ABSTRACT
A 36-year-old woman was admitted because of dyspnea on exertion and palpitations, during follow-up for ventricular septal defect since age 5. Physical examination revealed a grade IV/VI ejection systolic murmur at the second left intercostal space. Echocardiogram failed to recognize an unruptured aneurysm of the sinus of Valsalva protruding into the right ventricle which was seen on right ventriculogram (type I of Konno). Surgical treatment was successfully performed. Right ventriculography was much more effective rather than echocardiography in this case.
ABSTRACT
A 71-year-old woman with Lutembacher syndrome was admitted for severe congestive heart failure and cardiac cachexia. The preoperative cardiac catheterization showed a huge secundum atrial septal defect (Qp/Qs=3.08) with mitral valve stenosis, tricuspid valve regurgitation, atrial fibrillation and severe pulmonary hypertension. Patch closure of atrial septal defect, mitral valve replacement (SJM 25mm) and tricuspid annuloplasty (Key's method) were performed. However, she suffered prolonged respiratory failure postoperatively. Enforced alimentation for cardiac cachexia and careful administration for sustained heart failure resuscitated her severe postoperative status. The postoperative cardiac catheterization showed sufficient decrease of pulmonary pressure. Reports of successful surgical correction for Lutembacher syndrome in elderly are extremely rare. This is the oldest case of successful correction for Lutembacher syndrome in Japan. From our experience, the surgical treatment for Lutembacher syndrome should be considered even in elderly patients.
ABSTRACT
Ventricular Septal Defect (VSD) is the most frequent cardiovascular anomaly. VSD causes pulmonary hypertension through stenotic changes in the pulmonary vasculature, and this progress depends on the size of defect and associated cardiovascular anomalies. Since surgical repair has been performed in childhood for patients without a tendency toward spontaneous closure of VSD, operations in elderly patients, especially those aged over 40, are rare. We report an elderly patient with VSD complicated with severe pulmonary hypertension who underwent surgical repair. A 66-year-old man was admitted to our hospital because of general fatigue, chest oppression and palpitations. The pulmonary to systemic pressure ratio was 0.66. The oxygen saturation stepped up at the right ventricle level. The pulmonary to systemic blood flow ratio was 2.9, shunt ratio was 71% and resistance ratio was 0.12. The VSD was 18mm in diameter at the perimembranous trabecula and was closed with a Dacron patch through a right atrium incision. The lung biopsy specimen revealed little occlusive pulmonary vascular disease, Grade I according to the Heath-Edwards criteria. The patient had an uneventful recovery.
ABSTRACT
The effects of milrinone, a phosphodiesterase III inhibitor, were studied in patients with heart failure following coronary artery bypass grafting. Twenty patients with heart failure (either a cardiac index of less than 2.0<i>l</i>/min/m<sup>2</sup> or a pulmonary capillary wedge pressure of greater than 12mmHg) were divided into two groups according to whether or not they received postoperative milrinone administration. The control group (<i>n</i>=10) received no milrinone treatment and the milrinone group (<i>n</i>=10) received intravenous milrinone infusion at a speed of 0.5μg/kg/min postoperatively. The hemodynamic measurements were made perioperatively and clinical results were accessed perioperatively. Within-group comparison revealed a marked (<i>p</i><0.05) decrease in pulmonary capillary wedge pressure and systemic vascular resistance in the milrinone group. Cardiac indices were significantly (<i>p</i><0.05) greater in the milrinone group than those in the control group and within-group comparison revealed a significant (<i>p</i><0.05) increase in left ventricular stroke work index in the milrinone group. There was no significant difference in rate pressure product in between- and within-group comparison. The milrinone group had a significantly (<i>p</i><0.05) lower temperature difference between the rectum and the sole, and significantly (<i>p</i><0.05) less catecholamine requirements postoperatively. Milrinone was not associated with a significant increase in the prevalence of adverse effects. The results suggest that milrinone possesses positive inotropic and vasodilatory effects in patients with heart failure following coronary artery bypass grafting. In addition to catecholamines and vasodilators, milrinone may become a useful agent in the treatment of patients with postoperative heart failure.
ABSTRACT
The effects of human atrial natriuretic peptide (HANP, carperitide) were studied in 21 patients undergoing mitral valve surgery. The patients were randomized to receive either no carperitide treatment (control group, <i>n</i>=10) or carperitide (HANP group, <i>n</i>=11). Their hemodynamic status, diuresis and renal function were assessed perioperatively. The HANP group received continuous intravenous infusion of carperitide for 3 hours at a rate of 0.05μg/kg/min 3 hours after cardiopulmonary bypass. The HANP group had significantly lower systemic vascular resistance and less temperature difference between the rectum and the sole, and significantly greater cardiac index compared with those in the control group during infusion of carperitide, suggesting the improvement of cardiac performance by reducing afterload. The HANP group also had greater urinary output during the administration of carperitide, suggesting the significant diuretic effect of the regimen. The results indicated that the administration of carperitide may be a viable alternative strategy for the management of patients with postoperative heart failure. However, since transient oliguria was observed in 2 hypovolemic patients after the discontinuation of carperitide, careful monitoring is required during and after the infusion of the regimen in such patients.
ABSTRACT
Perioperative changes in thyroid function and hemodynamic state were studied in 6 hypothyroid patients and 15 euthyroid patients who underwent coronary artery bypass grafting. Serum free T<sub>3</sub> and total T<sub>3</sub> concentrations declined significantly in hypothyroid patients after the surgery. Serum total T<sub>3</sub> concentration decreased significantly also in euthyroid patients, indicating the occurrence of“euthyroid sick syndrome”in this group. Hypothyroid patients resulted in significantly lower left ventricular stroke work index despite greater central venous pressure and pulmonary capillary wedge pressure, and greater requirements of dopamine and dobutamine compared with those in euthyroid patients. The results indicated poorer postoperative cardiac performance in hypothyroid patients. Serum free T<sub>3</sub> concentration after cardiopulmonary bypass demonstrated a significant positive correlation with left ventricular stroke work index measured simultaneously. Preoperative serum free T<sub>3</sub> concentration showed a significant negative correlation with the postoperative dopamine and dobutamine requirements. Therefore, the results suggest that free T<sub>3</sub> has inotropic effects and the concentration of this hormone can be a predictor for a incidence of postoperative low cardiac output. In conclusion, since hypothyroid patients undergoing coronary artery bypass grafting are prone to have low cardiac output status, careful perioperative management, including hormone replacement therapy, is required for the patients.
ABSTRACT
We studied the effects of intermittent tepid blood cardioplegia on patients with prolonged aortic cross-clamping. Forty patients undergoing coronary artery bypass grafting with cross-clamp time of greater than 120 minutes were studied. The patients were divided into two groups according to the cardioplegic solutions, cold (4°C) crystalloid cardioplegia (Cold) and tepid (30°C) blood cardioplegia (Tepid). Cardiac function, myocardial enzyme and clinical outcomes were compared between the groups. Mean aortic cross-clamp time were 150±10 minutes in the Cold group and 149±4 minutes in the Tepid group. Recovery rate of spontaneous rhythm after cross-clamp removal and postoperative left ventricular stroke work index were significantly greater in the Tepid group than those in the Cold group. Duration of ventilation and ICU stay were significantly shorter and total release of CK-MB, requirements of dopamine during 48 hours after the operation and the incidence of low-output syndrome were significantly less in the Tepid group. There were no early deaths in the Tepid group versus three early deaths in the Cold group. In conclusion, intermittent tepid blood cardioplegia provided superior postoperative cardiac function and clinical results to conventional cold crystalloid cardioplegia, thus the technique appears to be safe for patients requiring prolonged aortic cross-clamping.
ABSTRACT
The results and surgical techniques were studied in 59 patients who had atherosclerotic lesions in the ascending aorta. Arterial grafting (AG) and sequential grafting for coronary artery bypass grafting (CABG) was used in as many as possible cases and the number of distal anastomoses with AG was 1.3/patient (internal thoracic artery (ITA), 56 anastomoses for 50 patients; gastroepiploic artery (GEA), 17; and inferior epigastric artery, 3). Calcification in the ascending aorta was noted in 26 patients and arterial cannulation was performed via the right axillary artery in 4 patients. Saphenous vein grafts were used for 51 patients and 30 of them required aortic reconstruction for proximal anastomosis. There were 2 hospital deaths (non-cardiac) and no neurological complications. It is difficult to perform CABG in the presence of atherosclerosis in the ascending aorta. However, the right axillary artery cannulation as the site of arterial cannulation and the use of sequential grafting, using ITA and GEA as the pedicled arterial conduits are useful to accomplish CABG in such patients. Neurological complication seems to be manufactured at a minimal level by cautious operative techniques.
ABSTRACT
Postoperative cardiac function, changes of LV wall motion and exercise tolerance test were studied in 49 patients who received coronary artery bypass grafting (CABG) using antegrade intermittent warm blood cardioplegia (IWBC) and had postoperative left ventriculography (LVG). The mean aortic cross clamp (ACC) time was 68.2±22.8 minutes, and the coronary perfusion time during ACC was 12.6±6.9 minutes (18.2±7.1% of total ACC time). Spontaneous return of normal sinus rhythm was seen in 45 patients (92%). Perioperative myocardial infarction occurred in only one patient and one patient required inotropic support>5μg/kg/min after operation. The mean cardiac index measured by Swan-Ganz catheter improved postoperatively, and the postoperative LVG revealed improvement of the LV wall motion in comparison with that of preoperative LVG, and no local asynergy due to inadequate distribution of IWBC was seen in the early postoperative period. The mean postoperative exercise tolerance performed in 24 patients was 6.6 METS (metabolic equivalents), and no patient revealed myocardial ischemia at exercise. In conclusion, the IWBC is considered to be an easy and safe technique for distal anastomoses of CABG with no influence upon the postoperative cardiac function and LV wall motion.