Cardiac herniation through mediastinotomy incision

A 43-year-old man was admitted to the emergency department after a cardiac arrest of unknown etiology. The patient's medical history was unremarkable except for surgery to remove a mediastinal lipoma two years earlier. In the intensive care unit, he was observed to have a mass bulging from the left chest wall. Echocardiography showed cardiac herniation through the chest wall, which was confirmed by thoracic computed tomographic scan.     

Complication of the Use of a Radiofrequency Device in Arthroscopic Shoulder Surgery: Second-Degree Burn of the Shoulder Girdle

Radiofrequency ablation (RF) energy devices are increasingly being used in arthroscopic surgery. This is a case report of a 53-year-old man who had second-degree burns of the shoulder and chest wall as a result of fluid overheating due to RF. During an extensive arthroscopic bursal dissection of the left shoulder, the suction device on the RF wand and the valve was left open, allowing fluid to drip onto the chest and arm of the patient. Three days after his surgery, on his first postoperative visit, the dressings were removed, and the patient was noted to have severe blistering on the lateral aspect of his arm and on the anterolateral aspect of his left chest wall. One year after the surgery, he still had residual scarring that was only mildly intermittently pruritic. The use of RF during arthroscopic surgery is very useful clinically; however, it is important to have a strict understanding of the potential hazards the thermal energy can cause to the surrounding soft tissue.     

Intrathoracic lipoma of which a pedunculated growth was confirmed by the development of pneumothorax before surgery; report of a case

The patient was a 47-year-old man who had been found to have an intrathoracic lipoma arising from the left chest wall during a routine physical examination 4 years previously, and had been followed-up. He visited our hospital because of left chest pain. Since the tumor had enlarged, he was scheduled for surgery. He developed pneumothorax before surgery, and imaging studies confirmed the presence of a pedunculated growth. It was easy to perform thoracoscopic resection of the tumor, which was diagnosed as lipoma by pathology. The patient is free of recurrence 2 years after surgery.     

Penetrating knife injury to the heart.

A 39-year-old man attempted to kill himself using a small knife to penetrate the left anterior chest wall because of trouble at work and with his girlfriend. On arrival at the emergency room, his consciousness was not clear and vital signs were unstable. The knife remained vertically located in the left anterior chest wall. A large left hemothorax was identified by chest X-ray, and moderate cardiac tamponade was detected by echocardiography. Left-sided chest drainage was performed by inserting a chest drainage tube, and about 2500 ml of hemorrhagic effusion was drained. An emergency operation was performed to relieve the cardiac tamponade and repair the penetrating cardiac injury. About an hour after arrival at the emergency room, a median sternotomy was performed in the operating room. The knife had injured the surface of the right ventricular outflow tract, the left lung, and the 3rd intercostal artery and vein. Cardiopulmonary bypass was immediately prepared for the repair of the cardiac injury. The wounds were successfully repaired with pledgeted sutures under cardiac beating. The postoperative course was uneventful with no sign of infection. The patient was discharged at 9 days after the operation. Here we have reported a case of successful surgical repair of a penetrating knife injury to the heart, which was managed by immediate resuscitation and emergency surgery.     

Chondromyxoid fibroma of the chest wall

A chondromyxoid fibroma of the chest wall is a rare occurrence. A case study of a 40-year-old woman diagnosed with this tumor in the left chest wall is presented. The lesion was removed by video-assisted thoracic surgery (VATS), and the final pathology examination confirmed a chondromyxoid fibroma. At present, this patient has continued to visit our outpatient unit regularly and has shown no recurrence during the past 1 year.     

Traumatic coronary artery dissection after blunt thoracic trauma--a case report

We present a case of cardiac infarction after blunt chest trauma. The 49-year-old patient suffered from severe angina and the ECG demonstrated a pattern of acute anterior wall myocardial infarction. Acute coronary angiography was performed showing complete occlusion of the left interventricular coronary artery due to dissection. An attempted revascularization by percutaneous transluminal coronary angioplasty failed and the patient was then submitted to bypass surgery. We conclude that possible heart injury should be considered in patients with blunt chest trauma to lead them to adequate therapy.     

Successful surgical management of rupture of the left ventricle and interventricular septum due to blunt chest trauma. Case report.

In a 35-year-old man blunt chest trauma caused rupture of the free wall of the left ventricle and the interventricular septum. Emergency pulse Doppler-2D echocardiography confirmed the clinical suspicion and immediate surgical repair was successfully undertaken. This appears to be the first reported case of survival after surgery for such combined cardiac rupture.     

Thoracoscopic removal of a suture needle from the posterior pericardium after coronary artery bypass grafting

We demonstrate a minimally-invasive thoracoscopic approach [video-assisted thoracic surgery (VATS)] for removal of a retained pericardial suture needle after standard coronary artery bypass grafting (CABG) surgery. A 46-year-old male presented with unstable angina. His workup demonstrated significant coronary artery disease for which he underwent a six vessel CABG, including entering the left chest for preparation of the left internal mammary artery (LIMA). At seven weeks, a postoperative chest X-ray demonstrated a foreign body (suture needle) present in the cardiac silhouette. Further computed tomography (CT)-scan imaging confirmed the suture needle to be localized in the left inferior-posterior pericardium. The patient underwent a left VATS exploration for removal of the suture needle. The pericardial suture needle was successfully retrieved thoracoscopically. The chest tube was removed on the first postoperative day and the patient was discharged to home on the second postoperative day. The patient's postoperative course and recovery were uneventful. A minimally-invasive approach can be undertaken for the removal of a foreign body even after prior open chest surgery, avoiding the associated morbidity of a repeat sternotomy.     

Cardiac arrest in the left lateral decubitus position and extracorporeal cardiopulmonary resuscitation during neurosurgery: a case report

Cardiopulmonary resuscitation (CPR) in the lateral position during noncardiac surgery has been described in only a few reports in the past. Here, we report a case of cardiac arrest in a 61-year-old man undergoing microvascular decompression surgery for trigeminal neuralgia in the left lateral decubitus position. During the initial 5 min of CPR, chest compression was performed in this position by two rescuers; one from the chest and the other from the back, pushing simultaneously. Because ventricular arrhythmia was refractory to conventional CPR even after placing the patient back to the supine position, extracorporeal life support was introduced in the operating room by using the femoro–femoral approach (right atrio-femoral veno-arterial bypass). This alternative CPR markedly decreased the frequency of ventricular arrhythmia. Subsequent coronary angiogram detected 99% stenosis of the right coronary artery. Ventricular arrhythmia ceased after coronary revascularization, and the patient was successfully weaned from the extracorporeal bypass circuit. The patient was discharged alive with minimal neurological impairment. We suggest that chest compression in the lateral position by two rescuers is an efficient resuscitation maneuver, and if an electrical storm is refractory to conventional CPR, extracorporeal life support should be considered in the operating-room setting.     

Perioperative management of a neonate with Cantrell syndrome

Cantrell syndrome is a congenital malformation with a pentalogy characterized by defects involving the abdominal wall, lower sternum, anterior diaphragm, and diaphragmatic pericardium, as well as congenital cardiac anomalies. We recently managed anesthesia in a patient with this syndrome and herein report our experience. The patient was a 14-day-old male neonate, who had been diagnosed with Cantrell syndrome, including ventricular septal defect, left ventricular diverticulum, abdominal wall defect, omphalocele, and sternal hypoplasia. Surgical interventions to close the ventricular septal defect, resect the left ventricular diverticulum, and close the omphalocele were scheduled. After cardiac surgery, the hernial contents were returned to their original compartment and, subsequently, an attempt was made to suture the abdominal wall. However, blood pressure fell markedly and the attempt was discontinued. The chest was left open postoperatively and the patient was transferred to the intensive care unit (ICU), during which time circulatory and respiratory management was very complex. Issues requiring particular attention in the management of anesthesia for patients with this syndrome include complications of diverse cardiac malformations, pulmonary hypertension, pulmonary hypoplasia, and respiratory and circulatory failure associated with increased intraabdominal pressure due to primary closure of the omphalocele. Accordingly, extreme caution must be taken to restore respiratory and circulatory control.     

A penetrating cardiac wound by a flying metallic fragment

A 54-year-old man suddenly felt a strike on his chest while mowing with a machine. At first he had no symptoms except for wound pain, but several hours later, he suffered from high fever with chilliness. The chest roentgenogram showed a foreign body localized within the cardiac shadow. The echocardiogram revealed that the metallic fragment was embedded in the inferior wall of the left ventricle. It appeared that the fragment entered the left ventricular cavity through his anterior chest wall, the right ventricular outflow tract and the ventricular septum. At the operation, the location of the foreign body was again confirmed by the intraoperative echocardiography and the fragment was successfully removed through a left ventricular incision under cardiopulmonary bypass. The postoperative course was uneventful and the case was reported with a review of the literature.     

A case of giant cell tumor originating from the rib

We have experienced a case of giant cell tumor originating from the rib. A 45-year-old male was admitted to our hospital because of a mass in the left chest wall. A tumor shadow was observed in the left side of chest X ray. Chest CT, bone scintigram showed tumor originating from the left 4th rib. The tumor was suspected giant cell tumor of bone by needle biopsy examination. The tumor was completely resected with chest wall surrounding the tumor. The defect of chest wall was reconstructed with Marlex mesh and the Latissimus dorsi muscle flap. The pathological diagnosis was a giant cell tumor of bone. The patient has been well for two years and one month since surgery, with no signs of recurrence.     

Successful removal of T4 lung cancer with left atrial invasion after induction chemotherapy

A 53-year-old man presented with cough, sputa and chest pain. The chest X-ray revealed a large mass shadow in the right lower lobe. Massive tumor extending into the left atrium was diagnosed by computed tomography (CT). The brushing cytology by broncoscopy was squamous cell carcinoma and its stage was IIIB. Chemothrapy using cisplatin, paclitaxel and gemcitabine hydrochloride was performed 8 courses during 6 months. The effect of the chemotherapy was complete response, enabling the surgical treatment. The right pneumonectomy with partial resection of the left atrium was performed by using vascular clamp. The defect of the left atrium could be sutured directly. Wide-spread necrotic change with very small amount of cancer cells in the atrial wall was confirmed by pathology. The patient has been well for 3 years and 6 months after surgery.     

A case of a left atrial primary malignant fibrous histiocytoma

Primary malignant fibrous histiocytoma (MFH) of the heart is very rere. We report a case of a primary intracardiac MFH. A 50-year-old woman underwent an operation for congestive heart failure due to left atrial (LA) tumor. Cardiac echocardiogram showed the tumor attached to the septal wall and posterior wall of LA. We extendedly resected the tumor with septal and partially posterior wall and reconstructed there with pericardial substitute. Pathological diagnosis was MFH. Although she did well postoperatively, cardiac echocardiogram showed a recurrent tumor in the LA at 10 days after operation. She developed respiratory failure, and chest and abdominal CT demonstrated metabolism to the lung, liver and bladder at post operative 47 days. At 77 days after operation, she expired. The prognosis of MFH is poor despite surgery. We recommend extended surgery, if the LA tumor had wide base attached to the septal or posterior wall.     

Rupture of the diaphragm and pericardium with cardiac herniation after blunt chest trauma

A 61-year-old man was transferred to our institution because of blunt chest trauma after accidentally falling. A chest roentgenogram (CXR) and computed tomography (CT) revealed bilateral hemopneumothorax and fractures of multiple left ribs, the pelvis, and the left femur. On the second day in hospital, the patient suddenly complained of dyspnea. Emergency CXR and CT revealed elevation of the left diaphragm, suggestive of a traumatic diaphragmatic hernia; emergency surgery was performed. We confirmed rupture of the diaphragm and pericardium with cardiac herniation: the pleural pericardium and diaphragm were torn individually, and the heart and abdominal organs had herniated into the pleural cavity. They were repaired, and there were no cardiopulmonary complications during or after the operation. Pericardiodiaphragmatic rupture with cardiac herniation after multiple blunt traumas is rare. We describe the successful treatment of a diaphragmatic and pericardial rupture with cardiac herniation, with special reference to pericardial injuries.     

Saphenous vein graft aneurysm: potential for mistaken identity

We report the unusual presentation of a saphenous vein graft aneurysm in a 72-year-old man who had undergone coronary artery bypass surgery 15 years prior to admission. The patient presented with a large mass on the anterior wall of the right ventricle and chest discomfort; initially believed to be a cardiac tumor. The patient underwent reoperative coronary surgery with excision of the saphenous vein graft aneurysm, followed by an uneventful postoperative course. Aortocoronary saphenous vein graft aneurysms are rare and their presentation may be mistaken for pulmonary or chest wall lesions. Complications include rupture, and therefore require attentive diagnosis and surgical therapy.     

Human Thoracic Anatomy Based on Computed Tomography for Development of a Totally Implantable Left Ventricular Assist System

Abstract: Human thoracic anatomy was studied using computed tomography (CT) for the development of a totally implantable electrohydraulic left ventricular system [Nimbus, Inc., and The Cleveland Clinic Foundation (CCF)]. To obtain statistical dimensional information for the chest wall, apex of the heart, and aorta, routine calibrated CT scans of 18 men and 17 women were analyzed. A special radiopaque vest was worn by the patient just prior to the scanning and X-ray procedures, so that each transverse scan could be assigned to a specific chest level after combination with a standard vertical referencing system set on the patient's radiogram. A polar coordinate system and direct measurement of transverse distances from the vertical column to points on the chest wall were employed to define collectively the shape and size of the intrathoracic surface of the chest wall. Locations of the aorta and apex were described by measuring their normalized distances from the midline and vertical column to the intrathoracic surface of the lateral and anterior chest wall. The radius of curvature of the intrathoracic wall lateral to the left ventricle was determined to be ˜ 10.4 cm for the average adult male chest. The present CCF intrathoracic pump with this curvature fits fairly well in both the average and individual thoraxes of these adult males. The location of the aorta, particularly of the descending aorta, was used to determine the optimal outlet design. The most critical anatomical area was the apex location. For adult males, an average distance of 2.8 cm from the apex to the internal chest wall was found. Because of this small dimension, careful design of the inflow port is being performed to avoid anatomical mismatch.     

A surgical case of T-cell non-Hodgkin's lymphoma originating in the wall affected by chronic tuberculous empyema following artificial pneumothorax]

A 63-year-old male patient underwent artificial pneumothorax for right pulmonary tuberculosis 39 years ago, and thereafter suffered from chronic empyema, though asymptomatic. In December, 1989, he was found to have a 5 cm tumor in his right chest wall. The tumor grew to 15 cm in 2 weeks and was associated with severe pain. A chest CT revealed that the tumor of the chest wall corresponded to the area of the wall affected by empyema. The patient underwent full thickness resection of the chest wall including the tumor and the empyematous wall (20 x 20 cm) on March 7, 1990. The tumor was 11 x 8 x 7 cm large and had developed from the empyematous wall to the lateral side of chest wall. There was no invasion of the thoracic cavity by the empyema. The lesion was pathologically diagnosed as diffuse, large to intermediate T-cell non-Hodgkin's lymphoma. Postoperatively the patient was treated with radiotherapy and VEPA therapy, but the tumor metastasized to both lungs, and the patient died 161 days after surgery. The majority of cases of malignant lymphoma reported to have originated in empyematous chest walls have been of the B-cell type. The T-cell type is rare, and the present case is only the second case reported. Chest CT was an effective method of diagnostic imaging in this disease.     

A suitable system of reconstruction with titanium rib prosthesis after chest wall resection for Ewing sarcoma

The recent improvements in chemotherapy and surgical resection in Ewing sarcoma (ES) increased the overall survival as well as the importance of chest wall reconstruction. These improvements are in order to avoid asymmetrical growth, functional and cosmetic compromise after surgery. Chest wall reconstruction still remains a big issue in young patients with ES. We present a case of ES of the left chest wall, arising from a rib, in a 14-year-old patient. He was admitted after neoadjuvant chemotherapy and radiotherapy. The patient underwent a chest wall resection of three ribs and a wedge lung resection of the upper lobe followed by chest wall reconstruction with Stratos? rib titanium prostheses. This new device is suitable for reconstruction after major chest wall resection with good cosmetic and functional results. During the follow-up, there was no evidence of local and distant recurrence, the pain was under control and there were no functional alterations in the chest wall.     

Cardiac lipoma originating from the left ventricular apex diagnosed using the magnetic resonance imaging fat suppression technique: Report of a case

A 70-year-old male patient had a tumor in the left ventricular apex that was detected by transthoracic echocardiography. He had no clinical manifestations. A diagnosis of benign lipoma was made using the noninvasive fat suppression technique of cardiac magnetic resonance imaging (MRI). Video-assisted surgery was performed to resect the tumor, and the histopathological examination confirmed the diagnosis of lipoma. A small part of the tumor was not resected. The postoperative course was uneventful. No signs of recurrence were detected on transthoracic echocardiography or MRI during a 22-month post surgical follow-up period.