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9.
Kyobu Geka ; 65(8): 640-3, 2012 Jul.
Article in Japanese | MEDLINE | ID: mdl-22868420

ABSTRACT

Liver cirrhosis has been shown a major preoperative risk factor in patients undergoing cardiac surgery. Although recent evidence comes from limited studies with relatively small number of patients, morbidity and mortality progressively increase with the severity of liver dysfunction. Patients with Child-Pugh classification B or C have significantly higher risks after open heart surgery using cardiopulmonary bypass. Recently, model for end-stage liver disease (MELD) score more reliably identifies patients who are at higher risk of mortality after open heart surgery. Off pump operation seems beneficial to prevent postoperative mortality and morbidity in patients with moderate to severe liver dysfunction in anecdotally reported cases, but further studies are warranted to prove its effectiveness. Incidence of major morbidity including hemodynamic instability caused by hyperdynamic circulation, systemic fluid retention, infection, and bleeding is high. Preoperative optimization of medical condition by correcting coagulopathy, poor nutrition, fluid retention and renal function is important in patients with high predictive risks. Non-cardiovascular morbidities including malignancies or hepatic decompression are the major limiting factors for long term survival. Careful consideration of expected risks and benefits is required to determine the surgical indication in those patients.


Subject(s)
Cardiac Surgical Procedures/methods , Liver Cirrhosis/complications , Humans , Intraoperative Care , Postoperative Care
10.
Thorac Cardiovasc Surg ; 52(4): 200-5, 2004 Aug.
Article in English | MEDLINE | ID: mdl-15293156

ABSTRACT

BACKGROUND: The hemi-clamshell approach provides a wide anterior view of the mediastinum, apical dome, and cervicothoracic area. However, only a few reports have been made regarding this technique. METHODS: The hemi-clamshell approach was used in 24 patients, of whom 5 had a Pancoast tumor, 15 had mediastinal involvement, and 4 underwent mediastinal lymphadenopathy for left-sided lung cancer. Twenty-one of the patients received preoperative therapy. RESULTS: Twenty-one operations were complete resections. In addition, 12 patients received cardio-vascular reconstruction and 5 a first rib resection. Postoperative major morbidity was 21 % (6/24) and mortality was 4.2 % (1/24). Nine patients died of systemic tumor relapse and 14 patients were alive after a median follow-up of 24 months (range 3 - 68 months) following the initial therapy. The 5-year survival rate of patients with mediastinal involvement was 37 % and that of 13 patients with postoperative stage I or II was 35 %. CONCLUSIONS: The hemi-clamshell approach provides a wide exposure allowing a safe and complete removal of lung cancer that involves the mediastinum and apical thoracic dome, leading to a better long-term survival rate for patients with this disease.


Subject(s)
Adenocarcinoma/surgery , Carcinoma, Squamous Cell/surgery , Lung Neoplasms/surgery , Thoracic Surgical Procedures/methods , Adenocarcinoma/pathology , Adult , Aged , Carcinoma, Squamous Cell/pathology , Female , Humans , Lung Neoplasms/pathology , Male , Middle Aged , Neoplasm Staging , Pneumonectomy/methods , Retrospective Studies , Survival Analysis , Treatment Outcome
12.
J Heart Lung Transplant ; 20(11): 1181-7, 2001 Nov.
Article in English | MEDLINE | ID: mdl-11704478

ABSTRACT

BACKGROUND: The left ventricular assist system (LVAS) has been used increasingly for patients with end-stage heart failure who are awaiting transplantation. Sympathetic nerve activity is known to correlate with cardiac function in chronic heart failure patients, but little is known about sympathetic nerve activity during LVAS support. In this study, we examined the status of sympathetic nerve activity in relation to mechanical support. METHODS: In this study, we included 10 consecutive patients with end-stage cardiomyopathy who were on LVAS support for at least 2 months (duration, 222 +/- 59 days). None of these patients achieved enough functional recovery to be taken off LVAS. In these patients, we used iodine-125-metaiodobenzylguanidine (125I-MIBG) scintigraphy to examine the change of sympathetic nerve activity after LVAS implantation, and compared the results with the change of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels as well as with histologic optional findings. Samples for ANP and BNP measurement were obtained before and 30 days after LVAS implantation. Specimens for histologic analysis were obtained at the time of LVAS implantation and at the time of cardiac transplantation or autopsy. RESULTS: We observed marked decrease in serum levels of ANP and BNP 1 month after LVAS implantation. But myocardial sympathetic nerve function, which was evaluated with 125I-MIBG scintigraphy and expressed as the heart-to-mediastinum activity ratio, remained below normal even 2 months after the LVAS implantation (1.57 +/- 0.19; normal, 2.34 +/- 0.36). Serial histologic analysis in these 10 patients showed continuous increase in percentage of fibrosis and cell diameter despite ventricular unloading by the LVAS. CONCLUSIONS: Sympathetic nerve function, which was evaluated on 125I-MIBG scintigraphy, did not improve during left ventricular support. Because none of the patients included in our study showed improvement in cardiac function or histologic findings, the recovery of myocardial sympathetic nerve function may be an important factor in myocardial recovery for cardiomyopathy patients on LVAS support.


Subject(s)
Cardiomyopathies/physiopathology , Heart-Assist Devices , Sympathetic Nervous System/physiopathology , 3-Iodobenzylguanidine , Adult , Atrial Natriuretic Factor/blood , Cardiomyopathies/diagnostic imaging , Cardiomyopathies/pathology , Cardiomyopathies/therapy , Echocardiography , Female , Heart Failure/physiopathology , Humans , Male , Middle Aged , Myocardium/pathology , Natriuretic Peptide, Brain/blood , Radionuclide Imaging , Radiopharmaceuticals , Sympathetic Nervous System/diagnostic imaging
13.
Jpn J Thorac Cardiovasc Surg ; 49(9): 570-5, 2001 Sep.
Article in English | MEDLINE | ID: mdl-11577448

ABSTRACT

OBJECTIVES: Concordant cardiac xenografts are known for delayed vascular rejection. Therapy combining with FK506 and cobra venom factor prolongs graft survival. The proposed underlying mechanism holds that cytoprotective proteins such as Bcl-2 play a role here. We studied the effects of gene transfection of human-bcl-2 on graft survival and coronary artery lesions in concordant cardiac xenografts, and discuss the role of cytoprotective genes in vascular xenograft rejection. METHODS: Golden-Syrian-hamster hearts were heterotopically transplanted into Lewis rats given FK506 (1 mg/kg daily) and cobra venom factor (0.2 mg/kg; day 0 and 1) intramuscularly. They were divided into 2 groups--grafts transfected vector with the human-bcl-2 gene (Group-B(+)) and vector without the gene (Group-B(-)) using the HVJ liposome method; 4 or 5 grafts from each group were explanted 1, 2, 3, or 4 weeks and more than 1 month after transplantation and evaluated by H-E, Elastic-Van-Gieson and immunohistochemical staining of Bcl-2. Coronary arterial lesions were examined using a scoring method. RESULTS: Bcl-2 expression in endothelial cells in Group-B(+) was confirmed within 2 weeks after transplantation but not thereafter. The coronary score in Group-B(+) was significantly lower than that in Group-B(-) within 2 weeks after transplantation but not thereafter. CONCLUSIONS: In this hamster-to-rat cardiac xenograft model, the bcl-2 gene was successfully transfected to the coronary endothelium and lasted 2 weeks. During Bcl-2 expression, coronary vascular lesions were suppressed more than in the untransfected group.


Subject(s)
Genes, bcl-2/genetics , Heart Transplantation/immunology , Transfection , Animals , Coronary Vessels/pathology , Cricetinae , Graft Survival , Immunosuppression Therapy/methods , Male , Mesocricetus , Rats , Rats, Inbred Lew , Rats, Wistar , Transplantation, Heterologous
14.
Ann Thorac Cardiovasc Surg ; 7(3): 170-4, 2001 Jun.
Article in English | MEDLINE | ID: mdl-11481025

ABSTRACT

A 58-year-old woman with ischemic cardiomyopathy and aortic valve stenosis, underwent aortic valve replacement and simultaneous endoventricular circulatory patch plasty (Dor operation). She underwent coronary artery bypass grafting for severe triple vessel disease 10 years ago. Recently she started to show severe congestive heart failure. Aortic valve stenosis with pressure gradient of 85-mmHg was also found. Coronary bypasses were all patent, but the left ventricle (LV) was severely dilated (LVDd/Ds=71/61 mm) and the ischemic cardiomyopathy was considered as the cause. She successfully underwent aortic valve replacement and endoventricular circulatory patch plasty. The initial postoperative course was complicated with intractable ventricular arrhythmia, but subsequent course was smooth and the patient was discharged with improved symptoms (NYHA Class II). Postoperative catheterization showed decreased left ventricular volume and improved contractility. This case implies the role of LV remodeling procedure in the ischemic cardiomyopathy combined with aortic valve lesion


Subject(s)
Aortic Valve Stenosis/surgery , Ventricular Dysfunction, Left/surgery , Aortic Valve Stenosis/physiopathology , Cardiomyopathy, Dilated/complications , Female , Heart Valve Prosthesis , Heart Ventricles/surgery , Humans , Middle Aged , Myocardial Ischemia/complications , Suture Techniques , Ventricular Dysfunction, Left/etiology
15.
Kyobu Geka ; 54(4): 315-20, 2001 Apr.
Article in Japanese | MEDLINE | ID: mdl-11296423

ABSTRACT

The limitation and indication of off-pump coronary artery bypass grafting (OPCAB) remain controversial. Since May 1999, we have applied OPCAB for all isolated coronary bypass cases routinely. Intraoperative conversion to CCAB occurred in 8 patients (10.8%). The main reasons for conversion were intramyocardial coronary arteries and arythmia-induced hemodynamic instability in the acute phase of myocardial infarction. We evaluated the results of OPCAB as compared to conventional coronary artery bypass (CCAB) as a historical control. The operative mortality was 1.6% in both groups. Postoperative complications including renal failure and requirements of circulatory support were significantly less in OPCAB. Postoperative max CPK-MB value, the amount of postoperative bleeding and the requirement of transfusion were also significantly less in OPCAB. Only neurological complication in OPCAB was temporary delirium in a high-aged patient, whereas three patients developed neurological complications including permanent stroke in CCAB. Right heart bypass was effectively utilized to maintain hemodynamics and expose the posterior vessels in patients with severely dilated and poorly functioning left ventricle (EF: 24-31%) and a patient with multiple severe stenosis in cerebral arteries. Coronary angiogram performed after the operation demonstrated 94% of graft patency. These results warrant the further application of OPCAB for multivessel surgical revascularization.


Subject(s)
Coronary Artery Bypass/methods , Coronary Disease/surgery , Minimally Invasive Surgical Procedures/methods , Adult , Aged , Aged, 80 and over , Cardiopulmonary Bypass , Coronary Artery Bypass/statistics & numerical data , Female , Heart Bypass, Right , Humans , Male , Middle Aged , Minimally Invasive Surgical Procedures/statistics & numerical data , Vascular Patency
16.
Semin Thorac Cardiovasc Surg ; 13(4 Suppl 1): 60-6, 2001 Oct.
Article in English | MEDLINE | ID: mdl-11805951

ABSTRACT

The characteristics in flow dynamics of stentless bioprosthetic valve implanted in aortic position has been reported using Doppler echocardiography and beneficial results have been demonstrated in patients. Because some disturbed flow characteristics were seen clinically with existence of pressure gradient, the nature of flow-velocity characteristics was evaluated in patients receiving Freestyle stentless aortic bioprosthesis using new three-dimensional MRI method. In 19 patients after AVR with Freestyle bioprosthesis, flow-velocity study was conducted using velocity-encoding phase-contrast magnetic resonance imaging (MRI). Three-dimensional flow profiles were reconstructed. The implantation techniques were subcoronary (SC) in 10, root inclusion (Incl) in 6, and full root (FR) in 3 patients. These results were compared to 4 pts with stented bioprosthesis and 4 healthy volunteers. In 3-D flow velocity profiles, there were variations from almost normal pattern to some disturbed flow pattern. All patients of FR showed the parabolic flow pattern nearly equal to normal subjects. Over half of the patients with SC and Incl showed disturbed flow pattern with increased pressure gradient. Although hemodynamically acceptable, Freestyle aortic bioprosthesis showed some degree of flow disturbance in subcoronary or inclusion method with increased transvalvular velocity that may cause late problems, and these findings evaluated by 3-D method should be implicated in surgical consideration.


Subject(s)
Aortic Valve/surgery , Bioprosthesis , Heart Valve Diseases/surgery , Heart Valve Prosthesis , Image Processing, Computer-Assisted , Magnetic Resonance Imaging/methods , Aged , Blood Flow Velocity , Echocardiography , Female , Heart Valve Diseases/physiopathology , Heart Valve Prosthesis Implantation/methods , Hemodynamics , Humans , Imaging, Three-Dimensional , Magnetic Resonance Imaging, Cine , Male , Middle Aged , Prosthesis Design
20.
Jpn J Thorac Cardiovasc Surg ; 48(4): 222-8, 2000 Apr.
Article in English | MEDLINE | ID: mdl-10824474

ABSTRACT

OBJECTIVES: Stentless bioprostheses have been gaining popularity in recent years as hemodynamically superior alternatives to conventional stented bioprostheses. METHODS: Between July 1996 and November 1998, 13 patients with aortic valve disease, 7 males and 6 females with a mean age (+/- SD) of 68 +/- 5 years, underwent an aortic valve replacement using the Medtronic Freestyle aortic bioprosthesis. The predominant lesions were stenosis in 8 patients and regurgitation in 5, while 2 patients had endocarditis. The operation was performed by a subcoronary technique in 9, root-inclusion technique in 3, and full root technique in 1 patient. RESULTS: Throughout the follow-up periods (with average follow-up period of 20.6 months), there was no hospital mortality, though there was one late death of unknown cause. The New York Heart Association class improved in all patients. The peak transvalvular gradient decreased from 18.4 +/- 9.8 to 12.6 +/- 9.6 mmHg, and the effective valve orifice area increased from 2.30 +/- 0.96 to 2.59 +/- 1.05 cm2 between the 1-month and the 6-month follow-up examinations. In patients with aortic regurgitation, the left ventricular end-diastolic/end-systolic volume index significantly decreased from 147 +/- 36/62 +/- 19 to 73 +/- 26/33 +/- 14 ml/m2 at 1 month after the operation. The left ventricular mass index also significantly decreased from 189 +/- 26 to 143 +/- 30 g/m2 in patients with aortic regurgitation and from 171 +/- 28 to 144 +/- 30 g/m2 in those with aortic stenosis. CONCLUSIONS: Although long-term follow-up is required for further evaluation, the early results appeared to indicate that the Freestyle aortic bioprosthesis was suitable for elderly patients requiring aortic valve replacement.


Subject(s)
Aortic Valve/surgery , Bioprosthesis , Heart Valve Prosthesis Implantation , Aged , Aortic Valve Insufficiency/surgery , Aortic Valve Stenosis/surgery , Female , Humans , Male
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