Histological evaluation of skeletonized internal thoracic artery using ForceTriad™.

BACKGROUND: The internal thoracic artery (ITA) is a useful graft for coronary artery bypass grafting. Skeletonization, a technique that uses an ultrasonic scalpel, is increasingly used. However, the cost of an ultrasonic scalpel is extremely high. The purpose of this study was to determine whether a new electrosurgical cautery device (ForceTriad™) is as effective as an ultrasonic scalpel. METHODS: Bilateral ITAs were harvested from eight pigs using the skeletonizing technique. The ITA on one side was harvested with an ultrasonic scalpel and on the other side using the ForceTriad™. Macroscopic and histological examinations were performed in sixteen ITAs. RESULTS: No significant differences in the time required for harvesting were observed. The macroscopic findings revealed no significant change in any of the samples. The histological findings showed that the degree of thermal injury was similar. The normal structure was maintained in all samples. The ForceTriad™ costs US$ 226.82 less per patient than the ultrasonic scalpel. CONCLUSION: The new electrosurgical cautery device ForceTriad™ was less expensive, but it was equally effective. It appears that skeletonization performed with the new device is equivalent to that performed with an ultrasonic scalpel.

Obstruction of St Jude medical valves in the aortic position: a consideration for pathogenic mechanism of prosthetic valve obstruction.

Between 1995 and 2000, 8 patients with St. Jude Medical (SJM) valves in the aortic position required 9 redo valve replacement for prosthetic valve obstruction. Obstruction of the prosthetic valve was diagnosed by simultaneous echocardiography and cineradiography, and process of restricted leaflet movement that progressed to hemodynamic impairment was observed by serial studies in three recent patients. An oral anticoagulation was considered to be adequate in all patients except one patient who had withdrawal of warfrain. Pannus was the sole cause of valve obstruction in seven events in 6 patients, and both thrombus and pannus in 2 patients. Pannus overgrowth was found on the inflow aspect of the SJM valve, and involved the ends of the straight edge of the leaflets over pivot guards. These results suggest that pannus might play the primary role in development of obstruction of aortic SJM valves in patients on adequate oral anticoagulation.

Right atrial thrombus associated with combined valvular disease: case report.

A 77-year-old man had a large right atrial (RA) thrombus associated with a combined mitral and tricuspid valve disease. Echocardiography showed a large, immobile, non-homogeneous, irregularly surfaced mass in the dilated RA, and prolapse of the anterior mitral leaflet resulting in massive mitral regurgitation. Computed tomography (CT) revealed a laminated structure with calcification and distinct margins, without invasion to the wall of the RA. On the basis of these echocardiographic and CT findings, a diagnosis of combined mitral and tricuspid valvular disease complicated with RA thrombus was made. Removal of the RA thrombus, mitral valve replacement and tricuspid annuloplasty were performed simultaneously, with successful outcome.

Aortic dissections complicating open cardiac surgery: report of three cases.

Between June 1991 and February 1999, three patients suffered ascending aortic dissection as a complication of cardiopulmonary bypass operations with aortic cannulation at our hospital. The dissection occurred during the operation in two of the three patients and several months after the operation in one. Among a total of 2207 cardiac operations performed during this period, the incidence of perioperative ascending aortic dissection was 0.14%. In addition to visual inspection and palpation, either epicardial or transesophageal echocardiography proved extremely useful for establishing an intraoperative diagnosis of ascending aortic dissection as a complication of open cardiac operation. One of the three patients underwent closed plication but subsequently died of vital organ ischemia. In this case, failure of reapproximation of the injured intima by closed plication might have led to extension of the dissection. Despite prolonged cardiopulmonary bypass and myocardial ischemic time, graft replacement of the ascending aorta was successfully carried out in the other two patients. Thus, we believe that graft replacement of the ascending aorta should be performed for patients with extensive aortic dissection complicating an open cardiac operation.

Obstruction of St Jude Medical valves in the aortic position: significance of a combination of cineradiography and echocardiography.

BACKGROUND: Obstruction of the St Jude Medical valve (St Jude Medical, Inc, St Paul, Minn) is a rare but serious complication. METHODS: Cineradiographic and echocardiographic evaluations of aortic St Jude Medical valves were simultaneously performed on 54 patients, with no signs of prosthetic valve dysfunction late after surgery. RESULTS: Although closing angles of the leaflets corresponded closely with the manufacturer data, restricted opening of the leaflets (opening angle >/= 20 degrees ) was found in 16 (group D) of the 54 patients by means of cineradiography. The opening angles were equal to or less than 14 degrees in the other 23 patients (group N) and between 15 degrees and 19 degrees in the remaining 15 (group M). Doppler-derived transprosthetic pressure gradients were significantly higher (P =.03) and the velocity index was significantly lower (P =.003) in group D than in group N. However, no significant differences were found in those values between group N and group M. Replacement of the aortic St Jude Medical valves was performed in 5 of the 16 patients, and the remaining 11 have been followed up because of relatively low pressure gradients. The cause of restricted leaflet movement was pannus formation without thrombosis in 4 patients and valve thrombosis with pannus formation in one. CONCLUSIONS: Reduced valve orifice area and restricted opening of the leaflets resulting from excess growth of pannus probably led to obstruction of the aortic St Jude Medical valves. A combination of cineradiography and echocardiography makes it possible to provide an accurate and detailed diagnosis of obstruction of the valve.

Successful removal of an infected pacemaker electrode by open heart surgery under extracorporeal circulation.

A 33-year-old male with sick sinus syndrome, who had received a pacemaker implant 18 years earlier, was complicated with a generator infection. Although the infected generator was removed, he was suffered from the recurrent local infection associated with a retained pacemaker lead. After a new pacemaker system implantation from the other side of the subclavian vein, we attempted to remove the lead utilizing a pacemaker removal kit. However, this intervention procedure was unsuccessful, because fibrous adhesions had developed around the lead, accompanied by calcification along its course. As a last resort, we opened the heart under extracorporeal circulation and removed the lead under direct vision. The post-operative course was uneventful. In order to remove a long-term implanted pacemaker lead, the direct surgical procedure with extracorporeal circulation is a favorable mean alternative to conventional intervention techniques.

Risk factors for posttransfusion graft versus host disease, mediastinitis, and late cardiac tamponade in heart surgery. Survey of 119 Japanese institutions.

OBJECTIVE: Correlations and risk factors remain to be unclarified for post-heart-surgery posttransfusion graft-versus-host disease, mediastinitis, and late cardiac tamponade caused by deteriorated host-defense mechanisms due to cardiopulmonary bypass both with and without steroid usage. METHODS: We sent questionnaires to 298 Japanese cardiovascular institutions asking for institution profiles, including infection control, steroid use in cardiopulmonary bypass, and prevalence of mediastinitis, late cardiac tamponade, and posttransfusion graft-versus-host disease during 1994. The overall prevalence of posttransfusion graft-versus-host disease since the start of service (from establishment of institution to date) was also requested. RESULTS: The number of pump cases at the 119 institutions responding (40%) were 91.6 +/- 67.9 cases/institution (total = 10,904). The prevalence of mediastinitis was 1.2 +/- 1.8 and that of late cardiac tamponade 1.0 +/- 1.8%. Posttransfusion graft-versus-host disease occurred in 1 of 10,904 patients (0.01%) during 1994 at an institution where steroids and nonirradiated blood were used in surgery. The simple institutional mean prevalence of posttransfusion graft-versus-host disease since establishing institutions was 0.08 +/- 0.13%. Of the 119 institutions surveyed, 86 used steroids in all pump cases (72%); 11 institutions used steroids in a limited number of cases (9%). The institutional mean of methylprednisolone-converted steroid dose was 21.5 +/- 16.4 mg/kg (n = 119). In multivariate regression analysis, operation time (p = 0.005) for mediastinitis, steroid usage (all, limited, or no cases) (p = 0.01) and % aneurysm (p = 0.05) for late cardiac tamponade, and steroid dosage (p = 0.002) for posttransfusion graft-versus-host disease were identified as significant risk factors. CONCLUSION: Our results suggest that massive steroid administration for cardiopulmonary bypass may increase the risk of posttransfusion graft-versus-host disease and late cardiac tamponade, but not mediastinitis.

[Dor operation for end-stage ischemic cardiomyopathy].

Endoventricular circular patch plasty (Dor operation) was used to treat end-stage dilated ischemic cardiomyopathy in 13 patients from January to December, 1997. There were 10 men and three women aged from 57 to 78 years (mean 63 years). Single, double, triple and left main trunk coronary disease was present in one, two, eight and two patients, respectively. Mean ejection fraction was 22% (6-30%) and signs of congestive heart failure were clear in all patients [New York Heart Association (NYHA) class III in eight patients and class IV in five patients]. Angina pectoris was present in five patients. Six patients had associated significant mitral regurgitation. Coronary artery bypass grafting (mean 3.2 grafts) was used in 11 patients and mitral valve reconstruction was performed in 6 patients (4: replacement and 2: repair) combined with akinetic area exclusion by the Dor technique. All patients were successfully weaned from cardiopulmonary bypass without mechanical support and no perioperative death occurred. Three patients died in hospital at 1-2 postoperative months due to pneumonia, stroke and heart failure, respectively. Two patients died during the late period due to stroke and sudden death. Among the eight survivors, six patients were in NYHA class I-II and two patients in class III. Ejection fraction increased from 22% to 36%, end-diastolic and systolic volume indices decreased from 168 +/- 58 to 123 +/- 39 ml/m2 and from 131 +/- 60 to 81 +/- 33 ml/m2, respectively. Pulmonary capillary wedge pressure decreased from 19 +/- 10 to 14 +/- 5 mmHg. The Dor procedure is an effective surgical alternative for patients with end-stage ischemic cardiomyopathy who are considered to be candidates for cardiac transplantation.

[Early result of volume reduction left ventriculoplasty (Batista operation) for dilated cardiomyopathy].

The Batista operation is intended to improve cardiac function by reducing the diameter of the left ventricle by excising of a sizable amount of the left ventricular free wall. Candidates for this operation are patients awaiting cardiac transplantation due to end-stage dilated cardiomyopathy and those unsuitable for transplantation because of age, physical or economical reasons. We performed this operation in 10 patients between December 1996 and October 1997. The baseline indication is left ventricular diastolic dimension > or = 70 mm and New York Heart Association (NYHA) class III or IV. There were eight men and two women aged from 16 to 60 years (mean 46 years). All had non-ischemic cardiomyopathy including seven idiopathic and one each of hypertrophic, arrhythmogenic right ventricular and valvular (sarcoidosis) cardiomyopathy. Eight patients were in NYHA class IV and six needed inotropic drip therapy prior to the operation. Nine patients had significant mitral regurgitation and six had tricuspid insufficiency concomitantly. Eight patients underwent mitral valve replacement and one was treated with mitral valve plasty. Six patients also had tricuspid plasty combined with partial left ventriculectomy. Eight patients survived. Mean value of left ventricular end-diastolic diameter was reduced from 77.8 mm to 59.8 mm, left ventricular end-diastolic volume index was reduced from 189.3 to 99.2 ml/m2, ejection fraction was increased from 19.0% to 33.8% and NYHA class improved from 3.8 to 1.8. Six months later, left ventricular dilatation was not noticed in four patients examined. The Batista operation offers real hope for patients with end-stage dilated cardiomyopathy, but we still have much to learn.

Improvement of postoperative graft patency rate for coronary revascularization.

For coronary artery revascularization, the long term patency rate of internal thoracic artery (ITA) is excellent and arterial conduit for coronary bypass grafting (CABG) has been actively pursued. Application of the right gastroepiploic artery (GEA) is on the increase but, the patency of the GEA graft is more technically demanding than that of ITA. To improve early postoperative graft patency for coronary artery bypass grafting (CABG) for arterial graft, we modified the technique for anastomosis and demonstrated the patency by postoperative angiogram in 26 consecutive patients receiving CABG. The graft was anastomosed to the coronary artery using two 8-0. Prolene sutures for arterial graft and 7-0 Prolene sutures for saphenous vein (SV) graft. The heal and toe sides of the graft were sutured separately by the parachute technique (double parachute technique), followed by running suturing and typing at bilateral sides. The number of distal anastomoses was 3.4/patient and 44 arterial grafts and 40 SV grafts were used for coronary revascularization. Arterial grafts consisted of 33 ITAs, 9 GEAs, and two inferior epigastric arteries. The angiograms taken 10 to 14 days after operation demonstrated 100% patency rate of arterial grafts and 39 out of 40 SV grafts were patent. The overall patency rate in the early postoperative period was 98.8% The "double parachute" technique for CABG is highly accurate anastomosis with good visualization and the patency rates for all kinds of grafts were found to have improved.

[Multiple systemic embolization from floating thrombus in left atrium].

A 66-year-old woman was referred to our hospital because of cerebral infarction, myocardial infarction and renal infarction. Further examination indicated that she was suffering from mitral valve stenosis with a floating thrombus in the left atrium. She underwent emergency mitral valve replacement and thrombectomy. The thrombus was attached to the left atrium by only four thin and weak strings and removed easily. We think that the thrombus was the precursor of a free-floating ball thrombus without stalk.

[Coronary artery bypass grafting for active aortitis syndrome with bilateral coronary ostial stenosis].

Coronary artery bypass grafting was performed on a 31-year-old female for treatment of active aortitis syndrome with unstable angina. Preoperative coronary angiography revealed ostial stenosis of coronary arteries. The ascending aorta was intensely inflamed. In the proximal anastomosis, the ascending aorta was sutured with an autogenous pericardial patch and anastomosed with the saphenous vein (SV) to be jointed to left anterior descending (LAD). At the same time, gastroepiploic artery (GEA) was connected to LAD by taking into account a degenerative change in remote stage. Right coronary artery was anastomosed with right internal thoracic artery (RITA). The postoperative course was satisfactory. On graft angiography SV and RITA were adequately patent, but GEA was unsatisfactorily patent because of its competition with SV for patency. This surgical procedure seemed to be an option to be indicated for a patient with unstable angina at an active inflammatory stage.

[Reoperative coronary revascularization without cardiopulmonary bypass].

We report a case of successful reoperation of coronary revascularization without cardiopulmonary bypass. The patient was a 62-year-old man, who had undergone coronary artery bypass grafting (CABG) to the LAD and CX with two saphenous vein grafts (SVG) for the left main lesion 12 years before. He required reoperation for unstable angina due to progressive ischemic heart disease and the diseased SVG. Preoperative coronary angiogram revealed total occlusion of major 3 branches and the diseased SVG to the LAD. The reoperation was performed without cardiopulmonary bypass through the repeated median sternotomy for revascularization of the LAD and RCA. The left internal thoracic artery and the gastroepiploic artery were anastomosed to the LAD and RCA under the beating heart without any hemodynamic or electrocardiographic deteriorations. The operation was uneventfully finished in 3 hr 40 min. without the use of blood products. Postoperative angiogram showed both new grafts were widely patent, and he was discharged 14 days after the operation without angina. We also performed 4 other cases of reoperative CABG without cardiopulmonary bypass, and conclude that this technique is a safe and effective alternative in a carefully selected group of patients for reoperative CABG to reduce several technical problems related to coronary reoperation.

[The second coronary reoperation via the left thoracotomy without cardiopulmonary bypass].

A 75-year-old female who had underwent coronary artery bypass grafting (CABG) reoperation 2 years before was readmitted because of unstable angina. Two arterial grafts and one saphenous vein graft (SVG) were all occluded one and half year after the primary operation. The second operation was approached via the repeated sternotomy. LAD and RCA were revascularized with a Y-shaped SVG which had only one inflow. Coronary angiogram revealed stenosis of LMT and RCA and occlusion of the inflow of the Y-shaped SVG. We performed the 3rd CABG via the left thoracotomy without cardiopulmonary bypass for revascularization of the LAD area. A new SVG was anastomosed from the descending aorta to the old SVG just proximal to the anastomotic site with LAD. Local coronary occlusion time was 7 min without any hemodynamic or electrocardiographic deteriorations. The operation was successfully performed in 3 hr 55 min. The patient recovered well uneventfully. Postoperative angiogram showed that the new SVG was adequately patent and she was discharged without angina. We conclude that CABG without cardiopulmonary bypass via the left thoracotomy is an useful alternative to decrease mortality and morbidity for reoperative myocardial reveascularization.

Limited effectiveness of FK506 administration for ongoing rejection in heterotopic rat heart transplantation.

A comparison was made of the histological findings for myocardial tissue of heterotopic transplanted rat hearts administered with FK506. ACI rats were used as donors and Lewis rats as recipients. FK506 was used for 6 days except for group I (control group). Group II received 0.32 mg/kg/day of FK506 from the day of operation while group III was given the same dosage from the 4th day after transplantation. Group IV was given 1.28 mg/kg/day of the agent from the day of grafting and group V received the same dose from the 4th postoperative day. The graft survival time was longer for all groups given FK506, but was significantly longer only for groups administered with FK506 from the day of operation. Histological studies performed 10 and 20 days after transplantation showed that a moderate rejection was seen in about half of the grafts receiving FK506 from the 4th day after grafting. An ultrastructural study of these cases showed that infiltrating large lymphocytes still remained in the interstitial tissues and that the cytoplasmic organelles of the myocytes had been focally destroyed. These results suggest that, although FK506 suppressed any further rejection, the effect might be limited and the myocardial changes of the cardiac graft might persist even after administration for ongoing rejection.

[A case of discrete type of subpulmonary stenosis].

We reported a 8-year-old girl having discrete type of subpulmonary stenosis. This patient was associated with atrial septal defect (ASD), valvular pulmonary stenosis, and persistent left superior vena cava (PLSVC). The incidence of this type of subpulmonary stenosis is less frequent than that of subaortic lesion. ASD was closed by the autologous pericardium and a transannular patch was used for enlargement of the right ventricular outflow tract followed by commissurotomy of the pulmonary valve and resection of subpulmonary discrete lesion. She was uneventful and postoperative pulsed doppler echocardiogram showed good results.

Long-term follow-up results after reconstruction of the mitral valve by leaflet advancement.

In this study, we discuss the clinical results of mitral leaflet advancement performed on 29 patients over the past 10 years and attempt to determine the indication. Preoperative diagnosis of mitral valve lesion consisted of mitral regurgitation in 21 patients and mitral stenosis in 8 patients. Mitral valve repair was applied to the anterior mitral leaflet in 2, the posterior mitral leaflet in 25, and bilateral leaflets in 2 patients. Reoperation was performed on 13 patients, and 1 patient died of renal failure immediately after reoperation. No reoperation was needed for 96.6% of the patients at 1 year, 89.5% at 5 years, 75.0% at 8 years, 63.8% at 10 years, and 52.6% at 15 years postoperatively. At reoperation, the repaired mitral leaflet was found to be calcified in 3 patients more than 9 years after the initial operation. Of the 12 survivors without reoperation, mitral stenosis associated with regurgitation was obvious in 6 patients. Of the 21 patients with preoperative mitral regurgitation, 90.0% showed no deterioration at 5 years, 79.7% at 8 years, and 69.1% at 10 years. On the other hand, for the 8 patients with mitral stenosis, the rates were 87.5% at 1 year, 62.5% at 5 years, 50.0% at 8 years, and 25% at 10 years. Our results suggest that mitral leaflet advancement shows satisfactory results in patients with mitral regurgitation but is not successful for patients with mitral stenosis in the long term because the repaired valve tends to be stenotic in the late postoperative period.

[Coronary artery bypass grafting: does the use of arterial graft for coronary artery bypass grafting increase surgical risk?].

Since April in 1988 coronary artery bypass grafting (CABG) was performed in 177 patients and the clinical results were compared in SVG-group (n = 37) in which only saphenous vein graft (SVG) was used as a graft conduit and AG-group in which one arterial graft (AG-1 group, n = 92) or more than two arterial grafts were used (AG-2 group, n = 48). In SVG-group the age was older than that in AG-group, while coronary vessels were most involved in AG-2 group and the mean number of distal anastomosis increased more in AG-group. The total pump time and aortic cross clamping time showed no significant differences among the groups. Furthermore, the occurrence of perioperative myocardial infarction, requirement of intra-aortic balloon pumping, frequency of re-chest open for hemorrhage, or sternal infection showed no significant differences among the groups. Postoperative hospital deaths were in four (three cardiac deaths) of SVG-group and four (one cardiac and two graft-versus-host disease) of AG-group. These results suggest that the use of AG does not increase surgical risk and AG can be positively used for CABG.

[Coronary artery bypass grafting in a patient with Kawasaki disease].

A 3-year-girl admitted because of angina at rest. She had been diagnosed as Kawasaki disease at the age of 3 months. At that time, a coronary aneurysm was detected by echocardiogram and aspirin had started to administer. At the age of 4 months, a cardiac arrest occurred after severe heart attack because of inferior myocardial infarction. At the age of 2 years and 6 months, she started to complain of a chest pain even at rest. Coronary angiography was performed, and it showed total occlusion of RCA and LAD. However, LAD was vaguely filled by collateral flow from diagonal branch, and 201Tl scintigraphy showed myocardial viability of anteroseptal area. At operation, the size of ITA was 1.2 mm in diameter. Coronary artery bypass grafting to LAD by ITA was performed. Three weeks postoperatively, graft patency was confirmed by coronary angiography. The girl discharged with good ability of exercise. The ITA seemed to be the first choice of conduit for CABG even in a small child, and to be useful for progressive surgical treatment of Kawasaki disease.

Morphological and functional study of free arterial grafts.

Morphological and functional changes of free arterial grafts in dogs were studied for 3 weeks after implantation and the changes were compared to those in implanted free vein grafts. In the arterial grafts, endothelial cells with abundant pinocytotic vesicles and some cytoplasmic folds were observed by transmission and scanning electron microscope and cell detachment was seen only at the site of anastomosis, while most cells were detached in the vein grafts. The site of mechanical damage in the arterial grafts was covered by regenerated endothelial cells which showed similar morphological findings to the normal arterial endothelial cells. In contrast, regenerated cells in the vein grafts started to cover the denuded area 7 days after the implantation and had completely covered it by 3 weeks. Prostacyclin was produced more abundantly in arterial grafts than in vein grafts at any phase after implantation. The level of prostacyclin production was between 30 and 40 pg/mg in any phase after implantation of free arterial grafts, while in vein grafts the level was 2.5 pg/mg at the day of implantation and increased to 13.6 pg/mg at 21 days. This study showed that the endothelial cells were well preserved and the level of prostacyclin production was high in the arterial grafts, and thus the grafts seemed to show potent anti-thrombogenicity after implantation. Although late changes in arterial and vein grafts were not investigated in this experimental protocol, these results may suggest that the arterial graft is superior to the vein graft even in the early period after its implantation as a free graft.