Delayed sternal closure after vacuum-assisted closure therapy for tracheo-innominate artery fistula repair

We report a case of successful innominate artery resection with delayed sternal closure after vacuum-assisted closure (VAC) therapy for a tracheo-innominate artery fistula (TIF). A 42-year-old woman with cerebral palsy underwent tracheostomy for respiratory assistance. On postoperative day 14, she was transferred to our hospital after an episode of massive hemoptysis. TIF was diagnosed based on the findings of multidetector computed tomography. Thus, we resected the innominate artery and started VAC therapy to control the postoperative local infection. The patient recovered uneventfully, without any infectious sequelae. Our strategy, which includes VAC therapy, for TIF repair may eliminate postoperative infective problems that could induce sequential bleeding and sternal compromise. To our knowledge, this is the first report of using VAC therapy for TIF.

Secondary omental and pectoralis major double flap reconstruction following aggressive sternectomy for deep sternal wound infections after cardiac surgery

Background

Deep sternal wound infection after cardiac surgery carries high morbidity and mortality. Our strategy for deep sternal wound infection is aggressive strenal debridement followed by vacuum-assisted closure (VAC) therapy and omental-muscle flap reconstrucion. We describe this strategy and examine the outcome and long-term quality of life (QOL) it achieves.

Methods

We retrospectively examined 16 patients treated for deep sternal wound infection between 2001 and 2007. The most recent nine patients were treated with total sternal resection followed by VAC therapy and secondary closure with omental-muscle flap reconstruction (recent group); whereas the former seven patients were treated with sternal preservation if possible, without VAC therapy, and four of these patients underwent primary closure (former group). We assessed long-term quality of life after DSWI by using the Short Form 36-Item Health Survey, Version 2 (SF36v2).

Results

One patient died and four required further surgery for recurrence of deep sternal wound infection in the former group. The duration of treatment for deep sternal wound infection in the recent group was significantly shorter than that in previous group (63.4 ± 54.1 days vs. 120.0 ± 31.8 days, respectively; p = 0.039). Despite aggressive sternal resection, the QOL of patients treated for DSWI was only minimally compromised compared with age-, sex-, surgical procedures-matched patients without deep sternal wound infection.

Conclusions

Aggressive sternal debridement followed by VAC therapy and secondary closure with an omental-muscle flap is effective for deep sternal wound infection. In this series, it resulted in a lower incidence of recurrent infection, shorter hospitalization, and it did not compromise long-term QOL greatly.

[Familial aortic dissection of non-Marfan syndrome with mutations in the transforming growth factor-beta receptor type 1 genes]

Marfan syndrome is an inherited connective tissue disorder with ocular, skeletal and cardiovascular systems and often causes acute aortic dissection. Interestingly, there have been several reports of familial thoracic aortic dissection in patients with autosomal dominant diseases without Marfan syndrome. Variation of the transforming growth factor-beta receptor (TGFBR) gene is reported to be one of the causes. We report a case of a familial aortic dissection not associated with Marfan syndrome, with mutation of TGFBR type 1. Hereditary aortic dissection of the non-Marfan syndrome that does not have clinical manifestations is not uncommon. Thus, the existence of familial aortic aneurysm should be in mind in diagnosis and treatment.

[Mitral valve replacement with St. Jude Medical mechanical heart valve in severely calcified mitral annulus; a simple and novel technique]

A 63-year-old woman who had been on hemodialysis for 20 years was referred to our institution to undergo mitral valve surgery for mitral valve stenosis. Intraoperative investigations confirmed severe calcification of the mitral leaflets and mitral annulus. We excised the only anterior leaflet, but preserved the posterior leaflet to prevent a fatal complication such as posterior left ventricular rupture or injury of the coronary artery. We passed 2-0 polyester mattress sutures through the anterior mitral annulus from the left ventricle to the left atrium, and then folded the posterior leaflet. Preserved posterior leaflet was fixed to posterior mitral annulus and prosthetic valve. The mitral valve was replaced using a St. Jude Medical mechanical heart valve with a specific structure, whose hinge shifts to the left atrial side and most of the leaflet to move its housing. This particular structure enables to perform this procedure without the need for excision of a severely calcified posterior mitral leaflet and annulus.

Impaired angiogenic potency of bone marrow cells from patients with advanced age, anemia, and renal failure

OBJECTIVE

The implantation of autologous bone marrow-derived cells has been used for the treatment of ischemic diseases, but obvious interindividual differences were observed in the improvement of regional perfusion and cardiac function after treatment. We examined the angiogenic potency of bone marrow cells from patients with different clinical backgrounds.

METHODS

Bone marrow cells were collected from 25 patients scheduled to undergo sternotomy for various surgical procedures. We examined the quality of bone marrow cells and investigated their angiogenic potency by using an ischemic limb model in mice with severe combined immunodeficiency.

RESULTS

When compared with their control cohort, bone marrow cells from patients with advanced age, renal failure, or anemia had significantly less c-kit- and CD34-positive stem cells (P < .05) and showed significantly lower vascular endothelial growth factor production and colony-forming units in culture (P < .05). Furthermore, the implantation of bone marrow cells from patients with advanced age, renal failure, or anemia into the ischemic limbs of mice also resulted in significantly worse blood flow recovery and clinical score when compared with the implantation of bone marrow cells from their control cohorts (P < .05). However, the bone marrow cells from patients with diabetes and hypertension did not show significant impairment of angiogenic potency when compared with their control cohorts.

CONCLUSIONS

The quality and angiogenic potency of bone marrow cells differs among patients. Advanced age, renal failure, and anemia should be the risk factors related to poor angiogenic potency of bone marrow cells for the treatment of ischemic diseases.

Ischemic pre-conditioning enhances the mobilization and recruitment of bone marrow stem cells to protect against ischemia/reperfusion injury in the late phase

OBJECTIVES

The aim of this study was to investigate whether the mobilization and recruitment of bone marrow stem cells (BMSCs) contribute to cardioprotection in the late phase after ischemic pre-conditioning (IPC).

BACKGROUND

IPC is an innate phenomenon in which brief exposure to sublethal ischemia provides tissue protection from subsequent ischemia/reperfusion (I/R) injury. A delayed cardioprotection also occurs after IPC, but the precise mechanism is unclear.

METHODS

IPC was created with 4 cycles of 5-min occlusion and reperfusion of the abdominal aorta in mice. Heart I/R injury was induced by occluding the left anterior descending artery for 30 min immediately (early phase) or 24 h (late phase) after IPC.

RESULTS

Serum vascular endothelial growth factor and stromal cell-derived factor-1alpha levels were increased significantly 1 and 3 h after IPC, but CD34+ and CD34+/flk-1+ stem cells in the peripheral blood were increased significantly 12 and 24 h after IPC (p < 0.05). Compared with the control treatment, both the early and late phases of IPC protected the heart against I/R injury. However, the recruitment of BMSCs was significantly greater in the heart when I/R injury was induced in late phase than in the early phase of IPC (p < 0.01). Interestingly, the blockade of the recruitment of BMSCs significantly attenuated the cardioprotective effect of IPC in the late phase (p < 0.01) but did not change in the early phase.

CONCLUSIONS

Cardioprotection was observed in the early and late phases of IPC; however, the enhanced mobilization and recruitment of BMSCs played an important role in the late phase of IPC.

[Subdural hematoma following cardiac surgery]

We report 3 cases of subdural hematoma following open heart surgery under cardiopulmonary bypass. In 2 patients, emergency removal and drainage of a subdural hematoma was performed by neurosurgeons, and conservative management was performed in the remaining one. All patients belonged to a high risk group of bleeding due to anticoagulation therapy, and they had no episode of head trauma. Subdural hematomas may have been due to rapid alterations in cerebral volume, leading to a tearing of the dural bridging veins under cardiopulmonary bypass. Although early diagnosis and prompt treatment is very important, it is often difficult to examine neurological findings after cardiac surgery. We consider that patients who need long-term sedation under anticoagulation therapy must have their neurological status checked at least once in a few days.

Computed tomographic angiography to evaluate the right gastroepiploic artery for coronary artery bypass grafting

OBJECTIVE

The right gastroepiploic artery (RGEA) is widely used as an in situ arterial graft for coronary artery bypass grafting (CABG); however, it is impossible to measure an RGEA or check for calcification or stenosis and assess its suitability as a graft before angiography or harvest. We evaluated the accuracy of preoperative three-dimensional computed tomographic angiography (3D-CTA) for assessing the suitability of RGEAs for CABG.

METHOD

We used 4-channel multidetector-row computed tomography with intravenous contrast medium. All the RGEAs had an intraluminar diameter greater than 1.5 mm. RGEAs longer than two-thirds of the greater curvature of stomach, longer than half of the greater curvature, and shorter than half of the greater curvature were defined as large, moderate, and small, respectively.

RESULT

Of the 36 patients examined, 5 (14%) had a small RGEA, 16 (44%) had a moderate RGEA, and 15 (42%) had a large RGEA. We confirmed intraoperatively that two small RGEAs were unsuitable for grafting because they could not reach the posterior descending artery (PDA). The other three small RGEAs were not used. Two of the large and moderate RGEAs with diffuse narrowing and severe calcification were also unsuitable for grafting. This eliminated the need for a laparotomy to harvest the RGEA in five (14%) patients. Intraoperative findings confirmed that all the moderate RGEAs could be anastomosed to the PDA. All the large RGEAs reached the posterolateral artery (PLA), and more than half reached the PLA branching circumflex artery.

CONCLUSION

Preoperative noninvasive evaluation by 3D-CT is effective for assessing the suitability of RGEAs for CABG.

[The Waffle procedure for constrictive epicarditis after direct closure of atrial septal defect; report of a case]

A 20-year-old man was admitted with a diagnosis of constrictive pericarditis 6 months after direct closure of atrial septal defect (ASD). He complained of fatigue and dyspnea. Cardiac echo cardiography, computed tomography (CT), magnetic resonance imaging (MRI) and cardiac catheterization suggested pericardial and epicardial constriction. During the operation, the thickened pericardium was peeled off. Multiple longitudinal and transverse incisions were made in the thickened epicardium as reported by waffle. Postoperative hemodynamic state was improved. The cardiac index increased from 1.91 to 3.17 l/min/m2. The pulmonary capillary wedge pressure (PCWP) decreased from 26 to 14 mmHg, although dip and plateau pattern was maintained. The postoperative course was uneventful.

[Aortic root abscess after percutaneous coronary intervention]

A 68-year-old man, who had undergone percutaneous coronary intervention for right coronary disease 2 weeks earlier, was admitted to our hospital for investigation of a fever. Blood culture and echocardiography revealed isolated aortic valve infective endocarditis. He was treated with antibiotics for more than 1 week, but echocardiography showed an aortic root abscess with severe aortic regurgitation. Thus, we performed aortic root replacement using an artificial Freestyle stentless bioprosthesis valve. The patient had an uneventful postoperative course and antibiotic treatment was continued for a further 8 weeks.

Pravastatin improves remodeling and cardiac function after myocardial infarction by an antiinflammatory mechanism rather than by the induction of angiogenesis

BACKGROUND

Recent studies have reported that the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (or statins) can improve angiogenesis. Using an acute infarction model, we examined the therapeutic merit of statins on angiogenesis, alone and in combination with cell-based therapy.

METHODS

Zucker fatty rats, a strain characterized by obesity, hyperglycemia, and hyperlipidemia, were used for this study. After ligating the left anterior descending artery, rats were given oral pravastatin 5 or 50 mg/kg per day, or an intramyocardial injection of a total 2 x 10(7) autologous bone marrow mononuclear cells, or a combination of both. Cardiac function was assessed by echocardiography before treatment, then 7, 14, and 28 days after treatment. Histologic estimation of microvessel density, lymphocyte infiltration, and collagen fiber accumulation in the infarcted myocardium was performed 28 days after treatment.

RESULTS

Cardiac function was improved, and collagen deposition was decreased significantly after either cell implantation or pravastatin administration alone, but no synergistic effect was seen by their combination. However, microvessel density in the infarcted myocardium was increased only by implantation of bone marrow mononuclear cells, and not by administration of pravastatin. Pravastatin resulted in significant decreases in the serum levels of interleukin 1beta and tumor necrosis factor-alpha, and also in the infiltration of CD45-positive cells, but not CD117-positive stem cells, in infarcted myocardium. Neither the number of circulating CD34-positive cells nor their endothelial differentiation potency was increased significantly 14 days after oral administration of pravastatin.

CONCLUSIONS

Pravastatin can improve cardiac function after myocardial infarction, but through an antiinflammatory mechanism, rather than by induction of therapeutic angiogenesis. No synergistic effect for inducing angiogenesis was found by the combination of pravastatin and implantation of bone marrow mononuclear cells.

The reduction of hemodynamic loading assists self-regeneration of the injured heart by increasing cell proliferation, inhibiting cell apoptosis, and inducing stem-cell recruitment

OBJECTIVES

Mitotic cardiomyocytes and cardiac stem cells have been identified recently in adult hearts, and both have been found to be increased in acute infarcted myocardium. Although these findings suggest potential self-repair of the heart after injury, obvious self-regeneration of the injured heart has never been observed clinically. We hypothesized that hemodynamic loading impairs myocardial repair.

METHODS

Myocardial infarction was induced in C57BL/6 mice by ligating the left anterior descending artery. After 60 minutes, either the infarcted heart was transplanted heterotopically into a healthy recipient C57BL/6 mouse to remove the ventricular hemodynamic loading (unloading group) or it was left as an infarcted heart under normal hemodynamic loading conditions in the same mouse (loading group). The infarcted hearts were dissected for histologic analysis after 3, 7, 14, and 28 days.

RESULTS

Histologic analysis showed that the wall thickness of the infarcted left ventricle was significantly greater and the area of infarction was significantly smaller in the unloading group than in the loading group. Immunostaining analysis revealed significantly more Ki-67-positive cells and significantly fewer apoptotic cells in the infarcted myocardium in the unloading group than in the loading group. There were also significantly more c-kit- and Sca-1-positive stem cells in the infarcted myocardium in the unloading group than in the loading group.

CONCLUSION

Our findings suggest that hemodynamic unloading assists self-regeneration of the injured heart by increasing cell proliferation, inhibiting cell apoptosis, and inducing stem-cell recruitment.

[Mid-term results of overlapping cardiac volume reduction for ischemic cardiomyopathy]

BACKGROUND

Left ventricular restoration (LVR) is thought to be effective for ischemic cardiomyopathy (ICM). We assessed the early and mid-term results of overlapping cardiac volume reduction (OLCVR) as an operation for LVR on patients with ICM.

METHODS

From February to June 2004, 4 patients with ICM underwent OLCVR in our department.

RESULTS

There was no death. Significant decreases in the left ventricular end diastolic volume index and in the left ventricular end systolic volume index were observed in the early postoperative period in all the 4 patients. These effects were still evident 1 year later, with improved New York Heart Association (NYHA) functional class and a smaller left ventricular diastolic diameter. One patient required implantation of a cardioverter defibrillator 16 months postoperatively.

CONCLUSION

The favorable early and mid-term results of the OLCVR indicate that it is an effective procedure for patients with ICM.

Successful aortic valve replacement for infective endocarditis in a patient with severe liver cirrhosis

Patients with liver cirrhosis are prone to the development of severe complications associated with high mortality rates after major surgery, especially cardiac surgery using cardiopulmonary bypass (CPB). We report the case of a 65-year-old man with acute infective endocarditis and aortic valve perforation, complicated by non-cardiac liver cirrhosis (Child-Pugh class B). After careful preoperative anti-inflammatory and systemic support treatment, we successfully treated infective endocarditis-induced aortic valve perforation by performing aortic valve replacement (AVR).

HMG-CoA reductase inhibitors reduce matrix metalloproteinase-9 activity in human varicose veins

Matrix metalloproteinases (MMPs) have been implicated in tissue degradation in varicose veins. The aim of this study was to investigate the effects of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) on the activity of MMPs in varicose veins. MMP-9 was present at significantly higher levels in varicose veins than in controls and was localized mainly in smooth muscle cells at the tunica media, where marked degradation of the extracellular matrix was observed. Both simvastatin and pravastatin strikingly suppressed MMP-9 activity in ex vivo culture of varicose veins. Simvastatin suppressed MMP-9 at both the mRNA and protein levels as well as at the urokinase-type plasminogen activator protein level, resulting in the dramatic suppression of MMP-9 activity induced by tumor necrosis factor-alpha. Therefore, statins suppress MMP-9 activity by multiple mechanisms in varicose veins, suggesting they may have clinical potential for the treatment of this disease.

[Ruptured infected descending aortic aneurysm successfully treated by omentopexy and a rifampicin-soaked vascular prosthesis; report of a case]

A 73-year-old man was admitted for investigation of back pain, blood-stained sputum, and a high fever. Computed tomography (CT) showed a pseudoaneurysm in the descending aorta and intravenous antibiotic therapy was begun immediately after blood had been taken for culture. However, his temperature continued to spike daily, up to 38 degrees C, and his CRP was also elevated. The blood cultures were negative. The aneurysm ruptured and we replaced the descending aorta with a rifampicin (RFP)-soaked vascular prosthesis, and wrapped it with greater omentum. Postoperative antibiotic therapy with vancomycin hydrochloride, RFP, and amikacin sulfate was continued for 8 weeks. The patient recovered uneventfully. Thus, an infected aneurysm was effectively treated with a RFP-soaked vascular prosthesis and omentopexy.

[Left coronary ostial stenosis caused by syphilitic aortitis]

We report 2 cases of cardiovascular disease related to end-stage syphilitic infection, which is now relatively rare. A 49-year-old man (case 1), and a 45-year-old man (case 2) were admitted to our hospital for angina pectoris. Cardiac catheterization showed severe aortic regurgitation and left coronary ostial stenosis. Active syphilis was detected in both cases by routine blood examination on admission. Oral ampicillin was started immediately to treat the syphilis; however, during the course of treatment, acute heart failure developed in both patients. We performed emergency aortic valve replacement and coronary artery bypass grafting. Intraoperatively, the orifice of the left coronary artery was almost occluded, and retrograde perfusion of cardioplegia was needed to induce cardiac arrest. Both patients recovered uneventfully. When treating patients with antibiotics for syphilitic disease, it is important to prepare for the possibility of urgent surgery.

[Strategy for thrombosed type A acute aortic dissection]

The surgical treatment for thrombosed type A aortic dissection is controversial. We treated 15 cases (28.8%) with thrombosed type A acute aortic dissection among 52 cases of all type A acute aortic dissection during past 7 years and 8 months. Nine cases was treated conservatively and 6 cases received emergent operation due to cardiac tamponade, shock, and ulcer-like projection (ULP) in the ascending aorta (> 50 mm). In the group of conservative therapy, 2 cases in which the ascending aorta was enlarged (54, 60 mm), was converted to operation in the acute phase because of further enlargement of ascending aorta and increase of cardiac effusion. The other patients (aortic diameter: 40-46 mm) who received conservative therapy were well controlled by medical therapy in the early and late phase except 1 who died suddenly in the follow-up. There was no mortality and late death in the operated patients. From these results, we conclude that thrombosed type A aortic dissection in which the diameter of ascending aortic aorta is larger than 50 mm, have cardiac tamponade and ULP in the ascending aorta might needs operation.

Low angiogenic potency induced by the implantation of ex vivo expanded CD117+stem cells

Ex vivo expansion of stem cells might be a feasible method of resolving the problem of limited cell supply in cell-based therapy. The implantation of expanded CD34+endothelial progenitor cells has the capacity to induce angiogenesis. In this study, we tried to induce angiogenesis by implanting expanded CD117+stem cells derived from mouse bone marrow. After 2 wk of culture with the addition of several growth factors, the CD117+stem cells expanded ∼20-fold and had an endothelial phenotype with high expression of CD34 and vascular endothelial-cadherin. However, >70% of these ex vivo expanded cells had a senescent phenotype by β-galactosidase staining, and their survival and incorporation were poor after implantation into the ischemic limbs of mice. Compared with the PBS injection only, the microvessel density and the percentage of limb blood flow were significantly higher after the implantation of 2 × 105freshly collected CD117+cells ( P < 0.01) but not after the implantation of 2 × 105expanded CD117+cells ( P > 0.05). These data indicate that ex vivo expansion of CD117+stem cells has low potency for inducing therapeutic angiogenesis, which might be related to the cellular senescence during ex vivo expansion.

CD117+ stem cells play a key role in therapeutic angiogenesis induced by bone marrow cell implantation

Therapeutic angiogenesis can be induced by the implantation of bone marrow mononuclear cells. We investigated the roles of mature mononuclear cell and stem cell fractions in bone marrow in this treatment. Although CD34 is the most popular marker for stem cell selection for inducing therapeutic angiogenesis, we separated CD117-positive cells (CD117+) from mature bone marrow mononuclear cells [CD117-negative cells (CD117-)] from mice using the antibody to the stem cell receptor, because some of the bone marrow stem cells that express CD117+ and CD34- might generate angiogenic cytokines and differentiate into endothelial cells. The angiogenic potency of CD117+ and CD117- cells was investigated in vitro and in vivo. Significantly higher levels of VEGF were secreted from the CD117+ cells than from the CD117- cells (P < 0.001). Most of the CD117- cells died, but the CD117+ cells grew well and differentiated into endothelial cells within 14 days of culture. The CD117+ cells survived and were incorporated in microvessels within 14 days of being implanted into the ischemic hindlimbs of mice, but the CD117- cells did not. The microvessel density and blood perfusion of the ischemic hindlimbs were significantly higher in the CD117+ cell-implanted mice than in the CD117- cell-implanted mice (P < 0.01). The microvessel density in ischemic hindlimbs was also significantly higher in the CD117+ cell-implanted mice than in the total bone marrow cell-implanted mice (P < 0.05). Thus CD117+ stem cells play a key role in the therapeutic angiogenesis induced by bone marrow cell implantation.

Granulocyte elastase release and pulmonary hemodynamics in patients with mitral valvular disease

In patients with atrial septal defect in whom pulmonary hypertension could develop as a consequence of left-to-right shunt, the extent of neutrophil-mediated lung injury induced by cardiopulmonary bypass (CPB) is related to the degree of increase in the preoperative pulmonary artery pressure. In the present study, we investigated the relationship between levels of granulocyte elastase (GEL) after CPB and preoperative pulmonary hemodynamics or changes in pulmonary function after the operation in patients with mitral valve disease, in whom pulmonary hypertension could develop as a result of pulmonary venous congestion. The plasma levels of GEL were measured before and after CPB in patients who underwent mitral valve replacement. Respiratory index (RI) was evaluated preoperatively and postoperatively. Preoperative pulmonary hemodynamics were determined within one month of the operation. Granulocyte elastase level rose significantly after CPB from baseline (134.3 +/- 44.6 mg/L versus 2042.1 +/- 1215.0 mg/L; p <0.001). Peak level of GEL was significantly correlated with preoperative systolic pulmonary artery pressure (r = 0.71; p = 0.020), mean pulmonary artery pressure (r = 0.64; p = 0.046), pulmonary capillary wedge pressure (r = 0.68; p = 0.032), and pulmonary-to-systemic arterial pressure ratio (r = 0.64; p = 0.045), but not with the hemodynamic variables for pulmonary blood flow or pulmonary resistance. Moreover, the value of (Postoperative RI - Preoperative RI)/Preoperative RI was positively correlated with the peak level of GEL (r = 0.76; p = 0.011). In conclusion, in patients with mitral valvular disease, as in those with atrial septal defect, the increase in GEL level after CPB is proportional to the increase in preoperative pulmonary artery pressure, which may cause the accordant pulmonary vascular damage.

Perioperative features of coronary artery bypass grafting in patients aged 75 years or older

OBJECTIVES

Coronary artery bypass grafting (CABG) is well established as an effective operation to overcome ischemic heart disease; however, the number of aged patients with a high operative risk undergoing this procedure has increased in recent years. This retrospective study evaluates our experience of performing CABG in a consecutive series of patients aged 75 years or older.

METHODS

To assess the hospital mortality and morbidity associated with this procedure, we retrospectively analyzed 49 patients aged 75 years or older (Elderly Group) who underwent CABG and compared the results with those of 88 patients aged 65-74 years (Control Group) who underwent CABG during the same period. Patients were examined for cerebrovascular diseases, and those with significant stenosis underwent pulsatile cardiopulmonary bypass. To avoid pulmonary complications, patients were extubated early.

RESULTS

The Control Group had a significantly higher incidence of arterial grafts than the Elderly Group (0.8 +/- 0.5 versus 0.3 +/- 0.5; p < 0.0001). The Elderly Group had a significantly higher incidence of postoperative complications than the Control Group, with supraventricular arrhythmia in 57.1% versus 28.4%, (p = 0.0009), delirium in 36.7% versus 11.4%, (p = 0.0004), pneumonia in 6.1% versus 0%, (p = 0.0439), and intubation duration of 88.3 +/- 212.5 hours versus 37.2 +/- 92 hours (p = 0.0296), respectively. However, there was no significant difference in hospital mortality between the two groups, being 8.2% versus, 2.3%, in the Elderly group and Control Group, respectively (p = 0.1867).

CONCLUSION

These findings indicated that when elderly patients were appropriately managed, CABG could be performed with an acceptably low risk to mortality.

[Heart transplantation for dilated cardiomyopathy possibly caused by fulminant acute myocarditis: a case report]

A 13-year-old boy [corrected] underwent heart transplantation for severe congestive heart failure due to dilated cardiomyopathy possibly caused by fulminant acute myocarditis. He suddenly suffered chest discomfort and loss of consciousness during running, and was referred to a hospital with cardiogenic shock. Electrocardiography showed ventricular tachycardia and echocardiography revealed severe hypokinesis in an extensive area of the left ventricular wall with markedly decreased left ventricular ejection fraction. Percutaneous cardiopulmonary support, intraaortic balloon pumping and artificial respiration were performed. He suffered from severe heart failure with septic shock and bleeding tendency. A left ventricular assist system was fitted at 73 days after onset, and he was transferred to the National Cardiovascular Center on the 119th hospital day. At 319 days after the left ventricular assist system operation, heart transplantation was performed. The etiology and treatment for severe heart failure, and several social problems which occurred during care for heart transplantation are discussed.

Local implantation of autologous bone marrow cells for therapeutic angiogenesis in patients with ischemic heart disease: clinical trial and preliminary results

A new therapy for severe ischemic heart disease has been developed; therapeutic angiogenesis induced by the local implantation of autologous bone marrow cells (BMC). After confirming that no detrimental changes were induced by this treatment in a canine heart model, a clinical trial was commenced in 1999. Thus far, 5 patients have been given this new treatment concomitant with coronary artery bypass grafting and all have been followed up for at least 1 year. Autologous BMC were implanted into the ungraftable area and postoperative cardiac scintigraphy showed specific improvement in coronary perfusion in 3 of the 5 patients. Postoperative chest radiography, electrocardiography, echocardiography and blood tests did not reveal any detrimental changes. In conclusion, this new therapy appears to be safe and could provide a treatment option for patients with otherwise untreatable ischemic heart disease.

[A coronary artery bypass grafting using cardiopulmonary bypass with intraaortic balloon pumping in patient with low cardiac function combined with cerebral vascular disease]

We reported a 55-year-old man, who had coronary and cerebral vascular disease. Cerebral angiography showed occlusion at left internal carotid artery (ICA) and 50% stenosis at right ICA C4 portion. But acetazolamide reactivity was kept symmetrically. Coronary angiography showed severe three vessel disease, and left ventriculography showed diffuse severe hypokinesis/akinesis, and EF was below 30%. The patient underwent coronary artery bypass grafting using cardiopulmonary bypass with intraaortic balloon pumping to keep intraoperative blood pressure high. After the operation he recovered uneventfully without neurological complication.

Atheromatous plaque in the distal aortic arch creating the potential for cerebral embolism during cardiopulmonary bypass

The present study evaluated the risk in cardiac patients of rupture of a plaque by a jet stream from the arch cannula. The entire thoracic aorta and cardiac function were routinely monitored by transesophageal echocardiography (TEE) in 88 adult patients who underwent coronary artery bypass surgery. The changes in the atheromatous plaque in the distal aortic arch were observed before and after cardiopulmonary bypass. Of the 88 patients, 13 were found to have preoperative atheromatous plaque at the distal aortic arch and 8 (61.5%) of them suffered plaque rupture caused by jet stream from the arch cannula. Only 1 patient experienced apparent embolic episodes manifesting as cerebral and left leg embolisms; the remaining 7 had no clinical embolic symptoms. In order to prevent atheroembolic events, attention should be paid not only to the ascending aorta, but also to the distal arch and in this regard TEE is useful for detecting atheromatous changes of the aorta.

[J-sternotomy approach for aortic valve reoperation]

Recent progress in cardiovascular surgery has promoted less non-invasive surgery. We reoperated in a forty-two year old female for aortic valve regurgitation using the J-sternotomy approach and experienced good results. The patient was operated on with AVR 12 years after her first cardiac operation. Chest computed tomography revealed an adhesion between the anterior chest wall and the right ventricle. We made a sternal incision from the sternal notch down to the fourth right intercostal space (J-sternotomy). Ascending aorta was cannulated in the conventional manner. A conventional Two-stage cannula was placed in the auricle of the right atrium. A venting tube was also cannulated through the right upper pulmonary vein. J-sternotomy and minimal adhesionectomy made for a good operative field to establish cardiopulmonary bypass and to perform aortic valve re-operation.

Modified Bentall operation with concomitant total aortic arch replacement for DeBakey type I aortic dissection: report of a case

The successful implementation of a reoperative Bentall procedure with concomitant total aortic arch replacement after ascending aortic replacement for acute aortic dissection is infrequently reported. We performed a modified Bentall procedure with total replacement of the aortic arch in a patient suffering from worsening aortic regurgitation (AR) and residual dissection. Our strategy involved the button method for coronary reconstruction, selective cerebral perfusion, the use of a composite graft with four branches for aortic arch replacement, and the administration of high-dose aprotinin to decrease bleeding.

[An approach to the emergency surgery for arch and/or ascending aortic aneurysm]

The outcome of emergency surgery for the aortic arch aneurysm and/or dissecting aneurysm is worse than that of elective surgery. To decide the future strategy of the emergency surgery for these disease, 11 patients with emergency surgery (= group E: 8 for aortic dissection and 3 for rupture of the aortic arch aneurysm, age; 61 +/- 13 SD) were compared with 12 patients who had elective surgery (= group S: 5 for aortic dissection and 7 for aortic arch aneurysm, age; 69 +/- 3 SD). Ascending aorta replacement was performed in 7 cases in group E v.s. 1 in group S, aortic arch replacement in 2 v.s. 5, ascending aorta and aortic arch replacement in 1 v.s. 4 and patch replacement of the aortic wall in 1 v.s. 2, respectively. Selective cerebral perfusion (SCP) upon the cardiopulmonary bypass (CPB) was used in 45% (5/11) in group E. v.s. in 92% (11/12) in group S, p < 0.05. CPB time, aortic clamp time and SCP time were not significantly different between E group and S group. Postoperative cardiac failure, respiratory failure, renal failure, brain injury and infection occurred at insignificant rates between both groups. Thirty-day and 3-year survivorships were 73% in group E, while in group S they were 92% and 75%, respectively. In group E there were 2 cases which had aortic wall injury due to the aortic clamp used during the surgery. We recommend the use of selective cerebral perfusion and open distal anastomosis in emergency surgery for aortic arch aneurysm and/or Stanford type A aortic dissection.

[Influence of cardiopulmonary bypass on biological response]

To investigate the influence of cardiopulmonary bypass (CPB) on biological response, we measured the serum level of tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), and granulocyte elastase (GEL) in 24 patients who underwent elective cardiac surgery and 32 patients who underwent elective gastroenterological surgery. All patients were alive. The serum level of GEL in cardiac patients was significantly higher than that in gastroenterological patients on the 1st and the 3rd postoperative day (P = 0.00008, P = 0.00097 respectively). In addition. there was a significant relationship between CPB time and the serum level of GEL immediately after CPB (r = 0.53, P = 0. 007). That is a reason why higher level of serum GEL in cardiac surgery is due to the bacterial translocation. TNF-alpha and IL-1beta were detected in only :3 patients who underwent over 250 minutes CPB. It is most important to shorten the CPB time in order to decrease the serum GEL and lessen the biological response surgery.