Redo Bentall operation for the aortitis syndrome.

The aortitis syndrome is a chronic inflammatory arterial disease with an unknown etiology that may present as a variety of vascular lesions. The surgical treatment of aortitis syndrome is associated with many potential difficulties due to the inflammatory nature of the disease. A patient with the aortitis syndrome underwent the Bentall operation for annulo-aortic ectasia and aortic regurgitation 11 years prior to presentation. The operation was not performed during the active inflammatory phase. An anastomotic dehiscence required reoperation, which was performed with Piehler's method. In the aortitis syndrome, the exclusion technique, Carrel patch repair of the coronary arteries and pledgeted anastomoses should be performed for aortic root reconstruction.

Clinical experience of Argatroban for anticoagulation in cardiovascular surgery.

PURPOSE: We have reviewed our experience with Argatroban-a direct thrombin inhibitor for anticoagulation--in a variety of cardiovascular operations, and in extracorporeal circulation, as a substitute for heparin. SUBJECTS AND METHODS: 60 patients receiving anticoagulation with Argatroban were classified into the following four groups. Group 1; 20 patients with anticoagulation therapy after cardiac surgery. Group 2; 8 patients with extracorporeal circulation for continuous hemofiltration for either pre- or post-operative control of acute renal failure. Argatroban was used alone or in combination with nafamostat mesilate. Group 3, one patient with replacement of the descending aorta with left heart assist and 15 patients with percutaneous cardiopulmonary support. And Group 4, 16 patients undergoing vascular surgery including the abdominal aorta. The target activated clotting time was individually set for each group. In Group 1, the coagulofibrinolytic activity and platelet function were measured precisely. Bleeding and complications were examined in all groups. RESULTS: Group 1; the targeted activated clotting time of 150-180 seconds was achieved by a dosage of 0.4-0.8 microgram/kg/min Argatroban. Group 2; the activated clotting time of 150-180 seconds was achieved by 0.05-1.6 micrograms/kg/min (concomitance), or by 0.02-2.5 micrograms/kg/min (alone). Group 3; the activated clotting time of 180-200 seconds by 0.05-3.86 micrograms/kg/min. And Group 4; the activated clotting time of around 150 seconds by 2.0 micrograms/kg/min with initial bolus infusion of 0.1 mg/kg. Argatroban did not promote post-surgery bleeding and had no unfavorable effect on coagulo-fibrinolysis or on platelet activity. CONCLUSION: Argatroban may be useful as an anticoagulant in the field of cardiovascular surgery as a substitute for heparin, without causing any post-surgery bleeding complication, or influencing the fibrinolytic activities or platelet functions.

[Surgical treatment of multiple aortic aneurysm].

Ten patients with multiple aortic aneurysms of both thoracic and abdominal aortic aorta, were evaluated clinically. The abdominal operations preceded the thoracic operations in the seven patients, and the four of them underwent two-staged operations with good results. Residual aneurysm ruptured in two patients and one patient died on the first operation because of abdominal aortic aneurysm rupture. The thoracic operations preceded the abdominal operations in the three patients, and one of them underwent a two-staged operation with good result. Because the risk of rupture of the unrepaired aneurysm is high, the treatment of the second aneurysm should be done in a short period.

Does dilatation of the sinotubular junction cause aortic regurgitation?

BACKGROUND: Some patients develop aortic regurgitation (AR) in association with dilatation of the sinotubular junction (STJ), despite having normal aortic valve. However, the relationship between dilatation of the STJ and AR is unclear. METHODS: Canine hearts and aortas were isolated. A suture was placed in each commissure and in the sinus of Valsalva at the STJ. These interrupted sutures were drawn horizontally, and strain on the sutures was varied. The sites of the retracted sutures were changed to various positions, and the opening and closing of the aortic valve was observed endoscopically. A beating heart model was used to observe changes in aortic valve function during mechanical retraction of the commissures or sinuses. RESULTS: Opening area of the valve increased when strain on all sutures or commissures was increased. When strain was increased on the sinus alone, coaptation of the valve was not affected. CONCLUSION: We observed endoscopically that mechanical dilatation of the STJ causes AR. These findings suggest that the principal cause of AR associated with dilatation of the STJ is outward deviation of the commissure.

Argatroban as a potential anticoagulant in cardiopulmonary bypass-studies in a dog model.

Argatroban is a selective thrombin inhibitor synthesized in Japan. Argatroban, which has a high affinity for thrombin, and markedly inhibits thrombin-induced reactions, has been used in patients with artherosclerosis obliterans. The efficiency of argatroban, instead of heparin, as an anticoagulant in dog models of cardiopulmonary bypass was explored. In the first study, argatroban was administered as a bolus plus infusion for 1 h during cardiopulmonary bypass at doses of 1.0 mg + 10 microg/kg per min, 2.0 mg + 10 microg/kg per min and 3.0 mg + 10 microg/kg per min (n = 2 per group). Activated clotting time and arterial gas analyses were performed beforehand and 10 min thereafter. In the second study, there were four groups. In the first group (n = 5), no coated extracorporeal circuit was used and heparin (2 mg/kg) was used as an anticoagulant. In the second group (n = 5), a coated extracorporeal circuit was used and heparin was used (2 mg/kg) as an anticoagulant. In the third group (n = 3), no coated extracorporeal circuit was used and argatroban (2.0 mg + 10 microg/kg per min) was used as an anticoagulant. In the fourth group (n = 5), a coated extracorporeal circuit was used and argatroban was used (2.0 mg + 10 microg/kg per min) as an anticoagulant. All animals were perfused for 120 min at 40 ml/kg per minute. Platelet count, activated clotting time, thrombin-antithrombin III complex, antithrombin III, fibrinogen, fibrinogen degradation products and C3a were measured to evaluate platelet, coagulofibrinolytic and the complement system. Activated clotting time values and the effect of argatroban during cardiopulmonary bypass indicated a dose-dependent response. The next highest dosing group (2.0 mg + 10 microg/kg per minute) had activated clotting time values of 250-300 seconds during cardiopulmonary bypass, and fell after reaching near-normal levels within 60 minutes. No clots were noted in the extracorporeal circuit. The argatroban group showed lower levels in their coagulofibrinolytic system compared with the heparin group. The platelet count remained at a high level in the argatroban group. It is concluded that the combination of heparinized cardiopulmonary bypass circuits, and the use of argatroban as an anticoagulant, is safe and reduces the activation of coagulation and fibrinolytic systems and preserves platelet count.

[Metastatic endometrial sarcoma of the right ventricular outflow tract associated with disseminated intravascular coagulopathy].

A case of myocardial metastasis of endometrial sarcoma to the right ventricular outflow tract is described. A 56-year-old woman was admitted with ecchymoses of lower limbs in September in 1995. Laboratory findings included thrombocytopenia and an increase of fibrinogen degradation products due to disseminated intravascular coagulopathy (DIC). Transesophageal echocardiography (TEE) demonstrated a large mass both in the right ventricular outflow tract and the proximal pulmonary artery. The mass was excised including base of the stalk. Cryoablation was employed on the endocardium where the stalk was originated. With pathological examination, the mass was identified to be endometrial sarcoma. The patient achieved an uneventful recovery and DIC was improved dramatically in a week after operation. Thirty-three months after the surgery, she has been well and free from local recurrent tumor.

[Usefulness of percutaneous cardiopulmonary bypass support in patients with difficulties in weaning from cardiopulmonary bypass].

A percutaneous cardiopulmonary support system (PCPS) was used in 12 patients (mean age 68 years) between March 1991 and June 1996 for difficulties weaning from ordinary cardiopulmonary bypass. Cardiac procedures preceding the placement of the PCPS were coronary artery bypass grafting in 8 patients, aortic valve replacement in 1, double valve replacement in 1, and ascending aortic replacement for acute aortic dissection in 1. These procedures were elective in 6 patients and emergent in 6. Intraaortic balloon pumps were used in all cases except in two cases with atherosclerotic occlusive disease. Nine (75%) of the patients were weaned from PCPS, and seven (58%) were discharged. There were no complications due to the placement of PCPS except for three episodes of lower leg ischemia. We conclude that PCPS is useful in addressing difficulties in weaning from ordinary cardiopulmonary bypass and there should be further discussion about the limitations of PCPS in cases of severe circulatory failure.

[Application of heparin-coated PCPS for traumatic cardiac rupture: report of a case].

Application of heparin-coated percutaneous cardio-pulmonary support system (PCPS) for a case with traumatic cardiac rupture is reported. A 50-year-old woman, who was injured in the traffic accident, was admitted to our hospital. Her consciousness was not alert in circulatory collapse. Echocardiography showed cardiac tamponade and pericardial centesis was done followed by re-filling. Urgent surgical intervention was necessary. When she was brought to operating room, she became cardiac arrest, necessitating cardio-pulmonary resuscitation followed by PCPS. Under PCPS support, hemodynamic state became stable and cardiac laceration was repaired. Laparotomy was also done because of the distension of abdomen during operation, and splenectomy was necessary for the injured spleen. She is doing well now. Generally, it is considered to be contra-indicated to apply PCPS for traumatic cases which may cause bleeding tendency because of anti-coagulant therapy. But this case report showed the possibility of application of PCPS for traumatic cases, if PCPS is established using heparin-coated system.

[A case report of aortic regurgitation associated with rheumatic arthritis].

We report a rare case of aortic regurgitation (AR) associated with rheumatic arthritis (RA). A 61-year-old female was admitted to our hospital with severe heart failure due to AR. She had a 8-year history of RA and had been treated with steroid therapy. Trans-esophageal echocardiography showed thickness and shortening of non coronary cusp (NCC) of aortic valve. After treated for heart failure, aortic valve replacement with SJM-HP 17 mm was done. At operation, right and left coronary cusps were almost normal, but NCC was thickened and shortened. The valve of NCC histology showed granuloma. She recovered uneventfully. Two cases of cardiac valvular disease, associated with granuloma of RA, were reported in Japan. We discussed these cases in this paper.

[Does dilatation of the sinotubular junction cause aortic regurgitation?: the use of the experimental model and preliminary result].

This study investigated the mechanism of aortic regurgitation caused by dilatation of the sinotubular junction. The canine model of dilatation of the sinotubular junction was used to observe coaptation of the aortic valve using direct imaging by endoscopy. Five adult mongrel dogs (body weight: 20-25 kg) were anesthetized and their hearts and thoracic aortas were extracted en bloc. Aortotomy was performed and an interrupted horizontal mattress suture was placed in each commissure and each sinus of Valsalva at the level of the sinotubular junction. The heart and thoracic aorta were fixed on a table and the interrupted sutures were drawn horizontally. As a result, the aorta of the junction level was dilated. Strain of the interrupted sutures were changed by weights of 20, 25, 50, 70 and 100 points (1 point = 3.5 g). The sites of the retracted sutures were the three commissures and three sinuses of Valsalva. With increased strain of the sutures, the opening of the aortic valve was exaggerated when drawing was done on either all sutures or the commissures. When drawing was done only on the three sinuses of Valsalva, coaptation of the aortic valve was uninterrupted. This study showed that dilatation of the sinotubular junction causes aortic regurgitation, which is mainly due to the outward deviation of the commissures.

[A case of ruptured thoracoabdominal aortic aneurysm with aortitis syndrome--operation with selective cold visceral arteries perfusion].

We report a successful result of treatment for a ruptured thoracoabdominal aortic aneurysm with aortitis syndrome. A 43-year-old male suffered sudden low back pain, that was diagnosed as a ruptured thoracoabdominal aortic aneurysm based on abdominal computed tomography. Preoperative angiography revealed a thoracoabdominal aortic aneurysm with occlusion of the superior mesenteric artery, and well developed Riolan's archade. The aneurysm was replaced by a prosthetic graft with partial femoro-femoral bypass in conjunction with selective cold perfusion for the visceral arteries. Total extracorporeal circulation time, and aortic clamptime, was 187 minutes and 132 minutes, respectively. The postoperative courses of liver and renal function were excellent. The patient recovered from surgery uneventfully. It was suggested that selective cold visceral perfusion was effective for prevention of renal and liver dysfunction associated with a ruptured thoracoabdominal aneurysm.

Emergency pulmonary embolectomy with percutaneous cardiopulmonary bypass.

BACKGROUND: The management of patients with acute pulmonary embolism remains difficult, particularly when cardiogenic shock is involved. The preoperative incidence of cardiac arrest compromises the results of emergency pulmonary embolectomy. In an attempt to reduce the operative mortality rate, we applied percutaneous cardiopulmonary bypass support to restore vital organ perfusion before the surgical intervention. METHODS: Percutaneous cardiopulmonary bypass support was preoperatively instituted in 3 patients with acute cardiopulmonary collapse caused by massive pulmonary embolism. In each patient, cardiac massage and endotracheal intubation were necessary due to loss of consciousness, hypotension, and severe cyanosis. Transesophageal echocardiography was performed to detect any evidence of thrombus in the main pulmonary artery, and each patient underwent the emergency pulmonary embolectomy using conventional cardiopulmonary bypass through a median sternotomy. RESULTS: Percutaneous cardiopulmonary bypass support immediately provided effective cardiopulmonary resuscitation. Transesophageal echocardiography clearly demonstrated any evidence of thrombus located in the pulmonary artery. Each patient was discharged from the hospital without any postoperative complication. CONCLUSIONS: The use of percutaneous cardiopulmonary bypass support immediately resuscitated and stabilized the cardiopulmonary function and allowed for successful emergency pulmonary embolectomy. In each patient, transesophageal echocardiography was useful for prompt and noninvasive diagnosis.

[Twenty cases of superior septal approach for mitral valve operation].

We experienced 20 cases of superior septal approach (SSA) for mitral valve surgery from June 1992 to December 1995. From pre-operative coronary angiography, sinus node arteries (SNAs) were grouped into three types, branched from right coronary artery (RCA: 45%), from left circumflex (LCx: 35%), and from both RCA and LCx (Bilateral: 20%). And, in diameter, they were grouped into two groups, above 1 mm (80%) and below 1 mm (20%). There were no peri-operative deaths and complications associated with SSA. In acute post operative phase, atrial fibrillation, junctional rhythm, atrial flutter, and sino-atrial block were observed, especially in patients whose SNA branched from RCA, and were above 1 mm in diameter. In late follow-up, all patients' rhythm returned to pre-operative rhythm, although some cases became bradycardia less than 60 per-minute. Bradycardia was observed in patients whose SNA branched from RCA, and were above 1 mm in diameter. There may be relationship between post operative arrhythmia and division of large SNAs originated from RCA. We concluded that SSA is safe and excellent approach for mitral valve surgery, especially in patients who require reoperations and in patients with small LA, although we should consider the advantages of SSA versus the risks of post operative arrhythmia and bradycardia.

[Two successful cases of surgical treatment for left ventricular rupture following myocardial infarction: the usefulness of percutaneous cardiopulmonary support system (PCPS)].

Two successful cases of surgical treatment for left ventricular (LV) rupture following acute myocardial infarction (AMI) are reported. The first case was a 62-year-old man with circulatory collapse caused by a blow out type LV rupture. The second case was a 68-year-old woman with a oozing type LV rupture. In both cases PCPS was applied for cardiopulmonary resuscitation. After stabilizing their hemodynamics and recovering consciousness with PCPS, surgical repair for LV rupture was performed successfully. The first case was getting well, but suddenly circulatory collapse occurred and he died for acute pulmonary arterial thromboembolism on 10 days after operation. The second case woman is doing well without complication 1 year after operation. In conclusion, PCPS may be useful for LV rupture following AMI for the recovery and maintenance of hemodynamics, and also play as a bridge for surgical repair.

Clinical use of extracorporeal lung assist for a patient in status asthmaticus.

A 23-year-old man was transferred to our hospital in an unconscious state due to hypercapnea with massive subcutaneous emphysema secondary to status asthmaticus. Mechanical ventilation was ineffective for removal of carbon dioxide and oxygenation. After the initiation of extracorporeal lung assist the patient was able to effectively clear his secretions. This resulted in marked improvement in his pulmonary compliance. There were no hemorrhagic pulmonary or hematologic complications. This is the first patient in whom we have used venovenous bypass in the treatment of status asthmaticus.

[Surgery for acute type A aortic dissection associated with Marfan syndrome].

Recently, extended operation has been recommended for aortic dissection associated with Marfan syndrome. However, the operation for acute type A aortic dissection associated with Marfan syndrome is controversial. Between May 1985 and July 1994, 5 patients associated with acute type A aortic dissection and Marfan syndrome underwent surgical repair. CT examination on all patients, the survivors of the initial operation, revealed a gradually enlarged residual pseudolumen. 2 patients who underwent aortic root reconstruction and ascending aortic replacement for the initial operation eventually had to undergo aortic arch repair. From the results of this study and the improvements of intraoperative cerebral protection, we recommend aortic arch repair with aortic root reconstruction and ascending aortic replacement on initial emergency operation for acute type A aortic dissection associated with Marfan syndrome.

Surgical treatment for acute aortic arch dissection.

Between March 1983 and December 1993, 24 consecutive patients with acute aortic dissection resulting from a tear located in the aortic arch or at the base of the innominate artery underwent surgical treatment. Before 1988, 11 patients (group 1) underwent either isolated ascending aorta replacement (eight cases) or composite graft replacement (three) by the conventional method. In this group, the hospital mortality rate was 36.4%; two of seven surviving patients required reoperation for aortic arch. After 1989, 13 patients (group 2) underwent either hemiarch replacement (five cases), total arch replacement (three), extended ascending aortic replacement or composite graft replacement with hemiarch replacement (one) under a brief period of circulatory arrest (mean 33.3 min) at a mean(range) rectal temperature of 20.8(18-23) degrees C by open distal anastomosis. The operative mortality rate in group 2 was 15.4%. Ten of 13 surviving patients are free from reoperation (mean follow-up 40 months). In most patients with acute type A dissection in which the tear is located at the proximal aortic arch or at the base of the innominate artery, the use of an open technique during a brief period of hypothermic circulatory arrest is advocated to: (1) perform a more secure distal anastomosis; (2) provide a more accurate assessment and resection of intimal disruption; and (3) avoid further aortic injury from the cross-clamp.

[Antiplatelet therapy after open heart surgery].

This study evaluated the effects of an antiplatelet drug for the patients after open heart surgery. Dipyridamole (D), aspirin (A), ticlopidine (T) and sarpogrelate hydrochloride (S) were chosen as an antiplatelet drug. The 6 groups were devided into as G 1 with warfarin (W) and D, as G 2 with W alone, as G 3 with A and D, as G 4 with A alone, as G 5 with A and T, and as G 6 with A and S. The indices of anticoagulation and antiplatelet were as follows: TT, APTT, PT, D. Dimer, fibrinogen, TXB2, 6 kPGF1 alpha, beta TG, vWF and platelet aggregation with Grading Curve methods. The results showed that D.Dimer was beyond the normal range in G 1 and G 2. Thromboxane B 2 was increased markedly in G 1 and G 2 and showed under the normal range in G 3 and G 6. In all groups, 6 kPGF1 alpha showed low levels than normal. Activation of platelet causes the increased beta TG which was not suppressed with the antiplatelet drugs administered. The platelet aggregation was not suppressed in G 1 and G 2. Mild to moderate suppression was seen in G 3 and G 4 with no difference between the two group. Moderate to marked suppression was demonstrated in G 5 and G 6. This study demonstrated that dipyridamole had no effects as antiplatelet function. Aspirin showed antiplatelet effects and the combination of aspirin with the another antiplatelet drugs demonstrated the additional effects.

Importance of preserving the mitral subvalvular apparatus in mitral valve replacement.

BACKGROUND: This clinical study sought to determine whether mitral valve replacement (MVR) with the preservation of both anterior and posterior chordae tendineae (MVR group II) would be more effective on the improvement of left ventricular regional wall motion than MVR with the preservation of posterior chordae tendineae alone (MVR group I). METHODS: Postoperative left ventricular wall motion was analyzed by a centerline method in three groups of MVR--group I (n = 13), group II (n = 15), and repair group (n = 15)--for mitral regurgitation. Shortening fraction of chordal length was determined in 100 chords, and these chords were divided into five regions. RESULTS: The comparison of postoperative versus preoperative shortening fraction among the three groups revealed that postoperative wall motion improved more strikingly at apical and diaphragmatic regions in the MVR group II and repair group in comparison to the MVR group I. The postoperative shortening fraction at the apical region in the MVR group II was significantly increased in comparison to preoperative shortening fraction (preoperative, 3.68% +/- 1.87%; postoperative, 5.38% +/- 2.33%; p < 0.05). However, postoperative shortening fraction in cardiac base was decreased in the MVR group II as well as other two groups. CONCLUSIONS: The MVR with the preservation of both anterior and posterior chordae tendineae contributed to the improvement of left ventricular regional wall motion in the apical and diaphragmatic regions.