Search

We experienced a rare case of an unroofed coronary sinus without a persistent left superior vena cava. A 55-year-old man, who was diagnosed with cerebral infarction, presented with suspected atrial septal defect (ASD) coexisting with paroxysmal atrial fibrillation. Before the operation, we diagnosed this case as coronary sinus ASD by contrast-enhanced coronary computed tomography (CT). There was a 20 mm segment of abnormal communication between the base of the left atrium and the roof of the coronary sinus. We repaired the defect by simple direct closure from the left atrium side, so that the coronary veins drained into the right atrium. The postoperative course was uneventful. Imaging played a crucial role in the diagnosis. Coronary CT angiography is well suited to help identify asymptomatic congenital heart disease.

An 80-year-old man was admitted to our hospital for examination of a ball thrombus incidentally found in the left ventricle (LV). Coronary angiogram revealed severe triple vessel disease and LV dysfunction. Although LV wall motion in the septum and the apex was akinetic, there were no signs of myocardial infarction. It was diagnosed as an acute LV ball thrombus with hibernating myocardium due to ischemia of the left anterior descending coronary artery. Emergency coronary artery bypass grafting (CABG) and excision of the thrombus were performed. Two weeks after surgery, LV function improved and the patient was discharged from the hospital without any complication. A LV ball thrombus without myocardial infarction is rare, and thought to be caused by hibernating myocardium.

We treated a 62-year-old male who had previously undergone a mitral valve plasty and aorto-coronary bypass. One year after the operation, he underwent pacemaker implantation for atrial fibrillation. Two months following implantation, the pacemaker generator was exposed due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. We selected a new catheter route from the right saphenous vein, and implanted a generator under the fascia of the external oblique abdominal muscle. Thereafter, the pacemaker is functioning without trouble and there is no evidence of infection.

Laryngotracheal injuries are serious complications in the case of penatrating neck trauma which may not commonly in Japan. In the last several decades, many authors have discussed method for accurate evaluation and immediate airway management for patient with laryngotracheal injury. But, standardization of the treatment is still controversial about mandatory exploration or selective exploration. We report 4 cases with fresh laryngotracheal injury due to penetrating neck trauma including 3 suicide attempt patients. In these cases, laryngotracheoplasty used by absorbable material was performed within 8 hours after trauma. Two cases of suicide attempt patients underwent tracheostomy at the lower level of the laryngotracheal injury. After these treatment, fiberoptic bronchoscopy was performed to evaluate the airway for 3 cases except 1 who was dead because of hemorrhagic shock on arrival. In 2 cases, the suture filament existed in the lumen of the larynx and trachea, there were no major granulation in the site of repairment and no infection. Three cases were extubated successfully and discharged without major airway problem. Two cases have psychiatric disease such as depression, so we must consider their psychiatric background in the future. In conclusion, penetrating laryngotracheal trauma, we should consider that serious airway injury may be hidden under the superficial small wounds. Also, rapid local wound exploration and laryngotracheoplasty is important for life-saving, and fiberoptic bronchoscopy is effective to prevent early respiratory complications and has value in the evaluation.

Recently, off-pump coronary artery bypass grafting (OPCAB) has been rediscovered and spread to avoid the deleterious effect of cardiopulmonary bypass. In OPCAB, surgical exposure of Cx grafting site often threats the hemodynamic stability. We retrospectively analysed the 13 patients with acute coronary syndrome due to LMT lesion who underwent emergent OPCAB to accomplish the safe Cx grafting. We assessed the intraoperative hemodynamic changes and early results of OPCAB through the use of new devices and techniques. Myocardial tissue oxygen saturation was measured by near-infra red spectroscopy during OPCAB. All procedures were completed without hemodynamic deterioration and conversion to cardiopulmonary bypass. No hospital deaths or complications were noted. The early patency rate was 100 percent and perioperative maximal CK-MB was 16.6 +/- 4.7 IU/l. Concomitant use of ischemic preconditioning and KATP opener, oxidative radical scavenger, PD III inhibitor, ameliorated ischemic cardiac dysfunction during occlusion of the coronary artery and improved the postischemic functional recovery. These results suggest that intra-operative compound management may decrease the risk of Cx grafting of OPCAB.

In an attempt to avoid the deleterious effect of cardiopulmonary bypass, off-pump coronary artery bypass grafting has been rediscovered and spread. We often accomplish the ischemic preconditioning (IP) in off-pump CABG. IP is the phenomenon in which sublethal episode of myocardial ischemia result in increased tolerance to a later, potentially lethal, episode of ischemia. To evaluate the cardioprotective effect of IP and an ATP-sensitive potassium channel (KATP) opener, oxidative radical scavenger, 43 clinical cases were examined. The myocardial tissue oxygen saturation was measured by near-infra red spectroscopy during IP. Twelve cases were subjected to accomplish simple IP (5 min x twice), and 29 cases received pharmacological IP (administrated allopurinol preoperatively and nicorandil intraoperatively; 3 min x once). The result showed that the tissue oxygen of pharmacological IP group is superior to that of simple IP group. The concomitant use of IP and KATP opener, oxidative radical scavenger both ameliorated cardiac dysfunction during the ischemia in anastomotic occlusion of the coronary artery, and improved the postischemic functional recovery. These results suggest that we would be able to decrease both duration and the number of times of IP by using KATP opener and oxidative radical scavenger.

Carotid endarterectomy (CEA) clearly benefits high stroke-risk patients with coronary or peripheral vascular disease, but its value of procedures is not still recognized for thoracic surgeons in Japan. Therefore we reviewed our technique of CEA and presented its usefulness and necessity.

A total of 181 endoscopic transthoracic sympathicotomy were performed at our hospital from December, 1992 to March, 1997. After single-lumen endotracheal intubation for general anesthesia, the patient was placed in half sitting position. A small (1 cm) incision was made in the anterior axillary line through the third intercostal space and an apical pneumothorax was created by insufflation of 1.8 L of CO2 in the pleural cavity through a Surgineedle. A 24 Fr. urological transurethral electroresectoscope was introduced through the same incision. The sympathetic chain could be observed through parietal pleura riding on the costovertebral junctions. In palmar hyperhidrosis the second and third thoracic sympathetic ganglia were electrocoagulated. In axillary hyperhidrosis the forth ganglion was included. The lung was expanded by limiting expiration and sucking CO2. The operation was repeated on the other side. Endoscopic transthoracic sympathicotomy was an efficient, safe and low invasive surgical procedure for the treatment of palmar, axillary hyperhidrosis, Raynaud's disease and Buerger disease.

We performed endoscopic transthoracic sympathicotomy (ETS) for angina pectoris in a 77-year-old female. She had multiple coronary disease of a history of failed percutaneous transluminal coronary angioplasty (PTCA). Bilateral ETS of Th2 to Th5 was carried out under general anesthesia without surgical complication, hemodynamic change and ECG change. Postoperatively she was free from angina and increased working capacity. ST depression on ECG was remarkably improved and the increase of heart rate and systolic blood pressure was suppressed on exercise test after a month of ETS. The effect of ETS to angina pectoris was suspected not to relieve anginal pain but also to reduce myocardial oxygen demand on exercise. We conclude that ETS is a safe, simple and low invasive procedure and it can be done in patients who are judged unsuitable for coronary artery bypass grafting (CABG) or PTCA.

Coronary artery bypass surgery in a 67-year-old male with severe calcified ascending aorta was performed without cardiopulmonary bypass under beating heart, utilizing the left internal thoracic artery graft. No neurological complication was observed and postoperative angiogram showed good graft patency. We think coronary revascularization without cardiopulmonary bypass can be one of the safe and reliable methods to avoid complications associated with aortic cross clamping and aortic cannulation with severely calcified aorta.

Two cases of vein patch angioplasty for ischemic heart disease were presented. The first case (59-year-old female) admitted to our hospital because of posterolateral infarction. Preoperative coronary angiogram (CAG) showed stenosis of 4-PD of RCA, proximal LAD and distal LCX. The second case (62-year-old male) admitted for operation of abdominal aortic aneurysm. Preoperative CAG showed stenosis of proximal RCA and mid LAD. Stenosis of 4-PD and proximal RCA was relieved by patch angioplasty using saphenous vein graft and coronary artery bypass to LAD was performed by left internal thoracic artery graft. Both cases showed successful enlargement of RCA stenosis and good graft patency at the postoperative CAG. Vein patch angioplasty is thought to be an alternative method for coronary revascularization to ischemic heart disease.

The thoracic sympathectomy was performed with standard laparoscopic and urologic equipment. After intubation, the patient was placed in a half sitting position. A Surgineedle was introduced into the pleural cavity through a 1 cm incision at the intercostal space between the first and second rib. An apical pneumothorax was created by insufflation of two litres of CO2. A 24 ch. urological trocar was inserted through the same incision, then the electroresectoscope was introduced into the pleural cavity. The sympathetic chain could be observed through parietal pleura riding on the costovertebral junctions. These areas were electrocoagulated. The lung was expanded by limiting expiration and sucking CO2. A postoperative chest X-ray was done to check no pneumothorax. This method was a simple and safe surgery, which was available for bilateral sympathectomy.