General Thoracic and Cardiovascular Surgery Cases最新文献

Background: In patients with uterine leiomyosarcoma and multiple pulmonary metastases complicated by pneumothorax during chemotherapy, repeated metastasectomy may contribute to long-term survival.

Case presentation: A 45-year-old woman underwent total hysterectomy for uterine leiomyosarcoma. She subsequently developed multiple pulmonary metastases and was treated with gemcitabine plus docetaxel (GD) chemotherapy. During the course of chemotherapy, she developed a pneumothorax, possibly as a consequence of tumor necrosis induced by treatment. Due to a rapidly declining in the performance status (PS), right lower lobectomy was performed to manage the pneumothorax and reduce the tumor burden. GD chemotherapy was resumed postoperatively but discontinued after a total of 14 cycles due to adverse events. As anticipated, the pulmonary metastases regrew. However, no evidence of extrathoracic disease was identified, and her respiratory function was deemed sufficient for surgery. She subsequently underwent one-stage partial bilateral lung resections, during which a total of 12 metastatic nodules were removed. Two years later, two additional metastatic lesions were resected. Since that time, 5 years and 8 months have passed without any recurrence or additional treatment. At the time of reporting, the patient had remained disease-free, 16 years after the initial hysterectomy, with PS of 0.

Conclusion: Uterine leiomyosarcoma is an aggressive tumor; however, in selected cases, long-term survival may be achieved through multimodal treatment approaches, including surgical resection of metastatic lesions.

Background: Boerhaave syndrome is a life-threatening condition caused by a spontaneous full-thickness rupture of the esophagus, typically following forceful vomiting. Esophageal variceal rupture is another potentially fatal condition commonly observed in patients with liver cirrhosis. These two conditions are usually reported independently, and their coexistence is extremely rare. Managing this combination is particularly challenging because of the need for both infection control and hemostasis in the presence of portal hypertension.

Case presentation: We report the case of a 51-year-old man with liver cirrhosis (Child-Pugh Grade B) and a history of endoscopic variceal ligation, who presented with hematemesis followed by vomiting. He had not consumed any alcohol at that time and exhibited no signs of melena. Computed tomography revealed mediastinal emphysema, right-sided hemopneumothorax, and esophageal perforation. Endoscopy confirmed a lower esophageal tear with active variceal bleeding. Emergency surgery was performed via a right thoracotomy. A 35-mm longitudinal tear in the lower esophagus was identified and sutured; however, owing to tissue fragility and signs of infection, a T-tube was placed at the perforation site. The patient had an uneventful postoperative course, resumed oral intake on postoperative day 17, and was discharged without any complications on day 46.

Conclusions: This was a rare case of Boerhaave syndrome complicated by ruptured esophageal varices. Surgical management with T-tube drainage was effective in controlling both infection and bleeding. Patients with esophageal varices may be at an increased risk of esophageal rupture, especially following vomiting. Awareness of this association is essential for timely diagnosis and management.

Background: Impending paradoxical embolism (IPDE) is a rare condition characterized by the presence of a thrombus in a patent foramen ovale. We were able to image a thrombus lodged in a patent foramen ovale and remove the thrombus before it could result in arterial embolism.

Case presentation: A 24-year-old woman was admitted to our hospital with chest pain and dyspnea. Pulmonary embolism was diagnosed via computed tomography. Additionally, transesophageal echocardiography revealed a thrombus lodged in a patent foramen ovale and fluttering in both atria, leading to a diagnosis of IPDE. Rather than incurring the risk associated with embolization by thrombolytic treatment, we elected to remove the incarcerated thrombus and close the patent foramen ovale under cardiopulmonary bypass.

Conclusions: We successfully treated a case of IPDE by removing the thrombus under cardiopulmonary bypass, before arterial thrombosis could occur.

Background: A pulmonary artery catheter (PAC) is widely used to manage various health conditions during cardiac surgery. However, it can cause rare but life-threatening complications such as pulmonary artery injury. Although surgical treatment is often required for pulmonary artery injury caused by a PAC, detailed reports of the surgical management of this complication are lacking. We present a case of PAC-induced pulmonary artery injury that occurred during cardiac surgery and was successfully managed with surgical treatment without pulmonary resection.

Case presentation: A 76-year-old woman with severe heart valve disease underwent replacement of the aortic and mitral valves and surgical repair of the tricuspid valve using a PAC. Massive bleeding into the airway occurred during withdrawal from cardiopulmonary bypass. Fluoroscopic contrast injection through the PAC identified a PAC-induced tear in the left pulmonary artery as the cause of the bleeding. Opening of the left fourth intercostal space was performed without changing the supine position of the patient. Bleeding was successfully controlled by ligating the damaged branch of the pulmonary artery (A6c) and suturing the roots of the peripheral pulmonary arteries (A9 and A10) without performing lung resection. The patient recovered without complications and was discharged in good condition.

Conclusions: Although PAC-induced pulmonary artery injury is associated with a high mortality rate, the patient survived cardiac surgery with lung preservation in the supine position.

Background: Infolding is a rare but potentially life-threatening complication of self-expanding transcatheter aortic valve replacement (TAVR).

Case presentation: We describe the case of an 80-year-old man who was referred for the treatment of severe aortic stenosis complicated by heart failure. Transthoracic echocardiography revealed the following: peak velocity, 6.1 m/s; mean pressure gradient, 102 mmHg; and aortic valve area, 0.26 cm². Computed tomography (CT) showed a bicuspid aortic valve with a R-L raphe, an annular area of 529 mm², and a perimeter of 83.4 mm. Considering the patient's severe emphysema, transfemoral TAVR was performed with the patient under deep sedation. A 34-mm Evolut FX valve was implanted after predilation with a 20-mm Inoue balloon. During deployment up to the point of no recapture, hypotension occurred without improvement, and mild infolding was suspected. However, full deployment was performed, as valve optimization was considered likely to stabilize hemodynamics. Post-deployment balloon dilation was performed; however, valve under-expansion and moderate aortic regurgitation persisted. Initial hemodynamics were stabilized; however, the patient gradually developed respiratory distress. Follow-up CT confirmed substantial valve infolding. Pulmonary hypertension, alveolar hemorrhage, and disseminated intravascular coagulation developed. Surgical aortic valve replacement with a 21-mm valve was performed 15 days post-TAVR. The explanted TAVR valve exhibited marked structural deformation. Although the patient's circulatory status improved postoperatively, he died of respiratory failure due to pneumonia.

Conclusion: This case highlights the importance of comprehensive preoperative anatomical assessment and intraoperative decision making in high-risk patients, particularly those with bicuspid valves. Valve selection (considering the valve type and size) must be meticulously tailored to the anatomical features surrounding the annulus. In addition, upon its recognition, substantial infolding should be promptly addressed by recapturing the valve, adjusting the valve size, or redeploying the valve with additional balloon aortic valvuloplasty.

Background: Total arch replacement with frozen elephant trunk (FET) has been reported to be associated with favorable aortic remodeling when used for aortic dissection. However, several complications associated with FET have been reported, including distal stent graft-induced new entry (dSINE), which potentially results in aortic rupture and late mortality. Frozenix Partial ET (Japan Lifeline Inc., Tokyo, Japan) is a unique FET device that has a non-stent zone at the distal 2 cm end to decrease the radial force to lower the incidence of dSINE. Owing to its novelty, there are few preceding literatures regarding its efficacy and complications. In this report, we present a case of an unanticipated complication arising from the use of Frozenix Partial ET subsequent to the initiation of extracorporeal membrane oxygenation (ECMO).

Case presentation: A 54-year-old male diagnosed with Stanford type A acute aortic dissection underwent emergency total aortic arch replacement, frozen elephant trunk with Frozenix partial ET (Japan Lifeline Inc., Tokyo, Japan), the Bentall procedure, and coronary artery bypass grafting. The patient developed cardiogenic shock, requiring extracorporeal membrane oxygenation with left common femoral artery and vein cannulation on postoperative day 1. Despite adequate ECMO flow, high doses of catecholamines were required to maintain blood pressure measured at the right radial artery. Transesophageal echocardiography revealed stenosis of the distal part of the FET presumably due to retrograde perfusion from the femoral artery. The addition of left axillary artery cannulation improved systemic circulation, reducing the dose of catecholamine.

Conclusion: Although designed to reduce the risk of dSINE, Frozenix Partial ET may induce unforeseen complications. Particularly, its non-stent distal part can become stenotic under conditions of retrograde perfusion. Surgeons should carefully choose where to cannulate in patients with this device requiring redo surgery or ECMO support.

Background: Delayed hemothorax due to aortic injury is rare, and its delayed diagnosis can be fatal. Herein, we report a case of delayed hemothorax owing to aortic injury following blunt chest trauma, which was successfully treated through emergency surgery.

Case presentation: A woman in her 70s fell on an escalator at a train station and was brought to our emergency department. Initial evaluation with computed tomography (CT) imaging revealed a thoracic vertebral fracture, bilateral lower rib fractures, and a right-sided hemothorax. She was admitted for observation and supportive care, and her condition remained stable for days. On day 9 of hospitalization, the patient suddenly experienced cardiac arrest. A plain chest X-ray showed a massive pleural effusion on the left side, prompting the insertion of a chest tube. The drainage was hemorrhagic, and laboratory tests showed a significant decline in the hemoglobin level to 4.9 g/dL. Following successful cardiopulmonary resuscitation and the return of spontaneous circulation, a contrast-enhanced CT scan of the chest was performed. However, no active extravasation or apparent source of bleeding was observed. Owing to ongoing hemodynamic instability and the substantial volume of hemothorax, emergency surgery was conducted to identify and control the source of hemorrhage. Intraoperatively, after evacuating a large hematoma from the left thoracic cavity, a small ulcerated hole was identified in the descending thoracic aorta, which appeared tortuous. Pulsatile bleeding was observed from this site. Manual compression was applied to achieve temporary homeostasis. Intraoperative ultrasound showed no evidence of aortic dissection. The bleeding site was sutured directly, and hemostasis was achieved. No additional significant intrathoracic injuries were identified. The aortic injury had resulted from mechanical irritation or penetration by the adjacent fractured lower rib. This represented a case of delayed hemothorax secondary to traumatic aortic injury, a rare but potentially fatal complication.

Conclusions: In cases of delayed hemothorax following blunt thoracic trauma-particularly with fractures of the lower left posterior ribs, clinicians should maintain a high index of suspicion for aortic injury. Prompt recognition and surgical intervention are critical for patient survival in such cases.

Management of resectable TXN2aM0 primary lung cancer is controversial, and data regarding the long-term outcomes and guideline recommendations for such cases are lacking. We present the characteristics and long-term outcomes of four patients who underwent complete thoracoscopic resection of TXN2aM0 primary lung cancer. All patients experienced an uneventful postoperative course and survived for 5 to 10 years postoperatively; however, one patient experienced local recurrence at 2 years postoperatively and one patient experienced local recurrence at 5 years postoperatively. Our limited experience suggested that long-term survival may be achieved with complete resection of TXN2aM0; however, late recurrence and local recurrence are possible.

Background: The Commando procedure, which involves replacement of both the aortic and mitral valves along with reconstruction of the intervalvular fibrous body, is technically demanding. Commando procedure typically performed via an incision extending from the ascending aorta to the roof of the left atrium. However, in patients with extensive adhesions due to prior cardiac surgery, adding a superior transseptal incision can provide good exposure and reduce the risk of surrounding tissue injury.

Case presentation: A 48-year-old woman with end-stage kidney disease on dialysis, diabetes mellitus, bilateral leg amputations from critical limb ischemia, and chronic steroid use presented in cardiogenic and septic shock. The patient had undergone mitral valve repair and coronary bypass surgery using saphenous vein grafts. Echocardiography revealed severe aortic and mitral valves stenosis. Given the extensive adhesions and complex anatomy, the Commando procedure was performed using a superior transseptal approach. A 25-mm MITRIS was implanted in the mitral position, and a 25-mm INSPIRIS in the aortic position. A tailored oval-shaped patch made of bovine pericardium was used to reconstruct the intervalvular fibrous body. The patient recovered without major complications.

Conclusion: The superior transseptal approach provided excellent exposure and a stable operative field, facilitating standardized surgical maneuvers throughout the Commando procedure.

Background: Primary pulmonary artery sarcoma progresses extremely rapidly and has a poor prognosis. This condition is managed with surgical resection and multimodality therapy. However, standardized treatment is not available.

Case presentation: A 54-year-old woman was brought to the emergency department because of chest pain and worsening dyspnea that had developed in the past month. Contrast-enhanced computed tomography scan revealed severe stenosis extending from the pulmonary artery trunk to the right pulmonary artery due to an embolic substance. Because primary pulmonary artery sarcoma was suspected, emergency surgery was performed to improve the patient's symptoms. In addition to maximal tumor resection, pulmonary artery valve replacement, artificial vessel replacement, and right total pneumonectomy were performed. Based on the assessment performed using the specimen collected perioperatively, a pathological diagnosis of angiosarcoma of the right pulmonary artery was made. The patient was discharged on postoperative day 17 with a good postoperative course. However, because of dyspnea, she was readmitted to the hospital on day 85. Tumor recurrence was noted, and chemotherapy was initiated. The patient developed cardiac failure and died on postoperative day 119. A pathological postmortem examination was performed. Metastatic lesions were found in the pericardial sac, left lung, right chest wall and pleura, and mediastinum.

Conclusions: In the present case, postoperative recurrence was observed despite maximal resection of the surrounding tissues with tumor invasion and simultaneous reconstruction. Chemotherapy was initiated but was ineffective. Gene panel testing can help identify novel treatment options for patients with neoplastic diseases without standardized treatment. In addition, preparations should be made before surgery.