Treatment for abdominal aortic graft infection: irrigation with electrolyzed strong aqueous acid, in-situ grafting, and omentoplasty

We report on successful surgical treatment of consecutive three patients with infection of an abdominal aortic graft, Therapy involved a combination of removal of the infected graft, elaborate debridement, irrigation with electrolyzed strongly acidic aqueous solution (ESAAS), in-situ regrafting, and omentoplasty. The use of ESAAS is discussed.

Genotypic analysis of hepatitis C virus in blood donors in Indonesia

A study was conducted to describe the genetic diversity of hepatitis C virus (HCV) in a population of positive blood donors from throughout Indonesia. Repeat analysis by reverse transcription-polymerase chain reaction (RT-PCR) of 102 anti-HCV positive samples showed that 67 gave HCV-specific positive signals by the PCR for the 5'-untranslated genomic region of HCV. Further genotypic analysis on 64 HCV RNA-positive samples indicated that 57 belonged to the following individual genotypes: 1a, 1b, 2a, 2b, and 3b. The predominant HCV genotypes in this donor population were 1b (57.8%), 2a (17.2%), and 3b (10.9%). The core sequences of the 4 indeterminate samples when aligned with published sequences of various HCV genotypes showed a range of homology from 16.16% to 78.67%. Comparative analysis of genotypic representation from other anti-HCV-positive study populations, including polytransfused pediatric and adult renal dialysis groups, is now being carried out to determine the potential genotypic association with mechanistic HCV spread.

Two different techniques of retrograde cerebral perfusion for thoracic aortic surgery through a left thoracotomy

The authors used profound hypothermic circulatory arrest and continuous retrograde cerebral perfusion for aortic surgery that involved the distal arch through a left thoracotomy. For the first seven patients, oxygenated blood from cardiopulmonary bypass was perfused retrogradely through a venous cannula positioned into the right atrium. In the last 11 cases, venous blood, provided by a perfusion from the lower body, was circulated passively in the brain with the descending aorta clamped. The period of profound hypothermic circulatory arrest was 34.6 +/- 11.1 min, and continuous retrograde cerebral perfusion was 31.3 +/- 11.1 min. Seventeen patients survived, but there was one early death. Two patients with a severely atherosclerotic aneurysm developed permanent neurological dysfunction. The combination of profound hypothermic circulatory arrest, continuous retrograde cerebral perfusion and open aortic anastomosis through a left thoracotomy protects the brain adequately, and facilitates evacuation of debris and air in the aortic arch. It produces satisfactory results for aortic surgery that involves the distal arch.

Oral administration of the dopamine prodrug docarpamine shortens need for drip infusion of dopamine in patients with low cardiac output syndrome after cardiac surgery

BACKGROUND

Docarpamine (DOC) is a dopamine prodrug which can be orally administered. It has been found that oral docarpamine transforms into dopamine in vivo, and increases cardiac output and renal blood flow as effectively as intravenous dopamine.

METHODS

We reviewed the records of 26 patients who had developed low cardiac output syndrome (LOS) after cardiac surgery and received docarpamine during the early postoperative course. Five patients discontinued docarpamine within 2 days due to arrhythmia. There were 3 hospital deaths. The remaining 18 patients were divided into two groups according to the timing of docarpamine administration. In group A docarpamine was administered during and after weaning from intravenous catecholamines, in group B only on demand after weaning from intravenous catecholamines.

RESULTS

There were 12 patients in group A and 6 in group B, and the severity of LOS was relatively milder in group B than in group A. Stable hemodynamics and sufficient daily urinary output were maintained by oral administration of DOC in both groups just as well as by drip infusion of catecholamines.

CONCLUSION

Sinse continuous drip infusion of catecholamine commonly slows recovery in LOS patients, it is considered that switching from drip infusion of catecholamines to oral DOC administration is safe and useful for earlier recovery in LOS patients after cardiac surgery.

Purulent pericarditis presenting as an extracardiac mass in a patient with untreated diabetes

A 50-year-old man with symptoms of bi-ventricular heart failure was transferred to our hospital with a diagnosis of extracardiac tumor. He had a 10 year history of untreated diabetes. Chest computed tomography (CT) revealed an extracardiac mass in the right atrio-ventricular groove. Cardiac catheterization revealed an elevated mean right atrial pressure of 18 mmHg, mean pulmonary wedge pressure of 16 mmHg, and the right ventricular pressure curve demonstrated typical dips and plateaus. At surgery, there was severe adhesion between the pericardium and epicardium, and the pericardium was severely thickened and contained turbid pus. In the left thoracic cavity, there was large amount of pleural effusion and pus. Therefore, the patient was diagnosed with purulent pericarditis caused by left empyema. The thickened pericardium at the anterior portion of the heart was resected, however resection of the remaining portion was abandoned because the adhesion was so tight. After surgery, the patient underwent irrigation of the heart and left thoracic cavity by 1% povidone iodine solution and 0.5 mg/ml of imipenem for 7 days. Bacteriologic culture of the pus from the pericardium revealed anaerobic gram negative bacteria. After 4 months of antibiotics infusion, his C reactive protein became negative and the patient was subsequently discharged from our hospital.

Combined cardiac surgery and total thyroidectomy: a case report

A 65-year-old woman with aortic stenosis, ischemic heart disease, and Graves' disease had complained of effort angina. She then suffered from liver dysfunction due to treatment with antithyroid drugs. One year after the start of radioiodine administration, she demonstrated unstable angina with palpitation and sweating. Laboratory studies revealed a recurrent hyperthyroid state, and a second coronary angiogram revealed progressive ischemic heart disease. Combined coronary artery bypass grafting, aortic valve replacement, and total thyroidectomy were performed. The postoperative course was uneventful without any problems associated with hyperthyroidism or hypothyroidism. Combined cardiac surgery and total thyroidectomy can be performed safely if the perioperative levels of thyroid hormone are maintained at euthyroid or hypothyroid levels.

A U-shaped association between home systolic blood pressure and four-year mortality in community-dwelling older men

BACKGROUND

Several studies in older people have found a U-shaped or J-shaped association of blood pressure with mortality. The increased mortality associated with the lowest levels of blood pressure in older people have been explained by concurrent illnesses and frailty, but previous studies used blood pressure measured on a single occasion. Such a casual value is different from the long-term average of blood pressure. We investigated the relation between the average level of 5-day consecutive home blood pressure and mortality in older people while adjusting for potential confounding factors including morbidity and frailty at baseline.

METHODS

In 1992, 1186 community residents of a rural Japanese town, Kahoku, aged 65 or older, measured their blood pressure in their homes 20 times (four times per day, 5 consecutive days). The mean value of the 20 measurements was used to examine the association between home BP and subsequent 4-year mortality. A proportional hazards model was fitted while adjusting for activities of daily living impairment, medical history, antihypertensive medication, smoking, use of alcohol, and depression.

RESULTS

A total of 134 persons died during the four-year follow-up period. There was no significant evidence that frailty is more prevalent in the lowest or highest systolic BP group than in intermediate groups. A U-shaped association between the average level of home systolic blood pressure and mortality was found in men while adjusting for potential confounding factors, including morbidity and frailty. We also showed the U-shaped curve of the association of systolic BP with all cause and noncardiovascular mortality in the whole population and the linear association of systolic BP with cardiovascular mortality.

CONCLUSIONS

We showed a U-shaped association between the average level of systolic blood pressure measured at home and mortality in older men while adjusting for potential confounding factors including morbidity and frailty. Not only high home systolic BP, but also low home systolic BP, is an independent risk factor for mortality in older men. The mechanisms underlying the association between BP and mortality differ by levels of systolic BP. Cardiovascular deaths tended to be higher in the highest SBP group, and only noncardiovascular deaths were increased in the lowest SBP group. The latter finding suggests that low SBP may be not only an independent risk of mortality but also an indicator of a subclinical noncardiovascular comorbid condition.

Chronic aortic dissection (DeBakey type II) with infective thrombus in the false channel

A 68-year-old man with a DeBakey type II chronic aortic dissection developed bacteremia secondary to a urinary tract infection with the Serratia species. This resulted in an infected thrombus in the false channel and a subsequent rupture of the ascending aorta. An emergency resection of the ascending aorta and a Dacron graft interposition were performed. The patient suffered from severe neurological insufficiency and died of pneumonia 6 months postoperatively. The optimal operation time and surgical options of an infected aortic dissection should be determined.

Aortic valve replacement for aortic regurgitation in a patient with primary antiphospholipid syndrome

A 42-year-old woman with the diagnosis of aortic regurgitation was admitted to hospital for surgical treatment. Ten years ago, primary antiphospholipid syndrome had been diagnosed, and she had a history of recurrent spontaneous abortions and deep vein thrombosis. She was suffering from moderate exertional dyspnea and chest pain. Catheter investigation revealed progressive dilatation of the left ventricle and a deterioration of the ejection fraction. The aortic valve was excised and replaced with a mechanical valve. A specimen of the aortic valve showed localized thickening and shrinkage of the midportion and base of each cusp, with vegetation on the surface. These localized, specific findings suggest that another mechanism may be involved in the cardiac valve pathology in patients with primary antiphospholipid syndrome. No hemostatic or thromboembolic problems were encountered after the surgery, and her postoperative course was uneventful.

[Efficacy of mupirocin in eradicating methicillin-resistant Staphylococcus aureus from nasal discharge in carrying cardiovascular surgical patients]

Methicillin-resistant Staphylococcus aureus from nasal discharge was identified in 37 (2.5%) cardiovascular patients operated between 1995 and 1997; 25 male and 12 female, ranging from 1 to 83 years (mean 63); 2 were excluded because of Arbekacin or Isodine-gel treatment. The first 17 were treated with Vancomycin inhalation (V group) and eradication was considered to have been achieved when 3 consecutive negative cultures were obtained; the subsequent 18 were treated with Mupirocin (M group) and eradication was determined by 1 negative culture. In post-eradication electively operated 13 V and 15 M, postoperative MRSA infection was observed in one M (wound infection); the interval from the first nasal culture to the operation was 68 +/- 58 in V and 32 +/- 12 days in M, respectively (p < 0.05). In the remaining 7 who had to undergo emergency surgery while waiting for eradication because of progression of symptoms (2 V) or prior to instituting treatment (2 V, and 3 M), postoperative MRSA infection was observed in 2 M (both pneumonia). No deaths from infection were observed. Though the time required for conversion of the nasal culture was longer in V (13 +/- 20) than in M (7 +/- 1 days) differences were not significant. Mupirocin is easier to use, eradication can be achieved generally within a week.

A case of anomalous origin of the pulmonary arteries: right pulmonary artery from the descending aorta and the left pulmonary artery from the ascending aorta

A 3-month-old girl classified as having persistent truncus arteriosus underwent surgical correction of the anomalous origin of the pulmonary arteries; the right pulmonary artery from the descending aorta and the left pulmonary artery from the ascending aorta. The patient died on the fourth postoperative day. The definite diagnosis and choice of surgical strategies should be further examined.

Coronary artery bypass grafting in a case with severe aortic atheromatosis associated with abdominal aortic aneurysm

A 69-year-old man with coronary artery disease associated with abdominal aortic aneurysm underwent a one-stage operation utilizing a low-flow cardiopulmonary bypass. Ordinary cardiopulmonary bypass was abandoned as a result of severe atheromatous finding in the entire aorta. However, coronary artery bypass grafting without cardiopulmonary bypass was hazardous as a result of heart enlargement and deteriorating function. Therefore, the abdominal aortic aneurysm was first replaced with a bifurcated graft. Coronary artery bypass grafting with two arterial grafts was then performed successfully on the beating heart with the support of a low-flow cardiopulmonary bypass connected to the bifurcated graft.

[Valve replacement in children]

Between May 1979 and September 1998, 202 children underwent surgical treatment for valvular heart disease. Of these 23, who ranged in age from 25 days to 15 years, underwent valve replacement, including 1 reoperation. The valve replacement consisted of the aortic valve in 5 patients, the mitral valve in 3, the tricuspid valves in 9, including 5 systemic atrioventricular valves for atrioventricular discordance, the pulmonary valve in 6, 5 bioprostheses and 18 mechanical prostheses. There were 4 operative deaths, 1 hospital death and 3 late deaths. At the 10-years follow-up, the actual survival rate was 67.8%, the event free rate was 76.1% and the freedom from reoperation rate was 86.2%. Valve re-replacement was performed in only 1 patient due to a thrombosed tricuspid valve. These results suggest that there is a small risk of major complications and reoperation in children who undergo valve replacement, whether a bioprosthetic valve or a mechanical valve. The long-term results of younger patients should be followed more closely according to their growth.

Plastic surgical reconstruction of left main coronary artery

OBJECTIVE(S)

To report the early and mid-term results of surgical plasty of the left main coronary artery in 12 patients operated upon between 1993 and 1997.

METHODS

The anterior approach was used in all patients. Saphenous vein (n = 4) of glutaraldehyde treated autologous pericardium (n = 8) were used as patch material. Additional coronary artery bypass grafting was performed in 7 patients, the first 3 as a safety back up, and for coexisting stenosis of other coronary branches not revascularized by the plastic procedure in the remaining 4.

RESULTS

Pathologic specimens of the left main coronary artery in 5 revealed atheroma in 3 and myxomatous intimal thickening in 2. The left main coronary artery was widely patent angiographically in all patients prior to discharge. Six patients consented to angiographic restudy 5-40 months after the procedure and revealed excellent results in 5. One patient upon whom autologous pericardial patch had been used underwent percutaneous coronary angioplasty for restenosis of the left main coronary artery and a new lesion of the proximal left anterior descending branch 5 months after the operation. There were no late deaths nor other cardiac events. All patients were in CCS class 1 at their last follow-up.

CONCLUSIONS

Surgical angioplasty of the left main coronary artery could be used to revascularize the left heart safely in patients with a discrete localized lesion of the left main coronary artery and is particularly useful in the face of unavailability of other conduits.

Early and mid-term outcomes of cardiac and thoracic aortic surgery in over-75-year-olds with postoperative quality of life assessment

The early and mid-term outcomes of cardiac and thoracic aortic surgery were reviewed in seventy-two consecutive patients aged 75 years and older, together with assessment of postoperative quality of life. Twenty-six patients had ischemic heart disease, twenty had valvular heart disease, one had congenital heart disease, and twenty-five had thoracic aortic aneurysm. Twenty-five (34.7%) required an emergency operation. There were 6 early deaths (8.3%) and 11 late deaths (17.2%), of which the emergency cases had higher mortality of 5 early deaths (20.0%) and 3 late deaths (15.0%). In particular, most cases with a ruptured thoracic aortic aneurysm died eventually from various complications including neurological dysfunction. The others with a non-ruptured aneurysm also had atherosclerotic aortic or arterial lesions which caused a lethal cerebrovascular accident or ischemic heart disease. The quality of life of 51 of 53 survivors was assessed using the Rosser and Watts index being based on disability and distress scores. The response was satisfactory--the disability score was 2.6 +/- 1.9 and the distress score was 1.4 +/- 0.4. The patients with a thoracic aortic aneurysm had worse quality of life scores than those of the ischemic heart disease or valvular heart disease patient-groups because of various perioperative complications. Our experiences demonstrate that the results including the postoperative quality of life following cardiac and aortic surgery in the elderly is satisfactory except for emergency cases. The results would prompt us to operate, if possible, electively in their stable conditions, even on elderly over-75-year-olds.

Single-stage surgery for distal aortic arch aneurysm and infrarenal abdominal aortic aneurysm through anterolateral approach

A 58-year-old man with a distal aortic arch aneurysm (DAA) associated with an infrarenal abdominal aortic aneurysm (AAA) successfully underwent a single-stage replacement of the aneurysms. A left anterolateral thoracotomy was used for replacement of the DAA, which was performed using profound hypothermic circulatory arrest and continuous retrograde cerebral perfusion. An extraperitoneal approach in conjunction with a lateral abdominal incision was employed for replacement of the AAA. The combination of an anterolateral thoracotomy and a lateral abdominal incision is useful in combined surgery for DAA and AAA.

Monitoring of regional cerebral oxygenation by near-infrared spectroscopy during continuous retrograde cerebral perfusion for aortic arch surgery

OBJECTIVE

To assess the value of monitoring of regional cerebral oxygen saturation (rSO2) during aortic arch surgery using continuous retrograde cerebral perfusion (CRCP) in conjunction with profound hypothermic circulatory arrest (HCA).

METHODS

The rSO2 of 12 consecutive patients was monitored non-invasively using near-infrared spectroscopy (NIRS) and the data were analyzed statistically.

RESULTS

The mean duration of HCA with CRCP was 62-/+14.1 min. The mean CRCP flow rate was 226+/-163 ml/min. Surgical outcomes were favorable with only a single hospital death (8.3%). However, the rSO2 decreased gradually in all patients during HCA, even combined with CRCP, and fell to 46+/-8.7% on average. It did not change so greatly before HCA and returned finally to its initial level at the end of re-warming. Only one patient developed a permanent neurologic deficit; this patient showed the greatest decrease of rSO2 from 56% to 29% after the longest HCA of 88 min. Two parameters, End-rSO2 (the ratio of post- to pre-HCA rSO2) and delta-rSO2 (the rate of decrease from preto post-HCA rSO2) were obtained since the initial values of rSO2 before surgery differed. There were linear correlations between the CRCP flow rate and each of these two parameters. A multiple regression analysis also revealed a linear equation relating the parameters, which allowed prediction of the safe duration of HCA in different conditions of CRCP and a more favorable adjustment of the CRCP condition in each patient.

CONCLUSIONS

The study suggests that the combination of HCA and CRCP has a limit of safe duration in spite of its potential usefulness for brain protection, and that rSO2 monitored by NIRS is useful in testing for adequate brain protection. It is hoped that monitoring of rSO2 can facilitate prediction of the safe duration of HCA with CRCP and a more favorable adjustment of CRCP.

Acute jaundice in Vientiane, Lao People's Democratic Republic

Analysis of serum samples from patients with acute jaundice by means of enzyme-linked immunosorbent assay and polymerase chain reaction testing provided the first profile of this condition in Vientiane, Lao PDR, in 1995 and 1996. In a case-control, hospital-based study, evidence of acute infections due to hepatitis A and B viruses was found in 14% and 10% of cases, respectively. Hepatitis E virus, however, did not appear to contribute to clinically recognized acute jaundice. Similarly, antibody to hepatitis C virus was recognized in almost equal proportions of cases (8%) and controls (6%), thus representing probable background infections. The detection of hepatitis G virus marks the first report of this virus in Lao PDR. The large proportion (21%) of new leptospiral infections in cases without acute hepatitis A or B was notable. This finding suggests significant regional underreporting of leptospirosis as a cause of acute jaundice. The limited laboratory diagnostic capabilities for confirming a differential diagnosis of leptospirosis contribute to the lack of attention paid to this important health problem.

Aortic valve replacement in a patient with previous coronary artery bypass grafting

Gaining a sufficient exposure for aortic valve surgery after previous coronary artery bypass grafting (CABG) has been a problem due to the patent saphenous vein grafts. Although a patient had had CABG twice we performed aortic valve replacement (AVR) with almost the usual exposure. We attached the proximal anastomosis in a more distal position of the ascending aorta than usual, at the first CABG, as he was diagnosed to have mild aortic valve stenosis prior to surgery. We consider this method allows easier AVR after previous CABG when the patient is diagnosed with mild aortic valve stenosis before CABG.

Post-stroke hypertension correlates with neurologic recovery in patients with acute ischemic stroke

To examine the clinical implications of post-stroke hypertension, defined as the rise in blood pressure on admission after the onset of ischemic stroke as compared with the blood pressure before stroke, and to assess the relationship between the value of post-stroke hypertension and neurologic recovery, we retrospectively studied 28 patients admitted to the hospital within 24 h (mean+/-SD, 6.7+/-7.0 h) after a first-ever, acute non-embolic ischemic stroke, whose blood pressure had been recorded at the outpatient clinic within 3 mo before stroke. The Canadian Neurological Scale was used to assess stroke severity, and neurologic recovery during the acute phase was calculated. The average duration of hospitalization was 18+/-9 d. The value of post-stroke hypertension and stroke severity on admission independently and significantly correlated with neurologic recovery (odds ratio, 1.06; 95% confidence interval, 1.00-1.12 and odd ratio, 0.20; 95% confidence interval, 0.06-0.72, respectively). There was also a significant linear correlation between the value of post-stroke hypertension and neurologic recovery (r= 0.50, p< 0.01). Furthermore, blood pressure after the onset of ischemic stroke was quite independent of blood pressure before stroke. We conclude that the value of post-stroke hypertension correlates with neurologic recovery in patients with acute non-embolic ischemic stroke. These results suggest that blood pressure control mechanisms change after the onset of acute ischemic stroke.

Coronary artery bypass grafting for an adult with coronary disease due to Kawasaki disease

Surgical treatment for patients over the age of forty with coronary aneurysms associated with Kawasaki disease is rare. We report on a 47-year-old man who underwent coronary artery bypass grafting using the left internal thoracic arteries (ITA) and right gastroepiploic (GEA). The postoperative course was uneventful. One month later, the normal stress thallium-201 myocardial perfusion imaging was normal and coronary angiography showed good patency for the ITA, GEA, and saphenous vein grafts. He had some coronary risk factors including smoking, hypertension and hyperlipidemia. Histological examination of a sample shows that the coronary artery sequelae of Kawasaki disease have already become part of increasing burden of adult ischemic heart disease.