Encephalitis Owing to Human Herpesvirus-6 after Cardiac Transplant

Human herpesvirus-6 (HHV-6), a beta herpesvirus closely related to cytomegalovirus (CMV), infects the majority of the population in childhood. Human herpesvirus-6 can be reactivated in the immunosuppressed patient. After bone marrow and orthotopic liver transplant, it has been linked to various clinical syndromes, including undifferentiated febrile illness, encephalitis, pneumonitis and bone marrow suppression. To date its infectious role after orthotopic heart transplant has not been well documented. We present the case of a 32-year-old cardiac transplant recipient who initially presented 8 weeks after his transplant with high fever and headache. He developed increasing confusion, pulmonary infiltrates and neutropenia. Cytomegalovirus viral loads were negative. Polymerase chain reaction (PCR) of blood and cerebrospinal fluid detected HHV-6 DNA, consistent with HHV-6-related encephalitis, pneumonitis and bone marrow suppression. He was treated with foscarnet with gradual improvement in clinical status. We review the literature on the significance of this virus post cardiac transplant.     

A case of ventricular fibrillation in the prone position during back stabilisation surgery in a boy with Duchenne''s muscular dystrophy

A 15-year-old boy with Duchenne's muscular dystrophy experienced prolonged cardiac arrest whilst in the prone position for spinal surgery. He was successfully resuscitated without apparent neurological sequelae by internal cardiac massage via a thoracotomy and external and internal direct current cardioversion. Recommendations are suggested for the pre- and peroperative management of such cases.     

Debulking and three‐dimensional reconstruction of a rare case of right atrium‐ventricular angiosarcoma

A 48‐year‐old man presented with chest pain and ischemic manifestations according to an electrocardiogram due to coronary artery compression from a cardiac mass and was admitted to the emergency room and underwent extensive debulking followed by right atrium and ventricular three‐dimensional reconstruction with concomitant tricuspid valve remodeling. He recovered a normal sinus rhythm and was discharged from the hospital a week later with a diagnosis of cardiac malignant angiosarcoma according to the pathological examination. He survived and had a normal cardiac structure and function performance, but vertebral metastasis was suspected after more than 4 months of follow‐up after the procedure.     

Tamponade after open-heart surgery with percutaneous cardiopulmonary support.

A 56-year-old man presented with late cardiac tamponade appearing on 9 postoperative day after weaning from percutaneous cardiopulmonary support. He had been referred to our hospital for congestive heart failure. He underwent aortic valve replacement and fell into postcardiotomy low output syndrome. He could not be weaned from extracorporeal circulation, and we had to use an intraaortic balloon pump and percutaneous cardiopulmonary support. On postoperative day 9, percutaneous cardiopulmonary support was successfully withdrawn without problems, but he showed signs of superior vena cava syndrome after the cannulas were removed. An echocardiogram also showed cardiac tamponade. When the wound was reopened, a lot of old clots had compressed the right atrium and, after clot removal, the patient's hemodynamic state improved markedly. It is important to be aware that percutaneous cardiopulmonary support may conceal hemodynamic deterioration due to cardiac tamponade and to take care that a patient does not experience hemodynamic deterioration after percutaneous cardiopulmonary support withdrawal.     

Airway obstruction following internal jugular vein cannulation

A patient developed neck swelling following removal of an internal jugular vein cannula. Although tracheal extubation was delayed, severe airway obstruction occurred resulting in a cardiac arrest. He was successfully resuscitated. Doppler ultrasonography revealed a huge cervical haematoma surrounding a carotid artery pseudoaneurysm. The carotid artery pseudoaneurysm was obliterated using radiological intervention.     

Temporary cardiac pacing for fatal arrhythmia in living-donor liver transplantation: three case reports

Cardiac pacing often turns out to be the only effective treatment of severe, life-threatening arrhythmias. We performed 77 living-donor liver transplantations (LDLT) from 1999 to 2007. In these cases, three recipients experienced fatal arrhythmia and required temporary cardiac pacing during the perioperative period. The first case was a 68-year-old woman diagnosed with liver cirrhosis and hepatocellular carcinoma (HCC). Her Model for End-Stage Liver Disease (MELD) score was 34. We performed LDLT using a right lobe graft. She showed complete atrioventricular block with cardiac arrest at postoperative day (POD) 42 after a bacterial infection. We performed a resuscitation and instituted temporary cardiac pacing. However, she was dead at POD 43. Pathologic findings at autopsy showed a diffuse myocardial abscess, which caused the fatal arrhythmia. The second case was a 58-year-old man diagnosed with HCC and liver cirrhosis; his MELD score was 9. We performed LDLT using a right lobe graft. He showed atrial fibrillation after septic shock. He also showed sinus bradycardia with a cardiac arrest at POD 10. We performed resuscitation and emergent temporary pacing. He recovered and was alive without recurrence of arrhythmia or infection. The third case was a 58-year-old woman diagnosed with multiple HCC. During preoperative regular check-up, she was diagnosed to have cardiac hypertrophy and was started on beta-blockers as treatment for cardiac hypertrophy. However, severe bradycardia necessitated temporary cardiac pacing. LDLT was performed safely after implantation of a pacemaker. Early use of temporary cardiac pacing for severe arrhythmias may be effective to maintain the hemodynamic state in LDLT.     

Treatment of bladder cancer in cardiac transplant patients

We report a patient who presented with superficial bladder tumors 8 years after cardiac transplantation. He was managed conservatively with intra-vesical therapy for 5 years and ultimately underwent a successful radical cystoprostatectomy and urethrectomy 13 years after cardiac transplantation. This illustrates that cardiac transplant patients with superficial tumors may be managed with conservative therapies, but close vigilance is necessary to identify the opportune time for extirpative surgery.     

Giant cardiac metastasis of myxoid liposarcoma causing cardiac tamponade; report of a case

We report a very rare case of cardiac metastasis of myxoid liposarcoma. A 55-year-old man presented with dyspnea. Two and a half years ago, he underwent resection of myxoid liposarcoma in the left thigh. Magnetic resonance imaging (MRI) revealed a giant tumor occupying the pericardiac cavity and pressing the heart and consequently causing cardiac tamponade. The patient underwent surgery through a left thoracotomy approach. The pericardiac cavity was filled with a giant tumor with a stalk from the right ventricle and 2 small nodules on the main pulmonary artery. He was relieved from the symptom: however, he had a recurrence of the tumor at the same site 5 months after the operation. He underwent surgery for the removal of the second tumor; however, he died 49 days after the operation. Although cardiac metastasis is a very rare condition, its awareness is essential for careful long-term follow-up for the early detection of a metastatic cardiac liposarcoma after the resection of the primary tumor.     

Remarkable Improvement of Cardiac Function After Pre-emptive Kidney Transplant in a Patient With Severe Mitral Regurgitation Accompanied by Low Cardiac Function: A Case Report

Patients with end-stage renal disease are at a high risk for cardiovascular diseases. It is controversial whether end-stage renal disease patients with low cardiac function can safely accept kidney transplant. Here, we present a 42-year-old kidney transplant recipient with severe mitral regurgitation accompanied by low cardiac function. He wanted to undergo a pre-emptive kidney transplant from his uncle. We decided to perform living kidney transplant prior to cardiac surgery. Despite adequate ultrafiltration and hemodiafiltration before operation, the patient's ejection fraction still remained 35% 1 day before transplant. He showed complete recovery of cardiac function in only 2 days after pre-emptive kidney transplant, although his body weight did not change before and after the operation. Early removal of the uremic toxin or inflammatory cytokines may play a role in rapid improvement of the cardiac function. Increase of vasoactive substances by improvement of kidney function may lead to reduction of afterload and amelioration of cardiac microcirculation. This report also suggests that optimal timing for operation might be important.     

Cerebral vein thrombosis after coronary artery bypass surgery

A case of cerebral vein thrombosis after cardiac artery bypass grafting is presented in a patient with coronary artery disease and prolonged angina. Postoperatively he failed the weaning trials because of brain dysfunction characterized by confusion, agitation and hyperpnea. He was initially considered to represent a typical case of post cardiac surgery brain underperfusion, but as he later developed persistent signs of endocranial hypertension, imaging of the brain vessels was carried out revealing obstruction of the left transverse and the frontal half of the oblique sinus. The patient was treated with anticoagulation and cerebrospinal fluid drainage through a lumbo-peritoneal shunt. He was discharged from the ICU in good condition after 102 days of hospitalization. As magnetic resonance imaging of the brain is generally recommended in cases with post cardiac surgery brain dysfunction with normal computed tomography scan, adding magnetic resonance phlebography to the examination protocol seems rational.     

Christiaan Barnard

ABSTRACT

Christiaan Neethling Barnard (1922–2002) was an accomplished cardiac surgeon and researcher who made significant contributions to the development of the discipline. He performed the first human-to-human heart transplant in 1967 in Cape Town, South Africa. He was trained in cardiac surgery at the University of Minnesota under pioneer surgeons C. Walton Lillehei and Richard L. Varco. Many future distinguished cardiac surgeons, such as Shumway, Cabrol, and many others, were his contemporaries at Minnesota. Barnard was a highly talented individual, very dedicated and committed to continuous excellent work, particularly in the early stages of his career. He made great advances to heart valve surgery, complicated congenital heart defects, orthotopic heart transplantation, heterotopic heart transplantation, xenotransplantation, and cardiac hypothermic storage. Barnard was the center of attention globally for several years after the seminal first heart transplant operation. Our work reviews the life, accomplishments, and personal character of this superb heart surgeon.     

A laparoscopic duodenojejunostomy for a duodenal obstruction from lymphoma

A patient with lymphoma in one-third of the duodenum causing a duodenal obstruction is described. The patient had a partial response with chemotherapy, but still was obstructed and unable to eat. He was losing weight, and chemotherapy had to be stopped. A gastrostomy tube was inserted for drainage because the stomach was quite distended. A jejunostomy tube was passed through the gastrostomy tube for feeding, but the patient did not tolerate the feeding. A laparoscopic bypass of the duodenumduodenal obstruction (from duodenum to jejunum) for this patient is shown on a video. The patient did very well after this bypass was provided. He was able to tolerate an oral diet on postoperative day 2, and on postoperative day 4, he was discharged home. He has since resumed chemotherapy, and is doing well, at this writing, 2 months after surgery. Electronic supplementary material is available for this article at     

Hyperkalemic cardiac arrest following succinylcholine administration: The use of extracorporeal membrane oxygenation in an emergency situation

We report an 11-year-old male with undiagnosed myopathy, who developed cardiac arrest secondary to severe rhabdomyolysis and hyperkalemia following succinylcholine administration. The patient required extracorporeal membrane oxygenation support from which he was eventually weaned successfully. He died eleven days after the cardiac arrest as a result of apparent ischemic brain injury.     

Emergency room thoracotomy for acute traumatic cardiac tamponade caused by a blunt cardiac injury: A case report

IntroductionTraumatic blunt cardiac injuries have a high mortality rate, and prompt diagnosis and treatment can be lifesaving in cardiac tamponade.Presentation of caseA 62-year-old man was transferred to the emergency department after a motor vehicle accident. He was hemodynamically unstable. A focused assessment with sonography in trauma (FAST) showed pericardial fluid with right ventricular collapse consistent with cardiac tamponade in the subxiphoid view. He collapsed despite a subxiphoid pericardiotomy. Owing to the ongoing hemodynamic instability, we performed a left anterolateral thoracotomy. Direct incision of the pericardium showed blood and clots within the pericardial space, indicating hemopericardium. The heart stroke and hemodynamic status recovered on removing the clot.DiscussionAlthough the physical findings of cardiac tamponade are not always apparent in life-threatening acute cardiac tamponade after blunt trauma, FAST is a reliable tool for diagnosing and following cardiac tamponade. A median sternotomy is a standard approach for evaluating cardiac injury in hemodynamically stable patients with or without cardiopulmonary bypass. However, a left anterior thoracotomy was the fastest, simplest life-saving procedure considering the need for open-chest cardiac massage given our patient’s life-threatening condition.ConclusionA prompt diagnosis using FAST and treatment can be lifesaving in traumatic acute cardiac tamponade. A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space.     

Primary cardiac angiosarcoma: presenting with cardiac tamponade followed by cerebral hemorrhage with brain metastases

A 49-year-old man presented with palpitation and shortness of breath. He was seen to have a massive pleural and pericardial effusion on radiography and echocardiography. Computed tomography (CT) scanning showed that cardiac tumors arose from the right atrium with epicardial and endocardial extension. Pathology examination of samples at pericardiotomy revealed them to be angiosarcoma. Two days after the surgery, he developed left hemiparesis. CT scans showed a large cerebral hemorrhage on the right temporal lobe with midline shift by brain metastases. He died 37 days after the surgery. At autopsy, he had metastases in the brain, multiple bones, and soft tissues but no lung or left-side heart involvement. Primary cardiac angiosarcoma is rare, and mostly arises from the right side of the heart. Common metastatic sites are the lungs and liver. There are only a few reports of brain metastases. In conclusion, this is a rare report of cardiac angiosarcoma presenting with pericardial tamponade. There were rapid brain and multiple bone metastases but no lung or left-side heart lesions.     

Left thoracotomy approach for left ventricular pseudoaneurysm due to myocardial infarction after mitral valve replacement for papillary muscle rupture

A 59-year-old man with acute mitral regurgitation due to papillary muscle rupture after myocardial infarction was admitted to our hospital. He underwent emergent mitral valve replacement with a mechanical valve by median sternotomy. Although postoperative echocardiography showed no sign of a ventricular aneurysm, echocardiography performed 5 weeks after the surgery showed enlarging left ventricular pseudoaneurysm of the inferior to the posterior cardiac wall. He underwent dacron patch closure of the orifice by fifth intercostal left thoracotomy. The postoperative course was uneventful and he was discharged on postoperative day 10. The patient was successfully treated for two life-threatening complications occurring subsequently after myocardial infarction.     

Recurrent cardiac arrest after splenectomy in a patient with ITP and diabetes mellitus

We report a case of 58-year-old man who had repeated cardiac arrests on the first post-operative day. The patient underwent splenectomy due to ITP (idiopathic thrombocytopenic purpura). He also had diabetes mellitus and nephrotic syndrome. There was no abnormal finding at the preoperative examination, except bleeding time of 6 minutes. The operation was finished without complications under general anesthesia. Midnight on the day of surgery, the first cardiac arrest occurred, and lasted for about 10 seconds. He recovered soon from the incident, but at 6 o'clock next morning, he developed severe bradycardia and cardiac arrest. He recovered again, but around 10 o'clock, he developed bradycardia and arrest again, and fell into a fit of convulsions and lost his consciousness. Again he recovered soon and no bradycardia and cardiac arrest occurred after this episode. Two years later, he was scheduled for vitrectomy due to diabetic retinosis. There were a few PACs and PVCs in his Holter-ECG, but no typical bradycardia and ST changes. During the operation, we injected atropine sulfate, dopamine hydrochloride and bucladesine sodium to increase his heart rate above 60 per minute. The operation was finished smoothly and there was no trouble perioperatively. A year later, he also underwent bilateral cataract extraction under local anesthesia without any troubles.     

Cardiac tamponade due to intrapericardial rupture of an amebic liver abscess

Pericardial abscess is rare in healthy individuals, especially the amebic type. We report a case of pericardial abscess and cardiac tamponade due to intrapericardial rupture of an amebic liver abscess. A 31-year old Japanese male complained of fever to a local hospital. A liver mass was discovered in his left hepatic lobe by an abdominal echogram. He was referred to the internal department of our hospital and was treated with quinolone antibiotics. Two weeks after medication, he suddenly complained of epigastralgia and severe orthopnea and was admitted. Abdominal computed tomographic scan showed an enlarged liver mass, and massive pericardial effusion suggested cardiac tamponade. He underwent an emergency subxiphoid partial pericardiectomy under local anesthesia. 1,000 ml of light brownish fluid was removed and his condition improved. Although no ameba was cultivated from the pus, the amebic serological test was positive. Metronidazole was administered and the patients was discharged 31 days after surgery.     

Obscure traumatic cardiac lesion after a penetrating chest injury: Review of the literature

We report a young man who sustained a penetrating chest injury after an assault. He was immediately transferred from a regional hospital to Queen Mary Hospital for definitive treatment after initial stabilization. Emergent thoracotomy was done in the operating theatre and primary repair of a cardiac laceration was performed. Postoperative transoesophageal echocardiography showed a large residual ventricular septal laceration with significant left to right intracardiac shunting. He had an open repair in a cardiac surgery centre the next day. A 1.5 cm laceration was found at the ventricular septum and repair was performed. Postoperative transoesophageal echocardiography showed no further ventricular septal defect. He underwent uneventful recovery and was discharged on day 6 postoperation. Follow up at 1 month postoperation did not show any abnormalities and he subsequently defaulted further follow up.     

A successful emergency surgical treatment of DeBakey type I dissecting aneurysm complicated with cardiac tamponade and bleeding shock]

A successful emergency replacement of the ruptured ascending thoracic aorta by means of ringed Dacron tube graft for 69-year-old male was presented, who had been admitted to our hospital with deep cyanosis and shock. He had experienced severe chest pain one hour prior to admission followed by mental confusion and was brought by ambulant service. Emergency chest enhanced computed tomography showed a clear ruptured dissecting aneurysm (DeBakey Type I) with complicated with pericardial tamponade. Soon after this admission he developed bradycardia with hypotension and quickly went into shock. After induction of anesthesia, cardiac arrest developed. External cardiac massage was started at the same time. Partial cardiopulmonary bypass using femoral vein to artery bypass with the membrane oxygenator was instituted and the body was cooled until moderate hypothermia (25 degrees C). The pericardium was opened and blood clot was removed. The ascending aorta ruptured which was replaced with ringed Dacron tube graft (24 mm in diameter). Patient tolerated procedure well and made good postoperative recovery with temporally mild mental confusion. He discharged 2 months after the surgery without any neurological or mental complication. He has been followed up for six months in excellent condition.