[Bronchial schwannoma diagnosis by surgical treatment; report of a case].

18-year-old male was referred to our hospital due to persistent cough. The patient was admitted for the investigation of the abnormal shadow on a chest X-ray and chest computed tomography (CT). Chest CT showed a 2.5 cm nodular shadow in the right lower lobe. Bronchofiberscopy revealed the polypoid lesion at the right lower lobe bronchus obstructing the entire lumen of B8-10. The tumor surface was smooth and rich in small vessels. Right lower lobectomy was peformed. The diagnosis of schwannoma was confirmd with the S-100 positive immunohistochemical stain. Bronchial schwannoma is relatively rare disease; less than 90 cases have been reported with respect to schwannoma of case report in Japan.

Thoracoabdominal aortic aneurysms repair under abdominal cavity cooling with visceral shunting technique--a case report.

Mild hypothermia induced by abdominal cavity cooling together with a selective visceral shunting technique can be a useful adjunct for thoracoabdominal aortic aneurysm repair. The authors adopted this combined technique for repair of selected Crawford type III and type IV aneurysms to reduce visceral ischemic damage and minimize the incidence of postoperative complications.

Left ventriculoplasty for ischemic cardiomyopathy.

OBJECTIVE: In order to treat ischemic cardiomyopathy, which is defined as non-aneurysmal diffuse akinetic left ventricle with chronic heart failure following myocardial infarction, the mid-term effect of the endoventricular circular patch plasty (EVCPP) was studied. MATERIALS AND METHODS: EVCPP has been performed on 54 patients (46 men and eight women with a mean age of 61 years) during 4 years from March 1997 to December 2000. Thirty-two patients (59%) were NYHA class III and 22 patients (41%) were class IV. Nine patients (17%) had mild angina pectoris before the operation but others had no chest pain. Single, double, triple, and left main disease were noted in six, 13, 32, and three patients, respectively. Mean left ventricular ejection fraction was 23.3 +/- 6.3% (6--30%). Coronary artery bypass grafting was concomitantly undergone by 51 patients (94%) and mitral valve reconstruction was done on 19 patients (35%). RESULTS: Two patients (3.7%) needed an intra-aortic balloon pump to wean from cardiopulmonary bypass. Seven patients (12.9%) died in the hospital. Among them, two patients (4.4%) out of 45 patients who underwent elective operation died of stroke and heart failure. Five patients (55.5%) out of nine patients who required emergency operation died of heart failure and multiorgan failure. Late death occurred in six patients (11.1%) due to arrhythmia and heart failure in each of three patients. Out of 41 survivors, 38 patients returned to NYHA class I or II and three patients to class III. Out of 50 patients who underwent left ventricular study before and after operation, ejection fraction increased from 22.8 +/- 6.6 to 36.2 +/- 8.0% and mean left ventricular end-diastolic volume and left ventricular end-systolic volume indices reduced from 152.8 +/- 24.6 to 105.0 +/- 36.5 and from 113.6 +/- 45.7 to 66.4 +/- 28.4 ml/m(2), respectively. Mean pulmonary wedge pressure decreased from 19.1 +/- 8.8 to 14.9 +/- 6.8 mmHg. One-, 2-, and 3-year actuarial survival rates were 87.9, 82.7 and 77.2%, respectively. CONCLUSION: Left ventriculoplasty using EVCPP is effective to exclude the akinetic LV segment, and left ventricular function and clinical status improve in patients with ischemic cardiomyopathy.

A leukocyte depleting filter reduces endothelial cell dysfunction and improves transplanted canine heart function.

BACKGROUND: To date leukocytes have been known to play a major role in reperfusion injury and have directed attention to leukocyte-endothelium interaction. This study was designed to investigate how much graft viability and the coronary microcirculatory function could be preserved by leukocyte depletion (LD) in a model of orthotopic cardiac transplantation. METHODS: The heart in 10 beagle dogs was arrested by introducing a 4 degrees C St. Thomas' cardioplegic solution. They were harvested, immersed in the cold saline for 3 hours, and then orthotopically transplanted. Five recipients underwent LD (LD group) at reperfusion with the use of a Pall BC1B leukocyte depleting filter inserted into the cardiopulmonary bypass (CPB) circuit. The other 5 dogs without filtration served as a control group. RESULTS: Leukocytes were about 80% filtrated and neutrophils were also 85% filtrated during the first 30 minutes of reperfusion in the LD group. A high level of adenosine triphosphate was maintained after transplantation in the LD group. The polymorphonuclear elastase level was significantly lower in the LD group. The cardiac function assessed by the slopes of the end-systolic pressure volume relation after transplantation was significantly higher in the LD group than in the control group (p < 0.05). The coronary vascular resistance responses to acetylcholine and nitroglycerin after transplantation were preserved significantly better in the LD group than in the control group (p < 0.05). CONCLUSIONS: These results suggest that a leukocyte depleting filter placed in the CPB circuit would prevent leukocyte-mediated endothelial cell injury, improve microcirculation of the myocardium, and lead to excellent graft function.

Left ventricle restoration in patients with non-ischemic dilated cardiomyopathy: risk factors and predictors of outcome and change of mid-term ventricular function.

OBJECTIVE: The partial left ventriculectomy (PLV) for end-stage dilated cardiomyopathy (DCM) which worked in some patients has been reported, although the hospital mortality is high. To reduce hospital mortality, we selected operative procedures of left ventricular (LV) restoration to improve the operative results. We analyzed the risk factors and predictors of outcome, and the mid-term changes of the LV function were determined. PATIENTS AND METHODS: Between December 1996 and September 2000, 74 patients with non-ischemic DCM received LV restoration. The age ranged from 14 to 76 years (mean, 49.0+/-14.0 years), and there were 63 men and 11 women. The etiology of the DCM was idiopathic DCM in 49 patients, and dilated hypertrophic cardiomyopathy in seven patients and others in 18. The preoperative New York Heart Association (NYHA) functional class was 29 in class III and 45 in class IV, in which 32 patients depended on inotropic support. PLV or septal anterior ventricular exclusion (SAVE) was selected depending on the akinetic lesion of the LV based on the intraoperative echo-test. Fifty-six patients received elective operations, and emergency operations were performed in 18 patients. The risk factors and predictors of outcome were analyzed in 74 patients, and in 35 patients who survived more than 1 year after receiving LV restoration, the mid-term cardiac function was examined by cardiac echogram and catheterization. RESULTS: PLV was performed in 62 patients and SAVE in 12 patients. Concomitant mitral surgery was performed in 66 patients (89%) and tricuspid annuloplasty in 42 patients (57%). There were 15 hospital deaths and 13 patients died after discharge from the hospital (cardiac deaths in nine and non-cardiac deaths in four). In the 46 late survivors, the NYHA class was I or II in 42 patients and III in four patients. Selection of the procedure of LV restoration (P<0.01), elective operation (P<0.05), and the preoperative volume of LV (endodiastolic volume index of <180 ml/m(2); P<0.05) were risk factors and predictors influencing hospital and late death. After the operation, the LV function improved significantly and the improvement was maintained at the mid-term period; the LV ejection fraction was 31.8+/-7.9% (P<0.01) at 1 year from 23.0+/-7.3% preoperatively, left ventricular diastolic diameter was 62.8+/-10.9 (P<0.01) from 81.7+/-8.2 mm and the LV endosystolic volume index was 88.5+/-45.8 (P<0.05) from 162.6+/-41.6 ml/m(2). CONCLUSIONS: The operative results improved with the selection of the procedures, with elective operation, and mitral plasty for less cardiac dilatation. The mid-term results of clinical status and LV function showed the effectiveness of the operation.

[Experience of four cases of postoperative pulmonary embolism requiring surgical treatment].

Four patients underwent a pulmonary embolectomy using cardiopulmonary bypass for acute pulmonary embolism which had occurred after various operations. In two cases, dehydration due to either diabetes insipidus or ileus had existed. In two cases, pulmonary embolism suddenly occurred in our hospital. In the remainder, the disease occurred in the previous hospitals and its diagnosis was established on the 6th and 7th postoperative days, respectively. In massive pulmonary embolism, echocardiography and/or enhanced chest CT are useful for prompt and noninvasive diagnosis. Thrombolytic therapy was performed in only one case before surgical embolectomy, which was not effective. Three patients were discharged without any postoperative complications, but one requiring preoperative external cardiac massage died of multiple organ failure 9 days after operation. Acute pulmonary embolism is one of the fatal postoperative complications. Recognition of this entity, and prompt diagnosis and treatment are essential for managing the fatal disease. Even in the early postoperative period, embolectomy using cardiopulmonary bypass is a safe and effective treatment.

[Left ventriculoplasty for non-ischemic cardiomyopathy with severe heart failure in 70 patients].

OBJECTIVES: Treatment of cardiac failure due to non-ischemic cardiomyopathy by left ventriculoplasty using partial left ventriculectomy (Batista operation) or septal anterior ventricular exclusion was evaluated. METHODS: Left ventriculoplasty was performed in 70 patients (59 men and 11 women with a mean age of 51 years) from December 1996 to June 2000. Preoperative New York Heart Association (NYHA) functional class was IV in 43 patients including 29 receiving inotropic support, and class III in 27 patients. Nineteen patients required emergency surgery because of on-going shock and 51 patients were operated electively. Combined cardiac procedures were mitral valve reconstruction in 62 patients (45 replacements, 17 repairs), tricuspid annuloplasty in 37, and aortic valve replacement in 4. The initial 24 patients underwent typical Batista operation regardless of myocardial viability. The other 46 patients underwent selective ventriculoplasty to excise or exclude the weakest part according to the findings of the intraoperative echo-guided volume reduction test. RESULTS: The intraaortic balloon pump was used in 12 patients and the left ventricular assist device in 2 patients. Three (5.9%) of the 51 patients who underwent elective operation and 12 (63.2%) of the 19 patients with emergency operation died in the hospital, giving an overall hospital mortality of 21.4% (15/70). Hospital mortality was reduced from 33.3% (8/24) in the initial 24 patients to 15.2% (7/46) in the recent 46 patients with the volume reduction test. Mean ejection fraction increased from 22.2 +/- 6.7% to 29.6 +/- 6.0%. Diastolic dimension decreased from 81.1 +/- 9.5 to 69.8 +/- 19.2 mm. End-diastolic and systolic volume indices decreased from 199.0 +/- 47.9 to 124.1 +/- 34.9 ml/m2 and from 154.0 +/- 41.2 to 89.3 +/- 31.7 ml/m2, respectively, at one postoperative month in the 55 hospital survivors. The mean pulmonary capillary wedge pressure decreased from 25.6 +/- 7.8 to 13.6 +/- 4.5 mmHg. Serum brain natriuretic peptide decreased from 999 +/- 647 preoperatively to 547 +/- 362 pg/ml one month after the operation. Thirteen patients (18.6%) died in the late period mainly due to heart failure. Among the 42 survivors, 37 patients returned to NYHA functional class I-II, and cardiac events were rare after one postoperative year. Actuarial survivals at 3 years in elective and emergency operations were 71.9% and 33.3%, respectively. CONCLUSIONS: Left ventriculoplasty is acceptably safe for elective operation and clinical improvement can be obtained by proper surgical procedures and careful postoperative medical treatment.

Thoracic and thoracoabdominal aneurysm repair under deep hypothermia using subclavian arterial perfusion.

BACKGROUND: Hypothermic circulatory arrest is a valuable adjunct for thoracic and thoracoabdominal aortic aneurysm repair. Retrograde aortic perfusion through the femoral artery, however, carries a risk of cerebral embolism or malperfusion. To avoid these complications we adopted antegrade aortic perfusion through a prosthetic graft attached to the left subclavian artery through a left thoracotomy. METHODS: Ten patients had repair of descending thoracic and thoracoabdominal aortic aneurysm under deep hypothermia with antegrade aortic perfusion through the left subclavian artery. Hypothermic circulatory arrest was used because proximal aortic control was hazardous due to rupture or intraluminal disease, or for spinal cord protection. RESULTS: There was no brain injury and one hospital death. The cause of death was massive bleeding from the gastrointestinal tract not related to deep hypothermia or the perfusion method. All 9 survivors were alive and well after a mean follow-up period of 9 months. CONCLUSIONS: Using the left subclavian artery as a site of aortic perfusion can avoid retrograde aortic perfusion, hence reducing the potential for brain injury due to embolic stroke or malperfusion through a dissected thoracoabdominal aorta.

The influence of human T lymphotropic virus type I infection on the outcome of cardiovascular surgery.

OBJECTIVE: Human T lymphotropic virus type I infects CD4(+) T cells and affects cell-mediated immunity. Cardiopulmonary bypass transiently alters lymphocyte subsets, resulting in a reduction in CD4(+) T cells and an increase in CD8(+) T cells. We proposed that cardiovascular operations and human T lymphotropic virus type I infection may act synergistically, resulting in serious damage to cell-mediated immunity. METHODS: A total of 517 consecutive patients who were preoperatively screened for anti-human T lymphotropic virus type I antibody and underwent cardiovascular operations with cardiopulmonary bypass were enrolled in this study. Of the 517 patients, 82 (16%) had positive test results for anti-human T lymphotropic virus type I antibody. The surgical outcome of patients with positive and negative results for anti-human T lymphotropic virus type I antibody was analyzed retrospectively. RESULTS: There was no difference between the 2 groups with respect to early mortality. Distribution of survival curve was also not significantly different (P =.5; mean follow-up duration, 2.4 +/- 1.8 years [range, 0-9.4 years] and 3.2 +/- 2.8 years [range, 0-9.8 years]) in the groups with positive and negative antibody results, respectively). In particular, long-term follow-up did not reveal adult T-cell leukemia or human T lymphotropic virus type I-associated myelopathy, and occurrence of neoplasm did not differ between groups. Early infectious complication was, however, significantly higher in the group with positive antibody results than in the group with negative results (P =.02). Logistic regression analysis revealed human T lymphotropic virus type I infection as a significant risk for this complication (P =.04; odds ratio, 2.5; 95% confidence interval, 1. 0-5.8). CONCLUSION: A combination of human T lymphotropic virus type I infection and cardiovascular operation is believed to increase the potential risk of infectious complications shortly after the operation. However, this synergistic effect seems to be transient and has little influence on long-term prognosis.

Preoperative autologous donation of blood for a simple cardiac anomaly: analysis of children weighing under twenty kilograms.

OBJECTIVE: Preoperative autologous donation of blood has been expanded to cardiac operations in children. However, because of problems such as lack of cooperation and hemodilution during cardiopulmonary bypass, its efficacy in small children is unclear. This study clarifies the clinical significance of preoperative autologous donation of blood in small children. METHODS: Thirty-seven patients weighing under 20 kg (age range, 3-9 years; weight range, 13-20 kg) underwent preoperative autologous donation and cardiac operations to treat a simple anomaly. Twenty-five age- and weight-matched patients who were not cooperative or refused preoperative autologous donation served as control subjects. Autologous blood was collected by the simple or leapfrog method and stored as blood components. Each collecting volume was 5 to 10 mL/kg. RESULTS: The donation was performed 6+/-2 times during 50+/-16 days, and the whole storage volume was 48+/-17 mL/kg. There was no serious complication. The minimum hematocrit level negatively correlated with the priming volume of cardiopulmonary bypass (preoperative donation patients: P<.01, r(2) = 0.4; control subjects: P =.5, r (2) = 0.03). Blood loss did not significantly differ between preoperative donation patients and control subjects, and the transfused blood volumes were 43+/-13 mL/kg and 29+/-22 mL/kg, respectively. All of the autologous blood products but fresh frozen plasma were reinfused. Use of homologous blood was significantly less in preoperative donation patients than in control subjects (0% vs 80%, P <.01). In preoperative donation patients postoperative recovery in hemoglobin level was significantly better, which is concurrent with a higher reticulocyte level. CONCLUSION: Preoperative autologous donation can be performed safely with clinical efficacy, even in children under 20 kg. This can be improved further through coupling with another procedure.

[Combined valve and coronary artery bypass surgery].

Between January 1997 and November 1999, 31 patients underwent combined valve and coronary artery bypass grafting (CABG) surgery in our institute. There was no hospital death and clinical symptom improved in all patients after surgery. Mean follow-up was 16.3 months. The actuarial survival rate was 96.8% at 1 year. There were 4 late deaths (CHF in 3, arrhythmia in 1). Tepid blood cardioplegia was effective for those operations. Operation of CABG combined with valve surgery or LV surgery could be safely performed. We therefore considered that complete correction of the lesion with not only CABG but also combined valve surgery or LV surgery was the procedures of choice in patients with complicated lesions.

Beneficial effect of additional cardioplegia flush during hypothermic static cardiac preservation.

BACKGROUND: The effects of various preservative solutions and methods have been studied to prolong the safety period of cardiac preservation. In this study, we used cardioplegic solution (CS) during cardiac preservation and investigated how flush CS yields good preservation of isolated hearts compared with only cold immersion. METHODS: Male Wistar rat hearts were arrested with 4 degrees C St. Thomas crystalloid CS. All hearts were immersed for 6 hr in a 4 degrees C Euro-Collins solution. Hearts were classified into seven groups by period and number of infusions of CS (20 ml/kg) during simple immersion of hearts. Infusion of CS during preservation was not used for group I. Infusion was performed at two hours after starting immersion for group II, at 3 hr for group III, at 4 hr for group IV, at 5 hr for group V, every hour for group VI, and every 2 hr for group VII. After preservation, the hearts were reperfused with blood using a support rat. Myocardial adenosine triphosphate was measured immediately after immersion of hearts. Biochemical examination of coronary effluents was performed at 15 min after reperfusion, and cardiac function was evaluated at 40 min after reperfusion. Myocardial specimens were subsequently taken for measurement of water content. RESULTS: Percentage recovery of left ventricular developed pressure and dp/dt in groups III, VI, and VII were higher than those in group I at each balloon volume, and left ventricular end-diastolic pressure in these groups was also significantly lower than that in group I. Levels of creatine kinase-MB and lactate in groups VI and VII after reperfusion were significantly lower than those in group I. Myocardial adenosine triphosphate was significantly better preserved in groups III, IV, VI, and VII than in group I. However, no significant difference in cardiac function or myocardial adenosine triphosphate was found among groups III, IV, VI, and VII. CONCLUSIONS: The use of CS during cardiac preservation is effective in preserving cardiac function and myocardial enzymes, and infusion may be sufficient if performed once-only at 3 or 4 hr from starting immersion in 6 hr storage of isolated rat hearts.

Distal arch aneurysm repair using stent-grafting and ascending aorto-left axillary bypass.

BACKGROUND: Transcatheter application of a stent-graft to the angulated aortic segments with critical side branches poses some problems. We report our technique of distal arch aneurysm repairs using stent-grafts inserted through the aortic arch and ascending aortoaxillary bypass. PATIENTS AND RESULTS: Three patients underwent successful distal arch aneurysm repair using a homemade semiflexible stent-graft placed under hypothermic circulatory arrest. The left subclavian artery was reconstructed by an extraanatomic bypass grafting between the ascending aorta and left axillary artery. Postoperative imaging demonstrated reduction of aneurysm size and no endoleaks from an intercostal artery. CONCLUSIONS: Our technique seems to be useful for repair of distal arch aneurysms and is a less invasive procedure.

Effectiveness of preoperatively obtained autologous platelet concentrates in open heart surgery.

BACKGROUND: Autologous blood components have been widely introduced in open heart surgery. However, the effectiveness of autologous platelet products remains controversial. METHODS: Autologous platelet concentrates (PC) were collected from patients (n = 35) scheduled for primary valvular heart surgery 1 to 3 days before the operation and were transfused immediately after cardiopulmonary bypass. Blood loss and platelet-related factors were compared with the control patients who had no PC (n=35). RESULTS: There were no serious complications in harvesting, preservation, and transfusion of autologous PC. The maximal platelet aggregation response significantly improved after its transfusion and tended to be higher with autologous PC stored 1 day than with ones stored 2-3 days. Activation of coagulation and fibrinolytic factors did not significantly differ between the groups. Postoperative blood loss was significantly less in autologous PC group, and seemed to have a negative correlation with platelet aggregation response. CONCLUSIONS: Autologous PC can be safely prepared and are clinically effective in reduction of postoperative blood loss in open heart surgery.

Application of a manifold system for temporary reperfusion during proximal anastomoses in conventional coronary bypass surgery.

We report the application of a manifold system which is attached to saphenous vein grafts after the completion of distal coronary anastomosis. This technique permits not only the direct delivery of cardioplegic solution into the distal coronary artery, but also the reperfusion of revascularized coronary arteries via saphenous vein grafts by changing the connection to the arterial circuit during proximal anastomosis under a partial occlusion of the aorta in conventional coronary artery bypass surgery.

Coronary artery aneurysm after stent implantation.

A coronary artery aneurysm that developed 6 months after coronary stent implantation in the left anterior descending artery, was treated by double coronary artery bypass grafting due to restenosis of the affected vessel and progression of right coronary artery stenosis. Although the poststenting aneurysm initially remained postoperative angiography showed that it had disappeared. In addition to thrombotic occlusion, another mechanism behind its disappearance may be that geometric changes of the implanted stent caused by heart retraction during surgery closed the entrance to the aneurysm.

Repair of an acute type A dissection: fate of the remnant false lumen and preserved aortic valve.

From January 1992 through March 1997, 75 patients (DeBakey type I/II = 56/19) underwent a surgical repair of a type A acute dissection. The patients included 37 men and 38 women ranging in age from 23 to 83 years with a mean of 65 years. All patients were admitted to our hospital with a mean interval of 2.2 days from the episode of onset. The overall hospital mortality rate was 25% (19/75). There were three late deaths among the 56 patients discharged from the hospital. The actuarial survival rate for the patients surviving the operation was 87% at 5 years after repair. A subsequent aortic operation was necessary in 6 patients, while 3 other patients who had late aortic complications were put on medical therapy alone. As a result, the aortic event-free survival rate was 54% at 5 years. For a type I dissection the false lumen was completely thrombosed after repair in 34%. The descending thoracic aorta with a patent false lumen was markedly enlarged in proportion to the follow-up time. After a conservative approach to the aortic valve, all but one patient demonstrated an adequate valve function throughout this study period. This experience with a midterm follow-up showed an acceptable durability of the preserved aortic valve and a progressive enlargement of the persistent false lumen with a high rate of aortic complications. Hence, all patients with a type A dissection need a close follow-up to assess the aorta for complications of either recurrent or residual aneurysms and dissections.

Is direct closure dangerous for treatment of doubly committed subarterial ventricular septal defect?

BACKGROUND: We performed direct closure of doubly committed subarterial ventricular septal defects with aortic cusp prolapse. Postoperative echocardiographic studies showed that this method improved coaptation of the prolapsing aortic cusp, especially in patients with mild aortic regurgitation (AR). METHODS: Twenty-one patients (mean age, 7.8+/-4.3 years; range, 2 to 18 years) with doubly committed subarterial ventricular septal defect underwent direct closure alone. Aortic valve prolapse was observed in all 21 patients, with mild AR found in 13 patients but not in the remaining 8. The site of the prolapsed aortic valve was in the right coronary cusp in all patients. We inserted an interrupted 4-0 or 5-0 polypropylene suture with a pledget from the lower margin of the ventricular septal defect to the pulmonary ring to increase protrusion of the prolapsed cusp by pushing it back and to improve coaptation of the aortic cusp. RESULTS: The interval between surgical treatment and the last postoperative evaluation ranged from 3 to 24 months (median, 11 months). No residual ventricular septal defect was detected in any patient. In the 8 patients who had aortic valve prolapse without AR preoperatively, no AR was found at follow-up. Of the 13 patients who had mild AR associated with aortic valve prolapse preoperatively, AR diminished in 7 and did not progress in the remaining 6. Furthermore, no anatomic changes in either the aortic or pulmonary annulus were found on follow-up echocardiography. In the group of 13 patients with mild preoperative AR, AR significantly persisted in patients who were more than 10 years old at operation (p<0.05). CONCLUSIONS: Our findings suggest that direct closure for this type of ventricular septal defect is safe and reliable in improving mild AR and that direct closure is more effective for younger patients in whom the prolapsing aortic cusp is mobile enough to be protruded. However, further long-term follow-up studies will be needed to ascertain the adequacy and usefulness of the method.