Current Status and Future Perspectives of Cardioplegic Protection in Cardiac Surgery, Highlighting the Mechanisms of Targeted Cellular Components / 日本心臓血管外科学会雑誌

“Depolarized arrest”, induced by hyperkalemic (moderately increased extracellular potassium) cardioplegia is the gold standard to achieve elective temporary cardiac arrest in cardiac surgery. Hyperkalemic cardioplegic solutions provide good myocardial protection, which is relatively safe, and easily and rapidly reversible. However, this technique has detrimental effects associated with ionic imbalance involving sodium and calcium overload of the cardiac cell induced by depolarization of the cell membrane. Hence, the development of an improved cardioplegic solution that enhances myocardial protection is anticipated as an alternative to hyperkalemic cardioplegia. In this review, we assess the suitability and clinical potential of cardioplegic agents to induce “non-depolarized arrest” from the viewpoint of rapid cardiac arrest, myocardial protection, reversibility, and toxicity. “Magnesium cardioplegia” and “esmolol cardioplegia” have been shown to exert superior protection with comparable safety profiles to that of hyperkalemic cardioplegia. These alternative techniques require further examination and investigation to challenge the traditional view that hyperkalemic arrest is best. Endogenous cardioprotective strategies, termed “ischemic preconditioning” and “ischemic postconditioning”, may have a role in cardiac surgery to provide additional protection. The elective nature of cardiac surgery, with the known onset of ischemia and reperfusion, lends it to the potential of these strategies. However, the benefit of preconditioning and postconditioning during cardiac surgery is controversial, particularly in the context of cardioplegia. The clinical application of these strategies is unlikely to become routine during cardiac surgery because of the necessity for repeated aortic crossclamping with consequent potential for embolic events, but offers considerable potential especially if “pharmacological” preconditioning and postconditioning could be established.

A Case of Marfan's Syndrome with Repeated Occurrence of Acute Aortic Dissection during Treatment / 日本心臓血管外科学会雑誌

A 26-year-old man with Marfan's syndrome suffered aortic dissection repeatedly during hospitalization. He was admitted with a diagnosis of annuloaortic ectasia with severe aortic regurgitation. A type A aortic dissection occurred after diagnostic angiography. Three weeks after the onset of the dissection, an aortic root replacement in combination with a total arch replacement was performed. Eight months later, residual dissection in the descending thoracic aorta was replaced with distal perfusion by a temporary bypass from the left subclavian artery to the descending thoracic aorta. At the termination of the operation, abdominal aortic dissection occurred with acute bilateral limb ischemia, which was treated with abdominal aortic intimal fenestration. He recovered uneventfully and was discharged 3 weeks after operation. In light of our experience, because of vascular fragility, great care should be taken in treating patients with Marfan's syndrome to avoid iatrogenic aortic dissection.

Cabrol, Technique Performed on a Patient with Corrected Transposition of the Great Arteries, Complicated by Annuloaortic Ectasia and Aortic Regurgitation / 日本心臓血管外科学会雑誌

Cabrol's technique was performed on a patient with corrected transposition of the great arteries (SLL), complicated by annuloaortic ectasia (AAE) and aortic regurgitation (AR). The patient, a 52-year-old male, complained mainly of dyspnea on physical exertion. In 1983, he underwent implantation of a pacemaker to treat advanced atrioventricular block. In 1994, his cardiac function deteriorated to NYHA III. Cardiac catheter examinations exhibited 2nd degree Seller's aortic valve insufficiency and 2nd degree insufficient closure of the left atrioventricular valve. The patient was Cardell classification B3, with a Shaher Type 4 coronary artery. A composite graft was made using a 27mm St. Jude Medical valve and a 30mm woven Dacron graft. The left atrioventricular valve had three leaflets, accessible from the right atrium using the septal approach. Kay's method was used to suture the posterior leaflet and reduce regurgitation. The patient has made favorable progress during the two-year follow-up period.

The Surgical Treatment of Endocardial Fibroelastosis and Endomyocardial Fibrosis / 日本心臓血管外科学会雑誌

We performed mitral valvuloplasty for 25 months old infant with endocardial fibroelastosis (EFE) and 21 months old infant with endomyocardial fibrosis (EMF). These two patients showing good post operative cause, have been followed up during 10 and 1 years respectively. The EFE and EMF are severe and progressive restrictive cardiomyopathy of unknown etiology. Most of cases with EFE and EMF have an enlarged left ventricle with incompetent atrioventricular valve. The prognosis of these patient is usually poor. We believe that the surgical treatment in early phase may be able to improve heart failure and also to protect the progression of these disease. This case with EMF is the first report of successfull surgical treatment for the patients with severe congestive heart failure whithin one year after birth in Japan.

Ruptured Dacron Prosthesis by Blunt Trauma 8 Years after Implantation for Axillo-femoral Bypass / 日本心臓血管外科学会雑誌

A case of a 77-year-old man is reported, who developed late rupture of the knitted Darcon velour graft by blunt trauma 8 years after implantation for axillo-femoral bypass. Dacron fiber deterioration, which led the graft to fragility, might have played a main role in the clinical setting. This case clearly emphasizes that with its possibility to be deteriorated life-long care and follow up should be taken for the patients who undergo arterial reconstructive surgery using Dacron prostheses.