[Management of coronary artery disease combined with aortic stenosis: how to do with mild aortic stenosis].

A total of fourteen patients with combined operation of coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) for coronary artery disease (CAD) and aortic stenosis (AS) were reviewed to evaluate the indication of the combined operation. Preoperative pressure gradient across the valve and effective orifice area were 21-89 mmHg (mean 64 mmHg), 0.5-1.9 cm2 (mean 0.92 cm2), respectively. The extent of CAD was 1-3 (mean 2.0). Fractional shortening (%FS) ranged from 13% to 43% with mean value of 28%. All patients underwent CABG and AVR. The number of grafts was 1-4 (mean 2.3) with internal thoracic artery used in 7 cases. Mechanical valves were employed for all patients except 1 case with cerebral aneurysm. There was no operative death, although low output syndrome developed in 2 cases. One had poor left ventricular function preoperatively, and the other was emergency case. Fractional shortening improved postoperatively even in two cases with preoperative %FS less than 20%, and all grafts were patent on postoperative coronary angiography. The event-free survival was 100% during 32 months of mean follow-up. Combined AVR with CABG is recommended to avoid risky secondary operation in patients of CAD and AS, even if one of which is relatively mild, because of the fact that operative and late results of the combined surgery are satisfactory.

Coronary artery bypass grafting using the "Super Pulse" dynamic pulsatile cardiopulmonary bypass device in patients with cerebrovascular occlusive disease.

Patients with coronary disease complicated by severe carotid or intracranial arterial stenosis underwent coronary artery bypass graft surgery (CABG) using a novel method of dynamic pulsatile cardiopulmonary bypass (Super Pulse CPB). The Super Pulse technique can maintain the systolic pressure and systolic-diastolic amplitude in such a way that they mimic the physiologic circulation. Forty-five patients (33 males and 12 females, mean age 65.1 years) with coronary disease who had a greater than 75% stenosis of the carotid or intracranial arteries were evaluated. Evaluation was performed for the following 3 groups: 8 patients with conventional pulsatile CPB (Group I), 8 patients with conventional pulsatile CPB plus intraaortic balloon pumping (Group II), and 29 patients with Super Pulse CPB. Maximum, minimum, and mean perfusion pressures during CPB were 112.7, 53.6, and 76.9 mmHg (integrated mean), respectively, in Group III. The systolic-diastolic amplitude was significantly better than for Group I and similar to baseline pressures. No patients in Group II or Group III developed perioperative cerebral disorders or myocardial infarction, while in Group I perioperative cerebral disorders developed in 3 patients, myocardial infarction occurred in 2 patients, and 2 patients died during hospitalization. The initial performance of the Super Pulse CPB indicates excellent safety, and is useful for patients with co-morbid cerebral arterial disease.

Minimally invasive direct coronary artery bypass grafting using the gastroepiploic artery for reoperation after the Cabrol procedure.

Obstruction of the right coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts (Cabrol method). Occlusion at the right coronary ostial anastomosis in a 36-year-old woman with aortitis syndrome who underwent a composite graft with a Dacron coronary graft is described. She underwent a third successful operation for right coronary reconstruction by minimally invasive direct coronary artery bypass grafting technique using the right gastroepiploic artery. This approach is likely to be extremely useful in avoiding resternotomy and cardiopulmonary bypass in patients requiring coronary reoperation.

Retrograde cerebral perfusion versus selective cerebral perfusion as evaluated by cerebral oxygen saturation during aortic arch reconstruction.

BACKGROUND: Time limits for neuroprotection by retrograde cerebral perfusion (RCP) and selective cerebral perfusion (SCP) in aortic arch aneurysm repair or dissection are undergoing definition. METHODS: Using near-infrared optical spectroscopy, changes in regional cerebrovascular oxygen saturation (rSO2) were compared between the two perfusion methods. RESULTS: Immediately before cardiopulmonary bypass, baseline rSO2 was 63.9%+/-6.9% for the RCP and 66.1%+/-5.3% for the SCP group (no significant difference). As patients were core-cooled to 20 degrees C, rSO2 increased to 73.1%+/-8.8% and 74.1%+/-7.9% in the RCP and SCP groups, respectively. With circulatory arrest, rSO2 suddenly decreased. After starting cerebral perfusion, rSO2 returned to prearrest values in the SCP group but continued decreasing steadily in the RCP group, to levels below baseline after about 25 minutes. At the end of perfusion, rSO2 was 57.4%+/-12.2% for the RCP group and 71.7%+/-6.9% for the SCP group, and the ratio of rSO2 to baseline value was 0.89 for RCP and 1.08 for SCP despite a shorter brain perfusion time for RCP (38.8+/-18.0 versus 103.3+/-43.3 minutes). Three of 5 patients whose ratios of rSO2 to baseline at the end of brain protection were 0.7 or less had neurologic deficits. CONCLUSIONS: Although SCP showed no clinically important time limitation, rSO2 continued to decrease with time during RCP. An rSO2 ratio less than 0.7 could represent a critical lower limit.

Emergency percutaneous cardiopulmonary bypass support for acute myocardial infarction.

We assessed the efficacy of emergency percutaneous cardiopulmonary bypass support (PCPS) in the treatment of patients with acute myocardial infarction complicated by cardiogenic shock. Emergency PCPS was instituted in 21 consecutive patients beginning in 1991. After the stabilization of the hemodynamics, coronary reperfusion was performed by means of coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. Of the seven patients with acute myocardial infarction involving either the left main or two-vessel territories, five survived more than 1 month, but only one patient remained alive and well after 20 months. The main cause of death for this group was low output syndrome. Four of 12 patients with acute left main trunkal occlusion in the catheter laboratory survived and showed a preserved cardiac function (mean followup 28.5 months). The main cause of death for this group was brain damage. Two patients with single-vessel territory acute myocardial infarction underwent PCPS to treat refractory ventricular fibrillation. Both patients were still alive and well at a 12-month followup. Percutaneous cardiopulmonary bypass support successfully stabilized the hemodynamics, allowing time to perform revascularization for all three groups of patients with life-threatening acute myocardial infarction. Recanalization was nevertheless unable to salvage the damaged myocardium in cases of prolonged ischemic time.

Leriche syndrome. Surgical procedures and early and late results.

During the past thirteen years, 29 patients underwent surgical intervention for Leriche syndrome. Fifteen patients (aged forty-two to seventy-two years, average 60.7 years) underwent anatomical bypass, and 9 of them whose thrombus was confined to the infrarenal aorta received a routine graft insertion. In the other 6 whose thrombus extended to the level of the renal arteries, an open thrombectomy of the juxtarenal aorta was first performed through a transection of the infrarenal aorta under renal ischemia (4-14 minutes, average 7). Twelve elderly or high-risk patients (aged sixty-eight to eighty-four years, average 75.3 years) underwent an axillobifemoral bypass, and another 2 (fifty-eight and sixty years old, respectively) who had been operated on at an earlier time received an ascending aortobifemoral bypass. In cases of anatomical bypass, no graft has occluded and all patients but 1, who died of cerebral infarction, have an active life now. In cases of extraanatomical bypass, 5 of the 28 grafts occluded and only 6 patients have survived. The other 8 patients died of malignancy, atherosclerotic complications, or unknown causes. The 10-year survival rate was 92.9% and 29.5% in the anatomical bypass and extraanatomical bypass group, respectively. In Leriche syndrome, anatomical bypass is preferred to extraanatomical bypass if conditions permit. In the juxtarenal type, an open thrombectomy under renal ischemia is mandatory for anatomical bypass, and a transection of the infrarenal aorta facilitates this procedure. Because the patients with Leriche syndrome are elderly and harbor arteriosclerotic lesions, a careful follow-up is mandatory.

Pericardiectomy and coronary artery bypass grafting for constrictive pericarditis after heart surgery.

A 63-year-old male was operated on for chronic heart failure due to myocardial ischemia and constrictive pericarditis after heart surgery. He was in New York Heart Association (NYHA) class III under a large dose of diuretics. He underwent a pericardiectomy and coronary bypass surgery without cardiopulmonary bypass. His cardiac function improved with a patent graft. He is now, 1 year after surgery, in NYHA class I under a tapering dose of diuretics.

Surgical treatment of ventricular septal perforation with right ventricular infarction.

A 71-year-old woman underwent an emergency surgery for ventricular septal perforation together with right ventricular infarction. The perforation of the anterior septum was closed using. Dacron patch combined with a little larger bovine pericardium, the surplus of which was stitched in the surrounding viable muscle. This procedure was performed only through the infarct of the right ventricle. She has been doing well with no residual shunt and lives a normal life now.

[Graft replacement of a thoracic aneurysm and coronary artery bypass grafting using retrograde cerebral perfusion through left thoracotomy--a case report].

A 67-year-old woman having descending thoracic aneurysm and 90% stenosis of the obtuse marginal artery underwent a concomitant operation of graft replacement of a thoracic aneurysm and coronary artery bypass grafting. The operation was performed through left posterolateral thoracotomy with total cardiopulmonary bypass using femoral artery, femoral vein and the pulmonary artery cannulation, deep hypothermia and retrograde cerebral perfusion (RGCP). RGCP was performed by high central venous pressure (17-18 mmHg) resulted from low flow perfusion of the lower body under clamping of the descending aorta. Distal coronary anastomosis was done during an initial 100ling period and proximal anastomosis was put on the replaced thoracic graft after coming off extracorporeal circulation (ECC). ECC time was 167 minutes, and RGCP time was 27 minutes. The patient did well after the operation. Postoperative coronary angiography showed the patent coronary bypass graft. We conclude that this method provides good exposure of the thoracic aorta and the coronary artery, and satisfactory brain protection.

Surgical treatment of infective endocarditis complicated by annular infection and cerebral infarction.

The surgical treatment of nine patients with infective endocarditis (IE) complicated by annular infection and five with IE complicated by cerebral infarction is described herein. In those with annular infection, after thorough débridement of the infected tissues, valve replacement was performed at the original position in five, at the supraannular position in three, and one underwent a translocation procedure. Aortic valve replacement was able to be performed at the original position in two patients by closing the defect at the aortic annulus with a patch after through débridement. The five patients who underwent original valve position replacement recovered well. Of the three who underwent supraannular position replacement, two died of septicemia after a redo operation, and one received pacemaker implantation. The patient undergoing the translocation procedure died of intestinal infarction. In the five patients who suffered cerebral infarction due to embolus of the vegetation, valve replacement was performed between 40 h and 5 months after its onset. Although one patient died of the rapid progression of brain damage, the other four are alive and well, including two who developed mycotic cerebral aneurysm in the infarcted areas. In conclusion, early surgery for IE is mandatory irrespective of active infection, due to the high mortality and morbidity associated with serious sequelae such as annular abscess or cerebral infarction.

[A comparison of changes of cerebrovascular oxygen saturation in retrograde and selective cerebral perfusion during aortic arch surgery].

To evaluate the effect of retrograde cerebral perfusion (RCP) and selective cerebral perfusion (SCP) on brain protection, changes of cerebrovascular oxygen saturation (rSO2) were studied in 14 patients with aortic arch reconstruction during the procedure. The rSO2 was monitored with spectroscopy instrument (Invos 3100, Somanetics). The mean value of rSO2 measured just before cardiopulmonary bypass was 65.9 +/- 6.2% in 7 patients with RCP, and was 64.9 +/- 4.7% in 7 patients with SCP. The value of rSO2 during core cooling of cardiopulmonary bypass was increased step by step. Although RCP time with a mean of 38.9 +/- 9.7 min was statistically shorter than SCP time (80.7 +/- 45.1 min), the mean value of rSO2 during cerebral protection in RCP group was decreased from 80.3 +/- 8.1% to 63.4 +/- 10.2%, lowest 46% with a ratio of 21.1%. In contrast, the mean value of rSO2 in SCP group was well maintained from 79.9 +/- 6.5 to 75.6 +/- 6.8%, lowest 63% with a ratio of 5.4%. Although no neurological deficits were recognized after operation in both groups, rSO2 in SCP group was sustained above the control value (65% just before cardiopulmonary bypass) but rSO2 in RCP group was decreased below the control value after 35 min. So we conclude that with regard to brain protection assessed from rSO2 measured by Invos 3100 cerebral oximeter, there is no time limitation of SCP during the procedure but RCP had a limit of the duration.

[Mitral valve repair for the treatment of ischemic mitral regurgitation].

Twenty-six patients with moderate and severe ischemic mitral regurgitation due to papillary muscle dysfunction underwent mitral valve replacement (MVR) or mitral annuloplasty (MAP) using modified Kay method. Emergent operation was performed in 12 patients of whom 11 had severe congestive heart failure even under IABP, 5 had cardiogenic shock and 9 needed respiratory care with intubation preoperatively. Elective operation was performed in 14 patients of whom 6 had history of congestive heart failure and 1 had episodes of ventricular tachycardia. As intraoperative findings of mitral valve, mural annular dilatation in 84.6%, prolapse of anterior leaflet in 23.1%, papillary muscle scar in 15.4%, chordal elongation in 15.4% and chordal rupture in 3.8% were seen separately or in combination. In 22 patients MAP using modified Kay method and CABG were performed, but in 4 patients MVR was needed because of the prominent prolapse of the anterior leaflet. Fourteen patients who underwent MAP with CABG and one MVR with CABG survived. Hospital mortality was higher in emergent (58.5%) than elective operation (28.6%). In the 15 survivors, mitral regurgitation decreased below Sellers 2, pulmonary wedge pressure decreased significantly (p < 0.01) and NYHA functional class improved to I or II postoperatively. During the follow up period of 15-100 (mean 38.7 +/- 21.6) months, 2 MAP+CABG patients died suddenly, but the remaining 13 patients were in NYHA class I or II and no progression of MR was seen. These results indicated that MAP+CABG is recommendable in the treatment of ischemic mitral regurgitation due to papillary muscle dysfunction, in order to preserve cardiac function and to reduce valve related complications.

[Efficacy of terminal warm blood cardioplegia against the reperfusion injury].

The effect of terminal warm blood cardioplegia (TWBC) was evaluated from the incidence of ventricular fibrillation and myocardial metabolism after release of aortic clamping in 70 patients (group I) who underwent open heart surgery using TWBC compared with 70 patients (group II) without TWBC. The incidence of ventricular fibrillation after unclamping in group I was 19.7% which was statistically less than 68.6% in group II. Both excess lactate (delta XL) and redox potential (delta Eh) demonstrated that anearobic myocardial metabolism after reperfusion was restored more rapidly in group I than in group II. Multivariate analysis showed the incidence of ventricular fibrillation after reperfusion was related to high concentrations of both calcium and sodium and low concentration of potassium in reperfused blood in group II. But it was only related to left ventricular myocardial temperature in group I. High concentration of calcium and low concentration of potassium in reperfused blood, and low myocardial temperature were most related to anearobic metabolism of myocardium following reperfusion in group II, whereas only pH value was closely related to recovery for myocardial metabolism in group I. In conclusion, TWBC was useful for improving microcirculation in myocardium and avoiding calcium-overload to myocardial cells, and resulted in reducing reperfusion injury in myocardium. Furthermore, acid content of TWBC and enough amount to raise myocardial temperature would provide more efficacy on myocardial preservation.

Mitral valve repair using an annuloplasty ring made of artificial woven Dacron graft.

A woven Dacron ring made of artificial graft was successfully used in combination with a modified Kay's annuloplasty for mitral valve repair. In this procedure, after excision and repair of the redundant prolapsed leaflets, Kay's annuloplasty was performed at both commissures to reduce the posterior annulus and to coapt the leaflets. A woven Dacron ring was then seated and tied to the annulus to provide long-term stabilization and prevent its further dilatation. The mitral orifice of the patient was reduced from 33 mm to 21 mm in diameter, and neither mitral regurgitation nor stenosis was found in the postoperative evaluation.

Surgical treatment of ventricular septal defect and its sequelae in adults.

We operated on 20 adult patients with ventricular septal defect (VSD). In 7 of these cases (aged 36 to 51 years, average 42.6 years), VSD was accompanied by sequelae other than pulmonary hypertension. Concomitant procedures in type-I VSD included a suspension of the prolapsed aortic cusp in 2 patients, a repair of the ruptured sinus of Valsalva in 2, and a new procedure for active infective endocarditis, described below, in 2. In this latter procedure, the aortic valve and infected Valsalva sinus were excised, and the pulmonary valve and the right ventricular wall to which the infection had extended were thoroughly debrided. The resulting defect was closed with a single patch, and a prosthetic valve was inserted in the position of the original aortic valve using this patch as part of the annulus. Another patient with the type-II VSD underwent concomitant tricuspid valve replacement for infective endocarditis. In the mean follow-up period of 77.1 months, 6 patients have been doing well in New York Heart Association class I, and the remaining patient with Valsalva repair remained in class II due to dilated cardiomyopathy.

Surgical treatment of ventricular septal defect and ruptured sinus of Valsalva associated with infective endocarditis.

Two patients with ventricular septal defect of Kirklin type I and ruptured right coronary sinus of Valsalva associated with infective endocarditis were operated on. Both had bacillus vegetation clinging to the aortic and pulmonary valves and the right ventricular intimal wall around the septal defect. Aortic and pulmonary regurgitation were also found. The surgical approach included vertical incision of the right ventricular outflow tract and pulmonary trunk and transverse aortotomy. The right coronary sinus of Valsalva showed distinct aneurysmal change in one patient. The aortic valve and infected Valsalva sinus were excised in both cases, and the pulmonary valve and right ventricular wall where infection extended thoroughly débrided. The resulting defect, including the ventricular septal defect and excised right Valsalva sinus and aortic annulus, was closed with one patch, and the prosthetic valve inserted in the position of the original aortic valve using this patch as part of the annulus. Both patients had a good postoperative course and are doing well, although slight pulmonary regurgitation persists.

[Surgical treatment of incomplete endocardial cushion defect in elderly patients].

We experienced 5 surgical cases of incomplete endocardial cushion defect who were 50 years old or older. Preoperatively, 3 cases were in New York Heart Association (NYHA) class II and 2 in class III. Catheterization study showed that systolic pulmonary arterial pressure was 24 to 48 (average; 38) mmHg and pulmonary-to-systemic flow ratio was 3.4 to 8.1 (average; 5.2). Left ventriculography showed mitral valve regurgitation (grade I-1 cases, grade II-3, grade III-1) with cleft and goose neck sign in all cases. Single atrium and patent foramen ovalis were associated in each one case. At operation, suture of mitral cleft and patch closure of ostium primum defect from mitral valve side were performed. Postoperatively, NYHA class, cardiomegaly, pulmonary arterial pressure and mitral regurgitation improved remarkably in all patients. During the follow-up period from 18 to 126 months (average; 57), right bundle branch block and supraventricular arrhythmia in electrocardiogram disappeared in 3 of 4 and 4 of 5 cases, respectively. Surgical treatment and postoperative course of incomplete ECD were reviewed in over-50-year-old patients, in reference to 17 surgical cases in Japan.

The problems of surgical treatment for cardiac myxoma and associated lesions.

Twenty-four patients with cardiac myxomas consisting of 22 left and 2 right atrial myxomas were operated on. All myxomas were removed with an excision of the attachment walls using a cardiopulmonary bypass. Two myxomas required a partial cardiopulmonary bypass from the femoral vein to the artery prior to operation because they were on the verge of becoming stuck in the atrioventricular valves and potentially causing shock. For embolic complications of myxoma, the embolus of the external carotid artery was extirpated before undergoing cardiac surgery. In a patient with pulmonary infarction, the infarcted lung was resected simultaneously. Another patient with a cerebral infarction received a clipping of an aneurysm which later appeared in the infarcted area. For associated cardiac lesions, two patients underwent a coronary artery bypass graft and one mitral valve replacement with tricuspid annuloplasty. In the former two cases, the myxoma was removed prior to coronary artery bypass grafting because the use of retrograde coronary perfusion was considered to be sufficient to protect the heart. In the latter case, the removal of the myxoma first disclosed a significant mitral lesion which had been masked by the huge myxoma. All patients but one, who died of pneumonia, showed a good recovery. In this series, the problems of surgical treatment for cardiac myxoma and associated lesions are also discussed.

[Aortic arch reconstruction without aortic cross-clamping using separate extracorporeal circulation].

Between March 1991 and October 1992, 21 consecutive patients underwent aortic arch reconstruction without aortic cross-clamping using separate extracorporeal circulation in combination with retrograde blood cardioplegia (Non-clamping selective cerebral perfusion). Twelve patients had true arch aneurysm, 3 had acute aortic dissection and 6 had chronic aortic dissection including 2 redo cases. Cardiopulmonary bypass (CPB) was instituted with an arterial cannula in the femoral artery and 2 cannulae in both vena cavae. When tympanum temperature was lowered to 20 degrees C by central cooling, CBP was stopped temporarily. As soon as the aortic arch was incised longitudinally together with aneurysm, flexible 12 Fr. balloon cannulae were inserted into the three arch arteries via their orifices and selective cerebral perfusion was started. The perfusion flow was kept between 0.3 L/m2/min and 0.35 L/m2/min with the pressure of catheter tip from 30 to 60 mmHg to keep tympanum temperature 18 degrees C. Heart was protected by retrograde continuous cold blood cardioplegia. During arch correction, the descending aorta was occluded by a balloon then abdominal viscera were perfused via a femoral return cannula and rewarming to 25 degrees C was started to prevent visceral organ failure and coagulopathy. The time of separate perfusion ranged 20 to 161 minutes with a mean of 99.9 minutes. Except one patient who died of pneumonia, 20 patient (95.2%) were discharged and doing well. No cerebral complication, myocardial infarction, lung bleeding and coagulopathy occurred. In order to prevent the infarction by debris and to protect vital organs, this method is reliable for aortic arch reconstruction.

Lung preservation with low-potassium dextran flush in a primate bilateral transplant model.

We used a bilateral lung transplant model to confirm, in primates, the results of lung preservation studies previously obtained in a canine single-lung transplant model. The donor lungs were flushed with low-potassium dextran solution and maintained semiinflated with 100% oxygen at 10 degrees C for a planned ischemic time of 12 hours for the lung implanted first. Of eight experiments performed, results in the 6 operative survivors form the basis of this report. After bilateral lung transplantation, animals were maintained on a ventilator for 6 hours; arterial oxygen tension, pulmonary artery pressure, and pulmonary vascular resistance were determined in the recipients at 2, 4, and 6 hours after transplantation and compared with donor values, which served as controls. Arterial oxygen tension in the recipients did not differ from the controls (p = not significant), whereas the pulmonary artery pressure and pulmonary vascular resistance showed significant elevation (p < 0.05 versus control values). After the 6 hours of assessment, the animals were extubated and 3 survived for 48 to 72 hours with a mean arterial oxygen tension of 69 mm Hg on room air. These results demonstrate excellent lung function after a minimum of 12 hours of preservation in a primate model in which the animal is totally dependent on the function of transplanted lung tissue, and confirm the potential for prolonged clinical lung preservation.