimmune hemolytic anemia. Therefore, prudent management and use of washed red blood cells transfusion would prevent hemolytic aggravation even in open heart surgery.

Surgical treatment of abdominal aortic aneurysm in patients over seventy years old

Aneurysmectomy is generally the first choice as treatment in most patients with abdominal aortic aneurysm. However, justification of surgical procedures in the aged has been questioned, because of the risk which increases with chronologic age. In the present study, our experience with patients over 70 who underwent abdominal aortic aneurysmectomy is discussed. Forty patients with abdominal aortic aneurysm underwent surgery in our institution up to January, 1983. Ten of these patients were 70 years or older. Operation was performed electively in 6 and as an emergency in 4. The one operative death (10 per cent) was the case of a 74-year old woman with a ruptured aneurysm. The operative mortality was 17.5 per cent in patients under 70 years of age. It would appear that advanced age,per se, is not a contraindication for abdominal aneurysmectomy.

A Case of Abdominal Aortic Aneurysm in a Systemic Lupus Erythematosus Patient.

全身性エリテマトーデスでの大血管病変の報告は稀である. 本疾患で23年の治療歴を持ち, 腹部大動脈瘤を発症した1例を経験した. 症例は49歳女性. 26歳時に全身性エリテマトーデスと診断され, ステロイド療法を開始され, 28歳時にループス腎炎と診断された. 内科外来通院中に腹部大動脈瘤を指摘され, 手術を行った. 動脈瘤は腎下型で最大径7cm, 長径8cm, 周囲との癒着はなかった. 動脈瘤壁は薄く, 一部石灰化し, 厚い壁在血栓を伴っていた. 直型人工血管で置換し, 術後経過良好で現在復職している. 動脈瘤壁の病理診断は動脈硬化性大動脈瘤であった. 全身性エリテマトーデス患者は炎症性疾患であるが, 動脈硬化が進行しやすいという側面も持っており, 比較的若年で動脈硬化性の大動脈疾患を発症する可能性があり, この点を念頭に置いた経過観察が必要である.

Open-Heart Surgery in Patients Over Sixty Years of Age:

One hundred five patients over sixty years of age underwent open-heart sur gery at Kagoshima University Hospital during the period 1978-1986. The over all operative mortality rate was 22.8% (early: 17.1%, late: 5.7%), much higher than that of 6.9% (early: 5.3%, late: 1.6%) in younger patients under sixty years of age who had this surgery during the same period. Those who under went valve replacements showed a particularly high mortality rate. The opera tive mortality was significantly influenced by such factors as preoperative degrees of heart failure according to the NYHA functional class, the incidence of postoperative complications, the duration of cardiopulmonary bypass proce dures, and the duration of ischemic arrest. Despite a high mortality rate in elderly patients, age per se should not be a contraindication since the majority of hospital survivors are active in their daily life and the operative mortality has been reduced every year.

Left Ventricular-Right Atrial Communication: A Report of Seven Cases With Surgical Treatment

Left ventricular-right atrial (LV-RA) communication is a rare congenital malformation. The diagnosis is rarely made clinically, and the true nature of the defect is usually not established until catheterization or surgery. We experienced seven cases of LV-RA communication: the infravalvular type in six and supravalvular in one. In four of seven patients the diagnosis of this anomaly was suggested before surgery. Operative death occurred in one patient — a 6.0-kg infant with a right-to-left shunt, Eisenmengers complex. The six patients surviving are doing well and have been free of symptoms for postoperative periods ranging from 6 to 29 months. Characteristic features of this anomaly from clinical, radiologic, electrocardiographic, echocardiographic, and catheterization findings are discussed.