胸部外科

Cardiac trauma is one of the most lethal injuries. We reported 7 patients with cardiac injuries who underwent surgical repair. They were 4 men and 3 women with a mean age of 64 years. The mechanisms of injuries were blunt trauma by traffic accident in 5 patients and penetrating trauma in 2 patients. The injured cardiac chambers were the right atrium in 2, the right ventricle in 2, the right ventricle and the ascending aorta in 1,the left atrium in 1 and the left ventricle in 1 patient. The wounds of all patients were repaired by direct suture closure. Only 1 patient with injuries in the right ventricle and the ascending aorta was repaired under cardiopulmonary bypass （CPB）. The patient with right atrial rupture and concomitant pelvic bone fructure died of retroperitoneal hemorrhage. According to the analysis by Trauma and Injury Severity Score（ TRISS）, probability of survival（Ps） values ranged from 0.002 to 0.978. A patient with a Ps value of 0.002 died of bleeding. Evaluation of the severity of trauma and injury by TRISS was considered generally reasonable.

We prospectively investigated the relation of adaptation, timing of atrioventricular valve replacement （AVVR）, valve type, size, durability of replacement valve, and preoperative cardiac function with prognosis of AVVR. The subjects included 26 patients［ 15.5 years old（ day 2-43 years）］ with functional single ventricle who underwent AVVR at our institution between August 1996 and January 2014. Of these patients, 24 had regurgitation, whereas 2 had stenosis. Of 7 patients who died, 3 were infants who died in the postoperative acute phase, and all of them had severe heart failure at the preoperative stage. The 5-year survival rate was 67％ as assessed by Kaplan-Meier curve. On univariate analysis of the preoperative data, pulmonary artery pressure （PAP）, pulmonary capillary wedge pressure, age at operation, body height, and body weight were significant risk factors for death；of these, only PAP remained in the last model for multiple regression analysis. AVVR for regurgitation is supposed to reduce cardiac volume load and help improve prognosis. Atrioventricular valve plasty or replacement should be performed prior to the development of severe heart failure.

Surgical trauma to the pericardial mesothelium during open heart procedures has formation of fibrovascular adhesions. Surgeons are confronted with cardiac adhesions, leading to an increased surgical risk such as intractable bleeding and possible catastrophic hemorrhage. In order to solve the problem, the anti-adhesion membrane has been developed and used. However, their performances are far from perfect, so it has been expected to develop a novel anti-adhesive material. For preparing an anti-adhesive material, there is 1 serious problem, a lack of golden standard of animal model for evaluation of anti-adhesivity. In this study, we tried to establish a standard system for evaluation of the performance of anti-adhesive materials for the chest-area surgery using rabbit. Setting the condition of the damage to heart, the objective evaluation system was established. And we performed experimental study to evaluate prevention of adhesions with pericardial substitutes and our product under development based on this model.

Primary cardiac tumors are relatively rare. Among them, papillary fibroelastoma （PFE） is the 2nd most common benign cardiac tumor after myxoma. However, despite its benign status, PFE may trigger fatal embolic events in some cases. Therefore, once PFE is diagnosed, immediate surgical resection of the tumor is recommended. We report our experience of 3 patients with cerebral infarction that were diagnosed as having PFE. All cases were complicated with cerebral infarction probably originating from a tumor embolus or thrombus. For that reason, after the tumor had been detected, urgent surgical resection of the tumor was considered to be necessary. Given the generally good postoperative outcomes, simple resection of the tumor while preserving valve function is considered sufficient to achieve a favorable outcome.

Ventricular septal rupture（VSR） after acute myocardial infarction（AMI） is a rare and serious complication that is associated with extremely high mortality. Delayed VSR is particularly uncommon and is difficult to diagnose and treat. A 68-year-old man presented with dyspnea on effort. Coronary angiography revealed subtotal occlusion of the right coronary artery（RCA） with collateral circulation to the chronically and totally occluded left anterior descending artery （LAD）. Elective stenting of the RCA was successfully performed for a recent MI of the RCA, while percutaneous coronary intervention（PCI） in the LAD ended in failure. At 21 days after the 1st PCI, the patient developed acute heart failure with new pansystolic murmur. Cardiac catheterization showed a left to right ventricular shunting without new coronary artery lesions. Fortunately, the hemodynamic status was stable, and we could perform elective surgical repair by right atrial approach. Simultaneously, a left internal thoracic artery bypass to the LAD was performed. The postoperative course was uneventful. The patient is currently doing well at 5 years after the operation.

A 61-year-old man was admitted to our hospital for an abnormal chest shadow. Computed tomography （CT） showed a pulmonary nodular shadow in the right middle lobe. He was diagnosed with stage cT2aN0M0 （IB） pulmonary adenocarcinoma and was treated with surgery of right middle lobectomy and mediastinal lymph node dissection. On 2nd day after surgery, he got aspiration pneumonia. CT showed consolidation of left lower lobe, stenosis of lower esophagus with dilation of the oral side and stagnation of residual foods. Esophagogram showed stenosis of the lower esophagus and stagnation of the contrast medium. He was diagnosed with esophageal achalasia. Balloon dilation was performed and the obstruction was improved. He has been well without recurrence of achalasia.

Antineutrophil cytoplasmic antibody （ANCA） negative pulmonary limited-form granulomatous with polyangiitis （GPA） is a rare type of GPA. A 53-year-old female had been followed as the possible pulmonary infarction of bilateral lungs for 4 years without any therapy. Chest computed tomography（CT） examination of the patient showed newly appeared nodular lesions in the lungs, which were suspected as malignancy by positron emission tomography （PET） -CT. Thoracoscopic lung biopsy of the lesions was performed and histopathological diagnosis was GPA showing multiple granulomas with vasculitis. Since both C and P-ANCA were negative and no evidence of kidney involvement, we finally diagnosed the lung lesions as ANCA negative limited-form GPA.