Indocyanine green angiography for intra-operative assessment in vascular surgery.

OBJECTIVES: Indocyanine green (ICG) angiography is used for the intra-operative assessment of the graft vessel in coronary artery bypass grafting to enable immediate revision if necessary. We report the feasibility and implications of an ICG colour imaging system, HyperEye Medical System (HEMS), in surgeries for arteriosclerosis obliterans (ASO) and abdominal aortic aneurysm (AAA) which carry risk of mesenteric ischaemia. METHODS: HEMS ICG angiography was used for the intra-operative assessment of 12 ASO patients and 10 AAA patients. RESULTS: In the ASO patients, HEMS angiography enabled visualisation of the graft and native artery. The fluorescent lucent region in the artery distal to the anastomosis was shown in 1 of 12 ASO patients. There was a 3-s time lag in the increase of intensity between the proximal artery and distal stenotic region. In AAA patients, HEMS angiography clearly showed the perfusion in the mesenteric arteries and intestinal wall as opaque. One AAA patient had segmental ischaemia due to thromboembolism and another one had diffuse ischaemia due to systemic malperfusion. The ischaemic region of the intestine was visualised as a fluorescent lucent area by HEMS angiography. CONCLUSION: HEMS angiography can accurately assess peripheral arterial perfusion in surgical cases with ASO and AAA.

[Insertion and removal of the intraaortic balloon pumping].

Intraaortic balloon pumping (IABP) is the most popular circulatory assist device. Although insertion and removal of IABP has proved to be a safer technique, a significant number of pitfalls have been seen. On the basis of our experience, we make several recommendations that may facilitate safer insertion and removal of IABP. Careful insertion and removal by experienced hands of cardiovascular surgeons should minimize complications.

[Vacuum assisted closure for postoperative mediastinitis using a portable aspirator].

We report a case of successful treatment of a methicillin resistant Staphylococcus aureus (MRSA) mediastinitis by vacuum assisted closure (VAC) using SB VAC system as a portable aspirator. A 67-year-old male with intellectual disability and diabetes mellitus suffered from angina pectoris and underwent on-pump coronary artery bypass grafting. He had a MRSA mediastinitis following the surgery. We started vancomycin administration and VAC. It was expected that using wall suction for VAC would be difficult because of his intellectual disability. So we performed VAC using SB VAC system as a portable aspirator. VAC therapy for mediastinitis after cardiac surgery is effective and SB VAC system can be used as a portable aspirator.

[Surgery for aneurysms of the aortic arch in elderly patients].

Surgery for aneurysms of the aortic arch in octogenarians can be performed with increased but operative mortality remains high. Minimally invasive operation may be required for further improvement of the outcome of surgery for aneurysms of the aortic arch in octogenarians. Aged patients with life-threatening events have excessive mortality and morbidity. We think that sugery for aneurysms of the aortic arch in octogenarians should not be withheld on the basis of age alone, but should be based on careful assessments of the relative medical risks and benefits, as well as the wishes of the patients and family.

Giant coronary artery aneurysm arising from sinus node artery.

A giant coronary aneurysm arising from the sinus node artery is reported. Diagnosis of this lesion by computed tomography and angiography is illustrated. The operative management is described. "Off-pump" aneurysmectomy was successfully performed. The role of occlusion test of the aneurysm inflow tract is emphasized.

Inverted left atrial appendage.

An unexpected left atrial mass was found during postoperative echocardiography in a 17-years old man following aortic valve replacement, suggesting thrombus, vegetation and neoplasm. Reoperation showed that the mass to be an inverted left atrial appendage. Left ventricular venting may cause such inversion. To prevent this complication, we suggest the use of careful monitoring and intraoperative transesophageal echocardiography.

[Aortic valve replacement for aortic valve stenosis due to congenital bicuspid aortic valve with abnormal positioning of coronary orifice, pseudotendon, and persistent left superior vena cava, report of a case].

A patient was a 65-year-old female who had a complaint of palpitation was diagnosed aortic valve stenosis due to congenital bicuspid aortic valve with pseudotendon by the echocardiographic examination. We suspected left single coronary artery by the aortography and the coronary artery angiography. Aortic valve replacement and resection of pseudotendon was performed with Carbomedics supra-annular aortic valve (21 A). During surgery, persistent left superior vena cava was detected. High-posterior take-off right coronary artery was casually detected at aortic closure. Ventricular fibrillation due to insufficient supply of cardioplegic solution at right coronary area frequently occurred after cardio-pulmonary bypass and percutaneous cardiopulmonary support was required. The patient was discharged 32 days after the operation. Preoperative and intraoperative evaluation was important in the case of aortic valvular disease.

[A case of successful reoperation for distal aortic arch pseudoaneurysm after replacement of descending aorta].

The patient was a 69-year-old man who had undergone replacement of descending aorta under close clump technique. Hoarseness occurred 8 years after the operation. Computed tomography and aortography revealed a saccular aneurysm of the distal aortic arch. During surgery, the pseudoaneurysm originated from a intimal defect close to the proximal anastomotic site of the graft. Total aortic arch replacement was successfully performed under retrograde and selective cerebral perfusion. The postoperative course has been uneventful.

Combined superior-transseptal approach versus conventional approach for mitral valve surgery.

OBJECTIVE: This study was designed to evaluate the safety and effectiveness of the combined superior-transseptal approach for mitral valve surgery. METHODS: We compared the preoperative status, operative factors, and postoperative outcomes among patients having mitral valve operations with three atrial incisions. The incisions were transseptal (n = 40), combined superior-transseptal (n = 33), and left atrial (n = 22). RESULTS: The cardiopulmonary bypass time and cross-clamp time were significantly higher in the superior-transseptal group compared with the transseptal group. No significant difference in blood loss was found among the three groups. The incidence of sinus node dysfunction in the early postoperative period was more common in the superior-transseptal group. The maintenance of sinus rhythm at the mid-term follow-up in patients with preoperative sinus rhythm was not significantly different among the three groups. On the other hand, a few patients in the superior-transseptal and transseptal groups with the preoperative sinus rhythm developed sick sinus syndrome requiring permanent pacemaker implantation. CONCLUSIONS: The use of the combined superior-transseptal approach was safe and effective, and was not associated with a higher incidence of rhythm disturbance. Because this approach provided an optimal exposure of the mitral valve and subvalvular apparatus, it has been positively adopted for use in patients undergoing complex and difficult mitral valve operation. To use this approach for patients undergoing mitral valve surgery through this approach, however, further follow-up study of the sinus node function is necessary.

[Simultaneous operation of intra-descending aorta bypass grafting and brachiocephalic artery reconstruction in a patient of aortitis syndrome].

A 42-year-old woman underwent concomitant intra-descending aorta bypass grafting and brachiocephalic artery reconstruction successfully. She was diagnosed as aortitis syndrome with brachiocephalic artery obstruction, severe stenosis of descending aorta and stenosis of right upper renal artery. Chief complaint was chest oppressive feeling, but none of brain nor upper extremity ischemia. Catheterization showed 100 mmHg pressure gradient across stenosis of descending aorta and 100 mmHg pressure gradient between ascending aorta and right brachial artery. In order to relieve hypertension and prevent right head and upper extremity ischemia, concomitant vascular reconstruction was performed using woven Dacron prostheses. Hypertension had subsided postoperatively, and she was relieved from any symptom.

A SP1 binding site in the GC-rich region is essential for a core promoter activity of the human endothelial nitric oxide synthase gene.

Endothelial nitric oxide synthase (eNOS) is an important oxygenase which catalyzes the conversion of L-arginine to L-citrulline to form nitric oxide (NO), a potent important factor for vasodilation and inhibition of platelet aggregation. We have analyzed characteristics of the promoter region of the human eNOS gene using the transient expression in human endothelial cells of CAT constructs with a series of 5'-deletion mutants. The 5'-flanking region between -116 and -98, which contains a putative consensus sequence for binding of transcription factor Sp1, is essential to direct a basal promoter activity. Gel mobility shift analysis involving anti-Sp1 antibody and competitor DNAs disrupted at the binding site for Sp1 reveals that Sp1 or its closely related protein(s) binds to the consensus sequence located between -104 and -96. These results indicate that the Sp1 site is essential for a core promoter activity of the human eNOS gene.

Floating cells in anterior chamber after IOL implantation.

Following planned extracapsular cataract extraction (PECCE) and posterior chamber lens implantation in rabbit eyes, aqueous humor samples were aspirated on the 3rd and 7th postoperative days and examined by transmission electron microscopy. The controls were cells from the aqueous humor of eyes which underwent only PECCE. Six different types of cells, namely, erythrocytes (including ghost erythrocytes), polymorphonuclear leukocytes, macrophages, lymphocytes, eosinocytes and plasmacytes, were observed in the aqueous samples, the following results were obtained. 1) In one control eye there was no significant difference in the ratio of macrophages between the 3rd and the 7th postoperative days. 2) On the 3rd postoperative day there was a significant increase in the macrophage ratio between one IOL implanted eye and one control eye (P less than 0.1). 3) On the 7th postoperative day there was a marked increase in one IOL implanted eye in the frequency of macrophages compared to the 3rd postoperative day of the same eye and the 7th postoperative day of one control eye. It was concluded that the macrophages had a close relationship with a specific cellular response to IOL implantation.

Spectrally selective flash early receptor potential (ERP) in dichromats.

The human spectrally selective flash early receptor potential (ERP) was studied in 12 dichromats: 6 protanopes (12 eyes) and 6 deuteranopes (12 eyes). Color filters used were Kodak Wratten filters No.23A, No.57, and No.47 for the red, green, and blue flash ERPs, respectively. The ERP amplitude was measured between the summits of R1 and R2. Mean amplitudes of the red flash ERP and green flash ERP were highly significantly decreased in the protanopes (p less than 0.001) and deuteranopes (p less than 0.01) as compared with the corresponding data in 10 normal subjects (20 eyes). The mean amplitude of the blue flash ERP was significantly lower than normal (p less than 0.001) in the deuteranopes. The mean ratio of the blue flash ERP amplitude to the red flash ERP amplitude showed a highly significant increase in the protanopes (p less than 0.001) and a highly significant decrease in the deutoranopes (p less than 0.001) compared with the mean ratio in the normal subjects, indicating a new, useful index for the objective clinical detection of congenital color defects.