[Danaparoid Sodium Controlled Chronic Disseminated Intravascular Coagulation Associated with Chronic Aortic Dissection and Patent False Lumen for a Long Term:Report of a Case].

The management of chronic disseminated intravascular coagulation( DIC) caused by aortic dissection has not yet been established. We report the successful treatment of a case of aortic dissection with a patent false lumen using danaparoid sodium for acute exacerbation of chronic DIC. 2,000 U danaparoid sodium per day has been stabilizing the coagulative and fibrinolytic parameters and has been relieving bleeding tendencies with no side effects for a long term.

[Thoracic Aortic Rupture of Stanford Type B Acute Aortic Dissection in a Patient with Polycystic Kidney Disease;Report of a Case].

We report a case of a 48-year-old man with polycystic kidney disease (PKD), who was emergently transported to our institution by ambulance because of thoracic aortic rupture of Stanford type B acute aortic dissection. PKD is a congenital disease associated with hypertension( 60%) and cerebrovascular disease (20%). Few reports have described sudden death due to the rupture of an abdominal aortic aneurysm and acute aortic dissection. In this case, emergency hemi-arch replacement was performed successfully. His postoperative course was uneventful, and he was discharged on the 15th postoperative day.

[Pericardial Fenestration in a Patient with Myocardial Metastasis and Cardiac Tamponade after Surgery for Esophageal Cancer;Report of a Case].

We report a case of pericardial fenestration in a patient with myocardial metastasis and cardiac tamponade after surgery for esophageal cancer. A 66-year-old man had been suffering from orthopnea, hypotension and general malaise due to cardiac tamponade and heart failure. Esophagectomy was performed with substernal gastric tube reconstruction for advanced esophageal carcinoma. Nine months after the operation, heart failure developed, and myocardial and pericardial metastasis was subsequently detected. Subxiphoidal pericardiocentesis was abandoned due to the substernal gastric tube, and pericardial fenestration was performed through a small left anterior thoracotomy at the 5th intercostal space. His symptoms were ameliorated immediately and the procedure contributed greatly to maintain his quality of life. Preoperative computed tomography was useful for revealing the anatomical positions of the gastric tube and important vessels.

[Aortic valve replacement for recurrent aortic stenosis after percutaneous transluminal balloon aortic valvuloplasty( PTAV) in a cancer patient].

We report a case of aortic valve replacement( AVR) for recurrent aortic stenosis(AS) after percutaneous transluminal balloon aortic valvuloplasty( PTAV) in a patient with left renal pelvis carcinoma. A 65-year-old female had been suffering from shortness of breath and syncope due to severe AS. She was considered to be a candidate for AVR. Preoperative examination revealed advanced left renal pelvis carcinoma that was a critical comorbidity for AVR. Ureteronephrectomy was also considered to be a contraindication. Despite conservative treatment, her condition was deteriorated. Emergency PTAV was performed when she was transferred to our hospital with circulatory shock. Her symptoms were ameliorated and left ureteronephrectomy was conducted 8 month after the PTAV. She was readmitted to our hospital 16 month after the PTAV and AVR was performed successfully.Antegrade transseptal PTAV is a very useful palliative therapy for AS with severe comorbidities as a bridge to surgery.

Surgical ventricular restoration improves the left ventricle basal wall function using quantitative gated SPECT.

OBJECTIVE: It is not clear whether surgical ventricular restoration (SVR) or procedures approaching mitral complex for controlling functional mitral regurgitation (MR) affect the regional left ventricular wall function. The purpose of the present study was to evaluate the regional LV function after SVR using overlapping left ventriculoplasty (OLVP) using quantitative gated myocardial perfusion SPECT (QGS). PATIENTS AND METHOD: Forty-one heart failure patients, including those with ischemic cardiomyopathy (ICM) (n = 25) and non-ICM (NICM) (n = 16), underwent SVR and/or papillary muscle approximation (PMA). The rest myocardial perfusion SPECT were performed before and early after operation (mean 25.8 ± 10.6 days). These patients were divided into 4 groups based on the surgical procedures (SVR and/or PMA) and etiology of patients (ICM or NICM) as follows: SVR (with or without PMA) of ICM, SVR of NICM, PMA of ICM and PMA of NICM groups. The regional wall thickening was compared before and after the operation between the four groups. RESULTS: NYHA functional classes were improved after the operation in all four groups. MR grade was also improved in three groups other than SVR of the ICM group. The left ventricular basal wall thickening was improved postoperatively in following three groups (SVR of ICM: 12.7 ± 3.8% to 16.5 ± 4.6% p <0.05, PMA of ICM: 11.1 ± 4.3% to 14.9 ± 4.8% p <0.05, SVR of NICM: 5.8 ± 6.6% to 12.3 ± 6.4% p <0.05), whereas PMA of the NICM group did not show an improvement. Wall thickening in the middle and distal levels was not improved in all groups. CONCLUSION: OLVP improved NYHA functional classes, and also improved the regional wall function at the basal level of the left ventricle. In contrast, lone PMA did not improve or impair the regional wall function at any of the levels.

Histopathological study of specimens obtained by left ventricular biopsy during ventriculoplasty for idiopathic dilated cardiomyopathy.

OBJECTIVE: Pathological changes in the myocardium in idiopathic dilated cardiomyopathy (DCM) are usually studied using endomyocardial biopsy specimens, but the relationship between pathological changes in the myocardium and clinical findings is unclear. The goal of the study was to examine correlations between clinical findings and histopathological findings in specimens of the left ventricular myocardium collected during left ventriculoplasty in DCM patients. METHODS: The subjects were 20 DCM patients (17 males and 3 females; mean age: 59 ± 14 years old) who underwent left ventriculoplasty, including 16 cases of overlapping ventriculoplasty (OLVP) and 4 of papillary muscle approximation (PMA) with left ventricular incision. Preoperative age, sex, The New York Heart Association (NYHA) classification, the brain natriuretic peptide (BNP) level, cardiothoracic ratio (CTR), echocardiographic data, history of diabetes mellitus, drug history of spironolactone, ACE inhibitor, ARB, and ß-blocker were used as clinical findings. Histopathological scores were determined for each patient and semi-quantitative data for hypertrophy, attenuation, vacuolation and fibrosis were obtained. RESULTS: A significant correlation was found between age and interstitial fibrosis. A significant inverse correlation was found between left ventricular diastolic diameter (LVDd) in echocardiographic data and interstitial fibrosis. There were no other significant relation between histopathological scores and clinical findings. CONCLUSION: From this study, we found that interstitial fibrous increased with aging and more dilated LVDd had less interstitial fibrosis. It is concluded that the kinetics of myocardial fibrosis with remodeling might be variable and histopathological findings does not reflect the clinical and hemodynamic changes in DCM patients. Further morphological data are needed to verify this result.

Occluding the junction of the middle cardiac vein in retrograde cardioplegia: a new retrograde cannula for optimizing retrograde cardioplegic delivery.

Retrograde cardioplegia often fails to provide adequate perfusion of the right ventricle and the posterior wall of the left ventricle because of the shunt through the thebesian vein. However, much of the retrograde cardioplegic solution may leak into the right atrium after veno-venous anastomoses at the apex of the heart, especially when a retrograde balloon cannula is inserted too deeply in the great cardiac vein, although this is not widely recognized. We designed a new retrograde cardioplegic cannula with three self-inflating balloons, which reduced the shunt flow by occluding the junction of the middle cardiac vein and improving in cardioplegic delivery. We describe the myocardial dye distribution achieved by using this new cannula in pig hearts and report the results of its clinical application.

A novel femoral arterial cannula to prevent limb ischemia during cardiopulmonary support: preliminary report of experimental and clinical experiences.

Distal limb ischemia may occur as a serious complication related to the use of femoral cannulation during veno-arterial cardiopulmonary support (CPS). We developed a simple cannula for femoral arterial cannulation with two holes in the side wall, which could provide the distal limb blood flow without additional cannulation or surgical procedure. This cannula can be inserted into the femoral artery by routine Seldinger technique. The distal blood flow from the side holes can be confirmed by Doppler detector without specialized techniques. In porcine experimental model, the distance between the position where the blood flow was first detected and those where the blood leakage took place was at least more than 10 mm. When this cannula and its side holes were adequately positioned, the mean distal limb flow ranged from 75 to 90 mL/min under CPS at a flow of 1.5 L/min. We employed this cannula for six patients in clinical settings. Three patients showed a good distal limb blood flow at the introduction position without its adjustment. The other three patients showed distal limb ischemia at the introduction position, but the limb ischemia was soon recovered after a slight adjustment of its position. There was no blood leakage from the percutaneous entry into the artery in all cases. We currently use this cannula as the first choice for patients undergoing a prolonged CPS.

Effectiveness of short-term treatment with nocturnal oxygen therapy for central sleep apnea in patients with congestive heart failure.

OBJECTIVES: To evaluate the short term effects of inhalation of oxygen at night in 51 patients with congestive heart failure (CHF) and sleep apnea syndrome (SAS). METHODS: Fifty-one patients with stable CHF (31 males, 20 females, mean age 79.0 +/- 11.9 years; brain natriuretic peptide level of > 100 pg/ml) were evaluated between September 2003 and August 2004, using a Morpheus monitor. The complication rate of SAS in patients with CHF was assessed and apnea hypopnea index, oxygen desaturation index 3%, heart rate, and autonomic nerve activity under room air compared to supplemental O2 (2 l/min) over two consecutive nights. RESULTS: Thirty-eight (75%)of the CHF patients had SAS. Of these SAS patients, 49% suffered from central SAS and 51% had obstructive SAS. Apnea hypopnea index and oxygen desaturation index 3% improved remarkably with supplemental oxygen (p < 0.001), in particular, the central SAS group demonstrated prominent improvement (p < 0.001). Obstructive SAS patients exhibited no significant changes (p = 0.3356), but tended to exacerbate the episodes of sleep apnea. Total heart rate was decreased (p = 0.0079). Nevertheless, heart rate variability analysis showed little effect of nocturnal oxygen therapy on the autonomic nervous system during sleeping. CONCLUSIONS: Nocturnal oxygen therapy improved the number of sleep apnea episodes and decreased total heart rate during sleep time for the CHF patients with central SAS, despite little influence on the autonomic nervous system, based upon assessment of heart rate variability. Obstructive SAS might exacerbate the episodes of sleep apnea.

Impact of papillary muscles approximation on the adequacy of mitral coaptation in functional mitral regurgitation due to dilated cardiomyopathy.

PURPOSE: We report early outcome of our modified papillary muscles approximation (PMA) as an adjunct to mitral annuloplasty (MAP) by analyzing the mitral coaptation zone echocardiographically and clinical outcome in three different procedures. METHODS: Mitral valve coaptation depth (MVCD) and tenting area were measured in patients with ischemic (n=8) or non-ischemic (n=22) dilated cardiomyopathy (ICM or non-ICM) undergoing either of following: Group I: isolated left ventricular volume reduction (LVVR) (n=11), Group II: PMA plus LVVR (n=14), Group III: isolated PMA (n=5). Clinical outcome including cardiac function were also investigated. RESULTS: Thirty-day mortality was 6.7%. Postoperative data in overall survivors showed significant improvement of ejection fraction (EF) (from 19+/-7 to 32+/-9%), left ventricular end-diastolic volume index (LVEDVI) (from 189+/-74 to 132+/-41 mL/m2), and left ventricular diastolic dimension (LVDd) (from 73+/-8 to 65+/-6 mm) (p<0.001). The overall preoperative MVCD (mm) and tenting area (cm2) was 10.4+/-2.8 and 2.4+/-0.6, respectively, which were both significantly reduced to 5.6+/-2.5 and 0.8+/-2.4 postoperatively (p<0.001). In comparison of the degree (%change) of improvement, Group II and III showed favorable effects on tethering force, compared with Group I. CONCLUSION: Our modified PMA is a relatively safe method to have the potential for improving tethering of the mitral valve and clinical outcome in evaluating mitral coaptation zone.

Off-pump coronary artery bypass grafting in a patient with paroxysmal nocturnal hemoglobinuria.

Paroxysmal nocturnal hemoglobinuria has not been described in patients undergoing off-pump coronary artery bypass grafting. A 65-year-old man who underwent percutaneous coronary stenting to the proximal left anterior descending artery for unstable angina was readmitted to our hospital complaining of recurrent chest pains. A coronary angiography revealed in-stent restenosis and new lesions of the distal left anterior descending artery as well as the left circumflex artery branch. He was found to have paroxysmal nocturnal hemoglobinuria which contributes to serious surgical complications including infection, bleeding, hemolysis and acute renal failure. After pancytopenia was treated with administration of granulocyte colony stimulating factor and transfusion of the washed red blood cells preoperatively, off-pump coronary artery bypass grafting was performed. Cardiopulmonary bypass was avoided in order to reduce activation of complements. His postoperative course was uneventful. Combination of appropriate perioperative management and off-pump cardiac surgery yielded an effective result in treating this patient without major complications.

Experimental study of a new operative procedure for nonischemic dilated cardiomyopathy: overlapping cardiac volume reduction operation.

PURPOSE: To assess a newly devised procedure for cardiac volume reduction without resecting any cardiac muscle and evaluate its effectiveness in an experimental settings. METHODS: Ten beagle dogs underwent a rapid pacing leading to heart failure for 3 weeks and then underwent left ventricular reduction by a procedure called the overlapping cardiac volume reduction operation (OLCVR), which consisted of a longitudinal incision in the left ventricular (LV) free wall, sutures from the left margin to the septal wall, and the right margin to the LV free wall. A slope of the linear preload recruitable stroke work relationship ( M(w)), with an X-intercept ( V(o)) were calculated as precise indicators of the LV systolic function. The constant of isovolumic pressure decay (Tau) and the peak filling rate (PFR) were also calculated as indicators of the LV diastolic function. RESULTS: The LV end-diastolic dimensions significantly decreased by OLCVR (43 +/- 2 to 25 +/- 1 mm). Fractional shortening significantly improved by OLCVR (11% +/- 2% to 30% +/- 4%). M(w) (erg. cm(-3). 10(3)) also significantly improved (21 +/- 2 to 33 +/- 3 ( P < 0.001)), whereas V(o), Tau, and PFR did not show any significant changes. CONCLUSION: The OLCVR significantly increased the early LV systolic function without any detrimental effects on the diastolic function. This procedure may therefore be a useful therapeutic option for end-stage cardiomyopathy.

Different effects of mibefradil and amlodipine on coronary vessels and during beta-adrenergic stimulation in conscious dogs.

Coronary effects of Ca -channel blockers mibefradil and amlodipine were compared in conscious dogs. Ten dogs were instrumented for measurement of aortic and left ventricular pressures, circumflex coronary blood flow velocity (CBFv), and coronary diameter (CD). A permanent catheter was implanted in the circumflex coronary artery. At doses having no systemic effects (7.5-150 micro g/kg), mibefradil and amlodipine increased CBFv and CD dose dependently. At the same dose, mibefradil increased less CBFv than amlodipine. However, for a similar increase in CBFv induced by amlodipine, mibefradil increased CD more. BAY K8644, an L-type Ca -channel agonist, prevented the CBFv and CD responses to amlodipine, but minimally affected the coronary responses to mibefradil. Intracoronary isoproterenol (6 ng/kg) increased LV dP/dt max, CBFv, and CD. Amlodipine markedly altered these responses, while mibefradil did not affect LV inotropic response and slightly altered CBFv response to isoproterenol. Thus, in conscious dogs, both mibefradil and amlodipine exert coronary vasodilation, with different patterns on coronary conductance and resistance vessels and during beta-adrenergic stimulation. These differences could be related to their actions on different Ca channels.

Reduced coronary vasodilator responses to amlodipine in pacing-induced heart failure in conscious dogs: role of nitric oxide.

1. This study examined whether NO is involved in the in-vivo coronary vasodilator effects of amlodipine (a calcium channel blocker) and whether heart failure (HF) alters the coronary responses to amlodipine. 2. Nine conscious dogs were chronically instrumented to measure circumflex coronary blood flow (CBF) and coronary diameter (CD). Drugs were administered directly into the circumflex artery through an indwelling catheter to avoid systemic changes. HF was induced by right ventricular pacing (240 b.p.m., 3 weeks). 3. Compared with control (C), in HF, coronary responses to acetylcholine (1 - 10 ng kg(-1)) were reduced while responses to nitroglycerin (0.1 - 0.5 microg kg(-1)) were unchanged. In C, amlodipine (30 - 150 microg kg(-1)), increased dose-dependently CBF and CD. After LNA (a NO synthase inhibitor, 2 mg kg(-1)), amlodipine produced less increases in CBF and CD (+121+/-26 ml min(-1) and +76+/-35 microm versus +196+/-40 ml min(-1) and +153+/-39 microm respectively for 150 microg kg(-1) amlodipine alone, both P<0.05). In HF, the coronary responses to amlodipine were reduced (150 microg kg(-1) of amlodipine increased CBF and CD +121+/-23 ml min(-1) and +77+/-21 microm respectively, both P<0.05). After LNA, the CBF responses to amlodipine tended to be reduced (+94+/-19 ml min(-1) at 150 microg kg(-1)) but CD responses were significantly reduced (+41+/-16 microm, P<0.05). The supplementation with L-arginine did not enhance the coronary responses to amlodipine. 4. These results indicate that, in conscious dogs, NO participates in the coronary responses to amlodipine and in HF, the coronary responses to amlodipine are reduced, which is related to a reduced NO production.