[Does transradial cardiac catheterization affect coronary artery bypass grafting?].

Recent technological advances have enabled the miniaturization of catheters for coronary angiography and intervention. As a result of this advancement, the transradial approach is becoming more popular. The advantages of this approach include a lower incidence of access site complications, earlier patient ambulation, improved patient satisfaction, and lower cost. The cardiologists of our institute have introduced this technique without delay and have taken the initiative in Japan. However, there are concerns regarding the effect of transradial cardiac catheterization on the condition of radial artery grafts for coronary artery bypass grafting (CABG). In this study, we evaluated the influence of transradial catheterization on CABG. We retrospectively evaluated 157 patients who had undergone CABG using the radial artery. The condition of the grafts was assessed intraoperatively. Postoperative coronary angiography was carried out 3 months after the surgical intervention. The patency of the grafts was assessed by 2 cardiologists. One-quarter of the radial artery grafts were affected by transradial catheterization. Since most of them were located only at the puncture site, the graft itself was capable of being used for grafting after the resection of its affected distal end. The patency rate was not affected by transradial catheterization.

[Mitral valve myxoma that was resected with valve plasty].

Cardiac myxomas arising from the mitral valve are extremely rare. We describe the case of an asymptomatic 47-year-old male patient with a myxoma measuring 11 mm in diameter originating from the anterior leaflet of the mitral valve as observed by transthoracic echocardiography. The tumor was excised, and a defect in the anterior leaflet of the mitral valve was patched with autologous pericardium. Mitral valve regurgitation was observed and partial annuloplasty was performed. Following this, mitral valve regurgitation was observed to be diminished.

Risk of facial splashes in four major surgical specialties in a multicentre study.

This study analyses the results of face-shield blood spatter contamination at six medical facilities to determine exposure risk when facial protection is not used. Blood spatter exposure was evaluated on the basis of overall incidence, location of spatter on face shields, surgical specialty, risk for operating room staff, length of surgery and volume of blood loss. Six hundred face shields were evaluated for blood spatter contamination by visual inspection as well as by staining with leucomalachite green. The face shield was divided into three regions: Orbital (O-region), Paraorbital (P-region) and Mask (M-region). Visual examination detected blood spatter contamination in 50.5% (303/600) of the face shields, whereas leucomalachite green staining detected blood contamination in 66.0% (396/600). Blood contamination was 36.6% (220/600) in the O-region, 37.8% (227/600) in the P-region and 57.0% (342/600) in the M-region. Among operating room staff, the incidence of blood spatter was greatest among lead surgeons at 83.5% (167/200), followed by the first assistant at 68.5% (137/200) and the scrub nurse at 46.0% (92/200). By specialty, cardiovascular surgery was at highest risk with an incidence of 75.3% (113/150) followed by neurosurgery at 69.3% (104/150), gastrointestinal at 60.0% (90/150) and orthopaedic surgery at 60.0% (90/150).

[Impacts of aortic valve replacement on cardiac function in patients with aortic stenosis].

To prevent patient-prosthesis mismatch (PPM) after aortic valve replacement (AVR), we set up our original standard criteria for the selection of the size of the prosthetic valve. We also routinely perform supra-annular enlargement in patients with small aortic annuli. The objective of this study was to assess the impact of our procedure on the postoperative cardiac function of patients suffering from aortic stenosis (AS). We retrospectively reviewed 102 consecutive surgical patients with AS from 1999 to 2004. The patients were classified into the following 3 groups based on the sizes of their prosthesis (group S : 19 mm prosthesis, n = 34; group M : 21 mm prosthesis, n = 51; and group L : > 23 mm prosthesis, n = 17). Cardiac function was evaluated using echocardiography preoperatively, immediately postoperatively, and 6 months after the operation. There were no hospital deaths during the study period. A favorable hemodynamic outcome of all 3 groups was achieved. Our surgical strategy for AS was thought to be useful to prevent PPM after AVR.

[Advantage of supra-annular patch enlargement in aortic stenosis with a small aortic annulus].

BACKGROUND: We routinely perform supra-annular patch enlargement as a strategy to avoid patient-prosthesis mismatch (PPM) in patients with a small aortic annulus who are undergoing aortic valve replacement (AVR). METHOD: We performed a retrospective review of 128 consecutive single AVR patients from 1999 to 2005. Of these, 34 patients underwent supra-annular patch enlargement. The enlargement was selectively performed in patients at risk of PPM. This involved patch extension of the aortotomy just above the annulus of noncoronary sinus, and valve implantation with stitches placed directly on the patch. Along with this procedure, AVR with a valve size appropriate to body surface area (BSA) was performed. RESULT: Of these patients, 74% were female and the mean BSA was less than 1.50 m2. The enlargement required an average of 33 minutes of additional aortic clamp time. The 30-day mortality was 0%. A favorable hemodynamic outcome was achieved. CONCLUSION: Our results show that supra-annular patch enlargement can be performed with minimal added risk, relative to standard root enlargement and a satisfactory hemodynamic status can be achieved by employing this procedure.

[Simultaneous operation for annulo-aortic ectasia and mitral regurgitation in a patient with non-Marfan syndrome; report of a case].

A 74-year-old woman with non-Marfan syndrome underwent aortic root replacement and mitral valve replacement simultaneously for annulo-aortic ectasia and mitral regurgitation. Postoperatively, she suffered from cholecystitis and underwent percutaneous transhepatic gull bladder drainage. After this intervention, her postoperative recovery was uneventful. The purpose of this study is to suggest the possibility of mitral regurgitation due to annular enlargement of the mitral valve as an outcome of deterioration of the annulo-aortic ectasia.

Combined resection of distal aortic arch for T4N0 non-small-cell lung cancer with aortic arch invasion.

Three men age: 39-51 years (mean: 43.3 years) with T4N0 lung cancer infiltrating the distal aortic arch underwent combined resection of the left upper lobe, distal aortic arch, and left subclavian artery using partial extracorponeal circulation. Selective cerebral perfusion was used in 2. One underwent induction therapy (CDDP + VP - 16 x 2 + radiation 30 Gy), and all underwent adjuvant therapy. No postoperative complications or postoperative death occurred. Average ICU stay was 2.3 days. All patients are alive without local recurrence. Two were disease-free 37 and 26 months after surgery, and 1 had adrenal gland metastasis 8 months after surgery. Extended resection of the aortic arch in lung cancer is thus feasible and worthwhile in patients with T4N0 non-small-cell lung cancer.

Thoracodorsal artery as a free arterial graft for myocardial revascularization.

When complete arterial revascularization of coronary circulation cannot be accomplished using the internal thoracic artery and other conventionally used arterial conduits, the thoracodorsal artery may be an excellent alternative. We report the use of the thoracodorsal artery as a free arterial graft in 3 patients, describe the harvesting technique, and review the anatomy.

Mitral exposure technique for redo cardiac surgery. A left mediastinal pleurotomy and minimal adhesiotomy method.

We report an improved mitral exposure technique for mitral valve re-operation. Left mediastinal pleurotomy through a median sternotomy achieves rotation of the heart and excellent exposure of the mitral valve allowing the apex to drop posteriorly. We employed this technique in redo mitral valve surgeries for over a 3-year period. This minimal adhesiotomy method is technically simple, safe and time-saving.

Adenovirus-mediated glial cell line-derived neurotrophic factor gene delivery reduces motor neuron injury after transient spinal cord ischemia in rabbits.

OBJECTIVE: Glial cell line-derived neurotrophic factor (GDNF) has protective effects on various injuries involving the central and peripheral nervous systems in vitro and vivo. However, the possible protective effect of GDNF on spinal cord ischemia and the exact mechanism involved in the ameliorative effect of GDNF on ischemic spinal cord injuries are not fully understood. Therefore, we investigated the possible protective effect of the adenovirus-mediated GDNF gene delivery on transient spinal cord ischemia in rabbits. METHODS: The adenoviral vector (lacZ gene as a control or GDNF gene contained) was injected directly into the lumbar spinal cord via a needle inserted into the dorsal spine 2 days before the animal was subjected to 15 minutes of spinal cord ischemia induced by infrarenal aortic occlusion. In situ terminal deoxynucleotidyl transferase (TdT)-mediated dUTP-biotin nick-end labeling (TUNEL staining) was performed, and temporal profiles of the GDNF and caspase-3 (caspase-3 is the marker of apoptotic change) immunoreactivity were investigated. RESULTS: In the control rabbit, the majority of motor neurons showed selective cell death at 7 days of reperfusion. Immunocytochemistry showed that in situ TUNEL staining was selectively detected at 2 days of reperfusion in motor neuron nuclei. GDNF and caspase-3 were selectively induced in the motor neuron cells at 8 hours of reperfusion. In the GDNF-treated group, a large population of motor neuron cells was still surviving at 7 days after having been subjected to 15 minutes of ischemia. Unlike the control group, the GDNF-treated group expressed GDNF persistently. Induction of TUNEL staining and immunoreactivity for caspase-3 were greatly reduced by the GDNF treatment. CONCLUSION: These results suggest that the reduction in motor neuron death by GDNF was greatly associated with a reduction in DNA fragmentation and apoptotic signals of the caspase-3 cascade; they further suggest a great potential for gene therapy for paraplegic patients in the future.

Deep circumflex iliac artery as a free arterial graft for myocardial revascularization.

When complete revascularization cannot be obtained with the internal thoracic artery and the other arterial grafts, the deep circumflex iliac artery (DCIA) may be an excellent alternative conduit. The deep circumflex iliac artery was used as a free graft for direct myocardial revascularization in 4 patients from January to July 1999. We describe our experience with this arterial conduit, review the anatomy of the artery, and present our harvesting technique.

Induction of glial cell line-derived neurotrophic factor and c-ret porto-oncogene-like immunoreactivity in rabbit spinal cord after transient ischemia.

The mechanism of spinal cord injury has been thought to be related with tissue ischemia, and spinal motor neuron cells are suggested to be vulnerable to ischemia. To evaluate the mechanism of such vulnerability of motor neurons, we attempted to make a reproducible model of spinal cord ischemia. Using this model, the inductions of glial cell line-derived neurotrophic factor (GDNF) and the c-ret porto-oncogene (RET) receptor tyrosine kinase were investigated with immunohistochemical analyses for up to 7 days of the reperfusion following 15 min of ischemia in rabbit spinal cord. Spinal cord sections from animals sacrificed at 8 h, 1, 2, and 7 days following the 15 min of ischemia were immunohistochemically evaluated using monoclonal antibodies for GDNF and RET. Following the 15 min of ischemia, the majority of the motor neurons showed selective cell death at 7 days of reperfusion. Immunoreactivity of GDNF and RET were induced at 8 h of reperfusion selectively in motor neuron cells. No glial cells were stained in the spinal cord sections. The induction of GDNF and RET proteins at the early stage of reperfusion may be related to the transient functional recovery of neurons after ischemia.

[Use of the radial artery graft in coronary artery bypass grafting: harvesting technique and spasm prevention].

The use of radial artery (RA) in coronary artery bypass grafting (CABG) has been increasing recently as a revival. In this report, we describe several practical suggestions for improving patency rate of the graft. Between April of 1997 and February of 1998, 41 CABGs were performed using RA graft, totalling 56 anastomoses. The early patency rate of the graft has been 100% (graft: 38/38, anastomosis: 53/53). Harvesting technique: with the use of Harmonic Scalpel, it is possible to atraumatically harvest the vessel in a short time. Although longitudinal fasciotomy of the adventitia has been recently reported to be effective in releasing spasm, the nature of the vessel raise concern that the fasciotomy may even induce spasm. We hypothesize that leaving the adventitia intact, preserving vasa vasorum, rather than performing fasciotomy leads to improvement of long-term patency. Spasm prevention: we consider the body temperature to be the most important factor. Therefore, we utilize normothermic cardiopulmonary bypass (CPB). Another important factor is that the arterial CO2 is kept at a high level during CPB. For dilation of RA graft, milrinone is used instead of papaverine. For the intra- and postoperative management, intravenous continuous administration of diltiazem was changed to nicorandil. Technically, essential resolution for improvement of patency rate is either to allow for large proximal anastomosis, or to make sequential anastomosis with another coronary artery which has a good run off. For these purposes, the proximal anastomosis on the ascending aorta seems to have the advantage over placing it on ITA.

[Postoperative chylothorax treated with fibrin glue and absorbent mesh: a case report].

A 66-year-old man was treated by graft replacement for a thoracic aortic aneurysm. Chylothorax occurred on postoperative day 2. In spite of cessation of oral intake and IVH management, chest tube drainage did not decrease, the patient became malnourished. A chest X-ray and CT scan revealed the massive pleural effusion. Reoperation assisted with a thoracoscopy was carried out for chylothorax on postoperative day 27. Because we were unable to find the thoracic duct and the leakage point, the fibrin glue and absorbent mesh was applied to parietal and mediastinal pleura. Four days after reoperation, the chest tube was removed. This method is useful for this type of a chylothorax and lymphorrhea.

[Atraumatic local interruption technique for coronary circulation in MIDCAB].

Various methods have been employed for "local" interruption of the coronary blood flow before anastomosis during MIDCAB. However, coronary artery injury caused by a snare and coronary artery stenosis at the snare site resulting in late complications have been reported. We utilize a technique that minimizes the risk of injury to the coronary artery. At about 1 cm proximal to the coronary artery incision, expanded polytetrafluoroethylene (ePTFE) suture (GORE-TEX Suture CV-3 with an 18 mm needle that is tightly curved) is placed around the coronary artery, picking up a large chunk of myocardium with the curve of the needle. A Teflon felt is then attached, and threaded through a tourniquet. The tourniquet is tightened with the minimum strength needed for hemostasis. In order to avoid damage to the distal side of the coronary artery incision, a snare is not placed. Instead, an intraluminal occluder is used to block the blood flow. Anastomosis can easily be obtained with the use of a stabilizer. Hemorrhage from passage of suture is negligible, even during administration of 1.5 mg/kg heparin, because there is no difference between the diameter of the needle and that of the thread (diameter: 0.422 mm). The thread stretches minimally along the major axis but is flexible along the minor axis and thus produces less vascular wall trauma than does polypropylene thread. Furthermore, when the coronary artery is tightened through the cushiony myocardium and the Teflon felt by the flexible GORE-TEX thread, the injury to the coronary wall is minimized.

Three-graft technique for ascending aorta and total aortic arch replacement.

We have developed a procedure for total aortic arch replacement using three separate Hemashield grafts and establishing deep hypothermic circulatory arrest and continuous retrograde cerebral perfusion followed by antegrade cerebral perfusion. This method is technically simple and yields secure anastomoses.

[Size estimation method for patch used in reconstruction of LV cavity].

The reconstruction of LV cavity is accomplished by suturing a patch to the viable myocardium to exclude the infarcted area from the high LV pressures. However, there is no clear guideline to estimate the size of patch used for LV reconstruction. We have designed a new method to determine the correct patch size, and applied it in 5 cases. The suture line of the patch is at the junction of contractile (functional) and infarcted portions of LV. The patch size is determined by the length of AB, termed "a", as the base, where "point A" represents the junction on the LV anterior wall side, and "point B" the junction of the LV posterior wall side, from RAO 30 degrees projection of the left ventriculogram obtained by cardiac catheterization. In LV aneurysm, we designed the patch in the range of a/2 < l < or = pi a/2, where patch length on RAO 30 degrees is considered "l". An effort was made to reconstruct to normalize LV volume and contour by designing the patch size to be a/2 < l < a, particularly when the contractile portion was enlarged by aneurysm. On the other hand, in post AMI VSD, LV contractile portion is not enlarged in early stage. Therefore, the patch was designed in the range of a < l < or = pi a/2 to maintain LV volume. Postoperative LV volume can be calculated prior to surgery, by using the lengths of the designed patch. Postoperative analysis indicated that the actual LV volume and contour were almost identical to our estimation. This method is very useful in planning the patch size for LV reconstruction.

[Clinical results of left ventricular free wall rupture following acute myocardial infarction].

We studied 19 cases of Left Ventricular Free Wall Rupture (LVFWR) following acute myocardial infarction, admitted to our CCU between 1987 and 1996. We were able to treat 15 patients and diagnosed 4 cases as LVFWR at postmortem after sudden deaths. Of the treated 15 patients, 11 survived: 1 out of 2 repaired under cardiopulmonary bypass (CPB), 5 out of 7 repaired without CPB, and 5 out of 6 non-surgically treated. Although the survival rate for those able to be treated was 73%, overall rate was 58%. There were 7 cases of blow-out type: 4 of which were sudden deaths, and 3 were operated. Thoracotomy and direct closure of rupture without CPB was done at bed-side in 2 cases. Even though hemostasis was successful, they did not survive. The 3rd case survived with the patch closure under CPB. In this case, the circulation was maintained pre-operatively with the pericardial-central venous bypass drainage method. This method seems to be extremely effective in saving blow-out cases. There were 12 subacute patients. Although 2 cases were lost, total of 10 patients were saved, including 2 direct suture closures of rupture without CPB, 3 median sternotomy and fibrin-glue fixations, 1 where only pericardial drainage was done, and 4 in whom percutaneous intrapericardial fibrin-glue fixation therapy was utilized. Since the risk of secondary damage to the fragile infarcted are from direct suturing of ruptured myocardium exists in LVFWR, we changed to the Infarction Exclusion Technique under CPB during surgical repair, based on our experiences with ruptured intraventricular septum. In general, the only treatment believed to be available for LVFWR has been surgical. However, our experiences suggest that other treatments may also be effective. If the best suitable method could be chosen from various therapies, it may contribute to improving outcome statistics. The reduction of left ventricular pressure in the treatment is extremely important, being the key to improving survival rate.

[Infarction exclusion technique for postinfarction ventricular septal defect].

A new technique for post-infarction ventricular septal defect is accomplished by suturing a single patch to healthy endocardium excluding the infarcted area from the high left ventricular pressure. We have used this infarction exclusion technique for 3 cases since 1994. Three patients developed cardiogenic shock before operation and were managed initially with an intra-aortic balloon pump. All patients were urgently operated using this technique, at the same time, CABG operation was performed in 2 cases from the finding of preoperative coronary angiography. All of the patients survived. The first patient had a residual shunt (L-R; 30%), which spontaneously resolved in one month after the operation. In this method, a two-dimensional plane patch has to be sutured to healthy endocardium like a three-dimensional dome. Consequently the edge of the patch has wrinkles, which cause a residual shunt easily at the suture line. So from the second case, previously prepared circular conic patch, which had been made from a plane circular patch, was sutured to the left ventricular endocardium. At the suture line, this conic patch was well fitted to the endocardium, and the patients had no residual shunt. Though this method has the advantage to retain left ventricular function and volume, the technique must be improved to prevent residual shunt after operation.

[A case report of reconstructive operation in traumatic tricuspid regurgitation].

Tricuspid regurgitation due to non-penetrating trauma occurred in a 21-year-old male patient who had received chest trauma in a motorcycle accident. Echocardiography demonstrated prolapse of the tricuspid anterior leaflet into the right atrium and massive tricuspid regurgitation. He was diagnosed as traumatic tricuspid regurgitation from his past history of the trauma. A reconstructive operation was performed successfully 4 years after the trauma. The chordal rupture of the anterior tricuspid leaflet was repaired using PTFE suture and annuloplasty of the dilated annulus was made using Carpentier ring. Tricuspid regurgitation was completely repaired as shown by the postoperative echocardiogram.