Two cases of cardiac injuries due to nonpenetrating trauma of the chest

Successful repair of nonpenetrating traumatic cardiac injury is uncommon. Two cases of nonpenetrating traumatic cardiac injuries from accident are reported. Case 1. Seventy eight year old man with shock was admitted to Iida City Hospital four hours after getting a bruise by a wood block on the anterior chest wall. Soon after his arrival ultrasonic cardiography was performed because of a doubt of cardiac trauma. And it revealed cardiac tamponade. Then the emergency operation was performed. After pericardial effusion was drained, rupture on the out-flow tract of the right ventricle was found and was successfully repaired without the aid of cardiopulmonary bypass. Case 2. Sixty five year old man with left heart failure was admitted to Iida City Hospital four months after getting a bruise on left chest and back from falling. Chest and back pain was reduced three weeks after the accident, however, shortness of breath was getting worse. Ultrasonic cardiography and aortography showed aortic regurgitation. Under cardiopulmonary bypass aortic valve replacement was performed. His aortic regurgitation was caused by perforation of non-coronary cuspid due to accident. Ultrasonic cardiography is useful to make a diagnosis of nonpenetrating traumatic cardiac injury. It is necessary to operate as soon as possible in cardiac rupture, and to select valve replacement for aortic regurgitation.     

Effect of posterior pericardiotomy on early and late pericardial effusion after valve replacement

OBJECTIVE: Pericardial effusion (PE) after cardiac surgery is frequent. It is more frequently seen after valve replacement or other types of heart surgery. Oral anticoagulants and antiplatelet agents may induce effusion development after open heart surgery. Our objective was to determine the efficiency of posterior pericardiotomy (PP) after cardiac valve operation for reducing the incidence of early and late PE and tamponade. METHODS: This prospective randomized study was carried out in 100 consecutive patients undergoing mechanical valve replacement between August 2001 and May 2003 in our institution. Patients were divided into two groups; each group consisted of 50 patients. Longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in Group 1. Posterior pericardiotomy was not done in Group 2. RESULTS: Early PE was detected in four patients (8%) and in 19 patients (38%) in Group 1 and Group 2, respectively (p < 0.001). No late PE effusion was developed in Group 1 despite nine (18%) late PE developing in Group 2 (p < 0.003). The rate of delayed pericardial tamponade was lower in Group 1, but this difference was not statistically significant (0% vs 10%; p < 0.056). CONCLUSION: These findings suggest that PP is an easy, feasible, and beneficial technique for reducing both the occurrence of early and late PE or pericardial tamponade in patients undergoing valve replacement.     

心脏外科术后心包积液的危险因素与治疗

目的 探讨心脏外科手术后心包积液的危险因素和治疗方法.方法 回顾分析22 462例患者临床资料,定义心包积液诊断标准.观察心包积液患者与无积液患者的临床表现,对症治疗,分析危险因素.结果 509例(2.3％)患者有心包积液262例有临床特殊症状,其中51例有心包压塞的临床表现.有、无心包积液的患者年龄、性别、冠心病史等因素差异无统计学意义(P＞0.05);而大体重、瓣膜病、主动脉阻断和体外循环时间差异有统计学意义(P＜0.05).结论 心包积液的危险因素有大体重,术前心功能Ⅲ、Ⅳ级,瓣膜病,先天性心脏病,大血管疾病,体外循环和主动脉阻断时间延长.超声引导下的心包积液穿刺引流是安全有效的.     

应用自体心包瓣置换术治疗主动脉瓣病变

目的　报告无支架自体心包瓣置换主动脉瓣手术的临床应用效果。　方法　11例单纯主动脉瓣病变患者行自体心包瓣置换主动脉瓣手术,术后定期随访。　结果　11例均存活,顺利出院,随访时间5～30个月,平均随访时间24.2±5.6个月。1例因中等量反流而行二次手术,其余10例心包瓣膜功能良好。　结论　该手术是一种治疗单纯主动脉瓣病变较为理想的方法,术后患者无需长期抗凝,手术近期效果满意,远期效果有待进一步随访。     

Thoracoscopic pericardial fenestration for persistent pericardial effusion after radiotherapy for esophageal cancer; report of a case

We performed thoracoscopic pericardial fenestration for persistent pericardial effusion after radiotherapy for esophageal cancer. An 85-year-old man who had radiation therapy (70.2 Gy) for esophageal cancer was admitted for shortness of breath. Chest computed tomography showed a pericardial effusion. During the 6 months prior to this admission, the patient had undergone percutaneous pericardial drainage 3 times for cardiac tamponade. We performed thoracoscopic partial pericardiectomy with creation of a pleuropericardial window via one access port. Histopathologically, no malignant cells were found in either the resected pericardium or the pericardial effusion. Therefore, we believe the persistent pericardial effusion was secondary to radiotherapy. There was no recurrence of the pericardial effusion for 7 months postoperatively. In summary, thoracoscopic pericardial fenestration is useful in both the diagnosis and treatment of persistent pericardial effusion.     

心脏瓣膜置换术同期行三尖瓣成形术治疗体会

目的探讨在二尖瓣和/或动脉瓣置换术同期行三尖瓣成形术的合理手术指征、方法及围术期的处理。方法回顾分析三尖瓣成形术治疗三尖瓣关闭不全136例,其中行Devega成形65例,人工环成形48例,Key,s成形23例。同时行二尖瓣置换94例,二尖瓣＋主动脉瓣置换42例。结果术后院内死亡5例,死亡率3.6%;迟发性心包填塞6例经心包引流治愈。术后随访2个月～8年,获访112例,5例死于顽固性心力衰竭,其余心功能明显改善。心脏超声示右心房及右心室较术前明显缩小。27例仍有轻中度返流。结论在瓣膜置换术中据三尖瓣环扩大的部位及返流程度,选择不同的成形方式对于三尖瓣关闭不全疗效满意。围术期及术后加强强心、利尿及扩血管治疗有效降低肺动脉高压,可进一步提高三尖瓣成形近、远期疗效。     

Pulmonary,Mediastinal, and Cardiac Presentations of Histoplasmosis

Sixty-one patients with histoplasmosis were identified. They ranged from 14 months to 67 years old. There were 56 male and 5 female patients. Disease presentations were categorized into pulmonary (47), mediastinal (11), pericardial (2), and cardiac (1). Twenty of the patients with pulmonary involvement had histoplasmomas treated by wedge resection (18) or lobectomy (2). Twenty-two of the 27 cavitary lesions were treated by lobectomy and 4 by segmental resection, and 1 required pneumonectomy. The patients with mediastinal granulomas or fibrosis underwent exploration for diagnosis and curative or palliative procedures. Two patients with pericardial histoplasmosis required pericardial windows to relieve acute tamponade. One patient with disseminated histoplasmosis required aortic valve replacement for histoplasmosis valvulitis with severe regurgitation. The 1 operative death was a patient requiring pneumonectomy for mediastinal histoplasmosis.Indications for operative intervention in pulmonary histoplasmosis included resection of a new or enlarging pulmonary nodule to provide a definite pathological diagnosis and resection of persistent thick-walled pulmonary cavities. Mediastinal granuloma with or without fibrosis required exploration for diagnosis, palliation, or cure. Fungal endocarditis necessitated treatment with amphotericin B and valve replacement to stabilize the patient's hemodynamic status and prevent embolization of large fungal vegetations. Pericardial effusion, a rare manifestation of histoplasmosis, was seen as acute tamponade requiring emergency intervention.     

Papillary fibroelastoma which occurred from the posterior leaflet of the mitral valve; report of a case

Papillary fibroelastoma is a rare benign tumor arising from the cardiac endothelium. In this report, we describe the surgical treatment for mitral valve papillary fibroelastoma with hypothyroidism. A 69-year-old woman was admitted to our hospital for the treatment of cardiac tamponade. Echocardiography revealed massive pericardial effusion and a small tumor attached to the posterior mitral leaflet. We drainaged the pericardial effusion, and found that the cause of pericardial effusion was hypothyroidism. After controling the thyroid function, open heart surgery was performed. We excised the tumor including a part of the posterior mitral leaflet, and mitral valve plasty was done. Both the surgical and histological findings showed papillary fibroelastoma, and the postoperative course was uneventful. To avoid embolic complications, early surgical intervention is recommended.     

A case of spontaneous chylous pericardial effusion in Poland syndrome

Chylous pericardial effusion is an uncommon entity that is most commonly associated with post-cardiac surgery, in particular aortic valve and minimally invasive cardiac surgery. Post-radiation therapy, infection, mediastinal neoplasm, lymphoma and a small group of idiopathic, spontaneous chylous pericardial effusion have also been reported as the causes. Here, we report a rare case of pericardial effusion secondary to chylous fistula in a 63-year-old man with Poland syndrome. The case highlights an unusual thoracic duct anomaly as a cause of our reported chylous pericardial effusion.     

Mechanical valve thrombosis in the tricuspid position--reoperative management of 2 cases

Because valve thrombosis occurred after the tricuspid valve replacement with the mechanical valve, we performed replacement of the mechanical valve with the bovine pericardial valve in two cases. Case 1: The patient, at 13 years old, received open-heart surgery to correct infundibular stenosis. At 23 years of age, decortication and tricuspid valve replacement (TVR) with a phi 31 mm Bj?rk-Shiley valve were performed due to constrictive pericarditis and tricuspid regurgitation developed after the initial operation. Thrombosis of the mechanical valve occurred after the TVR. Treatment with urokinase for the thrombolytic therapy failed to improve the valve opening. Finally 12 years after the TVR, replacement of the mechanical valve with a phi 27 mm Carpentier-Edwards bovine pericardial valve was performed. Case 2: The patient, at 21 years old, received open-heart surgery to close an atrial septal defect. At 40 years of age, mitral and tricuspid valve replacements were performed because regurgitation developed in both valves. The mitral and tricuspid valves were replaced with phi 27 mm and 31 mm St. Jude Medical valves, respectively. Thrombosis of the mechanical valve used for the TVR occurred 2 months after the replacement. The mechanical valve was replaced with a phi 27 mm Carpentier-Edwards bovine pericardial valve. In both cases, subjective symptoms improved and prosthetic valve complications did not occur after re-replacement with the bovine pericardial valve. These cases suggested that for TVR a bovine pericardial valve of sufficient size would be better to select than a mechanical valve.     

Carcinomatous pericarditis successfully treated with thoracoscopic pericardial fenestration; report of a case

We report a case of malignant pericardial effusion after lung cancer surgery treated with thoracoscopic pericardial fenestration. The patient was admitted to our hospital because of dyspnea. Computed tomography (CT) and ultrasound cardiography (UCG) revealed cardiac tamponade which was diagnosed as carcinomatous pericarditis by cytology. We attempted to inject 25 mg of cisplatin (CDDP) into the pericardial space twice. The response of the treatment was unexpectedly poor for the patient. The thoracoscopic pericardial fenestration was performed and the patient was discharged without a drainage tube on the 17th postoperative day. Malignant pericardial effusion is a common complication of advanced cancers and is often associated with significant morbidity. Thoracoscopic pericardial fenestration appears to be a safe, effective and minimally invasive treatment for patients with malignant pericardial effusion. This surgery might also have a favorable effect on the improvement of the quality of life for patients with malignant pericardial effusion resistant to chemotherapy.     

Chylopericardium as a complication of mitral valve replacement.

A patient developed chylopericardium after mitral valve replacement. Although there was early relapse with cardiac tamponade it eventually resolved with conservative management consisting of tube drainage initially and a medium chain triglyceride diet for two months.     

Early mechanical failures of the Hancock pericardial xenograft

From August 1981 to July 1984, a total of 97 Hancock pericardial xenografts were implanted in 84 patients, whose ages ranged from 13 to 75 years (mean 55.7 +/- 13). Mitral value replacement was performed in 17, aortic valve replacement in 54, and mitral-aortic valve replacement in 13. Operative survivors were reevaluated from July to September 1985. Cumulative duration of follow-up is 167 patient-years (range 0.5 to 4.1 years), and follow-up is 99% complete. The overall late mortality (at 4 years) is 3.6% +/- 1.4% per patient year, and the actuarial survival rate is 95.4% +/- 3% for aortic valve replacement, 74.7% +/- 16.5% for mitral valve replacement, and 67.1% +/- 20.7% for mitral-aortic valve replacement. One patient sustained a thromboembolic event after mitral valve replacement, but no such complications occurred after aortic or mitral-aortic valve replacement. Actuarial freedom from embolism at 4 years is 100% for aortic and mitral-aortic valve replacement and 93.3% +/- 6.4% for mitral valve replacement. Reoperation for Hancock pericardial xenograft dysfunction was performed in seven patients (five aortic and two mitral-aortic). In the aortic valve replacement group the causes were endocarditis in one, paravalvular leak in one, and primary tissue failure in three; all survived reoperation. The two patients with mitral-aortic valve replacement required reoperation because of primary tissue failure of both Hancock pericardial xenografts, and one died. All values explanted because of primary tissue failure showed commissural tears causing severe prosthetic regurgitation. Calcium deposits were severe in one and mild but unrelated to the cusp rupture in another. Collagen disarray was seen only at the site of the tears, whereas the collagen structure was well preserved in the intact parts of the cusps. Four patients with aortic valve replacement and one with mitral valve replacement show evidence of Hancock pericardial xenograft failure and are awaiting reoperation. The actuarial freedom from primary tissue failure at 4 years is 74.3% +/- 9.8% for aortic and 78.9% +/- 13.2% for mitral Hancock pericardial xenografts. At medium-term follow-up, the Hancock pericardial xenograft has shown poor durability and an extremely high rate of early mechanical failure, especially in the aortic position. These observations suggest the need for a close follow-up of Hancock pericardial xenograft recipients and possibly elective reoperation in asymptomatic patients with clinical evidence of prosthetic failure. These results have led us to discontinue the clinical use of this pericardial xenograft.     

How soon should drainage tubes be removed after cardiac operations?

Pericardial effusion frequently occurs after cardiac operation. Despite its high incidence, the etiological process of postoperative pericardial effusion remains unclear. Residual blood or thrombus has often been suggested as a possible cause, implying that the occurrence of pericardial effusion could be related to the effectiveness of postoperative thoracic drainage. This possible relationship, however, has never been studied. We found that prolonging the duration of thoracic drainage by 24 hours often increases total chest tube output considerably but does not affect the incidence of postoperative pericardial effusion: approximately 55% of 100 patients in this study were shown by two-dimensional echocardiography to have pericardial effusion on the sixth postoperative day, regardless of the duration of postoperative drainage. Because of this, and because a long period of drainage causes discomfort for the patient, mechanical irritation to the heart and the pericardium, and an increased risk of infection, we recommend removing drains as soon as their efficacy has peaked, preferably on the first postoperative day.     

Postpericardiotomy syndrome after minimally invasive repair of pectus excavatum

Minimally invasive repair of pectus excavatum (MIRPE) was first reported in 1998 and has gained wide acceptance since then. A 17-year-old girl who had undergone thoracotomy and cardiac surgery for transposition of great vessels at the age of 18 months presented with a deep, long pectus excavatum with asymmetry. After initial uneventful postoperative clinical course after MIRPE, the patient had bilateral pleural and pericardial effusion on the sixth postoperative day. Suspecting postpericardiotomy syndrome, systemic steroids were administered, and the symptoms resolved without affecting wound healing. Manifestation of a pericardial effusion combined with bilateral pleural effusion after MIRPE, especially in patients after cardiac surgery, may indicate a postpericardiotomy syndrome that can be treated successfully by intravenous steroids.     

Pericardial-mechanical valved conduits in the management of right ventricular outflow tracts. Preliminary report

Over the 3 year period from 1980 to 1982, mechanical prosthetic valves were implanted in the pulmonary pathway in seven patients. In two the procedure was a pulmonary valve replacement. In two it was an implantation of a pulmonary valve with transannular pericardial patching, and in three, complete pericardial (tube) conduits, which included mechanical valves, were constructed. There were neither perioperative nor late complications. Four patients were recatheterized. In three residual right ventricular hypertension was observed. In one of the three the cause of obstruction was not verified, but in the remaining two it was unrelated to the mechanical valve. No thromboembolic phenomena were observed.     

Successful surgical resection and reconstruction for a huge primary cardiac lymphoma filling the right heart

Primary cardiac lymphoma (PCL) is rare, with a frequency of 1.0%–1.6% among cardiac malignant tumors. Chemotherapy is often selected as a first‐line treatment for PCL. However, when the tumor causes heart failure or life‐threatening hemodynamic collapse, antecedent urgent surgery is required. We herein report a successful case of complete tumor resection and reconstruction of the right atrium and right ventricle using a bovine pericardial patch combined with tricuspid valve replacement in a patient with a huge PCL filling the right heart that manifested as tricuspid valve stenosis and subsequent heart failure.     

Clinical experience with subxiphoid drainage of pericardial effusions

To assess the effectiveness of subxiphoid pericardial tube drainage for treatment of pericardial effusion, we reviewed 41 consecutive patients who underwent this procedure during a 14-year period. The patients ranged in age from 7 months to 75 years. All were symptomatic preoperatively. The diagnosis of pericardial effusion was confirmed by echocardiogram in all but 2 patients. Eight patients had acute pericardial tamponade. Subxiphoid pericardial drainage was performed under general (n = 35) or local anesthesia (n = 6). A portion of the anterior pericardium was excised in each patient. There were no perioperative deaths. Thirty-day mortality was 19.5%; there were five late deaths. All deaths were unrelated to pericardial effusion or to the operation. One patient had recurrent effusion requiring pericardiocentesis on the 21st postoperative day. He died five days later of extensive lymphoma. Twenty-eight patients were followed from 1 month to 10 years; mean follow-up was 31.5 months. None developed recurrent effusion or pericardial constriction. We conclude that subxiphoid pericardial drainage is effective for treatment of pericardial effusion.     

Pretransplant‐corrected QT dispersion as a predictor of pericardial effusion after pediatric hematopoietic stem cell transplantation

Pericardial effusion is a potentially fatal complication following hematopoietic stem cell transplantation (HSCT). Therefore, the identification of risk factors could improve the outcome. Prolonged QT dispersion (QTD) and corrected QTD (QTcD) are associated with serious arrhythmias and sudden death in many forms of heart disease. However, no study has evaluated the efficacy of QTD and QTcD to predict pericardial effusion post‐HSCT. We studied 89 pediatric HSCT patients to identify preoperative risk factors for pericardial effusion with particular focus on QTD and QTcD. Pericardial effusion occurred in 15 patients (cumulative onset rate: 17.4%) within one year post‐HSCT, of which 8 (9.2%) were symptomatic. Patients with pericardial effusion following allogeneic HSCT showed significantly lower overall survival; however, pericardial effusion was not the direct cause of death in any patient. Univariate and multivariate analyses revealed that transplantation‐associated thrombotic microangiopathy (TA‐TMA) was an independent risk factor for post‐HSCT pericardial effusion. In addition, pretransplant QTcD was significantly prolonged in the pericardial effusion group. These results suggest that pediatric patients with abnormally prolonged QTcD before the preparative regimen for HSCT should be regularly followed‐up by echocardiography to detect pericardial effusion, particularly when accompanied by complications including TA‐TMA.