Utility of echocardiographic evaluation of donor hearts upon the organ procurement for heart transplantation.

BACKGROUND: Evaluating donor heart as accurately as possible upon the organ procurement would help lead careful post-transplant heart management. Our institution (National Cerebral and Cardiovascular Center, Osaka, Japan) has sent a transplant cardiologist upon the organ procurement for evaluating a donor heart ever since our first case of heart transplantation. METHODS: Thirteen consecutive bedside echocardiograms obtained from donors upon the organ procurement and post-transplant echocardiograms obtained from their recipients were retrospectively reviewed. The impact of donor echocardiograms on their recipients' post-transplant time course was analyzed and both the donor echocardiographic parameters and their recipients' parameters within 1 week after the heart transplant were compared. RESULTS: Both the left ventricular end-diastolic diameter and the ventricular wall thickness of donors correlated well with those parameters of their corresponding recipients (r(2)=0.740, p<0.0001, r(2)=0.704, p<0.0001, respectively). The information on coronary flow of the donor heart with risk factors for ischemic heart disease was useful for judging the availability for heart transplantation. The information on the pre-existing localized wall motion abnormality of donor hearts was useful for ruling out a possibility of rejection and other causes of wall motion abnormality after transplantation. The mean time required for bedside echocardiography for the donor heart was only 3.7 min. None of the recipients either developed primary graft failure or required treatment for cellular rejection. CONCLUSIONS: Detailed observation of donor hearts by bedside echocardiograms upon the organ procurement is of clinical benefit.

Efficacy of a heparin-coated closed circuit for intractable bleeding in adult cardiac surgery.

Hemostatic procedures and control of blood pressure concomitant with rapid transfusion of blood products aimed at recovery of coagulability are necessary for intractable bleeding during cardiac surgery. However, when the bleeding is massive and hemostasis is prolonged for several hours, operative maneuvers such as manual compression of the heart can affect hemodynamics, decrease cardiac output, and elevate atrial and venous pressure, with consequent hepatic, renal, and pulmonary dysfunction over time. Herein we present three cases of potentially fatal bleeding during open-heart surgery, in which we used a heparin-coated closed circuit for circulatory support after standard cardiopulmonary bypass. We achieved stable hemodynamics following surgical hemostatic maneuvers and avoided the postoperative multiple organ failure by using a cardiopulmonary support system.

Clinical course and outcome of heart transplant recipients: single center experience at the National Cardiovascular Center in Japan.

The number of heart transplant (HTx) surgeries in Japan is expected to increase under the Revised Organ Transplant Law. To date, among 69 HTx surgeries performed in Japan, 27 operations (39.1%) were performed at our institution, the National Cardiovascular Center (NCVC), located in Osaka. We have reviewed the outcomes of HTx conducted at NCVC during a 10 year period (May 1999 to January 2009). Among 27 heart transplant recipients at NCVC, the clinical charts of 26 recipients whose post-HTx period exceeded 1 year were retrospectively reviewed and compared to data from the International Society for Heart and Lung Transplantation (ISHLT) Registry. The survival rate of our recipients was 96.2% at 10.8 years, which was excellent even compared to the ISHLT Registry. The immunosuppressive regimen at NCVC was equivalent to that of the ISHLT Registry, except for more frequent use of Muromonab-CD3 (26.9% versus 3.3%, P < 0.0001) and an initial CSA-based regimen (65.3% versus 34.4%, P < 0.001). The drug we use for induction therapy has been recently changed from Muromonab-CD3 to Basiliximab. The incidences of post-HTx hypertension, diabetes, hyperlipidemia, and renal insufficiency were significantly less in patients at NCVC compared to those in the ISHLT Registry, however, the incidence of transplant coronary artery disease (TxCAD) was almost identical. Clinical review of post-HTx outcome at NCVC can provide useful information for Japanese transplant cardiologists who will engage in HTx management.

Improved long-term performance of pulsatile extracorporeal left ventricular assist device.

BACKGROUND AND PURPOSE: The majority of heart transplant (HTx) candidates require left ventricular assist device (LVAD) support for more than 2 years before transplantation in Japan. However, the only currently available device is the extracorporeal pulsatile LVAD. The long-term management of extracorporeal LVAD support has improved remarkably over the years. To determine which post-operative management factors are related to the long-term survival of patients on such LVAD, we retrospectively compared the incidence of complications and their management strategies between the initial and recent eras of LVAD use, classified by the year of LVAD surgery. METHODS: Sixty-nine consecutive patients supported by extracorporeal pulsatile LVAD as a bridge to HTx between 1994 and 2007 were reviewed retrospectively. The patients were assigned according to the time of LVAD surgery to either group A (n=30; between 1994 and 2000) or group B (n=39; between 2001 and 2007). RESULTS: Patients in group B survived significantly longer on LVAD support than those in group A (674.6 vs. 369.3 days; p<0.001). The 1- and 2-year survival rates were significantly higher in group B than that in group A (82% vs. 48%, p<0.0001; 68% vs. 23%, p<0.0001, respectively). The proportion of deaths due to cerebrovascular accidents was lower (17% vs. 50%, p<0.001) in group B compared with group A. The incidences of systemic infection were similar in both groups, but the proportions of patients alive and achieving transplant surgery after systemic infection were higher in group B than those in group A (55% vs. 14%, p<0.01; 14% vs. 36%, p<0.05, respectively). CONCLUSIONS: The long-term survival of patients even on "first-generation" extracorporeal LVAD has improved significantly in the recent era. Careful management of cerebrovascular accidents and systemic infection will play important roles in the long-term LVAD management.

Reversible posterior leukoencephalopathy syndrome (RPLS) in a heart transplant recipient treated by substitution of cyclosporine A with tacrolimus.

Reversible posterior leukoencephalopathy syndrome (RPLS) is one of the important adverse events following organ transplantation, associated with calcineurin inhibitors (CNIs). We describe a case of 54-year-old woman, who was diagnosed with RPLS within weeks after transplantation. Considering the risk of causing fatal rejection by discontinuation of CNIs, the immunosuppressive regimen of the patient was switched from a cyclosporine A-based regimen to a tacrolimus-based regimen. The patient recovered rapidly from RPLS following the switch to tacrolimus. This case demonstrated that not only discontinuation but also a substitution of CNIs would be a valid treatment option for RPLS in transplant recipients.

Traumatic tricuspid regurgitation caused by myocardial laceration: a three-dimensional echocardiographic study.

A 19-year-old man was admitted for severe traumatic tricuspid regurgitation (TR) 4 months after a traffic accident. Transthoracic echocardiography revealed severe TR, with an abnormal chordal structure. Three-dimensional echocardiography showed widely lacerated right ventricular endocardium involving many subvalvular components. In this case of traumatic TR, three-dimensional echocardiography was useful not only for its diagnosis but also in providing important information for surgical decision making.

The use of high-hydrostatic pressure treatment to decellularize blood vessels.

A decellularization method using high-hydrostatic pressure (HHP) technology (>600MPa) is described. The HHP disrupts the cells inside the tissue. The cell debris can be eliminated with a simple washing process, producing clean, decellularized tissue. In this study, porcine aortic blood vessel was decellularized by HHP. The mechanical properties and in vivo performance of the decellularized tissue were evaluated. Mechanical properties of the decellularized tissue were not altered by the HHP treatment. Reduced inflammation of the decellularized tissue was confirmed by xenogenic transplant experimentation. An allogenic transplantation study showed that decellularized blood vessel endured the arterial blood pressure, and there was no clot formation on the luminal surface. In addition, cellular infiltration into the vessel wall was observed 4 weeks after implantation, suggesting that HHP treatments could be applied widely as a high-quality decellularization method.

Initial experiences with the HeartMate vented electric left ventricular assist system in Japan.

We report three consecutive cases of long-term circulatory support using the HeartMate vented electric (VE) left ventricular assist system (LVAS). The HeartMate VE LVAS dramatically improved the functional status and quality of life of these three patients with end-stage heart failure, and all were successfully bridged to transplantation after 659, 995, and 1055 days of support on the device. Only an antiplatelet agent was used for anticoagulation therapy, and no cerebrovascular event occurred. Although the pump stopped in two of these three patients 665 days and 491 days after implantation, both were supported by the backup pneumatic driver thereafter. The drive-line exit site became infected in one patient and thinning of the left ventricular wall due to an unknown cause occurred in one patient.

[Medium-term results of aortic valve replacement with cryopreserved homograft valves: importance of a domestic homograft valve bank].

There are advantages to using aortic homografts as aortic valve replacements (AVR), particularly in patients with complex infective endocarditis. To determine the importance of a domestic homograft valve bank, our 23 surgical cases of homograft-AVR were reviewed. Since 2000, the Tissue Bank of the National Cardiovascular Center has supplied 23 aortic homograft valves for the treatment of complex aortic valve endocarditis. Fourteen of 23 patients had prosthetic valve endocarditis and 20 patients had an aortic annular abscess. The early mortality rate was 17% (4 patients), in all of whom prosthetic valve replacement had been performed previously. No recurrent endocarditis and no recurrent aortic regurgitation were noted at medium-term follow-up. An aortic homograft valve is the conduit of choice in cases of infective endocarditis and the importance of a domestic homograft valve bank should be recognized.

Reconstruction of a friable posterior mitral annulus after removing a calcified artificial ring using flipover technique of the anterior mitral leaflet.

We report a new technique for reinforcement of a friable posterior mitral annulus using the anterior leaflet after removing a calcified artificial ring. A 72-year-old woman underwent mitral valve replacement for mitral stenosis and recurrence of regurgitation after mitral valve repair at 53 years of age. She had been on chronic hemodialysis for 20 years. The posterior mitral annulus became highly friable after débridement of the calcified artificial ring. The anterior mitral leaflet was detached from its annulus and transferred to the posterior annulus to cover the defect. The anterior leaflet was anchored to the posterior annulus by valve sutures, and mitral valve replacement was performed successfully. Postoperative ultrasonic cardiography revealed preservation of left ventricular function with no perivalvular leakage.

Hybrid therapy for rapid enlargement of hibernating coronary arteriovenous fistulas.

The use of hybrid therapy for recurrent multiple coronary arteriovenous fistulas in a 56-year-old woman is reported. The patient underwent surgical closure of a coronary arteriovenous fistula of the right coronary artery under cardiopulmonary bypass at 47 years of age. Reoperation was required 9 years later for recurrence of the same fistula. It was divided under a beating heart. Early postoperative angiography showed complete occlusion of the right coronary fistula. However, hibernating fistulas of the left circumflex artery, which had been left untouched because of insignificant shunt with no remarkable change for 9 years, increased in size rapidly. Transcatheter embolization was successfully performed for these residual fistulas.

Is extracorporeal life support contraindicated in elderly patients?

BACKGROUND: Extracorporeal life support (ECLS) using percutaneous extracorporeal membrane oxygenation (ECMO) is now considered an important means of resuscitation for patients suffering from refractory cardiogenic shock. The indications for the use of ECLS have yet to be established, however, and its use for elderly patients is still controversial. We retrospectively evaluated the impact of ECLS on the survival of patients with cardiogenic shock to determine the validity of using ECLS in elderly patients (> or = 75 years of age). METHODS: Between 2000 and 2004, 91 patients were emergently placed on percutaneous ECMO. The patients were divided into two groups by age (group 1, n = 79: less than 75 years; group 2, n = 12: 75 years or older), which were compared for clinical outcome. Logistic regression analysis of the variables was performed to identify predictors of ability to be weaned from ECLS. RESULTS: Weaning from ECLS was achieved in 50 patients in group 1 (63.3%) and 6 patients in group 2 (50%; p = 0.37). Thirty-five patients in group 1 (44.3%) and 5 patients in group 2 (41.7%) were discharged from the hospital (p = 0.86). Logistic regression analysis revealed that patients with a body surface area of more than 1.50 m2, patients with cardiomyopathy, and patients who underwent interventions under ECMO support were more likely to be successfully supported by ECMO. CONCLUSIONS: Extracorporeal life support using percutaneous ECMO systems provides excellent cardiac support. It is also effective in resuscitating elderly patients, yielding hospital survival similar to that for younger patients.

Graft design strategies with optimum antegrade bypass flow in total arterial off-pump coronary artery bypass.

OBJECTIVE: In arterial conduits, graft flow is one of the major determinants of long-term patency. We sought to delineate the effect of strategy for graft arrangement and design to three-vessel disease by evaluation of the dominant flow direction in each segment of a bypass graft. MATERIALS AND METHODS: We reviewed coronary angiograms of 1571 bypass grafts in 395 patients who underwent total arterial off-pump coronary revascularization without aortic manipulation for three-vessel disease since December 2000. The graft flow graded as A (antegrade), B (competitive), C (reverse), and O (no flow=occlusion). The current arrangement and design has been introduced since March 2003, and consists of the in-situ left internal thoracic artery (ITA) to the anterior descending artery and the composite I-graft of the right ITA and radial artery to the left circumflex (LCX) and right coronary artery (RCA) territories. Either clockwise or counterclockwise orientation, the I-graft was chosen to achieve a sufficient antegrade flow. Group I consisted of 181 patients with a single in-situ ITA as a composite Y-graft. Group II consisted of 214 patients with bilateral in-situ ITAs, which subdivided into Subgroup II-A consisted of 80 patients with bilateral in-situ ITAs until February 2003, and Subgroup II-B consisted of 134 patients with bilateral in-situ ITAs since March 2003. RESULTS: The number of distal anastomoses was 3.52+/-0.63 in Group I, and 4.36+/-0.83 in Group II, respectively (p<0.0001). The overall graft patency rate was 98.6% (1549/1571), and there was no significance different between the groups. The rate of grade A in Group II was 863/933 (92.5%) and was significantly higher (p=0.049) than that of Group I 572/638 (89.7%). The rate of functioning bypass in Subgroup II-B was (95.8%) 568/593, and was significantly higher (p=0.03) than that in Subgroup II-A (92.4%) 314/340. In Subgroup II-B, 233/268 (86.9%) of the conduits had completely grade A bypass flow, and this ratio was significantly higher (p=0.04) than that in Subgroup II-A (79.4%) 127/160. CONCLUSION: Usage of bilateral ITAs and selecting the orientation of the I-graft to LCX and RCA branches provide maximal distal anastomotic sites with satisfactory graft patency rate, and simultaneously minimized the incidence of reverse and competitive flow.

Redo off-pump coronary bypass grafting with arterial grafts for Kawasaki disease.

Surgical revascularization for coronary artery lesions secondary to Kawasaki disease is relatively uncommon. The late stenosis of the saphenous vein graft is the problem to be solved. We report a case of redo off-pump coronary bypass grafting in a 35-year-old man, 20 years after bypass grafting using a saphenous vein graft. Off-pump total arterial revascularization was performed uneventfully. The procedure comprised grafting of bilateral internal thoracic arteries to left anterior descending branch and obtuse marginal branch, and radial artery to AV branch and posterior descending branch. Off-pump total arterial revascularization is a safe and less invasive procedure at the time of redo operation, even for patients with Kawasaki disease.

Angiographic flow grading and graft arrangement of arterial conduits.

OBJECTIVE: We sought to delineate the effects of competitive and reverse flow on the intermediate-term patency of arterial conduits and examined graft arrangements for maximizing antegrade bypass flow. METHODS: The angiograms of 2083 bypass grafts in 570 patients who underwent off-pump total arterial revascularization without aortic manipulation since December 2000 were reviewed. The blood flow in the bypass grafts were graded A (antegrade), B (competitive), C (reverse), or O (occlusion). The mean number of distal anastomoses was 3.65 +/- 0.94 per patient. RESULTS: In the early angiography 91.3% (1901/2083) of the bypasses were grade A. Thirty (1.4%) bypasses were grade O, whereas 2.9% (61/2083) were grade B, and 4.4%(91/2083) were grade C. In the multivariate analysis the end-to-side anastomosis (P < .0001), 4 or more distal anastomoses of the conduit (P = .01), native coronary stenosis of less than 75% (P < .0001), and target branch location of the right coronary artery territory (P < .0001) and left circumflex artery territory (P = .02) significantly correlated with grade non-A. The patency rate in the late angiography of the bypasses graded B or C in the early angiography was 7 (28.0%) of 25, whereas that of the bypasses graded A was 164 (89.1%) of 184 (P < .0001). The actuarial graft patency rate of the bypasses graded A was 72.3% at 3 years and was significantly higher than that of the bypasses graded B or C (28.6% at 3 years after surgical intervention, P < .0001). CONCLUSIONS: The sufficient antegrade bypass flow had a favorable effect on the graft patency of arterial conduits. The graft arrangement should be adjusted for each patient so as to maximize the antegrade bypass flow and to confirm the advantage of arterial grafts.

Off-pump coronary artery bypass grafting for acute myocardial infarction.

BACKGROUND: The aim of this study was to evaluate the surgical results of off-pump coronary artery bypass grafting (OPCAB) for patients with acute myocardial infarction (AMI) within 14 days of the infarction. METHODS AND RESULTS: From April 2000 to January 2005 among 841 patients who underwent OPCAB, 43 consecutive patients (5.1%) were examined. Mean age at operation was 69.5 years and mean time from the onset of AMI to surgery was 4.6 days. Seventeen patients (39.5%) had left main trunk disease. Three patients (7.0%) underwent OPCAB following unsuccessful percutaneous coronary intervention, and 1 patient (2.3%) underwent redo procedure 9 years after previous coronary artery bypass grafting (CABG). Six patients (14%) were admitted in cardiogenic shock. Intraaortic balloon pumping was inserted preoperatively in 20 patients (46.5%). The average maximum creatine kinase-myocardial band was 139+/-181 (U/L). The mean number of grafts was 3.2 and the rate of complete revascularization was 91%. Two of six patients with preoperative cardiogenic shock were converted to on-pump beating CABG due to ventricular arrythmia. The early graft patency rate was 98%. All patients survived except 2 with preoperative cardiogenic shock. CONCLUSIONS: OPCAB can be performed after AMI as a relatively low-risk procedure with an acceptable mortality rate, even within 14 days of the infarction.

The impact of mitral valve surgery combined with maze procedure.

OBJECTIVE: Recent studies indicated that successful maze procedure for atrial fibrillation (AF) adjunct to mitral valve surgery provided a lower incidence of stroke and recurrence of AF. The purpose of this study is to review the 13-year experience of these combined procedures and to identify the risk factors and late outcomes of successful maze procedures compared to failed maze procedures. METHODS: At a single institution, 521 consecutive patients underwent combined maze procedures with mitral valve replacements or valvuloplasties. Three kinds of maze techniques were primarily used: Cox-maze III, Kosakai maze, and cryo-maze procedure. Three months after the operation, 394 patients were in sinus rhythm (Group S) while the remaining 116 patients were in continuous or intermittent AF (Group F), excluding 11 early death patients. Risk factors for Group F were determined by the analysis of all patient demographics. Survival, freedom from stroke, cardiac events, and AF recurrence were analyzed. RESULTS: The proportion of the patients without any other simultaneous procedures was greater in Group S (41% vs 29%, P = 0.02). The distributions of mitral valve surgery and maze procedure techniques were similar in these two groups. A left atrium larger than 70 mm [hazard ratio (HR) = 2.6; 95% confidence interval range 1.04-6.3, P = 0.043], preoperative AF history longer than 10 years (HR = 8.2; 4.5-15.1, P < 0.001) and f-wave voltage in V1 smaller than 0.1 mV (HR = 6.2; 5.0-15.2, P < 0.001) were determined to be risk factors for unsuccessful maze procedures. All the results of Cox proportional hazards models showed superiority in Group S; actuarial survival rates (HR = 2.7; 1.04-7.0, P = 0.035), freedoms from stroke (HR = 3.0; 1.1-8.1, P = 0.003) and cardiac events (HR = 4.3; 2.9-6.1, P < 0.001). Freedom from AF recurrence rate was 98.4% at 5 years and 81.0% at 12 years in Group S, and 73.0% and 60.1% in overall patients. CONCLUSIONS: Patients with successful maze procedures resulted in higher survival rate, greater freedom from stroke and cardiac events. The large left atrium, small f-wave, and long AF duration were significant risk factors for failed maze procedures, suggesting that earlier surgical interventions would result in superior results in mitral valve surgery combined with maze procedure.

Infective endocarditis and pseudoaneurysm: fatal complications of mitral annular calcification.

We present a case of successful surgical repair for infected mitral valve and left ventricular pseudoaneurysm, which can be fatal complications of mitral annular calcification.

Long-term follow-up of transvenous defibrillation leads: high incidence of fracture in coaxial polyurethane lead.

BACKGROUND: As a result of longer follow-up after implantation of cardioverter defibrillators (ICD), fatigue of the leads has become a concern. The aim of this study was to determine the incidence and clinical presentation of ICD lead failures. METHODS AND RESULTS: The study population consisted of 241 patients with 249 ICD leads who underwent implantation of an ICD with a transvenous lead system. After device implantation, the patients were routinely followed up every 4 months. Five lead failures (2.0%) occurred as an oversensing of artifact during the follow-up period (2.6+/-2.1 years); 4 of those 5 patients received inappropriate shocks and 1 case of lead failure was identified in a patient with frequent episodes of non-sustained ventricular fibrillation. In particular, the right ventricular polyurethane transvenous lead in the Medtronic model 6936 failed in 4 (13%) of 31 cases. Percutaneous lead extraction was not available in all cases, so an additional ICD lead was inserted through the same site of the subclavian vein. CONCLUSIONS: Lead failures may occur 5 years after ICD implantation and polyurethane leads have an especially high incidence of failure. However, there were no follow-up parameters observed that predicted lead failures.