RESUMEN
Case 1 was a 59-year-old man who underwent aortic valve replacement (AVR) at the age of 38, for aortic regurgitation. Case 2 was a 51-year-old man who underwent AVR at the age of 34, for aortic regurgitation. Both cases required surgery for ascending aortic aneurysms. These patients showed aneurysm at the site of the prior aortotomy. In both of the patients used felt-strip was used for closing aortotomy. Intraoperative findings showed enlargement of the aorta around the felt-strip, which was a finding of true aneurysm. Both cases underwent ascending aortic replacement. The mechanism of aortic aneurysm development was thought to include persistent mechanical stimulation by the felt-strip and ischemia of the vasa-vasorum due to compression of the felt-strip. The use of felt-strips for the aortotomy suture should be avoided, especially in young patients.
Asunto(s)
Válvula Aórtica , Humanos , Masculino , Persona de Mediana Edad , Aorta/cirugía , Aneurisma de la Aorta/cirugía , Aneurisma de la Aorta/etiología , Aneurisma de la Aorta/diagnóstico por imagen , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/etiología , Implantación de Prótesis de Válvulas Cardíacas , Complicaciones PosoperatoriasRESUMEN
Pericardial effusion due to malignancy often needs drainage, however, it is difficult to repeat pericardiocentesis. We report a case of malignant pericardial effusion in a 55-year-old female, who had been diagnosed with sigmoid colon cancer and treated with surgical resection and chemotherapy 2 years before. She developed multiple organ metastasis and suffered from dyspnea due to increasing pericardial effusion. We performed pericardiocentesis repeatedly, but the pericardial effusion continuously increased. Therefore, we inserted a drainage catheter into the pericardial space, which was connected to a subcutaneously placed port system. She was discharged from the hospital, but expired 12 days later. In the case of malignant pericardial effusion, subcutaneous placing of a port system may be safe and useful.
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Taponamiento Cardíaco , Neoplasias , Derrame Pericárdico , Taponamiento Cardíaco/diagnóstico por imagen , Taponamiento Cardíaco/etiología , Taponamiento Cardíaco/cirugía , Drenaje , Femenino , Humanos , Persona de Mediana Edad , Derrame Pericárdico/diagnóstico por imagen , Derrame Pericárdico/etiología , Derrame Pericárdico/cirugía , Pericardiocentesis , PericardioRESUMEN
PURPOSE: To examine the relationship between the incidence of later cardiovascular events after abdominal aortic aneurysm (AAA) surgery and postoperative lipid levels. METHODS: Atherosclerotic risk factors including postoperative serum lipid levels were examined in 116 patients aged 70 or less undergoing an elective AAA surgery. Later cardiovascular events after AAA surgery occurred in 21 patients, including cerebral infarction (n = 4), catheter intervention or surgery for coronary artery disease (CAD) (n = 10) and other vascular disease. RESULTS: Postoperative cholesterol levels during the average follow-up period of 55.6 ± 44.3 (months) were 49.0 ± 15.7 (mg/dL) for high-density lipoprotein cholesterol (HDL-C), 97.9 ± 31.2 (mg/dL) for low-density lipoprotein cholesterol (LDL-C), which were both significantly improved compared to preoperative values (p <0.001). Cox hazard analysis indicated that preexistent CAD significantly increased in the risk for later cardiovascular events (hazard ratio 5.67; 95%CI 1.92-16.8; p = 0.002) and lowered postoperative LDL-C/HDL-C ratio <1.5 decreased in the risk after AAA surgery (hazard ratio 0.10; 95%CI 0.01-0.83; p = 0.033). Patients with postoperative LDL-C/HDL-C ratio <1.5 (n = 22) had a significantly better cardiovascular event-free rate than those with that ratio ≥1.5 (n = 94) (p = 0.014). CONCLUSION: Lowered postoperative LDL-C/HDL-C ratio <1.5 can decrease in the risk for later cardiovascular events after AAA surgery. These results may support the rationale for postoperative aggressive lipid-modifying therapy.
RESUMEN
PURPOSE: To examine the relationship between incidence of later, local vascular events (restenosis and occlusion) and clinical factors including lipid levels after surgical or endovascular treatment of peripheral artery disease (PAD). METHODS: Consecutive 418 PAD lesions (in 308 patients under the age of 70) treated with surgical (n = 188) or endovascular (n = 230) repair for iliac (n = 228) and infrainguinal (n = 190) lesions were retrospectively analyzed. Clinical features and lipid levels were compared between patients who developed vascular events (n = 51; VE group) and those who did not (n = 257; NoVE group). RESULTS: Among assessed factors, post-therapeutic low-density lipoprotein cholesterol (LDL-C) levels (mg/dL) were significantly higher in the VE group (120.4 ± 31.2) than in the NoVE group (108.2 ± 25.1) (P = 0.01). Infrainguinal lesions were more common in the VE than in the NoVE group (P <0.001). Cox hazard analysis indicated that infrainguinal lesions relative to iliac lesions significantly increased the risk of vascular events (hazard ratio (HR) 3.35; 95% CI 1.63-6.90; P = 0.001) and post-therapeutic LDL-C levels <130 (mg/dL) decreased the risk (HR 0.34; 95%CI 0.17-0.67; P = 0.002). CONCLUSION: Lowered post-therapeutic LDL-C levels can decrease the risk of later, local vascular events after PAD treatment. These results may support the rationale for aggressive lipid-modifying therapy for PAD.
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PURPOSE: To determine the predictive value of serum lipid levels on the development of later cardiovascular events after abdominal aortic aneurysm (AAA) surgery. METHODS: A total of 101 patients under 70 undergoing an elective AAA surgery were divided into the following two groups: 1) those who developed later cardiovascular events after AAA surgery, including cerebral infarction (n = 4), catheter intervention (PCI) or surgery for coronary artery disease (CAD) (n = 9) and other vascular disease. (CVE group; n = 19); 2) those without later events (NoCVE group: n = 82). Preoperative atherosclerotic risk factors including serum lipid levels were subjected to univariate and multivariate analysis. RESULTS: The CVE group showed a significantly lower high-density lipoprotein cholesterol (HDL-C) level (32.9 ± 6.6 vs 41.6 ± 12.1 mg/dL; p <0.001), higher low-density lipoprotein cholesterol (LDL-C) / HDL-C ratio (4.30 ± 1.01 vs 3.24 ± 1.15; p = 0.001), and higher prevalence of mild CAD (without an indication of PCI) (p = 0.029) preoperatively. Cox hazard analysis indicated that preexistent mild CAD (hazard ratio 4.70) and preoperative HDL-C <35 mg/dL (hazard ratio 3.07) were significant predictors for later cardiovascular events after AAA surgery. CONCLUSION: Patients at high risk for later cardiovascular events should require a careful follow-up and may also require an aggressive lipid-modifying therapy.
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OBJECTIVES: To identify the most prognostic predictor of Stanford type B aortic dissection at admission. PATIENTS AND METHODS: Forty-three patients with Stanford type B aortic dissection were divided into two groups: (1) those who developed dissection-related events later (EV group: n = 18), including the need for surgery (n = 12), rupture (n = 1), dissection-related death (n = 5), and aortic enlargement > or =5 mm in diameter per year (n = 15); (2) those without later events (NoEV group: n = 25). Clinical features, aortic diameters, and blood flow status were compared. RESULTS: The maximum aortic diameter at admission was 41.5 +/- 1.7 mm for the EV group, which was significantly greater than the NoEV group (34.4 +/- 0.9 mm, p <0.001). A maximum aortic diameter > or =40 mm was found in 11 patients (61%) of the EV group, whereas this maximum was found in 4 (16%) of the NoEV group (p = 0.004). A patent false lumen at admission was found in all patients of the EV group and in 17 (68%) of the NoEV group (p = 0.013). Other factors were not significant. A Cox hazard analysis indicated a maximum aortic diameter > or =40 mm as a significant predictor for dissection-related events (hazard ratio 3.13, p = 0.032). The presence of a patent false lumen did not reach a statistical significance. CONCLUSION: Our results indicated that a maximum aortic diameter > or =40 mm at admission was the most prognostic factor for developing late dissection-related events, rather than the presence of a patent false lumen.
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Aorta/patología , Aneurisma de la Aorta/patología , Disección Aórtica/patología , Rotura de la Aorta/patología , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/mortalidad , Disección Aórtica/fisiopatología , Disección Aórtica/cirugía , Angiografía de Substracción Digital , Aorta/fisiopatología , Aorta/cirugía , Aneurisma de la Aorta/mortalidad , Aneurisma de la Aorta/fisiopatología , Aneurisma de la Aorta/cirugía , Rotura de la Aorta/mortalidad , Rotura de la Aorta/fisiopatología , Rotura de la Aorta/cirugía , Aortografía , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Flujo Sanguíneo Regional , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
We report a case of hypertrophic obstructive cardiomyopathy (HOCM) successfully treated with septal myectomy and mitral valve replacement (MVR) combined with a resection of the hypertrophic papillary muscles. The patient, a 74-year-old woman, first underwent the conventional septal myectomy through aortotomy. The papillary muscles revealed a marked hypertrophy, but extended myectomy and precise resection of the hypertrophic papillary muscles were thought to be difficult through the aortotomy. Through the right-sided left atriotomy, MVR and resection of the papillary muscles were additionally performed. The patient was smoothly weaned from the cardiopulmonary bypass, and the postoperative course was uneventful. The outflow pressure gradient was relieved to 0 mm Hg, from 94. The mean pulmonary artery pressure was reduced to 27 mm Hg, from 42. The patient has been doing well in the New York Heart Association (NYHA) functional class between I and II during 45 months of follow-up, without complications related to the use of a prosthetic valve. Septal myectomy is the procedure of choice in the surgical treatment of HOCM for most cases, but some may require additional mitral valve procedures. In patients with marked hypertrophic papillary muscles, MVR and resection of the muscles may be an option of treatment to ensure a relief of the outflow obstruction and to abolish systolic anterior movement in units with limited experience.
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Cardiomiopatía Hipertrófica/cirugía , Tabiques Cardíacos/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Músculos Papilares/cirugía , Obstrucción del Flujo Ventricular Externo/cirugía , Anciano , Cardiomiopatía Hipertrófica/complicaciones , Cardiomiopatía Hipertrófica/diagnóstico por imagen , Puente Cardiopulmonar , Ecocardiografía Doppler en Color , Ecocardiografía Transesofágica , Femenino , Humanos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/etiología , Resultado del Tratamiento , Obstrucción del Flujo Ventricular Externo/diagnóstico por imagen , Obstrucción del Flujo Ventricular Externo/etiologíaRESUMEN
Retroperitoneal fibrosis (RPF) is a relatively rare disease which shows a periaortic mass in the retroperitoneal area and predisposes to an obstructive uropathy. We report a case of idiopathic RPF occurring in a patient who was suspected of impending rupture of abdominal aortic aneurysm. A 60-year-old male, with a 2-week history of abdominal pain, was transferred for evaluation of the periaortic mass. Computed tomographic (CT) scan revealed radiological findings such as leakage of contrast media from the aortic lumen and expansion of the periaortic mass. The patient underwent laparotomy, which revealed retroperitoneal fibrotic plaques in the absence of aortic aneurysm. The pathological findings of the biopsy specimen were consistent with idiopathic RPF. The patient received ureteral stent placement and was treated with steroid therapy. When a similar case is encountered, our recommendations are as follows: (i) Both CT scan and magnetic resonance (MR) imaging should be performed to determine whether the retroperitoneal mass is due to idiopathic or secondary RPF. If idiopathic RPF is suspected, the patient should receive primary steroid therapy. (ii) Retroperitoneal periaortic mass indicates a need for the assessment of obstructive uropathy. Early placement of the ureteral stent is necessary for urinary decompression and preservation of the renal function in patients with obstructive uropathy.
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Aneurisma Roto/etiología , Aneurisma de la Aorta Abdominal/etiología , Fibrosis Retroperitoneal/complicaciones , Fibrosis Retroperitoneal/cirugía , Aneurisma Roto/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Medios de Contraste , Diagnóstico Diferencial , Extravasación de Materiales Terapéuticos y Diagnósticos , Humanos , Masculino , Persona de Mediana Edad , Fibrosis Retroperitoneal/diagnóstico por imagen , Stents , Tomografía Computarizada por Rayos X , Obstrucción Ureteral/diagnóstico por imagen , Obstrucción Ureteral/etiología , Obstrucción Ureteral/cirugíaRESUMEN
BACKGROUND: We comparatively evaluated the protective effect of the immunophilin ligands cyclosporine A (INN: ciclosporin), FK506, and rapamycin on the spinal cord in a rabbit model of transient ischemia. Both cyclosporine A and FK506 inhibit calcineurin, whereas rapamycin does not. METHODS: Thirty-six male New Zealand White rabbits were divided into the following 6 groups: group C, 15 minutes of spinal cord ischemia; group FK, FK506 (1 mg/kg) administered 30 minutes before ischemia; group CsA, cyclosporine A (30 mg/kg) administered 30 minutes before ischemia; group CsA-C, chronic administration of cyclosporine A (20 mg/kg) for 9 days before ischemia; group R, rapamycin (1 mg/kg) administered 30 minutes before ischemia; and group R+FK, rapamycin (1 mg/kg) administered 20 minutes before FK506 pretreatment (1 mg/kg). Group CsA-C was added because the drug does not readily cross the blood-brain barrier. Neurologic function was evaluated by Johnson's 5-point scale at 8, 24, and 48 hours after ischemia, and histopathology was assessed 48 hours after ischemia. RESULTS: At 24 and 48 hours after ischemia, the Johnson score was better in groups FK (4.0 +/- 1.1), R+FK (3 +/- 1.1), and CsA-C (2.7 +/- 1.2) than in group C (0.8 +/- 1.2). Numbers of morphologically intact anterior horn cells were higher in groups FK (31.3 +/- 9.9), R+FK (23.2 +/- 4.5), and CsA-C (18.3 +/- 6.8) than in group C (6.3 +/- 4.3). CONCLUSIONS: FK506 and chronic administration of cyclosporine A, but not rapamycin, protect the spinal cord from transient ischemia. Although these results are compatible with inhibition of calcineurin in the mechanism of neuroprotective action of these drugs, other effects through different pathways cannot be excluded before further study.
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Ciclosporina/farmacología , Sirolimus/farmacología , Isquemia de la Médula Espinal/tratamiento farmacológico , Isquemia de la Médula Espinal/patología , Tacrolimus/farmacología , Animales , Ataxia/diagnóstico , Ataxia/epidemiología , Biopsia con Aguja , Modelos Animales de Enfermedad , Interacciones Farmacológicas , Inmunohistoquímica , Masculino , Examen Neurológico , Fármacos Neuroprotectores/farmacología , Parálisis/diagnóstico , Parálisis/epidemiología , Paraparesia/diagnóstico , Paraparesia/epidemiología , Probabilidad , Conejos , Distribución Aleatoria , Factores de Riesgo , Sensibilidad y Especificidad , Isquemia de la Médula Espinal/fisiopatología , Estadísticas no ParamétricasRESUMEN
Antithrombin III (AT III) deficiency is a rare hereditary disease that predisposes to thromboembolic complications. We report a case of AT III deficiency complicated with acute pulmonary thromboembolism, successfully treated with emergency pulmonary thromboembolectomy after insertion of an inferior vena cava filter. AT III activity before treatment was found to be 44% of normal value and remained less than 50% of normal throughout the postoperative course. In his family line, both the patient's aunt and deceased father had a history of pulmonary infarction. AT III activity of the patient's aunt was 47 to 58% of normal value. The patient was discharged on the 15th day after surgery and has been doing well for four years receiving warfarin as anticoagulant therapy. Careful follow-up is essential for early detection of the recurrent pulmonary thromboembolism resulting in pulmonary hypertension and/or right heart failure.