Yasuo Suehiro

Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: propensity score matching analysis

OBJECTIVES Deep sternal wound infection (DSWI) after cardiovascular surgery via median sternotomy remains a severe complication associated with a drastic decrease in the quality of life. We assessed the risk factors for in-hospital death caused by DSWI and the available treatments for DSWI. METHODS Between January 1991 and August 2015, we retrospectively reviewed 73 patients (51 males and 22 females, mean age 67.5 ± 10.3 years) who developed DSWI after cardiovascular surgery via median sternotomy. Pathogenic bacteria mainly comprised methicillin-resistant Staphylococcus aureus (MRSA) (49.3%). Fifteen patients (20.5%) died in hospital with DSWI. Treatment of DSWI consisted of open daily irrigation (up to 2006) or negative pressure wound therapy (NPWT) (2007 onwards), followed by primary closure or reconstruction of tissue flaps. We assessed the risk factors for in-hospital mortality from DSWI by comparing data from the 15 patients who died and the 58 survivors using propensity score matching analysis of the treatments used for DSWI. RESULTS Univariate analysis identified age, use of intra-aortic balloon pumping, prolonged mechanical ventilation, tracheotomy, prolonged intensive care unit stay, postoperative low output syndrome, postoperative myocardial infarction, postoperative renal failure, postoperative use of haemodialysis, postoperative pneumonia, postoperative cerebral disorder, MRSA infection, NPWT and tissue flaps as being associated with in-hospital mortality (P < 0.05). Multivariate analysis identified NPWT (odds ratio, 0.062; 95% confidence interval, 0.004-0.897; P = 0.041) and tissue flaps (odds ratio, 0.022; 95% confidence interval, 0.000-0.960; P = 0.048) as independently associated with reduced in-hospital mortality after DSWI. On comparing 22 patients receiving NPWT with 22 not on NPWT using propensity score matching, patients on NPWT had significantly lower in-hospital mortality than those without NPWT (NPWT vs non-NPWT, 5 vs 36%, P = 0.021). In DSWI infected by MRSA, NPWT significantly reduced the in-hospital mortality caused by DSWI (NPWT vs non-NPWT, 0 vs 52%, P = 0.003). CONCLUSIONS NPWT and tissue flaps may be favourable factors associated with reduced in-hospital mortality attributable to DSWI. NPWT as a bridge therapy to tissue flaps may play a major role in treating DSWI and improve the prognosis for patients with MRSA-infected DSWI.

A Surgical Case of Expanding Bilateral Coronary Aneurysms Regarded as Immunoglobulin G4-Related Disease

A 69-year–old man was referred to our department for surgical treatment of bilateral giant coronary artery aneurysms. He had no apparent clinical factors associated with atherosclerosis, such as diabetes mellitus, hyperlipidemia, or hypertension. Physical examination revealed no abnormalities. His medical history included malignant lymphoma that had been treated with chemotherapy and radiation therapy at the age of 60 years. He was also diagnosed with a plasma cell tumor in his tonsils at the age of 68 years. Just before treatment for this tumor, he developed sudden-onset myocardial infarction. Coronary angiography revealed 2 giant coronary aneurysms; one presented as a broad aneurysmal change of the right coronary artery (Figure 1A and Movie I in the online-only Data Supplement), and the other was located from the left main coronary artery to the left anterior descending artery (Figure 1B and Movie II in the online-only Data Supplement). On the basis of subsequent computed tomography, the maximum diameters of the right and left coronary aneurysms were 40 and 25 mm, respectively (Figure 2). Laboratory examination showed that the serum immunoglobulin …

Quadricuspid aortic valve complicated with infective endocarditis: report of a case

Congenital quadricuspid aortic valve is a rare cardiac malformation with an unknown risk of infective endocarditis. We report a case of quadricuspid aortic valve complicated with infective endocarditis. A 53-year-old Japanese woman was hospitalized with leg edema and a fever of unknown origin. Corynebacterium striatum was detected in the blood culture. Echocardiography demonstrated a quadricuspid aortic valve with vegetation and severe functional regurgitation. The condition was diagnosed as a quadricuspid aortic valve with infective endocarditis, for which surgery was performed. The quadricuspid aortic valve had three equal-sized cusps and one smaller cusp (type B according to Hurwitz classification). We dissected the vegetation and infectious focus and implanted a mechanical valve. Following the case report, we review the literature.

Intravascular ultrasound for transcatheter paravalvular leak closure.

Transcatheter closure of paravalvular leaks requires precise assessment of the location, size, and shape of the defect. Transesophageal echocardiography plays an important role in this process. We encountered a case of a paravalvular leak at the aortic position after aortic and mitral valve replacement. It was impossible to detect the precise location of the paravalvular leak with transesophageal echocardiography because of an acoustic shadow from the mitral mechanical valve. Intraoperative use of intravascular ultrasound was useful for determining the morphology of the defect and evaluating the procedure during the operation.

Right Axillary Artery Cannulation in Aortic Valve Replacement.

OBJECTIVE This retrospective study aimed to evaluate the results of our experience with axillary artery cannulation via a side graft in aortic valve replacement in patients with ascending aortic atherosclerotic disease. METHODS From January 2002 to 2012, we operated on 76 patients for aortic valve disease with the use of the axillary artery for arterial inflow in our institute. The indications for cannulation of the axillary artery were aortic aneurysm in 37 patients, severe aortic atherosclerosis in 28 patients, and re do surgery in 11 patients. RESULTS Right axillary artery cannulation via a side graft provides sufficient antegrade aortic flow of 2.6 ± 0.1 L/m(2) during cardiopulmonary bypass. No additional arterial cannulation was necessary to obtain sufficient perfusion during cardiopulmonary bypass. Although permanent perioperative stroke was observed in two patients, this did not occur during the operation. There were no problems with cannulation or wound and graft infections. During the follow-up period, there were no thrombotic events due to an axillary graft stump in the right upper extremities. CONCLUSIONS Axillary artery cannulation via a side graft is a useful and safe option for cardiopulmonary bypass in patients with atherosclerotic disease of the ascending aorta undergoing aortic valve replacement.

Successful surgical treatment of traumatic transection of the innominate artery: a case report.

Blunt traumatic injury to the innominate artery is relatively rare. We present the case of a 40-year-old woman who fell from a fourth-floor window and was transferred to our hospital with multiple injuries, hemodynamic shock, and disturbance of consciousness. Computed tomography with image reconstruction revealed transection of the innominate artery near its origin. Emergent surgery required establishment of cardiopulmonary bypass before sternotomy in preparation for uncontrollable hemorrhage. Proximal aortic arch replacement with a branch to the right axillary artery was successfully performed using circulatory arrest and selective cerebral perfusion.

Does rich coronary collateral circulation distal to chronically occluded left anterior descending artery compete with graft flow

OBJECTIVES In coronary artery bypass grafting (CABG), graft flow distal to a mild stenosis can compete with relatively preserved native flow through the stenosis and the competition can result in graft stenosis. In chronic total occlusion (CTO), coronary collateral circulation, which is essential to maintain myocardial viability distal to CTO, varies in extent among patients and the extent can be scored by Rentrop grade in coronary angiography. We investigated whether rich collateral circulation distal to CTO competes with distally anastomosed graft flow in association with Rentrop grade. METHODS Of 666 patients who underwent CABG from January 2001 to December 2012, 70 patients whose left internal thoracic artery (ITA) was grafted distal to CTO in the left anterior descending artery (LAD) were divided into three groups: Poor collaterals (Rentrop grades 0 and 1, Group P, n = 22), Moderate collaterals (grade 2, Group M, n = 23) and Rich collaterals (grade 3, Group R, n = 25). The intraoperative measurements of mean graft flow (MGF) and pulsatility index (PI) of left ITA grafts, early graft patency and long-term clinical outcomes were compared. RESULTS The MGF and PI of left ITA grafts differed significantly among the three groups (P = 0.025 and P = 0.046, respectively). Lower Rentrop grade was associated with preferable results of higher MGF and lower PI. The graft flow pattern in Group P showed a significantly higher MGF (P = 0.020) and lower PI (P = 0.041) than those in Group R. All early postoperative coronary angiograms showed patent left ITA grafts. Serial echocardiographic evaluations, survival rates and cardiac event-free rates were comparable with the follow-up of 5.00 ± 3.11 years. CONCLUSIONS Rich collateral circulation distal to CTO in LADs can potentially compete with graft flow, although the competition seems not to affect clinical outcomes probably due to the regression of collaterals surmounted by the graft flow. Rentrop grade is shown to certainly reflect the degree of collateral haemodynamic circulation distal to CTO and especially important to evaluate intraoperative graft flow appropriately, considering the possible phenomenon of graft flow competition.

Inverted Intercostal Hernia of Soft Tissue Manifested as Slow-Growing Chest Wall Tumor After Thoracotomy

An 80-year-old woman had an asymptomatic chest wall tumor. She had undergone thoracotomy to treat a benign lesion 11 years previously. Chest computed tomography revealed a convex lens-shaped mass 7 cm in diameter in the chest wall. Positron emission tomography demonstrated mild accumulation of F-deoxyglucose. We performed an exploratory thoracotomy; however, no mass lesion was found. Therefore, we thought that the soft tissue of the back was drawn into the pleural cavity through the widened intercostal space during the previous thoracotomy. We simply aligned the ribs using heavy surgical sutures. The patient has experienced good recovery, with no recurrence since the surgery.