A 62-year-old man presented with hemoptysis and hoarseness. He was diagnosed with an aortopulmonary fistula due to a thoracic aortic aneurysm rupture and was referred to our department. Emergency in-situ reconstruction of the aorta and pulmonary lobectomy were performed. Nine days postoperative, he developed empyema. Intrapleural urokinase and antibiotic therapy were selected as management instead of a video-assisted thoracoscopic debridement and decortication due to his worsening condition. The treatment was successful, and he was discharged from the hospital without any further complications. This study highlights the benefit of intrapleural administration of urokinase and antibiotics in patients with acute empyema, when surgical treatment is inappropriate.

The purpose of this study is to assess the impact of coronavirus disease 2019 (COVID-19) on the performance of cardiovascular surgery in Japan. The information gathered may be useful to prepare for a surgery in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) positive patients and prevent COVID-19 transmission from surgical patients to healthcare workers. [Methods] A web-based questionnaire was distributed to all accredited cardiovascular surgery centers in Japan. A total of 550 questionnaires were sent, and 310 (56.4%) were returned. [Results] Preoperative PCR or antigen testing was performed in all patients at 68.8% of centers. The proportion of surgeries postponed or cancelled was the highest for elective valvular and aortic surgeries and for emergency aortic surgeries. In most facilities elective surgeries were restricted to less than 50% of usual case volumes, while approximately 40% did not experience any negative impact on the case volume. Among the surgical patients, 32 were suspected to be SARS-CoV-2 positive, and 10 were confirmed. As preventive measures against spreading infection, more than 90% of the patients wore N95 masks, 33.3% full PPE, and 66.7% N95 mask+face shield. No case of patient-to-healthcare-worker transmission was reported. There were no postoperative deaths among the confirmed SARS-CoV-2 patients. [Conclusion] Restriction of surgical practice was placed on many institutions in the COVID-19 pandemic, but the degree of restrictions varied. Preoperative screening of all surgical patients and intraoperative use of PPE in those with suspected or confirmed SARS-CoV-2 infection adequately prevented transmission to healthcare workers. Since COVID-19 has a nationwide impact, it is important to continuously monitor surgical outcomes and infection rate by conducting perioperative surveys of COVID-19 patients.

We performed endovascular stent grafting of a perforated descending aorta, caused by empyema after surgery for lung cancer, in a 75-year-old man. After diagnosing hemorrhage from a perforation of the proximal descending aorta, caused by left empyema, the perforation was repaired with a saphenous vein patch and a pectoralis major muscle flap. However, re-hemorrhage from the same lesion occurred 2 months postoperatively. Temporary hemostasis was achieved with gauze packing and he was transferred to our hospital for endovascular stent grafting. The infection did not resolve after fenestration, so the descending aorta was cropped out to the fenestration lesion. Therefore, endovascular stent grafting was performed on the same day. Postoperatively the bleeding stopped completely without any signs of graft infection, and he was transferred to another hospital on postoperative day 9. No re-hemorrhage or graft infection of the aortic perforative lesion occurred in the early postoperative period. However, the patient died of massive bleeding from the aorta wall of the proximal stump of the stent graft, caused by recurrence of the infection 2 months after the 2nd operation. In this situation, endovascular scent grafting provides the only chance of saving the patient's life. If endovascular stent grafting is performed as a lifesaving procedure, meticulous operative technique is imperative.

A 72-year-old woman had undergone resection and graft replacement of the proximal ascending aorta for a DeBakey type II aortic dissection. She presented again 7 years later with progressive dyspnea and a cough. Computed tomography confirmed an aortic arch aneurysm and Doppler echocardiography demonstrated aortopulmonary shunting. Cardiac catheterization revealed a fistula between the aorta and pulmonary artery with a 54.3% left-to-right shunt and a Qp/Qs of 2.19. Operative repair was performed under profound hypothermic circulatory arrest with selective cerebral perfusion. The aortopulmonary artery fistula was closed from within the aneurysm using an equine pericardial patch and the transverse aortic arch was resected and replaced with a graft. The patient recovered uneventfully and was discharged on postoperative day 43.

To test the hypothesis that neutrophils play a role in ischemia/reperfusion injury during heart surgery, granulocyte elastase and myeloperoxidase release from coronary circulation were measured before and after aortic cross-clamping. The production of granulocyte elastase and myeloperoxidase across the coronary circulation elevated significantly after release of aortic cross-clamp. Furthermore, the level of granulocyte elastase and myeloperoxidase released from coronary circulation demonstrated positive correlation with the duration of the aortic cross-clamp. These data indicate that neutrophils play a major role in ischemia/reperfusion injury occurring during heart surgery.

To test the hypothesis that neutrophils play a role in lung injury during cardiopulmonary bypass, granulocyte elastase and myeloperoxidase release from pulmonary circulation were measured, as well as the respiratory index, before and after cardiopulmonary bypass. The production of granulocyte elastase and myeloperoxidase in the pulmonary circulation, and the respiratory index also elevated significantly after cardiopulmonary bypass. Furthermore, the level of granulocyte elastase and myeloperoxidase released from pulmonary circulation correlated with the changes of the respiratory index and preoperative pulmonary artery pressure. These data indicate that neutrophils play a major role in pulmonary dysfunction occurring after cardiopulmonary bypass, which is accentuated in patients with pulmonary hypertension.

Six cases without aortic reconstruction for 48 hours were encountered among 22 cases of Stanford type A acute aortic dissection from April, 1990 to July, 1996. They were one man and five women, with a mean age of 60.3 years old (from 52 to 82 years old). According to Hagiwara's definition, acute thrombotic aortic dissection (ATAD) was observed in four and acute opacified aortic dissection (AOAD) in two of six cases of Stanford type A acute aortic dissection without aortic reconstruction. One of the four ATAD cases was well-controlled by medical therapy, but the others could not be controlled and underwent aortic root reconstruction within 1 month. Two AOAD patients died due to rupture within 1 month. It is said in general that the patients with acute thrombotic aortic dissection can be treated medically, but we consider that they should be treated surgically because of the frequency of late rupture.

This experimental study was conducted to histopathologically determine whether the low-dose irradiation of donor hearts before transplantation can inhibit graft vasculopathy. Immediately after donor F 344 rat hearts were removed, they were treated with a single dose of radiation using 7.5Gy, 15Gy, or no radiation (control group). The F 344 hearts were transplanted into Lewis rats heterotopically, and cyclosporine A was injected intramuscularly for 20 days after transplantation in all groups. The hearts were harvested 90 days after transplantation, and examined for intimal thickening using elastica van Gieson staining. Severe intimal thickening was observed in both the irradiated groups, the percent intimal area of the coronary arteries was significantly increased in both these groups, to 34.3±12.9 in the 7.5Gy group and 37.0±8.9 in the 15Gy group, compared with 23.1±9.8 in the control group (p<0.01). In conclusion, these findings show that low-dose irradiation to donor hearts before transplantation does not inhibit graft vasculopathy.