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

We present the case of 60s male who underwent ductus arteriosus closure at the age of 10. He presented with hoarseness and a 25 mm-sized saccular aortic aneurysm was identified at the site of the closed ductus through the computed tomography( CT). The patient successfully underwent 1-debranch thoracic endovascular aortic repair resulting in improved hoarseness. While rare, several reports have documented aneurysm formation long after ductus arteriosus closure. Recent studies highlight favorable outcomes with endovascular repair. Despite its rarity, aneurysmal formation after ductus closure remains a serious complication. Given the increasing population of patients with prior ductus arteriosus closure and the discontinuation of long-term follow-up, awareness of the complication of aneurysmal formation is crucial. Not only congenital cardiologists but also general physicians should consider this differential diagnosis for patients presenting with symptoms such as hoarseness or back pain and a history of ductus closure.

A 66-year-old man developed exertional dyspnea. The patient had undergone total arch replacement for a dissecting aortic arch aneurysm at the age of 53 and conservative treatment for myocardial infarction at the age of 60. Several imaging studies revealed a giant pseudoaneurysm that likely originated from a true ventricular aneurysm. The pseudoaneurysm severely compressed the right ventricle. Surgery was promptly performed. The patient had a history of cardiac surgery and had exclusively dense pericardium adhesion. Therefore, we incised the pseudoaneurysm and sutured the rupture orifice directly from inside the pseudoaneurysm under rapid pacing. This approach may represent an effective surgical alternative in patients with small rupture orifice and dense adhesions.

A 69-year-old woman was diagnosed with a pacemaker infection after generator-exchange. Eight years ago, she underwent mitral and tricuspid valve replacement and had biventricular pacing with three pairs of epicardial leads placed in the right atrium, right ventricle, and left ventricle for left ventricular dysfunction. Skin perforation due to infection was detected 1 month after generator-exchange. At first, antibiotic treatment, generator-re-exchange, and pocket repositioning surgery were performed. Following all these failed attempts, a temporary pacemaker was placed, the infected generator was removed, and the lead was cut short. Eight days later, new intravenous caradiac resynchronization therapy pacemaker (CRT-P) implantation was performed. However, despite the repeat debridement, infection at the lead stumps recurred. Moreover, plain chest computed tomography (CT) revealed an abscess around the leads in the anterior mediastinum. Eventually, leads were removed under extracorporeal circulation via re-sternotomy. Postoperative course was uneventful, and she has been doing well without recurrence of infection for 6 years after operation.

An 84-year-old woman was referred to our department with an abnormal mass detected on a chest computed tomography (CT) scan. The CT scan revealed a tumor between the sternum and the right ventricle, fed by the left internal thoracic artery. Multiple hepatic nodules were also observed. An ultrasound-guided biopsy was performed on the liver nodule, which was diagnosed as a solitary fibrous tumor. The tumor was compressing the heart, and the patient was at risk of sudden death, therefore, a decision was made to resect tumor. Preoperative embolization of the left internal thoracic artery was performed to prevent massive intraoperative bleeding. The tumor was resected via a median sternotomy approach. Intraoperatively, feeding vessels entering the tumor from the diaphragm were also identified. Total blood loss was 70 ml. The postoperative course was uneventful.

The management of patients on direct oral anticoagulants (DOACs) who require an emergency cardiac surgery has been disputed in Japan. Recently, the use of andexanet alfa as an antidote for apixaban and rivaroxaban, is approved in the setting of life-threating or uncontrollable major bleeding. However, the efficacy and safety of andexanet alfa have been investigated. We report a case of 72-year-old man taking rivaroxaban who required the emergency coronary artery bypass grafting. He received andexanet alfa prior to the operation. Heparin resistance was noted before starting cardiopulmonary bypass. Consideration should be given to the use of andexanet alfa before or during cardiopulmonary bypass.

Inhaled nitric oxide( iNO) therapy is commonly used to improve pulmonary hypertension and oxygenation in adult patients undergoing open heart surgery, mostly being applied to mechanical ventilation (MV). We often face rebound of pulmonary artery pressure (PAP) after reduction or discontinuation of iNO therapy, resulting in prolonged MV. Twenty-three cases, to which iNO therapy during MV (MV-iNO) were initiated, then continuously treated with iNO therapy using high-flow nasal cannula (HFNC-iNO) after extubation, were retrospectively investigated. During MV-iNO, mean PAP( mPAP) was significantly lower than before starting iNO therapy (p<0.001). Also, mPAP on HFNC-iNO was significantly lower than mPAP before iNO therapy during MV (p<0.001). There was no significant difference of mPAP between MV-iNO and HFNC-iNO (p=0.38). MV was discontinued in 330 minutes (median), oxygenation was maintained after switching from MV-iNO to HFNC-iNO and there were no cases of reintubation, perioperative mortality, or adverse events due to iNO therapy. HFNC-iNO is considered as useful method in maintaining decreased mPAP and improved oxygenation after extubation in adult patients after open heart surgery.

A 46-year-old man was treated with ascites due to idiopathic portal hypertension. Chest X-ray showed a massive pleural effusion on the right side. Also, contrast-enhanced ultrasonography showed that contrast medium was effusing from abdominal cavity into the thoracic cavity via diaphragm. He was diagnosed with pleuroperitoneal communication. Thoracoscopic surgery was performed and thoracoscope revealed ascites with indocyanine green (ICG) drained from multiple cystic area in the central tendon of the diaphragm. After suturing with non-absorbable thread with reinforcement, the whole diaphragm was covered with a polyglycolic acid sheet and fibrin glue. Postoperatively, there was no reaccumulation of pleural effusion. ICG fluorescence intraoperative imaging was an useful method in detecting the pleural holes.

An 80-year-old man had a guidewire in his aorta since catheter laboratory accident 4 years ago. He recently started to suffer mental distress and underwent coronary angiography that revealed an entrapped guidewire and significant stenoses in each of three major coronary arteries. The guidewire could not be removed using transcatheter technique. Thus, after careful consideration, we decided to perform entrapped guidewire removal through minimally invasive surgical approach instead of median sternotomy. Post-operative course was uneventful. Although surgical approach should be tailored in each case, minimally invasive approach can be a choice for entrapped guidewire removal.

Some cases of coronary artery occlusion by prosthetic valves after surgical aortic valve replacement (SAVR) may be diagnosed and treated during operation if it is difficult to be separated from cardiopulmonary bypass. We present a case of a 74-year-old woman with symptomatic aortic stenosis due to bicuspid valve and a narrow aortic valve annulus. SAVR was considered to be feasible over transcatheter aortic valve implantation given her anatomy and frailty. A few hours after successful SAVR using a 19 mm bioprosthetic valve, she became hemodynamically unstable in the intensive care unit, and coronary angiography revealed severe stenosis at the right coronary artery orifice. Percutaneous coronary intervention was deemed technically demanding, and she subsequently underwent coronary artery bypass grafting. On the 35th postoperative day, the patient was transferred to another facility for rehabilitation. Two years after surgery, she has no chest symptoms and constantly visits the outpatient clinic by herself.

Pancreatic pseudocysts rarely extend to the mediastinum and can be fatal if mediastinitis is complicated. In this report, we describe a case of mediastinitis associated with mediastinal pancreatic pseudocyst successfully treated by the thoracoscopic mediastinal drainage. The patient was a man in his 40s with a history of alcoholic acute pancreatitis. Chest and abdominal computed tomography (CT) scan taken for his complaints of back pain and dyspnea showed a pancreatic pseudocyst extending to the mediastinum. First, an endoscopic nasopancreatic drainage( ENPD) tube was placed, and then thoracoscopic mediastinal drainage was performed through the right thoracic cavity. After the operation, the pseudocyst in the mediastinum rapidly disappeared even though there was no drainage from the ENPD tube. Postoperative recovery of the patient was uneventful, and the patient was discharged on the 17th postoperatively day. This case suggests that the importance of prompt treatment for mediastinitis and the effectiveness of the thoracoscopic surgery.