Blind subxiphoid pericardiotomy to relieve critical acute hemopericardium: a final report.

PURPOSE: Percutaneous catheter drainage (PCD) has been considered a standard method of relieving acute cardiac tamponade. Although conventional subxiphoid pericardiotomy is useful even for clotted hemopericardium, it has been believed to be unsuitable for emergency treatment because it is a time-consuming procedure. We report our modified pericardiotomy technique that can be used for emergency management. METHODS: We designed a prospective observational study to evaluate blind subxiphoid pericardiotomy (BSP) for critical cardiac tamponade due to hemopericardium. Emergency patients (n = 148) with acute hemopericardium secondary to trauma (n = 12), acute aortic disease (n = 122), or cardiac rupture following acute myocardial infarction (n = 14) were the subjects. Early results were compared between the BSP group (n = 53) and the PCD group (n = 95). RESULTS: BSP was effective at relieving cardiac tamponade in all 53 cases, but PCD was ineffective in 12 cases (12.6 %, p = 0.008). Procedure-related complication rates of BSP and PCD were 0 and 16.8 %, respectively (p = 0.002). Survival rates for the BSP and PCD groups were 18.9 and 6.3 %, respectively (p = 0.018). Since 2005, when we discarded the restriction that only board-certified surgeons should perform BSP, acute care physicians (including trainees) have performed BSP for 22 patients without procedure-related complications. CONCLUSIONS: BSP was safe and effective for cardiac tamponade due to acute hemopericardium. Critical complications during PCD for hemopericardium could not be avoided in some cases because of clots in the pericardium.

[The techniques of arterial anastomosis].

There are different techniques of arterial anastomosis. The selection of the most suitable technique is based on multiple evaluations, which include the position and direction of inserting point of suture, suturing procedure, anastomotic tension, suture intervals, pathogenesis and wall thickness of the artery, and satisfactory field of the anastomotic site. It is important to perform an accurate anastomosis to ensure enough blood flow without bleeding at the anastomotic site. Carrying out an accurate basic technique can prevent such complications of anastomosis as occlusion, pseudoaneurysm, and infection.

[Thoracoabdominal aortic aneurysm repair after detection of the Adamkiewicz artery by magnetic resonance angiography; a way to shorten operating time and improve outcome].

Surgical results were compared between 18 patients (group A) who underwent preoperative anatomic characterization of the Adamkiewicz artery by magnetic resonance angiography (MRA) and 38 patients (group B) without such imaging. In group A, intercostal or lumbar arteries related to the aneurysm were reattached to the graft only when they represented the origin of the Adamkiewicz artery. In group B, reconstruction from the Th 7 intercostal and the L2 lumbar arteries was performed whenever possible. In-hospital mortality was 16.7% in group A and 15.8% in group B. Total aortic clamp time and operating time were only 84 and 437 min in group A, compared with 134 and 589 min in group B. Three patients showed postoperative paraplegia in group B. No spinal cord injury occurred in patients whose artery had been detected preoperatively. Preoperative anatomic delineation of the Adamkiewicz artery by MRA can reduce risk of ischemic injury to the spinal cord and decrease operating time required for repair of thoracoabdominal aortic aneurysms.

[Antegrade selective cerebral perfusion for extended total arch replacement using separated graft technique; reassessment from the type of aneurysms and dissections].

One hundred eighty two patients with thoracic aortic aneurysms or dissections who required total arch replacement (TAR) were operated on with separated graft technique and selective cerebral perfusion (SCP) between 1991 and 2000. These patients were divided into 4 groups according to the pathology as follows: group 1; acute type A dissection, group 2; chronic type A dissection, group 3; distal arch aneurysm and group 4; proximal arch aneurysm. For SCP, both the innominate artery and the left common carotid artery were cannulated when the patient was cooled to a rectal temperature of 22 degrees C. Hospital mortalities were 27% in group 1, 14% in group 2, 19% in group 3, and 8% in group 4. Independent predictors of hospital mortality were shock, visceral, and leg ischemia in group 1, and circulatory arrest time of the lower half body to be more than 1 hour and cardiopulmonary bypass time to be more than 5 hours in group 3. Permanent neurological complication occurred in 3% in group 1 and 8% in group 3. Hospital mortality was affected by the type of aneurysms and dissections. It is necessary to give careful consideration to the indication of TAR with SCP, especially in acute type A dissection and distal arch aneurysm.

Significance of distal fenestration in graft replacement for chronic aortic dissection.

It is recently controversial whether distal fenestration is necessary in graft replacement for chronic aortic dissection. Several groups started to try the exclusion of intimal entry by the insertion of a stent-graft as a treatment for chronic aortic dissection, while conventional surgical techniques consisted of graft replacement with distal anastomosis to both the true and false channels. It should be kept in mind that the resultant occlusion of the false lumen after obliteration of the false channel could promote spinal cord ischemia. We report a patient with delayed paraplegia after graft replacement without distal fenestration for chronic type B aortic dissection. It is possible that not all cases of chronic aortic dissection are good for stent-grafting.

[Minimal incision abdominal aortic aneurysm repair]. / Die Minilaparotomie zur Versorgung des abdominellen Bauchaortenaneurysma.

OBJECTIVE: The use of a limited incision for abdominal aortic aneurysm (AAA) repair was evaluated, and its outcome was analyzed in comparison to standard open repair. PATIENTS AND METHODS: Between February 2000 and August 2001, 20 patients with an AAA underwent minimal incision repair (MINI) for tube graft implantation. The minimal skin incision was made after localization of aneurysm neck and aortic bifurcation by CT and DSA. For repair of the upper part of the AAA the abdominal incision was retracted toward the head of the patient who was in a jackknife decubitus position. Conversely, when the peripheral portion of the AAA was treated, the abdominal incision was retracted caudally with the patient in a flat or slightly bent decubitus position. The operation itself was performed using the standard conventional technique. The length of the abdominal incision was 10 cm. Clinical characteristics and in-hospital outcome of this procedure were compared to a group of patients who underwent repair of AAA by means of a standard open technique (OPEN). RESULTS: Patients age in the MINI and OPEN groups were similar (69 +/- 11 vs. 69 +/- 9 years). However, there were significant differences between the MINI and OPEN groups in the time for starting oral intake of food (2,4 +/- 1,2 vs. 7,4 +/- 5,5 postoperative days, p = 0,003), time for starting to walk outside the room (2,2 +/- 0,7 vs. 4,6 +/- 2,2 postoperative days, p = 0,01) and operation times (197 +/- 37 vs. 294 +/- 83 min, p = 0,0004). CONCLUSION: Minimal incision repair is technically feasible and combines the benefits of a minimal incision with those of conventional open repair, reducing patient recovery time.

[Surgical treatment of cardiovascular manifestations of Marfan syndrome].

The present study determines the effect of surgical treatment of cardiovascular manifestations of Marfan syndrome in 72 patients by 114 operations, during 34-year period. This therapy resulted in aortic root repair, aortic arch replacement, or both in 78, mitral valve repair in 9, descending thoracic aortic replacement in 14, thoracoabdominal aortic replacement in 10, and abdominal aortic replacement in 6, including total aortic replacement in 4 and nearly total aortic replacement in 4 patients. Fusiform aneurysms were present in the the ascending aorta in 37, the aortic arch in 2, the thoracoabdominal aorta in 2, and the abdominal aorta in 6 patients. Aortic dissection occurred in 40 (55.6%), including type A aortic dissection in 29 patients. Aortic root repair included separate valve-graft in 8, Bentall composite valve-graft in 25, composite valve-graft with button technique in 26, composite valve-graft with interposition graft technique in 10, and valve sparing procedure in 5 patients. The overall early (30-day) mortality was 7.9%. The early survival was 75% in separate valve-graft procedure and 99.2% in composite valve-graft procedure. Late coronary dehiscence did not occur in the patients with Bentall technique in which the reattachments of coronary ostia were performed in 2 layers, but occurred in 50% of patients with the coronary anastomoses in 1 layer. Aortic valve regurgitation relapsed in 2 of the 5 patients with valve sparing procedure. Event free rate for the patients with composite valve-graft using button technique was 81.1% at 10 years. There were 14 late deaths; dissection or rupture of the residual aorta, composite graft endocarditis and cardiac failure were the principle causes of late deaths. In conclusion, Marfan patients with cardiovascular diseases can undergo surgical treatment with a low operative risk and low morbidity. Although late endocarditis remains a serious problem, we believe that Marfan syndrome is a contraindication for valve sparing procedure. Because of the potential for late dissection or aneurysm in other areas of the aorta, patients with Marfan syndrome should have serial computed tomographic scans indefinitely.

[Esophageal rupture just after the graft replacement of thoracoabdominal aorta for chronic aortic dissection].

A 51-year-old man with thoracoabdominal aortic aneurysm (DeBakey IIIb type chronic aortic dissection) first underwent the graft replacement of thoracic aorta with elephant trunk technique. Postoperatively, the residual false lumen just distal to the inserted graft as an elephant trunk enlarged in a short period, and it compressed the esophagus. He underwent the second graft replacement of thoracoabdominal aorta 2 months after the first surgery. Just after the second surgery, he had the esophageal rupture probably because of direct damage due to the enlarged aneurysm and loss of the arterial blood supply due to the graft replacement. He died of bleeding from the distal anastomosis because of the uncontrolled graft infection. It may have to be kept in mind that the esophageal rupture after the graft replacement could be one of the reason of the graft infection when the aortic aneurysm severely compressed the esophagus preoperatively.

A clinically relevant CTLA4-Ig-based regimen induces chimerism and tolerance to heart grafts.

BACKGROUND: We determined whether a nontoxic CTLA4-Ig-based conditioning regimen effected mixed chimerism and donor-specific tolerance when heart and bone marrow were transplanted simultaneously. METHODS: Fully mismatched rat strain combinations were used. Recipients received total-body irradiation (300 centigrays), bone marrow (10(8) cells), and cardiac transplants from the donor on day 0. Subsequently, recipient animals received CTLA4-Ig (2 mg/kg, every other day, x 5 doses), tacrolimus (1 mg/kg/day; days 0 to 9), and one dose (10 mg) of antilymphocyte serum on day 10. RESULTS: All bone marrow recipients (n = 7) developed mixed chimerism (mean = 25% +/- 9% at 1 year) and accepted cardiac allografts permanently (> 375 +/- 32 days). Recipients that received conditioning regimen but no bone marrow (n = 5) rejected donor hearts within 51 +/- 13 days (p < 0.01). Recipients that accepted heart grafts also permanently accepted (> 180 days) donor-specific skin grafts, but rapidly rejected (< 10 days) third-party skin grafts. CONCLUSIONS: A nontoxic CTLA4-Ig-based conditioning regimen effects mixed chimerism and donor-specific tolerance when heart and bone marrow are transplanted simultaneously. This regimen may have clinical application.

Surgical treatment of thoracoabdominal aortic aneurysm after repairs of descending thoracic or infrarenal abdominal aortic aneurysm.

OBJECTIVE: The outcome of thoracoabdominal aortic aneurysm repair after operations for descending thoracic or infrarenal abdominal aortic aneurysm was investigated. METHODS: Between May 1982 and July 2000, 102 patients underwent thoracoabdominal aortic aneurysm repair. Of these patients, 36 had previously undergone operations for descending thoracic or abdominal aortic aneurysm. To evaluate the influence of previous descending thoracic or infrarenal abdominal aortic aneurysm repair on the results of TAAA replacement, patients were divided into two groups: one group of patients who had previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group I, n=36) and one group of patients who had not previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group II, n=66). RESULTS: Patients with previous descending thoracic or infrarenal abdominal aortic aneurysm repair had more chronic dissection and extensive thoracoabdominal aortic aneurysm. The distal aortic perfusion time and total aortic clamp time were both longer in group I. The total selective visceral and renal perfusion time and operation time did not differ significantly between the two groups. In 30-day mortality rates were 5.5% in group I and 13% in group II. Major postoperative complications included paraplegia in 14% of patients in group I and 3.1% in group II, renal failure requiring hemodialysis in 22% of patients in group I and 19% of patients in group II, respiratory failure in 36% of patients in group I and 30% of patients in group II, postoperative hemorrhage in 11% of patients in group I and 16% of patients in group II. CONCLUSION: The presence of a previous descending thoracic or infrarenal abdominal aortic aneurysm did not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.

Simultaneous cardiac operations with pulmonary resection for lung carcinoma.

OBJECTIVES: A procedure remains to be established for managing patients with both cardiac and pulmonary diseases requiring surgical interventions. We review our experience with 6 patients having cardiac disease and lung cancer surgically treated simultaneously to determine whether simultaneous surgery is safe and effective. METHODS: Subjects were 6 men with a mean age of 64 +/- 10 years undergoing cardiac surgery combined with pulmonary lobectomy from January 1986 through June 2000. Cardiac procedures consisted of coronary artery bypass in 3, coronary artery bypass plus left ventricular aneurysm repair, aortic valve replacement, and minimally invasive direct coronary artery bypass surgery in 1 patient each. All underwent lobectomy. RESULTS: No early deaths occurred. Bleeding complications occurred in 2 patients and lymph node dissection was incomplete in 3. Two died of carcinoma-related events, 1 at 28 and the other at 84 months after surgery. One died suddenly from a cardiac-related event 42 months after surgery. Only 1 patient is currently alive and disease-free at 104 months after surgery. CONCLUSION: Simultaneous surgery can be conducted with acceptable mortality. The occurrence of bleeding complications and incomplete lymph node dissection, however, indicates combined procedures only in patients requiring simultaneous surgery due to their disease or unable to tolerate a second operation.

[Video-assisted minithoracotomy versus conventional posterolateral thoracotomy for performing lobectomy of lung carcinomas].

This study was performed to evaluate the advantages of video-assisted minithoracotomy over conventional posterolateral thoracotomy for performing lobectomy of lung carcinomas. Thirty-two patients with clinical T1N0M0 non-small cell lung carcinoma underwent lobectomy with R2a mediastinal lymphadenectomy. Of these, sixteen patients underwent posterolateral thoracotomy (between April 1994 and November 1995: T group), and sixteen patients underwent video-assisted thoracic surgery (between December 1997 and April 1999: V group). No significant differences were found in the two groups with respect to the total number of mediastinal lymph nodes dissected (T group: 16.9 +/- 8.7. V group: 14.3 +/- 7.2) or operative time (T group: 182.3 +/- 48.8 min, V group: 174.9 +/- 28.8 min). The intraoperative blood loss was significantly less in the V group (T group: 222.3 +/- 107.1 ml, V group: 143.3 +/- 92.6 ml, p < 0.05), and the postoperative max CPK was also less (T group: 1,484 +/- 496, V group: 785 +/- 327, p < 0.0001). Duration of chest tube drainage (T group: 11.3 +/- 3.6 days, V group: 7.9 +/- 2.7 days) and the requirement of epidural analgesia (T group: 6.7 +/- 2.2 days, V group: 5.0 +/- 0.8 days) were less in the V group (p < 0.01), and the length of postoperative hospitalization as also shorter in the V group (T group: 26.3 +/- 8.3 days, V group: 20.6 +/- 4.1 days, p < 0.05). In conclusion, video-assisted minithoracotomy is less invasive than posterolateral thoracotomy for performing lobectomy of lung carcinomas, and has an advantage in that it improves the postoperative quality of life.

[Clinical study of warm heart surgery in emergent coronary artery bypass grafting].

Twenty-six nonrandomized patients undergoing emergent coronary artery bypass operation were assigned to either the cold group (traditional intermittent cold blood cardioplegia and slight hypothermic cardiopulmonary bypass (n = 7) or the warm group (intermittent warm blood cardioplegia and normothermic cardiopulmonary bypass) (n = 19). Preoperative variables were similar in both groups except the number of renal dysfunction patients were greater in the cold group. The time from removal of the aortic crossclamp to discontinuation of cardiopulmonary bypass was significantly shorter in the warm group and the incidence of heartbeat spontaniously converted to normal sinus rhythm after removal of the aortic crossclamp was higher in the warm group. The warm group showed good results concerning postoperative blood loss volume, change of base excess, time required for awakening and extubation. Significant differences were found in the hospital mortality rates between the groups (cold: 57.1%, warm: 5.3%). This study suggested a beneficial influence of warm heart surgery on postoperative hemodynamics, metabolic recovery and hospital mortality in emergent coronary artery bypass grafting.

Mixed hematopoietic chimerism prevents allograft vasculopathy.

BACKGROUND: Mixed hematopoietic chimerism has been shown to induce long-term acceptance of transplant organs. We determined whether mixed chimerism prevented allograft vasculopathy, using the rat aortic allograft model. METHODS: Mixed chimeras were prepared by reconstituting lethally irradiated (1100 cGy) WF rats with a mixture of T-cell depleted (TCD) syngeneic (WF) plus TCD allogeneic (ACI) bone marrow. Donor-specific (ACI) or third-party (F344) aortic grafts were transplanted into mixed chimeric animals 1 to 2 months after bone marrow reconstitution. No immunosuppressive drugs were administered. At 30 days postoperatively, aortic allografts were harvested for histology and measurement of cytokine mRNA by semiquantitative RT-PCR. Some aortic grafts were harvested at 90 and 180 days after transplantation for histological analysis. The degree of intimal hyperplasia and cytokine gene expression were compared among 4 groups: I (syngeneic; ACI donors to ACI recipients), II (allografts; ACI to WF), III (donor specific; ACI donor to chimeras) and IV (third-party; F344 to chimeras). RESULTS: There was no difference in the degree of intimal hyperplasia (IH) between groups I and III. Groups II and IV had significantly more IH than group I. Compared to group I, levels of mRNA for IFN-y, IL-2, IL-10 and iNOS in groups II and IV were higher, while there was no difference in mRNA levels between group I and III. CONCLUSIONS: These data suggest that mixed chimerism prevents allograft vasculopathy. Mixed chimerism holds great promise in clinical transplantation as a means to prevent allograft vasculopathy.

Mixed hematopoietic chimerism induces donor-specific tolerance for lung allografts in rodents.

Mixed hematopoietic chimerism is a state in which bone marrow hematopoietic stem cells from two genetically different animals coexist. We investigated whether mixed hematopoietic chimerism, resulting from the transplantation of host and donor bone marrow into a lethally irradiated rat, would confer donor-specific tolerance to lung allografts. Recipient rats (Fisher or or Wistar Furth [WF]) were irradiated (1,100 cGy) and reconstituted with a mixture of T-cell-depleted syngeneic plus allogeneic bone marrow. After mixed chimerism was documented by the presence of donor- and host-derived cells in the peripheral blood 4 wk after bone marrow reconstitution, mixed chimeras underwent orthotopic left lung transplantation with donor-specific and third-party lung allografts. No immunosuppressive agents were administered after lung transplantation. All donor-specific lung allografts were accepted by mixed chimeras (n = 40), while all third-party grafts (n = 7) were rejected within 10 d, a time course similar to that for grafts transplanted into naive recipients (n = 14). Radiation control recipients (n = 7) who did not develop mixed chimerism because the donor bone marrow had failed to engraft, also rejected donor-specific grafts within 10 d. We conclude that mixed hematopoietic chimerism induces donor-specific transplantation tolerance to lung allografts.

Mixed allogeneic chimerism prevents obstructive airway disease in a rat heterotopic tracheal transplant model.

BACKGROUND: Mixed bone marrow chimerism reliably produces donor-specific transplantation tolerance for a variety of solid organ and cellular grafts. We used a rat heterotopic tracheal transplant model for chronic rejection to investigate whether mixed chimerism could successfully prevent obstructive airway disease. METHODS: Mixed allogeneic chimeras were prepared by reconstituting lethally irradiated Wistar-Furth (WF) recipients with a mixture of 5 x 10(6) T-cell-depleted syngeneic (WF) and 100 x 10(6) T-cell-depleted allogeneic (ACI) bone marrow cells (ACI + WF --> WF). Mixed chimerism was present in all animals 28 days after bone marrow transplantation. Donor-specific, syngeneic, or major histocompatibility complex (MHC)-disparate allogeneic tracheas were implanted in recipient's omentum and removed for histologic analysis 30 to 150 days after transplantation. RESULTS: At 30 days after implantation, median luminal obstruction grades (0=none, 4=complete) of syngeneic and allogeneic tracheas were 0 and 4, respectively. Donor-specific (ACI) tracheas implanted in chimeric (ACI + WF --> WF) recipients were remarkably free of obstruction (median luminal obstruction grade=0 at 150 days) and had excellent preservation of respiratory epithelium. Third-party F344 tracheas implanted in chimeric recipients developed progressive luminal obstruction (grade 2 at 30 days, grade 3 at 90 days). CONCLUSIONS: Mixed allogeneic chimerism induces donor-specific tolerance and prevents development of the characteristic fibroproliferative obstructive lesion of bronchiolitis obliterans in a rat heterotopic tracheal transplant model. Excellent preservation of tracheal structure and morphology was achieved across major and minor histocompatibility barriers.

Inducible nitric oxide synthase suppresses the development of allograft arteriosclerosis.

In cardiac transplantation, chronic rejection takes the form of an occlusive vasculopathy. The mechanism underlying this disorder remains unclear. The purpose of this study was to investigate the role nitric oxide (NO) may play in the development of allograft arteriosclerosis. Rat aortic allografts from ACI donors to Wistar Furth recipients with a strong genetic disparity in both major and minor histocompatibility antigens were used for transplantation. Allografts collected at 28 d were found to have significant increases in both inducible NO synthase (iNOS) mRNA and protein as well as in intimal thickness when compared with isografts. Inhibiting NO production with an iNOS inhibitor increased the intimal thickening by 57.2%, indicating that NO suppresses the development of allograft arteriosclerosis. Next, we evaluated the effect of cyclosporine (CsA) on iNOS expression and allograft arteriosclerosis. CsA (10 mg/kg/d) suppressed the expression of iNOS in response to balloon-induced aortic injury. Similarly, CsA inhibited iNOS expression in the aortic allografts, associated with a 65% increase in intimal thickening. Finally, we investigated the effect of adenoviral-mediated iNOS gene transfer on allograft arteriosclerosis. Transduction with iNOS using an adenoviral vector suppressed completely the development of allograft arteriosclerosis in both untreated recipients and recipients treated with CsA. These results suggest that the early immune-mediated upregulation in iNOS expression partially protects aortic allografts from the development of allograft arteriosclerosis, and that iNOS gene transfer strategies may prove useful in preventing the development of this otherwise untreatable disease process.