Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance.

OBJECTIVES: Spinal cord protection during thoracoabdominal aortic surgery is challenging for surgeons. We performed thoracoabdominal replacement using a strategy for maintaining spinal cord perfusion pressure. Here, we report our experience with this procedure and the surgical outcomes. METHODS: Between January 2000 and December 2014, 130 patients [male: 91 (74.6%), female: 39 (25.4%); mean age: 66.6 ± 12.8 years] underwent thoracoabdominal replacement using cardiopulmonary bypass at Hiroshima Shimin Hospital, Japan. The surgical outcomes of these patients were analysed. RESULTS: The in-hospital mortality rate of all patients was 2.5%. The incidence of postoperative paraplegia was 3.8%. Aortic event-free survival rates at 1, 3 and 5 years were 98.2%, 93.9% and 80.7%, respectively. CONCLUSIONS: The present study suggests that our strategy for maintaining spinal cord perfusion pressure provides acceptable outcomes.

Outlet strut fracture and leaflet escape of Bjork-Shiley convexo-concave valve.

Prosthetic valve fracture is a serious complication and may arise in patient post-valve replacement. We experienced an outlet strut fracture and leaflet escape of a Bjork-Shiley convexo-concave valve. We performed an emergency redo mitral valve replacement and successfully retrieved the fractured strut and escaped leaflet from superficial femoral artery and the abdominal aorta. The patient showed an uneventful postoperative recovery.

Outcomes of Anterolateral Thoracotomy With or Without Partial Sternotomy for Kommerell Diverticulum.

BACKGROUND: Kommerell diverticulum is a rare aortic arch anomaly. The indications for operative intervention and surgical strategy are still controversial. The standard surgical procedure at our institution is total aortic arch plus descending aortic replacement using anterolateral thoracotomy with partial sternotomy. The aberrant subclavian artery is reconstructed anatomically or extraanatomically. METHODS: From 2002 to 2014, 6 patients (1 woman), aged 55 to 78 years, underwent graft replacement through an anterolateral thoracotomy or anterolateral thoracotomy with a partial sternotomy approach for Kommerell diverticulum. All patients underwent graft replacement of the descending aorta or total aortic arch plus descending aorta in addition to aberrant subclavian artery reconstruction. RESULTS: No hospital deaths or major complications occurred. Recurrent nerve injury developed at discharge in 1 patient. All patients were well during the follow-up period (range, 11 to 116 months). CONCLUSIONS: Kommerell diverticulum and its associated symptoms were surgically treated with acceptable outcomes.

Operative results of the anterolateral thoracotomy with partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch.

Objectives: There are various treatment strategies for chronic-type B aortic dissection involving the aortic arch. Our aim was to review our surgical experience in the anterolateral thoracotomy with the partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch. Methods: From January 2000 to October 2015, 39 patients underwent the single-stage open surgery for chronic-type B aortic dissection involving the aortic arch using the anterolateral thoracotomy with partial sternotomy approach. Results: Among the 39 patients, 32 were men (82.1%; mean age at surgery, 61.3 ± 11.9 years), with a mean dissecting aortic aneurysm diameter of 50.21 ± 12.20 mm; 28 patients (71.8%) had patent false lumens of the descending aorta. The median interval from dissection occurrence until surgery was 34.05 ± 52.34 months. Twenty-one patients underwent descending aortic replacement plus total aortic arch replacement and 18 underwent descending aortic replacement (plus partial aortic arch replacement). Overall in-hospital mortality and postoperative stroke rates were 5.1% (2 patients) and 10.3% (4 patients), respectively. Survival rates at 1, 3 and 5 years were 94.7%, 94.7% and 90.2%, respectively. Aortic event-free rates at 1, 3 and 5 years were 90.9%, 90.9% and 80.2%, respectively. Conclusions: The anterolateral thoracotomy with partial sternotomy approach is a useful surgical procedure with acceptable outcomes for chronic-type B aortic dissection cases involving the aortic arch, when aortic remodelling using thoracic endovascular aortic repair cannot be performed.

[Closure of Ascending Aortic Entry by Debranching Endovascular Management in an Elderly Patient with Acute Stanford Type A Dissection].

An 85-year-old woman was hospitalized by emergency for an acute Stanford type A aortic dissection. Computed tomography showed a primary entry on the ascending aorta and pericardial effusion. Although her hemodynamics was unstable due to cardiac shock, her family wished no open surgery considering her age and frailty. A couple of days later, her condition became stabilized with antihypertensive therapy. Since the dissection was limited within the ascending aorta, closure of the entry with the stentgraft was considered appropriate and much less invasive as compared with an open surgery. After obtaining informed consent with her family, thoracic endovascular aortic repair was performed with Gore C-TAG with 2-debranch. The procedure was completed without complications and the entry closure was confirmed by aortography. Her postoperative course was uneventful. Her physical activity restored to the preoperative level and she was discharged.

[Thoracic endovascular aneurysm repair combined with debranching and chimney methods in a high risk patient; report of a case].

We report a case of a 77-year-old man with a thoracic aortic aneurysm, combined with chronic myelomonocytic leukemia, polymyalgia rheumatica, and atial fibrillation. Open surgery was considered as high risk because he was severely ill. Instead, partial debranching and stent graft( TEVAR) were performed by chimney method. He had no major complication after surgery, and was discharged on foot on the 15th postoperative day. In high risk cases of thoracic aortic aneurysm, TEVAR with debranching and chimney methods is effective.

Postinfarct cardiac free wall rupture detected by multidetector computed tomography.

Cardiac free wall rupture after myocardial infarction is one of the life-threatening complications, which often results in sudden onset of cardiogenic shock caused by cardiac tamponade. Multidetector computed tomography (MDCT) provides valuable information in any clinical setting. There have been a few case reports on detecting cardiac rupture by means of CT. We report here a rare case of postinfarct cardiac free wall rupture, whose myocardial tear could be detected by MDCT.

Atrionatriuretic peptide improves left ventricular function after myocardial global ischemia-reperfusion in hypoxic hearts.

Atrionatriuretic peptide (ANP) is reported to be useful for attenuating myocardial ischemia-reperfusion injury and improving left ventricular function after reperfusion. However, ANP may be either ineffectual or harmful in cases where the myocardium has been chronically hypoxic since birth. This can be a result of the concomitant high levels of cyclic guanosine monophosphate (cGMP) produced within the myocardium. This study aimed to verify the validity of using ANP to improve left ventricular function after myocardial ischemia-reperfusion injury. For this purpose, a cyanotic congenital disease model that was developed using isolated rat hearts was used. Hearts were obtained from Sprague-Dawley rats that were housed from birth until 6 weeks of age either in a hypoxic environment with 13-14% FiO(2) (hypoxic group) or in ambient air (normoxic group). These hearts were subjected to 30min of normothermic global ischemia followed by 30min of reperfusion using the Langendorff technique. Left ventricular functional recovery in hearts administered ANP (0.1µM) into the reperfusion solution was compared with those hearts that were not administered ANP in both hypoxic (without ANP: n=6, with ANP: n=6, with ANP and HS-142-1[an antagonist of ANP]: n=6) and normoxic hearts (without ANP: n =6, with ANP: n=6). In the hypoxic hearts, ANP administration improved the percent recovery of the left ventricular developed pressure (76.3±9.2% without ANP vs. 86.9±6.7% with ANP), maximum first derivative of the left ventricular pressure (82.4±1.1% without ANP vs. 95.8±6.5% with ANP), and heart rate (85.6±4.7% without ANP vs. 96.1±5.2% with ANP) after reperfusion. The improvement and recovery of these cardiac functions were closely related to significantly increased levels of postischemic cGMP release after ANP administration. The effect of ANP was blocked by HS-142-1. The improvements observed in the hypoxic group were similar to those found in the normoxic group. ANP administration during reperfusion improved left ventricular function after myocardial acute global ischemia-reperfusion equally in both the chronically hypoxic and age-matched normoxic groups.

Age-dependent vulnerability to ischemia-reperfusion injury of cyanotic myocardium in a chronic hypoxic rat model.

This study evaluated the effects of chronic hypoxia from birth on the resistance of rat hearts to global ischemia, with special emphasis on the duration of hypoxia. Male Wistar rats were housed from birth for 4 weeks or 8 weeks either in a hypoxic environment (FiO2 = 0.12) or in ambient air (8 animals for each group). Isolated rat hearts were perfused for 40 min with oxygenated Krebs-Henseleit buffer, subjected to 20 min global no-flow ischemia at 37, and then underwent 40 min of reperfusion. A non-elastic balloon was inserted into the left ventricle and inflated until the pre-ischemic LVEDP rose to 8 mmHg. Cardiac function was measured before and after ischemia. The post-ischemic percent recovery of LVDP in hypoxic hearts was worse than in normoxic hearts (4 weeks:55+/-7 vs. 96+/-3%, p0.01;8 weeks:40+/-5 vs. 92+/-4%, p0.01), and was worst in the 8-week-hypoxic hearts. Similarly, the percent recovery of dP/dt in the hypoxic hearts was lower than in the normoxic hearts (4 weeks:51+/-5 vs. 96+/-7%, p0.01;8 weeks:31+/-6 vs. 92+/-7%, p0.01), and was lowest in the 8-week-hypoxic hearts. In conclusion, cyanotic myocardium revealed an age-dependent vulnerability to ischemia-reperfusion injury in a chronic hypoxic rat model.

Early postoperative recovery by chronic dialysis patients after coronary artery bypass grafting.

OBJECTIVE: A faster start at rehabilitation has been a great benefit in reducing complications and costs after coronary artery bypass grafting (CABG). We studied early postoperative recovery from CABG in dialysis patients. METHODS: From January 2001 to May 2006, a total of 401 patients underwent isolated CABG at our institution. We retrospectively studied 348 consecutive elective cases, which were divided into two groups; 18 with dialysis (group D) and 330 without dialysis (group N), with respect to having meals, standing, and walking. RESULTS: An analysis of patient demographics revealed significant differences in gender, comorbidity of old cerebral infarction, anemia, and water balance during operation (P <0.05). Operative and in-hospital mortalities were 0% in group D. The percentages of the patients who were eating meals, standing, or walking on postoperative day (POD) 1 in group D were 88.9%, 66.6%, and 27.8%, respectively. In group N, these percentages were significantly higher: 96.1%, 85.5%, and 75.8%. But by POD 2, these values became similar. We considered that the delay of rehabilitation in group D was mainly due to hemodialysis on POD 1. CONCLUSION: Early postoperative recovery from elective isolated CABG in dialysis patients delayed a day against nondialysis patients. The delay was considered a result of the inevitable dialysis on POD 1.

Modified low-flow ultrafiltration ameliorates hemodynamics and early graft function and reduces blood loss in living-donor lobar lung transplantation.

BACKGROUND: This study analyzed the clinical application of modified low-flow ultrafiltration (MUF) to minimize cardiopulmonary bypass (CPB)-related adverse effects in patients undergoing living-donor lobar lung transplantation (LDLLT). METHOD: The study enrolled 33 consecutive patients who underwent LDLLT from 1999 to 2004: 8 patients underwent conventional CPB without MUF (control group), and 15 underwent arteriovenous MUF (MUF-treated group). Hemodynamics, graft function, blood loss and blood transfusion requirements, and clinical outcomes were analyzed. RESULTS: There was a significant increase in systolic blood pressure and a decrease in pulmonary to systemic pressure ratio in the MUF-treated group (p < 0.05). No hemodynamic changes occurred in the control group. MUF resulted in significant improvements in arterial oxygen tension/fraction of inspired oxygen ratio (PaO(2)/FiO(2;) 411 +/- 107 vs 272 +/- 107 mm Hg, p < 0.05) and the alveolar-arterial oxygen difference (a-aDO(2); 158 +/- 84 vs 315 +/- 127 mm Hg, p < 0.05) at 15 minutes after CPB. There were no differences in PaO(2)/FiO(2) and A-aDO(2) between the groups beyond 6 hours post-operatively. Post-operative blood loss and blood transfusion requirements were lower in the MUF-treated group than in the control group (p < 0.05). There were no differences in survival, duration of ventilation, intensive care unit stay, and hospital stay between the groups. CONCLUSIONS: The low-flow MUF brought improved hemodynamics and gas exchange capacity of transplanted grafts and lowered post-operative blood loss and blood transfusion requirement. This strategy may minimize CPB-related adverse effects in patients undergoing LDLLT.

Successful combined treatment of primary cardiac malignant lymphoma with urgent cardiac operation and chemotherapy.

A 56-year-old man, suffering from rapidly worsening general fatigue, dyspnea on exercise and epigastralgia, was referred for evaluation and treatment of a cardiac tumor. Transthoracic echocardiography showed a 6-cm large mass occupying both the right ventricle and atrium. Gallium scintigraphy showed high uptake in the tumor site. Lymphoma was highly suggested. Urgent operation was performed and as much tumor and thrombus were removed as possible. The postoperative course was good, with cessation of right heart failure. Pathological examination suggested malignant lymphoma, diffuse large B-cell type. The patient was treated with rituximab, cyclophosphamide, Adriamycin, vincristine, and prednisone (CHOP-R) postoperatively and has survived for 2 years without signs of recurrence.

Discrepancy between intraoperative transesophageal echocardiography and postoperative transthoracic echocardiography in assessing congenital valve surgery.

BACKGROUND: The purpose of this study was to investigate the discrepancy between intraoperative transesophageal and postoperative transthoracic echocardiography in assessing residual regurgitation in children undergoing valve repair. METHODS: Forty-two consecutive children (median age, 5.1 years) who underwent valve repair for valvar regurgitation from 2001 to 2004 were retrospectively analyzed. The patients were divided into two groups: atrioventricular valve group (n = 33) and aortic valve group (n = 9). Regurgitation grade, fractional shortening, and atrioventricular inflow velocity obtained by intraoperative transesophageal echocardiography were compared with those obtained by transthoracic echocardiography at discharge (median, 11 days) and at follow-up (median, 8 months). RESULTS: Intraoperative transesophageal echocardiography revealed specific residual lesions in 4 patients, leading to successful re-repair. Fractional shortening obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (p < 0.01). In the atrioventricular valve group, the regurgitation grade obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (0.7 +/- 0.8 versus 1.4 +/- 0.9; p < 0.01), and agreement between the two examinations was found in 12 patients (38%). Peak atrioventricular inflow velocity obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (p < 0.01). In the aortic valve group, there was no significant difference between the regurgitation grades in the two examinations (0.8 +/- 0.8 versus 1.1 +/- 0.9), and complete agreement in regurgitation grade was found in 5 (56%) of 9 patients. CONCLUSIONS: There were considerable discrepancies between the examinations in evaluation of residual atrioventricular valve regurgitation and potential atrioventricular valve stenosis: most of the residual regurgitations were underestimated by intraoperative transesophageal echocardiography. In contrast, reasonable agreement was found between the two examinations in evaluation of aortic valve regurgitation.