Intraoperative endotoxin adsorption for visceral malperfusion complicating acute type A aortic dissection

En bloc resection and extended replacement of the infected aortic arch

We present the technical details of en bloc resection and extended replacement of an infected aortic arch. A 74-year-old man underwent emergent surgery under a diagnosis of impending rupture of an infected aortic arch aneurysm. The patient's chest was entered through a median sternotomy with a left thoracotomy at the fourth intercostal space. After dissection of the left phrenic and left recurrent nerves, the infected aortic arch was widely excised en bloc under circulatory arrest with selective cerebral perfusion. It was replaced with a rifampicin-bonded prosthetic graft. The prosthesis and anastomoses were covered with a harvested omental flap. Although an appropriate approach and supportive therapy are indispensable, en bloc resection of the infected tissue is an important technique when treating infected aortic aneurysms.

Intraoperative direct hemoperfusion with a polymyxin-B immobilized fiber column for treatment of infective endocarditis

PURPOSE

Endotoxin adsorption treatment (direct hemoperfusion using a polymyxin-B immobilized fiber column, or PMX-DHP) is now considered a useful option for treating severe sepsis. However, the efficacy of PMX-DHP for infective endocarditis (IE), in which the causative microorganisms are usually gram-positive cocci, remains unclear. In the present study, we investigated the impact of intraoperative PMX-DHP on clinical parameters during the treatment of IE.

METHODS

From November 2006 to December 2009, a total of 11 patients with active IE underwent emergent surgery using intraoperative PMX-DHP. The perioperative courses of these patients were compared with those of seven patients who underwent emergent surgery for active IE with the conventional method from January 2003 to October 2006.

RESULTS

PMX-DHP was associated with a significant decrease in the postoperative catecholamine dose and duration. Intubation time and intensive care unit length of stay for the PMX-DHP group was significantly shorter than that for the conventional therapy group. There was also a significant difference in the number of failed organs postoperatively between the two groups.

CONCLUSION

Intraoperative PMX-DHP demonstrated several positive effects, such as a drastic decrease in the doses of inotropic agents and shortening of the duration of mechanical ventilation, in patients who underwent emergent surgery for active IE. Intraoperative PMX-DHP can be a useful option for the treatment of critically ill patients with IE.