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Coronary artery disease (CAD) remains a leading cause of mortality and morbidity in developed countries. Although urgent revascularization is the cornerstone of management of acute coronary syndrome (ACS), for patients with stable CAD recent large-scale clinical trials indicate that a mechanical 'fix' of a narrowed artery is not obviously beneficial; ACS and stable CAD are increasingly recognized as different clinical entities. We review the perspectives on (1) modifying the diagnostic pathway of stable CAD with the incorporation of modern estimates of pretest probability, (2) non-imaging evaluations based on their availability, (3) the optimal timing of invasive coronary angiography and revascularization, and (4) the implementation of medical therapy during the work-up.

Although the mechanism of systolic anterior motion (SAM) of the mitral valve is unknown, it is known to have a multifactorial pathophysiology. Echocardiographic analysis of the mitral leaflet revealed the step-wise progression of SAM, and intraventricular flow analysis revealed the contribution of drag force generated by the misled flow below the posterior leaflet. Although several diverse clinical features of SAM are already known, some key features need to be abstracted from among them to understand the regulation of SAM establishment. This paper reviews past articles that have investigated the mechanism of SAM and proposes a mechanism-based concept to provide insights for better comprehension of SAM recognition.

We report the case of a 57-year-old female suffering from recurrent malignant undifferentiated pleomorphic sarcoma of the left atrium. Metastasis to the posterior mediastinum was detected upon first presentation. Incomplete resections were carried out twice before mitral valve replacement was finally performed. The tumor recurred 16 months later and was treated with radiation therapy, which has proved to be effective in bringing about tumor regression for 2 years, to date. The patient has survived for 7 years since the first surgery.

Small-sized bioprosthetic valves are sometimes associated with suboptimal hemodynamic performance, leading to a patient–prosthesis mismatch. Trifecta pericardial valves are designed to improve hemodynamic performance. The purpose of this study was to investigate the hemodynamic properties of small-sized Trifecta valves and their efficacy in preventing a patient–prosthesis mismatch. This was a retrospective analysis of 108 patients undergoing surgical aortic valve replacement with a Trifecta valve of 23 mm or less in a single Japanese institution. The hemodynamic performance was evaluated with an echocardiography examination in all patients after surgery, and the development of a patient–prosthesis mismatch was judged with the measured in vivo indexed effective orifice area. There was one early and seven late mortalities. There were no valve explants due to structural valve deterioration. Postoperative mean pressure gradients of 19-, 21-, and 23-mm valves were 15.1, 11.4, and 9.0 mmHg, respectively. The effective orifice area of 19-, 21-, and 23-mm valves was 1.41, 1.69, and 1.78 cm2, respectively. Patient–prosthesis mismatch occurred in 14 patients (1 severe and 13 moderate) and the incidence was 13.0% (15.4% in 19 mm, 18.0% in 21 mm, and 3.3% in 23 mm). The small-sized Trifecta valves showed excellent hemodynamic performance and were associated with a low incidence rate of patient–prosthesis mismatch.

The ideal blood-salvaging strategies for off-pump coronary artery bypass graft procedures have not been determined. We developed a new blood-salvaging system that uses a cardiotomy suction. The purpose of this study was to examine the efficacy of this novel method. This was a retrospective study involving 50 consecutive patients undergoing off-pump coronary artery bypass grafting. In 25 patients, a simple cardiotomy suction system was used (cardiotomy suction group). These individuals were compared with 25 historical cohorts who were treating with the conventional cell saver system (cell saver group). There was no in-hospital mortality in either group. In the cell saver group, there was one major complication (stroke) and two minor complications (saphenous vein graft occlusion, superficial wound infection). In the cardiotomy suction group, there was one minor complication (subclinical pulmonary emboli). The cardiotomy suction group received significantly fewer transfused RBC (cardiotomy: 0.56 ± 1.4 units vs. cell saver: 2.46 ± 3.3 units, p = 0.005). The serum total protein and albumin levels were significantly higher in the cardiotomy group. Our newly developed simple cardiotomy suction system, when compared with the conventional cell saver system, produced similar clinical results and attenuated postoperative hemodilution. Our system may emerge as a preferable alternative for blood salvage during off-pump coronary artery bypass grafting.

In the surgical treatment of acute aortic dissection, the attachment of the dissected wall using surgical glue can be an effective procedure to stabilize the fragile dissected wall. A 42-year-old man underwent aortic root replacement for acute type A aortic dissection. However, after aortic declamping, he experienced severe myocardial impairment, which required an additional procedure of coronary artery bypass grafting. The unexpected myocardial ischaemia can be attributed to the inattentional use of surgical glue.

Background After reports of cardiac impairment caused by mitral annuloplasty with rigid rings, several prosthetic rings with semi-rigidity were introduced. The influence of semi-rigid rings on postoperative cardiac function remains unknown. This study compared postoperative cardiac function between patients receiving a semi-rigid prosthetic ring and those receiving a flexible ring or band. Methods and results Transthoracic echocardiographic data of 305 patients who underwent mitral valve repair for degenerative mitral regurgitation (227 patients receiving a semi-rigid ring and 78 receiving a flexible ring or band) were retrospectively reviewed. The imbalance in the preoperative characteristics between groups was adjusted with propensity score matching. Left ventricular ejection fraction, end-diastolic dimension, and end-systolic dimension were compared at 1 week, 6 months, and 1 year after surgery. Propensity score matching yielded 68 matched pairs of patients for whom there were few group differences in preoperative covariates. Between patients receiving a semi-rigid ring and those receiving a flexible ring or band in the propensity-matched cohorts, there were no significant differences in ejection fraction (P=0.322), end-diastolic dimension (P=0.576), or end-systolic dimension (P=0.567). Conclusions There was little difference in the influence on postoperative cardiac function between semi-rigid rings and flexible rings or bands.

Background Selection of a cannulation site for the repair of acute type A aortic dissection remains controversial. Several cannulation sites have been introduced, but each is associated with a risk of adverse complications. Transapical cannulation is a simple procedure to restore antegrade blood flow during ECC. However the efficacy of this procedure is unknown. Methods Among 400 patients undergoing surgical repair of acute type A dissection at Sakakibara Heart Institute between 2003 and 2010, transapical cannulation was performed in 52 patients, and these patients were included in this study. Transapical cannulation was selected as the initial cannulation site in 44 patients and as conversion from femoral cannulation in 8 patients. Results There were 4 in-hospital mortalities (mortality rate, 7.7%) and 5 patients had strokes (stroke rate, 9.6%). Transapical cannulation was successful in 47 patients (90.4%). Conversion of the cannulation site was necessary in 5 patients: Malperfusion on initiation of ECC was observed in 4 patients and emergence of aortic regurgitation was observed in 1 patient. The cannula was moved to another artery for correction in these patients. There was no mortality in patients undergoing conversion of the cannulation site. Conclusions Transapical cannulation is considered an effective option for the repair of acute type A aortic dissection. Transapical cannulation cannot eliminate the risk of intraoperative malperfusion, and therefore careful assessment with intraoperative monitoring is necessary.

Background Efficacy of papillary muscle approximation (PMA) has not been well defined. Methods Mitral valve configuration was assessed using echocardiography before and 1 week after the surgery in 27 consecutive patients undergoing surgical correction of ischemic MR. Comparisons were made between patients undergoing restrictive mitral annuloplasty (RMAP) alone (n = 13, RMAP group) and those undergoing PMA in addition to RMAP (n = 14, PMA group). Results In the RMAP group, the annular diameter was reduced by 43% after surgery, and annular reduction was greater in the posterior portion than in the anterior. Consequently, the tethering angle of the posterior leaflet (PL) increased after surgery. In the PMA group, the annular diameter was reduced by 33%, and annular reduction was greater in the posterior. In this group also, the tethering angle of PL increased significantly after surgery, although the degree of augmentation was lower compared with that in the RMAP group. Conclusion The addition of PMA to RMAP could attenuate but do not eliminate the tethering augmentation of PL.

Background We assessed mitral valve (MV) function using serial echocardiography as an indicator of the durability of MV repair. The aim of this study was to analyze the mechanisms of recurrent regurgitation after MV repair for degenerative disease. Methods From 1991 to 2007, 736 patients had valve repair for mitral regurgitation caused by leaflet prolapse: 346 patients had posterior and 390 had anterior leaflet prolapse. The mean age was 54.6 ± 14.6 years, with 495 males. The durability and mechanisms of recurrent regurgitation were evaluated by the findings of echocardiography and reoperation. Follow-up and late echocardiography averaged 5.7 ± 3.9 and 5.1 ± 3.6 years, respectively. Results Survival was 91.9% ± 1.5% at 10 years. Freedom from reoperation and moderate or severe regurgitation at 10 years were 91.2% ± 1.7% and 84.5% ± 2.1%, respectively. Reoperations were performed for recurrent regurgitation in 29 patients, hemolysis in 5, and endocarditis in 1. Based on the findings of reoperation, the mechanisms of repair failure were procedure related in 9 (25.7%), valve related in 25 (71.4%), and unknown in 1. Late echocardiography revealed none to trivial regurgitation in 511 patients, mild in 153, moderate in 26, and severe in 40. Anterior leaflet prolapse, preoperative atrial fibrillation, and no use of annuloplasty ring were independent predictors of recurrent regurgitation. The main causes of moderate or severe regurgitation were leaflet thickening in 34 patients, leaflet prolapse in 20, dehiscence in 10, and unknown in 2. Conclusions The main mechanism of recurrent regurgitation after MV repair is progressive degeneration that is characterized by leaflet thickening and prolapse, especially in patients with anterior leaflet prolapse.

A new vascular graft (Triplex [Vascutek Terumo, Tokyo, Japan]) has a three-layer structure and no biologic coating material. We assessed inflammatory reaction and mediastinal tube drainage after thoracic aortic surgery using this graft.Between January 2009 and September 2009, 127 patients underwent open ascending aortic or arch repair. Triplex grafts (Vascutek Terumo) were used in 39 patients. After matching surgical procedures, 35 matched pairs (35 with Triplex, group A; 35 with coated graft, group B) were created. We compared postoperative inflammatory markers, amount, and duration of mediastinal drainage between the two groups.There was no difference in postoperative inflammatory marker levels between the two groups. The median total amounts of mediastinal drainage were 690 mL (group A) and 1,500 mL (group B) (p0.001). The median durations of drainage were 67 and 128 hours, respectively (p0.001). Multivariate linear regression analyses showed that use of the Triplex graft is an independent predictor of the small amount and short duration of mediastinal drainage.Triplex grafts reduce the amount and duration of mediastinal drainage after thoracic aortic surgery, which may promote early ambulation and fast postoperative recovery.

Background Revascularization of the diffusely diseased coronary artery is a big challenge for both cardiologists and cardiac surgeons. Long reconstruction of the diffusely diseased vessel may be a useful surgical option. The aim of this study is to assess clinical and angiographic outcomes of extensive reconstruction (≥4 cm) of the left anterior descending coronary artery (LAD) using an internal thoracic artery (ITA) graft with or without endarterectomy. Methods We retrospectively reviewed 213 patients who underwent extensive reconstruction of the LAD using an ITA graft between September 2004 and July 2009. The diffusely diseased LAD was extensively incised, additional endarterectomy was performed if necessary, and then the LAD was reconstructed with an ITA graft in a long on-lay fashion. Early and 1-year postoperative angiography was performed in 188 patients (88.3%) and 152 patients (71.4%), respectively. Results The mean length of the reconstructed LAD was 5.4 ± 1.2 cm. Endarterectomy was performed in 46.0% of the patients. The operative mortality was 1.4%. Low cardiac output and perioperative myocardial infarction were observed in 3.3 and 5.2% of the patients, respectively. Freedom from death and other cardiac or cerebrovascular events was 91.5 ± 2.2% at 3 years. The early and 1-year patency rates of the ITA to LAD grafting were 95.7% and 93.4%, respectively. Conclusions Extensive reconstruction of the diffusely diseased LAD using an ITA graft could be performed safely. Early and 1-year angiographic outcome were excellent. This surgical revascularization is an useful option for revascularization of the diffuse coronary artery disease.

Objective This study assessed the safety and efficacy of off-pump bilateral internal thoracic artery grafting in patients with left main disease. Methods We reviewed the records of 768 patients who underwent off-pump bilateral internal thoracic artery grafting between September 2004 and June 2009. Bilateral internal thoracic artery grafts were used for the left coronary system in all patients, of whom 268 had left main disease and 500 did not. We compared operative and postoperative variables and early and 1-year angiographic patency rates of the bilateral internal thoracic artery between the 2 groups. Results The perioperative mortality and incidence of postoperative complications were not significantly different between groups. In patients without left main disease, the left and right internal thoracic arteries were used for the left anterior descending artery in 87.4% and 12.2% of patients, respectively. In patients with left main disease, the left and right internal thoracic arteries were used for the left anterior descending artery in 70.5% and 29.1% of patients, respectively. In patients with left main disease, the patency rates for the left and right internal thoracic arteries at 1-year postoperative follow-up were 97.0% and 93.2%, respectively. In patients without left main disease, the patency rates for the left and right internal thoracic arteries at 1-year follow-up were 97.6% and 91.6%, respectively. The patency rates of the left and right internal thoracic arteries did not differ significantly in patients with or without left main disease ( P = .9803 and P = .7205 in left and right internal thoracic arteries, respectively). Conclusions Off-pump bilateral internal thoracic artery grafting was safe and effective in patients with left main disease. The patency rates of both grafts were comparable to those of patients without left main disease.

Background The aim of this study was to assess the angiographic patency rates of grafts used for coronary artery bypass surgery. Methods We reviewed the records of 930 patients who underwent isolated coronary artery bypass grafting between September 2004 and June 2009. Of these patients, 95.1% underwent off-pump coronary artery bypass grafting. Early and 1-year angiographic patency rates of grafts were assessed. Results Mean anastomoses per patient were 4.0 ± 1.3. Operative mortality was 0.5%. Stroke occurred in 2.2% of patients, and 1.3 % had mediastinitis. Early and 1-year patency rate of total grafts was 97.4% and 87.5%, respectively. One-year patency rate of the left internal thoracic artery, right internal thoracic artery, radial artery, gastroepiploic artery, and saphenous vein graft was 96.1%, 92.0%, 69.5%, 81.4%, and 82.6%, respectively. One-year patency rates of in situ and free right internal artery graft were not significantly different ( p = 0.13). One-year patency rate of the radial artery was significantly worse than that of the free right internal thoracic artery graft ( p p Conclusions Multiple coronary arterial revascularizations in various combinations of grafts were clinically safe and effective for isolated coronary artery bypass surgery. Bilateral internal thoracic artery grafting for the left coronary artery system was the most reliable strategy as shown by angiographic patency rates.

Objective We sought to compare early and 1-year angiographic results of various coronary artery bypass grafting configurations with the right internal thoracic artery in combination with the left internal thoracic artery. Methods We reviewed the records of 705 patients who underwent bilateral internal thoracic artery grafting between September 2004 and November 2008. The right internal thoracic artery was used as an in situ graft in 547 patients and as a free graft in 158 patients. We compared operative and postoperative variables and early and 1-year angiographic patency rates of the right internal thoracic artery between the groups. Results The operative mortality and incidence of postoperative complications were not significantly different between groups. The overall patency rates of the right internal thoracic artery were 98.8% at early angiography and 94.3% at 1-year postoperative follow-up. There were no significant differences in patency rate between in situ and free right internal thoracic artery grafts (98.6% vs 99.3% early and 95.3% vs 89.8% at 1 year). The best patency rate of the right internal thoracic artery was achieved with in situ grafting to the left anterior descending system (99.4% early and 98.5% at 1 year). Conclusions Patency rates of in situ and free right internal thoracic artery grafts were similar in early and 1-year angiographic studies. Among various configurations, the best patency of the right internal thoracic artery was obtained with in situ grafting to the left anterior descending coronary artery.

Background Composite grafting is a useful technique that avoids the need for aortic manipulation and enables a wide range of target vessels to be revascularized, effectively using the limited arterial grafts available. However, it has not been clarified whether composite grafting can achieve angiographic outcomes equivalent to those obtained with individual grafting for specific target vessels. Methods We retrospectively reviewed 830 distal arterial graft anastomoses in 256 patients who underwent off-pump coronary artery bypass surgery and also underwent 1-year follow-up coronary angiograms. Four hundred and ten anastomoses using a composite grafting technique were compared with 420 anastomoses using individual grafting. Results In target vessels with mild stenosis, the incidence of graft occlusion or string sign was significantly higher in composite internal thoracic arteries (ITA) than in individual ITA grafts (composite 20.3% versus individual 7.3%; p = 0.018) and showed a higher tendency in composite radial arteries (RA) than in individual RA grafts (59.3% versus 36.4%, p = 0.09). In contrast, the incidence was similar between composite and individual ITA grafts (5.7% versus 3.3%, p = 0.278) and composite and individual RA grafts (11.5% versus 29.6%, p = 0.297) in target vessels with severe stenosis. Conclusions The angiographic outcomes of composite grafts were closely related to the severity of stenosis of the target coronary artery. In target vessels with mild stenosis, composite grafting resulted in a higher incidence of graft occlusion or string sign than individual grafting did.

これまでの高齢者に対する冠状動脈バイパス術（CABG）の基本戦略は主に1990年以前の報告に基づいており，75歳以上では手術リスクが高い（死亡率10%前後）ため，より慎重な手術適応が必要と考えられてきた．ところが，最近10年間の報告を見ると，高齢者のCABGの治療成績は飛躍的に向上している．欧米の臨床レジストリーをみると過去10年間で死亡率は約半減し，また大規模な比較試験では遠隔期成績におけるCABGの優位性はむしろ高齢者においてより顕著であることが示されている．またCABGの手術手技についても，off pump CABGの積極的な導入が短期成績をより改善する可能性が示され，遠隔期成績では若年者同様にITAの使用や完全血行再建がやはり望ましいことがいくつかの報告で示されている．このように現在は高齢者CABGの治療方針の再考の時期にあると考えられ，最近の報告を中心に，高齢者に対するCABGの現状を検討する．

The internal thoracic artery (ITA) remodels its diameter in response to flow requirements. The objective of this study was to elucidate the remodeling capacity of the reconstructed coronary artery using the ITA.We evaluated coronary angiograms in 63 patients who had left anterior descending artery (LAD) segmental reconstruction with or without endarterectomy after off-pump coronary artery bypass graft surgery. The diameters of the ITA and reconstructed coronary artery were measured early and at 1 year after surgery.The mean diameter of the reconstructed LAD was significantly larger than that of the ITA, but significantly decreased 1 year after surgery (2.69 +/- 0.53 mm versus 1.87 +/- 0.39 mm; p0.0001). The proximal ratio, the ratio of the ITA to proximal reconstructed coronary artery, and the distal ratio, the ratio of the distal LAD to distal reconstructed coronary artery, increased to a value of almost 1.0 (0.77 +/- 0.11 versus 1.05 +/- 0.18, p0.0001, and 0.77 +/- 0.14 versus 0.92 +/- 0.12, p0.0001, respectively). Based on the mean diameter of the reconstructed coronary artery, there were no relationships between the use of endarterectomy and the degree of native coronary stenosis. The proximal ratio in the group with severe stenosis was significantly greater than that in the group with mild stenosis (1.08 +/- 0.18 versus 0.95 +/- 0.16; p = 0.036), although the distal ratio was not different between the two groups.Vascular remodeling of the coronary artery reconstructed with the ITA is observed within 1 year after surgery.

Coronary revascularization methods continue to be refined, and the emergence of the drug-eluting stent (DES) has especially changed clinical practice related to ischemic heart disease. For chronic hemodialysis (HD) patients, however, the impact of DES on clinical outcome is yet to be determined. Forty-six consecutive chronic HD patients who underwent myocardial revascularization in our institute were retrospectively reviewed. Twenty-eight patients underwent coronary artery bypass surgery (CABG) and 18 patients underwent percutaneous coronary artery intervention (PCI). Patient characteristics were similar between the two groups. In the CABG group, bilateral internal thoracic artery (ITA) bypass grafting was performed in 27 patients and off-pump CABG was performed in 20 patients. In the PCI group, a DES was used in 12 patients. The number of coronary vessels treated per patient was higher in the CABG group (CABG: 4.25 +/- 1.32 vs. PCI: 1.44 +/- 0.78; p < 0.001). Two-year survival rates were similar between the two groups (CABG: 94.1% vs. PCI: 73.9%; p = 0.41), but major adverse cardiac event-free survival (CABG: 85.9% vs. PCI: 37.1%; p = 0.001) and angina-free survival (CABG: 84.9% vs. PCI: 28.9%; p < 0.001) rates were significantly higher in the CABG group. The one-year patency rate for the CABG grafts was 93.3% (left ITA: 100%, right ITA: 84.6%, sapenous vein: 90.9%, gastro-epiploic artery: 100%), and six-month restenosis rate for PCI was 57.1% (balloon angio-plasty: 75%, bare metal stent 40%, DES: 58.3%). Even in the era of DES, clinical results favored CABG. The difference in clinical results is due to the sustainability of successful revascularization.

Background It is generally considered that patients with prior myocardial infarction (PMI) have worse outcomes than those without PMI after coronary artery bypass grafting (CABG). However, any difference in outcomes of patients with anterior or inferior PMI undergoing CABG has never been determined. Methods We retrospectively reviewed the records of 310 patients with anterior or inferior PMI who underwent isolated CABG between September 2004 and September 2008. Of these, 151 patients had anterior PMI (anterior group), and 159 patients had inferior PMI (inferior group). Preoperative and postoperative variables were compared between the groups. Multivariate logistic regression analysis was used to identify independent predictors of major postoperative complications including death. Results Patients of the inferior group were significantly older (68.3 ± 9.2 vs 65.5 ± 11.0; p = 0.015) and had more diseased vessels per patient (2.9 ± 0.3 vs 2.8 ± 0.5; p = 0.009) than the anterior group. A higher rate of mild or moderate mitral regurgitation was observed in the inferior group (18.2% vs 8.6%; p = 0.0209). The operative mortality was higher in the inferior group (5.0% vs 0%; p = 0.0073). Rates of respiratory failure (6.9% vs 0.7%; p = 0.0199) and requirement for hemodialysis (5.7% vs 0.7%; p = 0.0056) were higher in the inferior group. Multivariate analysis revealed inferior PMI ( p = 0.0068) as the only independent predictor of major postoperative complications including death. Conclusions The present study indicates that patients with inferior PMI have poorer outcomes after isolated CABG than those with anterior PMI.

Objective: It is well known that the presence of carotid artery stenosis increases the risk of perioperative stroke in patients undergoing cardiac surgery with cardiopulmonary bypass. Although off-pump coronary artery bypass grafting (CABG) can avoid the adverse effects of cardiopulmonary bypass, the influence of carotid artery stenosis on the incidence of stroke in patients undergoing off-pump CABG has not been well clarified.Methods:We conducted a retrospective study of 461 patients who underwent elective off-pump CABG after screening for carotid artery stenosis at our institute between September 2004 and May 2007. The incidence and etiologies of stroke were identified. Preoperative screening revealed significant carotid artery stenosis in 49 patients. Clinical results were compared between patients with and without carotid artery stenosis. Results: Postoperative stroke occurred in two (0.43%) of the 462 study patients, and in-hospital mortality occurred in three (0.65%). Stroke was due to decreased perfusion resulting from hypovolemic shock in one and thrombosis in the other. There was neither stroke nor inhospital mortality in patients with carotid artery stenosis, although there were two strokes (0.49%) and three in-hospital mortalities (0.73%) in patients without carotid artery stenosis. Conclusions: The influence of carotid artery stenosis on the incidence of perioperative stroke may be little in off-pump CABG, especially in patients with moderate carotid artery stenosis. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Background Surgery for acute type B aortic dissection is associated with significant mortality and morbidity. The purpose of this study was to assess the clinical outcome of surgical management of complicated acute type B aortic dissection. Methods During the last 5 years, 112 patients were admitted for acute type B aortic dissection. Of these patients, 24 consecutive patients were enrolled who underwent surgical management during the acute or subacute stage. The mean age was 66.7 ± 9.1 years; 8 patients were female. Indications for surgery were rupture in 10 patients, impending rupture in 7, and malperfusion in 7. Fifteen patients were transferred from another hospital. The overall clinical outcome including morbidity, aorta-related events, and death were retrospectively assessed. Results The mean duration from the time of onset to surgery was 7.1 ± 9.0 days. Graft replacement of the aorta included the total aortic arch with cerebral perfusion in 6 patients, and replacement of the distal aortic arch or descending aorta with left heart bypass in 12. The remaining 6 patients underwent peripheral bypass for ischemia. Significant complications occurred in 7 patients (24.8%). The operative mortality rate was 8.3% (2 of 24); 5.6% (1 of 18) with central operation and 16.7% (1 of 6) with peripheral operation. The 5-year survival rate was 82.6 ± 7.9% and freedom from aorta-related events at 1 and 5 years were 95.2% ± 4.7% and 68.0% ± 16.6%, respectively. Conclusions Surgical management of patients with complicated acute type B dissection has an acceptable perioperative risk and survival. This study suggests earlier surgery with left heart bypass may be beneficial for appropriate patients.

Background Exercise intolerance of the hand after harvest of the radial artery is not well understood, although mild reductions of blood flow to the hand are reported. To ascertain its prevalence, patient symptoms implying potential exercise intolerance were evaluated by measuring transcutaneous oxygen pressure of the hand during grip exercise. For ascertaining predictive values, we verified ulnar flow reserve measured by Doppler ultrasonography before the harvest of radial artery. Methods Forty patients whose radial artery was harvested for coronary bypass graft, were interviewed and tested 1 year after operation, and their preoperative ultrasonographic data compared. Results Five patients (12.5%) had mild symptoms implying exercise intolerance. Exercise tests revealed severe decreases in tissue oxygenation in 7 patients (17.5%), but in accordance with symptoms ( p = 0.0018). Tissue oxygenation in the operated hand was lower than in the nonoperated even in asymptomatic patients ( p = 0.0011). Preoperative Doppler echography revealed that ulnar arteries of symptomatic patients were smaller ( p = 0.0019) and carried lower blood flows during manual compression of the radial artery ( p = 0.0004) compared with those of asymptomatic patients. Smaller ulnar arteries (less than 1.4 mm/m 2 ) with poor flow reserves (less than 60 mL · min −1 · m −2 during radial compression) appear to indicate risks for exercise intolerance ( p = 0.0004). Conclusions More than 10% of patients after harvest of radial arteries had mild symptoms implying exercise-intolerance, which accorded with abnormal tissue oxygenation during grip exercise. Work habits of patients should be considered in radial harvest decisions, especially if preoperative Doppler echography indicates lower flow reserves for the ulnar artery.

腹部大動脈瘤(AAA),虚血性心疾患(CAD)両疾患26例に外科的治療を行った.平均年齢72.6±3.7歳,男性21例,女性5例,AAAの平均最大径は58.0±12.7mmであった.11例は一期的手術を,15例は二期的手術を行った.一期的手術群では4例でon pump CABGを,high risk症例3例を含む7例でoff pump CABGを行った.手術死亡はなく,術後急性腎不全,肺炎,呼吸不全を認めた.二期的手術群にも手術死亡なく,1例に急性腎不全を認めた.待機中のAAA破裂はないが,巨大瘤症例2例で切迫破裂により緊急手術を行った.全身状態良好例の一期的手術の治療成績は良好であり,積極的な施行が望ましいと思われた.High risk症例においても,AAA治療に緊急を要する例などでは,off pump CABGを用いた一期的手術は可能と思われた.

透析患者11例(血液透析(HD)患者8例,腹膜透析(PD)患者3例)の心臓手術を経験した.年齢は36歳から73歳(平均57.3歳),男性7例,女性4例,透析期間は1～19年の平均5.6年,疾患は弁膜症1例,虚血性心疾患10例であった.透析管理方法として,術前はHD患者では前日に通常どおりの透析を行い,PD患者においては前日まで通常どおりPDを行った.術中は血液濾過を行い,術後はHD患者では第1病日よりHDを行い,その後は隔日でHDを行った.PD患者ではICU帰室早期よりPDを再開した.HD患者では初回透析時に低血圧をきたす傾向が認められたが,カテコラミン投与,アルブミン負荷にて対応可能であった.HD群,PD群ともに,尿毒症性毒素の除去,電解質濃度,酸塩基平衡いずれも良好にコントロールできた.手術死および在院死はなく,平均入院日数は41.0日であり,ほぼ満足できる成績が得られた.

Heterogeneous double cardiac tumor is rarely encountered. We present a case of simultaneous resection of myxoma and papillary fibroelastoma. Transesophageal echocardiography showed typical characteristics of each tumor. The myxoma was completely excised with a surgical margin, and the papillary fibroelastoma was shaved, preserving the cusp of the aortic valve. Pathohistologic examination confirmed the diagnosis. We discuss the echocardiographic characteristics and preferred surgical approaches for the two tumors.(J Card Surg 2010;25:35-37)

1991年より1995年までの6年間に経験した胸部および腹部の真性重複大動脈瘤8症例を対象として治療手順などについて検討を加えた. 男性6例, 女性2例で, 年齢は50歳から73歳までの平均65.6歳であった. 大動脈瘤における重複大動脈瘤の頻度は10%と比較的多く, 全大動脈瘤患者に対し大動脈全長の検索を施行すべきと思われた. 治療は5症例に対し胸部, 腹部のいずれにも手術を行い, 2症例に対して腹部のみ, 1症例に対しては胸部のみ手術を行った. 二期的手術では1症例のみ胸部手術を優先し, 4症例で腹部手術を優先した. 二期的手術患者の待機中の動脈瘤の破裂はなかった. 手術の優先順位は破裂の頻度の高いものから行うのが原則であるが, 破裂の危険性が同程度であれば残存動脈瘤の破裂と血栓遊離による脳梗塞に配慮して, 胸部大動脈瘤の大きさと部位から手術順位を決定することが重要であると考えられた.

OBJECTIVES: The systolic anterior motion (SAM) of mitral valves occurs at a certain rate despite the introduction of several preventive procedures. The purpose of this study was to investigate its mechanism by analysing the change in mitral valve morphology associated with operative procedures. METHODS: Components of mitral valves were measured before and after operative procedures by transoesophageal echocardiography in 179 patients who underwent mitral valve repair. Comparisons were made between 15 patients with SAM (SAM group) and 164 patients without SAM (non-SAM group). RESULTS: Morphological analysis in all the studied patients revealed that operative procedures shifted the coaptation point towards the left ventricular outflow tract by 6.9 mm and increased the extra portion of anterior leaflet that extended beyond the coaptation point by 5.4 mm. These changes were enhanced in the SAM group. Intergroup comparison revealed that there were no differences in the preoperative mitral valve morphologies between the two groups. After operative procedures, however, the SAM group showed smaller annular diameter and smaller coapted anterior/posterior length ratio compared with the non-SAM group. CONCLUSIONS: The results of this study show that operative procedures might modify the morphology of mitral valves susceptible to developing SAM. Postoperative smaller annular diameter and anterior shift of coaptation point were considered to contribute to the development of SAM.

ObjectiveA hyperkinetic heart has been suggested as a risk factor for systolic anterior motion (SAM) after mitral valve repair, but the influence of preoperative left ventricular (LV) function on the development of SAM has not been elucidated.MethodsTransthoracic echocardiographic data were retrospectively reviewed in 441 patients who underwent mitral valve repair for degenerative mitral regurgitation. Comparisons were made between patients with and without SAM (SAM cases vs noncases).ResultsThe incidence of SAM was 6.1% (27/441). There were no differences in preoperative characteristics and operative procedures between the 2 groups except the prevalence of Barlow disease. The SAM cases exhibited a higher preoperative ejection fraction (EF) (SAM cases, 70.0% ± 7.1%; noncases, 65.1% ± 6.9%; P 45 mm) LV. The incidence of SAM was highest among patients with a small hyperkinetic heart.ConclusionsThe study indicates that the development of SAM after mitral valve repair is associated with preoperative LV function. A small hyperkinetic heart is considered a risk factor for SAM and should be treated with caution.

Background There are many options for proximal anastomosis during off-pump coronary artery bypass grafting (CABG), but the efficacies of these procedures have not been well clarified. Therefore, we examined the clinical impact of our strategy to modify the proximal anastomosis procedure for aortic atherosclerosis. Methods We retrospectively reviewed 535 consecutive patients undergoing off-pump CABG between 2004 and 2007. The patients were divided into three groups depending upon the type of proximal anastomosis procedure: 241 patients with normal or mild atherosclerosis underwent partial clamping (clamp group), 81 patients with moderate atherosclerosis underwent the procedure with Heartstring (Guidant Corporation, Santa Clara, CA, USA), 28 patients underwent with Enclose II (Novare Surgical Systems, Inc., Cupertino, CA, USA) (device group), and 185 patients underwent the procedure without clamping, including six with severe atherosclerosis (no-touch group). Results There were seven in-hospital mortalities (1.3%) and five strokes (0.9%). There was no difference in the mortality rate (clamp, 1.2%; device, 1.8%; no-touch, 1.1%; p = 0.42) or stroke rate (clamp, 0.8%; device, 2.8%; no-touch, 0.5%; p = 0.09) among the three groups. Graft patency was similar regardless of the method (clamp, 94.7%; Heartstring, 96.7%; Enclosed II, 96.0%; p = 0.80). Conclusions Our strategy to modify the proximal anastomosis procedure resulted in a low stroke rate. Aortic clamping could be performed safely in patients with normal or mild atherosclerotic aorta. In patients with moderate atherosclerosis, the result of an anastomotic device may need a further investigation.

ObjectiveSome arterial grafts have progressive narrowing or occlusion during the first postoperative year despite angiographic patency in the immediate postoperative period. This study analyzed the incidence and predictors of arterial graft deterioration.MethodsWe reviewed 778 distal anastomoses of arterial grafts in 243 patients who underwent off-pump coronary artery bypass grafting. All patients underwent both early and 1-year follow-up coronary angiography, with all arterial grafts patent on the early angiograms. Arterial graft deterioration was defined as diffuse graft stenosis or occlusion newly found at 1-year follow-up angiography.ResultsGraft deterioration was present in 13.8% (string sign, 6.9%; occlusion, 6.8%) of distal anastomoses. The incidence of graft deterioration was higher among cases of non–internal thoracic arterial graft (27.7% vs 6.0%, P

Background In patients with mitral endocarditis, reconstruction of the damaged mitral valve (MV) is still challenging, and its durability remains unknown. We evaluated the long-term outcomes of MV repair for mitral regurgitation (MR) in patients with infective endocarditis. Methods From 1991 to 2006, 633 patients had MV repair for MR caused by leaflet prolapse: 78 had endocarditis (active in 14, healed in 64) and 555 had degenerative disease. Durability was assessed by reoperation and recurrent MR. Results The overall hospital mortality rate was 1.0% (endocarditis 0% vs degenerative 1.1%; p = 0.99). The 10-year survival and freedom from reoperation were 91.1 ± 1.6% and 92.2 ± 1.7%, respectively, with no differences between endocarditis and degenerative disease. Older age, New York Heart Association class III or IV, impaired ventricular function, and no use of annuloplasty were independent predictors of all-cause death. Freedom from moderate or severe MR was 99.8 ± 0.2% at 2 weeks, 91.9 ± 1.5% at 5 years, and 83.3 ± 2.3% at 10 years, for all patients and did not differ between groups at 10 years ( p = 0.388). Anterior leaflet prolapse, preoperative atrial fibrillation, and no annuloplasty were independent predictors of recurrent MR. In endocarditis patients, recurrent MR was mainly caused by leaflet thickening and calcification, but not by recurrence of endocarditis. Conclusions MV repair for endocarditis is associated with low operative mortality and morbidity, and its long-term durability is comparable with that of repair for degenerative disease. This study suggests that a degenerative process causes late failure after MV repair for endocarditis.

Background To avoid complications related to aortic manipulation, devices were developed to perform clampless anastomosis. However, there are few studies concerning the late patency of the graft. The aims of this study were to investigate the patency rate of saphenous vein (SV) graft after off-pump coronary artery bypass grafting (OPCAB) and to evaluate the influence of a clampless hand-sewn proximal anastomosis on late graft patency. Methods Patients (n = 232) were enrolled who underwent OPCAB with SV grafts from 2004 to 2007 and had follow-up angiography. For proximal anastomoses, a clampless device was used in 73 (group A; HEARTSTRING [Guidant Corporation, Santa Clara, CA] in 54, Enclose II [Novare Surgical Systems, Inc, Cupertino, CA] in 19), and partial clamping was used in 159 (group B). The proximal anastomosis procedure was modified according to the results of epiaortic ultrasonography. Coronary angiography was performed early (11.8 ± 10.4 days) and one-year postoperatively (n = 180, 371.5 ± 102.6 days). Results There were no significant differences in patient characteristics between the two groups except for a higher reoperation rate in group A. The overall SV patency rate at the early and one-year postoperative angiography was 95.7% and 83.0%, respectively. The patency rates were similar between the two groups (early: 97.3% vs 98.1%, p = 0.729; 1 year: 87.0% vs 81.3%, p = 0.316). There was also no significant difference in the target vessel revascularization rate during follow-up (6.8% vs 10.1%, p = 0.623). Conclusions Intermediate-term angiographic follow-up demonstrate an acceptable SV patency rate after OPCAB. The SV patency rate with a clampless device for proximal anastomosis is comparable with that with partial clamping during the first postoperative year.

There have been several reports of a malpositioned pacemaker lead as a complication in pacemaker implantation. Herein we report a rare case of a malpositioned pacemaker lead in the left ventricle, which could occur in patients with cardiac structural abnormalities. A 70-year-old woman, who had undergone implantation of a pacemaker at the left subclavian position for complete atrioventricular block five years previously, was evaluated because of dyspnea and low grade fever. Echocardiography revealed a congenital atrial septal defect through which the lead was placed into the left ventricle. Whereas percuteneous lead removal seemed to be full of risk with concerns of thromboembolic events and infective endocarditis, the patient was referred to our hospital for surgical removal of the wire and closure of the defect. The lead was a screw-in type and removed and was extracted in the theatre using radiography. Intraoperatively it was found that the lead was positioned in the left ventricle apex after perforating the posterior mitral leaflet. Repair of the mitral valve perforation and closure of the septal defect and epicardial pacemaker lead implantation was performed. This case demonstrated the possibility of malposition of the pacemaker lead to the left ventricle in a transvenous pacemaker implantation procedure, which may lead to thromboembolic complication or infective endocarditis, and the pre-eminent role of echocardiography in the diagnosis of cardiac structural abnormalities. A malpositioned pacemaker lead in the left ventricle is a rare complication that can occur in patients with cardiac structural abnormalities. Lateral chest roentgenogram and echocardiography is efficient in preventing this complication. The removal of the lead in concerns of thromboembolic events and infection is preferable.

Objectives: Despite the long-term benefit, the operative results of conventional coronary artery bypass grafting for chronic hemodialysis patients remain unsatisfactory. The efficacy of off-pump coronary artery bypass grafting for hemodialysis patients is yet to be determined. The purpose of this study was to investigate the postoperative physiology of off-pump coronary artery bypass grafting for hemodialysis patients. Methods: Twenty-five hemodialysis cases who underwent isolated coronary artery bypass grafting were reviewed. Fifteen of these patients underwent off-pump coronary artery bypass grafting (off-group) and 10 underwent on-pump coronary artery bypass grafting (on-group). Comparisons were made in cardiac function (cardiac index and stroke volume index), respiratory function (AaDO2), hemodialysis management (blood urea nitrogen, creatinine, right atrial pressure, pulmonary wedge pressure), and bleeding tendency (postoperative blood loss and blood transfusion). Results: There was no operative mortality, but 3 major postoperative complications occurred (2 sternal wound infections in the off-group and 1 pneumonia in the on-group). There was no difference in cardiac index or stroke volume index. AaDO2 was significantly lower in the off-group. Plasma concentrations of blood urea nitrogen and creatinine were similar between groups. Right atrial pressure was lower and pulmonary wedge pressure tended to be lower in the off-group. Postoperative bleeding and blood transfusion were similar between groups. Conclusion: Our study confirmed that off-pump coronary artery bypass grafting is feasible for hemodialysis patients. Physiologic data showed that off-pump coronary artery bypass grafting might be effective in preserving postoperative lung oxygenation.

The radial artery (RA) is gaining popularity as a bypass conduit for coronary artery bypass grafting, and its impact on clinical practice has been extensively explored. In the present article, we provide a review of postoperative hand circulation, vascular biological characteristics of the RA graft, the efficacy of vasodilator therapies, and mid-term clinical results of use of the RA graft. Fundamental studies revealed excellent vascular biological characteristics of the RA graft as a living arterial conduit, making it almost equivalent to the internal thoracic artery (ITA) graft. Clinical studies have yielded encouraging mid-term results. Most studies reported in favor of the RA graft over the saphenous vein graft with regard to patency rate, freedom from cardiac events, and survival. However, superiority of either the RA or right ITA graft has not been conclusively determined. The long-term results of RA grafts remain unknown, but at present, supplementary use of an RA graft with a left ITA graft appears feasible for CABG.

Background Despite a negative Allen test, some patients develop hand ischemia after radial artery harvesting. The presence of large interosseous collaterals may reduce the sensitivity of Allen test. To evaluate the combination of ulnar flow measurements and the Allen test as an effective screening technique, we performed Doppler ultrasonography during Allen's maneuver. Methods The Allen test was used to select candidates for harvesting radial artery from 80 patients undergoing coronary bypass surgery. Results Of 71 patients with a negative Allen test, one patient developed hand ischemia. This patient was one of six (7.5 %) possessing low ulnar flow levels (less than 40 ml/min/m(2) during compression of the radial artery). This low-flow group had a higher risk for ischemia of the 71 patients with a negative Allen test. The post-operative flow differed greatly from the pre-operative flow in eight patients (11.3 %), which was likely due to large sacrificed interosseous collaterals. Conclusion Combined use of ulnar flow measurement with the Allen test appears to increase the sensitivity of the Allen test. Neither test, however, is sufficient for a group of patients with large interosseous collaterals.

Background: Coronary shunts are widely used to prevent myocardial ischemia during off-pump coronary artery bypass graft (OPCAB) procedures. Although clinical effectiveness has been reported, actual perfusion flow has not been well assessed. The purpose of this study was to evaluate actual shunt flow and its pattern during passive coronary perfusion in clinical OPCAB. Methods: In 15 OPCAB cases, the coronary perfusion flow of the external shunt (1.7 or 2.0 mm) during anastomosis and the free flow of the shunt were measured with an in-line electromagnetic or ultrasonic flow probe. The perfused coronary blood vessel was either the left anterior descending coronary artery or the right coronary artery. The inflow vessel of the external shunt was either the femoral artery (FA) or the ascending aorta (AA). Results: Free flow values of a 1.7-mm FA shunt, 1.7-mm AA shunt, and 2.0-mm FA shunt were 34 ± 7, 39 ± 3, and 44 ± 7 mL/min. Perfusion flows were 13 ± 4, 14 ± 3, and 22 ± 4 mL/min, respectively. Perfusion flow was significantly lower than free flow and correlated well with coronary resistance. Although inflow site did not influence net perfusion flow, diastolic/systolic flow fraction ratio was significantly greater when the shunt was perfused from the FA. Conclusions: External shunt from FA would provide limited but effective perfusion flow with a physiological pattern, which is passively regulated by coronary resistance.