BackgroundRecurrent hepatocellular carcinoma accompanied by a right atrial tumor thrombus is rare. No standard treatment modality has been established. Surgical treatment may be the only curative treatment; however, surgery has been considered high risk. We herein describe a patient who underwent resection of a recurrent right atrial tumor thrombus under normothermic cardiopulmonary bypass on a beating heart.Case presentationA 60-year-old man underwent a right hepatectomy for hepatocellular carcinoma with diaphragm invasion. During the preoperative cardiac screening, he was diagnosed with an old myocardial infarction with triple-vessel coronary disease. Percutaneous coronary intervention was performed for the left anterior descending artery and left circumflex coronary artery. High-grade stenosis remained in his right coronary artery. Nine months later, computed tomography showed recurrent hepatocellular carcinoma in the diaphragm and a tumor thrombus extending from the suprahepatic inferior vena cava into the right atrium. Surgical resection of the recurrent tumor was performed through a right subcostal incision with xiphoid extension and median sternotomy. The recurrent tumor was incised with the diaphragm and pericardium. Intraoperative ultrasonography revealed that the tumor thrombus was free from right atrium wall invasion and that the right atrium could be clamped just proximal to the tumor thrombus. The right atrium, infrahepatic vena cava, left and middle hepatic veins, and hepatoduodenal ligament were encircled. Cardiopulmonary bypass was performed to prevent ischemic heart disease caused by intraoperative hypotension. Total hepatic vascular exclusion was then performed under normothermic cardiopulmonary bypass on heart beating. The inferior vena cava wall was incised. The tumor thrombus with the diaphragmatic recurrent tumor was resected en bloc. The patient had a favorable clinical course without any complications.ConclusionThe recurrent hepatocellular carcinoma in the diaphragm and the right atrial tumor thrombus were safely resected using normothermic cardiopulmonary bypass on heart beating.

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MAR provides no benefit. The authors presume that these differences may be due to the competing health risks associated with renal dysfunction, suggesting that the use of multiple arterial grafts may not be justified in this population.In direct contradiction however, in a recently published analysis of 95,780 patients who underwent single arterial revascularization propensity score matched (4:1) with 24,160 patients who underwent bilateral arterial revascularization, a survival benefit for the bilateral group at a mean follow-up period of approximately 7.9 years was shown. 2 In this population, CKD was prevalent in 11.2% of the matched cohorts, and multivariable cox regression analysis showed that the hazard ratio was 1.08 (95% confidence intervals: 1.05, 1.11) after adjusting for coronary artery disease (CAD) risk. This is in agreement with a previous study comparing the use of internal mammary artery versus saphenous vein graft in 7308 (1:1 propensity score matched) patients on maintenance dialysis, which showed a hazard ratio of 0.89 (95% confidence intervals: 0.84, 0.93) at median follow-up period of 1.9 years. 3 Although there is still clearly a discrepancy in the current literature regarding the superiority of either approach for the general population, it would seem that CKD patients should not be treated as any other patient. 4,5 It is well established that CKD deteriorates the outcomes for patients undergoing cardiac surgery not only for CAD but for valvular disease as well. 6,7 Although this specific population of patients is underrepresented in CAD clinical trials, making extrapolation of the outcomes from certain studies questionable, it would nevertheless seem that the presence of CKD should be a major consideration in how surgeons counsel their patients and approach their care in the operating room. 8

ObjectiveOnce a replaced prosthetic graft is infected, it is usually necessary to re-replace the thoracic aorta to achieve complete resolution of the infection. It is, however, an exceedingly invasive approach to perform such a repeat surgery on patients in a poor condition. We have managed both re-replacement of an infected prosthetic graft and conservative therapy with vacuum-assisted wound closure (VAC) without re-replacement. These two treatment modalities were retrospectively assessed.MethodsRetrospective clinical chart review was undertaken on 21 patients with prosthetic graft infection after thoracic aortic replacement between December 1999 and December 2012. Surgical outcomes were evaluated between the two groups: re-replacement group (group R, n = 14) and no-replacement group (group NR, n = 7).ResultsIn-hospital survival rates were 64.3 % in group R and 85.7 % in group NR. Mortality in group R included five patients, sepsis in two patients, and intraoperative aortic rupture, heart failure, and cerebral infarction in one. Mortality in group NR included one patient (sepsis). In terms of long-term outcome, one patient in group R and one patient in group NR died of rupture of a residual aortic aneurysm, and one patient in group NR died of renal disease during follow-up (52.8 ± 41.5 months for R and 43.2 ± 28.5 months for NR; mean ± standard deviation).ConclusionsRe-replacement of an infected prosthetic graft after a thoracic aortic operation still carries a significant risk for mortality. VAC therapy may provide an acceptable option for such a subgroup of patients with this serious condition.

BACKGROUND/OBJECTIVE: In this research, using our proposed method, clinical measurements on the pulsatile velocity of blood vessel wall were conducted for cases with aneurysm. Furthermore, detailed analyses of frequency and attracter of trajectories of velocity of blood vessel wall were conducted. On the basis of these analyses, we tried to conduct unified clarification of the change and disturbance of frequency and wave form of pulsatile velocity of blood vessel wall caused by blood vessel diseases such as aneurysm. RESULTS: In the pulsation motion of blood vessel wall, vasomotion, which is a regular long periodic fluctuation of amplitude of the pulsatile velocity of blood vessel wall, was found to exist. Furthermore, the shift of its frequency into low frequency region was found to correspond well with an increase in I * , an indicator of progressive degree of visco elasticity of blood vessel wall and it reflects the mechanical deterioration of blood vessel wall. This long periodic fluctuation of amplitude of the pulsatile velocity of blood vessel wall exists in the low frequency region that composes the frequency of the pulsatile velocity of blood vessel wall. On the other hand, wave forms in high frequency region that compose the frequency of pulsatile velocity of blood vessel wall were found to correspond well with each pulsatile velocity wave form of blood vessel wall itself and their disturbances caused by the existence of aneurysm was typically reflected in these wave forms. CONCLUSION: By dividing frequencies that compose the frequency of the pulsatile velocity of blood vessel wall into low and high frequency regions and conducting analyses at each region, the possibility of accurate selective detection of blood vessel diseases such as mechanical deterioration of blood vessel wall (low frequency region) and morphological change of blood vessel wall that is aneurysm (high frequency region) was indicated.