Intra-Abdominal Pressure Monitoring after Ruptured Abdominal Aortic Aneurysm Surgery / 日本心臓血管外科学会雑誌

In the postoperative treatment of ruptured abdominal aortic aneurysm surgery, the relationship between intra-abdominal pressure (IAP) and the clinical course is not been clearly understood. From April 2000 to January 2003, we treated 109 cases of abdominal aortic aneurysm surgery (non-rupture 71 cases, rupture 38 cases) and measured intra-abdominal pressure in 30 of the ruptured cases which we analyzed in this study. The patients were divided into 2 groups. The H-group included 12 patients with maximum IAP equal to or higher than 20mmHg, and the L-group included 18 patients with a maximum IAP less than 20mmHg. Clinical characteristics were compared between the 2 groups. The mean age was 79.3±7.6yr in the H-group and 70.7±10.1yr in the L-group (<i>p</i>=0.019). Preoperative shock was diagnosed in 83.3% of the H-group patients, and 61.1% of the L-group patients the (<i>p</i>=0.26). Postoperative maximum values of intra-abdominal pressure were 22.3±2.0mmHg in the H-group, and 15.4±2.4mmHg in the L-group. Duration of intubation was 87.7±110.0h in the H-group, and 25.1±29.2h in the L-group (<i>p</i>=0.04). Food intake was started 14.4±11.2d after surgery in the H-group, and 8.5±4.8d after surgery in the L-group (<i>p</i>=0.094). The length of ICU stay was 6.7±6.5d in the H-group, and 2.9±2.1d in the L-group (<i>p</i>=0.033). Length of hospital stay after surgery was 54.1±25.8d in the H-group, and 25.2±6.8d in the L-group (<i>p</i>=0.001). Complications occurred in 8 cases out of 11 surviving cases (73%) in the H-group, and in 3 cases out of 17 surviving cases (18%) in the L-group (<i>p</i>=0.0024). Complication in the H-group included acute renal failure, paralytic ileus, respiratory failure, abdominal wall dehiscence, and acute arterial occlusion, and that in the L-group included acute renal failure, upper limb paresis, and lower limb paresis. Monitoring of intra-abdominal pressure was considered beneficial to recognize complication and decide therapeutic strategy after ruptured aortic aneurysm surgery.

A Case of Spontaneous Resolution of Systolic Anterior Motion after Mitral Repair / 日本心臓血管外科学会雑誌

A 70-year-old patient underwent modified maze procedure and mitral repair including quadrangular resection, annular plication (Reed procedure), and flexible ring annuloplasty with Cosgrove ring. Systolic anterior motion (SAM) of the anterior mitral leaflet and mild mitral regurgitation was observed on weaning from cardiopulmonary bypass. The patient was medically treated, and postoperative echocardiography revealed disappearance of the SAM 11 days after surgery. In addition to the surgical condition of rather excessive annular plication and small ring, transient conditions including inotropic support, insufficient volume under diastolic dysfunction of left ventricle, and loss of atrial contraction were thought to be the causes of SAM.

Clinical Study of Anticytokine Therapy during Cardiopulmonary Bypass / 日本心臓血管外科学会雑誌

Cardiac operations involving cardiopulmonary bypass can cause a systemic inflammatory response such as elevation of inflammatory cytokines, which can cause organ failure. We investigated cytokine production and its inhibition by ulinastatine in patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass. Thirty-three patients received either ulinastatine (300, 000 units, intracoronary artery injection immediately after aortic closs-clamping, UTI group, <i>n</i>=16) or no ulinastatine (control group, <i>n</i>=17). Arterial blood samples were obtained at aortic closs-clamping, 5 minutes after aortic declamping, and 6, 12 and 18 hours after surgery and there were assayed for interleukin-6 (IL-6), interleukin-8 (IL-8), and polymorphonuclear leukocyte elastase (PMNE). In addition, we examined liver function (GOT, GPT, and total bilirubin), renal function (blood urea nitrogen and serum creatinine), and oxygenatory function (PaO₂/FIO₂) postoperatively. IL-8 levels at 5 minutes after aortic declamping and maximum IL-8 levels were significantly lower in the UTI group than in the control group (25.5±12.8 vs. 47.8±38.9pg/dl, <i>p</i><0.05, and 28.6±13.2 vs. 58.4±40.0pg/dl, <i>p</i><0.05). Blood urea nitrogen on the second post operative day (POD) and three POD and creatinine on the second POD were also significantly lower in the UTI group than the control group. Furthermore, IL-8 and PMNE levels significantly correlated positively with blood urea nitrogen and creatinine. There was significant negative correlation between IL-8 and oxygenatory function. These results shows that the ulinastatine can inhibit IL-8 levels following cardiac surgery. To combat the increase of inflammatory cytokines such as IL-8 after cardiopulmonary bypass, the ulinastatine should be used for anticytokine therapy to protect the kidneys, lungs, and other organs, and thereby decrease the risk of complications.

The Influence of Continuous Warm Blood Cardioplegia on Intraoperative Cardiac Aerobic Metabolism / 日本心臓血管外科学会雑誌

Continuous warm blood cardioplegia (CWBC) was compared with cold crystalloid cardioplegia (CCC) with regard to intraoperative cardiac aerobic metabolism. Thirty-six adult patients who underwent CABG were divided into two groups. The CWBC group (<i>n</i>=21) received continuous warm blood cardioplegia while the CCC group (<i>n</i>=15) received 4°C St. Thomas' Hospital cardioplegic solution. Some parameters of cardiac anaerobic metabolism were measured intraoperatively. We continuously measured the oxygen saturation of coronary sinus blood (ScsO₂) after aortic declamping until 5 minutes after cardiopulmonary bypass (CPB). CK and CK-MB levels were measured at admission to ICU, and on the first and second postoperative day (POD) in both groups. CPB time, aortic-cross clamp time and incidence of postoperative low output syndrome were similar in the two groups. The spontaneous return to sinus rhythm after aortic declamping was significantly higher in the CWBC group. ScsO₂ was significantly higher in the CWBC group. The lactate uptake ratio of myocardium, excess lactate and redox potential were similar in the two groups. CK and CK-MB levels were significantly lower in the CWBC group. We concluded that the CWBC group was superior to the CCC group in terms ScsO₂, CK and CK-MB levels. Other parameters of cardiac anaerobic metabolism were similar in the two groups.

The Superiority of Continuous Warm Blood Cardioplegia about Postoperative Cardiac Function / 日本心臓血管外科学会雑誌

Continuous warm blood cardioplegia (CWBC) was compared with cold crystalloid cardioplegia (CCC) with regard to postoperative cardiac function. 36 adult patients underwent CABG divided into two groups. The CWBC group (<i>n</i>=21) received continuous warm blood cardioplegia while the CCC group (<i>n</i>=15) received 4°C St. Thomas' Hospital cardioplegic solution. Some parameters or cardiac function, CK and CK-MB levels were measured at admission to ICU, and on the first and second postoperative day (POD) in both groups. The amount of dopamine and dobutamine were measured at admission to ICU and 6, 12, 18, 24 hours after admission to ICU in both groups. Cardiopulmonary bypass (CPB) time, aortic-cross clamp time and incidence of postoperative low output syndrome were similar in the two groups. The spontaneous return to sinus rhythm after aortic declamping was significantly higher in the CWBC group. The cardiac index measued at admission to ICU, 1 POD and 2 POD was significantly larger in the CWBC group. Pulmonary capillary wedge pressure and right atrial pressure measured at 1 POD and 2 POD were significantly lower in the CWBC group. Systemic vascular resistance measured at admission to ICU, at 1 POD and 2 POD were significantly lower in the CWBC group. Left ventricle stroke work index and left ventricle work index measured at admission to ICU were significantly larger in the CWBC group. Right ventricle stroke work index and right ventricle work index were similar in the two groups. The amount of dopamine at admission to ICU and at 6 and 12 hours after admission to ICU were significantly lower in the CWBC group. The amounts of dobutamine at admission to ICU and at 6, 12, 18 and 24 hours after admission to ICU were significantly lower in the CWBC group. CK levels measured at admission to ICU and at 1 POD were significantly lower in the CWBC group. CK-MB levels measured at admission to ICU, 1 POD and 2 POD were significantly lower in the CWBC group.