Refractoriness to platelet transfusion following double valve replacement in an ITP patient who had undergone splenectomy

Reports of patients with idiopathic thrombocytopenic purpura (ITP) undergoing cardiac surgery are rare, and almost all of the reported cases required platelet transfusion. ITP patients, especially those having a history of splenectomy or a history of heavy bleeding, may have to undergo multiple platelet transfusions. Such transfusions may induce alloimmunization against the human leukocyte antigen (HLA) and result in refractoriness to subsequent platelet transfusions. We report a case of a 63-year-old female with ITP, with a history of splenectomy and multiple platelet transfusions, who underwent aortic and mitral valve replacement. Although corticosteroid administration, high-dose immunoglobulin therapy, and repeated platelet transfusion led to a temporary increase in platelet count and successful hemostasis, refractoriness to platelet transfusion occurred postoperatively because of the presence of the anti-HLA antibody. In addition, the patient showed complications of pyothorax. Corticosteroids might have exerted an inhibitory influence on the occurrence of pyothorax.

[Application of modified ultrafiltration to cardiac surgery in adults]

Modified Ultrafiltration (MUF) was developed for blood concentration and reduction of postoperative edema in cardiac surgery in children. Its beneficial effects on postoperative hemodynamics have been reported. We applied MUF to cardiac surgery in adults and evaluated its usefulness. Between August, 1995 and April, 1997, MUF was performed in 41 adult patients. MUF was carried out immediately after the cessation of cardiopulmonary bypass. The mean fluid volume removed was 1,135.9 +/- 274.1 ml. The patient's haematocrit significantly increased from 23.2 +/- 2.6% to 26.9 +/- 3.2% (p < 0.0001). The dose of inotropes administered was maintained constant during MUF, and no changes were observed in CVP and the heart rate. However, the systolic blood pressure increased from 99.5 +/- 14.7 to 113.2 +/- 16.2 mmHg (p < 0.0001) and cardiac index from 4.2 +/- 0.9 to 4.9 +/- 1.3 l/min/m2 (p = 0.0006). It was suggested that MUF was an useful technique of haemoconcentration and appeared to have beneficial effects on postoperative hemodynamics in adult cardiac surgery.

Combined catheter embolization and femorofemoral bypass for pseudoaneurysm of the right external iliac artery: report of a case

Performing direct surgery for postoperative hemorrhage caused by intraperitoneal arterial injury is very difficult. We report herein the case of a 52-year-old woman who developed sudden right lower abdominal pain after numerous laparotomies and radiotherapy for advanced uterine cancer. A diagnosis of pseudoaneurysm of the right external iliac artery was made, and an emergency catheter embolization and femorofemoral bypass was successfully performed under local anesthesia. The patient was able to walk the next day. To the best of our knowledge, this is the first report of such a combined procedure in the literature.

[Coronary artery bypass grafting and the repair of ventricular septal defect in idiopathic thrombocytopenic purpura]

A 57-year-old man with idiopathic thrombocytopenic purpura (ITP) underwent coronary artery bypass grafting and repair of ventricular septal defect. He had not been taken any treatments for ITP for the last two years and platelet count was only 26,000 on his admission. He received 5 days of intravenous high dose immunoglobulin therapy but there was no significant increase of platelet count. He received platelet transfusion during and after the surgery resulting in good postoperative course and no problems of hemostasis.

Surgical repair of ventricular septal defect associated with absence of right superior vena cava and persistent left superior vena cava: a case report

A nine-month-old boy, weighing 4840 g, with VSD associated with absent right superior vena cava and persistent left superior vena cava, successfully underwent surgical repair of VSD. This anomaly is rare and causes some surgical and electrophysiological problems. We discussed these problems and described the details of surgery in our case.

[Massive mediastinal bleeding due to spontaneous rupture of the vertebral artery in von Recklinghausen disease]

In Von Recklinghausen disease, patients rarely demonstrate vascular abnormalities, but several reports have noted massive bleeding from vascular rupture. A 28-year-old man with Von Recklinghausen disease was admitted to our hospital because of swelling on the left neck accompanied by dyspnea. Neck and thoracic CT revealed a high density shadow on the mediastinum and left upper thorax which was suspected to indicate hemomediastinum. Under suspicion of bleeding from the intrathoracic artery, the patient underwent on surgery. Massive hematoma disrupted visual recognition of bleeding point, but under anatomical consideration, we concluded that the bleeding was from the ruptured left vertebral artery (VA) which branched independently from the aorta. The left VA was ligated distally and proximally. Left subclavian artery, injured unexpectedly, was not reconstructed but sutured carefully because of its fragility. Thus massive bleeding was controlled. Histology of the neighboring subclavian artery revealed involvement with neurofibrinomatosis. Although the patient's left arm demonstrated a slightly low blood pressure, he was discharged without complaint on the 56th postoperative day.

[Cardiac surgery for the patients with hyperthyroidism]

Since open heart surgery may cause thyrotoxic crisis during the perioperative period in patients with hyperthyroidism, close monitoring and control are needed. We performed open heart surgery in 2 patients with hyperthyroidism, and good results were obtained. A 71-year-old patient with mitral valve insufficiency underwent mitral valve repair by replacement of chordae tendineae with polytetrafluoroethylene sutures and annuloplasty with a Duran's Ring. The other 20-year-old patient with aortic valve insufficiency underwent aortic valve replacement with an SJM valve. In the two patients, cardiopulmonary bypass for a prolonged period was required during surgery. However, thyrotoxic crisis could be prevented by controlling thyroid function by preoperative treatment with anti-thyroid agents, concurrent medication with Lugol's iodine solution immediately before surgery and re-administration of anti-thyroid agents early after surgery.

The relation between arterial oxygen tension and cerebral blood flow during cardiopulmonary bypass

OBJECTIVES

Neurological impairment occurs in up to 25% of infants undergoing cardiopulmonary bypass with or without circulatory arrest. Potential causes include alterations in cerebral blood flow, hypoxia and embolisation. During cardiopulmonary bypass, arterial oxygen tension is maintained at levels which under normal conditions cause cerebral vasoconstriction; this is a potential mechanism for ischaemia. The aim of this study was to explore the relation between arterial oxygen tension and cerebral blood flow during cardiopulmonary bypass.

METHODS

Near infrared spectroscopy was used to explore the relation between arterial oxygen tension and cerebral blood flow in 14 patients (median age 8 months; range 1 month to 10 years 11 months). The relations between arterial oxygen tension, arterial carbon dioxide tension, temperature, haematocrit, pump flow rate, mean arterial pressure and cerebral blood flow, were examined using multivariate analysis.

RESULTS

There was no relation between cerebral blood flow and arterial oxygen tension, but a highly significant relation was observed between cerebral blood flow and pump flow rate, with cerebral blood flow decreasing 4.2-fold per L.m-2.min-1 decrease of pump flow rate.

CONCLUSION

There was no relation between arterial oxygen tension and cerebral blood flow during cardiopulmonary bypass, but low pump flow rate may lead to reduced cerebral blood flow.

Supravalvular stenotic mitral ring with ventricular septal defect

BACKGROUND

Supravalvular mitral ring is exceedingly uncommon.

METHODS

We report a 4-year-old girl with supravalvular stenotic mitral ring and ventricular septal defect (VSD). The VSD was closed by a Dacron patch and the supravalvular ring was excised. For treatment of supravalvular mitral ring with obstruction, surgical resection is commonly performed.

RESULTS

There are no reports of long-term follow-up after resecting the supravalvular mitral ring.

CONCLUSION

In our case, no mitral stenosis was evident on postoperative echocardiogram performed 3 years after surgery.

Myxoma of the aortic valve

Myxoma of the aortic valve is exceedingly uncommon. In this article, we report a 58-year-old man with myxoma arising from the aortic valve. Aortic valve replacement was performed, and postoperative histologic examination showed myxoma of aortic valve.

Pseudoaneurysm of the left ventricle following repair for ventricular septal perforation

The patient was a 64-year-old man who was treated surgically for an infarct-related ventricular septal perforation. Pseudoaneurysm of the left ventricle was recognized on the 38th postoperative day. Emergency surgery was performed. It seemed that insufficient resection of the infarcted myocardium was performed during the initial surgery to avoid narrowing the ventricular dimension by direct closure of the left ventricle, but this resulted in pseudoaneurysm of the left ventricle. Left ventricular free wall plasty with a patch should be performed during the initial surgery.

[Successful repair of right atrial rupture due to nonpenetrating trauma of the chest]

A 24-year-old male was brought to our hospital after being injured in a traffic accident. On arrival, his blood pressure was 70/44 mmHg and his pulse rate was 135/min and regular. Chest X-p revealed cardiomegaly but there was no pleural effusion or bone fracture. Echocardiogram revealed cardiac tamponade and he was diagnosed as cardiac rupture due to non penetrating trauma. Under midline sternotomy, right atrial rupture was repaired. The patient developed cardiac arrest lasting approximately 8 minutes during anesthetic induction, so he needed to be ventilated for 8 days. However his postoperative course was not so eventful and he was discharged 38 days after surgery without any neurophysiological disturbance.

Effects of auricular acupuncture stimulation on nonobese, healthy volunteer subjects

Effects of auricular acupuncture stimulation on nonobese healthy volunteers were investigated. Subjects (n = 35) averaged 34.5 years old, and BMI was 25.3 kg/m2. Small (0.15 x 2.0 mm) auricular needles were applied intracutaneously into the bilateral cavum conchae that was identified by having less than 100 k omega resistance. Body weight was measured four times a day and charted by the subjects themselves. Results showed that, in the period 11-2, in which only body weight was measured, without auricular acupuncture stimulations, 57.1% of the subjects reduced their body weight. This indicates that charting body weight themselves might be useful to maintain their weight. In the auricular acupuncture treated period, 19 (70.4%) out of 27 decreased (p < 0.01), 5 (18.5%) was increased, and 3 (11.1%) had no change in body weight. In conclusion, the results suggest that success in maintaining weight reduction can be attributed to graphic illustration of one's weight pattern. Bilateral auricular acupuncture stimulation can also reduce body weight of healthy non-obese subjects. This is consistent with the suggestion that it might be effective in the treatment of obese patients.

Clinical significance of reverse redistribution phenomenon after coronary artery bypass grafting

The reverse redistribution (RR) phenomenon is a decrease in thallium 201 uptake during redistribution compared with 201Tl uptake immediately after exercise. We evaluated RR in 23 patients after coronary artery bypass grafting. Postoperative RR was present in 48% and was significantly more common in patients with a history of myocardial infarction (62%). The patients were classified according to the presence (+) or absence (-) of RR. An analysis of left ventricular wall motion showed significant improvement after coronary artery bypass grafting in the RR+ group (n = 12) but not in the RR- group (n = 11). Quantitative myocardial viability was evaluated using the defect volume ratio, mean defect severity, and defect severity index. The preoperative defect volume ratio was higher in the RR+ group than in the RR- group (p < 0.05). In the RR- group, no improvement in these indices was observed after operation. In contrast, the RR+ group showed significant improvement in all three indices (p < 0.05). These results indicate that after coronary artery bypass grafting, an adequate blood supply to the remaining myocardium may induce RR. This phenomenon, therefore, may be a significant indicator of postoperative myocardial viability.

Surgical repair of a ventricular septal defect in a patient with trisomy 8 syndrome

We surgically repaired a ventricular septal defect (-VSD) in a patient with trisomy 8 syndrome. This case illustrated a number of characteristic clinical features associated with trisomy 8 syndrome patients which have previously been reported in the literature. However, our patient's VSD was not found to be particularly different from the VSD of patients without chromosomal abnormalities during either the surgery or the postoperative course.

Effects of hypothalamic paraventricular nucleus: electrical stimulation produce marked analgesia in rats

The effect of the electrical simulation induced analgesia (ESIA) on the hypothalamic paraventricular nucleus (PVN) was investigated by the paw pressure test, which was used to avoid any tissue damage to the paw of Wistar-SPF/VAF male rats. A stimulating electrode was chronically implanted in the parvocellular (PVN-prv) or magnocellular (PVN-mgn) divisions of the PVN. The ESIA was examined at least 10 days after surgery. The electrical stimulation of the PVN markedly showed analgesia (ESIA), but stimulation of most locations outside the PVN did not produce ESIA. Stimulation threshold for the ESIA was lower from PVN-prv than from PVN-mgn, but neither region was affected by naloxone administration (10 mg/kg, i.p.). These results indicate that the PVN is a part of the pain inhibitory system in the CNS, and show that PVN-ESIA might not be mediated either by opioids or by neuropeptides such as vasopressin.

Effects of auricular stimulation on feeding-related hypothalamic neuronal activity in normal and obese rats

It is known that auriculotherapy occasionally affects dramatic body weight reduction for obese patients, although the physiological and anorexigenic functions are not clear. Effects of auricular stimulation on feeding-related lateral (LHA) and ventromedial (VMH) hypothalamic neuronal activity in normal and experimental (hypothalamic and dietary) obese rats were investigated. The LHA and/or VMH neuronal activity were recorded from feeding-related regions in Wistar SPF/VAF male and experimental (hypothalamic and dietary) obese rats, anesthetized with urethane-chloralose, under stereotaxic coordination. Recording was through 3 M KCI glass microelectrodes, while stimulating the ipsilateral vagal innervated region of the auricle. This is equivalent to the cavum conchae in the human, and was identified by resistance less than 10-50 k omega. The stimulating electrode was a stainless steel ear acupuncture (0.12 x 2.0 mm). The latency of potentials evoked in the LHA by unilateral stimulation of a specific site in the ear was 28.1 +/- 3.3 ms (8-92, n = 41). LHA neuronal activity was depressed 45.6% (n = 12, p < 0.01), and VMH activity was excited (60.5%, n = 18, p < 0.01). The auricular acupuncture stimulation clearly modulates feeding-related hypothalamic neuronal activity of experimental (both hypothalamic and dietary) obese rats. These auricle acupuncture stimulation effects were correlated to the degree of obesity. In conclusion, the results suggest that auricular acupuncture stimulation may not reduce appetite, but is more likely concerned with satiation formation and preservation. Thus, auricular acupuncture should be more effective on obese rats than on normal rats.

A clinical study on the effects of pulsatile cardiopulmonary bypass on the blood endotoxin levels

Levels of endogenous endotoxins have been reported to increase after cardiopulmonary bypass. Endotoxin levels have also been implicated in multiple organ failure and may contribute to the immunocompromised state seen after bypass. We evaluated the effects of pulsatile cardiopulmonary bypass circulation on endogenous endotoxin levels. The study population consisted of 15 consecutive adult patients who underwent cardiac operations with cardiopulmonary bypass. Pulsatile flow was used during aortic crossclamping in eight patients (group I) and nonpulsatile flow was used in the remaining seven patients (group II). Changes in blood endotoxin levels were monitored during aortic crossclamping, after release of the clamp, and after weaning from bypass. The blood endotoxin level at each stage was expressed as a percentage of the level at the beginning of bypass. Group I patients a significantly lower blood endotoxin percentage than group II (from 20 to 120 minutes after the initiation of aortic crossclamping). In group I, the blood endotoxin percentage was nearly constant during aortic crossclamping. After release of aortic crossclamping, group I also had a lower blood endotoxin percentage than group II. Endogenous endotoxin levels appear to increase in the presence of intestinal congestion and ischemia. Improvement in intestinal circulation by pulsatile cardiopulmonary bypass may prevent increases in endogenous endotoxin levels by reducing these factors.

Optimal perfusion pressure for experimental retrograde cerebral perfusion

We evaluated cerebral metabolism during retrograde cerebral perfusion (RCP) and circulatory arrest during profound hypothermia, and also investigated the effects of perfusion pressure on RCP. Twenty-four adult mongrel dogs were placed on cardiopulmonary bypass and cooled to a nasopharyngeal temperature of 20 degrees C. At this temperature, hypothermic circulatory arrest (HCA; n = 6), and RCP with a perfusion pressure of 10 mmHg (RCP10; n = 6), 20 mmHg (RCP20; n = 6), and 30 mmHg (RCP30; n = 6) were carried out for 60 minutes. RCP was performed with oxygenated blood via the bilateral maxillary veins, and the retrograde flow rate was regulated to maintain a mean perfusion pressure of 10, 20, or 30 mmHg in the external jugular vein. At 60 minutes of RCP, we measured nasopharyngeal temperature; regional cerebral blood flow (rCBF); cerebral oxygen consumption, carbon dioxide excretion, and excess lactate; cerebral tissue adenosine triphosphate (ATP), adenosine diphosphate (ADP), adenosine monophosphate (AMP) and energy charge; and cerebral tissue water content. In the RCP10 group, there was excess cerebral lactate, and ATP and energy charge were low. In the RCP30 group, the water content of cerebral tissue was significantly higher than in other groups. In the RCP20 group, temperature was maintained in a narrow range, oxygen consumption and carbon dioxide excretion could be observed, there was no excess lactate, and ATP and energy charge were significantly higher than in the HCA group. In conclusion, RCP can provide adequate metabolic support for the brain during circulatory arrest, and a perfusion pressure of 20 mmHg is most appropriate for RCP.

[Experimental study of optimal perfusion pressure during retrograde cerebral perfusion]

The effects of retrograde perfusion pressure on the brain was experimentally investigated during profound hypothermic circulatory arrest. Fifteen adult mongrel dogs were placed cardiopulmonary bypass and induced profound hypothermia of 20 degrees C at nasopharyngeal temperature. Retrograde cerebral perfusion (RCP) with perfusion pressure of 10 mmHg (RCP10; n = 5), 20 mmHg (RCP20; n = 5), 30 mmHg (RCP30; n = 5) underwent for 60 minutes. The oxygenated blood was infused via the bilateral maxillary veins, and the flow rate was kept to maintain a desired pressure in the external jugular vein for each group. Regional cerebral blood flow (rCBF), excess lactate, cerebrospinal fluid pressure (CSFP), adenosine triphosphate (ATP) concentration of cerebral tissue, and water content of cerebral tissue were measured. In the RCP10 group, cerebral excess lactate was positive and ATP concentration was low. In the RCP30 group, the water content of cerebral tissue was significantly higher than those in the other groups. In the RCP20 group, the excess lactate was maintained in a negative range, and ATP concentration was significantly higher than in the RCP10 group. In conclusion, RCP may provide metabolically adequate support for the brain and a perfusion pressure of 20 mmHg was appropriate for RCP in dogs.