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

Spontaneous rupture of the aorta is a rare, lethal condition that is hard to diagnose preoperatively. We report two cases of patients who presented with sudden-onset chest or pharyngeal pain. Contrast-enhanced computed tomography (CT) showed an ulcer-like projection, mediastinal hematoma, and pericardial effusion, but no definitive intimal flap. Emergency surgery was performed with a tentative diagnosis of thrombosed-type aortic dissection. In both cases, there was a localized aortic transmural laceration with a thrombus near the sino-tubular junction on the pulmonary artery side. Based on a focal intimal defect with no or minimal dissection in adjacent area, the diagnosis of spontaneous rupture of the aorta was made. Both patients were successfully treated with replacement of the ascending aorta and had favorable outcomes. When hemopericardium or mediastinal hematoma is present without clear evidence of aortic aneurysm or dissection, spontaneous rupture of the aorta must be considered, as prompt surgical intervention is crucial for survival.

A 78-year-old man with a history of surgery for rectal cancer three years before underwent hybrid surgery for a 35-mm right subclavian artery aneurysm. First, the vertebral artery was transposed to the common carotid artery to maintain its bloodstream. Second, axillo-common carotid artery ipsilateral bypass was constructed to preserve the carotid-artery flow. Finally, endovascular repair was performed via the axillary artery to exclude the subclavian artery aneurysm. A 13-mm×10-cm GORE VIABAHN and subsequently an upside-down 27-mm×14-cm GORE EXCLUDER Contralateral Leg were placed from the brachiocephalic artery to the subclavian artery distal to the aneurysm with coiling of the internal thoracic artery and ligation of the proximal common carotid artery. No postprocedural neurological complication occurred despite occlusion of the transposed vertebral artery on contrast-enhanced computed tomography (CT). The patient was uneventfully discharged 11 days after the hybrid surgery. Less invasive hybrid surgery may be useful to repair a right subclavian artery aneurysm.

A 75-year-old man with a history of aortic valve replacement was referred to our department with a diagnosis of prosthetic valve endocarditis. Although antibiotics treatment was initiated, infection progressed rapidly to develop aortic root abscess and pseudoaneurysm. The patient underwent urgent surgery which included extensive debridement of near-circumferential infected annulus. Aortic annulus reconstruction with a bovine pericardial patch was performed followed by aortic valve replacement. The postoperative course was uneventful and the patient was discharged from the hospital after six weeks of intravenous antibiotic therapy. The causative bacteria were identified as Cutibacterium species by 16S ribosomal deoxyribonucleic acid( rDNA) sequencing, following 56 days of blood sample incubation collection. Due to slow growth of the pathogen, endocarditis by Cutibacterium species is known for gradual progression and difficulty in pathogen identification. The present case highlights that endocarditis by Cutibacterium may cause rapid progression with extensive tissue destruction. 16S rDNA sequencing was useful in identifying the pathogen. Extensive debridement and reconstruction of the aortic annulus with a bovine pericardium a successfully salvaged the patient.

A 73-year-old woman underwent total arch replacement with an open stent graft for a distal arch thoracic aortic aneurysm. Six months later, purulent discharge appeared from the upper edge of the median sternotomy wound. She had no fever, inflammatory markers were minimal, and repeated bacterial, fungal, and mycobacterial cultures were negative. Computed tomography (CT) revealed a peri-graft abscess extending to the upper mediastinum. Because local wound care failed, redo sternotomy, thorough irrigation, and pedicled omental flap filling around the graft were performed nine months after the initial operation. Intraoperative cultures were also negative, and the lesion was diagnosed as a sterile peri-graft abscess. She has remained free from recurrence for one year after reoperation.

A 45-year-old obese woman on long-term hemodialysis presented with fever and dizziness. Blood cultures revealed Streptococcus agalactiae, and echocardiography demonstrated large mobile vegetations on the mitral valve with preserved valve function. Chronic pyoderma involving the lower abdomen, groin, and vulva was considered the probable source of bacteremia. Because of severe obesity, multiple comorbidities, and extensive skin infection in the inguinal region, minimally invasive cardiac surgery (MICS) via right thoracotomy was performed, avoiding median sternotomy and femoral cannulation. Cardiopulmonary bypass was established using right axillary artery perfusion and jugular and inferior vena cava drainage. Vegetations were successfully removed without mitral valve repair. The postoperative course was uneventful, and no recurrence of infection was observed during two years of follow-up. This case highlights the feasibility of alternative cannulation strategies in MICS for infective endocarditis complicated by extensive skin disease.

High-flow arteriovenous fistulas (AVFs) in hemodialysis patients can cause significant hemodynamic stress by increasing venous return and right ventricular preload, sometimes leading to pulmonary hypertension (PH) and high-output heart failure. We report two hemodialysis patients who underwent cardiac surgery and unremitting exertional dyspnea and intradialytic hypotension despite improved leftheart function. In case 1, a 74-year-old man demonstrated an AVF flow of 2.91 l/min with a resistance index of 0.47. In case 2, a 74-year-old man had an AVF flow of 3.84 l/min and resistance index of 0.46. Both patients underwent surgical closure of the high-flow AVF. Following intervention, estimated pulmonary artery systolic pressure decreased from 55 to 25 mmHg in case 1 and from 35 to 25 mmHg in case 2. In both cases, patients became hemodynamically stable during dialysis sessions without need for vasopressors. These outcomes underscore that persistent PH after cardiac surgery in dialysis patients may be attributable to excessive AVF flow, which is a potentially manageable factor. Quantitative flow measurement (Qa) and the Qa/cardiac output ratio should be incorporated into routine evaluation, and timely intervention should be considered. Our experience highlights the clinical importance of recognizing high-flow access as a treatable cause of post-cardiac surgery PH.

We experienced a case of a giant aortic aneurysm caused by untreated syphilis infection. The patient was a 68-year-old male who was asymptomatic. An ascending aortic aneurysm and moderate aortic valve regurgitation were detected during transthoracic echocardiography, and preoperative blood tests revealed a syphilis infection. The patient underwent ascending-to-total arch replacement and sino-tubular(ST) junction plication. Postoperatively, antibiotic therapy was initiated immediately. The pathological diagnosis confirmed that the aneurysm was caused by untreated syphilis infection. The postoperative course was favorable, and the patient was discharged on postoperative day 22. As of 36 months post-surgery, the patient remained in good condition.

An 81-year-old woman underwent endovascular treatment for a cerebral aneurysm under general anesthesia with intubation using a 7.0-mm endotracheal tube. Shortly after extubation, she developed hemoptysis. Bronchoscopy revealed a longitudinal laceration and bleeding of the tracheal membranous wall, extending from approximately 4-cm below the vocal cords to near the carina. Hemostasis was achieved with diluted epinephrine. Chest computed tomography (CT) showed no pneumomediastinum or perforation. Given her stable condition and that the injury was confined to the mucosal layer, conservative management was chosen. Follow-up bronchoscopy on day 5 showed healing without rebleeding or stenosis. This case highlights the importance of careful risk assessment and appropriate endotracheal tube size selection, particularly in elderly, small-framed women. It is important to develop an algorithm for selecting endotracheal tube size based on risk factors such as age, sex, and body habitus, in order to prevent tracheal injury.

We report the case of a 19-year-old woman with partial anomaly of pulmonary venous return (PAPVR) associated with a secundum atrial septal defect( ASD). She initially presented with dyspnea during a febrile episode and was diagnosed with ASD but was lost to follow-up. One year later, she developed progressive exertional dyspnea. Contrast-enhanced computed tomography (CT) demonstrated anomalous drainage of the right upper pulmonary vein into the superior vena cava, confirming the diagnosis of PAPVR. Elective surgical repair using the double-decker technique was performed. Postoperative recovery was uneventful, and she was discharged without complications.

Chylothorax is an uncommon but clinically relevant complication following thoracic aortic surgery. Although conservative management is usually the initial approach, persistent high-output chylous effusion may require surgical intervention, for which accurate identification of the leakage site is important. We describe two cases of refractory postoperative chylothorax following aortic surgery, in which surgical management was guided by intranodal lipiodol lymphangiography combined with computed tomography (CT). The first patient developed chylothorax after descending aortic replacement via left thoracotomy for chronic Stanford type B aortic dissection. Despite fasting, total parenteral nutrition, and octreotide administration, chylous drainage persisted. Lymphatic imaging suggested a localized leak adjacent to the distal anastomosis of the descending aortic graft, and direct local ligation was performed. The second patient developed chylothorax after total aortic arch replacement for a distal arch aneurysm. Imaging demonstrated chyle leakage from the dorsal aspect of the arch graft, where local repair was considered difficult;therefore, thoracoscopic thoracic duct ligation via a right-sided approach was selected. In both cases, chylothorax resolved promptly after reoperation without recurrence. Lipiodol lymphangiography combined with CT provides valuable anatomical information for identifying the leakage site and thoracic duct course, thereby facilitating selection of an appropriate, case-specific surgical strategy in refractory postoperative chylothorax.