[Zasshi] [Journal]. Nihon Kyobu Geka Gakkai最新文献

Jehovah's Witness who require operation represent a challenge to the physician because of the patients' refusal to accept blood transfusion. We report an 8-year-old male of Jehovah's Witness who underwent a surgical treatment of infective endocarditis. He was transferred to our hospital because of high fever and heart murmur. Echocardiogram revealed a developing vegetation of aortic cusps and an aneurysmal change of the non-coronary sinus Valsalva. On admission he was complicated by anemia, purulent meningitis and suppurative arthritis of left knee. There were no signs of cardiac failure. Erythropoietin (6000 U thrice weekly) and iron (60 mg daily) were given for 11 weeks prior to surgery, raising the hemoglobin level from 9.2 g/dl to 18.4 g/dl. Aortic valve replacement and plasty of the sinus Valsalva were then performed. Intraoperatively hemoglobin concentration dropped to 10.3 g/dl and it raised to 15 g/dl postoperatively. We also used Cell-Saver to reduce blood loss. The patient made an uncomplicated recovery. Erythropoietin therapy contributed substantially to the successful outcome of this case.

A three-year-old girl with complex cardiac anomalies and right isomerism successfully underwent a modified Fontan procedure and reconstruction of the nonconfluent pulmonary artery using autologous tissues. These cardiac anomalies included single right ventricle, atresia of the pulmonary trunk with nonconfluent pulmonary artery, atrial septal defect, common atrioventricular valve, bilateral PDAs, and bilateral SVCs. Preoperative cardiac catheterization showed elevated pulmonary artery pressure (mean pressure of 24 mmHg) and a small orifice of common pulmonary vein chamber. Pulmonary arteriographies showed balanced development of the branches. Indication for Fontan procedure was finally determined by measurement of the pulmonary artery and vein pressures and pulmonary vascular resistance before the cardiopulmonary bypass in the operation. Nonconfluent pulmonary artery was reconstructed by direct anastomosis of the right and left branches in the posterior aspect and enlarged with autologous pericardium patch. Intracardiac anomalies were repaired by enlargement of common pulmonary vein orifice (from 5 mm to 15 mm in diameter) and right atrial oblique partition. Furthermore, Fontan circulation was established by pulmonary artery angioplasty, direct anastomosis of left SVC to left pulmonary artery and direct anastomosis of right atrial appendage to pulmonary artery. Postoperative clinical course was uneventful, and cardiac catheterization showed mean right atrial pressure of 14 mmHg, cardiac index of 3.5 l/min/m2, and no pressure gradient at the site of reconstruction of the pulmonary artery.

A 57-year-old man underwent Bentall's procedure (Piehler's modification) and partial aortic arch replacement for Stanford type A chronic aortic dissection. Circumferential detachment of intima with intimal intussusception into the aortic arch was found at the time of operation. Preoperative findings did not show the intimal tear involving entire circumference of the ascending aorta. He was asymptomatic but coughing before consulting our hospital. He was discharged from the hospital 26 days after operation.

A 1.8-year-old boy was first admitted to our hospital at 12 days of age with the diagnosis of transposition of the great arteries (TGA), ventricular septal defect (VSD), and left ventricular outflow tract obstruction (LVOTO). Echocardiography and catheter examination at 10 months of age disclosed severe organic stenosis of left ventricular outflow tract (LVOT) with its diameter of 5.6 mm (50% of N) and the left to right ventricular (LV/RV) pressure ratio of 0.6. At 1.8 years of age, he underwent complete correction which comprised intraatrial switch (Senning procedure), direct closure of VSD, and removal of thickened endocardium at LVOT. Because of the residual LVOTO, evidenced by postoperative LV/RV pressure ratio of 1.4, placement of 14 mm PTFE graft extracardiac conduit was concomitantly performed. The conduit from the left ventricular apex to the main pulmonary artery effectively lowered the left ventricular pressure with LV/RV pressure ratio of 0.68. Repeat catheter examination at 2.10 years of age revealed further descent of LV/RV pressure ratio to 0.32. Based on the findings that balloon occlusion of the conduit elicited only a minimal elevation of the left ventricular pressure (from 30 to 34 mmHg), the conduit was removed at 3.6 years of age. The third catheter examination at the age of 3.9 years confirmed LV/RV pressure ratio of 0.43. The patient is leading a normal life. without medication 3 years after the operation. This experience draws us to conclude that placement of left ventricle-to-pulmonary artery conduit concomitantly with the intraatrial switch is a useful adjunctive procedure for the complete correction of TGA, small VSD, and LVOTO, and that, in a subset of the patients, this procedure may allow amelioration of LVOTO and secondary removal of the conduit.

The peptic ulcer of gastric tube using for esophageal reconstruction is rare. We report herein five cases of peptic ulcer of gastric tube used for esophageal reconstruction after esophagectomy for esophageal carcinoma. The reconstructive route, in all cases, was posterior mediastinum. In one case, 10 days after esophagectomy, he had high grade fever and pneumonia of right lower lobe of lung. Endoscopic examination revealed a deep ulcerative lesion on anterior wall of gastric tube and fistula formation on membranous part of trachea. The partial resection of gastric tube was performed for closing to tracheo-gastro fistula. In other four cases, the location of ulcer was middle or lower third of gastric tube. One had multiple peptic ulcer and other had single. Two cases of four underwent post irradiation therapy. One case of then, the Helicobacter infection detected using by rapid urease test and histological examination. We analyzed of Helicobacter pylori infection and serum gastrin level of gastric tube in outpatients who have used gastric tube for esophageal reconstruction after radical esophagectomy. Helicobacter pylori infection was positive at 56% (9/16) of all patients. The serum gastrin level of patients who was positive of Helicobacter pylori infection is not significantly higher than that of patients who was negative. We consider that post operative irradiation therapy and Helicobacter infection might play in development of peptic ulcer of gastric tube.

We studied three preservation solutions such as St. Thomas' hospital cardioplegic solution No. 2 (ST), the University of Wisconsin solution (UW) and Bretschneider's solution (BR) for protective properties, especially in terms of temperature dependence during the preservation. Rat hearts were studied and divided into three groups; ST. UW and BR. In each group, six hearts were carried out perfusion, cardioplegic infusion, ischemia and reperfusion for four different conditions. Using an isolated working rat heart model, the hearts were subjected to 5 minutes Langendorff perfusion followed by 20 minutes working perfusion. During this working period, cardiac functions such as aortic and coronary flow, aortic pressure, and heart rates were measured every 5 minutes. After working perfusion, 3 minutes of cardioplegic infusion was carried out either with UW, ST, and BR at 37, 20, 4, 1 degree C. The hearts were subjected to either 35 min at 37 degrees C, 120 min at 20 degrees C, 300 min at 4 degrees C, or 450 min at 1 degree C. The hearts were immersed in the same solution during ischemia. The hearts were reperfused at 37 degrees C, initially in the Langendorff mode for 15 min. Coronary effluent was collected for the measurement of CK leakage during reperfusion. The heart were then converted to the working mode for 20 minutes. During working reperfusion period, the variables of cardiac function were again measured and expressed as a percentage of their individual preischemic control values. Under conditions of 37 degrees C ischemia, % recovery of cardiac output (%CO) in ST group is 62.8 +/- 2.8%, although the hearts preserved with UW and BR were not recovered. Under conditions of 20 degrees C ischemia, %CO in UW, ST and BR were 46.8 +/- 2.7, 82.0 +/- 3.1 and 41.4 +/- 2.6%, respectively. Under conditions of 4 degrees C ischemia, %CO in UW, ST and BR were 66.2 +/- 8.0, 68.6 +/- 2.3 and 47.2 +/- 2.9%, respectively. Under conditions of 1 degrees C ischemia, %CO in UW, ST and BR were 70.6 +/- 3.3, 56.5 +/- 1.6 and 43.0 +/- 2.5%, respectively. In conclusions, ST revealed the best protective properties for the heart preservation between 37 degrees C and 20 degrees C ischemia. The properties of ST was similar to that of UW under conditions of 4 degrees C, although UW showed most excellent protective properties under conditions of 1 degrees C ischemia. These results suggested that, protective ability of preservation solution might be changed by the temperature during preservation period.

This study estimates the perioperative left ventricular function of VSD and TOF by using Pressure-Volume (PV) loop. The most characteristic hemodynamic change of VSD is a decreased volume load. Although ejection fraction significantly decreased after the operation, this change did not mean a deteriorated left ventricular contractility. Emax, which is an index of left ventricular contractility on PV loop, improved and pressure-volume area (PVA) which is correlated with 02 consumption of left ventricule was reduced. Mechanical efficiency of left ventricular energetic state did not significantly change. Left ventricular volume and ejection fraction in TOF slightly increased after the operation. Increased ejection fraction reflected a compensation to volume overload after surgery. Emax slightly decreased and PVA increased. Meanwhile mechanical efficiency increased after the operation indicating well preserved ventricular contractility. In particular, the shape of PV loop of both VSD and TOF eventually became usual square after operation due to recover of the isovolumic contraction and relaxation phase. These characteristics had better to be concerned for improvement of surgical techniques as in conotruncal repair, particularly in TOF in the setting of better quality of life with low atrial pressure.

A 51-year-old woman was admitted because of general fatigue assumed to be due to climacteric disturbance. Laboratory examinations suggested a diagnosis of hyperparathyroidism based on high serum levels of Ca, intact PTH, and high-sensitivity PTH. No abnormalities were found in the cervix. Chest X-ray films and CT scans showed a mass measuring 4 cm in the right postero-upper mediastinum. The tumor was positive on a parathyroid scintigram, and was diagnosed as a mediastinal parathyroid adenoma with hyperparathyroidism. Operative findings showed a tumor surrounded by the superior vena cava, vagus nerve, azygos vein, and brachiocephalic artery. Careful resection of the hypervascular tumor from surrounding tissues was performed using a thoracoscopic technique alone. The postoperative course was uneventful. Serum values of Ca, intact PTH, and high-sensitivity PTH decreased to within normal ranges. after surgery. Pathohistological study confirmed the diagnosis of parathyroid adenoma including a cyst caused by degeneration of the tumor.

Pericardiectomy is the only effective surgical procedure for constrictive pericarditis, but we have often experienced a lack of significant improvement of hemodynamic parameters, this being attributed to the presence of residual constriction. We have had two patients with constrictive pericarditis. In these patients, we decorticated the pericardium as usual, anterior to the bilateral phrenic nerves without cardiopulmonary bypass, and then, multiple longitudinal and transverse incisions were carefully made in the fibrous epicardium, avoiding the predicted course of major coronary branches and the myocardium. At the end of the procedure, the epicardial fibrous surface acquired a waffle-like appearance. With this maneuver, relief of constriction was achieved and the myocardium was able to reexpand, thus obtaining an adequate hemodynamic response. Our two patients recovered fully, and were discharged on the 18th and 19th postoperative day. They are presently free of clinical symptoms.