Surgery for primary cardiac tumors. Clinical experience and surgical results in 60 patients.

BACKGROUND: We reviewed our clinical experience with primary cardiac tumors, attempting to clarify the surgical management of these rare entities. METHODS: Between October 1978 and November 1999, we experienced 60 surgical cases of primary cardiac tumors. There were 23 male and 37 female patients (age range, 7 months to 84 years). Tumors included the following 3 groups: myxomas (n=49), nonmyxoma benign tumors (n=3), and malignant tumors (n=8). We reviewed the presenting symptoms, diagnostic data, anatomical findings, and surgical techniques, and evaluated the surgical RESULTS. Late follow-up was 95% complete (mean follow-up, 7.7+/-7.1 years). RESULTS: Tumors produced obstructive, embolic, and/or constitutional symptoms in most cases. Generally, echocardiography alone gave sufficient information for operation. Full-thickness excision was performed in 42 patients with myxoma. Complete excision was achieved in all of the nonmyxoma benign tumors and in none of the malignancies. Early mortalities in the 3 groups were 8.2% (4/49), 0% (0/3), and 12.5% (1/8), respectively. Late mortalities were 9.5% (4/42), 0% (0/3), and 100% (7/7), respectively. One patient with myxoma had recurrence, the cause of which was likely to be inadequate resection. The late deaths in patients with malignancies were due to metastasis or local recurrence. CONCLUSIONS: Benign tumors are generally curable if surgically excised. Preoperative refractory cardiac dysfunction or embolism should be avoided by the accurate evaluation on echocardiography. The prognosis of malignant tumors is poor if they are only debulked. However, aggressive surgery that can palliate obstruction and allow time for adjuvant therapy should be carried out.

Influence of renal function on serum and urinary heart fatty acid-binding protein levels.

BACKGROUND: Serum heart fatty acid-binding protein (H-FABP) has been reported to be a sensitive and early indicator of myocardial damage. However, circulating H-FABP may be cleared considerably from kidney, similar to that found for myoglobin. Therefore, the possibility exists that any change in renal function affects serum H-FABP concentration, and thus leads to erroneous interpretation. To evaluate the influence of renal function on H-FABP levels, we conducted a prospective study. METHODS: Nineteen patients undergoing isolated primary coronary artery bypass grafting were enrolled in this study. The patients were classified by the preoperative creatinine clearance into two groups: the control group (n=12); patients with creatinine clearance of 40 mL/min or greater, and the renal dysfunction group (n=7); patients with creatinine clearance of less than 40 mL/min. Serum H-FABP, CK-MB, troponin-T and urinary H-FABP levels were measured perioperatively. RESULTS: None of the patients had perioperative myocardial infarction. No significant differences were found in CK-MB and troponin-T levels between the groups. The renal dysfunction group resulted in significantly (p<0.05) higher serum H-FABP levels and lower urinary H-FABP levels than those in the control group, postoperatively. The creatinine clearance correlated inversely with the peak levels of serum H-FABP (r=-0.75, p=0.0001) and correlated with the peak levels of urinary H-FABP (r=0.64, p=0.003). CONCLUSIONS: The results indicate that the kidneys play an important role in the clearance of serum H-FABP. Thus, caution must be taken in interpreting this marker for myocardial damage during cardiac surgery in patients with renal dysfunction.

Biological activity of endogenous atrial natriuretic peptide during cardiopulmonary bypass.

To evaluate the effect of cardiopulmonary bypass (CPB) on atrial natriuretic peptide (ANP) biological activity in patients undergoing cardiac operations, we conducted a prospective study. Ten patients undergoing mitral valve surgery were enrolled. Plasma levels of ANP and cyclic guanosine monophosphate (cGMP), hemodynamic variables, and renal function parameters were assessed perioperatively. The molar ratio of cGMP to ANP (as a marker for ANP biological activity) decreased significantly (p < 0.05) during CPB despite similar plasma ANP levels. The ratio correlated inversely with the duration of CPB (r = -0.85, p = 0.002). The ratio also correlated with fractional sodium excretion (r = 0.65, p = 0.04) and correlated inversely with pulmonary vascular resistance (r = -0.79, p = 0.009) and atrial filling pressure (r = -0.84, p= 0.003) postoperatively. CPB decreased the molar ratio of cGMP to ANP, which may represent ANP biological activity, such as vasodilation and natriuresis. The phenomenon may contribute to water-sodium retention and pulmonary hypertension after cardiac surgery.

Effects of intraoperative administration of atrial natriuretic peptide.

BACKGROUND: Biological activity of endogenous atrial natriuretic peptide (ANP) may decrease during cardiopulmonary bypass. To evaluate the effects of intraoperative administration of exogenous ANP in patients undergoing cardiopulmonary bypass, we conducted a prospective randomized study. METHODS: Eighteen patients undergoing mitral valve surgery were randomized to receive either ANP treatment (ANP group; n = 9) or no ANP treatment (control group; n = 9). Atrial natriuretic peptide was given immediately after initiation of cardiopulmonary bypass for 6 hours (0.05 microg x kg(-1) x min(-1)). Plasma ANP, brain natriuretic peptide and cyclic guanosine monophosphate (cGMP) levels, hemodynamic variables and renal function were assessed perioperatively. RESULTS: Administration of ANP increased plasma cyclic guanosine monophosphate levels, urine output and fractional sodium excretion, and decreased preload, afterload and plasma brain natriuretic peptide levels significantly (p < 0.05). Plasma cyclic guanosine monophosphate levels correlated with plasma ANP levels (r = 0.95, p = 0.0001), correlated with fractional sodium excretion (r = 0.53, p = 0.02), and correlated inversely with systemic vascular resistance (r = -0.54, p = 0.02). CONCLUSIONS: Intraoperative administration of ANP had potent effects on natriuresis and systemic vasodilation by elevating cyclic guanosine monophosphate levels. The results suggest that the technique is useful for the management of hemodynamics and water-sodium retention after cardiopulmonary bypass.

Biocompatibility of heparin-coated extracorporeal bypass circuits: new heparin bonded bioline system.

Biocompatibility of a new type of heparin-coated cardiopulmonary bypass equipment, the Bioline, was evaluated in coronary artery bypass surgery cases. The heparin-coated (H) group (n = 15; Quadrox Bioline oxygenator/reservior and Carmeda BioMedicus BP-80 centrifugal pump) was compared with the nonheparin-coated (N) group (n = 12; uncoated, otherwise similar oxygenator, centrifugal pump, tubing, and filter set). Both groups used full systemic heparinization. The peak values of neutrophil elastase, C3a, IL-6, and IL-8 at 2 h after cardiopulmonary bypass (CPB), and C3a levels at the end of CPB and at 2 h after CPB were significantly reduced in the H group compared with those of the N group. However, no statistically significant intergroup differences were observed in thrombin-antithrombin complex, D-dimer, beta-thromboglobulin, or platelet factor-4. No significant differences were observed in hemostasis time, postoperative 12 h blood loss, required amount of blood transfusion, or intubation time. In conclusion, the Bioline demonstrated partially improved biocompatibility, in terms of leukocyte and complement activation, and proinflammatory cytokine production. However, it did not improve platelet activation, coagulation, or fibrinolysis cascade under full systemic heparinization. As a result, the clinical beneficial impact seemed to be the minimum.

Effects of angiotensin-converting enzyme inhibitor during warm blood cardioplegia.

BACKGROUND: Effects of captopril, an angiotensin-converting enzyme inhibitor, during warm blood cardioplegia were assessed in the blood-perfused, isolated rat heart. METHODS: The isolated hearts were arrested for 60 minutes with warm blood cardioplegia given at 20-minute intervals and were reperfused for 60 minutes. The control group (n = 10) received standard cardioplegia and the captopril group (n = 10) received cardioplegia supplemented with captopril (2 mmol/L). Cardiac function, myocardial metabolism, and cardiac release of circulating adhesion molecules were assessed before and after cardioplegic arrest. RESULTS: Left ventricular end-diastolic pressure and -dp/dt were significantly (p<0.05) lower and coronary blood flow was significantly (p<0.05) greater in the captopril group than the control group during reperfusion. The captopril group resulted in significantly (p<0.05) less cardiac release of lactate, thiobarbituric acid reactive substances during reperfusion. Cardiac release of intercellular adhesion molecule-1 was significantly (p<0.05) less in the captopril group at 60 minutes of reperfusion. CONCLUSIONS: The results suggest that supplementation of captopril during warm blood cardioplegia provides superior myocardial protection by suppressing lipid peroxidation and leukocyte-endothelial cell interaction during reperfusion.

Surgical treatment for graft stenosis after repair of an interrupted aortic arch: report of two cases.

We report herein two cases of patients who underwent successful reoperation for graft stenosis after repair of an interrupted aortic arch (IAA). The first patient was a 10-year-old girl who suffered from upper limb hypertension 9 years after her initial operation. Cardiac catheterization revealed a pressure gradient of 55 mmHg across the repaired arch. At reoperation, a left subclavian turndown anastomosis was performed, following which the hypertension resolved and a cardiac catheterization done 5 years later demonstrated sufficient growth of the restored arch with no significant gradient. The second patient was a 17-year-old boy who suffered from general fatigue and intermittent hypertension 12 years after his initial operation. Cardiac catheterization revealed a gradient of 60 mmHg across the repaired arch. He underwent an extraanatomic ascending to descending aortic bypass employing an additional 18-mm graft, and a postoperative cardiac catheterization showed no gradient between the ascending and descending aorta. Our experience has shown that IAA should be repaired without prosthetic grafts if possible. Although extraanatomic bypass is useful for reducing the operative risks at reoperation, a large graft should be used to avoid the need for a third operation. For young children expected to outgrow a second graft, performing an endogenous anastomosis, such as a left subclavian turndown anastomosis, should be considered as an alternative.

Coronary artery bypass surgery in a patient with myasthenia gravis.

A 73-year-old man with myasthenia gravis required quadruple coronary artery bypass grafting due to triple-vessel disease. Anesthetic management was performed with general anesthesia using a reduced dose of muscle relaxant with the aid of a neuromuscular transmission monitor. He was extubated 14 hrs after surgery without difficulty under this monitor. His postoperative course was uneventful. A patient with myasthenia gravis who required coronary artery bypass surgery was successfully performed by the deliberate preoperative evaluation of patient's myasthenic and cardiac status, and by the careful perioperative management.

A case report of surgical treatment of quadricuspid aortic valve associated with regurgitation.

A case of a 65-year-old woman who had a quadricuspid aortic valve associated with aortic regurgitation is reported. The patient had severe aortic regurgitation and four equally divided aortic cusps. The valve abnormality was detected by a transesophageal echo and an aortography. The incomplete aortic valve was excised and replaced by a St. Jude Medical prosthesis. Although this case had no coronary abnormality, a coronary displacement is often reported in quadricuspid aortic valve cases. In order to perform an operation safely, accurate information which is obtained by a non-invasive examination of the transesoph-ageal echo is quite valuable as it can indicate the need for further preoperative examinations of the coronary arteries.

Plasma exchange for hyperbilirubinemia following implantation of a left ventricle assist system: a case report.

A 49-year-old patient with end-stage dilated cardiomyopathy underwent implantation of a left ventricular assist system (LVAS). Although the systemic circulation seemed to be improved, the serum total bilirubin (Tbili) level increased sharply in the early postoperative period (preoperative Tbili, 5.7 mg/dl; postoperative day 3, 33.6 mg/dl). Plasma exchange (PE) was performed 7 times from postoperative day 4, and the Tbili level decreased to 16.3 mg/dl by postoperative day 11. Thereafter, serum Tbili normalized concomitant with improved circulatory condition. The cause of the hyperbilirubinemia was considered to be temporary right ventricular dysfunction or hepatic sinusoid endothelial dysfunction. The liver function was recoverable, so PE had been effective in this case. Unfortunately, the patient suffered a midbrain infarction and ultimately died. From this experience, PE is recommended if it is judged that liver function can be preserved and circulation is adequate, but its implementation should not be delayed. It is essential that LVAS is implanted before damage occurs to end-organ function and thus prevent hyperbilirubinemia.

Energy metabolism after cardiac surgery utilizing the indirect calorimeter: a new breath by breath technique.

The aim of this study is to clarify the relationship between pyrexia and energy expenditure (EE) after cardiac surgery utilizing the indirect calorimeter. Further the present study tried to determine in changes of energy substrate during mechanical ventilation after cardiac surgery. EE, oxygen consumption (VO2), carbon dioxide production (VCO2), cardiac index (CI), core temperature, and energy substrate were continuously measured in 26 patients after cardiac surgery. The patients were divided into two groups according to the highest core temperature postoperatively; Pyrexia group: > or = 38.5 degrees C, Non-pyrexia group: < 38.5 degrees C. EE after cardiac surgery in non-pyrexias was 1.33 times higher than calculated EE according to the Harris-Benedict equation. Moreover, EE in pyrexias was approximately 1.6 times higher. The mean EE in pyrexias increased to 27.8%/degree C. No significant differences were observed in VO2 or VCO2 between two groups. Time course of CI in pyrexias was different from that in non-pyrexias. Accordingly, energy substrate was not shifted in both groups except fat. This study suggested that the maintenance of core temperature below 38 degrees C after cardiac surgery is important on the aspect of energy metabolism.

Effects of supplemental L-arginine during warm blood cardioplegia.

OBJECTIVES: Effects of supplemental L-arginine, nitric oxide precursor, during warm blood cardioplegia were assessed in the blood perfused isolated rat heart. METHODS: The isolated hearts were perfused with blood at 37 degrees C from a support rat. After 20 minutes of aerobic perfusion, the hearts were arrested for 60 minutes with warm blood cardioplegia given at 20-minute intervals. This was followed by 60 minutes of reperfusion. The hearts were divided into the following three groups according to the supplemental drugs added to the cardioplegic solution. The control group (n = 10) received standard warm blood cardioplegia. The L-ARG group (n = 10) received warm blood cardioplegia supplemented with L-arginine (3 mmol/l). The L-NAME group (n = 10) received warm blood cardioplegia supplemented with L-arginine (3 mmol/l) and L-nitro-arginine methyl ester, a competitive inhibitor of nitric oxide synthase (1 mmol/l). After 60 minutes of cardioplegic arrest, cardiac function, myocardial metabolism and myocardial release of circulating adhesion molecules were measured during reperfusion. RESULTS: Left ventricular end-diastolic pressure was significantly lower (p<0.05) in the L-ARG group than in the control group and the L-NAME group during reperfusion. Isovolumic left ventricular developed pressure, dp/dt and coronary blood flow were significantly greater (p< 0.05) in the L-ARG group during reperfusion. The L-ARG group resulted in early recovery of lactate metabolism during reperfusion. Myocardial release of circulating intercellular adhesion molecule-1 (ICAM-1) and E-selectin were significantly less (p<0.05) in the L-ARG group at 15 minutes of reperfusion. CONCLUSIONS: The results suggest that augmented nitric oxide by adding L-arginine to warm blood cardioplegia can preserve left ventricular function and ameliorate endothelial inflammation. The technique can be a novel cardioprotective strategy in patients undergoing cardiac surgery.

Plasma and urinary levels of heart fatty acid-binding protein in patients undergoing cardiac surgery.

To evaluate the clinical significance of the plasma and urinary levels of heart fatty acid-binding protein (H-FABP) in patients undergoing cardiac surgery, a prospective study was conducted. Ten patients undergoing coronary artery bypass grafting were enrolled. Blood samples for determination of plasma H-FABP (pH-FABP), the MB isoenzyme of creatine kinase (CK-MB) and troponin-T (TnT), and urine samples for determination of urinary H-FABP (uH-FABP) were collected serially. None of the patients had perioperative myocardial infarction. The time to reach the peak level after aortic declamping was significantly (p<0.05) shorter for pH-FABP (1.4+/-0.5 h) than for CK-MB (2.5+/-0.5 h), TnT (6.6+/-1.3 h) or uH-FABP (3.0+/-0.6 h). Peak levels of pH-FABP correlated with those of CK-MB (r = 0.51, p = 0.04), TnT (r = 0.60, p = 0.03) and uH-FABP (r = 0.61, p = 0.03), and peak levels of uH-FABP correlated with CK-MB (r = 0.57, p = 0.04). Postoperative uH-FABP levels correlated inversely with the left ventricular stroke work index (r = -0.63, p = 0.04). This study demonstrated that H-FABP appears rapidly in plasma after reperfusion and reaches its peak earlier than other available biochemical markers; it appears also in urine and the levels correlated with cardiac function. Plasma and urinary H-FABP may be an early and sensitive biochemical marker for the diagnosis of myocardial injury in patients undergoing cardiac surgery.

Left ventricular myxoma: report of a case.

Although recent advances in echocardiography have made it easier to detect cardiac tumors, left ventricular myxomas are still rare and often not found until the patient presents with a history of syncopal episodes or systemic embolization. Left ventricular myxomas are usually benign and curable; however, unreliable excision of the myxoma due to poor visualization of the left ventricular cavity can result in recurrence. To prevent recurrence, it is necessary to select the most appropriate surgical approach to excise the myxoma completely. We report herein the case of a patient in whom surgical excision of a left ventricular myxoma arising from the posterior wall of the left ventricle was successfully performed.

[Influence of milrinone on internal mammary artery grafts].

To evaluate the effects of milrinone on blood flow in the left internal mammary artery (LIMA) grafts and hemodynamic variables, we conducted a prospective randomized study. Twenty-four patients undergoing coronary artery bypass grafting were randomized to receive milrinone treatment (Milrinone; n = 12) or no milrinone treatment (Control; n = 12). Milrinone was given after induction of anesthesia at a speed of 0.5 microgram/kg/min for 24 hours. After start of cardiopulmonary bypass (CPB), CPB perfusion flow was adjusted to 2.4 l/m2 and LIMA blood flow was measured. Blood samples for determination of plasma cAMP levels were collected and hemodynamic measurements were also assessed perioperatively. LIMA blood flow was significantly greater in Milrinone than that in Control (40 +/- 4 vs 29 +/- 4 ml/min/m2, p < 0.05). Plasma levels of cAMP were significantly (p < 0.05) greater in Milrinone than those in Control at tha start of CPB (18 +/- 1 vs 13 +/- 1 pmol/ml) and at the end of CPB (24 +/- 2 vs 17 +/- 2 pmol/ml). Systemic vascular resistance was significantly (p < 0.05) lower and cardiac index was significantly (p < 0.05) greater in Milrinone than those in Control postoperatively. With its positive inotropic and systemic vasodilator activities, milrinone may have direct vasodilator effect on LIMA.

Isolated tricuspid valve regurgitation resulting from severe annular dilatation: case report.

A rare case of isolated tricuspid regurgitation (TR) in a 65-year-old man is presented. Echocardiography revealed enlargement of the right atrium, dilatation of the tricuspid valve annulus without thickening or prolapse of the leaflets, and an intact atrial septum. No downward displacement of the tricuspid septal leaflet was observed by echocardiography. Mild mitral regurgitation and severe TR were detected on color flow Doppler studies. Cardiac catheterization indicated elevated right atrial pressure, with a pronounced V-wave. No left-to-right shunt was detected at the right atrium. At surgery, severe annular dilatation of the tricuspid valve (without organically diseased or deformed tricuspid leaflets) was observed, and tricuspid annuloplasty with a prosthetic ring performed. Postoperative echocardiography and right ventriculography showed trivial TR.

Recovery from lymphocytopenia following extracorporeal circulation: simple indicator to assess surgical stress.

This study investigated whether the lymphocyte count is a useful indicator to assess surgical damage following extracorporeal bypass. In Study 1, to investigate the correlation between extracorporeal circulating time (ECCT) and lymphocyte counts, 40 elective CABG patients were studied retrospectively. The lymphocyte recovery ratio (LRR), which represented the actual lymphocyte count divided by the preoperative lymphocyte count, was determined preoperatively, and on postoperative day (POD) 1, POD 3, and POD 5. In Study 2, the correlation between the interleukin-8 (IL-8) level and LRR was examined prospectively in elective CABG patients (n = 20). We measured the LRR and serum IL-8 levels preoperatively and during extracorporeal circulation (ECC) at 5 min, at the end of ECC, and 1, 3, and 12 h following ECC termination. Study 1 showed that the LRR decreased until POD 1 and gradually increased thereafter. The LRR had a negative correlation with the ECCT. In Study 2, the IL-8 level demonstrated a time course opposite to that of the LRR; it increased until 3 h after ECC termination and declined thereafter. There was a significant negative correlation between the LRR on POD 3 and the IL-8 level at 3 h after ECC termination. In summary, long-term ECC induced significant and prolonged lymphocytopenia. The LRR had a negative correlation with IL-8. These results indicated that the LRR may represent the degree of surgical stress following ECC; therefore, the counting of lymphocytes can be a quite useful bedside monitor to assess surgical damage and prognosis.

Ventricular septal defect of the atrioventricular canal type--report of a surgically treated case.

A 19-month-old male infant with Down syndrome was referred for investigation of heart murmur. An electrocardiogram showed normal axis (+100 degrees) of the QRS complex, incomplete right bundle branch block, and biventricular hypertrophy. Echocardiography revealed a ventricular septal defect (VSD) and a cleft of the anterior mitral leaflet with mild value regurgitation. The anterior mitral leaflet and the septal tricuspid leaflet attached to the same level of the ventricular septum were also delineated, however, no atrial septal defects were detected. Cardiac catheterization demonstrated pulmonary hypertension and a left to right shunt at the right ventricle. During operation, no defects in the atrial septum and no cleft of the septal tricuspid leaflet were found. Cleft of the anterior mitral leaflet, continuity between the mitral anterior leaflet and the tricuspid septal leaflet, and a VSD of the atrioventricular canal type were confirmed. The cleft of the anterior mitral leaflet and the VSD were repaired with the aid of cardiopulmonary bypass. The patient recovered uneventfully.