[Surgical repair of coarctation of the aorta in adults]

We report the surgical treatment of coarctation of the aorta (CoA) in 3 adults, 2 women and 1 man, aged between 18 and 32 years old. All of the patients had blood pressure gradients higher than 70 mmHg between the upper and lower limbs. In 2 patients, we simply clamped the aorta and excised the CoA: while in the other patient, we excised the CoA using partial extracorporeal circulation with a femoro-femoral (F-F) bypass. Reconstruction was done by an end to end anastomosis in 2 patients and with an artificial tube graft in 1 patient who regulred the extended aortic arch repair. Postoperatively, the pressure gradients between the upper and lower limbs dropped to below 20 mmHg in intensive care unit (ICU). Two of the patients have now stopped taking antihypertensive drugs and the other patient is taking half the preoperative dose.

[Bilateral partial anomalous pulmonary venous connection; report of a case]

We have experienced a case of bilateral partial anomalous pulmonary venous connection with a fossa ovalis type of atrial septal defect and pulmonary stenosis. The right upper pulmonary vein returned to the superior vena cava and the left upper pulmonary vein returned to the left innominate vein via the vertical vein. The atrial septal defect was enlarged and the right upper pulmonary vein was baffled into the left atrium with an equine pericardial patch. The left upper pulmonary vein was divided and anastomosed to the left atrial appendage. Pulmonary commissurotomy was also done for concomitant pulmonary stenosis. Postoperative course of the patient was excellent with constantly normal sinus rhythm. Angiography 2 weeks after operation showed no evidence of pulmonary venous obstructions on both sides.

[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.

Effects of cardioplegic arrest and reperfusion on rabbit cardiac ryanodine receptors

Calcium overload is considered to be a primary contributor to ischemia-reperfusion injury. Cardiac sarcoplasmic reticulum (SR), the main regulator of intracellular Ca2+ concentration under normal conditions, is a target for ischemic myocardial injury. The ryanodine receptor (RyR) is the SR Ca2+ release channel. Previous reports have shown that a reduction in RyR activity during global myocardial ischemia correlates with concomitant myocardial dysfunction. Crystalloid cardioplegia, a technique for myocardial protection during heart operations, reduces Ca2+ accumulation during global ischemia. Hence, the effects of cardioplegia on RyR in isolated rabbit hearts was investigated. The study also compared [3H] ryanodine binding before ischemia (control group), after 30 min of ischemia (either global ischemia (GI group) or cardioplegic arrest (CA group)), and after 20 min of reperfusion. The GI group, but not the CA group, showed a significant reduction in the maximum number of binding sites (Bmax) for RyR compared with the control group (Control vs GI group: after ischemia, 1.33+/-0.27 vs 0.83+/-0.12 pmol/mg protein, p<0.05; after reperfusion, 1.33+/-0.27 vs 0.80+/-0.08 pmol/mg protein; p<0.05). CA group: after ischemia, 1.22+/-0.20 pmol/mg protein; after reperfusion, 1.15+/-0.28 pmol/mg protein). The affinity (Kd) values for [3H] ryanodine binding were not different among the 3 groups at any point. The preservation of RyR numbers during cardioplegia correlated with the concomitant preservation of cardiac functions. The results indicate that number of functional RyR was much better preserved during cardioplegia than during global ischemia. It is postulated that cardioplegia-induced protection of cardiac RyR may result in the protection of SR function during ischemia-reperfusion.

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.

Stress caused by minimally invasive cardiac surgery versus conventional cardiac surgery: incidence of systemic inflammatory response syndrome

The present study was conducted to evaluate the degree of stress in patients induced by minimally invasive cardiac surgery (MICS) in comparison with that caused by conventional cardiac surgery. We did this by assessing the incidence of systemic inflammatory response syndrome (SIRS). A total of 48 adult patients who underwent surgery for single valve disease were included in this study, 27 of whom underwent conventional surgery and 21 MICS. We evaluated the stress inflicted on the patients in these two groups by analyzing the duration and degree of SIRS and the level of C-reactive protein (CRP). SIRS was assessed by measuring body temperature, heart rate, respiratory rate, and white blood cell counts. There were no significant differences in the operating times, perfusion times, or aorta clamp times between the two groups; and the mean volume of blood transfusion did not differ significantly either. There was no significant difference in the incidence of SIRS or the mean duration of SIRS between the two groups. The CRP levels did not differ significantly between the two groups. Thus although MICS is superior to conventional cardiac surgery in that only a small skin incision is required, the stress experienced by the patient may be the same as that experienced by the patient undergoing conventional cardiac surgery.

Correlations among expression of intercellular adhesion molecule 1, cellular infiltration, and coronary arteriosclerosis during chronic rejection using the rat heart transplantation model

Immunologic mechanisms contribute to the development of coronary arteriosclerosis. In this study the rat heart transplantation model was used to investigate correlations among the expression of intercellular adhesion molecule 1, cellular infiltrate, and coronary arteriosclerosis during chronic rejection. Lewis rats served as heart donors and F-344 rats as recipients. Heart transplantations were performed heterotopically. The recipients were treated with cyclosporin A (5 mg/kg/day) by daily intramuscular injection for 30 days, beginning on the day of transplantation. Rejection grade and the intimal area were measured. The expression of intercellular adhesion molecule 1 and the numbers of infiltrating CD4- and CD8-positive cells and macrophages were examined immunohistochemically. The area of the intima was significantly increased in the allograft group after transplantation. In the allograft group, the level of expression of intercellular adhesion molecule 1 was considerably increased over the same time period. There was increased cellular infiltration in the 60-day group, and many expressed intercellular adhesion molecule 1. The expression of intercellular adhesion molecule 1 in vascular endothelium, infiltrating cells, and the sarcolemmal membrane of myocytes remained constant up to 120 days in the allograft group. In the allograft group, the number of infiltrating CD4- and CD8-positive cells and macrophages increased significantly between 30 and 60 days, and the infiltration of these cells remained constant. Continuous expression of intercellular adhesion molecule 1 induces the infiltration of T cells and macrophages, and the inflammation caused by such cells and their soluble products contributes to the arteriosclerotic process.

Right axillary cannulation in the left thoracotomy for thoracic aortic aneurysm

Perfusion from the femoral artery is commonly used in the open proximal method of performing distal aortic arch aneurysm repair or Stanford type B aortic dissection repair under circulatory arrest through left thoracotomy. However, it is associated with a significant risk of retrograde emboli or malperfusion, and with other problems including a restricted time of circulatory arrest to the brain and difficulties in de-airing from the arch branches and proximal ascending aorta. To overcome these problems, we developed a method of performing right axillary perfusion through left thoracotomy.

Right axillary arterial perfusion for a ruptured type B aortic dissection: report of a case

The results of surgical treatment for a ruptured type B aortic dissection remain far from satisfactory. It is believed that additional perfusion from the right axillary artery might be more beneficial than perfusion from only the femoral artery during surgery for a ruptured thoracic aneurysm. The right axillary perfusion is more likely to perfuse the vital organs proximal to the ruptured area, and thus avoid retrograde emboli. In addition, if the open proximal method is performed, then the right axillary perfusion is able to facilitate the evacuation of air from the aortic lumen. We present herein the case of a patient in whom a ruptured type B acute aortic dissection was successfully treated by applying right axillary perfusion through a left thoracotomy.

[Could apoptosis be contributed to the occurrence of aortic dissection?]

This clinical study was conducted to determine whether apoptosis is contributed to the occurrence of aortic dissection. The subjects comprised 11 patients who underwent Stanford type A aortic dissection and 4 autopsy cases, being the control group. The occurrence of apoptosis was determined by the TUNEL assay using an aortic wall specimen, and the distribution of macrophages and h-MMP-9 was examined by immunohistological staining. Apoptotic cells were observed in the aortic specimens for all of the 11 patients who underwent Standford type A aortic dissection, but not in any of the 4 autopsy cases. Moreover, apoptotic cells were present in large numbers on the surface of the false lumen strongly in 8 patients who underwent surgery within 1 month after aortic dissection, but not in 3 who underwent treatment after than 1 month. Those phenomena were also observed in the immunohistological staining of CD 68 and h-MMP-9. These findings indicate that apoptosis could be contributed to the occurrence of aortic dissection.

[Dose the serum brain natriuretic peptide (BNP) level after open heart surgery reflect myocardial protection?]

This clinical study was conducted to determine whether the serum BNP level after open heart surgery reflects myocardial protection. The levels of BNP and CPK-MB were measured before and after 12 hours of cardiopulmonary bypass, then 1, 3, and 6 days after open heart surgery, and the relationship between the maximum levels of BNP and the CPK-MB after open heart surgery was examined. The patients were divided into two groups according to whether or not the maximum CPK MB was more than 100 IU/l after open heart surgery. A significant relationship between the maximum BNP and the maximum CPK-MB after open heart surgery was observed (p = 0.013). Moreover, the BNP was significantly increased in the group of patients with a maximum CPK-MB > or = 100 IU/l, compared to that in those with a maximum CPK-MB < 100 IU/l, 12 hours 1 day, and 6 days after open heart surgery (p < 0.01). These findings indicate that the serum level of BNP after open heart surgery can reflect myocardial protection.

Nitric oxide release from coronary vasculature before, during, and following cardioplegic arrest

Nitric oxide (NO) is known as a vasodilatory molecule synthesized by vascular endothelium. The NO-dependent vasodilatory response of coronary artery is impaired after ischemia and reperfusion. In the present study, the release of NO from coronary vasculature was evaluated before and during cardioplegic arrest and after reperfusion. Nine patients undergoing heart surgery were studied. Multidose crystalloid cardioplegics were used for myocardial protection. The coronary affluent and effluent were obtained simultaneously before cardioplegic arrest, at each cardioplegic administration, and after reperfusion; and the levels of nitrite and nitrate, the stable end-products of NO, were measured. The NO release from the coronary vasculature was determined as the difference in the levels of nitrite and nitrate between the coronary effluent and affluent. The level of nitrite/nitrate release from coronary vasculature was 6.8 +/- 3.7 microM before cardioplegic arrest. During cardioplegic arrest the nitrite/nitrate release decreased, reaching 1.3 +/- 1.3 microM (p < 0.05, vs. before cardioplegic arrest) at the fourth administration of the cardioplegic. At 3 to 5 minutes after reperfusion, nitrite/nitrate release further decreased to 0.36 +/- 0.34 microM (p < 0.05, vs. before cardioplegic arrest). During cardioplegic arrest the NO release decreased and reached significance at approximately 70 minutes of cardioplegic arrest compared to that before cardioplegic arrest. After reperfusion, NO release was further reduced, with statistical significance compared to that before cardioplegic arrest. Our data may indicate that cardioplegic arrest and reperfusion cause endothelial dysfunction.

[Dose the administration of low-dose aprotinin contribute to an anti-inflammatory effect in coronary artery bypass grafting?]

A study was conducted to determine whether the administration of low-dose aprotinin contributed to an anti-inflammatory effect in coronary artery bypass grafting. Levels of the inflammatory cytokines; IL-6, IL-8, and GEL, were measured before and after cardiopulmonary bypass, then 1, 3 and 6 days after coronary artery bypass grafting, in a group of patients given aprotinin (n = 7) and a control group (n = 15). A comparison of the levels of all these inflammatory cytokines between the two groups revealed no significant difference at any time point. This indicates, that low-dose aprotinin did not contribute to an anti-inflammatory effect in coronary artery bypass grafting.

A newly designed adapter for testing an ex vivo mitral valve apparatus

Few instruments are currently available to test mitral valve function in an ex vivo state due to the technical difficulties involved. To investigate the native ex vivo mitral valve or prosthetic mitral valve with chordae, we developed a mitral valve adapter with an annulus suturing portion and 2 papillary muscle suturing sites that can be changed in angle, direction, and length of chordae. We used this adapter to test an ex vivo mitral apparatus in beagle dogs and evaluated the morphology and function of the mitral apparatus by endoscopy. Our newly designed mitral valve adapter proved extremely useful for examining the ex vivo mitral valve anatomy and function and for testing stentless mitral prostheses with annular-papillary muscle continuity.

An ascending aortic aneurysm caused by giant cell arteritis: report of a case

A 69-year-old woman was referred to our hospital for investigation of an abnormality detected by a chest roentgenogram, and was subsequently found to have an ascending aortic aneurysm. She had not suffered any symptoms such as headache or polymyalgia rheumatica. Aneurysmectomy and reconstruction of the ascending aorta was performed using cardiopulmonary bypass, and pathological examination of the aneurysmal wall revealed giant cell arteritis (GCA). Preoperatively, she had not suffered any temporal pain, and no signs of inflammation were detected serologically. GCA is a rare cause of aortic aneurysm in the Japanese population, and a brief review of the literature on this unusual entity is presented following this case report.

Prediction of graft prolongation by mixed lymphocyte culture following anti-CD4 monoclonal antibody treatment among different donor-recipient combinations

This study was conducted to examine whether mixed lymphocyte culture (MLC) could be used as a predictor of the efficacy of anti-CD4 monoclonal antibody (MAb) immunosuppression in vivo in a mouse model. C57BL/10 or BALB/c hearts were transplanted into C3H.He recipients. Anti-CD4 MAb administration prolonged graft survival, but there was a clear difference between the two donor-recipient combinations studied, the median survival time (MST) being >100 days in the C57BL/10 --> C3H group, and 17 days in the BALB/c --> C3H group. Anti-CD8 MAb prolonged the survival of C57BL/10 hearts slightly to a MST of 22 days, but the BALB/c hearts were rejected at control rates. Combining anti-CD4 and anti-CD8 antibody therapy prolonged the survival of C57BL/10 hearts indefinitely, but had little effect on the survival of BALB/c grafts, achieving an MST of only 24 days. Next, MLCs were performed in the presence and absence of the MAbs and compared with the graft survival data. The inhibition rates in the MLC, being the C3H lymph node cell responder, correlated well with graft survival. When three kinds of C3H responder cells, namely lymph node (LN) cells, T cells, and CD4+ cells, were examined to determine which was the most suitable for predicting graft survival, the MLC results showed that the responses of LN cells correlated most closely with graft outcome. In conclusion, MLC using LN cells as the responder is a useful tool for predicting allograft survival induced by anti-CD4 MAb therapy.

[Is left ventricular regional wall motion after CABG influenced by cardioplegic protection?]

This clinical study was conducted to determine whether different techniques of cardioplegic protection reflected left ventricular regional wall motion after CABG. A total of 43 patients with more than 90% stenosis of the LAD (seg 6 and/or 7) before CABG, who had patent grafts were allocated to two groups: namely, the crystalloid group, comprised of 23 patients given cold crystalloid cardioplegia and topical ice slush, and the blood group, comprised of 20 patients given tepid blood cardioplegia delivered intermittently antegrade. Each group was divided into two subgroups according to whether the left ventricular regional wall motion showed no change or deterioration after CABG. We also examined the relationship between the grading of the collateral artery before CABG and the postoperative ventricular regional wall motion. The number of patients who showed deterioration after CABG was higher in the crystalloid group than in the blood group (p = 0.008). Moreover, patients in the crystalloid group whose collateral artery had been graded as 0 before CABG tended to show deterioration of left ventricular local wall motion after CABG (p = 0.07). Whereas those patients in the blood group did not. In conclusion, the incidence of deterioration after CABG was higher in the crystalloid group than in the blood group.

The preoperative administration of lentinan ameliorated the impairment of natural killer activity after cardiopulmonary bypass

The aim of this study was to determine whether the preoperative administration of lentinan, which is used clinically to activate T cell function in cancer patients, prevents the impairment of lymphocyte function after cardiopulmonary bypass (CPB). A total of 25 adults undergoing coronary artery bypass grafting were enrolled in this study. Lentinan (2 mg) was given to 10 randomly selected patients 7 d before surgery, while the other 15 patients were considered as a control. The white blood cell count, percentage of lymphocytes, subsets of lymphocytes, and natural killer cell activity were measured preoperatively, immediately after CPB and 1, 3, and 6 d after surgery. The white blood cell counts and the percentage of lymphocytes were not significantly different between the two groups; however, the percentage of CD4-positive cells in the lentinan group recovered to normal more rapidly than in the control group. Although natural killer cell activity was impaired in the control group after CPB, it maintained a nearly normal level in the lentinan group. The preoperative administration of lentinan for patients undergoing CPB ameliorated the impairment of natural killer activity and promoted the rapid recovery of CD4-positive cells.

[A one-staged operation for mitral regurgitation and giant bulla in a patient with severe pulmonary hypertension: report of a case]

A 57-year-old woman was admitted to our hospital for the treatment of mitral regurgitation and giant bulla with severe pulmonary hypertension. A dobutamine-induced test performed preoperatively resulted in a decrease of the systolic pulmonary artery pressure by 30 mmHg. Subsequently, mitral valve replacement and bullectomy were performed concomitantly. The patient recovered from heart failure, and the pulmonary artery pressure clearly decreased during the perioperative period. This case report serves to demonstrate the effectiveness of performing a one-staged operation for mitral regurgitation and giant bulla with severe pulmonary hypertension.

[Coronary artery bypass grafting for a patient with angina pectoris and ulcerative colitis]

The implementation of coronary artery bypass grafting for angina pectoris with ulcerative colitis has been rarely reported. A 63-year-old man has a past history of acute myocardial infarction in 1984 and ulcerative colitis since 1988. Coronary angiography and cardiac catheterization showed total obstruction of segment 2, 95% stenosis of segment 6, 75% stenosis of segment 7 and total obstruction of segment 12 with LVEF 23%. Coronary artery bypass grafting was performed under IABP support and cardiopulmonary bypass with aprotinin infusion after an inflammatory reaction of ulcerative colitis was adequately suppressed. Ulcerative colitis was controlled by administering 40 mg of predonisolone during perioperative period.

Coronary artery bypass grafting in the acute phase after renal transplantation: report of a case

To the best of our knowledge, only 3 cases of coronary artery bypass grafting (CABG) performed under cardiopulmonary bypass (CPB) on patients in the chronic phase after renal transplantation have been reported in Japan. The first case of a patient who underwent CABG in the acute phase after renal implantation in Japan is herein described. Perioperatively, oral immunosuppressive agents were discontinued and they were given intravenously. Cyclosporin A (Cy-A) was administered via a continuous intravenous infusion in the acute phase after renal transplantation and closely monitored, because the blood concentration of Cy-A can vary a great deal during the perioperative period. This case report serves to demonstrate that as long as appropriate immunosuppressive drugs are perioperatively administered, CABG under CPB can be safely performed on patients who have undergone renal transplantation without subsequent rejection, infection, or renal damage, even during the acute phase.

Coronary bypass surgery after renal transplantation

We report, herein, cases of two renal transplantation patients who underwent coronary artery bypass grafting and discuss the perioperative management of this clinical situation. The first case was a 43-year-old male who underwent coronary artery bypass grafting 50 days after renal transplantation, and the second was a chronic case of a 49-year-old male who underwent coronary artery bypass grafting 17 years after renal transplantation. Prior to the operation, the first patient was continuously administered 2 mg/kg/day of cyclosporin A with the dosage regulated according to the plasma level. The second patient was administered 50 mg/day of cyclophosphamide intravenously instead of an oral dosage of 50 mg/day of azathioprine just prior to the operation. In both patients, perfusion pressure during cardiopulmonary bypass was maintained at approximately 80 mmHg in order to obtain optimal urine output. The CD4/CD8 ratio was monitored for indication of graft rejection, but no remarkable changes were observed perioperatively in either patient. Both patients followed a good clinical course and their postoperative renal function was well maintained. The urine output during cardiopulmonary bypass was 300 ml and 650 ml, respectively. The patients were discharged 15 and 27 days after their operation, respectively. In conclusion, coronary artery bypass grafting can be safely performed in patients who have undergone renal transplantation, if there is appropriate perioperative usage of immunosuppressive agents and maintenance of perfusion pressure during cardiopulmonary bypass.

[Minimally invasive cardiac surgery for aortic valve disease]

Recent surgical advances leading to good operative results have contributed to the trend to useminimally invasive approaches, even in cardiac surgery. Smaller incisions are clearly more cosmetically acceptable to patients. When using a minimally invasive approach, it is most important to maintain surgical quality without jeopardizing patients. A good operative visual field leads to good surgical results. In the parasternal approach, we use a retractor to harvest an internal thoracic artery in coronary artery bypass surgery. Retracting the sternum upward allows for a good surgical view and permits the use of an arch cannula rather than femoral cannulation. When reoperating for aortic valve repair, the j-sternotomy approach requires less adhesiolysis compared with the traditional full sternotomy. No special technique is necessary to perform aortic valve surgery using the j-sternotomy approach. However, meticulous attention must be paid to avoiding left ventricular air embolisms to prevent postoperative stroke or neurocognitive deficits, especially when utilizing a minimally invasive approach. Transesophageal echo is useful not only for monitoring cardiac function but also for monitoring the persence of air in the left ventricle and atrium. This paper compare as the degree of invasion of minimally invasive cardiac surgery and the traditional full sternotomy. No differences were found in the occurrence of systemic inflammatory response syndrome between patients undergoing minimally invasive cardiac surgery and the traditional technique. Therefore it is concluded that minimally invasive surgery for patients with aortic valve disease may become the standard approach in the near future.

[Relative valve area stenosis after replacement of a Starr-Edwards mitral valve (model 6520) for corrected TGA (S, L, L): report of a case]

The patient was a 38-year-old man who had undergone mitral valve replacement with a Starr-Edwards disc valve (model 6520, 3 M, phi 30 mm, functional valve area: 2.85 cm2) at the age of 15 years for TR combined with corrected TGA. He developed dyspnea on exertion and palpitations at the age of 30 years, and paroxysmal supraventricular tachycardia appeared at the age of 35 years. Cardiac catheterization revealed that the PCWP was 30 mmHg and the TVA was 1.1 cm2, and a diagnosis of stenosis of the prosthetic valve was made. Thus, replacement of the Starr-Edwards disc valve using a BICARBON double leaflet valve (phi 27 mm, functional valve area: 2.85 cm2) was performed. The operative findings of the Starr-Edwards disc valve revealed a normal appearance and no pannus growth. Postoperative echocardiography and cardiac catheterization found that the TVA was 3.7 cm2 and the PCWP was 13 mmHg. The actual valve area of the disc valve sewn on the ventrical, which was anatomically RV construction might have been smaller than the ideal area; however, the double leaflet valve proved efficient in our patient. This case report serves to demonstrate that because of the postoperative difference in measurement between the actual valve area and the prostheticin ball or disc valve, patients undergoing mitral valve replacement must be followed up carefully.

[Experimental study of coronary artery anastomosis using VCS clips]

The experiment was intended to test the feasibility of VCS clips for coronary anastomosis during minimally invasive direct coronary artery bypass grafting (MIDCAB). Six dogs were anesthetized under endotracheal intubation and were placed on right lateral position. Three 10.5-mm ports were placed on the left lateral chest wall (3rd, 5th and 7th intercostal space) and the left internal thoracic artery (LITA) was dissected completely from its root to bifurcation under thoracoscope. Chest was opened through the left 6th intercostal space. The anastomotic site of LAD was dissected and was then occluded temporally for 5 minutes to obtain ischemic preconditioning. The anastomosis was performed by the following procedure; horizontal mattress sutures of 8-0 polypropylene were placed on heel, toe and the center of both lateral sides. Two VCS clips (8 in total), 0.9-mm in size, were applied between every two sutures. After the measurement of graft flow, the pedicle was transected and an angiography was done. Graft flow was 12-17 ml/min (mean 14.7 +/- 2.1 ml/min) and cineangiogram showed good patency of LITA and no anastomotic stenosis. VCS clips were supposed to have a potential for facilitating port access coronary artery bypass grafting.

Recovery after prolonged cross-clamping tepid blood cardioplegia: report of a case

Despite a prolonged repetitive aortic cross-clamp time of 411 min, a patient who suffered a left ventricular rupture after undergoing mitral valve replacement following mitral valvuloplasty and Maze procedure recovered without any permanent residual left ventricular dysfunction. During the aortic cross-clamping we used tepid blood cardioplegia for myocardial protection. This case report serves to demonstrate the potential of tepid blood cardioplegia as an effective method of myocardial protection.

Late postoperative respiratory function in adults after surgical correction of atrial septal defects. Analysis of respiratory dysfunction patterns

Respiratory function after repair of atrial septal defect (ASD) was analysed in 44 adults (> 40 years), 21 of whom had preoperative respiratory dysfunction, 14 of restrictive type, defined as % vital capacity (% VC) less than 80% of predicted value, 3 with an obstructive pattern, defined as % forced expiratory volume/1 s (% FEV1) less than 70% of predicted value, and 4 patients with a mixed pattern. Increased % VC was found postoperatively in all 14 patients with restrictive respiratory dysfunction, with normal values in 8 out of the 14. Although the three patients with obstructive, and the four with mixed-pattern respiratory dysfunction improved preoperatively in % VC or % FEV1, or both, none had normalized values. We conclude that preoperative restrictive respiratory dysfunction in ASD patients frequently normalizes postoperatively, but not dysfunction of obstructive or mixed restrictive-obstructive type.

Increased serum interleukin-8: correlation with poor prognosis in patients with postoperative multiple organ failure

This study investigated whether cytokines and colony-stimulating factors can predict prognosis in patients with postoperative multiple organ failure (MOF). We evaluated 14 patients with postoperative MOF who underwent operation for cardiovascular disease. Seven patients recovered from MOF (survivors) and seven did not recover and died (nonsurvivors). The white blood cell (WBC) count, granulocyte colony-stimulating factor, monocytic colony-stimulating factor, interleukin-6 (IL-6), and IL-8 were measured on the day the patients were judged to be in MOF and each week thereafter until the patients recovered or died. Survivors and nonsurvivors were equivalent in terms of age, gender, proportion of use of extracorporeal circulation, operation time, volume of blood transfusion, time from operation to the onset of MOF, the MOF score, proportion of bacteremia, duration of MOF, and number of failed organs. The mean duration of MOF was less than 2 weeks in both groups; therefore the measurements were compared on the first day of MOF and 1 week later. No significant differences between the two groups in terms of WBC counts, colony-stimulating factors, and IL-6 levels were noted. However, the serum level of IL-8 was significantly higher in nonsurvivors than in survivors. Patients with a high serum levels of IL-8 at the time of MOF had a poor prognosis.

Progressive hyperthermia during thoracoscopic procedures in infants and children

We describe the development of progressive hyperthermia during thoracoscopic procedures in infants and children. Twelve patients (four infants and eight children) underwent closure of a patent ductus arteriosus using the video-assisted technique. A progressive increase in body temperature of more than 2 degrees C occurred in six of the patients during surgery. The increase in body temperature correlated inversely with body weight and directly with duration of surgery (r = -0.76, P = 0.003 and r = 0.68, P = 0.01, respectively). We found that the thoracoscope produces 28.5 joule.min-1 of constant energy in vitro. Our findings show progressive hyperthermia during thoracoscopic procedures, due to energy release from the thoracoscope. This could be a significant complication in infants undergoing prolonged operations.

Granulocyte elastase release and pulmonary hemodynamics in patients with atrial septal defect

BACKGROUND

In patients with increased pulmonary artery pressure, the pulmonary vascular endothelium is morphologically and functionally abnormal and may be vulnerable to neutrophil-mediated injury induced by cardiopulmonary bypass (CPB). We investigated the relation between levels of granulocyte elastase (GEL), interleukin-6, or interleukin-8 after CPB and preoperative pulmonary hemodynamics or changes in pulmonary function after the operation.

METHODS

We measured plasma levels of GEL, interleukin-6, and interleukin-8 before and after CPB in patients who underwent closure of an atrial septal defect. Preoperative and postoperative respiratory index were evaluated. Preoperative pulmonary hemodynamics were determined within 1 month before the operation.

RESULTS

The level of GEL rose significantly after CPB from baseline (164.8 +/- 81.3 versus 819.4 +/- 320.3 microg/L; p < 0.01). Levels of interleukin-6 and interleukin-8 showed no significant changes after CPB. Peak level of GEL was significantly correlated with preoperative systolic pulmonary artery pressure (r = 0.76; p = 0.017), mean pulmonary artery pressure (r = 0.75; p = 0.021) and pulmonary-to-systemic arterial pressure ratio (r = 0.77; p = 0.016), but not with the hemodynamic variables for pulmonary blood flow or pulmonary resistance. Moreover, the value of (postoperative respiratory index - preoperative respiratory index)/preoperative respiratory index was positively correlated with the peak level of GEL (r = 0.72; p = 0.030).

CONCLUSIONS

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.

[Surgery for the treatment of infective endocarditis in the active and inactive stages]

Twenty-eight patients (16 M, 12 F, age 11 approximately 72 yr, mean 52.8 yr) underwent surgery for infective endocarditis. Of the 27 patients, 16 were in the active stage and 11 were in the inactive stage. In patients in the active stage, aortic valve replacement (AVR) was performed in 5, mitral valve replacement (MVR) in 7, AVR + MVR in 1, AVR + MVR + tricuspid valve plasty (TVP) in 1 and other procedures in 2. In patients in the inactive stage, AVR was performed in 3, MVR in 4, AVR + MVR in 2, and other procedures in 2. Causative organisms were detected in 56.3% of the patients in the active stage and 54.5% in the inactive stage. Also in patients in the active stage, infection was not prolonged. No deaths occurred among patients in the inactive stage but five patients (31%) died postoperatively; 4 of the five also died, for had severe heart failure before surgery, three died of multiple organ failure and one died of subarachnoid hemorrhage due to infective aneurysm. We recommend surgery for the treatment of infective endocarditis even in the active stage before emergence of heart failure.

[Repair of left ventricular free wall rupture with GRF glue associated with acute myocardial infarction: report of a case]

Histopathological examination of a repair of left ventricular free wall rupture associated with acute myocardial infarction using GRF glue was reported. A 63-year-old male with cardiac rupture due to LMT total occlusion was referred to our ward after unsuccessful PTCA with institution of IABP and PCPS. Left ventricular rupture repair by GRF glue and xenograft pericardial patch with concomitant myocardial revascularization (SVG-LAD, CX) was performed under cardiopulmonary bypass. Hemostasis around the ventricular rupture was easily accomplished. Unfortunately, the patient died at 14 POD because of low output syndrome caused by broad myocardial infarction. At autopsy, rupture site was examined histologically and was revealed that GRF glue made a tight adhesion between patch and myocardium. Neither abnormal inflammatory cells nor giant cells were found. We concluded that GRF glue might be a effective histocompatibly in hemostasis for left ventricular rupture associated with acute myocardial infarction.

[Influence of cardiopulmonary bypass on lymphocyte function]

It is known that lymphocyte function is impaired after cardiopulmonary bypass (CPB). In this study, the lymphocyte stimulation test (LST) with PHA was used before and after CPB in 28 adult patients, and compared with the surgical parameters and serum cytokine (IL-6, IL-8) levels. LST was impaired after CPB in all patients. Although this value usually recovered by the third postoperative day (POD); (normal group, n = 16), some patients showed prolonged duration of the impaired LST (delayed group, n = 12). Therefore, the parameters of surgery, white blood cell (WBC) count, lymphocytes and subsets, and serum cytokine levels were compared between the normal and the delayed groups. There was no significant difference in the number of WBCs or lymphocytes between these two groups. OKT4-positive cells were reduced on the first POD in both groups, and in the normal group, the number of OKT4-positive cells recovered more quickly than in the delayed group. Serum IL-6 and IL-8 levels in the delayed group were elevated after CPB, and were significantly higher in the delayed group than in the normal group. In conclusion, patients who showed prolonged impairment of lymphocyte function may be partly due to prolonged CPB.

Evaluation of brain oxygenation during selective cerebral perfusion by near-infrared spectroscopy

BACKGROUND

Although selective cerebral perfusion (SCP) has been used for cerebral protection in aortic arch operations, the appropriate perfusion conditions of SCP are unclear.

METHODS

We used near-infrared spectroscopy, which evaluates brain ischemia noninvasively and continuously, to determine whether perfusion with SCP (core temperature, 20 degrees C; flow rate, 10 mL.kg-1.min-1) was acceptable in terms of oxyhemoglobin and deoxyhemoglobin in patients having SCP for aortic arch operations (SCP group, n = 6) versus patients having cardiopulmonary bypass (CPB) for coronary artery bypass grafting (CPB group, n = 6).

RESULTS

There were no significant differences in age (65 +/- 10 versus 63 +/- 12 years), CPB time (199 +/- 67 versus 199 +/- 52 minutes), changes in hematocrit (-12.9% +/- 3.7% versus -12.5% +/- 6.0%), lowest blood pressure (43 +/- 7 versus 45 +/- 10 mm Hg), or highest central venous pressure (8 +/- 2 versus 9 +/- 4 mm Hg) between the SCP and CPB groups. In the SCP group, the maximum decrease in oxyhemoglobin level and the maximum increase in deoxyhemoglobin level were -5.0 to -11.4 mumol/L and -0.1 to 3.9 mumol/L, respectively; in the CPB group, the respective changes were -3.2 to -14.2 mumol/L and -0.4 to 3.6 mumol/L. Changes of oxyhemoglobin and deoxyhemoglobin levels in the SCP group were almost within the range of those in the CPB group. There were no brain complications in either group.

CONCLUSIONS

As described here, SCP is acceptable and safe for brain protection in aortic arch procedures.

Relationship between respiratory distress and cytokine response after cardiopulmonary bypass

The influence of cytokines on the inflammatory response in surgery has recently been the subject of investigations. We measured tumor necrotic factor-alpha (TNF-alpha), interleukin 1 beta (IL-1 beta), interleukin 6 (IL-6), interleukin 8 (IL-8), and granulocyte elastase (GEL) in 26 patients undergoing elective cardiac operations using cardiopulmonary bypass (CPB), preoperatively, immediately after CPB, and on post-operative days (PODs) 1, 3, and 6. To evaluate the effect of these cytokines on pulmonary function, the patients were divided according to whether the oxygenation index (OI) on POD 1 was > 250 or < 250, into groups A and B, respectively. TNF-alpha and IL-1 beta were undetectable and there were no significant differences in the preoperative IL-6, IL-8, and GEL levels. However, immediately following CPB, the mean IL-6, IL-8 and GEL levels in both groups were significantly higher than the preoperative levels (P < 0.01). Moreover, all these levels were significantly higher in group B than in group A, at 162 +/- 150 pg/ml vs 64 +/- 53 pg/ml (P < 0.05) for IL-6; 53 +/- pg/ ml vs 22 +/- 20 pg/ml (P < 0.01) for IL-8; and 2477 +/- 1642 mg/ l vs 1397 +/- 774 mg/l (P < 0.01) for GEL. The IL-6 levels returned to the preoperative values in both groups on POD 1; however, the GEL levels remained significantly higher in group B than in group A postoperatively, at 616 +/- 326 mg/l vs 378 +/- 70 mg/l on POD 1, and at 292 +/- 70 mg/l vs 218 +/- 62 mg/ l on POD 3 (P < 0.05). Thus high levels of cytokines such as IL-6, IL-8, and GEL may be detrimental to respiratory function.

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.

A video-assisted thoracoscopic surgical technique for interruption of patent ductus arteriosus

We describe herein a technique for patent ductus arteriosus (PDA) closure using a method of video-assisted thoracoscopic surgical (VATS) interruption derived from video-assisted endoscopic surgery. This technique of repair was performed on five patients with a mean age of 3 years and a mean weight of 13.7 kg during 1994 and 1995. Under general anesthesia, two 10-mm trocars and two or three 5-mm trocars were inserted through the left thoracic wall. A video camera and specially designed surgical tools including scissors, dissectors, and a clip applicator were then introduced. The ductus was dissected, and two titanium clips were applied to interrupt the ductus completely. Successful closure of the PDA by this video-assisted technique was achieved in all patients. The only complication which developed in one patient was hoarseness for 2 weeks postoperatively. The hospital stay ranged from 7 to 12 days and there were no serious complications or deaths. There results indicate that video-assisted thoracoscopic surgical interruption is a safe and effective technique for achieving closure of PDA.

[Reconstruction of right ventricular outflow tract-pulmonary artery utilizing autologous tissue in extreme tetralogy of Fallot after coil embolization for major aortopulmonary collateral artery: report of a case]

We report a successful surgical treatment for tetralogy of Fallot with pulmonary atresia. A 18-year-old girl was admitted because of increasing exertional dyspnea and cyanosis. She had undergone bilateral classical Blalock-Taussing shunt. Prior to the correction, two major aortopulmonary collateral arteries were embolized using steel coils. Under cardiopulmonary bypass, posterior wall of the pulmonary artery was anastomosed directly to the cranial margin of the ventriculotomy for a floor made of autologous tissue. The roof was reconstructed using a patch with a monocusp. The patient is in a good postoperative condition. A coil embolization is useful and this reconstruction utilizing autologous tissue could prevent a late stenosis of the reconstructed pulmonary artery tract.

[Usefulness of scheduled IABP for CABG]

We examined the usefulness of intra-aortic balloon pumping (IABP) before the coronary arterial bypass grafting (IABP) before the coronary arterial bypass grafting (CABG) in patients with severe ischemic heart disease. Left main trunk (LMT) disease, unstable angina and low ejection fraction (less than 40%) were indications for scheduled IABP. Eleven patients underwent IABP before CABG surgery (the scheduled IABP group), and five patients didn't before CABG surgery (the unscheduled IAPB group). Analysis comprised the duration of IABP and mortality. There were no significant differences between the two groups in age, pre-operational cardiac index, ejection fraction, aorta clamp time or total perfusion time. IABP application times were significantly longer in the unscheduled IABP group than in the scheduled IABP group (p < 0.05). No death occurred in the scheduled group, but three patients in the unscheduled group died (p < 0.05). No complications were observed due to IABP in any patient of either group. We conclude that scheduled IABP is useful for patients with severe ischemic heart disease.

[Thoracoscopic closure of patent ductus arteriosus for children: two case report]

We reported thoracoscopic closure of patent ductus arteriosus (TCPDA) performed on two children. All of two patients had no residual shunt postoperatively. Postoperative pain was less than left thoracotomy procedure. In addition TCPDA had merits cosmetically. We concluded that TCPDA was less invasive and safety procedure compared with conventional procedure.

Effect of cardioplegic arrest and reperfusion on coronary reserve and autoregulation

BACKGROUND

The effects of cardioplegic arrest and reperfusion on the coronary vasculature remain to be characterized. This study was designed to investigate changes in coronary reserve and autoregulation after hypothermic cardioplegic arrest and reperfusion.

METHODS

Isolated rabbit hearts were perfused in a retrograde manner with Krebs-Henseleit bicarbonate buffer solution at a pressure of 80 cm H2O. Baseline measurements were performed for (1) coronary flow; (2) vasodilatory response to 5-hydroxytryptamine (10(-7) mol/L) and nitroglycerin (10(-4) mol/L); (3) autoregulatory capacity, quantified as closed-loop gains; and (4) isovolemic left ventricular function. Hearts were then subjected to cardioplegic arrest for 90 minutes. Twenty minutes after reperfusion, measurements were repeated.

RESULTS

Coronary flow decreased significantly after reperfusion (6.2 +/- 1.1 versus 5.3 +/- 1.1 mL.min-1.g-1; p < 0.01). The response to 5-hydroxytryptamine as percentage increase of flow decreased significantly after reperfusion (134.0% +/- 12.0% versus 109.1% +/- 6.8%; p < 0.01). However, there was no significant change in the response to nitroglycerin after reperfusion (121.3% +/- 17.6% versus 136.6% +/- 13.3%). The closed-loop gain demonstrated negative values before arrest but became positive after reperfusion, indicating loss of autoregulation after reperfusion. There was no significant change in left ventricular function.

CONCLUSIONS

The coronary flow reserve in response to 5-hydroxytryptamine and autoregulation were impaired after cardioplegic arrest and reperfusion, whereas nitroglycerin-induced vasodilatory response and left ventricular function were preserved.

[Postoperative immunological capacity after coronary artery bypass grafting in a patient with chronic hemodialysis: comparison with data from patients without chronic hemodialysis]

Recently, coronary artery bypass grafting (CABG) has been performed safely in patients maintained on hemodialysis. However, the postoperative immunological capacity of patients undergoing CABG during chronic hemodialysis has not been fully investigated. Recently we performed CABG in a patient undergoing chronic hemodialysis and measured the immunological parameters. The WBC count, the populations of lymphocytes, OKT 4-positive cells, and OKT 8-positive cells, and NK activity were determined, and the lymphocyte stimulation test (using PHA) was performed before and after cardiopulmonary bypass, then, 1, 3, and 6 days after CABG. We compared these data with those from 17 patients without chronic hemodialysis. The immunological capacity after CABG in the patient with chronic hemodialysis was similar to that of patients without chronic hemodialysis. We suggest that CABG in patients with chronic hemodialysis is a safe operation with regard to the immunological capacity.

[Significance of systemic inflammatory response syndrome at cardiopulmonary bypass]

Systemic Inflammatory Response Syndrome (SIRS) is a new concept of entry criteria for sepsis. This concept, when applied to area of Multiple Organ Failure (MOF), is considered to be a preparatory state for MOF. To study the significance of SIRS state at cardiac surgery, we measured the body temperature, white blood cell count, respiratory rate and heart rate of 18 patients who underwent elective cardiac surgery, from the 1st post-operative day to the 7th post-operative day. We also measured Interleukin-6 and 8 (IL-6 and IL-8) to understand the relationship between the SIRS state and inflammatory cytokines just after cardiopulmonary bypass (CPB), at the 1st, 3rd and 6th postoperative day. The result was as follows: Patients with CPB more than 120 minutes have more frequency and longer duration of SIRS than patients with CPB less than 120 minutes. Serum levels of IL-8 at SIRS state were revealed statistically higher than at non-SIRS case. Duration of SIRS state was related to CPB time and serum levels of IL-6 and IL-8 just after CPB. We concluded that SIRS state is an indication for anti-cytokine therapy to prevent MOF, and it is important to shorten CPB time in order to decrease the duration of SIRS.

[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.