[Open heart surgery without the use of homologous blood in infants and young children: effectiveness of the intraoperative autologous blood donation from arterial monitoring line]

Open heart surgery without the use of homologous blood transfusion was attempted in 81 pediatric patients weighing 5.5-14.9 kg. Autologous blood was donated from arterial monitoring line after induction of anesthesia. This donated blood, actual volume of 9.2 +/- 1.7 ml/kg, was reinfused following the cessation of extracorporeal circulation. Hemodilution resulting from autologous blood donation was well tolerated by all patients. Sixty-eight patients (84%) were operated on successfully without the need for homologous blood. These data suggest that autologous blood donation from arterial monitoring line is a safe and effective method to avoid homologous blood transfusion especially in infants and young children undergoing open heart surgery.

[A total correction for tetralogy of Fallot without the use of homologous blood]

In 22 consecutive patients with tetralogy of Fallot (TF), a total correction was attempted without the use of a homologous blood transfusion from September 1995 to March 1997. The 22 patients were divided into two groups according to their surgical procedures; namely, either a simple correction (group I: n = 14) or a complex correction including the relief of peripheral pulmonary stenosis and/or the division of a previous systemic-pulmonary shunt (group II: n = 8). In 77% of all patients, surgery was performed without a homologous blood transfusion. No differences were found in the non-transfusion rate and the hematocrit (Ht) values between the two groups and, as a result, we thus confirm that this additional procedure is not a risk factor for surgery without a homologous blood transfusion. According to the correlation of the red blood cell volume before and after surgery, the preoperative Ht value corresponding to the postoperative Ht of 30% could be accurately predicted. The calculated Ht values were 41.0% in the patient weighing 15 kg, 42.5% in those weighing 10 kg, and 46.9% in those weighing 5 kg. These data suggest that a surgical correction without a homologous blood transfusion can therefore be safely performed in almost all patients with TF.

[A case report of one-stage repair for transposition of the great arteries with intact ventricular septum and coarctation of the aorta in neonate]

We report a neonatal case of one-stage repair for transposition of the great arteries with intact ventricular septum (TGA with IVS) and coarctation of the aorta (CoA). The surgery was performed at 27 days of age when the patient, a male, weighed 3408 g. Preoperative cardiac catheterization and angiography confirmed the diagnosis of TGA with IVS, CoA, atrial septal defect, patent ductus arteriosus, persistent left superior vena cava, left sided juxta-positioning of appendages and dextrocardia. The procedure was simultaneous subclavian flap aortoplasty through a left thoracotomy and an arterial switch operation through a median sternotomy. The patient's postoperative course was uneventful and he has grown well. Postoperative cardiac catheterization revealed mild pulmonary stenosis (pressure gradient of 19 mmHg between the right ventricle and the pulmonary artery) and mild aortic arch kinking from the arterial switch maneuver. One-stage repair, the combination of subclavian flap aortoplasty and arterial switch operation, provides a good clinical result in this complex malformation.

Separation of the natural atria in experimental implantation of total artificial heart

Atrial connections in a single-unit total artificial heart (TAH) may be difficult to make because of the rigidity of the device and the fixed position of the atrial inlets. We developed a technique to separate the natural atrial borders in an experimental implantation of a unitary TAH. In this technique, the interatrial groove was dissected to separate the posterior wall of the right atrium from the roof of the left atrium before cardiopulmonary bypass (CPB) was initiated. After initiation of CPB and cardiectomy, the atrial septum was separated completely, and the right atrial wall was reconstructed with glutaraldehyde-treated autopericardium. We believe that this simple adjunctive technique provides increased mobility of the atrial cuffs and allows for an easier connection of the unitary TAH.

Intraarterial perfusion of the hindlimb with pyridoxalated hemoglobin polyoxyethylene conjugate solution in anesthetized dogs

To evaluate the potential clinical usefulness of a modified hemoglobin, pyridoxalated hemoglobin polyoxyethylene conjugate (PHP), the hindlimb vascular bed was perfused with PHP solution while monitoring tissue oxygen tension (PtO2) in anesthetized dogs. The hindlimb region was perfused through the external iliac artery with a roller pump at a varying perfusion rate. PtO2 was measured using a PO2-monitoring probe inserted into the gracial muscle. After surgical preparation for perfusion, the iliac arterial flow rate was 19.9 +/- 5.6 ml/min, and baseline PtO2 was 38.4 +/- 1.3 mm Hg. Perfusion with autologous arterial blood with the pump increased PtO2 and perfusion pressure (PP) in a perfusion rate-dependent manner. Perfusion with PHP solution at 20 ml/min decreased PtO2 from the initial baseline level, but an increase in the flow rate to 40-55 ml/min restored or induced an elevation of PtO2. Results demonstrated that PHP solution can deliver oxygen to local tissue and maintain tissue oxygen tension at the same level as autologous arterial blood at a high enough flow rate.

Human intraperitoneal response to a left ventricular assist device with a Ti-6AI-4V alloy surface

The soft tissue reaction to long-term implantation of an intraperitoneal left ventricular assist device (LVAD) was investigated. The HeartMate 1000 (Thermo Cardiosystems, Inc., Woburn, MA) is a pneumatically driven blood pump with smooth titanium alloy (Ti-6AI-4V) outer surfaces that is placed intraperitoneally in the left upper quadrant and sutured to the anterior abdominal wall. It is being used currently as a bridge to cardiac transplant, which sometimes requires extended support times. We examined the tissue capsule that formed around the rigid circular pump housing of four LVADs (duration of implant: 61, 86, 128, and 153 days) for gross, histologic, immunohistochemical, and ultrastructural analysis. Immunostaining was performed using monoclonal and polyclonal antibodies against cytoskeletal tissue markers (vimentin, desmin, alpha-smooth muscle actin), T and B lymphocytes, carcinoembryonic antigen, factor VIII, and cytokeratins (CAM 5.2 AE1/AE3, 34 beta E12, and 35 beta H11). Direct fluorescent immunolabeling for fibrinogen was also performed to characterize cell and tissue type. Histologic analysis of the 3 to 4 mm thick capsule with white, glistening inner surfaces showed fibrovascular tissue with multipotential subserosal cells (MSCs), capillary endothelium, collagen, and a few mononuclear infiltrates. The immunohistochemical profile of the MSCs differed from myofibroblasts despite a morphologic similarity. Transmission electron microscopy revealed abundant rough endoplasmic reticulum and peripherally arranged myofilaments within the spindle shaped cells. It was hypothesized that capsule formation was initiated by fibrin deposition, followed by proliferation of MSCs and subsequent formation of fibrovascular tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

The development of a clinically relevant canine model of postperfusion syndrome

Investigation into the complex etiology of the postperfusion syndrome (PPS) has been limited by access to only retrospective human case studies, and performance of animal studies that examine biochemical predictors of injury rather than the PPS itself. To determine whether a reproducible canine model of the clinical syndrome was possible, seven dogs underwent cardiopulmonary bypass (CPB) with a bubble oxygenator for 0 (n = 1, sham), 2 (n = 1), 4 (n = 1), and 6 (n = 4) hours. Arterial oxygenation, chest radiographs, serum creatinine, and total leukocyte and platelet counts continued to change through the second postoperative day, illustrating the need for prolonged follow-up (48 hours) to accurately detect postperfusion organ dysfunction. The dogs that did not undergo CPB for 6 hours (n = 3) did not develop important pulmonary dysfunction postoperatively, but three of the four dogs undergoing 6 hours of CPB developed profound, persistent, arterial hypoxemia associated with radiographic, histologic, and hemodynamic evidence of severe PPS. Early evidence of renal dysfunction was also apparent within 84 hours of 6 hour CPB. It is concluded that the canine long duration (6 hour) CPB model, with prolonged (48 hour) postoperative monitoring, generates a reproducible, clinically relevant model of human PPS.

Longitudinal propagation of contraction in the isolated conduit coronary arteries of humans and pigs

We examined the longitudinal propagation of contraction in isolated human and pig coronary arteries. Epicardial coronary arteries of about 2 cm were cut open longitudinally, and the tension development of circular muscles was measured simultaneously at three sites (both cut ends and the midportion of the segment). Cyclic tension changes arising at one site of human coronary artery propagated smoothly to the other sites, and the whole length of segment worked as a single unit. Contraction induced by locally applied prostaglandin F2 alpha or histamine also propagated in four of seven preparations. The remaining three human and all seven pig coronary arteries showed propagation of such drug-induced contraction after treatment with 10 mM tetraethylammonium (TEA). In pig coronary arteries treated with TEA, electrical stimulation evoked a reproducible local contraction and its propagation. Propagation velocity was 9.0 +/- 0.7 at 0.8 mM calcium concentration and increased to 11.1 +/- 0.9 and 13.1 +/- 1.4 mm/sec as calcium concentration rose to 1.8 mM and 7.2 mM, respectively. Local contraction did not propagate at calcium concentrations of 0.2 mM or less. The calcium antagonist diltiazem decreased the propagation velocity dose dependently and blocked propagation of contraction at 0.3 microM without significant effects on the magnitude of local contraction. We conclude that smooth propagation of contraction develops in epicardial coronary arteries of humans and pigs and that the propagation may depend on calcium influx.

Effect of cold cardioplegic solution and hypothermia on response to acetylcholine in perfused epicardial coronary artery of pig

The effect of cold cardioplegic solution and hypothermia on the response to acetylcholine, a major postganglionic neurotransmitter of the parasympathetic nervous system, was studied using perfused epicardial coronary arteries of pigs. Cold crystalloid cardioplegic solution (5 degrees C) and hypothermia including topical cooling with slushed ice significantly augmented the coronary flow reduction by acetylcholine at one and two hours after rewarming. Cold Krebs-Henseleit solution (5 degrees C) with hypothermia showed similar effects. However, cardioplegic solution at 37 degrees C did not affect the responsiveness. The coronary flow reduction induced by potassium chloride (60 mmol/L) did not change even after the administration of cold cardioplegic solution (5 degrees C) or cold Krebs-Henseleit solution (5 degrees C), indicating that cooling did not necessarily augment the coronary contractile response generally. It is concluded that cooling and subsequent rewarming can potentiate the contractile response of the coronary artery of the pig to acetylcholine. This suggests that cold cardioplegic solution with hypothermia can promote intraoperative coronary spasm upon activation of the parasympathetic nervous system.

Effects of perivascular nerve stimulation on the flow rate in isolated epicardial coronary arteries of pigs

The effect of perivascular nerve stimulation on coronary contraction was examined by perfusing the isolated epicardial coronary artery of pigs. Coronary flow decreased in a frequency-dependent manner after electrical stimulation, with a maximum percent flow reduction of 23.8 +/- 1.1% (n = 10) at 20 Hz. The reduction in flow rate was not inhibited by phentolamine nor propranolol but was inhibited by atropine. Neostigmine enhanced the flow reduction induced by nerve stimulation. Acetylcholine reduced the flow rate dose dependently but norepinephrine showed no effect. We conclude that perivascular nerve stimulation of the epicardial coronary artery of pigs causes a modest flow reduction through activation of a cholinergic mechanism.

[Clinical studies of SM-4300 in combination with antibiotics against severe bacterial infections]

SM-4300, a newly developed human immunoglobulin preparation was evaluated in 24 patients with severe bacterial infections and the following results were obtained. The clinical efficacy was excellent in 4 cases, good in 7, fair in 5, poor in 3 and unknown in 5 with the effective rate of 57.9%. No serious side effect nor abnormalities in laboratory findings due to administration of SM-4300 were observed except 1 case with slight elevation of GOT and GPT.