Technique of Duplex Scanning for Selection of Optimal Peripheral Anastomosis Site for Distal Bypass.

INTRODUCTION: Selection of the optimal anastomosis site is essential for obtaining good results from distal bypass. Herein, a unique, precise technique that uses pre-operative duplex scanning for selecting this site is presented. TECHNICAL SUMMARY: Before distal bypass surgery, duplex scanning is performed to assess patency and flow. Use of the venous preset mode and controlling the slant function allows visualisation of colour Doppler flow inside the arteries, thus enabling selection of the best segment for anastomosis. CONCLUSION: Use of duplex scanning in the appropriate mode consistently enables selection of the best anastomosis site for distal bypass, even when there is heavy calcification.

Impact of reduced endogenous anti-coagulation protein activity on vascular events of peripheral arterial disease.

AIM: Aim of the study is to elucidate the prevalence and the prognosis of patients with peripheral arterial disease (PAD) who have reduced endogenous anti-coagulation protein activity. METHODS: Ninety six patients with PAD were studied, including 45 patients with intermittent claudication and 51 with critical limb ischemia. Among them 65 patients underwent peripheral artery bypass grafting. Venous blood samples were obtained and plasma activity level of Protein C (PC), Protein S (PS), Plasminogen (PLG), Antithrombin (AT) were measured. Based on the patients' clinical database the prevalence and clinical relevance was studied. RESULTS: In our PAD patients PC activity is reduced in 18.8%, PS activity is reduced in 16.7%, PLG activity was reduced in 15.6% and AT activity was reduced in 24.0%. The incidence of AT activity deficiency was significantly higher in patients with critical limb ischemia than patients with claudication (P<0.01). After revascularization, arterial event free rate of patients with PC or PS activity deficiency and those with PLG deficiency were significantly lower than those without during the mean follow-up period of 26+/-31 months. The incidence of thromboembolic episodes and leg amputation rate were significantly worse in patients with PC deficiency. CONCLUSIONS: PAD patients with reduced endogenous anti-coagulation proteins show worse prognosis than those without. Surgeons must be aware of it to improve the outcome of arterial revascularization.

Preliminary study of autologous blood predonation in pediatric open-heart surgery impact of advance infusion of recombinant human erythropoietin.

We applied an autologous blood predonation protocol using recombinant human erythropoietin in pediatric open-heart surgery. The study included 69 children weighing 8 kg or more. Twice before operation, 8 ml/kg of blood was taken. At each donation, 100 (group 1; n = 20), 200 (group 2; n = 11), or 300 (group 3; n = 13) units/kg of erythropoietin was given subcutaneously. In group 4 (n = 25), 300 units/kg of erythropoietin was given 1 week prior to the first donation, followed by 300 units/kg given at each donation. No harmful events occurred during the donation period. During the donation period, the patients' hematocrit decreased but the hematocrit 1 day after the operation remained at 32.1 +/- 0.6% and was 33.3 +/- 0.6% 2 weeks later. The decrease in hematocrit was minimal in group 4 (39.0 +/- 0.6% before donation to 37.5 +/- 0.5% before operation) compared with that of the other three groups. Among those who completed the protocol, 58 patients (93.5%) were discharged without homologous blood transfusion. We consider our protocol of autologous blood predonation using erythropoietin to be safe and effective for avoiding homologous blood transfusion in pediatric patients. The early infusion of erythropoietin prior to the first donation minimizes the decrease in hematocrit level before operation.

Plasma hepatocyte growth factor levels after open heart surgery for congenital heart disease.

BACKGROUND: Hepatocyte growth factor (HGF) is a polypeptide which acts protectively against endothelial cell dysfunction. A high plasma level of HGF is shown when the endothelium is injured. We measured plasma HGF levels during and after open heart operations for congenital heart disease, to elucidate its involvement with endothelial cell injury. EXPERIMENTAL DESIGN: prospective study. SETTING: perioperative setting. PATIENTS: 18 children electively operated upon for congenital heart disease using CPB. RESULTS: Plasma HGF levels (ng/ml) before cardiopulmonary bypass (CPB) were 0.36+/-0.07 in 10 children (S-group) who were older and with simpler diseases, and 0.48+/-0.12 in 8 children (C-group) who were younger and with relatively complex diseases. HGF levels significantly increased after CPB, and gradually decreased thereafter. Plasma HGF levels 3 and 6 hours after CPB were significantly greater in the C-group than in the S-group (1.13+/-0.12 vs 1.68+/-0.1 6 3 hours after, and 1.09+/-0.19 vs 2.35+/-0,43 6 hours after; p<0.05 for both). There were significant positive correlations between HGF levels 6 hours after CPB and the duration of the CPB, the aortic crossclamping time, and plasma thrombomodulin levels just after CPB in all patients (p<0.05 for all). CONCLUSIONS: This data suggests that increased HGF levels are associated with endothelial cell injury induced by CPB, and that the increases are much greater in younger patients with complex anomalies.

Right atrial rupture in blunt chest trauma.

The mortality rate from cardiac rupture by blunt chest injury is high. Here, we report a case of 27-year-old male who suffered a right atrial rupture by blunt chest injury and was successfully treated. The hemodynamics were stabilized by pericardiocentesis with a 5F Pigtail catheter for cardiac tamponade and rapid fluid transfusion. Then the right atrial rupture was repaired without a cardiopulmonary bypass. The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day.

Local anesthetic inhibition of voltage-activated potassium currents in rat dorsal root ganglion neurons.

BACKGROUND: Local anesthetic actions on the K+ channels of dorsal root ganglion (DRG) and dorsal horn neurons may modulate sensory blockade during neuraxial anesthesia. In dorsal horn neurons, local anesthetics are known to inhibit transient but not sustained K+ currents. The authors characterized the effects of local anesthetics on K+ currents of isolated DRG neurons. METHODS: The effects of lidocaine, bupivacaine, and tetracaine on K+ currents in isolated rat DRG neurons were measured with use of a whole cell patch clamp method. The currents measured were fast-inactivating transient current (I(Af)), slow-inactivating transient current (I(As)), and noninactivating sustained current (I(Kn)). RESULTS: One group of cells (type 1) expressed I(Af) and I(Kn). The other group (type 2) expressed I(As) and I(Kn). The diameter of type 2 cells was smaller than that of type 1 cells. Lidocaine and bupivacaine inhibited all three K+ currents. Tetracaine inhibited I(As) and I(Kn) but not I(Af) For bupivacaine, the concentration for half-maximal inhibition (IC50) of I(Kn) in type 2 cells was lower than that for I(Kn) in type 1 cells (57 vs. 121 microM). Similar results were obtained for tetracaine (0.6 vs. 1.9 mM) and for lidocaine (2.2 vs. 5.1 mM). CONCLUSIONS: Local anesthetics inhibited both transient and sustained K+ currents in DRG neurons. Because K+ current inhibition is known to potentiate local anesthetic-induced impulse inhibition, the lower IC50 for I(Kn) of small type 2 cells may reflect preferential inhibition of impulses in nociceptive neurons. The overall modulatory actions of local anesthetics probably are determined by their differential effects on presynaptic (DRG) and postsynaptic (dorsal horn neurons) K+ currents.

Nitric oxide synthase expression in lungs of pulmonary hypertensive patients with heart disease.

Since little is known about the contribution of endothelial nitric oxide synthase (e-NOS) to the mechanism of pulmonary vasospasm and the development of pulmonary vascular occlusive disease, we elucidate how e-NOS is expressed in lung biopsy specimens obtained from operative patients with pulmonary hypertension. Lung biopsy specimens were obtained from 17 patients who underwent open-heart operations for various heart diseases. A piece of normal lung specimen was also obtained from the resected lungs of three lung cancer patients as a control. e-NOS expression was visualized with a monoclonal antibody against e-NOS, and the level of expression was partially quantified. Significantly high levels of e-NOS expression were seen in adult patients, whose preoperative mean pulmonary arterial pressures were greater than 20 mm Hg. In contrast, e-NOS expression in pediatric patients with the same levels of mean pulmonary arterial pressure was the same as that in the controls and in low pulmonary arterial pressure. There was a statistically significant positive correlation between the level of e-NOS expression and Heath--Edwards grading. These data suggest that the e-NOS expression in lung tissue is induced when pulmonary vascular obstructive diseases progress.

Midterm results after ventricular septation for double-inlet left ventricle in early infancy.

We performed ventricular septation for a 40-day-old boy with double-inlet left ventricle and discordant ventriculoarterial connection but without pulmonary stenosis. Postoperative cardiac function is satisfactory, with no evidence of pulmonary hypertension or subaortic stenosis. Nine years after the operation, the patient has an active life, is free from symptoms, and requires no medication. He may be the first patient to survive ventricular septation for double-inlet left ventricle in early infancy.

Autologous blood donation with recombinant human erythropoietin for abdominal aortic aneurysm surgery.

We evaluated the efficacy of autologous blood donation using recombinant human erythropoietin for elective abdominal aortic aneurysm (AAA) surgery regarding postoperative recovery. Twenty-five AAA patients who completed surgery without receiving a homologous blood transfusion were divided into two groups, consisting of a control group (n = 12) who did not bank any autologous blood, and a donation group (n = 13) who did bank more than 800 ml of autologous blood with the use of erythropoietin. The hematocrit (Ht) level of the control group decreased from 41.1% +/- 1.2% before the operation to 36.2% +/- 0.9% just afterwards (P > 0.01). In the donation group, however, the Ht did not change significantly during either the donation period or the perioperative period. The postoperative period before oral food intake and natural defecation were both significantly shorter in the donation group than in the control group. The first day of mobilization was also earlier in the donation group. In conclusion, autologous blood donation using erythropoietin for AAA surgery is therefore considered to promote the early recovery of patients.

Ductal aneurysm of adult patients.

A ductal aneurysm is very rarely diagnosed in adults. We experienced 2 cases of adult ductal aneurysm. Both cases developed hoarseness and computed tomographic scanning demonstrated a typical 'triple star sign' at the aortopulmonary window level. They underwent surgical repair with successful results. During the same period, we experienced 38 operations for true thoracic aneurysm. The ductus origin was found in 5.2% of these patients. The ductal aneurysm may no longer be considered a 'rare' vascular disease with more careful diagnostic procedure.

[A case report of successful mitral valve replacement for congenital mitral stenosis associated with coarctation of the aorta and ventricular septal defect].

A 5-month-old infant with coarctation of the aorta, ventricular septal defect and mitral stenosis known as "Shone's anomaly" is presented. He underwent the repair of coarctation of the aorta by means of the extended aortic arch anastomosis and banding of the pulmonary trunk at 1 month of age and the patch closure of ventricular septal defect and debanding of the pulmonary trunk at 3 months of age in our institution. About 2 months after second surgery, he had been admitted to our institution due to developing tachypnea and he needed the support of mechanical ventilation. The chest X-ray showed pulmonary congestion and the echocardiography revealed only one papillary muscle of mitral valve and pressure gradient about 30 mmHg through mitral valve. Mitral stenosis due to parachute mitral valve was suspected and he was subjected to an emergent surgery. Initially we performed mitral valve repair for parachute mitral valve but echocardiography during the surgery revealed moderate grade of mitral regurgitation and a hemodynamics was not satisfactory. Eventually mitral valve replacement was successfully done with Carbo-Medics mechanical valve (19 mm in diameter) in the position of left atrial wall because his mitral annulus was so small as 10 mm in diameter. The postoperative course was uneventful and the patient has been doing well.

Interaction of bupivacaine and tetracaine with the sarcoplasmic reticulum Ca2+ release channel of skeletal and cardiac muscles.

BACKGROUND: Although various local anesthetics can cause histologic damage to skeletal muscle when injected intramuscularly, bupivacaine appears to have an exceptionally high rate of myotoxicity. Research has suggested that an effect of bupivacaine on sarcoplasmic reticulum Ca2+ release is involved in its myotoxicity, but direct evidence is lacking. Furthermore, it is not known whether the toxicity depends on the unique chemical characteristics of bupivacaine and whether the toxicity is found only in skeletal muscle. METHODS: The authors studied the effects of bupivacaine and the similarly lipid-soluble local anesthetic, tetracaine, on the Ca2+ release channel-ryanodine receptor of sarcoplasmic reticulum in swine skeletal and cardiac muscle. [3H]Ryanodine binding was used to measure the activity of the Ca2+ release channel-ryanodine receptors in microsomes of both muscles. RESULTS: Bupivacaine enhanced (by two times at 5 mM) and inhibited (66% inhibition at 10 mM) [3H]ryanodine binding to skeletal muscle microsomes. In contrast, only inhibitory effects were observed with cardiac microsomes (about 3 mM for half-maximal inhibition). Tetracaine, which inhibits [3H]ryanodine binding to skeletal muscle microsomes, also inhibited [3H]ryanodine binding to cardiac muscle microsomes (half-maximal inhibition at 99 microM). CONCLUSIONS: Bupivacaine's ability to enhance Ca2+ release channel-ryanodine receptor activity of skeletal muscle sarcoplasmic reticulum most likely contributes to the myotoxicity of this local anesthetic. Thus, the pronounced myotoxicity of bupivacaine may be the result of this specific effect on Ca2+ release channel-ryanodine receptor superimposed on a nonspecific action on lipid bilayers to increase the Ca2+ permeability of sarcoplasmic reticulum membranes, an effect shared by all local anesthetics. The specific action of tetracaine to inhibit Ca2+ release channel-ryanodine receptor activity may in part counterbalance the nonspecific action, resulting in moderate myotoxicity.

Tetralogy of Fallot with levoatrial cardinal vein.

A levoatrial cardinal vein is a rare congenital anomaly of the systemic veins. It is frequently associated with left-side obstructive anomalies. We report a case of tetralogy of Fallot with a levoatrial cardinal vein. The innominate vein was absent and two left upper pulmonary veins connected to this vein. There were no left-side obstructive anomalies.

Plasma adrenomedullin level after cardiopulmonary bypass.

Adrenomedullin is an intrinsic vasodilator which is metabolized mainly in the pulmonary circulation. We measured plasma levels of adrenomedullin in children with congenital cyanotic heart disease (CY group, n = 6), children with high pulmonary blood flow due to congenital heart disease (PH group, n = 8), and in adults with mitral valve disease (MV group, n = 7) before and 3 h after cardiopulmonary bypass (CPB). Before CPB, the adrenomedullin level was the highest in the MV group, possibly due to chronic heart failure. Three hours after CPB, the plasma adrenomedullin level (pg/ml) increased to 1712.7 +/- 498.4 in the CY group, 167.6 +/- 26.4 in the PH group, and 1404.3 +/- 313.7 in the MV group, the level in the PH group being significantly lower than the rest. In the PH group, there was statistically significant negative correlation between the mean pulmonary arterial pressure at the preoperative catheter study, and the adrenomedullin level 3 h after CPB. These results illustrate that the adrenomedullin level increased after CPB, but that the increase was less marked in the PH group, implying that where the pulmonary vasculature was damaged most, this results in increased vasoconstriction.

Successful operative treatment for acute triple-barreled aortic dissection in a patient with Marfan's syndrome: report of a case.

Triple-barreled aortic dissection is a rare form of aortic dissection associated with high mortality. We report herein the case of a 41-year-old woman with Marfan's syndrome who developed acute triple-barreled aortic dissection from a Stanford type B dissecting aneurysm. Successful graft replacement of the proximal third of the descending thoracic aorta was subsequently performed. To the best of our knowledge, this is the first case of successful operative treatment for an acute triple-barreled aortic dissection ever to be reported.