[New technique to determine graft length using the proximal anastomotic system during off-pump coronary artery bypass grafting].

For determining the graft length for an aortic connector, grafts to the circumflex (Cx) and the posterior descending (PD) regions often present problems. Difficulties in determining the appropriate distance between the aorta and coronary artery have been reported to be due to changes in the morphology of the heart following the evolution of Cx and PD. We set an intermediate point (IMP) in advance and then determine graft distance in 2 steps. When using the IMP method, determination of the graft length in the Cx region is not difficult. However, attention should be paid to determine the distance between the IMP and anastomosed site without deforming the heart, as the graft length becomes shorter if the heart as a whole is pulled up by traction of the diaphragm during evolution to the PD region.

[A constrictive pericarditis on oral steroid and immunosuppressant treated with bilateral anterolateral thoracotomy; report of a case].

A successful case of pericardiectomy without median sternotomy for an immunosuppressive 59-year-old man with constrictive pericarditis (CP) was reported. He had a history of invasive thymoma, myasthenia gravis and pure red cell aplasia, and he was on oral steroid and immunosuppressant. Pericardiectomy was performed by the approach of bilateral anterolateral thoracotomy to avoid troubles due to median sternotomy under immunosuppression, and there was no postoperative infection such as mediastinitis. Bilateral anterolateral thoracotomy was considered to be useful for immunosuppressive cases.

[Beating heart coronary artery bypass grafting for acute myocardial infarction].

We consider that off-pump coronary artery bypass grafting (CABG) [OPCAB], which results in local myocardial ischemia, is more effective for patients with acute myocardial infarction (AMI) than conventional CABG under cardiac arrest with global myocardial ischemia. Twenty-one patients (15 males, 6 females) received OPCAB for AMI, among whom surgery was performed following percutaneous coronary intervention (PCI) failure in 4 and PCI was performed prior to OPCAB in 2, while PCI was not performed in the remaining 15. Preoperatively, 16 patients had intraaortic balloon pumping (IABP), and 4 had IABP and percutaneous cardiopulmonary support (PCPS). The mean interval from onset to surgery was 11.7 (range 3 to 40) hours. In 20 cases, a complete revascularization was performed. The mean number of bypasses was 2.3 and OPCAB was carried out in 14 patients. In 2 cases, OPCAB was converted to on-pump beating CABG for complete revascularization. Fourteen patients (67%), each maintained with preoperative left ventricular ejection fraction (EF), were discharged with an elective bypass. Four patients died after on-pump beating CABG, in whom EF was lower than 10%. In addition, 3 died of low cardiac output syndrome (LOS) under PCPS and 1 of ventricular fibrillation. Based on our results, we considered that complete revascularization using OPCAB was effective for cases of AMI with PCI difficulty. However, in shock cases requiring PCPS, cardiac function was not improved even after revascularization. Therefore, it is necessary to study new procedures for shock cases during the period from onset to surgery.

[The method of skeletonized right gastroepiploic artery is useful for following upper abdominal cancer operations].

We reported 5 cases of upper abdominal malignant tumors in patients with previously underwent coronary artery bypass grafting (CABG) using in situ gastroepiploic artery (GEA) graft. In our cases, we found that the GEA grafts were easily identified during abdominal operation when the GEA were collected by the skeletonize method.

[Off-pump coronary artery bypass grafting/beating coronary artery bypass grafting for a patient with low left ventricular ejection fraction].

Beating coronary artery bypass grafting could be performed for a 47-year-old man with left ventricular ejection fraction (LVEF) of 9.3%. Post-operative LVEF was improved to 51.6%. Conventional coronary artery bypass grafting (CABG) used to be contraindicative for patients with LVEF below 20%. Recently, such patients are involved to indication of off-pump CABG (OPCAB) or beating CABG, because we consider OPCAB are lower complications than conventional CABG. We were able to bypass the circumflex for the patient while we had been used percutaneous cardio-pulmonary support (PCPS). We could perform beating coronary artery bypass grafting for a patient of the low LVEF.

Changes in T-cell receptor subsets after cardiac surgery in children.

T cells are divided into two subsets, alphabeta and gammadelta, according to the T-cell receptor (TCR) expressed. Recent findings indicate that gammadelta T cells serve as the first defense against microbial pathogens, and represent a link between innate and acquired immunity. We conducted a study to investigate the changes in circulating TCR subsets after cardiac surgery in children. Blood samples from 24 children who underwent cardiac surgery with cardiopulmonary bypass (CPB) were collected serially to analyze TCR subsets by flow cytometry. The alphabeta T cells reached a nadir on postoperative day (POD) 1, but recovered to pre-CPB levels on POD 3. On the other hand, the gammadelta T cells decreased after CPB and did not recover to pre-CPB levels even after POD 7. The alphabeta/gammadelta T-cell ratio was increased after POD 3. In children, gammadelta T cells recover more slowly than alphabeta T cells after cardiac surgery. These changes in TCR subsets may contribute to postoperative immunosuppression.

Long-term results of simultaneous carotid endarterectomy and myocardial revascularization with cardiopulmonary bypass used for both procedures.

OBJECTIVE: Controversy continues about the treatment of patients with a concomitant occlusive disease of the coronary and carotid arteries. Our operative strategy in these patients is to do simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass with mild hypothermia. We report our experience with this kind of one-stage procedure and its retrospective long-term results. METHODS: From February 1985 to September 1998, 340 patients underwent simultaneous carotid endarterectomy and myocardial revascularization. The average age of the patients was 65.3 years; 45.6% were neurologically symptomatic, and 44.4% had bilateral carotid stenosis. The indication for carotid endarterectomy was lumen diameter reduction of more than 75%, angiographic signs of thrombogenic endovascular morphology, or both. Carotid endarterectomy was performed in conjunction with cardiopulmonary bypass with mild hypothermia, hemodilution, systemic heparinization, and controlled hemodynamics under pulsatile perfusion for additional cerebral protection. RESULTS: There were 16 perioperative neurologic complications (4.7%), 11 permanent deficits (3.2%), and 9 cardiac complications (2.6%). Early mortality was 2.6% (SE 0.8%): 2 patients had a stroke and 2 had a myocardial infarction. The 5-year survival was 78.9% (SE 2.6%), and freedom from ipsilateral stroke and cardiac event were 93.2% (SE 1.5%) and 87.5% (SE 2.1%), respectively. The predictor for early death was age over 70 years, and predictors for late death were age over 70 years, previous myocardial infarction, previous stroke, and bilateral carotid stenosis of greater than 90%. CONCLUSION: On the basis of our long-term results, we believe that simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass is a method safe enough to prefer its routine use with acceptable low operative risk and satisfactory long-term morbidity.

Evaluation of left ventricular volume using automatic border detection in children: a comparison with conventional off-line echocardiographic quantification.

BACKGROUND: Evaluation of the clinical usefulness of the one-line automatic border detection system for determination of left ventricular volume in children in comparison to the conventional off-line method. METHODS: Eighty consecutive patients in whom clear images were obtained by two-dimensional echocardiography were studied. Using the Hewlett-Packard Sonos 2500 with a 3.5 or 5.5 Mhz phased array transducer, all patients were studied in the apical four-chamber imaging plane for automatic border detection and apical four-chamber and two-chamber imaging planes for manual tracing. Left ventricular end-diastolic and end-systolic volumes were measured and compared using the bi-plane Simpson method. RESULTS: Left ventricular end-diastolic volumes obtained by automatic border detection correlated well but were slightly underestimated compared to those obtained by manual tracing (r = 0.98). Left ventricular end-systolic volumes obtained by automatic border detection also correlated well with those obtained by manual tracing (r = 0.96). Left ventricular ejection fractions compared favorably. However, left ventricular volumes obtained using the classical Pombo M-mode echocardiography showed poorer correlation with those obtained by manual tracing methods. CONCLUSIONS: Automatic border detection is a promising method for real-time estimation of left ventricular volume. In patients with good endocardial tracking, automatic border detection can be used for routine studies of cardiovascular disease, even in children.

Chronic effects of oral prostacyclin analogue on thromboxane A2 and prostacyclin metabolites in pulmonary hypertension.

Abnormal biosynthesis of thromboxane and prostacyclin has been implicated in patients with primary pulmonary hypertension and secondary pulmonary hypertension associated with congenital heart disease, and could be involved in the pathogenesis of pulmonary vascular disease. The chronic effects of an oral prostacyclin analogue, beraprost sodium, on thromboxane and prostacyclin biosynthesis and on pulmonary circulation were investigated in 15 children with pulmonary hypertension. The plasma concentrations of thromboxane B2 and 6-keto-prostaglandin F1 alpha were measured, as was the urinary excretion of 11-dehydro-thromboxane B2 and 2,3-dinor-6-keto-prostaglandin F1 alpha, which are stable metabolites of thromboxane A2 and prostacyclin, respectively. In patients with pulmonary hypertension, the plasma concentration of thromboxane B2 and the ratio of thromboxane B2 to 6-keto-prostaglandin F1 alpha were greater than in healthy controls: 210 +/- 49 versus 28 +/- 4 pg/mL (P < 0.05) and 32.6 +/- 8.9 versus 5.7 +/- 1.8 (P < 0.01), respectively. After 3 months of administration of beraprost, the plasma concentration of thromboxane B2 and the ratio of thromboxane B2 to 6-keto-prostaglandin F1 alpha were reduced significantly: 210 +/- 49 to 98 +/- 26 pg/mL (P < 0.01) and 32.6 +/- 8.9 to 18.0 +/- 6.7 (P < 0.05), respectively. In contrast, the plasma concentrations of 6-keto-prostaglandin F1 alpha in patients were slightly but not significantly higher than in controls, and did not change significantly after administration of beraprost. The concentrations of 11-dehydro-thromboxane B2 and 2,3-dinor-6-keto-prostaglandin F1 alpha in urine correlated significantly with thromboxane B2 and 6-keto-prostaglandin F1 alpha, respectively, in plasma. Beraprost improved the imbalance of thromboxane and prostacyclin biosynthesis and has a potential efficacy for preventing the progressive development of pathological changes in pulmonary vasculature.

[A surgical case of aorto-pulmonary septal defect in a low weight neonate].

We report a surgical case of aorto-pulmonary septal defect (APSD) in a neonate weighing 1693 gm. A male twin baby delivered after 39 weeks and 5 days of gestational period was diagnosed as APSD. RAA, PFO and PLSVC by a echocardiography and a MRI. Because of the progressive cardiac failure, operation was performed under cardiopulmonary bypass and profound hypothermic circulatory arrest at 30 days of age and weighing 1693 gm. APSD was closed completely by a Dacron patch. Postoperative course was almost uneventful except for pulmonary hypertension crisis. He recovered without brain damage.

[Changes in neutrophil counts and lymphocytes subpopulations of a ECLS instituted patient].

A 4-year-old girl with tetoralogy of Fallot developed acute heart failure after ASD semiclosure. As drugs had no effect, ECLS was instituted. She gradually recovered from acute heart failure. ECLS was detached at 5 days after institution. Neutrocytopenia and lymphocytopenia became apparent during ECLS institution. The Subpopulations of T cell and NK cell decreased, and B cell subpopulation increased on the contrary during ECLS institution. This lymphocytopenia was caused by a decrease in T cell, especially CD4(+) cell numbers. It is necessary to minimize the potential for infection during ELCS institution.

Additive effect of beraprost on pulmonary vasodilation by inhaled nitric oxide in children with pulmonary hypertension.

Combined administration of inhaled nitric oxide and beraprost sodium resulted in a more intense decrease in pulmonary vascular resistance than nitric oxide given alone (mean -33% vs -45%, p <0.05), without serious systemic hypotension. Combined therapy with nitric oxide and beraprost sodium is highly desirable in treating primary and secondary pulmonary hypertension in children.

Acute effect of oral prostacyclin and inhaled nitric oxide on pulmonary hypertension in children.

The hemodynamic effects of acute oral administration of a newly-developed prostacyclin analogue (beraprost sodium; 1-2 micrograms/kg), inhaled nitric oxide (NO; 20 ppm) and tolazoline hydrochloride (1 mg/kg) were measured in 17 children (mean age 1 year and 9 months) with pulmonary hypertension complicating congenital heart disease or primary pulmonary hypertension. Beraprost, NO and tolazoline achieved approximately equivalent reductions in pulmonary vascular resistance (20%, 26% and 18%, p < 0.05), but the greatest percentage decrease of pulmonary to systemic resistance ratio was obtained after administration of NO (33%, p < 0.05). Furthermore, combined administration of beraprost and NO produced the maximum effect of pulmonary vasodilation without adverse effects (49%). Beraprost appears to be an effective and available substitute for NO and tolazoline in screening for pulmonary vasodilator responsiveness. The combined use of beraprost and NO may provide an alternative treatment for pulmonary hypertension in children without serious complications.

Inhaled nitric oxide after lung ischemia reperfusion; effect on hemodynamics and oxygen free radical scavenger system.

OBJECTIVE: Pulmonary hypertension and transient graft dysfunction may complicate the postoperative course of patients undergoing lung transplantation. Recent studies have suggested that ischemia followed by reperfusion impairs release of endothelium-derived nitric oxide (NO). We investigated the acute effect of inhaled NO on hemodynamics and the oxygen free radical scavenger system after reperfusion following lung ischemia. METHODS: Fourteen anesthetized mongrel dogs were ventilated mechanically. After median sternotomy the left lung was rendered ischemic by totally clamping the left pulmonary hilum. After 90 min, the left lung was reperfused for 150 min by unclamping of the left hilum and clamping the right pulmonary hilum so that all pulmonary blood flow was directed to the left lung. Seven dogs inhaled 30 parts per million (ppm) NO during reperfusion (NO group); the other seven dogs were ventilated without NO inhalation (control group). Hemodynamics, gas exchange, superoxide dismutase activity and lipid peroxide of pulmonary venous blood, and wet/dry ratio of reperfused lung were measured. RESULTS: Neither of the two groups showed any change in systemic blood pressure prior to or following reperfusion. Immediately after reperfusion, mean pulmonary arterial pressure was significantly less (23.2 +/- 4.2 mmHg) in the NO group than in the control group (32.7 +/- 5.8 mmHg), as had been throughout reperfusion. Pulmonary vascular resistance and right ventricular end diastolic pressure were lower after reperfusion in the NO group. Superoxide dismutase activity after reperfusion in the control group significantly decreased to 41% of preischemic value. In the NO group, however, no decrease was seen and a significantly higher value was observed. The wet/dry ratio of reperfused lung was 5.47 +/- 0.52 in the control group and 4.72 +/- 0.36 in the NO group, with decreased pulmonary moisture noted in the NO group. There was no difference in lipid peroxide between the two groups. CONCLUSION: NO inhalation suppressed pulmonary hypertension after reperfusion following lung ischemia without affecting systemic arterial pressure. As superoxide dismutase activity was not depressed in the NO group, NO inhalation might enhance suppression of oxygen free radicals. These findings suggest that NO inhalation may be therapeutically useful after lung transplantation.

[Composite arterial conduits with internal thoracic artery and inferior epigastric artery for a myocardial revascularization].

From November 1992 to February 1995, 10 patients were submitted to myocardial revascularization using composite arterial conduit with internal thoracic artery (ITA) and inferior epigastric artery (IEA). The age ranged from 48 to 68 years (mean age, 60.3 years); all patients were male. All patients had double-or triple vessel disease. The mean ejection fraction was 61.8% (range, 43 to 77%). We used 28 arterial conduits including 5 right ITAs, 10 left ITAs, 10 IEAs, and 3 right gastroepiploic artery. 10 IEAs were anastomosed to one ITAs and 10 composite arterial conduits were constructed (branched in 3, lengthened in 7). In 5 patients a double ITAs were used in a single patient. There was no operative mortality and fetal complication. Early postoperative angiographic controls demonstrated 100% patency of composite grafts in 9 of 10 patients. The composite arterial graft using ITAs and IEAs is feasible and the anastomoses so performed are completely safe.

[The management of mediastinitis after cardiac surgery].

Of 1067 consecutive patients who underwent cardiac surgery from 1985 to 1992, 19 (1.7%) patients experienced sternal wound complications. All patients required operative intervention with positive bacterial cultures. Before 1990, a group of 13 patients were treated by continuous closed irrigation with dilute povidone-iodine solution. Four patients died (30%). In another group of 6 patients who received omental or pectral muscle flap transfer after 1990, 2 patients died (33%). The mean duration of hospitalization for mediastinitis was 63 days in this group, which was significantly shorter than that of the former group (105 days). From these experiences, we conclude that omental or pectral muscle transfer is an excellent method of management for mediastinitis after cardiac surgery, and is better than continuous closed irrigation method.

[A case report of coronary artery bypass grafting surgery with aprotinin in a patient undergoing chronic haemodialysis].

A 61-year-old patient who was receiving haemodialysis because of chronic renal failure developed unstable angina pectoris with three vessel disease. We performed successful coronary artery bypass grafting, using aprotinin to reduce blood loss. Blood loss during the operation was 750 ml, and during a 6 hour period after the operation it was 150 ml. This amount seemed to be small. No adverse clinical effects attributable to aprotinin were seen, and urine volume and plasma creatinine were not different before and after the operation. In summary, aprotinin is useful adjunct to open heart surgery in chronic haemodialysis patients.

[Comparison of long-term clinical results and cost-effectiveness of percutaneous coronary angioplasty and coronary artery bypass grafting].

Cost-effectiveness was studied in 313 cases who had PTCA and 161 cases who had CABG as a first measure of interventional therapy for their coronary heart disease. Follow-up time ranged from 2 years to 5 years and 9 months with a mean interval of 3 years and 10 months. In the PTCA group a mean of 1.33 successfully dilated vessels/patient was obtained, but a total of 100 additional PTCA or bypass surgery procedure was necessary in the follow-up period. In the CABG group a mean of 2.60 patent grafts/patient was obtained. Mean length of hospital stay and charge was 21.9 days and 2,071 thousand yen in the PTCA group, and 82.2 days and 5,122 thousand yen in the CABG group through the entire follow up period. Cardiac event-free survival rate was significantly worse in the PTCA group. In the subgroup of two vessel disease, mean number of successfully dilated targets or patent grafts was 1.32 in the PTCA group and 1.88 in the CABG group. Total length of hospital stay and charge was 24.1 days and 2,352 thousand yen in the PTCA group and 86.2 days and 4,903 thousand yen in the CABG group. Cardiac event-free survival rate was significantly worse in the PTCA group. In the subgroup of three vessel disease, PTCA yielded 1.34 dilated target vessels, whereas CABG 2.66 patent grafts, which was two times more than the former one. Total length of hospital stay and charge was 32.7 days and 2,612 thousand yen in the PTCA group, and 82.4 days and 5,225 thousand yen in the CABG group.(ABSTRACT TRUNCATED AT 250 WORDS)