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

Double outlet left ventricle (DOLV) is an uncommon congenital cardiac defect which was first reported by Sakakibara and associates. We studied anatomical aspects relevant to surgical repair in our 4 cases and additional 28 cases which had been reported on the literatures. The locations of ventricular septal defect (VSD) were subaortic in 20 cases, subpulmonary in 7, doubly-committed in 2 and unknown in 2. The positions of the aorta relative to the pulmonary artery were right or left anterior oblique in 11 cases, right or left side-by-side in 9, right or left posterior oblique in 10 and unknown in 3. The definitive surgery included Rastelli type operation in 18 cases, right ventricular outflow tract repair with closure of VSD in 6, intraventricular conduit repair in 4 and Fontan type operation in 4. In regard to the selection of the procedure, the size of right ventricle, the presence of pulmonary stenosis, the location of VSD and the relationship of the great arteries are very important. Although most of the patients underwent the Rastelli type operation, the right ventricular outflow tract reconstruction or intraventricular conduit repair could be adopted particularly in patients with posterior oblique position of the aorta relative to the pulmonary artery or subpulmonary VSD.

A 58-year-old man underwent sleeve upper lobectomy for squamous cell carcinoma of the right lung in April 1993. Eleven months after the operation, local recurrence at the bronchial suture line was detected by bronchoscopy. As the patient declined our proposal for performing reoperation, the recurrent tumor was treated with concurrent radiotherapy and chemotherapy, which resulted in only minimal response. After these treatment, the tumor was still localized at the right pulmonary hilus with no distant metastasis, and patient's pulmonary function was preserved good enough to undergo reoperation. Therefore, with a patient's consent to reoperation, we performed completion pneumonectomy with carinal wedge resection in September 1994. Pedicled serratus anterior muscle flap was applied to the suture line in order to prevent anastomotic complications. Postoperative course was uneventful except for pneumonia, and the anastomosis had healed well. As of March 1997 the patient is alive with no evidence of tumor recurrence. Completion pneumonectomy with carinal resection carries a high risk of operative morbidity and is seldom indicated. We reported a patient underwent this procedure for recurrent lung cancer and discussed about its indication and procedure.

The expandable metallic stent was used in 10 patients with carcinomatous airway stenosis. In all patients, the respiratory symptoms improved immediately after insertion of the stent. Eight of the 10 patients, performance status improved. Totally, the use of expandable metallic stent improved the quality of life for patients with carcinomatous airway stenosis. Complication was minimal. We conclude that expandable metallic stent for treatment of carcinomatous airway stenosis are useful in emergent cases.

It is known that lymphocyte function is impaired after cardiopulmonary bypass (CPB). In this study, the lymphocyte stimulation test (LST) with PHA was used before and after CPB in 28 adult patients, and compared with the surgical parameters and serum cytokine (IL-6, IL-8) levels. LST was impaired after CPB in all patients. Although this value usually recovered by the third postoperative day (POD); (normal group, n = 16), some patients showed prolonged duration of the impaired LST (delayed group, n = 12). Therefore, the parameters of surgery, white blood cell (WBC) count, lymphocytes and subsets, and serum cytokine levels were compared between the normal and the delayed groups. There was no significant difference in the number of WBCs or lymphocytes between these two groups. OKT4-positive cells were reduced on the first POD in both groups, and in the normal group, the number of OKT4-positive cells recovered more quickly than in the delayed group. Serum IL-6 and IL-8 levels in the delayed group were elevated after CPB, and were significantly higher in the delayed group than in the normal group. In conclusion, patients who showed prolonged impairment of lymphocyte function may be partly due to prolonged CPB.

We performed the concomitant operation for constrictive pericarditis and coronary artery disease in an octogenarian. A 82-year-old male was hospitalized with dyspnea, edema of the lower extremities and pleural effusion on chest X-ray film. Cardiac catheterization revealed constrictive pericarditis and 75% stenosis of left anterior descending artery. Extensive pericardiectomy was performed including posterior wall of left ventricle and left atrium under the beating heart by using femoro-femoral partial bypass. Single CABG with a saphenous vein graft was performed following pericardiectomy. Postoperative cardiac catheterization showed good recovery of hemodynamics and patency of the bypass graft. Postoperative course was uneventful. The patient was discharged on twenty fifth postoperative day.

A 53-year-old woman was referred to our hospital for further evaluation of a mediastinal tumor. The tumor was diagnosed as a mediastinal angiomyolipoma by computed tomography and angiographic findings. Transarterial embolization was performed three times, then the tumor was completely organized. Although angiomyolipomas are often found in the kidney, those in the mediastinum are very rare. Angiomyolipoma is a benign tumor, then small asymptomatic tumor may be conserved. When the tumor is large in size and has a high risk of spontaneous rupture, arterial embolization is valuable for treatment of the tumor.

Recently, use of heparin-coated circuits during normothermic cardiopulmonary bypass has become a trend in cardiovascular surgery. In light of this, heparin administration protocols during bypass should be reevaluated. In twenty patients who underwent cardiac surgery using a heparin-coated circuit under normothermia, heparin concentration was measured with Hepcon/HMS. Before initiating bypass, 300 IU/kg of heparin was administered with additional heparin to maintain activated clotting time (ACT) at more than 400 seconds. The heparin dose response (HDR) was measured before heparin administration. HDR is a heparin concentration calculated to correspond to an ACT of 480 seconds. As an index of heparin control during bypass, average heparin concentration/HDR (HC/HDR) was calculated. HC/HDR was correlated with Fibrinogen degradation products E (R = -0.52). D dimer (R = -0.45). Thrombin antithrombin complex (R = -0.54). Antithrombin III (R = 0.50) and platelet number (R = 0.44), but not with 24-hour postoperative blood loss. In conclusion, even when using a heparin-coated circuit plasma coagulation activity was not sufficiently suppressed by use of a conventional ACT monitoring protocol during normothermic bypass. Therefore, the maintenance of HC/HDR at a higher level may be indicated.

This paper describes the utility of the minimally invasive CAB procedure as an adjuvent therapy to allow angioplasty for left main stenosis. A 73-year-old male who had chronic renal failure and left main coronary disease underwent a combined therapy with minimally invasive CABG and PTCA. The operation was reformed with a 9 cm incision. The fifth costal cartilage was removed. Internal thoracic artery (ITA) was dissected from the left side of the chest wall and anastomosed to the midportion of the left anterior descending coronary artery (LAD) with 7-0 with 7-0 Prolene. He was extubaded a few hours after the operation and resumed his dialysis schedule. On the fifth postoperative day he was electively returned to the catheterization laboratory, where he underwent successful angioplasty of the LMT to Lcx after patency of the LITA-LAD graft had been verified. He was discharged from our hospital ten days postoperatively.

A young adult patient, 21 years old female, with left subclavian pseudoanurysm caused by blunt chest trauma is reported. The patient was carried to the emergency room of our hospital with the blunt trauma and lung contusion due to the traffic accident. On chest roentgenogram no fractures of ribs and subclavia were seen, but the superior mediastinum was widened. Superior mediastinal hematoma was suspected by CT scan. Following examination of aortogram revealed an pseudoaneurysm of the left subclavian artery at the origin of left internal artery. Emergency operation was performed with left postero-lateral thoracotomy and the aneurysm was located just the point at the bifurcation of internal mammary from left subclavian artery. Internal mammary artery was clipped and the fissure of the subclavian of the subclavian artery was repaired by direct suture under temporary occlusion of the subclavian artery. Postoperative course was uneventful and superior mediastinal hematoma was not noticed on chest roentgenogram and CT of 18 days postoperatively.

The efficacy of both preliminary and continuous hemodialysis during extracorporeal circulation (ECC) was evaluated in the pediatric population. Preliminary hemodialysis of the priming solution was initiated in eight children (HD-I group), while both preliminary and continuous hemodialysis during ECC was performed in another eight children (HD-II group). The control group which consisted of eight children did not undergo hemodialysis. Urine volume during ECC, perfusion pressure, and water balance were measured and compared among the three groups. In the HD-I and HD-II groups, the total urine volume during ECC was greater than in control group, but there was no significant difference. In the control group, the perfusion pressure temporally decreased after the pump was operating for five minutes, but the perfusion pressures remained stable in the HD-I and HD-II groups. Therefore, preliminary hemodialysis appears to prevent the "initial drop" seen in perfusion pressures. Water balance in the control group tended to be in positive balance, but both the HD-I and HD-II groups appeared to be in negative balance. Significant differences between HD-I and HD-II in contrast to the control group (p < 0.05) and p < 0.04, respectively) were observed. Preliminary hemodialysis is useful during ECC in infants and children because by maintaining perfusion pressure urine output remains adequate while a net negative water balance is achieved. Preliminary hemodialysis will increase the continuous hemodialysis in infants who are subjected to prolonged extracorporeal circulation.