Impact of valve prosthesis-patient mismatch on long-term survival and left ventricular mass regression after aortic valve replacement for aortic stenosis

BACKGROUND AND AIM OF THE STUDY: The influence of prosthesis-patient mismatch on long-term results after aortic valve replacement remains controversial. The aim of this study was to evaluate the effect of prosthesis-patient mismatch on survival and the extent of left ventricular mass regression after aortic valve replacement for aortic stenosis. METHODS: We retrospectively reviewed 146 patients who underwent isolated aortic valve replacement for aortic stenosis between 1990 and 2005. Prosthesis-patient mismatch was defined as an effective orifice area/body surface area 相似文献   

Use of ultrasound for thoracic paravertebral block

Thoracic paravertebral block is the technique of injecting local anesthetic adjacent to the intervertebral foramina, resulting in unilateral somatic and sympathetic nerve blockade. Previous studies have reported its effectiveness for thoracic surgery including breast surgery and relief of postoperative and chronic pain of unilateral origin from the chest and abdomen. The technique is relatively easy to learn and safer than thoracic epidural. Its clinical advantages include the inhibition of stress and pressor responses to surgical stimuli, maintenance of hemodynamic stability, low incidence of complication, long duration of analgesia, and few contraindications. Recent advances in ultrasound technology can further increase the effectiveness and the safety of thoracic paravertebral block, although identification of the nerve and needle is not still possible.     

Ectopic cystic thymoma associated with Raynaud's phenomenon.

Mediastinal cystic tumors are well-marginated round lesions that comprise 12% to 18% of all mediastinal masses. These lesions include a variety of diseases with overlapping radiologic appearances and variable prognoses. Pathological examinations are almost always required for differential diagnosis. We encountered a case of anterior mediastinal tumor discovered in the process of investigation of Raynaud's phenomenon. Taking into account the tumor location, a pericardial cyst was initially suspected. However, the tumor was surgically resected and histopathological examinations demonstrated thymus-like tissue in the cyst walls. Raynaud's phenomenon greatly improved after surgery. These findings suggested that cystic thymoma originated from ectopic thymic tissue and is accompanied by paraneoplastic syndrome.     

Management of adrenal metastasis from hepatocellular carcinoma

Purpose: Although the adrenal gland is a common site of extrahepatic metastasis from hepatocellular carcinoma (HCC), there are no definitive guidelines for the treatment of adrenal metastasis. This study examines the effectiveness of various treatments for this disease. Methods: We retrospectively analyzed 20 patients treated for adrenal metastasis of HCC by adrenalectomy (n = 13), transarterial chemoembolization (TACE), or percutaneous ethanol injection therapy (PEIT) (n = 7). Results: There were no significant differences in cumulative survival rates between patients given adrenalectomy and those given TACE or PEIT, either after completing treatment for primary HCC or after the first treatment for adrenal metastasis. Six of seven patients with tumor thrombi in the inferior vena cava (IVC) from adrenal metastasis underwent adrenalectomy combined with intracaval thrombectomy, five of whom survived for more than 1 year after surgery, and two of whom are still alive without any recurrence more than 3 years after surgery. PEIT showed good results for small adrenal metastasis. Conclusion: These findings suggest that therapeutic modalities should be chosen according to the clinical features of each individual, including the size of the metastatic tumor, whether there is invasion into the IVC, the function of the remaining liver, and the existence of intra- and/or nonadrenal extrahepatic lesions. Furthermore, intracaval tumor thrombectomy could be indicated for patients with IVC thrombus if they are suitable candidates for surgery. Received: July 9, 2001 / Accepted: July 2, 2002 Reprint requests to: Y. Shimahara     

New Pancreatic Duct-Invagination Anastomosis Using UltrasonicDissection for Nonfibrotic Pancreas with a Nondilated Duct

Nonfibrotic pancreases with a nondilated duct are susceptible to pancreatic fistula or leakage following pancreaticoduodenectomy. We developed a novel pancreatic duct-invagination anastomosis using an ultrasonic dissector and applied this technique to 14 consecutive pancreaticoduodenectomies and 1 segmental pancreatectomy for otherwise normal pancreases. With the aid of an ultrasonic dissector, even branch pancreatic ducts were skeletonized, ligated securely, and divided during pancreatic transection. Moreover, the main duct was exposed (> 1 cm) easily by ultrasonic dissection and a small-caliber pancreatic tube was inserted into the duct on the stump. Subsequently, pancreatic duct invagination could be easily done through a 10 G intravenous catheter passed through the gastrointestinal tract. The main duct was anchored to the adjacent serosa, but any pancreatic parenchymal sutures, possibly leading to internal laceration and/or parenchymal ischemia particularly in soft nonfibrotic pancreases, were avoidable during the procedures. All the anastomoses were done within 10 minutes. Only 1 patient (6.7%)developed pancreatic fistula, which resolved spontaneously in 21 days postoperatively. Neither anastomotic leakage nor remnant pancreatitis was seen in this series. Although a prospective, randomized study is needed, this technique may contribute to reduced morbidity after pancreaticoduodenectomy for a nonfibrotic pancreas with a nondilated main duct.     

Endoscopic fenestration of posterior fossa arachnoid cyst for the treatment of presyrinx myelopathy--case report

A 32-year-old man presented with an arachnoid cyst of the posterior fossa manifesting as cervical syringomyelic myelopathy. Magnetic resonance (MR) imaging demonstrated edematous enlargement and T2 prolongation of the cervical spinal cord, indicating a "presyrinx" state. MR imaging showed the inferior wall of the cyst, which disturbed cerebrospinal fluid (CSF) pulsatile movement between the intraspinal and intracranial subarachnoid spaces. The cyst wall was fenestrated with a neuroendoscope. The presyrinx state and the CSF movement improved. Posterior fossa arachnoid cyst, as well as Chiari malformation, can cause CSF flow disturbance at the craniocervical junction and syringomyelia. Endoscopic fenestration is less invasive than foramen magnum decompression and should be the procedure of choice.     

Traumatic middle meningeal artery pseudoaneurysm and subsequent fistula formation with the cavernous sinus: case report

BACKGROUND: A combination of pseudoaneurysm and arteriovenous fistula of the middle meningeal artery is rare. We describe a case of traumatic pseudoaneurysm of the middle meningeal artery, which subsequently formed a fistula with the cavernous sinus. CASE DESCRIPTION: A 23-year-old man suffered from blunt head trauma and skull fractures. Sixteen days later, he suddenly experienced headache and a bruit was auscultated over the left ear. Three-dimensional computed tomographic angiography revealed dilatation of the left middle meningeal artery. The dilation proved to be a pseudoaneurysm on cerebral angiograms and it was also found to have formed a fistula with the cavernous sinus. Both lesions were successfully obliterated by endovascular embolization using microcoils. CONCLUSION: Head injury may lead to asymptomatic pseudoaneurysm or dural arteriovenous fistula. Neurosurgeons should always bear in mind the possibility of such vascular injuries after blunt head trauma to prevent any hemorrhagic complications.     

Anesthesia protocols for early vitrectomy in former preterm infants diagnosed with aggressive posterior retinopathy of prematurity

Aggressive posterior retinopathy of prematurity (ROP) can, if left untreated, rapidly progress to total retinal detachment within 1–2 weeks. Early surgical intervention with vitrectomy has been attempted to treat and prevent further retinal detachment. We investigated the anesthetic management of 29 infants with aggressive posterior ROP undergoing early vitrectomy. Postmenstrual age at surgery ranged from 35 to 47 weeks (median 41). Weight ranged from 1408 to 3478 g (median 1875). All infants underwent general anesthesia with fentanyl and sevoflurane. Mean surgical and anesthetic times were 88.6 and 143.6 min, respectively. In two patients, vitrectomy was postponed for one week due to enteric perforation in one patient and meningitis in the other, because the anticipated perioperative risk was deemed high. There were no intraoperative complications, except in one patient who developed pulmonary edema following upper airway obstruction. All patients survived to be discharged from NICU or transferred to the referring hospital. In all cases, complete or partial retinal reattachment was successfully achieved. Early vitrectomy for aggressive posterior ROP may be effective despite associated perioperative risks. As this condition progresses rapidly, prompt preoperative organization, including anesthetic planning, is important and useful. Anesthesiologists can play an important role in the perioperative management of such high-risk infants.     

Two cases of quadricuspid aortic valve

Quadricuspid aortic valve (QAV) is a rare congenital aortic valve anomaly. We present two cases of QAV diagnosed by using echocardiography including transesophageal echocardiography (TEE) and cardiac computed tomography (CT). The first case, QAV with four equal-sized cusps, was identified in a 58-year-old man. The second case, QAV with a small accessory cusp between the right coronary and non-coronary cusp, was identified in a 42-year-old man. TEE and cardiac CT could lead to accurate diagnosis of QAV. QAV in these two patients could be diagnosed before indication for surgery but it is necessary to continue careful follow-up.     

Constraint stress, microstructural characteristics, and enhanced mechanical properties of a special fibroblast-embedded collagen construct

Cell-contracted collagen gels could provide rejection-free biomaterials for tissue engineering, but their application is limited by relatively low mechanical strength. We developed a special type I collagen construct (based on embedded fibroblasts) that was formed into a gel thread by using two anchors to constrain gel contraction in one direction. Each gel thread contained 2 mg of type I collagen and 1.0 x 10(6) fibroblasts, and had an initial volume of 3 mL. After 9 days in culture, this preparation was transformed into a thread-like construct measuring 26 x 2.3 x 0.21 mm. Investigation of the microstructure showed that the collagen fibrils longitudinally between two cells had most aligned with the direction of the constraint stress and had assumed higher density than those in the freely contracted controls. During culturing, the constraint stress first increased then decreased, with implications for the nature of the interaction between the embedded cells and collagen matrix. Under uniaxial tensile testing, the ultimate stress and material modulus increased by factors of 6 and 16, respectively, compared with controls, while the maximal strain decreased by 590%. Compared with the similar constructs in the literature, the thread gel was fabricated by means of a novel mold configuration so that it contracted to thread shape much faster, and more importantly, the constraint force was firstly reported in this article. The improved mechanical properties show that the gel thread could be an effective biomaterial for such tissue engineering applications as the fabrication of blood vessels, ligaments, and tendon grafts.