A 46-year-old man who had been hospitalized for treatment of pneumonia was referred to our hospital with a diagnosis of acute pulmonary thromboembolism. Multi-detector row computed tomography revealed massive thrombi in the bilateral main pulmonary arteries. Transthoracic echocardiography showed dilated right heart chambers and a large floating thrombus in the right atrium. Emergency thromboembolectomy was performed. Although fresh thrombi were removed from the right atrium and left main pulmonary artery, organized old thrombi were present in the bilateral pulmonary arteries, leading to a diagnosis of chronic thromboembolic pulmonary hypertension. Because no instruments were available for pulmonary endarterectomy, the surgery was terminated with percutaneous cardiopulmonary support. Five days postoperatively, pulmonary endarterectomy was performed under deep hypothermic circulatory arrest. The postoperative course was uneventful, and the patient returned to his preoperative lifestyle without the need for oxygen support.

A 46-year-old man who developed fever and general fatigue was referred to our hospital with suspicion of infective endocarditis. A ventricular septal defect had been previously diagnosed. Transthoracic echocardiography revealed vegetation on the aortic, mitral, and pulmonary valves, and each valve had significant regurgitation. An emergency operation was performed because of congestive heart failure. The aortic and mitral valves were replaced with mechanical valves. The pulmonary valve was repaired ; the anterior leaflet was resected and replaced by glutaraldehyde-treated autologous pericardium. The patient's postoperative course was uneventful. Recurrence of infection was not observed for 3 years after the operation. Triple-valve endocarditis, especially that involving a combination of the aortic, mitral, and pulmonary valves, is rare. Involvement of multiple valves on both sides of the heart may be attributed to a congenital intracardiac shunt. Early surgical intervention may be useful to control infection and heart failure, as in the present case.

BACKGROUND/AIMS: In Japan, it is customary to take a daily bath during which the body is immersed in water to the neck. During full-body immersion, hydrostatic pressure is thought to compress the chest and abdomen, which might influence esophageal motor function and intra-gastric pressure. However, whether water immersion has a significant influence on esophageal motor function or intragastric pressure has not been shown. The aim of this study was to clarify the influence of full-body water immersion on esophageal motor function and intragastric pressure. METHODS: Nine healthy male volunteers (mean age 40.1 +/- 2.8 years) were enrolled in this study. Esophageal motor function and intragastric pressure were investigated using a high-resolution 36-channel manometry device. RESULTS: All subjects completed the study protocol. Intragastric pressure increased significantly from 4.2 +/- 1.1 to 20.6 +/- 1.4 mmHg with full-body water immersion, while the lower esophageal high pressure zone (LEHPZ) value also increased from 20.5 +/- 2.2 to 40.4 +/- 3.6 mmHg, with the latter being observed regardless of dietary condition. In addition, peak esophageal peristaltic pressure was higher when immersed as compared to standing out of water. CONCLUSIONS: Esophageal motor function and intragastric pressure were altered by full-body water immersion. Furthermore, the pressure gradient between LEHPZ and intragastric pressures was maintained at a high level, and esophageal peristaltic pressure was elevated with immersion.
Abdomen ; Baths ; Esophageal Sphincter, Lower ; Gastroesophageal Reflux ; Humans ; Hydrostatic Pressure ; Immersion ; Japan ; Male ; Manometry ; Neck ; Peristalsis ; Thorax ; Water

A 62-year-old man had been given a diagnosis of atrial septal defect (ASD) 20 years previously, but the condition was left untreated. A heart murmur was detected on a routine health examination, so he visited our institution where a diagnosis of type II ASD and moderate tricuspid regurgitation was given. Cardiac catheterization revealed a pulmonary to systemic flow ratio (Qp/Qs) of 2.9, pulmonary vascular resistance of 3.1 units, and systolic pulmonary artery pressure of 90 mmHg. The patient underwent open surgery consisting of a patch closure of the ASD, and tricuspid annuloplasty. His pulmonary arterial pressure rose and his blood pressure dropped, and left cardiac failure developed on postoperative day (POD) 2. The administration of catecholamines and a phosphodiesterase (PDE) III inhibitor failed to correct the left cardiac failure. We performed intra-aortic balloon pumping (IABP) immediately, and his hemodynamic condition stabilized. The IABP catheter was removed on POD 10. The postoperative development of circulatory failure suggested that it was almost too late for surgery for ASD. It has been believed that surgery for ASD is relatively safe. However, it seems that, the considering the possible occurrence of postoperative cardiac failure in elderly patients with accompanying pulmonary hypertension, careful postoperative management is necessary.

A 51-year-old man admitted to our hospital because of an ECG abnormality pointed out by his local doctor. He had been hospitalized for scarlet fever at age 10. A coronary artery CT scan showed coronary artery aneurysm of the left main trunk (LMT), and coronary angiography showed 3-vessel disease including a chronic total occlusion of the right coronary artery (RCA). We performed conventional coronary artery bypass grafting (CABG) using an arterial graft and aneurysmectomy. The patency of the graft was confirmed by coronary angiography postoperatively. The pathological diagnosis of the coronary aneurysm was Kawasaki disease. CABG is a standard procedure for coronary artery aneurysms with Kawasaki disease. However, there are no established treatment guidelines on whether to perform aneurysmectomy. We chose CABG with aneurysmectomy because of the possibility of intra-aneurysmal thrombosis leading to peripheral occlusion, and the cause of the coronary artery aneurysm could not be determined. However, even if additional treatment by percutaneous coronary intervention (PCI) is not possible, it is important to avoid occlusion of the graft.

Cardiac papillary fibroelastoma (CPF) is a rare benign cardiac tumor. It commonly arises from the left side heart valve. We present two rare cases of CPF that originating from the right side of the heart confirmed by surgical resection. Case 1 : A 67-year-old man was admitted for surgical resection of a cardiac tumor located in the right atrium. Transesophageal echocardiography revealed a mobile mass attached on the anterior leaflet of the tricuspid valve. The tumor was resected by open heart surgery. Histopathologic examination confirmed the tumor to be a CPF. Case 2 : A 68-year-old man was admitted for surgical resection of a tumor occurred from the tricuspid valve. Transthoracic echocardiography revealed a tumor attached to the medial leaflet. The tumor was resected. Histopathologic examination confirmed it to be a calcified mass. However, the surface of tumor had many papillary projections macroscopically. We redo the histopathologic examination, and confirmed the tumor as a CPF finally. In both cases, postoperative courses were uneventful.

Minimally invasive cardiac surgery (MICS) for treating valvular disease was introduced in our division in July 1997, and we have treated a total of 236 cases by July 2002. Among the various types of surgical treatment, there were 21 cases (M-group) of double valve replacement (DVR) to treat combined valvular disease. There had been 8 cases (F-group) of DVR by means of conventional full sternotomy during the period from January 1990 to June 1997, before the introduction of MICS. A comparison of the results of these surgical treatments yielded the following results. There were no differences in operation time and blood loss during the operations between the 2 groups, whereas the aortic cross clamp time and cardiopulmonary bypass time were significantly longer in the M-group than the F-group (M-group: 189±6 and 228±7min; F-group: 132±18 and 183±16min, respectively). There were significantly more cases of concomitant maze operation in the M-group than in the F-group. There were no differences in the durations of postoperative intubation or ICU stay. The days required from operation to starting walking were significantly shorter in the M-group compared to in the F-group (M-group: 2.4±0.2 days; F-group: 3.3±0.2 days), while there were no differences in the postoperative hospitalization periods. There were no major postoperative complications, and 1 case each there was 1 death in each group during the hospitalization period. Although the aortic cross clamp time and cardiopulmonary bypass time were longer in the M-group than in the F-group, the postoperative course and surgical outcome were good. So MICS for DVR was considered acceptable. In addition, MICS was thought to provide high patient satisfaction with regard to cosmesis or thoracic fixation, although early discharge from the hospital, which was possible in cases of single valve MICS, was not obtained.

A 24-year-old woman with an abdominal aortic aneurysm (AAA) caused by mucoid medial degeneration of the aortic wall in the absence of Marfan syndrome is reported. She required a Y-shaped graft replacement of the abdominal aorta through a minimal incision and recovered successfully.

We encountered a case of ascending aorta pseudoaneurysm due to a Freestyle-valve free-wall fistula after a modified Bentall procedure with the button technique. A 60-year-old man with Marfan's syndrome who contracted annuloaortic ectasia presented with the onset of Stanford A type acute aortic dissection 3 years ago. The patient underwent aortic root replacement with a Freestyle-valve and ascending and hemi-arch aortic replacement. Thirty-seven months after this operation the patient was re-operated because of pseudo-ascending aorta aneurysm. The cause of the pseudo-aneurysm was a fistula of the Freestyle-valve free-wall and the left coronary artety (LCA) ostial reconstruction component. The fistula was repaired by direct closure with pledgets. The patient was discharged from the hospital 24 days after the operation.

A conventional reoperation via full sternotomy approach is associated with a higher risk of heart injury compared with first time operations. We employ a minimally invasive cardiac surgery (MICS) for valve reoperations in order to minimize dissection of sternal adhesions. We evaluated MICS for mitral reoperation in this report. We retrospectively analyzed 20 patients (group P) who underwent mitral reoperation via partial lower hemisternotomy (PLH) from July 1997 through March 2002, and 13 patients (group F) who underwent mitral reoperation via full sternotomy from April 1990 through June 1997. All patients received mitral valve replacement in both groups. Concomitant Maze procedures were significantly more frequent in group P (group P: n=8, group F: n=1). Aortic cross clamp times were significantly longer in group P (group P: 110±5min, group F:87±11min). The blood loss during operations was significantly less in group P (group P: 666±100ml, group F: 2, 405±947ml). Postoperative ventilation time and the length of intensive care unit stay were significantly shorter in group P. In group P and F the occurrence of a heart injury associated with sternotomy was 0/20 (0%), 2/13 (15%) respectively. Hospital mortality was 0/20 (0%), 2/13 (15%) respectively. There were neither any hospital deaths nor any postoperative major complications in group P. We conclude that PLH for mitral reoperations could be performed safely and is an alternative approach for mitral reoperations.