Search

An abstract of the article "27 years experience with the gastroepilopic artery graft in CABG" by H. Suma is presented.

Major advances over the past decade in the field of ancient DNA are providing access to past paleogenomic diversity, but the diverse functions and biosynthetic capabilities of this growing paleome remain largely elusive. We investigated the dental calculus of 12 Neanderthals and 52 anatomically modern humans ranging from 100,000 years ago to the present and reconstructed 459 bacterial metagenome-assembled genomes. We identified a biosynthetic gene cluster shared by seven Middle and Upper Paleolithic individuals that allows for the heterologous production of a class of previously unknown metabolites that we name "paleofurans." This paleobiotechnological approach demonstrates that viable biosynthetic machinery can be produced from the preserved genetic material of ancient organisms, allowing access to natural products from the Pleistocene and providing a promising area for natural product exploration.

We herein report the case of a 78-year-old woman who was diagnosed as having disseminated herpes zoster (DHZ) complicated with probable varicella-zoster pneumonia during maintenance therapy for microscopic polyangiitis. Because the patient had severe renal dysfunction, amenamevir administration was started to avoid any neurotoxicity of acyclovir, which is suggested to be optimal for treatment. It ameliorated her symptoms without any adverse events. This is the first report suggesting the efficacy of amenamevir in the treatment of severe herpes zoster infection with coexisting DHZ and probable varicella-zoster pneumonia. Amenamevir could thus be a treatment option for severe varicella zoster virus infections.

Objectives: Cyclophosphamide (CYC) has been proposed as a standard induction regimen for interstitial lung disease (ILD) associated with systemic sclerosis (SSc). However, there remain patients with SSc-ILD who are intractable to the therapy. This study aimed to identify factors associated with inadequate response to CYC and investigate how to treat SSc-ILD, especially in the need for glucocorticoids (GCs) combined with CYC., Methods: This retrospective study included consecutive patients diagnosed with SSc-ILD and treated with CYC between 2009 and 2020. Logistic regression models were used to determine the prognostic factors indicating significant progression of ILD (SP-ILD). The clinical findings of patients treated with vs. without GCs were compared., Results: Nineteen patients were registered, with a median age of 61.0 years. Fifteen were females, and five were classified into SP-ILD. Baseline high C-reactive protein (CRP) levels and non-widespread or localized ground-glass opacities (GGOs) predicted SP-ILD in multivariable analyses, and the cut-off level of CRP was 0.41 mg/dL. In clinical courses, SSc-ILD with high inflammation temporarily responded to CYC, regardless of the combined use of GCs; however, the therapeutic effects deteriorated soon after stopping CYC., Conclusion: High CRP levels with non-widespread GGO predicted progressive ILD in patients with SSc treated with CYC., (© 2021 Japan College of Rheumatology.)

Severe digital ischemia (SDI), which presents with digital ulcers, necrosis, or gangrene, has been reported to be a rare manifestation of anti-aminoacyl transfer RNA synthetase (ARS) antibody-positive polymyositis/dermatomyositis or anti-synthetase syndrome. A retrospective study was conducted between 2009 and 2020 at our department to investigate the clinical features of anti-ARS antibody-positive patients with SDI and identify their predictors. A total of 46 patients who were positive for anti-ARS antibody were included, four of whom (8.7%) presented with SDI. The characteristics of the patients with SDI were as follows: the median age was 74 years, with 75% being female; anti-Jo-1 antibody, Raynaud's phenomenon, interstitial lung disease, and myositis were observed in two (50%), four (100%), four (100%), and three patients (75%), respectively. Next, we reviewed the literature of anti-ARS antibody-positive patients with SDI and investigated the predictors of SDI by analyzing a total of 51 patients, including the previously reported five patients with SDI. Multivariable analyses revealed that Raynaud's phenomenon and myositis independently predicted the development of SDI in patients with anti-ARS antibody. In conclusion, digital ulcers, necrosis, or gangrene seem to be more common presentations in our study, and Raynaud's phenomenon and myositis can predict the complications of SDI in anti-ARS antibody-positive patients., (© 2021 Japanese Dermatological Association.)

Summary: The primary hypothesis of the ROMA trial is that in patients undergoing primary isolated non-emergent coronary artery bypass grafting, the use of 2 or more arterial grafts compared with a single arterial graft (SAG) is associated with a reduction in the composite outcome of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization., The secondary hypothesis is that in these patients, the use of 2 or more arterial grafts compared with a SAG is associated with improved survival. The ROMA trial is a prospective, unblinded, randomized event-driven multicentre trial comprising at least 4300 subjects. Patients younger than 70 years with left main and/or multivessel disease will be randomized to a SAG or multiple arterial grafts to the left coronary system in a 1:1 fashion. Permuted block randomization stratified by the centre and the type of second arterial graft will be used. The primary outcome will be a composite of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization. The secondary outcome will be all-cause mortality. The primary safety outcome will be a composite of death from any cause, any stroke and any myocardial infarction. In all patients, 1 internal thoracic artery will be anastomosed to the left anterior descending coronary artery. For patients randomized to the SAG group, saphenous vein grafts will be used for all non-left anterior descending target vessels. For patients randomized to the multiple arterial graft group, the main target vessel of the lateral wall will be grafted with either a radial artery or a second internal thoracic artery. Additional grafts for the multiple arterial graft group can be saphenous veins or supplemental arterial conduits. To detect a 20% relative reduction in the primary outcome, with 90% power at 5% alpha and assuming a time-to-event analysis, the sample size must include 845 events (and 3650 patients). To detect a 20% relative reduction in the secondary outcome, with 80% power at 5% alpha, the sample size must include 631 events (and 3650 patients). To be conservative, the sample size will be set at 4300 patients. The primary outcome will be tested according to the intention-to-treat principle. The primary analysis will be a Cox proportional hazards regression model, with the treatment arm included as a covariate. If non-proportional hazards are observed, alternatives to Cox proportional hazards regression will be explored., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Throughout its 30-year history, the right gastroepiploic artery (GEA) has been useful for in situ grafts in coronary artery bypass grafting (CABG). The early graft patency rate is high, and the late patency rate has improved by using the skeletonized GEA graft and proper target selection, which involves having a target coronary artery with a tight >90% stenosis. Total arterial revascularization with the internal thoracic artery and GEA grafts is an option for achieving better outcomes from CABG procedures.

Previous studies have demonstrated that a light-dark cycle has promoted better sleep development and weight gain in preterm infants than constant light or constant darkness. However, it was unknown whether brief light exposure at night for medical treatment and nursing care would compromise the benefits brought about by such a light-dark cycle. To examine such possibility, we developed a special red LED light with a wavelength of >675 nm which preterm infants cannot perceive. Preterm infants born at <36 weeks' gestational age were randomly assigned for periodic exposure to either white or red LED light at night in a light-dark cycle after transfer from the Neonatal Intensive Care Unit to the Growing Care Unit, used for supporting infants as they mature. Activity, nighttime crying and body weight were continuously monitored from enrolment until discharge. No significant difference in rest-activity patterns, nighttime crying, or weight gain was observed between control and experimental groups. The data indicate that nursing care conducted at 3 to 4-hour intervals exposing infants to light for <15 minutes does not prevent the infants from developing circadian rest-activity patterns, or proper body growth as long as the infants are exposed to regular light-dark cycles.

Objective: We compared the midterm results of mitral valve repair with and without leaflet resection, and revealed the effectiveness of this technique, even for in the posterior leaflet alone., Patients: From August 2002 to March 2014, a total of 306 mitral valve repairs were carried out at our hospital. Of these patients, 50 cases did not undergo leaflet resection (Artificial Chordae; Group A) and 56 cases underwent leaflet resection (Resectional; Group R). There were no significant differences in the preoperative profiles., Results: The follow up rate was 98% and 100% respectively. The mean cardiopulmonary bypass time and aortic cross clamp time were not significantly different. The average ring size was significantly larger (p <0.01) in Group A. All cause mortality at 3 years and 8 years was both 97.8% in Group A and was both 98.1% in Group R. Freedom from moderate mitral regurgitation at 3 years was 97.1% and at 8 years was 91.7% in Group A and 97.4% and 94.6% in Group R respectively. There were no cases of mortality, re-operation for recurrent mitral regurgitation, hemolytic anemia and infectious endocarditis., Conclusion: We demonstrated good midterm results in mitral valve repair without leaflet resection. However, further follow-up was needed.

Coronary artery bypass grafting is the most common cardiac surgery operation performed worldwide. It is the most effective revascularization method for several categories of patients affected by coronary artery disease. Although coronary artery bypass grafting has been performed for more than 40 years, no detailed guidelines on the choice of coronary artery bypass grafting conduits have been published and the choice of the revascularization strategy remains more a matter of art than of science. Moreover, there is a clear contradiction between the proven benefits of arterial grafting and its very limited use in everyday clinical practice. In the hope of encouraging wider diffusion of arterial revascularization and to provide a guide for clinicians, we discuss current evidence for the use of different conduits in coronary artery bypass surgery and propose an evidence-based algorithm for the choice of the second conduit during coronary artery bypass operations., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The right gastroepiploic artery (GEA) has been recognized as a suitable and reliable conduit for coronary bypass surgery. From a sizable number of experiences, we know the use of this artery does not increase surgical risk, and no gastric ischemia nor abdominal complications occur with takedown of the GEA. This artery undergoes less significant arteriosclerosis and demonstrates physiological adaptability as seen in the internal thoracic artery (ITA). From our experience with over 1,500 GEA grafts, the operative mortality was 1.26%, and 5-, 10-, and 15-year survival rates were 91.7%, 81.4%, and 71.3% respectively, while the cardiac death-free survival rates were 95.8%, 91.7%, and 88.6%, respectively. The cumulative patency rate of the GEA graft was 98.5% at 1 month, 93.7% at 1 year, 86.2% at 5 years, and 70.2% at 10 years. The GEA graft is a safe and effective arterial conduit for coronary artery bypass grafting (CABG).

Over the past 3 decades, several observational studies established a role for surgical ventricular restoration (SVR) in the treatment of ischemic cardiomyopathy. In 2009, the Surgical Treatment for Ischemic Heart Failure (STICH) trial reported their findings and found no benefit of adding SVR to coronary artery bypass surgery in ischemic dilated cardiomyopathy. The STICH findings precipitated a decline in interest in SVR. In this article, we review the historical background and observational data that established a role for SVR. We critically review the STICH trial, and contend that the limitations are such that the study cannot provide any reliable conclusion on the role of SVR because of suboptimal patient selection and inadequacy of volume reduction (only 19% mean reduction in volume). Several post-STICH publications continue to demonstrate that SVR is effective in dilated ventricles, provided the procedure achieves >30% volume reduction. It is critical that surgeons continue their work in SVR, and continue to analyze their data, to enable better clarification of the indications and future role for this procedure., (Copyright © 2012 Elsevier Inc. All rights reserved.)

A 29-year-old man was hospitalized because of heart failure causing dilated cardiomyopathy (DCM). On admission, he had elevated creatinine kinase levels (hyper CKemia) (4283IUl⁻) and false enlargement of bilateral calves. By a muscular biopsy, he was diagnosed as Fukuyama-type muscular dystrophy. Although neuromuscular diseases are often related to cardiomyopathy, reports showing a relation between cardiomyopathy and Fukuyama-type muscular dystrophy have been rare. Our group performed the partial left venticulectomy of the posterior wall and approximation of the papillary muscle, mitral valve annuloplasty, and tricuspid valve annuloplasty for DCM in the patient with Fukuyama-type muscular dystrophy, after obtaining informed consent from the patient and his family. At the 1-year follow-up examination, the neuromuscular symptoms had not progressed, and the left ventricular function was improved (left ventricular end-diastolic dimension (LVDd) 77-66 mm, left ventricular end-systolic dimension (LVDs) 73-59 mm, and ejection fraction (EF) 26-30%). This is the first case report of a left ventriculoplasty in a patient with Fukuyama-type muscular dystrophy., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

We investigated mid-term outcomes after ring annuloplasty with the MC3 ring and aimed to identify factors associated with recurrent tricuspid regurgitation (TR). From October 2006 to October 2010, 136 patients (male:female 80:56, with a mean age 64.7±11.8 years) underwent tricuspid valve (TV) annuloplasty for functional TR. The indications for TV annuloplasty were (1) severe TR, or (2) mild or moderate TR with pulmonary hypertension (systolic pulmonary artery pressure >50 mmHg) or tricuspid annular (TA) dilatation, in patients undergoing mitral valve (MV) surgery. The average follow-up period was 1.5±0.8 years. The overall survival rates were 97.1±0.15%, 93.4 ± 0.02% and 90.7 ± 0.28% at three months, one year and four years, respectively. Freedom from recurrent moderate TR was 98.5±0.01, 95.6 ± 0.17% and 90.6 ± 0.03% at three months, one year and four years, respectively. Multivariate analysis revealed that residual TR was significantly associated with preoperative severe TR, left ventricular end-diastolic dimension >70 mm, right ventricular dimension >40 mm, dilated cardiomyopathy (DCM) and left ventriculoplasty. This MC3 ring corrects TR effectively, and provided good results. We must point out, however, that additional or alternative surgical options should still be considered for high-risk of repair failure, such as those with DCM or high pulmonary hypertension.

Transvenous endocardial cardioverter defibrillator lead implantation is contraindicated in patients with prosthetic tricuspid valves (TVs). A 61-year-old male was hospitalized due to right heart failure, severe TV regurgitation, and non-sustained ventricular tachycardia (VT), which required Sotalol. The patient received an implantable cardioverter defibrillator (ICD) using an epicardial cardioverter defibrillation patch during a TV replacement (TVR) for VT and severe TV regurgitation because of arrhythmogenic right ventricular cardiomyopathy. There were no complications and the stimulation thresholds were stable. ICD implantation with the use of an epicardial cardioverter defibrillation patch serves as a safe, easy and effective therapy for patients undergoing TVR complicated with ventricular arrhythmia.

The ubiquitin (Ub)-proteasome system (UPS) is an important proteolytic mechanism for selecting and digesting cytotoxic proteins. The aim of this study is to elucidate expression and in situ localization of the UPS in the myocardium from patients with dilated cardiomyopathy (DCM) with refractory heart failure. The expression profile of the oxidative stress-induced cytotoxic proteins was also examined. Myocardium was obtained from 26 patients with DCM at the left ventriculoplasty. Ten normal autopsied hearts served as controls. Myocardial expressions of Ub and proteasomes were studied immunohistochemically. Oxidative stresses were examined in point of localization of the oxidation-induced modifier molecules (OMM). The relationship between immunohistochemical results and clinical parameters was also evaluated. Both Ub and proteasomes were stained positive in granular structures accumulating between the myofibrils and adjacent to nuclei in cardiomyocytes. The OMMs were also positive in the same Ub-positive granular structures. The area fraction of Ub, proteasomes and OMM was significantly higher in DCM hearts than in normal controls. Significant positive correlation was observed between the area fractions of Ub and plasma levels of brain natriuretic peptide (p = 0.046) in DCM hearts. In conclusion, enhanced expression of the UPS colocalized with OMM in cardiomyocytes may be involved in the pathophysiology of DCM hearts.

Background: Although clinical studies have suggested a link between inflammation markers and atrial fibrillation (AF), it is still unclear whether local immunologic responses actually exist in human atria during AF., Methods and Results: To address this point, human left appendages were obtained from 16 patients who underwent cardiac surgery (5 with sinus rhythm (SR) and 11 with AF) and subjected to immunohistochemical analysis. In all the AF specimens, adhesion and migration of CD45-reactive cells were consistently observed predominantly in the atrial endo- and subendomyocardium and more prominently than in SR. Most of them were immunologically active CD68-positive macrophages, whereas CD3-positive T cells infiltrated to a lesser extent. Scavenger-receptor A staining revealed maturation of macrophages not in the endocardium but in the midmyocardium, a gradient from endo- to midmyocardium. In the endocardium, along with adhesion molecules (intracellular adhesion molecule-1 and vascular cell adhesion molecule-1), a chemotactic protein-1, which facilitates the recruitment, was more abundantly expressed in AF than in SR. Cytokines including transforming growth factor-beta and interleukin-6 were frequently expressed by these macrophages., Conclusions: These observations collectively imply active adhesion and recruitment of macrophages across the endocardium in human fibrillating atria, thereby supporting the concept of local immunologic inflammatory responses around the atrial endocardium of AF.

Papillary fibroelastoma (PFE) is the third most common primary neoplasm of the heart. The lesions generally appear singly, but multiple PFEs may rarely occur. The case is reported of multiple PFEs in a woman initially admitted for acute cerebral infarction. Echocardiography revealed four masses, one located on each cusp of the aortic valve and one on the left ventricular outflow tract. All four lesions were successfully removed surgically. An histopathologic examination revealed PFEs arising from the ventricular and valvular endocardium.

Objective: A poor functioning dilated left ventricle with mitral regurgitation is the worst condition in chronic ischemic heart failure. Our 7-year experience in combined mitral valve and left ventricular reconstruction was evaluated., Materials and Methods: Among 246 patients having undergone a left ventriculoplasty for postinfarction left ventricular dysfunction in our experience, there were 76 patients with advanced heart failure due to dilated ischemic cardiomyopathy with mitral regurgitation (70 males and 6 females with a mean age of 60 years). All patients had NYHA class III (n = 41) or IV (n = 35) heart failure, including 26 patients (34%) with inotropic support before the operation. All patients had a mitral regurgitation of more than 2+ and 46 patients (61%) had 3+ or more. Mitral reconstruction (61 repairs, 15 replacements) and left ventriculoplasty (Dor 34, SAVE 36, PLV 6) were undergone in combination with CABG (74%)., Results: Operative mortality was 7.9% (5.0% in 60 elective and 18.8% in 16 emergency operations). The ejection fraction and cardiac index increased from 24.9 +/- 7.0% to 33.3 +/- 8.7%, and 2.0 +/- 0.4 l/min/m2 to 2.6 +/- 0.4 l/min/m2, respectively (p < 0.001). The endodiastolic and endosystolic volume indices, and diastolic dimension decreased from 165.9 +/- 43.2 ml/m2 to 121.2 +/- 31.1 ml/m2, 123.3 +/- 38.9 ml/m2 to 74.0 +/- 27.5 ml/m2, and 69.5 +/- 7.7 mm to 61.2 +/- 7.1 mm, respectively (p < 0.001). Late deaths were noted in 13 patients (17.1%), with 10 cardiac deaths. One- and 5-year survival rates were 80.2% and 67.7%, respectively. The mean NYHA class improved from 3.5 to 1.4 among the survivors. Multivariate analysis showed that patients with a mitral regurgitation of 3+ or more and preoperative endosystolic volume index were significant predictors for postoperative mortality. However, age, preoperative inotropes and pulmonary hypertension did not show any significant differences., Conclusion: Combined mitral and left ventricular reconstruction is effective in treating advanced heart failure with endstage ischemic cardiomyopathy associated with a dilated left ventricle and mitral regurgitation.

Batista introduced the partial left ventriculectomy (PLV), which is based on physics alone. With experience, it has been found that the extent of myocardial disease and viability of retained muscle is an important determinant of early and late survival. Although the PLV has been almost abandoned in many countries following the negative message from the Cleveland Clinic, it is still alive in Japan with a refined concept, surgical technique and patient selection. In a series of 63 patients undergoing PLV for idiopathic dilated cardiomyopathy since 1996, operative mortality was 9.5%, and 1-, 3- and 5-year survival rates were 71.1%, 56.2% and 45.9%, respectively. Improved survival has obtained by using appropriate patient selection and concomitant restrictive mitral annuloplasty (1-, 3- and 5-year survival rate =86.5%, 78.6% and 59.4%, respectively, in the most recent 33 patients). Because of insufficient availability of donors for heart transplantation, nontransplant cardiac surgery for medically refractory heart failure is important. Ventricular restoration procedures, including PLV, should be seriously considered as an important option for endstage heart failure.

Background: To treat advanced heart failure due to idiopathic dilated cardiomyopathy, surgical ventricular restoration with mitral reconstruction was conducted and evaluated., Methods: In 95 patients (81 men, mean age: 54 years), New York Heart Association class III/IV was 44/51, and 33 patients (36%) were inotropic dependent preoperatively. Mitral regurgitation (>or=2+) was noted in all patients. All patients underwent left ventriculoplasty (septal anterior ventricular exclusion in 38, partial left ventriculectomy in 57) and mitral reconstruction (repair 53, replacement 42). Fifty-two patients (55%) had concomitant tricuspid repair. Intra-aortic balloon pumping and left ventricular assist device was used in 24 patients and two patients, respectively., Results: Hospital mortality was 11.6% (11 of 95), with 6.6% (5 of 76) in elective and 31.6% (6 of 19) in emergency operations. The ejection fraction and cardiac index increased from 22.3+/-6.3% to 27.2+/-8.0% and from 2.3+/-0.5 ml/m2/min to 2.8+/-0.5 ml/m2/min, respectively (p<0.001). The endodiastolic volume index, endosystolic volume index and diastolic dimension decreased from 232.9+/-56.1 ml/m2 to 160.0+/-49.8 ml/m2, from 178.9+/-46.7 ml/m2 to 113.8+/-44.7 ml/m2 and from 82.0+/-9.0 mm to 68.9+/-11.6 mm, respectively (p<0.001). Late death occurred in 27 patients with 22 cardiac deaths. The mean NYHA class was 1.7 among the survivors. One-, 3- and 5-year survival rates were 72.8%, 61.4% and 50.5%, respectively. In the 62 patients who were non-inotropic dependent preoperatively, 1-, 3-, and 5-year survival rates (81.8%, 73.7% and 62.9%) were significantly better than the inotropic-dependent group (55.3%, 37.3% and 28.0%). Patients with mitral annuloplasty showed a significantly higher 5-year survival rate than patients with mitral valve replacement (59.6% vs 43.6%) in univariate analysis. By application of the exclusion site selection method, the two different ventriculoplasty procedures did not show significant difference in survival rates. Multivariate analysis showed that preoperative inotropes and old age were significant predictors for postoperative mortality., Conclusion: The selected ventriculoplasty in combination with mitral annuloplasty is a useful option for patients with an extremely dilated left ventricle in idiopathic dilated cardiomyopathy. Surgery should be considered before inotropic dependency occurs when prior medical treatment has failed.

Background: Cardiac sarcoidosis is frequently overlooked or misdiagnosed as idiopathic dilated cardiomyopathy (DCM), primarily because of difficulties in its diagnosis. This is a crucial issue because appropriate therapy with immunosuppressive agents can be initiated if early diagnosis is achieved., Methods and Results: Thoracic computed tomography (CT) was retrospectively analyzed in detail with special reference to lymph node swelling (LNS) in the mediastinum of 8 patients diagnosed with idiopathic DCM who underwent left ventriculoplasty (LVP), and were later proven to have active cardiac sarcoidosis by histological evaluation of the resected myocardium. Twenty age-matched patients with idiopathic DCM who also underwent LVP served as controls. On conventional chest radiographs, none of the cardiac sarcoidosis patients exhibited lymph node involvement, including bilateral hilar lymphadenopathy. However, CT demonstrated significant mediastinal LNS in 7 (88%) of them and in only 1 (5%) of the 20 controls. There was a significant difference in the incidence of LNS in the 2 groups (p=0.00005)., Conclusion: Evaluation of mediastinal lymphadenopathy by CT is an easy and valuable initial screening method for distinguishing cardiac sarcoidosis from idiopathic DCM.

Objective: Retinoic acid-inducible gene-I (RIG-I) is a member of the DExH box family proteins and serves as an intracellular signalling molecule involved in the regulation of various genes. Mesothelial cells are active in generating a variety of bioactive factors, and RIG-I may serve as a potential intracellular molecule regulating part of these factors. We have addressed the expression of RIG-I in pericardial mesothelial cells., Methods and Results: Cultures of human mesothelial cells separated during cardiac surgery were established. Interferon (IFN)-gamma was found to stimulate the expression, in cultured mesothelial cells, of RIG-I mRNA and protein in time- and concentration-dependent manners. We also performed immunohistochemical analysis of heart tissues to examine the expression of RIG-I in mesothelial cells. Intense immunoreactivity was detected in reactive pericardial mesothelial cells in non-specific pericarditis and in dilated cardiomyopathy., Conclusion: RIG-I may be involved in the inflammatory reaction in pericardial mesothelial cells.

Background: To improve the long-term results of coronary artery bypass grafting (CABG), several arterial conduits have been used, including the skeletonized right gastroepiploic artery (GEA) graft., Methods and Results: The skeletonized GEA graft was used for CABG in 223 patients over a 6-year period (208 males, 15 females, mean age 64 years). 1-, 2- and 3-vessel and left main trunk disease was noted in 1, 28, 122 and 72 patients, respectively. Internal thoracic artery, radial artery and saphenous vein grafts were concomitantly used in 217 (97%), 73 (33%) and 41 (18%) patients, respectively, and the mean number of grafts was 3.5. The sites of GEA grafting were 1 anterior descending, 10 diagonal, 97 circumflex, and 185 right coronary arteries, with 154 single in-situ, 33 free and 36 composite grafts, including 56 sequential grafts. There was 1 (0.4%) operative death. New Q wave was noted in 2 (0.9%) patients. Postoperative angiography revealed 97.6% early postoperative (within 1 month) and 91.5% midterm (mean 27 months) patency rates for GEA grafts. The cumulative 4-year patency rate of the skeletonized GEA graft was 86.4%., Conclusion: The skeletonized GEA is a safe and effective arterial conduit for CABG.

Background: To improve the longterm outcome after CABG, several strategies have been used using arterial conduits. Our 20 years experience with the right gastroepiploic artery (GEA) graft was evaluated., Methods and Results: In 1352 patients having CABG with the GEA graft, (1092 men, mean 63 years, 99% multivessel disease, and mean EF 0.51), internal thoracic artery, saphenous vein, and radial artery grafts were concomitantly used in 1312 (97%), 783 (58%), and 128 (8%) patients, respectively. The mean number of distal anastomoses was 3.1, and 2.4 coronary arteries were bypassed with arterial grafts. The sites for GEA grafting were 70 anterior descending, 268 circumflex, and 1089 right coronary arteries. The operative mortality was 1.26%. In 1118 follow-up patients (82.6%), 5, 10, and 15 years survival rates were 91.7%, 81.4%, and 71.3%, and the cardiac death-free survival rates were 95.8%, 91.7%, and 88.6%, respectively. The cumulative patency rate of the GEA graft was 97.1% at 1 month, 92.3% at 1 year, 85.5% at 5 years, and 66.5% at 10 years, respectively. In 172 skeletonized GEA grafts with 233 distal anastomoses, the patency rate at immediate, 1, and 4 years after surgery was 97.6%, 92.9%, and 86.4%, respectively. In 124 patients with late (5 to 17 years) restudy, patency rate was 96% (114/119) in the left internal thoracic artery, 87% (108/124) in GEA, and 68% (67/98) in saphenous vein grafts. New stenosis was uncommon in GEA., Conclusion: The GEA graft is a safe and effective arterial conduit for CABG.

Background: Mitral valve surgery is a recommended treatment for congestive heart failure; however, its effect for idiopathic dilated cardiomyopathy (DCM) with an extremely enlarged left ventricle (LV) is not well documented. We examined our long-term results of mitral valve surgery for idiopathic dilated cardiomyopathy., Methods: Fifty-five patients of idiopathic dilated cardiomyopathy have undergone mitral valve surgery to treat intractable congestive heart failure since 1998. Forty-two patients were male with an average age of 55. Preoperative New York Heart Association functional class was III in 25, IV in 30, and 19 were dependent on inotropic infusion. The mitral valve was repaired in 37 patients and replaced in 18. The tricuspid valve was repaired in 35 patients and replaced in 3. We divided 46 elective cases into two groups by LV end-systolic volume index., Results: Postoperatively, an intraaortic balloon pump was required in 2 patients and a left ventricular assist device in 1; both were emergent cases. Hospital mortality was noted 4.3% in elective cases (2 of 46) and 14.5% in overall cases (8 of 55). One-year, 3-year, and 5-year survival rate of elective cases was 73.3%, 58.2%, and 51.7%, respectively. Left ventricle size has decreased and LV contractility has increased in a small LV group year by year, but those in a large LV volume group have not changed subsequently after surgery. There was a significant difference noted in the survival rate of the two groups divided by LV end-systolic volume index., Conclusions: Mitral valve surgery for idiopathic dilated cardiomyopathy to treat end-stage heart failure is relatively safe and effective in elective status. However, isolated mitral reconstruction without any other type of surgery may not suffice for an extremely enlarged LV.

Background: Eight-year experience with the septal anterior ventricular exclusion procedure for congestive heart failure due to idiopathic dilated cardiomyopathy was evaluated., Methods: In 36 patients (27 men and 9 women with a mean age of 60 years) with heart failure; New York Heart Association class III/IV (21/15); and mitral regurgitation 2+ or greater, the procedure was indicated when the diastolic dimension was 75 mm or greater, and the septum was akinetic. A long, narrow oval patch was sutured to form a downsized elliptical left ventricle by excluding the septum and anterior wall. Mitral reconstruction was combined for all patients (26 repairs with undersized ring and 10 replacements with bioprosthesis) and tricuspid repair was added for 16 patients (44%)., Results: Hospital mortality was 13.8% (5 of 36), with 6.5% (2 of 31) in elective and 60% (3 of 5) in emergency operations. Ejection fraction increased from 20.9% +/- 6.4% to 27.5% +/- 8.8%, left ventricular diastolic dimension decreased from 81.9 +/- 9.2 mm to 70.1 +/- 10.0 mm, and left ventricular endodiastolic and endosystolic volume indices decreased from 236.5 +/- 65.0 mL/m2 to 183 +/- 60.5 mL/m2 and from 181.3 +/- 55.4 mL/m2 to 133.5 +/- 54.1 mL/m2, respectively. Left ventricular endodiastolic pressure decreased from 24.3 +/- 9.7 mm Hg to 19.4 +/- 7.6 mm Hg. Brain natriuretic peptide decreased from 975 +/- 866 pg/mL to 404 +/- 366 pg/mL at 1 to 6 postoperative months. Eleven late deaths were noted and were due to heart failure (6), sudden death (4) and stroke (1). The mean New York Heart Association class was 1.7 among the survivors. One- and 3-year survival rates were 67.5% and 60.7%, respectively., Conclusions: The septal anterior ventricular exclusion procedure with mitral reconstruction is a useful option for the treatment of advanced idiopathic dilated cardiomyopathy in extremely dilated left ventricle with akinetic septum.

Objective: Restoration of left ventricle size and shape is an effective surgical procedure in patients with dilated cardiomyopathy. This report defines early and intermediate results following the reshaping of the left ventricle from spherical to ellipsoid configuration in patients with ischemic cardiomyopathy, employing a technique for LV restoration (LVR) that uses form rather than disease as the endpoint for oblique patch placement., Methods: Between 1998 and 2004, a cohort of 83 patients with dilated ischemic cardiomyopathy underwent an operation to reshape the left ventricle. In 54 patients the Dor procedure was done, and 29 underwent the septal anterior ventricular exclusion (SAVE) procedure to emphasize the elliptical shape, whereby patch placement followed an oblique trajectory between the LV apex and septum below the aortic valve. Ventricular form, rather than the disease scar marked the suture placement site endpoint to create an ellipse. The mean age was 58+/-27, but SAVE patients had larger end systolic volume index (135+/-38 vs 95+/-25). Overall preoperative NYHA functional class III was in 69% and IV in 31 patients, but more SAVE patients were in class IV (38% vs 28%). The procedures were elective in 72 and emergent in 11, with similar entry criteria for each procedure., Results: In combination with LVR operation, mitral surgery was performed in 49/83 and tricuspid annuloplasty in 23/83 patients, but these procedures were more common after SAVE (59% vs 44% and 45% vs 19%, respectively), because of larger LV volumes in SAVE patients; 2.8+/-1.3 coronary artery bypass grafts were used. Perioperative use of IABP or LVAD was 15 and 1, respectively in 83 patients. Hospital death was in 1/11 or 9% after emergent operations and 3/72 or 4% in elective procedures, with no difference between groups. After discharge from the hospital, NYHA class improved to class I or II in 57 patients, class III/IV in 14 patients, with 10 late deaths. The 5-year survival rate after the elective operation was 80.3% in SAVE and with elective operation and 77.4% in the Dor procedure., Conclusion: The SAVE or Pacopexy technique is easy to reshape the dilated left ventricle from spherical to ellipsoid form after the LVR, and the resultant improved configuration may contribute to the overall results for patients with ischemic dilated cardiomyopathy.

Objective: Left ventricular restoration is used to treat patients with chronic progressive heart failure caused by nonischemic dilated cardiomyopathy. This study addresses the use of site selection to determine either lateral wall or septal exclusion., Methods: Evolution of intraoperative echocardiography to define the site of poorest contraction and use of multiple biopsies to show the nonhomogeneous nature of damage are reviewed. To address the heterogeneity of extent of fibrosis in nonischemic cardiomyopathy, target selection was used to determine the mode of left ventriculoplasty. Either the lateral wall was excluded by partial left ventriculectomy (PLV) or septal anterior ventricular exclusion (SAVE or Pacopexy) was employed if the septum was primarily diseased. Surgical results in 107 high-risk (43% NYHA (New York Heart Association) class III and 57% class IV) patients with idiopathic dilated cardiomyopathy over the past 9 years are reviewed., Results: Overall hospital mortality was 7.1% in 84 elective operations and 60.9% in 23 emergency operations, and fell from 42.8% (6 of 14) to 15.0% (14 of 93), when site selection for the area of left ventricular excision or exclusion was determined by the intraoperative echocardiography test. The SAVE/Pacopexy procedure was performed in 36 patients with 62.2% 5-year survival rate. For the entire cohort of PLV and SAVE/Pacopexy population, overall ejection fraction increased from 20 to 31%, and NYHA class improved from 3.6 to 1.8. The 1-, 5-, and 7-year survival rates were 66.9, 46.0, and 36.2%, respectively. In patients having the operation before inotropic dependent, the survival rate was 78.1, 58.0, and 50.2%, respectively., Conclusions: Left ventriculoplasty is effective for patients with idiopathic dilated cardiomyopathy with heart failure by proper patient selection, appropriate timing of the operation, and choice of the surgical procedure (exclusion site selection).

Patients with ischemic cardiomyopathy (ICM) are at an extremely high risk of death and ischemic events. This study aims to evaluate the impact of left ventricular restoration (LVR) and mitral valve surgery on the cardiac and clinical functional status of the patients with ICM. Twenty-six patients (46-80 years, mean: 64 years) with severely dilated heart (left ventricular end-systolic volume index: LVESVI > or = 100 ml/m2) who had coronary artery bypass grafting (2.8+/-1.3), mitral valve surgery, and LVR were enrolled in this study. Left ventricular end-diastolic volume index and LVESVI significantly decreased (from 169+/-44 to 130+/-41 ml/m2, P=0.0005, from 120+/-33 to 89+/-43 ml/m2, P=0.0012). Left ventricular ejection fraction showed no change. MR showed significant improvement (from 2.7+/-0.6 to 1.0+/-0.4, P<0.0001) and NYHA functional class showed improvement (from 3.2+/-0.8 to 1.5+/-0.9, P<0.0001). A 5-year survival rate was 71.2%. In conclusion, this aggressive approach with LVR aiming to treat end-stage ICM by relief of ischemia, reduction of LV wall tension by decreasing LV volume and stopping mitral leak, is effective for LV volume reduction and improvement of clinical functional status.

Background and Methods: An international registry of left ventricular volume reduction (LVVR) procedures, including partial left ventriculectomy, has been expanded, updated, and refined to include 568 cases voluntarily reported from 52 hospitals in 12 countries., Results: Gender, age, ventricular dimension, ethnology, myocardial mass, presence or absence of mitral regurgitation, as well as transplant indication, had little effect on event-free survival, which was defined as either absence of death or ventricular failure requiring mechanical assist or transplantation. Poor preoperative patient condition such as New York Heart Association classification IV, depressed contractility and decompensation requiring an emergency procedure were associated with reduced event-free survival. Other risk factors included an early surgery date, lack of experience, dilated cardiomyopathy as the underlying pathology and extended myocardial resection. Performance of LVVR reached a peak by 1998, but was largely abandoned by 2001, except in Asia, where experienced institutes continue to perform it in patients in better condition with preserved myocardial contractility., Conclusion: Avoidance of risk factors appears to have contributed to the recent survival improvement and may help stratify patients for LVVR. While performance has been decreasing, the concept has been extended to other LVVR and less invasive procedures, which are now under clinical trials.

This is the presentation of coronary artery bypass grafting with gastroepiploic artery (GEA) in both skeletonized GEA harvesting technique and anastomosis: After median sternotomy and harvesting internal thoracic artery, the median incision is extended less than one inch. Following laparotomy, dissection of GEA is started from two third distal of the great curvature of the stomach and ended above the pylorus. The GEA is passed into pericardial cavity through a small tunnel in the diaphragm. The most common site of the anastomosis is distal right coronary artery (postero-descending or atrioventricular branch or both). The suture starts from the left side of the "heal" of the GEA and proceeds in a counter-clockwise fashion for three stitches until pulling down the GEA to the coronary artery. After the completion of the anastomosis, the clamp of the GEA is released to check the anastomotic hemostasis. The technique for harvesting skeletonized GEA is shown and an overview of the literature of the CABG using GEA is presented.

Objectives: The aim of this study is to evaluate the relationship between left ventricular (LV) wall property and the results of LV volume reduction surgery (LVR) to treat dilated cardiomyopathy (DCM) in an experimental model., Methods: DCM was introduced in 18 Lewis rats by autoimmunization with cardiac myosin. Among them, 12 rats underwent LVR and the rest were served as controls. They were subjected to echocardiography and cardiac catheterization for dimensional and functional measurements. The animals were sacrificed 4 weeks after surgery, and the fraction of myocardial fibrosis was calculated in 4 divided parts of the LV wall., Results: Percent fibrosis varied widely from 4.7 to 45.2%. LV volume reduction surgery improved cardiac function immediately after surgery in all rats (Emax, 0.28+/-0.14 to 0.48+/-0.18 mmHg/microl; LV end-diastolic pressure, 21.0+/-6.1 to 13.3+/-5.1 mmHg, P<0.05, respectively). Four weeks later, 6 hearts remained in good shape with smaller LV end-diastolic dimension (Dd) than baseline values (LV Dd, 9.7+/-0.6mm; fractional area change (FAC), 40.3+/-8.4%) and the other 6 had more redilation in diameter and more deterioration in function than baseline values (LV Dd, 10.9+/-0.6mm; FAC, 25.8+/-6.9%; P<0.05, respectively). Percent fibrosis in the septum differed 11.1+/-3.4 vs. 27.8+/-2.8% between the two groups (P<0.01). There was a significant correlation between the ratio of LV redilatation after surgery and percent fibrosis in the septum (r=0.951, P<0.01)., Conclusions: Although the initial benefit of LVR was confirmed, the long-term result was affected by the amount of residual fibrosis. This information suggests that surgical site selection is important to achieve a good result of LV restoration surgery for DCM.

Objectives: The purpose of this study was to test how surgical ventricular restoration (SVR) affects early and late survival in a registry of 1,198 post-anterior infarction congestive heart failure (CHF) patients treated by the international Reconstructive Endoventricular Surgery returning Torsion Original Radius Elliptical shape to the left ventricle (RESTORE)team., Background: Congestive heart failure may be caused by late left ventricular (LV) dilation after anterior infarction. The infarcted segment is often akinetic rather than dyskinetic because early reperfusion prevents transmural necrosis. Previously, only dyskinetic areas were treated by operation. Surgical ventricular restoration reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments., Methods: The RESTORE group applied SVR to 1,198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined, and risk factors were identified., Results: Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair; p < 0.001). Perioperative mechanical support was uncommon (<9%). Global systolic function improved postoperatively. Ejection fraction (EF) increased from 29.6 +/- 11.0% preoperatively to 39.5 +/- 12.3% postoperatively (p < 0.001). The left ventricular end-systolic volume index (LVESVI) decreased from 80.4 +/- 51.4 ml/m(2) preoperatively to 56.6 +/- 34.3 ml/m(2) postoperatively (p < 0.001). Overall five-year survival was 68.6 +/- 2.8%. Logistic regression analysis identified EF or=80 ml/m(2), advanced New York Heart Association (NYHA) functional class, and age >or=75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were NYHA functional class III or IV and postoperatively, 85% were class I or II., Conclusions: Surgical ventricular restoration improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent five-year outcome.

Ventriculoplasty was introduced to treat patients with chronic progressive heart failure from end-stage non ischemic dilated cardiomyopathy, which was presumed to be a homogeneous disease. However ventriculoplasty is not commonly used today, because variable results follow using only lateral ventriculoplasty as the treatment tool. This report traces our evolution in surgical management, defines that the homogeneous disease concept is not correct, and centers upon the importance of site selection, appropriate timing, and methods of patient selection. Left ventriculoplasty by either partial left ventriculoplasty (PLV) or septal anterior ventricular exclusion (SAVE or Pacopexy) was performed in 96 high risk (44% NYHA Class III, and 56% Class IV) patients with idiopathic dilated cardiomyopathy over the past 8 years. Overall hospital mortality was 8% in elective operations and 57% in emergency operations. Hemodynamic and functional improvement was evident from ejection fraction rising from 20% to 31%, and improved NYHA Class 3.6 to 1.8. The global series showed 1, 5 and 7 year survival rate was 66.4, 44.7 and 41.3%, respectively. However surgical results improved as experience allowed development of a strategy for timing, and defining proper exclusion site selection. Non homogeneous ventricular disease was identified, and 69% 4 year survival resulted from our intraoperative definition of the most diseased segment (septum or lateral wall), and then exclusion of this site. This evolving experience indicates that left ventriculoplasty is effective treatment for patients with end-stage cardiomyopathy, provided proper patient selection, appropriate timing of the operation, and choice of procedure are used as keys to a successful outcome.

Congestive heart failure may be caused by late left ventricular (LV) dilation following anterior infarction. Early reperfusion prevents transmural necrosis, and makes the infarcted segment akinetic rather than dyskinetic. Surgical ventricular restoration (SVR) reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments. The international RESTORE group applied SVR in a registry of 1198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined and risk factors identified.Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair, p < .001) Perioperative mechanical support was uncommon (< 9%). Global systolic function improved postoperatively, as ejection fraction increased from 29.6 +/- 11.0% to 39.5 +/- 12.3% (p < .001) and left ventricular end systolic volume index decreased from 80.4 +/- 51.4 ml/m(2) to 56.6 +/- 34.3 ml/m(2) (p < .001). Overall 5-year survival was 68.6 +/- 2.8%, Logistic regression analysis identified EF < or = 30%, LVESVI > o = 80 ml/m(2), advanced NYHA functional class, and age > or =75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were class III or IV, and postoperatively 85% were class I or II.SVR improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent 5-year outcome.

Enteroviruses have been implicated in the pathogenesis of idiopathic dilated cardiomyopathy (IDC). Recently, the association of adenovirus or parvovirus with IDC has been reported. Viral infection in the myocardium of American and Japanese patients with end-stage IDC was evaluated. Myocardial specimens from 30 American patients with IDC and 47 Japanese patients with IDC were analyzed for the presence of cardiotropic viruses. The strand-specific detection of enteroviral ribonucleic acid (RNA) was performed to determine viral activity in hearts with IDC. Established reverse transcription-polymerase chain reaction (PCR) or PCR techniques were used to detect genomic sequences of influenza viruses, mumps virus, adenovirus, parvovirus, herpes simplex viruses, varicella-zoster virus, and Epstein-Barr virus. Enteroviral RNA was detected in 7 of the 30 American patients (23%) and in 15 of the 47 Japanese patients (32%). Minus-strand enteroviral RNA, an indicator of active enteroviral RNA replication, was demonstrated in 5 of 7 plus-strand-positive American patients (71%) and in 12 of 15 plus-strand-positive Japanese patients (80%). Sequence analysis revealed that the viruses detected were Coxsackie B viruses. No genomic sequences of other viruses were detected in the myocardium of either American or Japanese patients with IDC. Therefore, active group B Coxsackie virus RNA replication in the myocardium was demonstrated in a significant proportion of American and Japanese patients with end-stage IDC. There was no evidence of persistent infection by other viruses in hearts with IDC. Specific therapy should be designed for Coxsackie virus positive patients with IDC., (Copyright 2004 Excerpta Medica, Inc.)

Objective: We have developed a technique for biologic coronary artery bypass grafting, which is a revival of a classic concept with modern biotechnology., Methods: Acute myocardial infarction was created by ligating the major branch of the circumflex artery in rabbits. Animals were divided into four groups: a nontreated group (group N), a group in which omentum was used to wrap the infarcted area (group G), a group in which a gelatin hydrogel sheet incorporating 100 microg basic fibroblast growth factor was placed over the infarcted area (group F), and a group in which the infarcted area was similarly treated with basic fibroblast growth factor followed by omental wrapping (group FG). Cardiac function was subsequently assessed by echocardiography. Postmortem angiography through the gastroepiploic artery was done in groups G and FG. Infarct size and arteriolar density were evaluated., Results: Group FG showed a better fractional area change than did the other groups (group N P <.001, group G P =.002, group F P <.001). Angiography revealed that communication from the gastroepiploic artery to the coronary artery was created through a rich bed of neovascularization in all 7 animals of group FG, whereas poor collaterals were recognized in only 2 of 7 animals in group G. Infarct size was reduced to a greater extent in group FG than in groups F, G, and N (10% +/- 3%, 16% +/- 5%, 19% +/- 7%, 23% +/- 2%, respectively, group F P =.04, groups G and N P <.01). The number of arterioles 20 to 100 microm in diameter was increased to a greater extent in group FG than in groups F, G, and N (23 +/- 5 arterioles/mm(2), 14 +/- 3 arterioles/mm(2), 10 +/- 1 arterioles/mm(2), 4 +/- 2 arterioles/mm(2), respectively), with the differences being significant., Conclusions: These results show that bypass from the gastroepiploic artery to coronary arteries can be achieved without surgical anastomosis through slow release of basic fibroblast growth factor in this rabbit acute myocardial infarction model. This new revascularization concept, biologic coronary artery bypass grafting, could be applicable for revascularizing many tiny coronary vessels in patients who are difficult to treat with conventional surgery or catheter intervention.

Purpose and Methods: There is increasing evidence that inflammatory cytokines play an important role in the development of heart failure. To evaluate the role of cytokines in nonischemic DCM, we analyzed the relative quantity of cytokine mRNA expression in the hearts from DCM patients with refractory heart failure, using the ABI PRISM7700 real-time PCR system. We used heart tissues resected from 32 DCM patients at the time of elective partial ventriculectomy (PLV), and five biopsy specimens with normal histological findings as control., Results and Discussion: Interleukin (IL)-1beta, IL-10, and Tumor Necrosis Factor (TNF)-alpha mRNA were expressed at low levels in all normal hearts. The number of IL-10-positive DCM cases was significantly smaller than normal controls (P = 0.0036). One (10%) of 10 DCM patients with IL-10 mRNA expression died after PLV, and 10 (45%) of 22 DCM patients without IL-10 mRNA expression died. IL-1beta mRNA was overexpressed (over twice the mean of control subjects) in 15 of 32, and TNF-alpha mRNA in 10 of 32 patients. We propose the classification of DCM patients into subgroups on the basis of cytokine mRNA expression. Anticytokine therapy or cytokine therapy may have potential in improving the condition of heart failure in certain subgroups of DCM patients., Conclusions: We suggest that DCM patients with heart failure deteriorate without IL-10 mRNA expression in the myocardium. The classification of DCM patients into subgroups on the basis of cytokine mRNA expression may have great value in considering the treatment of this heterogeneous disease state.

Objective: Association of mitral regurgitation (MR) with ischemic cardiomyopathy (ICM) increases the degree of heart failure and its surgical management remains controversial. The aim of this study was to report the surgical results in patients with or without MR in association with ICM., Patients and Methods: Ninety-two patients with ischemic cardiomyopathy (left ventricular [LV] ejection fraction less than 30% with global akinesis) underwent LV restoration. Pre-operative New York Heart Association (NYHA) functional class was either in class-3 or -4 in all patients. MR was moderate to severe in 38 patients (MR-group) and none or mild in 54 patients (noMR-group). Moderate to severe MR was repaired in addition to the complete coronary artery bypass (CABG) and LV restoration. All patients were followed up and echocardiogram was repeated every 6 months after the surgery., Results: The procedure of LV restoration was selected pre- and intra-operative examination and endoventricular circular patch plasty was performed in 76, partial left ventricle resection in three, and septal anterior exclusion in 13. CABG was performed in 85 patients with mean 2.4+/-1.1 grafts in MR-group and 3.2+/-0.4 grafts in noMR-group (P<0.0001). In MR-group mitral valve plasty was performed in 24 and replacement in 14. Undersized (26 or 28 mm) circumferential mitral ring was used in 16 patients for mitral plasty. Emergent operation required in 15 patients (13 in MR-group and two in noMR group) and the hospital mortality was 18.4% in MR-group and 3.7% in no MR-group. Mitral regurgitation recurred in two patients with posterior ring annuloplasty and they underwent valve replacement. The post-operative NYHA functional class improved to class-1 or -2 in 65 patients and cumulative survival in 5 years including emergent and hospital deaths was 60.9% in MR-group and 70.1% in noMR-group., Conclusion: In association of MR to ICM, emergent operation required more often and perioperative mortality rate was high. However, the aggressive combined mitral operation in addition to CABG and LV restoration showed the improvement of clinical symptom and quality of life after the surgery.

Congenitally corrected transposition of the great arteries (CCTGA) is a rare congenital heart disease characterized by atrioventricular (AV) and ventriculo-arterial discordance;(1) that is, the left ventricle supports the pulmonary circulation and the right ventricle supports the systemic circulation. The most common cardiac anomalies in CCTGA include ventricular septal defect, pulmonary outflow tract obstruction and abnormalities of the systemic AV valve. (1) The dysfunction of the systemic ventricle occurs with increasing frequency in older patients with CCTGA, independent of their commonly associated structural defects.(2-4) We report a patient with CCTGA undergone the partial ventriculectomy for his systemic ventricular dysfunction.

From December 1996 to May 2001, we have performed 82 cases of left ventriculoplasty (LVP) for nonischemic dilated cardiomyopathy (DCM). Surgical procedure was partial left ventriculectomy in 70 patients and septal anterior ventricular exclusion in 12 patients with evaluation by utilizing intraoperative echocardiography. There were 70 men and 12 women with a mean age of 49, varying from 14 to 76. All patients had medically refractory heart failure with New York Heart Association (NYHA) Functional Class III in 33 patients and NYHA IV in 49; 34 patients were supported by inotropic infusion prior to the operation. Intra-aortic balloon pump (IABP) and left ventricle assist device (LVAD) were used in 12 and 2 patients at perioperative period, respectively. Hospital mortality was 8.2% in elective operation (5/61), 57.1% in emergency operation (12/21), and 20.7% overall. One- and four-year survival rates were 75.5% and 69.3% in elective cases, 37.9% and 0 in emergency cases, and 64.7% and 3.6% overall, respectively. Left ventricular (LV) ejection fraction increased from 22.3% to 29.0% at the time of surgery and has maintained around 33% up to two years. LV diastolic dimension and LV end diastolic pressure decreased from 83.8 mm to 65.0 mm; from 31.7 mmHg to 22.0 mmHg have maintained around 70 mm and 22.1 mmHg up to two years, respectively. Over one year most of the survivors were medically controlled within NYHA Class I-II. In conclusion, careful choice of surgical procedure by utilizing intraoperative echocardiography enables left ventriculoplasty to effectively treat severe heart failure with nonischemic cardiomyopathy.

In the 35 years of coronary artery bypass grafting, several kinds of conduits have been utilized and assessed. It is clear now that the saphenous vein graft deteriorated with time mainly due to atherosclerosis in the graft called "vein graft disease." The internal thoracic artery graft, on the contrary, stays patent very well in the long-term period and this evidence directly related to the superior later outcome in terms of longevity and postoperative cardiac events. To extend the use of arterial conduits for myocardial revascularization, several autologous arteries have been investigated and utilized clinically. With proper use of these new arterial conduits in addition to internal thoracic artery, coronary artery bypass grafting with multi-arterial grafts can be performed safely, and better long term result can be expected., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

In failing hearts, cardiomyocytes degenerate and interstitial fibrosis, which indicates cardiomyocyte loss, becomes more prominent in the myocardium. However, the precise mechanism of cardiomyocyte degeneration that leads to cell death is still unclear, although it is presumed that lysosomal function and autophagy play an important role because lysosomal activity increases under stress such as hypoxia. Myocardium that had been resected during partial left ventriculectomy performed in patients with dilated cardiomyopathy (DCM) was examined. Under light microscopy, some cardiomyocytes had a marked scarcity of myofibrils and had prominent cytoplasmic vacuolization. Atrophic and degenerated cardiomyocytes were often observed adjacent to replacement fibrotic tissue. Immunohistochemistry showed positivity for lysosome-associated membrane protein and a lysosomal catheptic enzyme in vacuoles of various sizes in the cardiomyocytes and these lysosomal markers were markedly increased in atrophic and degenerated cardiomyocytes. Electron microscopy revealed that degenerated cardiomyocytes had many vacuoles containing intracellular organelles, such as mitochondria, and were considered to be autophagic vacuoles. In DCM hearts, autophagy appeared to be associated not only with degradation of damaged intracellular organelles but also with progressive destruction of cardiomyocytes. It is possible that autophagic degeneration is one of the mechanisms of myocardial cell death.