Recent experience of integrated myocardial management: the newest strategy for myocardial protection

From April 1994 until June 1996, we exclusively utilized the integrated myocardial management (IMM) proposed by Buckberg et al. at UCLA. Two hundred sixty-two consecutive patients undergoing open heart surgery at our hospital were divided into 2 groups, the non-IMM (n = 49, from July 1993 until March 1994) and the IMM (n = 213, from April 1994 until June 1996) groups. Although many older and more severely ill patients were treated with IMM, acceptable clinical outcomes with comparable safety and efficiency were obtained. Shorter durations of total cardiopulmonary bypass (CPB) and aortic cross-clamping (AXC) were needed in the IMM group despite there being many more procedures undertaken during a single cross-clamp period.

[Quantitative evaluation of aqueous flare in psoriasis using a laser flare-cell meter]

We evaluated aqueous humor protein concentration in psoriasis using a laser flare-cell meter, which can quantify aqueous flare precisely and objectively. Psoriatic severity was evaluated on the basis of psoriasis area and severity index (PASI) score. Aqueous flare was measured in 40 eyes of 20 psoriasis patients (sixteen psoriasis vulgaris, three guttate psoriasis, and one psoriatic arthritis) and 28 eyes of 14 normal controls. Aqueous flare value was significantly higher in psoriatic patients than in normal controls (p < 0.01). There was no difference between psoriasis vulgaris and the other types of psoriasis. Aqueous flare value was higher in patients with psoriatic history longer than 10 years than in those with less than 10 years (p < 0.05), and also higher in patients with severe psoriasis (PASI score > 10) than in those with mild psoriasis (PASI score < 10) (p < 0.05). But no statistically significant differences in aqueous flare value were found among cyclosporin, etretinate, and psoralen ultra violet A therapies. These findings strongly suggest that patients suffering from psoriasis have slight damage of the blood-aqueous barrier even if they have no ocular symptoms, and that the degree of blood-aqueous barrier damage increases with time and severity of psoriasis.

[The problem of 19 mm St. Jude Medical valve prosthesis in the small aortic annuls--19 mm St. Jude Medical valve vs 23 mm St. Jude Medical valve]

We compared the results of 19 mm SJM aortic valve replacements with those of 23 mm SJM aortic valve replacements conducted the same period. [Material & Method] The subjects were 21 patients who underwent valve replacement with a 19 mm SJM prosthesis (the SJM19A group). The age ranged among 16 and 65-year-old, mean of 51. The body surface area was 1.24 to 1.76 m2, mean of 1.48 m2. The post-operative follow-up period was 156 months at maximum and 44 months on average. We compared the SJM19A group with the SJM23A group by chest X-ray and echocardiography. [Results] Two patients in the SJM19A group died soon after surgery. Of the other patient, 19 were categorized NYHA I and one in NYHA II classification in their late phase. Arrhythmia of Lown IVa developed in one patient. The cardio-thoracic ratio decreased from preoperative 60% in the late phase after surgery (p < 0.002) in the SJM19A group, although there was no significant difference with that in the SJM23A group. Echocardiographic improvement in left ventricular hypertrophy was considerable between before and late after surgery in the SJM19A group, while it was not significantly different between the SJM19A and SJM23A group. The mean value of aorta-left ventricle pressure difference in the late stage was 32 mmHg in the SJM19A group and significantly different from the value in the SJM23A group (p < 0.001). This pressure difference tended to be greater as the follow-up period was progressed, while the percentage decrease in the myocardial mass of the left ventricle tended to decreased with longer follow-up period. This data suggests that an increasing level of aorta-left ventricle pressure difference should raise little problem in the mid-term late stage after surgery but possibly cause a serious problem in the long term. Clinical observation should be continued over a long period of time after surgery.

[A case of isolated congenital mitral insufficiency]

A 1-year and 8-month-old girl admitted to our hospital because of wheeze and dyspnea. Echocardiogram and cardiac catheterization confirmed isolated congenital mitral insufficiency with pulmonary hypertension. She was treated with reconstructive surgery consisting of suture of clefted anterior mitral leaflet and annuloplasty. Her postoperative course was uneventual and mitral regurgitation was remarkably improved.

Human heart-type cytoplasmic fatty acid-binding protein as an indicator of acute myocardial infarction

Human heart-type cytoplasmic fatty acid-binding protein (HH-FABPc) has been proposed as an early biochemical indicator of acute myocardial infarction (AMI). However, skeletal muscles also contain HH-FABPc identical to that found in the heart. Before HH-FABPc can be clinically employed as an indicator of AMI, its content in various tissues other than the heart must be known. Accordingly, we measured the HH-FABPc content of various human muscles and organs, using a sandwich enzyme-linked immunosorbent assay (ELISA) for HH-FABPc. HH-FABPc was abundant in the ventricles (0.46 mg/g wet weight and 1.5% of the cytoplasmic protein in the left ventricle), while the atria contained slightly less HH-FABPc (0.25 mg/g wet weight and 0.7% of the cytoplasmic protein in the left atrium). Of the skeletal muscles tested, the diaphragm contained about one-quarter of the HH-FABPc content of the heart, but other skeletal muscles contained very low levels of this protein. Other than the muscles, the kidneys contained less than one-tenth of the HH-FABPc in the heart, and negligible amounts were found in the liver and small intestine. The distribution of HH-FABPc in the heart and skeletal muscles was comparable to that of cardiac-specific creatine kinase (CK-MB) activity, and was inverse to the distribution of myoglobin. The plasma myoglobin/HH-FABPc ratio, determined in patients with AMI and those without AMI, closely reflected that in the heart and skeletal muscles. These findings indicate that HH-FABPc may be useful as a specific indicator of AMI, and the plasma myoglobin/HH-FABPc ratio could provide valuable information for the diagnosis of AMI.

Effect of sulfo-N-succinimidyl palmitate on the rat heart: myocardial long-chain fatty acid uptake and cardiac hypertrophy

Abnormal long-chain fatty acid metabolism has been suggested as having a role in the genesis of certain cardiac diseases, and depressed myocardial long-chain fatty acid uptake has been clinically demonstrated in some patients with hypertrophic cardiomyopathy. However, the site where long-chain fatty acid metabolism is affected in cardiomyopathy remains unclear. Although cardiac hypertrophy is reported to be induced in rats by a fat-free diet, little is known of the consequences of depressed myocardial long-chain fatty acid uptake. Sulfo-N-succinimidyl derivatives of long-chain fatty acids have been shown to irreversibly inhibit long-chain fatty acid transport. To investigate the possible linkage of abnormal long-chain fatty acid uptake with cardiac hypertrophy, myocardial long-chain fatty acid uptake was blocked in rats using a sulfo-N-succinimidyl derivative of palmitate (SSP). SSP was intraperitoneally administered to rats for 12 weeks, and its effects on physiological parameters, and cardiac morphology were studied, SSP treatment (20 mg/kg) caused a 12% increase in heart weight (663.7 +/- 33.6 mg in controls v 741.2 +/- 26.5 mg after SSP treatment) and an 11% increase in the heart weight to body weight ratio (2.46 +/- 0.10 in controls v 2.72 +/- 0.17 after SSP) without any significant change of body weight. No significant differences were observed in blood pressure, heart rate, and serum hormones (insulin and triiodothyronine) between the control and SSP-treated groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral valve replacement for congenital parachute mitral valve]

A one-year-old boy was admitted with refractory congestive biventricular heart failure for medical treatment. On echocardiogram and cardiac catheterization revealed severe mitral stenosis from parachute deformity with pulmonary hypertension. During the operation, a single round orifice of 7 mm in diameter was detected in the mitral valve and adhered chordae were attached to a large single papillary muscle which was located at the posteromedial portion of the left ventricle. An isolated muscle band which was not attached to the mitral valve was observed at the anterolateral wall of the left ventricle. The mitral valve was replaced with 16 mm Carbo-Medicus prosthesis. Postoperative catheterization revealed residual pulmonary hypertension which was responsive to Imidarine infusion. He was discharged from the hospital without any sequelae, and has been on regimen including anticoaglant and vasodilator.

[Chronic left ventricular epicardial pacing by the perforated endocardial electrode through the cardiac vein]

We report a rare complication of endocardial pacing electrode implantation. A 64-year-old man, who was implanted transvenous pacemaker system by the other hospital one month ago, visited our outpatient clinic with the complaint of diaphragmatic twitching. Left ventricular pacing was highly suspected because of right bandle branch block pattern by 12 leads ECG. Pericardial effusion was observed by echocardiography, and angiography revealed the pacing electrode coursing through the coronary sinus and perforated the cardiac vein towards the posterior wall of the left ventricle. A new generator and a pacing electrode were implanted on the other side. Pericardial drainage was not performed because hemodynamics was stable. The patient discharged hospital on 18th postoperative day without any complication.

[Comparison of the long-term results of intra or extracardiac implanted bioprosthetic valves]

The long-term results following intra or extracardiac implanted bioprosthetic valves were compared. Forty-one patients, whose average age at the operation was 43.3 +/- 10.7 (mean +/- SD) year-old, were implanted 33 Hancock and 11 Carpentier-Edwards porcine valves, 35 in mitral, 6 in aortic and 3 in tricuspid position. Twenty-five children, whose average age was 6.0 +/- 3.5 year-old (p < 0.01) at the operation, underwent right ventricular-pulmonary artery conduit repair with 16 Hancock, 7 Carpentier-Edwards porcine valves and 2 Ionescu-Shiley pericardial valves. There were only one late death and one operative death in the patients implanted intracardiac bioprosthetic valves. Seven intracardiac and 12 extracardiac implanted bioprosthetic valves were removed at the reoperation for prosthetic valve dysfunction. The probabilities free from reoperation after 7 and 9 years of follow-up was 91% and 82%, respectively, with intracardiac implanted valves, on the other hand 51% (p < 0.05) and 8.6% (p < 0.05), respectively, with extracardiac implanted valves. Valve dysfunction in extracardiac implantation was mainly related to the stenosis due to fusion of comissure and/or calcification. Regurgitation due to tear and/or perforation was mainly associated with intracardiac implanted bioprosthetic valves.

New modification of the Damus-Kaye-Stansel operation

We report a successful modification of the Damus-Kaye-Stansel operation for transposition of the great arteries when the coronary arteries are unsuitable for transfer. The procedure includes creation of a neoaorta with end-to-end anastomosis of the proximal pulmonary artery to the distal ascending aorta and creation of an aortopulmonary window between the proximal great arteries. A valved conduit is interposed between the right ventricle and the distal pulmonary artery.

[Surgical treatment of subaortic stenosis]

We reviewed 10 cases with subaortic stenosis (SAS) who underwent surgical repairs in our hospital. They were divided into 3 groups. Group I-A included patients with discrete SAS which had been detected before the initial operation. Group I-B included patients with discrete SAS which became apparent following the initial operations. Group II patients included SAS except the discrete type. Surgical treatment of each group was discussed. In group IA, there were no early deaths nor late deaths. There was 1 reoperation due to restenosis. Group IB had 3 cases which included VSD with CoA, Taussig-Bing anomaly, and common atrioventricular canal with VSD. In the Taussig-Bing anomaly case, an arterial switch (Lecompte maneuver) was performed 3 years ago. SAS was successfully relieved with the right ventriculotomy and VSD patch incision. Group II had 3 cases. There were 2 operative deaths and 1 late death. SAS was relieved by, in two cases, Stansel anastomosis with BT shunt and, in the last one, palliative arterial switch operation. It was extremely difficult to detect SAS in group II, when SAS had rapidly progressed following PAB in neonate and early infant. Our present policy is that PAB would be performed if there is no apparent SAS before the initial operation. SAS should be relieved as soon as possible if it is apparent at the postoperative period. Either Stansel anastomosis with BT shunt or palliative arterial switch operation would be the best choice in such a difficult case.

[Two cases of coronary artery fistula with coronary artery aneurysm]

Two cases of coronary artery fistula with coronary artery aneurysm were reported. Coronary angiography showed dilated right coronary artery with the formation of aneurysm drained to the right atrium and to the right ventricle respectively. The inflow ostium from the coronary artery to the aneurysm were closed from inside adding aneurysmorraphy. Postoperative clinical courses were uneventful and residual shunts were not detected by angiography. We reported these cases with literature.

[Right-sided infective endocarditis with ventricular septal defect]

Two patients underwent surgical treatment for right-sided infective endocarditis with ventricular septal defect. In both cases, blood cultures showed Peptostreptococcus, and the operation was performed at non-active phase after antibiotics therapy. The case 1 was a 7-year-old girl who was observed a vegetation on the chorda of the anterior paillary muscle by echocardiography. The defect was directly closed and the vegetation was excised. The case 2 was 22-year-old female who had been diagnosed of VSD in her infancy. A high fever continued and echocardiography revealed a vegetation attached to the septal tricuspid leaflet. Partial excision of the leaflet and autopericard patch plasty was performed, and the VSD was directly closed. Postoperatively intravenous antibiotic therapy was given for periods of 6 weeks, and clinical course were uneventful in both cases. Local excision of vegetation and leaflet repair by autopericard patch plasty should be performed in cases with localized vegetation and minor valvular regurgitation.

[Reoperation with a bifurcated nonvalved extracardiac conduit for stenosis of the valved conduit and the pulmonary bifurcation after a Ross-Rastelli operation]

We report a case of successful reoperation with a bifurcated nonvalved extracardiac conduit for stenosis of the valved conduit and the pulmonary bifurcation after a Ross-Rastelli operation. The patient was 11-year-old female, who had undergone Ross-Rastelli operation with a 16 mm Carpentier-Edwards valved conduit for pulmonary atresia with ventricular septal defect at six year-old following Blalock-Taussig shunt at four year-old. She required reoperation for progressive right heart failure due to stenosis of the valved conduit and the pulmonary bifurcation. The reoperation was performed under cardiopulmonary bypass with aortic crossclamp. The stenosed valved conduit placed between the right ventricle and the right pulmonary artery was removed and replaced with 18 mm EPTFE graft. Because the direct repair of the pulmonary bifurcation stenosis was thought to be difficult, a 12 mm ringed EPTFE graft was anastomosed to the left pulmonary artery distal to the bifurcation stenosis as a branch of the 18 mm EPTFE main graft. Although transitional heart failure required IABP support in her early postoperative course, she subsequently recovered and discharged the hospital at the 37th postoperative day. Her right ventricular pressure reduced from 105 mmHg to 54 mmHg by the cardiac catheterization. She is now alive and well without any complaints.

[A surgical case of cor triatriatum]

A case report of a variant type of cor triatriatum was presented. The patient was critically ill when she was admitted to our hospital. An emergent operation was performed under the cardio-pulmonary bypass. The right atrium was incised, then the interatrial septum was incised. Inspection revealed an abnormal membrane in the left atrium. All the pulmonary veins were drained into the accessory chamber. The left atrial appendage was also connected with the accessory chamber. The membrane was not including the mitral valve tissue. It was resected completely. Postoperative course was uneventful.

[Pacemaker implantations in children with regard to the site of implantation]

We reviewed thirty eight children, ranged 3 days to 15 years (mean, 7.2 years) of age, who underwent permanent pacemaker implantations in our hospital. Long-term results including the site of generator pocket were discussed. They are alive and well except two early and three late deaths that were not related to the pacemaker implantation. Twenty-seven epicardial and 11 endocardial electrodes were implanted at the initial operations. Thirteen pulse generators implanted in subaxillar position had no complications, otherwise, 12 subcostal implantation resulted 4 skin necrosis and 3 lead fractures. Eleven anterior chest implantations used for relatively older children resulted in one skin necrosis. We recommend subaxillar implantation for children, especially for small infants. The replacements of pulse generators due to battery depletion were done between 1.7 to 5.5 years (mean 4.0 years). Because epicardial implanted electrodes often show higher stimulation threshold than epicardial ones, pacing rate should be as lowered as possible if the patient had no symptom. Stab-in leads placed on the atrial wall sometimes caused the elevation of stimulation threshold and undersensing. We conclude that the development of more reliable and stable electrode is desired to improve the long term results of pacemaker therapy in children although the improvement of pulse generator itself and the operative procedure.

[A case report: partial anomalous pulmonary venous return of the left lung communicating with the left atrium through the aberrant vein]

A rare case with partial anomalous pulmonary venous return was presented. The left superior pulmonary vein was drained into the left innominate vein via a common vertical vein and it also communicated with the left atrium via a small aberrant vein. All the other pulmonary veins were normally drained into the left atrium. The surgical repair was performed through the midline sternotomy. The junction of the vertical vein and the left innominate vein was ligated with slight elevation of the pressure in the left pulmonary vein. Under the cardiopulmonary bypass, the secundum atrial septal defect was closed by direct sutures. The postoperative course was uneventful and there was no pulmonary congestion in the left upper lung field.

[Surgical treatment of unroofed coronary sinus]

We have experienced four cases of unroofed coronary sinus. Three cases were partial forms and one case was a complete form. Two of them were successfully diagnosed before operation. Surgical viewpoints were discussed. In the absence of LSVC, the coronary sinus defect may be simply closed. In the cases with PLSVC, several types of repair were discussed. It has been reported that this defect is usually associated with simple or complex cardiac malformations, including tricuspid atresia or tetralogy of Fallot. In our case with TA, oversight of this anomaly before and during operation resulted in the urgent reoperation. A surgeon should always keep in mind this anomaly, even if the coronary sinus is not large.

[A successful two-staged Fontan procedure for tricuspid atresia with bilateral superior venae cavae and left pulmonary arterial stenosis]

A 10-year-old boy with tricuspid atresia (type I-b), bilateral superior venae cavae and left pulmonary arterial branch stenosis was treated successfully by a two-staged Fontan procedure. At 7 years of age, left Glenn shunt was performed after creation of a communicating vessel between the right and left superior vena cava, using a GORE-TEX graft of 10 mm of diameter. Three years later, after having confirmed graft patency, Fontan procedure was achieved without any problems. We think the innominate vein creation by an artificial material was a key design for the following successful two-staged Fontan procedure in this case.

[Cardiac strangulation with permanent epicardial pacemaker lead]

A 3-year-old boy underwent corrective surgery for tetralogy of Fallot. During the operation, permanent epicardial pacemaker leads were implanted for complete A-V block, which was transient and a generator implantation was not necessary. The postoperative course was uneventful and he had been doing well until nine years of age, when he was admitted to our hospital with general fatigue. The data of echo cardiogram and cardiac catheterization showed the biventricular heart failure with right ventricular outflow tract obstruction (RVOTO). Because of his rapid deterioration refractory to the intensive medical therapy, semi-emergency surgery was recommended to relieve his RVOTO. It was found during the operation that the looped pacemaker leads had carved deeply in the atrioventricular groove, so that compressed the main pulmonary artery, left main coronary artery and encircled left ventricle. The pacemaker leads were dissected as long as possible, and cut segmentally. Additionally a patch enlargement of the main pulmonary artery was necessary to relieve the residual stenosis. Although IABP support was needed in a while, his postoperative course was uneventful, and postoperative examinations showed normal cardiac function. This rare complication, so called "cardiac strangulation", should be in mind when the implantation of permanent pacemaker leads is indicated in pediatric cases.

[Late results of the subclavian flap repair for aortic coarctation-effects on the left upper limb]

Late results of the subclavian flap repair for the aortic coarctation and effects on the left upper limb were evaluated on 9 patients who were operated on and had been continuously followed up at Hyogo Kenritsu Amagasaki Hospital. Their mean age at operation was 2.3 years (range 9 days-5.7 years), and mean follow-up period 5.9 years (range 3.1 years-8.3 years). Reoperation for restenosis was necessary in one patient and it proved the initial aortotomy and patch angioplasty had not been extended sufficiently beyond the stenotic segment. In the remaining 8 patients, the mean values of arm-to-leg systolic pressure gradient and peak flow velocity at the descending aorta by Doppler echocardiogram were 2.5 mmHg and 1.9 m/sec respectively. Length and arm circumference of the left upper limb were all significantly shorter than those of the right side. The left systolic brachial pressure and core temperature of the hand were also significantly low comparing with those of the right side. No patients, however, complained the ischemic symptoms of the left upper limb. In conclusion, the subclavian flap repair is thought to be a safe and long effective procedure for the aortic coarctation.

[A case of an aberrant subclavian artery-esophageal fistula due to prolonged nasogastric intubation]

A case of fatal hematemesis due to an aberrant right subclavian artery-esophageal fistula is presented. The patient was a 9-year-old male child with complex congenital heart disease and developed the fistula by prolonged tracheal and nasogastric intubation after Fontan type operation. To avoid this unusual but serious complication, aberrant subclavian artery should be treated surgically before repair of complex cardiac anomaly.

[Long-term results of porcine bioprosthetic valves]

Between November 1977 and October 1980, 54 patients underwent valve replacements with porcine bioprostheses at Hyogo Kenritsu Amagasaki Hospital. The late complications and the long term durability of 53 porcine bioprostheses were documented in 48 patients after discharge (34 mitral, 7 aortic, 2 tricuspid, and 5 multiple, consisting of 38 Hancock, 15 Carpentier-Edwards prostheses). Cumulative duration of follow-up is 420 patient-years. The valve related late mortality was 0.52%/patient-years. There were 6 thromboembolic events (1.6% patient-years), only 1 episode of endocarditis (0.26%/patient-years). Valve dysfunction is defined as stenosis or regurgitation by echocardiogram or cardiac catheterization. There were 21 instances of porcine bioprosthetic dysfunction (6.6% patient-years). Freedom from valve dysfunction at 12 years was 24.4%. There were 17 valves of mitral bioprosthetic dysfunction (6.4% patient-years). The incidences of mitral stenosis (MS), mitral regurgitation (MR), and paravalvular leakage were 4.5, 3.6, and 0.7%/patient-years respectively. Freedom from MR was higher than MS at 8 years. The 14 patients were needed reoperation due to valve dysfunction (3.6%/patient-years). We concluded that the porcine bioprostheses showed a high incidence of valve dysfunction at 7 to 8 years after operation, we presently choose mechanical valve in most cases.