A 73-year-old woman with acute myocardial infarction (Seg. 6: 100%) was admitted to our hospital. She underwent percutaneous transluminal angioplasty (PTCA) and stent insertion to Seg. 6 on that day and anticoagulant therapy with urokinase and heparin was started in CCU. On the 4th day, chest pain developed suddenly and echocardiography revealed cardiac tamponade, so we suspected left ventricular free wall rupture. When blood pressure increased to 100 mmHg in the operating room, the left ventricular free wall rupture became "blow out" type. After establishing extracorporeal circulation, we glued Xenomedica and autologous pericardium using gelatin-resorcin-formaldehyde glue (GRF glue) to the linear tear without damaging the myocardium and coronary arteries and reducing left ventricular volume. Bleeding was completely controlled. This experience suggests that this procedure might be effective for left ventricular free wall rupture.
We have experienced three patients with right-sided active endocarditis combined with multiple pulmonary infarction. Ventricular septal defect (VSD), aortic regurgitation (AR), tricuspid regurgitation (TR) and congestive heart failure were present in case 1. TR was present in case 2. VSD, TR and patent ductus arteriosus were present in case 3. alpha-Streptococcus caused endocarditis in case 1 and 3; Candida albicans caused endocarditis in case 2. Antibotic therapy had no effect in case 2 and 3. Case 1 and 3 developed pulmonary hemorrhage, which resolved before the operation in case 1, but not in case 3. Our three patients underwent surgery and recovered successfully. They were discharged on the 43th, 58th and 32th postoperative day and are presently free of clinical symptoms. These experiences suggest surgery should be undertaken in the following situations: 1. antibiotic therapy has no effect on the infection, 2. hemodynamics are worsening, and 3, pulmonary infarction and pulmonary hemorrhage occur repeatedly.
Background
Anomalous pulmonary venous connection (APVC) is a congenital malformation in which the pulmonary veins connect to the systemic venous system but not to the left atrium. APVC can be classified as total or partial (PAPVC). PAPVC is rare among surgical patients with lung cancer, and most cases are detected incidentally during surgery. We herein report a patient with lung cancer in whom PAPVC was diagnosed before surgery, which made it difficult to determine the surgical procedure.
Case presentation
A 71-year-old man was followed-up as an outpatient after surgery for renal cell carcinoma. Chest computed tomography showed a 22-mm nodule in the right lower lobe and PAPVC in the right upper lobe. He was diagnosed with lung adenocarcinoma (cT1cN0M0 stage IA3) and scheduled for surgery. Preoperative catheterization showed a pulmonary to systemic flow ratio (Qp/Qs) of 1.64 and mean pulmonary artery pressure (MPAP) of 16 mmHg. Surgical repair of PAPVC is indicated when a patient is symptomatic and has a Qp/Qs ≥1.5–2.0. The patient was scheduled for right lower lobectomy, but postoperative worsening of right heart strain was considered. Concomitant PAPVC repair was therefore considered, but he had no atrial septal defect and was asymptomatic; therefore, PAPVC treatment was considered unnecessary. However, we planned to perform concomitant PAPVC repair if his circulatory dynamics worsened during surgery or if his MPAP exceeded 25 mmHg. His MPAP was 20 mmHg and his circulatory dynamics remained stable, and right lower lobectomy was therefore completed. His postoperative course was favorable. Follow-up catheterization at 6 months showed a Qp/Qs of 1.19 and MPAP of 18 mmHg, with no evidence of increased right heart strain. There was no evidence of right heart failure or recurrence of lung cancer at last follow-up at 18 months after surgery.
Conclusions
We present a case of right lower lung cancer complicated by PAPVC in the right upper lobe. This case suggests that concomitant repair of PAPVC in the right upper lobe may not be necessary when performing right lower lobectomy, although the patient’s Qp/Qs and MPAP should be considered.
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