[Pulmonary artery sling and single ventricle treated with a simultaneous operation of slide tracheoplasty, left pulmonary artery reimplantation, and bidirectional cavo-pulmonary shunt].

Pulmonary artery sling is frequently combined with tracheal stenosis, and occasionally combined with congenital heart defects. However, there are few reports of successfully treated cases that were combined with single ventricle. In this article, we report a successfully treated case of pulmonary artery sling combined with tracheal stenosis, single ventricle, pulmonary atresia, vascular ring, and bilateral superior vena cava. A male infant was referred to our hospital for central cyanosis, and was diagnosed with single ventricle (tricuspid stenosis, multiple ventricular septal defect, and hypoplastic right ventricle)with pulmonary atresia by echocardiogram. Tracheal stenosis was shown at cardiac catheterization. Pulmonary artery sling and tracheal diverticulum were diagnosed by computed tomography (CT) and magnetic resonance imaging(MRI)examination. Furthermore, the patient was complicated by vascular ring, which consisted of right aortic arch, an aberrant left subclavian artery, and patent ductus arteriosus, and this ductus arteriosus was connected to the left subclavian artery and pulmonary arterial trunk. After 6 months of medical treatment, including continuous infusion of prostaglandin, re-evaluation was performed by cardiac catheterization. We considered that bidirectional cavo-pulmonary shunt was appropriate for the patient since his pulmonary vasculature had matured well. An operation was performed under the use of cardio-pulmonary bypass. Release of vascular ring by division of the ductus, bilateral bidirectional cavo-pulmonary shunt, and a slide tracheoplasty for tracheal stenosis were performed simultaneously. His recovery was uneventful, and he is currently waiting to receive a Fontan-type operation.

[Experience of 3 successfully treated cases of tracheo-innominate artery fistula and significance of preventive surgery].

Tracheo-innominate artery fistula (TIF) is a rare but fatal complication after tracheostomy. Necessary lifesaving measures include proper ventilation, temporary hemostasis, and surgery. Recently, we successfully managed 3 cases of TIF. Ventilation and temporary hemostasis were secured by a long endotracheal tube and overinflated cuff. Division of the innominate artery, restoration of the tracheal fistula with an autologous pericardial patch or direct closure, and aorto-innominate bypass grafting or extra-anatomical bypass grafting with a polytetrafluoroethylene (PTFE) graft were performed through an emergency median sternotomy. All 3 patients recovered with no problems. After TIF occurs, the patient's condition rapidly worsens, and the risk of bacterial contamination in the operative field may increase. Surgical intervention should be performed for patients with tracheal stenosis who are judged to be at high risk for TIF. This preventive surgery includes bypass grafting to divide the innominate artery and partial resection of the anterior bony thorax(upper sternum, medial part of clavicles, and anterior part of upper ribs if necessary). We believe that this procedure will improve tracheal stenosis and minimize the risk of TIF. Thus far, 10 patients have undergone this operation, and their mid-term results are satisfactory.

Anatomically corrected malposition of the great arteries with tubular hypoplasia of the aortic arch: a case report of surgical correction.

Anatomically corrected malposition of the great arteries (ACMGA) is rare congenital cardiac anomaly. In a heart with ACMGA, both great arteries arise from the appropriate ventricle but they exit parallel to each other. The pulmonary trunk is located posterior and to the right of the aorta. ACMGA associated with tubular hypoplasia of the aortic arch is an extremely rare cardiac malformation and it has previously been reported in only four patients. In addition, successful surgical repair for this combination of anomalies was achieved in only one patient. We describe clinical and morphologic features in a neonate with this complex anomaly. The patient successfully underwent the staged operation.

Aortoesophageal fistula due to esophageal ulcer.

Aortoesophageal fistula is a rare but fatal disease. Many such fistulas are caused by an aortic aneurysm, a previous operation, or esophageal disease. We report a case of aortoesophageal fistula due to an esophageal ulcer. A 66-year-old man suffered massive hematemesis; he was diagnosed as having an aortoesophageal fistula due to an esophageal ulcer after examination by upper endoscopy, computed tomography, and angiography. He had no aortic aneurysm, nor was there a history of a previous operation. An emergency operation was performed, but we could only accomplish closure because clamping of the aorta was impossible, and the source of the bleeding could not be established. He died 4 days later after sudden hemorrhage. Surgical outcome depends on early surgical intervention before massive hemorrhage occurs.

Migration of left ventricular thrombus causing abdominal aortic embolism during cardiac surgery in a child with severe left ventricular dysfunction.

A 1-year-old girl with severe left ventricular dysfunction presented with large floating thrombi in the left ventricle. Surgical thrombectomy was urgently required. During cannulation, transesophageal echocardiogram detected that the thrombus had vanished from the left ventricle. Whole body angiogram under very low-flow cardiopulmonary bypass successfully obtained the exact site of embolization with reducing total amount of contrast media in the operating room. Consequently, under deep hypothermic circulatory arrest, the obstructive thrombi at the abdominal aorta were successfully removed using Fogarty catheters from ascending aortotomy. Although delayed sternal closure was postoperatively required, no complication including thromboembolic events were observed for a 1.5-year follow-up period.

Perioperative circulating blood volume and cardiac function in valve disease.

Circulating blood volume is important in managing fluid balance and cardiac function after surgery under cardiopulmonary bypass. Appropriate management differs among the valve disorders, but perioperative blood volume has not yet been considered. From February 2001 to March 2003, perioperative blood volume, fluid balance, cardiac index, and left ventricular stroke work index were measured in 31 patients: 10 with aortic stenosis, 9 with aortic regurgitation, 3 with mitral stenosis, and 9 with mitral regurgitation. All immediate postoperative blood volume measurements were less than preoperative values, and gradually returned to baseline. At all time points, blood volume in patients with aortic or mitral regurgitation was high, whereas it was low in those with stenosis, especially mitral stenosis. Fluid balance was positive in all patients. Postoperatively, there was a positive correlation between cardiac index and blood volume in all groups. The left ventricular stroke work index in the mitral regurgitation group was significantly higher than other groups, the aortic stenosis group was slightly lower, the mitral stenosis and mitral regurgitation groups were higher than the baseline, and the aortic regurgitation group was essentially unchanged. Thus, it is necessary to consider blood volume perioperatively in different valvular diseases to manage water balance.

Impact of multi-detector row computed tomography on the tactics of cardiovascular surgery: from qualitative evaluation to quantitative assessment.

OBJECTIVE: We assessed the role of multi-detector row computed tomography in cardiovascular surgery. METHODS: The efficacy of multi-detector row computed tomography was assessed concerning the graft patency of coronary artery bypass, arterial atheromatous degeneration, small vessel imaging, and left ventricular volume measurement. Images were reconstructed using both the volume-rendering and the maximum-intensity-profile methods. Arterial atherosclerotic degeneration was assessed by aortic wall volume and aortic calcification volume. RESULTS: In the assessment of bypass graft patency, multi-detector row computed tomography showed a 98% correct positive ratio with sensitivity and specificity of 98% and 100%, respectively. Atheromatous degeneration showed matching results in more than 70% of cases compared with intraoperative findings. More than 92% of arterial branches with diameters of 3 mm or greater were detected by preoperative multi-detector row computed tomography images, though only 6% of branches with diameters of 2 mm or less could be visualized. There was a positive linear correlation between left ventricular volumes determined by multi-detector row computed tomography and those calculated from cine angiography. CONCLUSION: Multi-detector row computed tomography clearly visualized coronary bypass grafts and aortic arterial branches, providing detailed vascular images. Atheromatous degeneration assessed by multi-detector row computed tomography was equivalent with intraoperative findings in more than 70% of cases. Left ventricular volumes measured by multi-detector row computed tomography correlated closely with those determined by cine-angiography. Multi-detector row computed tomography is an efficient and promising modality in cardiovascular surgery.

Capillary leakage in cardiac surgery with cardiopulmonary bypass.

Cardiopulmonary bypass causes a systemic inflammatory response, which can lead to capillary leak syndrome. In 15 adults undergoing elective cardiac surgery with cardiopulmonary bypass, we determined the volume and peak time of capillary leakage from the measurements of extracellular fluid volume and circulating blood volume taken preoperatively, at various intervals up to 24 hours after surgery, and on the 7th postoperative day. Extracellular fluid volume rose from 15.5 +/- 2.7 L preoperatively to a peak 4 hours after surgery of 18.3 +/- 3.2 L and remained elevated at 24 hours. Circulating blood volume fell from 4.10 +/- 0.68 L preoperatively to 3.20 +/- 0.58 L at the end of surgery. Fluid administered intraoperatively did not raise the circulating blood volume. Intraoperative fluid balance was positive at 2.62 +/- 0.72 L but negative at all time points postoperatively. There was significant postoperative capillary leakage, increasing from 4.7% +/- 2.3% of body weight at the end of surgery to a peak 4 hours later of 5.4% +/- 2.0% and falling to 2.8% +/- 3.3% at 24 hours. This knowledge of the pattern of change in capillary leakage after cardiac surgery with cardiopulmonary bypass might serve as a valuable guide for postoperative management.

The prevalence and severity of cerebrovascular disease in patients undergoing cardiovascular surgery.

OBJECTIVES: The degree of preoperative cerebrovascular disease in patients undergoing cardiovascular surgery has not been well studied. Thus, the purpose of this study was to evaluate the prevalence and severity of cerebrovascular disease in such patients. METHODS: The subjects were 91 patients who underwent cardiovascular surgery. We investigated the prevalence and severity of cerebral infarction (CI), intracranial artery stenosis (ICAS) of > or =50%, cervical carotid artery stenosis (CCAS) of > or =50%, and periventricular hyperintensity (PVH) using magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). RESULTS: The prevalence of cerebrovascular diseases was: CI, 79 patients (86.8%) [33 had some small infarctions, 38 had multiple small infarctions, eight had broad infarctions greater than 15 mm); ICAS, 17 patients (18.7%)]; CCAS, 30 patients (33.0%) [21 had stenosis of <70%, and nine had stenosis of > or =70% or occlusion]; and PVH, 79 patients (86.8%). CONCLUSION: Patients undergoing cardiovascular surgery have a high prevalence of cerebrovascular disease in varying degrees.

Bacterial translocation secondary to small intestinal mucosal ischemia during cardiopulmonary bypass. Measurement by diamine oxidase and peptidoglycan.

OBJECTIVES: To demonstrate that small intestinal mucosal ischemia occurs during cardiopulmonary bypass by measuring serum diamine oxidase activity, an index of small intestinal mucosal ischemia, in perioerative patients undergoing cardiovascular surgery with and without cardiopulmonary bypass. METHODS: Twelve successive patients who underwent coronary artery bypass grafting with cardiopulmonary bypass (Group I) were compared to 10 patients who underwent off-pump coronary artery bypass grafting (Group II). Serum diamine oxidase activity, blood lactate concentration, and serum peptidoglycan concentration were measured perioperatively. RESULTS: Serum diamine oxidase activity rose after the start of cardiopulmonary bypass and continued to rise throughout cardiopulmonary bypass in Group I, while activity was unchanged in Group II. The serum lactate concentration mirrored the change in the diamine oxidase activity in both groups. The peptidoglycan concentration in Group I rose after the start of cardiopulmonary bypass and returned to near normal concentrations after surgery. CONCLUSIONS: The parallel rise in diamine oxidase activity and the serum lactate concentration in Group I implies that ischemic injury to the mucosa of the small intestine occurs during cardiopulmonary bypass, and the rise in the serum peptidoglycan concentration indicates that bacteremia did occur. Thus, cardiopulmonary bypass causes hypoperfusion of small intestinal mucosa and consequently bacterial translocation.

A prospective randomized study of sternal closure: comparison of Mersilene tape versus standard wire closure.

BACKGROUND: To compare in a prospective randomized study Mersilene tape and standard metal wire for complications and pain upon sternal wound closure. METHODS: Sixty-four patients scheduled for cardiac surgery were prospectively randomized to undergo sternal closure using either Mersilene tape (n=30) or standard metal wire (n=34). The intensity of postoperative pain from the chest wound was assessed using a visual analogue scale (VAS) on the second and seventh postoperative days and one month after surgery. The examinations with chest X-ray and computed tomography (CT) one month after surgery were performed to evaluate the chest wound and sternum. Follow-up data on sternal and wound healing was assessed for up to one year. RESULTS: No deaths, sternal dehiscence or infection occurred in either group. No wound complications were observed in either group during the year following surgery. A review of data revealed that there was no difference in the intensity of postoperative pain according to the VAS between the two groups. Chest CT demonstrated that no patients in either group had cuts in the sternum. CONCLUSION: This prospective randomized study showed Mersilene tape sternal closure not to be more closely associated with increased complications or patient discomfort due to sternal wound than the standard wire closure.

Combined carotid endarterectomy and cardiac surgery for concomitant carotid and cardiac disease.

OBJECTIVES: Carotid artery disease is one of the important factors of neurological complications after cardiac surgery. In this study we present our surgical experience and discuss its implication for patients with carotid and cardiac disease. METHODS: Five patients underwent combined carotid endarterectomy (CEA)/cardiac surgery including thoracic aortic repair. There were three male and two female patients, with a mean age of 67+/-10 years (range, 54-75 years). All patients had an 80% or greater stenosis in the unilateral internal carotid artery. Three patients had coronary artery disease and underwent combined CEA/off-pump coronary artery bypass grafting (OPCAB). One patient had an aortic valve stenosis (AS) with repeated syncope and chest pain, and underwent combined CEA/aortic valve replacement. The remaining patient had an extremely large aortic arch aneurysm (90 mm) and underwent combined CEA/total arch replacement. RESULTS: There were no surgical or hospital deaths. No perioperative complications including myocardial infarction and stroke occurred. During the follow-up period, lasting from 2 months to 27 months (mean, 13 months), there were no late deaths, neurological complications nor cardiac events. CONCLUSIONS: Combined CEA/cardiac surgery offered an acceptable morbidity in these complex patients. Due to the preliminary nature of our study, further follow-up and experience with our management strategy are necessary.