General Thoracic and Cardiovascular Surgery Cases最新文献

Background: Thymic adenocarcinoma is a rare histological subtype of thymic carcinoma. Non-mucinous enteric-type thymic adenocarcinomas are extremely rare.

Case presentation: A 54-year-old woman with an abnormality detected on chest radiography was admitted to our hospital. Chest computed tomography showed a 5.5-cm-diameter mass in the anterior mediastinum. Blood carcinoembryonic antigen (CEA) level was highly elevated at 127 ng/ml (normal < 5), while other tumor markers, including alpha-fetoprotein, β-human chorionic gonadotropin, and interleukin-2R levels, were normal. Radiological findings suggested that the tumor was a thymic epithelium (Masaoka stage III). Surgery is performed for diagnostic and therapeutic purposes. Intraoperative findings revealed extensive pericardial invasion requiring a median sternotomy. The left brachiocephalic vein, pericardium, and lungs were resected along with the tumor to achieve complete resection. Histological findings revealed that the tumor was composed of tall, columnar adenocarcinoma forming irregular lumina with no mucin production. Immunohistochemistry showed that cytokeratin 20 was partially positive and caudal type homeobox 2 was positive in approximately 50% of the tumor cells. Based on the morphological and immunohistochemical findings, enteric-type thymic adenocarcinoma was diagnosed per the 5th edition of the World Health Organization classification. The tumor was subtyped according to the Masaoka (stage IVB) and TNM classification criteria (T3N1M0 stage IVA). Plasma CEA levels decreased to normal levels after surgery. Further genetic analysis of the tumor revealed a pathogenic TP53 stop-gain mutation (p.Arg213*), leading to the loss of p53 protein function. Postoperative adjuvant radiation therapy (54 Gy in 27 fractions) was administered under the suspicion of incomplete microscopic resection. Reportedly, the patient is in complete remission four years post-surgery.

Conclusions: We encountered a rare case of non-mucinous enteric-type thymic adenocarcinoma harboring a pathogenic TP53 mutation. Further studies are required to enunciate the features of this subtype of thymic carcinoma.

Background: Cardiac hemangiomas located in the right heart can lead to serious complications, including right ventricular outflow tract (RVOT) obstruction, arrhythmias, and sudden cardiac death. Although surgical resection remains the primary treatment, complete excision of intramural tumors poses risk of impairing cardiac function. This case report describes the successful resection of a large right ventricular hemangioma using intraoperative voltage mapping, which enable maximal tumor removal while preserving myocardial integrity and preventing postoperative heart failure.

Case presentation: A 76-year-old female underwent a routine health examination in July 2024, during which cardiomegaly and nonspecific ST-segment changes were detected on electrocardiography. Contrast enhanced computed tomography revealed a well-defined 60 mm mass within the right ventricle, causing significant ROVT stenosis. No evidence of distant metastasis or elevated tumor markers was detected. The patient underwent tumor resection via median sternotomy. Intraoperative voltage mapping was utilized to delineate viable myocardium at the tumor margins. The tumor was excised while preserving functional myocardial tissue. Cryoablation was performed at the resection margins, and resultant defect in the right ventricular wall was reconstructed using a bovine pericardial patch. Histopathological analysis confirmed the diagnosis of cardiac hemangioma. The patient experienced an uneventful postoperative course had no postoperative complications and was discharged on postoperative day 16. Preoperative and postoperative cardiac magnetic resonance imaging demonstrated preserved right ventricular function.

Conclusions: Intraoperative voltage mapping proved to be a valuable adjunct in the surgical management of right ventricular tumors, enabling effective tumor resection while preserving myocardial tissue and maintaining postoperative cardiac function.

Background: Orthotopic heart transplantation after the Fontan operation presents technical surgical challenges due to the connection of systemic veins to pulmonary arteries and well-developed systemic-to-pulmonary collateral arteries. The altered anatomy and hemodynamics necessitate extensive vascular reconstruction. We report a successful orthotopic heart transplantation with three years of ventricular assist device (VAD) support in a child who had undergone the Fontan operation.

Case presentation: A 10-year-old boy had undergone extracardiac total cavopulmonary connection (18 mm expanded polytetrafluoroethylene conduit) at 2 years of age for a large ventricular septal defect, straddling tricuspid valve, and mitral stenosis. Following the Fontan operation, his systemic ventricular function gradually deteriorated. At 7 years of age, a Berlin Heart EXCOR® Pediatric VAD was implanted due to progressive heart failure, and he was listed for heart transplantation. Three years later, a heart transplant was performed. Cardiopulmonary bypass was established via cervical cannulation before re-sternotomy. The superior vena cava and extracardiac conduit were detached from the pulmonary artery. The pulmonary artery was reconstructed from hilum to hilum with a large bovine pericardial patch. Well-developed systemic-to-pulmonary collaterals caused excessive left atrial return; therefore, the left atrial anastomosis was performed under deep hypothermic circulatory arrest. The systemic veins were reconstructed with bicaval anastomosis, and inferior vena caval continuity was restored by leaving a short segment of the previous conduit. The procedure was completed without complications. Postoperative recovery was uneventful, and the patient was discharged on day 35.

Conclusions: This case illustrates a successful approach to orthotopic heart transplantation in a child with failing Fontan circulation supported by a VAD. Reconstruction of the pulmonary artery using a large pericardial patch and restoration of bicaval continuity were key to overcoming complex anatomical challenges.

Background: As breast cancer grows slowly, recurrences more than 10 years after surgery are not uncommon. However, isolated metastasis to the thymus without extra-mediastinal lesions is extremely rare.

Case presentation: A 51-year-old woman underwent right mastectomy for right breast cancer 10.5 years ago. Following surgery, she received adjuvant chemotherapy, radiotherapy, and 10 years of anti-estrogen therapy, with no evidence of recurrence during that period. However, due to a slow upward trend in carcinoembryonic antigen levels, PET imaging was performed and revealed an irregular tumor measuring 20 × 27 × 75 mm in diameter. This consisted of both cystic and solid components, and was located within the thymus, just above the left brachiocephalic vein, with an abnormal 18 F-fluorodeoxyglucose uptake. The tumor was confined to the thymus, with no lesions were detected in the lungs or any other organs. Differential diagnoses included thymic hyperplasia, thymoma, thymic carcinoma, and malignant lymphoma. We performed thymectomy via median sternotomy for both diagnosis and treatment. Immunohistochemical staining confirmed isolated thymic metastasis of breast cancer. The patient is currently being treated postoperatively with aromatase inhibitor and cyclin-dependent kinase 4/6 inhibitor.

Conclusion: We present a surgical case of an extremely rare asynchronous, isolated thymic metastasis that occurred over 10 years after initial breast cancer surgery. This case underscores the importance of considering thymic metastasis in the differential diagnosis of anterior mediastinal tumors in patients with a remote history of breast cancer.

Background: Antiphospholipid syndrome (APS) is an autoimmune prothrombotic disorder that is frequently associated with systemic lupus erythematosus (SLE). Cardiac surgery in patients with APS presents unique challenges because activated clotting time (ACT) monitoring can be unreliable, frequently yielding falsely prolonged results due to the presence of lupus anticoagulant. Although heparin concentration-based monitoring is more accurate, devices such as the Hemostasis Management System Plus have been discontinued, creating a gap in practical anticoagulation management.

Case presentation: We report two female patients with APS and severe aortic regurgitation (AR) who underwent aortic valve replacement (AVR) under cardiopulmonary bypass (CPB). Case 1: A 58-year-old woman with long-standing SLE and APS underwent preoperative ACT simulation using her serum mixed with a 60 U/mL heparin solution to estimate the ACT corresponding to a heparin concentration of 3.0 U/mL. The resulting ACT range (567-708 s) guided intraoperative anticoagulation. AVR with a mechanical valve and left atrial appendage amputation (LAAA) was performed. Protamine was administered at half the calculated dose. Postoperative bleeding was transient and well controlled. Case 2: A 62-year-old woman with recent APS, deep vein thrombosis, and infective endocarditis underwent ACT simulation. The simulated ACT ranged from 325 to 413 s, and an intraoperative ACT target of > 450 s was established. AVR and LAAA were performed uneventfully with half dose protamine. No thrombotic or bleeding complications occurred.

Discussion: These cases highlight the limitations of conventional ACT monitoring in patients with APS and demonstrate the utility of individualized preoperative ACT simulation as a practical alternative. This approach allowed safe anticoagulation management without requiring advanced equipment. Reduced protamine dosing likely minimized the risk of rebound hypercoagulability, a concern in APS. Notably, despite identical heparin concentrations, ACT responses varied among the patients, underscoring the need for personalized strategies.

Conclusion: Preoperative ACT simulation using patient serum offers a practical, accessible, and individualized method for guiding anticoagulation therapy in patients with APS undergoing cardiac surgery. This technique may enhance perioperative safety in resource-limited settings, and warrants further validation in larger cohorts.

Background: Surgical site infections following median sternotomy are common and can lead to extended hospital stays, prolonged courses of intravenous antibiotics, increased healthcare costs, and, in many cases, the need for repeated debridement or additional surgical interventions. Recognizing this significant unmet clinical need, we adopted an alternative approach in the present case report to address and resolve the problem.

Case presentation: We herein report a case of a 52-year-old female patient, that developed a deep incisional infection with localized dehiscence after a median sternotomy performed for left atrial myxoma removal. Klebsiella aerogenes was cultured from the wound swabs and, despite prolonged intravenous antibiotic therapy and regular debridement we were unable to obtain culture negativity or wound healing over the course of several weeks. A commercially available Taurolidine 2% solution was employed every other day to irrigate the wound, which led to culture negativity within five days. Complete reepithelization was reached after a total of five weeks.

Conclusion: Reports of various taurolidine solutions promoting healing in complex wound lesions are scarcely available. In our case it proved to be an effective therapeutic option, preventing the need for additional surgical intervention and facilitating healing by secondary intention.

Background: The prevalence of atrial fibrillation (AF) is increasing in Japan, largely because of the aging population. Catheter ablation, particularly pulmonary vein isolation, is a widely adopted intervention for maintaining sinus rhythm. We report a case of robot-assisted lobectomy for lung adenocarcinoma in a patient with a history of cryoablation for AF.

Case presentation: A 76-year-old man with paroxysmal AF and prior cardiogenic stroke was referred for catheter ablation. Pre-ablation chest computed tomography revealed an enhancing 18 × 15 mm nodule in the right lower lobe, suggestive of lung cancer. The patient underwent cryoballoon ablation with successful pulmonary vein isolation. Three months later, a robot-assisted right lower lobectomy was performed. Intraoperatively, dense inflammatory adhesions were observed around the inferior pulmonary vein, likely induced by prior ablation, which significantly impeded dissection. The surgical technique was adapted accordingly, including the use of a 45-mm blue stapler owing to the increased tissue thickness. No adhesions were observed around the pulmonary artery or the bronchi. Lobectomy with lymph node dissection was performed without complications. The postoperative course was uneventful, and the patient was discharged on postoperative day 7.

Conclusion: This case highlights the need for heightened intraoperative caution during lobectomy in patients with a history of catheter ablation. Ablation-induced adhesions around the pulmonary veins can obscure anatomical landmarks and complicate robot-assisted thoracic surgery, thereby increasing technical difficulty and potential procedural risks.

Background: Accurately distinguishing between coronary arteriovenous malformations (CAVMs) and fistulas is challenging. We encountered a case of preoperatively undiagnosed CAVM.

Case presentation: We report the case of a 45-year-old woman diagnosed with cardiac enlargement during a routine health examination. Transthoracic echocardiography showed normal left ventricular systolic function with an ejection fraction of 68%, normal valve function, and a well-defined mass adjacent to the posterior and inferior cardiac walls of the left ventricle. Transesophageal echocardiography revealed a solid mass with a partial honeycomb structure adjacent to the posterior cardiac wall of the left ventricle. A contrast-enhanced computed tomography (CT) scan revealed a solid mass (115 × 79 × 30 mm) with heterogeneous enhancement adhering to the posterior wall and arterial inflow into the mass. Angiography of the right coronary artery revealed mild contrast agent pooling in the venous phase, suggesting the presence of a nutrient vessel in the mass. Cytological examination and histopathological diagnosis after CT-guided needle biopsy revealed Class III tumor with no malignant findings. Considering the challenges in diagnosis with the current tests and the potential risk of cardiac tamponade caused by repeated biopsies, we adopted a policy that tumorectomy should be performed to elucidate the diagnosis. Additional surgical procedures could then be conducted if the intraoperative diagnosis showed a malignant tumor. Intraoperative findings showed that the mass was firmly adherent to the heart between the inferior and lateral walls of the left ventricle. The intraoperative diagnosis of the tumor showed no malignancy. Planned tumorectomy was performed after careful dissection of tumor adhesion. Part of the left marginal vein of the coronary sinus that could not be dissected from the adhesions was resected. Immunohistochemical studies demonstrated CD31+ vascular endothelium, suggesting that the mass was an arteriovenous malformation. The patient's postoperative course was uneventful, without any signs of recurrence.

Conclusion: This case highlights the difficulty of diagnosing CAVM preoperatively and shows that when tumor imaging is ambiguous, CAVM should be considered and early surgical exploration is crucial.