[Treatment of a massive tracheal bleeding with percutaneous cardiopulmonary support].

A 69-year-old woman was admitted to our hospital with heart failure. Echocardiography demonstrated severe mitral valve regurgitation due to chordae rupture of the posterior mitral leaflet. Although she was intubated and ventilation was initiated, her condition did not improve. On the 17th hospital day, she was scheduled to undergo mitral valve plasty. After induction of anesthesia, massive bleeding occurred from the tracheal granuloma (diameter, 3 cm), which had developed at the tip of the tracheal tube, and the airway was obstructed. Emergency percutaneous cardiopulmonary support (PCPS) was then introduced. Thereafter, endoscopic hemostasis was performed, followed by the excision of the granulation tissue using a gastric fiberscope. After excising the tissue, the patient could be ventilated; therefore, she was weaned from PCPS. The maximum PCPS flow was 4.0 l/min, and it was conducted for a 210-minutes duration. Her respiratory condition improved, and she was weaned from the ventilator 3 days after surgery. Mitral valve plasty was performed 55 days after the first operation, and she was discharged from the hospital in good health.

[Reoperation due to failure of a Freestyle bioprosthesis].

We report re-do aortic valve and ascending aorta replacements by using the valve-on-valve technique for primary tissue failure of a Freestyle bioprosthesis. A 74-year-old male, who had had a 25 mm Freestyle bioprosthetic valve implanted by the sub-coronary method 5 years previously for aortic valve regurgitation due to congenital bicuspid valve, was referred to our hospital for dyspnea and palpitation. He presented with heart failure secondary to aortic regurgitation due to primary tissue failure, and computed tomography demonstrated an enlarged ascending aorta (5 cm in diameter). The operative findings revealed that the Freestyle bioprosthetic valve had a leaflet tear at the left coronary cusp. We replaced the degenerated Freestyle bioprosthesis with a 19 mm Mosaic aortic bioprosthesis by using the valve-on-valve technique, and ascending aorta replacement was performed simultaneously. This technique can be useful for re-do surgery for degenerated stentless valves to avoid potential risks of complete excision of the bioprosthesis.

[Unruptured aneurysm of the sinus of Valsalva associated with right ventricular outflow tract stenosis; report of a case].

A 51-year-old female was referred to our hospital for heart murmur and was diagnosed with right ventricular outflow stenosis by echocardiography. Six years later, follow-up echocardiogram revealed that the stenosis was caused by an aneurysm of the sinus of Valsalva (2 cm in diameter) originated from the right coronary sinus. Resection and patch closure of the aneurysm were carried out under complete cardiopulmonary bypass. The aneurysm was not associated with ventricular septal defect and was categorized as Sakakibara-Konno type I. Postoperative state was uneventful. Systolic murmur disappeared and pressure difference in the right ventricular outflow was normalized.

[Hemolysis after ascending and arch replacement of the aorta; report of a case].

A 60-year old man presented with hemolytic anemia, heart failure, and renal dysfunction 4 years after ascending and total arch replacement for Stanford type A aortic dissection. The hemolysis was caused by graft compression by a pseudoaneurysm arising from a proximal anastomosis. Reoperation of resection of pseudoaneurysm and repair of ascending aorta and arch successfully resolved these problems.

[Left circumflex coronary aneurysm with separated left main trunk].

We report a left circumflex coronary aneurysm associated with separated left main coronary trunks (LMT). A 66-year-old man was admitted to our hospital for further examination of dyspnea on effort. He has been performed maintenance hemodialysis since 1999 for chronic renal failure. Coronary angiography and multislice spiral computed tomography (CT) revealed an unusual coronary anatomic variance in which separate origins of the left anterior descending (LAD) and left circumflex (LCx) coronary arteries arose from the left coronary aortic sinus. Furthermore, these images of the LCx revealed an aneurysm 2 cm in diameter and 99% stenosis at the proximal of side of the aneurysm. Under cardioplegic arrest, the aneurysm was ligated and coronary artery bypass grafting (left thoracic artery to posterolateral branch) was performed. The patient was discharged at the 20th postoperative day without any complication.

[Acute aortic regurgitation by spontaneous rupture of a fibrous strand in fenestrated aortic valve; report of a case].

Although fenestration of the aortic valve cusps is a common anatomic finding, it rarely causes aortic regurgitation. We describe acute aortic regurgitation by spontaneous rupture of a fibrous strand in fenestrated aortic valve. A 65-year-old man was referred with sudden onset of dyspnea and cough. He diagnosed acute heart failure due to severe aortic valve regurgitation. After medical therapy, the aortic valve replacement was performed. Operative findings reviewed that a fibrous strand in the fenestrated non-coronary cusp was ruptured, which caused severe aortic regurgitation. Pathological examination showed the myxomatous degeneration. The postoperative course was uneventful, and the patient was discharged on postoperative day 11 with good health.

[Effects of intra-coronary and intra-graft administration of nicorandil for coronary spasm after coronary artery bypass grafting].

Coronary artery spasm after coronary artery bypass grafting (CABG) is relatively rare, but when it occurs, it is fatal. In cases of circulatory collapse just after surgery, coronary spasm should be suspected, and immediate diagnosis by coronary angiography is necessary. We conducted a study to assess the clinical characteristics of coronary spasm after CABG and the usefulness of intra-coronary and intra-graft administration of nicorandil. Study subjects were 7 patients (6 men and 1 woman, mean age 60.4 years) in whom coronary spasm after CABG was diagnosed angiographically from January 1992 to December 2003. Off-pump CABG (OPCAB) had been performed in 2 patients. Despite continuous administration of nitroglycerin and diltiazem hydrochloride during surgery, sudden circulatory collapse occurred during surgery or within 24 hours after CABG in all 7 patients. All required mechanical circulatory support, and emergency coronary angiography revealed severe graft and native coronary spasms. Intracoronary and/or intra-graft administration of diltiazem hydrochloride or nitroglycerin was not very effective, however, administration of nicorandil was effective for vasodilatation. One patient suffered brain damage and died, but the other 6 patients recovered and were discharged without complication. In conclusion, intra-coronary and/or intra-graft administration of nicorandil appears to be useful for the treatment of coronary spasm after CABG.

[Papillary fibroelastoma of the right atrium; report of a case].

Papillary fibroelastoma is a rare benign tumor commonly arising from a heart valve. We describe an unusual papillary fibroelastoma that arose from the right side of the interatrial septum. An intracardiac tumor was discovered by routine echocardiography in an asymptomatic 68-year-old woman. The echocardiographic examination revealed a 20 mm mobile tumor in the right atrium. Tricuspid obstruction was not observed, nor was regurgitation. The tumor was resected through a right atriotomy. It had multiple papillary fronds and arose from the interatrial septum. Pathologic examination confirmed papillary fibroelastoma. The postoperative course was uneventful, and the patient was discharged on postoperative day 13.

[Repair of thoracic and thoracoabdominal aortic aneurisms by the use of hypothermic circulatory arrest].

From 1993 to 2003, repair of thoracic and thoracoabdominal aortic aneurysms using hypothermic circulatory arrest via the left thoracotomy was performed in 115 patients at our hospital. Ninety-one of them were elective cases and 24 of them were emergent cases. Hospital mortality rate was 3.3% in elective cases and 12.5% in emergent cases. Over all hospital mortality rate was 5.2%. Ischemic spinal cord injury was occurred in 2 patients (1.7%). Both of them needed total replacement of thoracoabodominal aorta by the graft. In the near future, Adamkiewicz artery may be detected by the imaging technology preoperatively and we expect the repair of thoracoabdominal aortic aneurysm may become safer operation avoiding spinal cord injury. Hypothermic circulatory arrest is a relatively safe and reliable method for the repair of thoracic and thoracoabdominal aortic aneurysms.

[Prognosis and percentage of employment after the surgery in Marfan syndrome].

The percentage of employment in the Marfan patient after the Bentall procedure was studied. Eighteen of 20 patients (90%) returned to their daily life and are working well after the surgery. Seven patients (35%) needed the second operation due to the enlargement of false lumen during the follow-up period. Fatal cardiovascular accidents occurred in 7 their families (35%) in our series. Careful follow-up, adequate selection of medical and surgical treatment including second operation, medical examination of their families are important to keep the good quality of life in the Marfan patient.

[Long-term surgical outcomes of aortic arch aneurysm].

Between January 1990 and October 2001, arch replacement was performed in 99 patients with aortic arch aneurysm at Omiya Medical Center. For brain protection during surgery, antegrade selective cerebral perfusion was performed. There were 11 (11.1%) hospital death, and causes were heart failure (3), pneumonia (2), respiratory failure (1), mediastinitis (1), cerebral infarction (1), sepsis (1), myocardial infarction (1), and bleeding (1). During follow-up, 24 patients died, and causes were pneumonia (4), malignancy (3), heart failure (2), cerebral infarction (2), rupture of residual aneurysm (2), asthma (1), myocardial infarction (1), sepsis (1), multiple organ failure (1), traffic accident (1), and unknown (6). Postoperative survival was 75.2% at 3 years, 61.5% at 5 years, and 35.3% at 8 years. Event free ratio was 71.8% at 3 years, 58.6% at 5 years, and 30.8% at 8 years. Surgery of the aortic arch using selective cerebral perfusion is a safe and demonstrated acceptable short- and long-term outcomes.

Platelet damage caused by the centrifugal pump: laser-light scattering analysis of aggregation patterns.

Platelets are damaged by shear force during centrifugal pumping; however, the mechanism of this damage has not been fully investigated. A new laser-light scattering (LS) assay method enables quantification of real-time changes in the number of platelet aggregates of different sizes. Using this method, we assessed the kinetics of platelet damage caused by the centrifugal pump from the standpoint of platelet aggregation capacity. Conventional optical density (OD) and LS methods were used to measure platelet aggregation with a Kowa AG-10 aggregometer. Platelet aggregation in fresh human blood was evaluated in a mock circuit for 3 h under a flow rate of 5.0 L/min and a pressure head of 100 mm Hg. Test samples were obtained before pumping for control, and at 1, 2, and 3 h after the start of pumping. The test series was begun 8 times. Aggregation after stimulation by 2.0 microg/ml collagen was determined; small (9 to 25 microm), medium (25 to 50 microm), and large (50 to 70 microm) aggregates were counted by the LS method. OD measurement at hourly intervals showed significant reduction in platelet aggregation. The LS method showed that generation of small and medium aggregates was not suppressed during pumping, but that generation of large aggregates was significantly reduced at 2 and 3 h of pumping. Platelet aggregation is significantly suppressed during centrifugal pumping, and the resulting platelet dysfunction is due mainly to inhibited development of small aggregates into larger aggregates.

Preoperative risk factors for hospital mortality in acute type A aortic dissection.

BACKGROUND: Acute type A dissection is associated with postoperative complications and a high mortality rate. This study was performed to determine the perioperative risk factors leading to hospital mortality in patients with acute type A aortic dissection. METHODS: One hundred twenty-two patients with acute type A aortic dissection treated surgically within 48 hours after onset were enrolled in this study. Thirty-two perioperative risk factors were used in statistical analysis for prediction of mortality. Risk factors for hospital death were investigated with univariate and multiple logistic regression analysis. RESULTS: The in-hospital mortality rate including operative death was 12.3% (15 of 122 patients) and the actuarial survival rate (including in-hospital death) was 72%+/-6% at 5 years. Univariate analysis revealed 10 risk factors to be statistically significant predictors of hospital death: age, year of operation (1990 to 1995), Marfan syndrome, preoperative ST segment elevation, heart failure from aortic regurgitation, preoperative shock, preoperative coma, long operation time (> 6 hours), long cardiopulmonary bypass time (> 4 hours), and massive blood transfusion (> 20 units) (p < 0.05). Multiple logistic regression analysis confirmed preoperative ST-T segment elevation and massive blood transfusion to be statistically significant independent risk factors for hospital death (p < 0.05). CONCLUSIONS: Preoperative ST-T elevation and massive blood transfusion during operation were identified as significant independent risk factors for hospital mortality after operation for acute type A aortic dissection. Our findings should contribute to estimation of operative risk in individual patients.

Platelet activation and aggregation during normothermic cardiopulmonary bypass.

OBJECTIVE: The usefulness of heparin-bonded circuits under normothermic cardiopulmonary bypass has not been elucidated. We studied platelet activation and aggregation differences between heparin-bonded and nonheparin-bonded circuits in patients undergoing surgery involving normothermic cardiopulmonary bypass. METHODS: Eight patients underwent coronary artery bypass grafting with non heparin-bonded circuits (controls) and 7 the same with heparin-bonded circuits (heparin group). Heparin bonding was applied to the blood contact surface of our system, including the oxygenator and connecting tubes. Patient body temperature was kept between 36 and 37 degrees C. Beta-thromboglobulin and platelet factor 4 were measured before, during, and after cardiopulmonary bypass, and platelet aggregation was evaluated by laser-light scattering. RESULTS: Changes in beta-thromboglobulin and platelet factor 4 during and after cardiopulmonary bypass were similar in both groups. Small particle formation was the primary aggregate induced during and after cardiopulmonary bypass in both groups, and serial changes in particle formation up to 24 hours after cardiopulmonary bypass were similar in both groups. CONCLUSIONS: Our results indicate that in 2-3 hours of normothermic cardiopulmonary bypass, heparin-bonded circuits are similar to nonheparin-bonded ones in platelet compatibility.

Long-Term surgical outcomes following intraluminal sutureless graft insertion for type A aortic dissection.

The long-term outcome of sutureless intraluminal graft insertion remains unclarified. Therefore, we reviewed the late surgical outcomes of patients who underwent this procedure for acute type A dissection. Between March 1990 and May 2000, 80 patients aged from 36 to 92 years underwent isolated replacement of the ascending aorta for type A acute aortic dissection. The surgical procedures performed were replacement with an intraluminal sutureless graft in 18 patients (group 1) and suturing of the aorta with a conventional Dacron prosthesis in 62 patients (group 2). The cross-clamp, extracorporeal circulation, circulatory arrest, and operation times were significantly shorter in group 1 than in group 2, and the amount of total blood transfusion was also significantly less in group 1 than in group 2. The hospital mortality rates were 11.1% (2/18) in group 1 and 9.7% (6/62) in group 2 (P > 0.999). The 5-year actuarial survival rates (including operative mortality) were 71% +/- 11% in group 1 and 77% +/- 9% in group 2 (P = 0.268). The event-free survival rates at 5 years were 80% +/- 10% in group 1, and 67% +/- 13% in group 2 (P = 0.780). Regarding graft-related complications, long-term follow-up revealed one graft-related death and one reoperation in group 1 (12.5%), and no graft-related complications in group 2 (0%) (P = 0.047). In conclusion, intraluminal sutureless grafts required less blood transfusion, and shorter cross-clamp, extracorporeal circulation, circulatory arrest, and surgery times. However, the procedure did not improve the hospital mortality or long-term outcome. In fact, the rate of graft-related complications was significantly higher in the intraluminal sutureless group than in the sutured group. Therefore, the intraluminal graft insertion technique should be used only under exceptional circumstances.

Percutaneous extracorporeal life support for treatment of fatal mechanical complications associated with acute myocardial infarction.

Mechanical complications of acute myocardial infarction (AMI), such as free wall rupture, ventricular septal perforation (VSP), and mitral regurgitation due to papillary muscle rupture, are associated with high mortality rates. These complications result in extreme deterioration and increased risk of death in patients who do not receive timely resuscitation and surgical treatment. We studied the effectiveness of percutaneous extracorporeal life support (ECLS) for fatal mechanical AMI complications. Nine patients (7 men and 2 women, mean age 69 +/- 6 years) who suffered circulatory collapse refractory to conventional resuscitation were treated with ECLS. Circulatory collapse was caused by free wall rupture in 4 patients, VSP in 4, and mitral regurgitation due to papillary muscle rupture in 1. All patients were successfully resuscitated by ECLS and underwent surgical repair with conventional cardiopulmonary bypass. Eight patients required ECLS after surgery. Four of the 9 patients (2 with free wall rupture, 1 with VSP, and 1 with papillary muscle rupture) were successfully weaned from ECLS and were discharged. Three of the 4 survivors had no major complications, but the remaining survivor suffered neurological deficit. Four patients died while on devices. The duration of ECLS was from 13 to 167 h (mean 76 +/- 57 h) with a maximum bypass flow of 2.0 to 3.9 L/min (mean 2.9 +/- 0.6 L/min). There were no device-related complications during the support period. Total weaning rate was 56% (5/9), and survival was 44% (4/9). We conclude that ECLS can provide appropriate circulatory support during resuscitation and subsequent postoperative circulatory support for cardiovascular collapse associated with AMI complications.

Cytokine mediated endothelial activation during and after normothermic cardiopulmonary bypass: heparin-bonded versus non heparin-bonded circuits.

Studies evaluating cytokine production under normothermic cardiopulmonary bypass (CPB) are limited. We evaluated cytokine production, levels of thrombomodulin (TM), and soluble endothelium-derived adhesion molecules (ICAM-1) under normothermic CPB with and without heparin-bonded circuits. Nine patients treated with non heparin-bonded circuits (control group), and seven patients treated with heparin-bonded circuits (heparin group) were the subjects. Granulocyte elastase (G-E), and interleukin (IL) -6 and IL-8 were chosen as proinflammatory mediators, and TM and ICAM-1 served as indicators for endothelial damage. Blood samples were obtained before CPB, 30 minutes after initiation of CPB, at the termination of CPB, and 2 and 24 hours after CPB. G-E values in the heparin group were lower than those in the control group after 30 minutes of CPB. A G-E surge occurred at the end of CPB, and IL-6 and IL-8 surges were observed 2 hours after CPB in both groups. TM and ICAM-1 values, which were reduced at the initiation of CPB, returned to initial levels 2 hours after CPB, and exceeded them 24 hours after CPB compared with preCPB levels. Both groups showed similar changes. We conclude that there are no significant differences in serial G-E, IL-6, IL-8, TM, or ICAM-1 levels between the heparin and control groups during or after normothermic CPB for 2 to 3 hours.

Platelet activation in the gyro C1E3 centrifugal pump: comparison with the terumo capiox and the Nikkiso HPM-15.

The Gyro C1E3 was developed as a cardiopulmonary bypass pump incorporating the sealless double pivot bearing system. In this study, we evaluated platelet activation induced by the Gyro C1E3 in vitro and in comparison to that of other centrifugal pumps. Rates of increase (RI) for beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4) in the Gyro C1E3 were calculated from in vitro data and compared with the rate of increase in the Capiox (Terumo) and HPM-15 (Nikkiso) pumps. Fresh human blood was used, and a flow of 5.0 L/min with a DeltaP (pressure difference between the outlet and inlet of the pump) of 100 mm Hg employed. RI = Deltabeta-TG/DeltaN and DeltaPF4/DeltaN were used where Deltabeta-TG is the increase in beta-TG, DeltaPF4 is the increase in PF4, and DeltaN is the increase in the passing number and where N = Qt/V (t = time, V = priming volume, and Q = flow rate). The mean RI for beta-TG was 0.26 +/- 0. 05 in the Gyro C1E3, 0.20 +/- 0.07 in the Capiox, and 0.15 +/- 0.02 in the HPM-15. The mean RI for PF4 was 0.15 +/- 0.03 in the Gyro C1E3, 0.12 +/- 0.05 in the Capiox, and 0.09 +/- 0.04 in the HPM-15. While there was no difference in RI for beta-TG and PF4 between the Gyro C1E3 and Capiox, RI for beta-TG and PF4 were significantly higher in the Gyro C1E3 than in the HPM-15 (p = 0.006 and 0.029). In vitro evaluation using RI for beta-TG and PF4 showed platelet damage caused by the Gyro C1E3 and the Capiox to be nearly equal while the HPM-15 was less traumatic to platelets than the Gyro C1E3.

Early and late surgical outcomes of acute type A aortic dissection in patients aged 75 years and older.

BACKGROUND: With the general increase in human lifespan, aortic surgeons are faced with an increasing prevalence of acute type A aortic dissection in the elderly. In this study, we reviewed early and late surgical outcomes of acute type A dissection (operation within 48 hours after onset) in patients aged 75 years and older. METHODS: Between 1990 and 1999, 109 patients underwent emergency operation for acute type A dissection at Omiya Medical Center. Twenty-three patients were aged 75 years and older (elderly group, mean age, 79.1 +/- 4.7 years) and 86 were younger than 75 years old (younger group, mean age, 58.7 +/- 10.8 years). Early and late outcomes of both groups were compared. RESULTS: The hospital mortality rates were 13.0% (3 of 23) in the elderly group and 10.5% (9 of 86) in the younger group (p = 0.71). In the elderly, actuarial survival rate (including the operative mortality rate) at 1, 3, and 5 years was 78% +/- 9% for each point. In the younger group, the rates were 88% +/- 4% at 1 year, 83% +/- 4% at 3 years, and 81% +/- 5% at 5 years (p = 0.57). Actuarial event-free rates were 84% +/- 8% at 1 year, 77% +/- 11% at 3 years, and 77% +/- 11% at 5 years in the elderly group. In the younger group, the rates were 96% +/- 2% at 1 year, 88% +/- 4% at 3 years, and 81% +/- 7% at 5 years (p = 0.27). CONCLUSIONS: No significant differences in the hospital mortality, actuarial survival, or event-free rates were observed between the two groups. Operation for type A acute aortic dissection in patients aged 75 years or older can be performed with acceptable risk of death, and long-term results are satisfactory.

Transient rise in serum soluble Fas (APO-1/CD95) in patients undergoing cardiac surgery.

The Fas molecule, also designated APO-1/CD95, belongs to the tumor necrosis factor (TNF) receptor family. It is a widely expressed membrane-anchored protein that induces apoptosis by Fas/Fas ligand (Fas-L) mediation. It was reported that Fas-mediated apoptosis plays an important role in regulation of the immune system, systemic inflammatory response, and ischemia/reperfusion injury. A soluble form of Fas (sFas) is produced either through the proteolytic cleavage of membrane-bound receptors or by alternative splicing, and sFas is thought to be implicated in apoptosis. In addition, sFas released damaged cells, and elevated serum levels of sFas reflect systemic tissue damage. To examine the specificity of sFas production during cardiac surgery with cardiopulmonary bypass, we serially measured the serum sFas levels in 13 patients during and after surgery. Blood samples were obtained before surgery, at the end of cardiopulmonary bypass, at the end of surgery, and at 12 h after surgery. Levels of serum sFas were determined by sandwich ELISA. Seven patients undergoing other types of surgeries served as controls. Although increased sFas was not observed in the control group, a significantly higher sFas level was detected in cardiac surgical patients at the end of surgery than before surgery (p = 0. 028), and the level decreased at 12 h after surgery. A significant correlation was observed between the maximum sFas values and the length of surgery (r = 0.659, p = 0.012) and cardioplegic arrest (r = 0.559, p = 0.046). Elevated serum sFas levels were observed in patients undergoing cardiac surgery, and these serum sFas levels reflect the severity of a surgery. sFas may play an important role in the pathophysiology of surgical damage caused by cardiac surgery with cardiopulmonary bypass.