Emergent coronary artery bypass grafting using percutaneous cardiopulmonary support in a patient with a quadricuspid aortic valve; report of a case

A 63-year-old man was admitted to our hospital for acute myocardial infarction. A cardiac catheter study showed 3 vessels coronary disease. He was treated by percutaneous coronary intervention for a left anterior descending arterial (LAD) lesion. Unfortunately, cardiac tamponade following stenting for LAD was complicated. A percutaneous cardiopulmonary support system was commenced along with an emergent coronary artery bypass grafting to the LAD and obtuse marginal branch. A quadricuspid aortic valve was discovered by an aortotomy and identified as Hurwitz-Roberts classification type b. Blood from the left coronary main trunk had already stopped. Intraaortic balloon pumping was instituted while weaning from the cardiopulmonary bypass. The patient's postoperative course was uneventful and all bypass grafts were sufficient. He was well 1 year after the operation.     

A case of cardiac tamponade following esophageal resection

We report a rare case of cardiac tamponade after esophageal resection for esophageal cancer. A 69-year-old man underwent subtotal esophagectomy and reconstruction of the gastric tube with cervical anastomosis via the poststernal route and three-field lymphadectomy via a median sternotomy. On postoperative day 4, the patient developed dyspnea, chest oppression, and hemodynamic instability due to cardiac tamponade. Emergency percutaneous catheter drainage was performed to manage the cardiac tamponade. Acute pericarditis due to the original surgical procedure was suspected to be the cause of the tamponade. Although rare, cardiac tamponade should be considered as a cause of hemodynamic instability after esophageal resection.     

Infarct exclusion for postinfarction left ventricular free wall rupture with severe congestive heart failure

A 70-year-old man was transferred to our hospital with severe congestive heart failure and ventricular arrhythmia due to acute myocardial infarction. He had experienced chest pain 3 weeks previously and was admitted to another hospital for dyspnea, where he required assist ventilation, 1 week prior to the transfer. An echocardiogram revealed a broad anteroseptal infarction and very poor left ventricular function with an ejection fraction (EF) of 22%. He remained in a severe congestive heart failure condition despite a full administration of catecholamines. Coronary angiogram findings revealed an occlusion of the proximal left anterior descending coronary artery and 1 week later severe hypotension was suddenly presented. An echocardiogram showed pericardial effusion with signs of cardiac tamponade. A pericardiocentesis was performed and hemodynamic improvement was obtained for a short time, after which the patient underwent urgent open heart surgery. During the operation, exclusion of the anteroseptal akinetic area using an oval patch was performed under a cardiopulmonary bypass and ventricular fibrillation. Severe cardiac failure remained postoperatively and the patient could not be weaned from cardiopulmonary bypass, therefore, we implanted a percutaneous cardiopulmonary support (PCPS) and started intraaortic balloon pumping (IABP). The patient was weaned from PCPS at 26 days after surgery and from IABP at 30 days. Following hospital release, he has continued to do well without heart failure for 39 months after the operation.     

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.     

A surgical intervention using percutaneous cardiopulmonary support for contralateral pneumothorax following pneumonectomy.

We here, describe a 63-year-old man presenting with a contralateral pneumothorax following pneumonectomy. After setting up a percutaneous cardiopulmonary support (PCPS) system in advance in preparation for hypoxemia during the operation, resection of bullae was performed. His oxygen saturation and hemodynamic status were stable intraoperatively and we achieved a successful and safe operation swiftly. He had no complications and was discharged on the 10th postoperative day.     

Use of an extracorporeal left ventricular assist system after acute myocardial infarction due to occlusion of the keft main coronary artery

A 35-year-old man presented to our institution one day after the onset of dyspnea. Coronary angiography revealed the occlusion of the left main trunk. The left main coronary artery and the left circumflex artery were recanalized, but he was hypotensive with low cardiac output. Even after he was placed on circulatory support with veno-arterial extracorporeal membrane oxygenation (ECMO), hemodynamic deterioration could not be reversed, and lung edema developed. The decision was made to use Toyobo LVAS?. With institution of left ventricular assist system (LVAS), however, the patient’s arterial saturation decreased. Peripheral veno-venous (V-V) ECMO was promptly established, and the patient’s arterial saturation improved. On postoperative day 3, the patient was successfully weaned from V-V ECMO. He was extubated on postoperative day 28. The patient was recovered without any serious complications. Although echocardiography showed no substantial improvement in left ventricular function, his general condition is doing quite well with the assist of Toyobo LVAS?. He is on rehabilitation program and awaiting heart transplantation.     

Successful repair of penetrating cardiac injury with chopstick; report of a case

We used percutaneous cardiopulmonary support (PCPS) to resuscitate a 54-year-old man who had stabbed himself in the left anterior chest with a chopstick. Chest computed tomography showed that the chopstick had penetrated the heart. As he was in shock due to the development of tamponade while waiting for emergency surgery, we immediately decided to initiate PCPS. After cardiopulmonary bypass was established through a median sternotomy replacing PCPS, the chopstick was removed and the stab wounds were closed by mattress sutures. The postoperative course was uneventful.     

Surgical treatment of left ventricular pseudoaneurysm after acute myocardial infarction in subacute phase; report of a case

A 81-year-old man who was complaining of chest pain was admitted. He was diagnosed as acute myocardial infarction. Coronary angiogram was performed and an occlusion of the circumflex coronary artery (#13) was diagnosed. Percutaneous coronary intervention (PCI) was done successfully. Cardiac tamponade was showed on the 3rd day after PCI. Percutaneous pericardial drainage was done and his hemodynamic was improved. Transthoracic echocardiogram showed left ventricular pseudoaneurysm with 2 cm in diameter and expanding to 5 cm in diameter after 3 weeks. Patch closure was carried out under cardiopulmonary bypass on subacute phase. His postoperative recovery was uneventful. Left ventricular pseudoaneurysm is a rare complication of acute myocardial infarction (AMI) and surgical treatment of this disease was discussed.     

Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy

Patients undergoing pulmonary embolectomy often experience hemodynamic deterioration during induction of general anesthesia (GA). Therefore, we studied the incidence and possible risk factors for hemodynamic deterioration during GA induction. Fifty-two consecutive patients undergoing emergent pulmonary embolectomy at our institution were included. Hemodynamic collapse after GA induction was defined as hypotension refractory to vasopressor, inotrope, or fluid administration, requiring cardiopulmonary resuscitation followed by urgent institution of cardiopulmonary bypass (CPB). Demographic variables, comorbidities, specific location of thromboemboli, preoperative inotropic support, and anesthetic drugs used for GA induction were evaluated as possible risk factors. After GA induction, hemodynamic collapse occurred in 19% of patients (n = 10). However, the occurrence of hemodynamic instability was not predicted by any of the evaluated risk factors. In addition, the incidence of in-hospital mortality did not differ between hemodynamically stable or unstable patients (10%; 4 of 42 versus 10%; 1 of 10 patients, respectively). In conclusion, hemodynamic deterioration after GA induction develops frequently during emergent pulmonary embolectomy. On the basis of our experience from this study and the unpredictable nature of hemodynamic deterioration, we suggest that patients undergoing pulmonary embolectomy should be prepared and draped before GA induction, and a cardiac surgical team should immediately be available for emergent institution of cardiopulmonary bypass.     

Open heart surgery in a patient with a history of Takotsubo cardiomyopathy

An 81-year-old man had a history of Takotsubo cardiomyopathy induced by general fatigue after travel and acute gastritis 2 years previously. Recently, dyspnea on effort had been worsening. Since preoperative echocardiography showed severe aortic valve regurgitation (AR) with left ventricular (LV) dilatation, aortic valve replacement (AVR) by the standard procedure was indicated. Since the safety of the perioperative clinical course including recurrence of Takotsubo syndrome and hemodynamic compromise was unclear, a thorough examination was performed before surgical intervention. AVR with a 21 mm Mosaic bioprosthesis was performed. Transesophageal echocardiography (TEE) during operation did not demonstrate any sign of Takotsubo syndrome and good LV function was maintained. The patient was discharged on postoperative day 18 without any cardiac events including arrhythmia or clinical symptoms such as chest pain. Based on these results, open heart surgery under cardiopulmonary bypass (CPB) and cardiac arrest could be safely performed in patients with a history of Takotsubo cardiomyopathy with minimum use of cardiac agents including cathecholamine and sufficient perioperative removal of emotional and physical stress.     

A case report of successful surgical treatment following the emergency circulatory assist by percutaneous cardiopulmonary support system for acute postinfarction left ventricular free wall rupture]

Percutaneous cardiopulmonary support system (PCPS) was applied for a 85 years old man with circulatory collapse caused by left ventricular free wall blow out rupture following acute anterior myocardial infarction. PCPS was started after the cardiac massage for 7 minutes without thoracotomy or release of cardiac tamponade and flow of ranging from 2.3 to 2.7 L/min/m2 was achieved. The patient was transferred to operating room and closure of the ventricular rupture was performed under the usual cardiopulmonary bypass. Postoperative recovery of cardiac function and consciousness was satisfactory but he was died of multiple organ failure caused by sepsis at 36 postoperative day. PCPS and consecutive surgical therapy seemed useful method for the treatment of left ventricular free wall blow out rupture.     

Usefulness of right ventricular indices in early diagnosis of cardiac tamponade.

Early diagnosis of postoperative cardiac tamponade is impeded by its clinical similarity to left ventricular failure. Moreover, the hemodynamic changes necessary to diagnose cardiac tamponade are detected by conventional monitoring technique only after clinical compromise. Early signs of cardiac tamponade and left ventricular failure were studied with emphasis on right ventricular function in anesthetized dogs. One group (n = 20) had cardiac tamponade produced by incrementally increasing pericardial pressure (2 to 20 mm Hg), and another group (n = 20) had acute left ventricular failure produced by successive ligation of the anterior descending coronary artery at the lower, middle, and upper thirds. Besides standard hemodynamic measurements, right ventricular function was examined with a rapid-response thermodilution catheter. During cardiac tamponade, cardiac output, right ventricular ejection fraction, right ventricular stroke volume, and right ventricular end-diastolic volume were significantly decreased from baseline values after a pericardial pressure of 8 mm Hg or more (p less than 0.05). Right atrial and pulmonary arterial pressures were not significantly elevated until 14 and 20 mm Hg of pericardial pressure, respectively. Although cardiac function in the left ventricular failure group was reduced after each ligation, right ventricular ejection fraction remained unchanged. This study suggests that right ventricular indices may facilitate earlier diagnosis of cardiac tamponade with greater accuracy.     

Therapeutic strategy of perioperative use of percutaneous cardiopulmonary bypass support (PCPS) for adult cardiac surgery

Subject and method: Percutaneous cardiopulmonary bypass support is beneficial for patients with circulatory collapse. However, therapeutic strategies of percutaneous cardiopulmonary bypass support for post-cardiotomy LOS have not been determined. We reviewed 9 patients undergoing cardiac surgery and treated with percutaneous cardiopulmonary bypass support to determine an adequate strategy for perioperative use of percutaneous cardiopulmonary bypass support. Patients included 8 males and 1 female with a mean age of 56.4 ± 3.9 years. Six patients with IHD underwent CABG for 5 and CABG + MVR for 1 patient and 3 patients with valvular disease underwent AVR, AVR + MVR, and Ross operation respectively. Indication for percutaneous cardiopulmonary bypass support was post-cardiotomy LOS in 7 and preoperative cardiogenic shock in 2 patients. All patients underwent IABP associated with percutaneous cardiopulmonary bypass support. Systemic blood pressure was regulated to 100–120 mmHg by percutaneous cardiopulmonary bypass support flow and with minimum inotropic supports.Results: Six of 9 patients (66.7%) were weaned from percutaneous cardiopulmonary bypass support and 5 patients were discharged. Five of 6 patients (83.3%) with IHD were weaned from percutaneous cardiopulmonary bypass support compared to 1 of 3 patients (33.3%) (p=0.134) with valvular disease. Hemodynamic conditions in patients weaned from percutaneous cardiopulmonary bypass support were markedly improved within 40 hours of the introduction of percutaneous cardiopulmonary bypass support (mean percutaneous cardiopulmonary bypass support running time: 23.9 ± 5.5 hrs). In contrast, those unable to be weaned from percutaneous cardiopulmonary bypass support (mean percutaneous cardiopulmonary bypass support running time: 84.3 ± 6.3 hrs) showed no improvement and developed major complications such as cerebral damage or multiorgan failure.Conclusions: Perioperative use of percutaneous cardiopulmonary bypass support may be more effective for patients undergoing coronary artery surgery. Limited use of percutaneous cardiopulmonary bypass support within 48 hours may be applicable for post-cardiotomy patients.     

Therapeutic strategy of perioperative use of percutaneous cardiopulmonary bypass support (PCPS) for adult cardiac surgery.

SUBJECT AND METHOD: Percutaneous cardiopulmonary bypass support is beneficial for patients with circulatory collapse. However, therapeutic strategies of percutaneous cardiopulmonary bypass support for post-cardiotomy LOS have not been determined. We reviewed 9 patients undergoing cardiac surgery and treated with percutaneous cardiopulmonary bypass support to determine an adequate strategy for perioperative use of percutaneous cardiopulmonary bypass support. Patients included 8 males and 1 female with a mean age of 56.4 +/- 3.9 years. Six patients with IHD underwent CABG for 5 and CABG + MVR for 1 patient and 3 patients with valvular disease underwent AVR, AVR + MVR, and Ross operation respectively. Indication for percutaneous cardiopulmonary bypass support was post-cardiotomy LOS in 7 and preoperative cardiogenic shock in 2 patients. All patients underwent IABP associated with percutaneous cardiopulmonary bypass support. Systemic blood pressure was regulated to 100-120 mmHg by percutaneous cardiopulmonary bypass support flow and with minimum inotropic supports. RESULTS: Six of 9 patients (66.7%) were weaned from percutaneous cardiopulmonary bypass support and 5 patients were discharged. Five of 6 patients (83.3%) with IHD were weaned from percutaneous cardiopulmonary bypass support compared to 1 of 3 patients (33.3%) (p = 0.134) with valvular disease. Hemodynamic conditions in patients weaned from percutaneous cardiopulmonary bypass support were markedly improved within 40 hours of the introduction of percutaneous cardiopulmonary bypass support (mean percutaneous cardiopulmonary bypass support running time: 23.9 +/- 5.5 hrs). In contrast, those unable to be weaned from percutaneous cardiopulmonary bypass support (mean percutaneous cardiopulmonary bypass support running time: 84.3 +/- 6.3 hrs) showed no improvement and developed major complications such as cerebral damage or multiorgan failure. CONCLUSIONS: Perioperative use of percutaneous cardiopulmonary bypass support may be more effective for patients undergoing coronary artery surgery. Limited use of percutaneous cardiopulmonary bypass support within 48 hours may be applicable for post-cardiotomy patients.     

Successful extracorporeal resuscitation of a probable perioperative anaphylactic shock due to atracurium

We report the case of a 55-year-old woman ASA 2 scheduled for a cholecystectomy, who presented 25 minutes after the induction, a circulatory arrest probably due to a cardiac anaphylaxis attributed to atracurium. After 60 minutes of futile resuscitation without any spontaneous cardiac rhythm a percutaneous cardiopulmonary bypass (CPB) was initiated. Twenty minutes later and after three external electric shocks electric cardiac activity returned normal. The weaning was possible 120 minutes later with catecholamine support. She left the intensive care unit on postoperative day seven after a laparotomy secondary to splenic injury due to intensive cardiopulmonary resuscitation. She was discharged home without any neurologic or cardiac sequellae. Biological assessment done during the circulatory arrest and cutaneous tests performed ten weeks later confirmed an isolated allergy to atracurium. CPB is the most efficient support in case of reversible cardiac arrest but unfortunately the less accessible outside from cardiac surgery unit.     

Fulminant apical ballooning syndrome after replacement of a prosthetic aortic valve

A 70-year-old woman was readmitted to our hospital with a fever of 39°C on the 30th day after replacement of a prosthetic aortic valve. She required percutaneous cardiopulmonary support for her heart failure and was weaned after 7 days. Echocardiography revealed an akinetic and aneurysmally dilated left ventricular apex and hyperdynamic basal segments. This case indicates that fulminant apical ballooning syndrome might be added to the list of potential complications after cardiac surgery.     

Emergency department initiation of percutaneous cardiopulmonary support for traumatic cardiac tamponade with coagulated pericardial effusion

Cardiac rupture following blunt trauma is associated with a high mortality rate. We present a rescued case of blunt traumatic cardiac tamponade successfully initiated with percutaneous cardiopulmonary support (PCPS) at the emergency department (ED) without pericardiocentesis.A 27-year-old woman was transferred to our hospital after a motor vehicle accident. She presented with profound shock, and the cardiac portion of the focussed assessment of sonography for trauma (FAST) showed almost coagulated pericardial effusion. We considered that the haemodynamic collapse was caused by cardiac tamponade, and we initiated PCPS in the ED. Subsequently, her systemic perfusion was preserved by PCPS, and she was transferred to the operating room safely. A laceration of the right atrium was successfully repaired. In cardiac tamponade, blood accumulation in the pericardium may be localised and the formation of blood clots may cause difficulty with aspiration. The initiation of PCPS afforded time to surgeons prior to definitive surgical repair and enabled the patient's transfer to the operating room securely.This report demonstrated the case of a rare, but successful outcome of resuscitation of a patient with blunt traumatic cardiac rupture with cardiac tamponade. PCPS is considered as an important treatment option in ED for traumatic cardiac tamponade, particularly if the effusion has clotted.     

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.     

Prompt institution of percutaneous cardiopulmonary support managed perioperative refractory vascular spasm after isolated coronary artery bypass grafting surgery

A 51-year-old Japanese male underwent on-pump coronary artery bypass grafting surgery. After weaning from cardiopulmonary bypass (348 min), sudden bradycardia and hypotension occurred, followed by ventricular fibrillation. Although defibrillation and infusion of catecholamine restored sinus rhythm, transesophageal echocardiography demonstrated severely reduced contraction of both ventricles, and perioperative vascular spasm was suspected. As vascular spasm was refractory to medications, percutaneous cardiopulmonary support (PCPS) system was quickly instituted under cardiac massage. Coronary angiography revealed vascular spasm of not only the native coronary arteries but also the implanted left internal thoracic artery. After 3 days of full hemodynamic assist, PCPS was withdrawn with no obvious abnormalities in regional wall motion by transesophageal echocardiography. The patient was extubated on postoperative day 6 with no impaired brain function. In this case, the immediate diagnosis of refractory vascular spasm by transesophageal echocardiography and full cardiocirculatory assistance by PCPS helped to save the life of the patient.     

Adult respiratory distress syndrome after cardiac surgery

Adult respiratory distress syndrome, characterized by high permeability pulmonary oedema caused by endothelial cell damage, resulting in refractory hypoxemia, has a very high mortality. Cardiopulmonary bypass is said to be responsible for the development of adult respiratory distress syndrome after cardiac surgery. The present study was performed in order to identify predicting and aetiological factors of adult respiratory distress syndrome and multiple organ failure after cardiac surgery. Between January 1984 and December 1993, 3848 patients underwent cardiac surgery with cardiopulmonary bypass in the authors' institution, and were analysed in a retrospective manner. The operations performed were 3444 coronary artery bypass grafts (CABG), 267 valve and 137 combined (CABG + valve) procedures. The incidence of adult respiratory distress syndrome was 1.0% (38 of 3848) with an overall mortality rate of 68.4% (26 patients); 24 of these died from multiple organ failure. Multivariate regression analysis identified hypertension, current smoking, emergency surgery, preoperative New York Heart Association (NYHA) class 3 and 4, low postoperative cardiac output and left ventricular ejection fraction < 40% as significant, independent predictors for adult respiratory distress syndrome. Combined cardiac surgery and diffuse coronary disease were also significant predictors; cardiopulmonary bypass time was not. Thirty-six of the 38 patients that later developed adult respiratory distress syndrome had low postoperative cardiac output, 12 requiring intra-aortic balloon pump support. The remaining two had severe hypotension caused by postoperative bleeding. Twenty-six adult respiratory distress syndrome patients (68%) had confirmed gastrointestinal complications (e.g. intestinal ischaemia). Adult repiratory distress syndrome is a rare complication after cardiac surgery but is associated with a very high mortality. Preoperative predictors were identified. Cardiopulmonary bypass alone was not found to be an important factor. Postoperative low cardiac output leading to splanchnic hypoperfusion may be the most important single factor in developing adult respiratory distress syndrome after cardiac surgery.