Kyobu geka. The Japanese journal of thoracic surgery最新文献

Background: For malperfusion in Stanford type A acute aortic dissection, we resolve static intestinal ischemia prior to central repair, rapidly unload the left ventricle for myocardial ischemia, and resolve cerebral or lower limb ischemia using cardiopulmonary bypass, We evaluated the validity of this strategy, Subjects:Among 165 emergency surgeries for Stanford type A acute aortic dissection performed since 2009, malperfusion was present in 52 cases(brain 23/heart 9/kidney 8/intestine 4/lower extremity 21)[overlap present], Results:Mean age was 63±12 years;29 patients were male;1 case had Marfan syndrome, The median time from onset to extracorporeal circulation initiation was 5 hours(range 2~51), Postoperative extracorporeal membrane oxygenation(ECMO)was used in 5 cases;in-hospital mortality occurred in 8 cases;and 8 cases had residual sequelae of cerebral infarction(controlled reperfusion in 1), Conclusion:Strategies for treating coronary malperfusion require improvement, In cerebral malperfusion, controlled reperfusion may be effective, with fewer residual sequelae in treated cases.

The patient was a 79-year-old male, During the course of treatment for eosinophilic pneumonia, he developed left-sided pneumothorax, Despite the implementation of thoracic drainage, air leakage persisted, Computed tomography(CT)revealed a left pneumatocele, which was deemed to be the underlying cause of pneumothorax, Consequently, thoracoscopy-assisted operation was performed, Six months postoperatively, no recurrence of pneumothorax was observed, and the pneumatocele had significantly decreased in size, Surgical intervention for refractory pneumothorax associated with pneumatocele is therefore considered to be an appropriate and effective therapeutic approach.

Stanford type A acute aortic dissection(AAAD)is a life-threatening cardiovascular emergency, Early surgical repair is essential to prevent fatal outcomes, According to the 2023 Annual Report of the Japanese Association for Thoracic Surgery, AAAD cases increased by 4.4% in 2022, with an in-hospital mortality of 10% for AAAD, Although surgical outcomes have improved with advances in cerebral protection techniques, patients with cerebral malperfusion remain at high risk of poor neurological outcomes and mortality, with postoperative death rates reported between 15~30%, Antegrade selective cerebral perfusion(ASCP)is the standard method for cerebral protection during circulatory arrest, However, in AAAD patients with carotid artery occlusion or severe stenosis, conventional ASCP may result in uneven cerebral perfusion, risking ischemia in the affected hemisphere, To address this, we introduced a two-roller pump technique, in which each carotid artery(affected and non-affected)is perfused independently using separate ASCP circuits, Cerebral perfusion was monitored with transcranial Doppler and regional cerebral oxygen saturation(rSO2), The common carotid artery(CCA)was exposed via median sternotomy without additional neck incision, and direct cannulation was performed to establish targeted perfusion, The two-roller pump technique allowed independent regulation of flow and pressure for each carotid artery, Intraoperative monitoring confirmed stable perfusion to all cerebral vessels, including the previously occluded CCA, The two-pump technique prevented uneven blood distribution, reduced cerebral ischemia time, and was associated with improved immediate neurological outcomes, It enables immediate, controlled reperfusion of the affected hemisphere, potentially improving neurological outcomes, and offers a practical option for urgent surgical management of severe cerebral malperfusion in AAAD.

Objective: This study aimed to evaluate the outcomes of surgical strategies for DeBakey typeⅢ retrograde Stanford type A dissection(RAAD), Methods:We retrospectively analyzed 46 patients with RAAD treated at our hospital, Surgical procedures included ascending aorta repair(AAR, n=20), total arch replacement(TAR, n=17), and thoracic endovascular aortic repair(TEVAR, n=9), Early and late outcomes were assessed, Results:The AAR group had shorter operative times but a higher incidence of long-term aortic-related mortality, The TAR group showed no long-term aortic-related mortality but experienced early complications such as spinal ischemia, In the TEVAR group, several patients required early reintervention, Conclusion:An individualized surgical strategy is essential for the management of RAAD, While secure entry closure may improve long-term outcomes, each approach carries specific risks, AAR and TEVAR remain appropriate options for selected cases.

The optimal management of Stanford type A acute aortic dissection with mesenteric malperfusion(AMI)is controversial, Our strategy of AMI is open superior mesenteric artery(SMA)bypass prior to aortic repair, if we suspect AMI on computed tomography(CT)scan, whatever other findings might be or not, The need of treatment of mesenteric malperfusion prior to aortic repair is not always concerned with digestive symptom, lactate, intraoperative finding, The mortality was 15.8%, which was an allowable result, Our strategy might be proper at instances of, allowable time for management of open SMA bypass, unnecessarily of endovascular treatment, confirming an enteric property and ability to respond to various rapid hemodynamic changes.

In a 77-year-old man, there was difficulty in removing a guidewire that had strayed into the right ventricle during leadless pacemaker insertion. Surgical removal was required. During removal of the wire, the tendon cords of the anterior tricuspid valve were pulled out, resulting in acute severe tricuspid regurgitation. The patient underwent tricuspid valve repair under cardiac arrest. He had a good postoperative course, a permanent pacemaker was implanted on postoperative day 14, and he was discharged on postoperative day 20. Although complications associated with catheter procedures have been increasing in recent years, there have been no reports of cases in which a guidewire became entangled in the tendon cords of the tricuspid valve. We discuss the cause of this case from the viewpoint of preventing recurrence and refer to acute tricuspid regurgitation that occurred during the removal of the catheter.

We report two cases of metastatic cardiac tumors managed surgically. Case 1 involved a 52-year-old man with colorectal cancer and pulmonary metastases who developed respiratory distress during chemoradiotherapy. Imaging revealed a right atrial mass extending into the right ventricle. Mass reduction of the intracardiac tumor was surgically performed to reduce embolic risk and to enable subsequent chemotherapy. Postoperative chemotherapy resulted in complete remission without recurrence. Case 2 involved a 50-year-old woman with cervical cancer who experienced worsening dyspnea during treatment. Positron emission tomography (PET) and echocardiography identified a tumor extending from the right atrium to the pulmonary artery. As complete resection was unfeasible, mass reduction with tricuspid valve replacement was performed, followed by chemotherapy. The patient remains alive. Pathology confirmed metastatic cardiac tumors in both cases. These tumors present variably depending on the primary cancer and metastatic pattern, making diagnosis and treatment challenging. In symptomatic cases, especially with heart failure or embolism, prompt surgical intervention is critical. Mass reduction can relieve symptoms and improve survival. A focused literature review is also included to support clinical decision-making.

We report a case of reoperation for pseudoaneurysm late after Bentall procedure. A 61-year-old man who had undergone Bentall procedure eight years previously was found to have fluid collection around the graft on routine computed tomography (CT) follow-up. Contrast-enhanced CT revealed extravasation of contrast medium, and he was diagnosed with a pseudoaneurysm of the aorta. During surgery, extracorporeal circulation was temporarily stopped prior to resternotomy to avoid massive hemorrhage. The pseudoaneurysm was due to dehiscence of 4/5 circumference of the proximal suture line. The previous composite graft was removed and replaced with a new graft. The patient recovered well and was discharged on postoperative day 12. This case illustrates the importance of regular imaging surveillance after aortic root replacement and careful surgical planning for reoperations to prevent catastrophic bleeding complications.

The patient is an 86-year-old woman. She had ascites and was being treated with diuretics, but developed dyspnea, so a chest computed tomography( CT) scan was performed which revealed right pleural effusion. After aspiration of pleural effusion, abdominal distention due to ascites decreased and video-assisted thoracoscopic surgery was performed on suspicion of pleuroperitoneal communication. The diaphragm was sutured using an automatic suture device because a hole was found in the diaphragm. Insufflation into the abdominal cavity technique was safety and useful for identifying pleuroperitoneal communication.

A 76-year-old woman was admitted to our hospital with an abnormal shadow on a chest computed tomography (CT) scan. A chest magnetic resonance imaging (MRI) revealed an anterior mediastinal cyst of 7 cm in diameter with an internal septal-like structure, leading to the differential diagnosis of mediastinal lymphangioma. After administering milk, we performed video-assisted thoracoscopic excision of the lesion. After excision of the cyst, no cloudy fluid leakage was observed from the excised margin. Immunohistochemical analysis showed that the cells lining the cyst walls were stained positive for D2-40, therefore the lesion was diagnosed as a mediastinal lymphangioma. Mediastinal lymphangioma is rare, and postoperative lymphatic leakage is common in surgical cases. In this case, mediastinal lymphangioma was selected as the differential diagnosis based on the preoperative MRI findings, and complete resection was achieved without complications by administering milk before surgery.