Usefulness of JapanSCORE—Comparative Study of the Usefulness of the JapanSCORE and the Logistic EuroSCORE / 日本心臓血管外科学会雑誌

Risk analysis models are becoming more important in various aspects of the clinical setting. We have used the logistic EuroSCORE as a risk analysis model, but there is divergence between the model and actual clinical reality in our country. The Japan Score is a risk model based on the Japan Adult Cardiovascular Surgery Database and it is considered to be better reflect from Japanese clinical results. We compared the logistic EuroScore (ES) and Japan Score (JS) and their predictive accuracy, using our clinical results. Between October 2006 and June 2011, 733 operations suitable for evaluation by the Japan Score were performed at our institute. Isolated coronary artery bypass grafting (CABG) was performed in 151 cases, valve surgery (Valve) in 346 cases and aortic surgery (Aorta) in 236 cases. In these cases we calculated 30-day mortality using the EuroSCORE and JapanSCORE and compared the results and prediction accuracy, by calculating the receiver operating characteristic curve (ROC curve) and the area under the ROC curve (AUC). We also calculated 30-day mortality and morbidity by the JapanSCORE and analyzed it by the same method. In the entire group, logistic 30-day mortality by ES and JS was 7.28 and 4.05% respectively. The AUC was 0.740 and 0.806, while 30-day mortality and morbidity calculated by JS was 17.72% and the AUC was 0.646. In the CABG group the 30-day mortality by ES and JS was 5.7 and 3.18% respectively, the AUC was 0.636 and 0.770, the 30-day mortality and morbidity was 13.37% and the AUC was 0.631. In the Valve group 30-day mortality by ES and JS was 6.00 and 3.79% respectively. The AUC was 0.715 and 0.794, 30-day mortality and morbidity was 17.54% and the AUC was 0.606. In the Aorta group 30-day mortality was 10.17 and 4.99% respectively. The AUC was 0.720 and 0.827. The 30-day mortality and morbidity was 20.83% and the AUC was 0.640. The 30-day mortality calculated by JS was significantly lower than that of ES (<i>p</i><0.001). The prediction accuracy of both of the ES and the JS was satisfactory but the prediction accuracy of JS was better than that of the ES. The prediction accuracy of the logistic 30-day mortality and morbidity were not as accurate as 30-day mortality. JS was a good risk analysis model not only for prediction of surgical results but also for improving surgical outcome.

Cardiac Surgery for Takayasu's Disease / 日本心臓血管外科学会雑誌

Eight patients with Takayasu's disease underwent cardiac surgery between 1983 and 1998. All were women and the age at the time of operation ranged from 42 to 68 years (mean, 53.8 years). They were divided into two groups according to the coronary artery involvement: group A (<i>n</i>=3) had aortic regurgitation with an intact coronary artery and underwent aortic valve replacement (AVR); group B (<i>n</i>=5) had coronary artery lesion and underwent coronary artery bypass grafting (CABG) concomitant with or without AVR. All AVR procedures were performed using mechanical valves. At the CABG operation, saphenous veins alone were used in three cases and the left internal thoracic artery and saphenous veins in two. The actuarial survival rate was 65.6% at 5 years and 32.8% at 10 years. There were no early or late deaths in group A. On the contrary, there were one hospital death and two late deaths in group B. We discussed the timing of surgical intervention, the kind of prosthetic valve, the material of bypass graft and the procedure of CABG, the postoperative steroid use, and the surgical prognosis. The optimal timing of surgery for cardiac involvement is, needless to say, the inactive phase of inflammation. However, there are some patients who require operations during the active phase because of medically intractable or worsening symptoms. There is a consensus regarding the kind of prosthesis, and the mechanical valve is usually employed. There are still controversies regarding the material of grafts. We do not know the late results of saphenous vein graft in Takayasu's disease although saphenous vein is thought to be the choice of graft and several CABG procedures are advocated. The left internal thoracic artery might be used as a graft if the patient with Takayasu's disease had no subclavian artery lesions and was stable with an antiinflammatory regimen. We recommend the postoperative steroid therapy to control inflammation and also describe the antiinflammatory regimen after cardiac surgery in Takayasu's disease. It is essential that we have to meticulously follow up the patients with Takayasu's disease who underwent cardiac operations, paying especial attention to the side effects of steroid as well as the progression of inflammation.

Two Cases of Infected Aortic Abdominal Aneurysm with Spondylodiskitis / 日本心臓血管外科学会雑誌

We encountered two cases of infected aortic abdominal aneurysm with spondylodiskitis. Both cases were diagnosed on the basis of fever, back pain and pulsatile abdominal mass. A 69-year-old man, case 1, underwent <i>in situ</i> reconstruction 1 year from the onset, because the infection was controllable by antibiotics and he had diabetes mellitus. A 68-year-old man, case 2, underwent operation while his infection was still active, because of paralysis of the bilateral lower extremities, aggravated by invasion of the vertebrae by the abscess. To prevent artificial graft infection, he underwent axillo-femoral bypass, which was extra-anatomical reconstruction, after the infected aneurysm and vertebrae were removed during aortic clamping above the aneurysm and bilateral common iliac arteries. Each stump was sutured and anterior fixation of the vertebrae was performed using an iliac bone graft. The postoperative course of both patients was successful. These cases suggest that the timing and procedure of the operation for infected aortic abdominal aneurysm with spondylodiskitis should be decided depending on the activity of infection, complications, age and activity of daily life of patients.

Sternotomy Approach in a Case of Giant Ascending Aortic Aneurysm and Annuloaortic Ectasia Previously Operated for Pure Pulmonary Stenosis / 日本心臓血管外科学会雑誌

A 29-year-old man, who had undergone valvotomy for pure pulmonary stenosis at 6 months of age, was admitted to our institution for surgical treatment of a giant ascending aortic aneurysm and annuloaortic ectasia. Chest MRI revealed a 14-cm ascending aneurysm in contact with the sternum. After establishing femoro-femoral bypass for hypothermia, a left lateral thoracotomy was perfomed at the 4th intercostal space. Pulmonary artery cannulation was performed for left heart venting, and the proximal aortic arch was dissected for aortic cross-clamping. Median sternotomy was performed under circulatory arrest at 18°C and the aortic arch was opened. Under retrograde cerebral perfusion, the proximal arch was replaced by an artificial graft, and then aortic root replacement was completed using a composite graft under CPB. The postoperative course was uneventful, and the patient was discharged on the 37th postoperative day. He has been well without any complications. This case suggests that our method of approach to the giant aortic aneurysm with sternal adhesion and aortic regurgitation, and the use of extracorporeal circulation in view of the annuloaortic ectasia is effective and safe in case of reoperation.