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Introduction: We hypothesized that perioperative fibrinogen level, platelet count, and rotational thromboelastometry (ROTEM) data values decrease in proportion to cardiopulmonary bypass (CPB) time, particularly in patients who underwent deep hypothermic circulatory arrest (DHCA). Methods: A total of 160 patients were enrolled and divided into the following three groups depending on CPB time: <2-h, 2– 3-h, and >3-h groups. Blood samples were obtained during CPB weaning. Platelet count, ROTEM data, fibrinogen level, and antithrombin level were determined. For propensity matching, we selected 15 patients who underwent DHCA and 15 patients who did not undergo DHCA and used propensity scores to match CPB time and other characteristics. Results: The <2-h, 2–3-h, and >3-h groups included 74, 63, and 23 patients, respectively. No significant differences in platelet count and fibrinogen level were observed between the groups. Antithrombin level and amplitude of clot firmness at 10 min in the EXTEM and FIBTEM tests were lowest in the >3-h group. Similarly, blood loss volume and transfusion volume were highest in the >3-h group. Significant differences in platelet count, ROTEM data, lowest esophageal and bladder temperatures, and transfusion volume were observed between patients who underwent DHCA and patients who did not undergo DHCA. Conclusions: The longer the CPB time, the greater the perioperative blood loss volume and transfusion volume, particularly if CPB time is greater than 3 hours. Sub-group analysis revealed that DHCA affects perioperative platelet count and function as well as blood loss volume. [ABSTRACT FROM AUTHOR]

Although intraoperative intravenous fluids are commonly administered to reverse intraoperative hypotension during cardiac surgery, the appropriate volume remains unclear. This study aimed to evaluate the relationship between the intraoperative fluid balance and sequential organ failure assessment (SOFA) score in patients undergoing cardiac surgery to determine the impact of intraoperative intravenous fluids on their organs. This was a post hoc analysis using data from a multicenter, retrospective, observational study across 14 intensive care units (ICUs) in Japan. Adult patients admitted to ICUs after elective coronary artery bypass grafting or valve surgery from January 1 to December 31, 2018 were enrolled. We compared patients with intraoperative fluid balance < 20 ml/kg to those with fluid balance ≥ 20 ml/kg and conducted a multiple regression analysis for the SOFA score within 24 h of ICU admission. Of the 1567 included patients, 870 met the eligibility criteria. A total of 725 patients (83%) had an intraoperative fluid balance of ≥ 20 ml/kg. In the univariate analysis, the SOFA score (interquartile range) was 7 (6–8) and 7 (6–9) in the intraoperative fluid balance < 20 ml/kg and ≥ 20 ml/kg groups, respectively (p = 0.017). Multiple regression analysis showed a positive association between intraoperative fluid balance and SOFA score within 24 h of ICU admission [standardized coefficient 0.0065 (95% confidence interval 0.0036–0.0095), p < 0.001]. Intraoperative fluid balance in patients undergoing cardiac surgery was significantly associated with higher SOFA scores within 24 h of ICU admission. [ABSTRACT FROM AUTHOR]

Sutureless offers an alternative to standard valves in surgical aortic valve replacement (SAVR). We sought to confirm the efficacy and safety of the Perceval sutureless valve in Japanese patients. Prospective observational study of 204 patients who underwent SAVR with Perceval at 19 sites in Japan between March and December 2019. The primary outcomes were 30-day mortality and postoperative complications; the secondary outcome was all-cause mortality at 1 year. Efficacy outcomes were changed in New York Heart Association (NYHA) class, pressure gradients, effective orifice area (EOA), EOA indexed to body surface area (EOAi) and severity of aortic regurgitation. Mean age was 77.7 years, 62.7% were female. Procedural success rate was 99.0%. The median cross-clamp and cardiopulmonary bypass times were 68.0 and 108 min. Perceval size S and M were implanted in 95 (46.6%) and in 76 (37.3%) of patients, respectively. The 30-day and late mortality rate were 0.5% and 4.4%, while the new permanent pacemaker implantation rate was 4.4%. Mean pressure gradient was 13.0 mmHg at discharge, reaching 11.0 mmHg at 1 year; while the mean EOA was 1.5 cm2 at discharge remaining stable up to 1 year. No moderate or severe leakages were present at discharge or at 1 year. NYHA class improved by ≥ 1 level in 55.1% of the patients at discharge and in 69.4% of the patients at 1 year. 1-year outcomes of SAVR with the Perceval sutureless valve in Japanese patients were favorable. This valve offers a promising alternative to conventional biological AVR in this Japanese population. [ABSTRACT FROM AUTHOR]

Background: Evaluating patients' risk for acute kidney injury (AKI) is crucial for positive outcomes following cardiac surgery. Our aims were first to select candidate risk factors from pre- or intra-operative real-world parameters collected from routine medical care and then evaluate potential associations between those parameters and risk of onset of post-operative cardiac surgery-associated AKI (CSA-AKI). Method: We conducted two cohort studies in Japan. The first was a single-center prospective cohort study (n = 145) to assess potential association between 115 clinical parameters collected from routine medical care and CSA-AKI (≥ Stage1) risk in the population of patients undergoing cardiac surgery involving cardiopulmonary bypass (CPB). To select candidate risk factors, we employed random forest analysis and applied survival analyses to evaluate association strength. In a second retrospective cohort study, we targeted patients undergoing cardiac surgery with CPB (n = 619) and evaluated potential positive associations between CSA-AKI incidence and risk factors suggested by the first cohort study. Results: Variable selection analysis revealed that parameters in clinical categories such as circulating inflammatory cells, CPB-related parameters, ventilation, or aging were potential CSA-AKI risk factors. Survival analyses revealed that increased counts of pre-operative circulating monocytes and neutrophils were associated with CSA-AKI incidence. Finally, in the second cohort study, we found that increased pre-operative circulating monocyte counts were associated with increased CSA-AKI incidence. Conclusions: Circulating monocyte counts in the pre-operative state are associated with increased risk of CSA-AKI development. This finding may be useful in stratifying patients for risk of developing CSA-AKI in routine clinical practice. [ABSTRACT FROM AUTHOR]

At facilities where the number of cases of cardiopulmonary bypass(CPB) is less than 100 per year, which accounts for 60％ of the cardiac surgery facilities in Japan, it is difficult to acquire and maintain the operation technique of CPB by the open circuit. Therefore, a valve-type semi-closed extracorporeal circulation (VACC) system was devised. In the VACC, which is a closed circuit like ECMO (extracorporealmembrane oxygenation), the volume control reservoir(VR)is connected to the venous circuit via a check valve as a safety valve. The safety valve opens and closes depending on the pressure gradient between the VR which is under negative pressure and the venous circuit. As a result, the VACC can be switched between an open circuit and a closed circuit. For the purpose of improving safety in the case of air entering the venous circuit, which is the weakness of the closed circuit, water experiments to simulate an accidental venous decannulation were conducted. In the VACC, like the open circuit, when one of the two venous cannulas was decannulated, an air lock occurred. That is a phenomenon in which venous drainage and air movement are stagnant due to being obstructed by the siphon effect of a mass of air in the venous circuit. The safety valve was open when an air lock occurred, and it was easy for it to occur when the negative pressure was weaker. If a venous cannula is decannulated, the negative pressure in the venous circuit will be augmented, and then the pressure in the venous circuit will be limited to the pressure in the VR. Therefore, the suction power of a mass of air is reduced, and air movement is stagnant. As a result, an air lock occurs. When using a closed circuit, venous decannulation causes a large amount of air entering. On the other hand, the VACC can control air behavior in the venous circuit by adjusting the pressure in the VR; for example, by opening the VR to atmospheric pressure. [ABSTRACT FROM AUTHOR]

The risk factors and the appropriate interventions for perioperative junctional ectopic tachycardia (JET) in congenital heart disease (CHD) surgery have not been sufficiently investigated despite the severity of this complication. This study aimed to examine the risk factors and interventions for perioperative JET. From 2013 to 2020, 1062 surgeries for CHD (median patient age: 4.3 years, range 0.0–53.0) with or without a cardiopulmonary bypass (CPB) were performed at Hokkaido University, Japan. We investigated the correlation between perioperative JET morbidity factors, such as age, genetic background, CPB/aortic cross-clamp (ACC) time, use of inotropes and dexmedetomidine, STAT score, and laboratory indices. The efficacy of JET therapies was also evaluated. Of the 1062 patients, 86 (8.1%) developed JET. The 30-day mortality was significantly high in JET groups (7% vs. 0.8%). The independent risk factors for JET included heterotaxy syndrome [odds ratio (OR) 4.83; 95% confidence interval (CI) 2.18–10.07], ACC time exceeding 90 min (OR 1.90; CI 1.27–2.39), and the use of 3 or more inotropes (OR 4.11; CI 3.02–5.60). The combination of anti-arrhythmic drugs and a temporary pacemaker was the most effective therapy for intractable JET. Perioperative JET after CHD surgery remains a common cause of mortality. Inotrope use was a risk factor for developing JET overall surgery risk. In short ACC surgeries, heterotaxy syndrome could increase the risk of JET, which could develop even without inotrope use in long ACC surgeries. It is crucial not to delay the treatment in cases with unstable hemodynamics caused by this arrhythmia. It is recommended to reduce numbers not dose of inotropes. [ABSTRACT FROM AUTHOR]

Context: Postoperative hyperthermia, which may lead to cognitive decline, is a common complication of cardiovascular surgery with cardiopulmonary bypass (CPB). Aims: The aim of this study was to examine the effectiveness of perioperative intravenous acetaminophen on body temperature in adult patients after cardiovascular surgery with CPB. Settings and Design: This was a single-center retrospective study focusing on adult patients who underwent elective cardiovascular surgery with CPB at a university hospital in Japan. Subjects and Methods: Patients were divided into two groups based on whether they received acetaminophen perioperatively. In the acetaminophen group, 15 mg/kg intravenous acetaminophen solution was infused at 30 min after discontinuation of CPB and every 6 h after intensive care unit (ICU) admission. Statistical Analysis Used: The primary outcome was the maximum axillary temperature within 12 h after ICU admission. The effects of acetaminophen on postoperative body temperature were estimated by the standardization and inverse probability weighting using propensity scores. Results: A total of 201 patients were included in the final analysis (acetaminophen group, n = 101; non-acetaminophen group, n = 100). The maximum axillary temperature within 12 h after ICU admission was 37.20 ± 0.54 C in the acetaminophen group and 37.78 ± 0.59 C in the non-acetaminophen group. Acetaminophen lowered the standardized mean of primary endpoint (0.54 C, 95% confidence interval, 0.69 to 0.38) compared to non-acetaminophen. Conclusions: Perioperative intravenous acetaminophen inhibited body temperature elevation after cardiovascular surgery with CPB, compared with the non-acetaminophen group. [ABSTRACT FROM AUTHOR]

Context: Postoperative hyperthermia, which may lead to cognitive decline, is a common complication of cardiovascular surgery with cardiopulmonary bypass (CPB).Aims: The aim of this study was to examine the effectiveness of perioperative intravenous acetaminophen on body temperature in adult patients after cardiovascular surgery with CPB.Settings and Design: This was a single-center retrospective study focusing on adult patients who underwent elective cardiovascular surgery with CPB at a university hospital in Japan.Subjects and Methods: Patients were divided into two groups based on whether they received acetaminophen perioperatively. In the acetaminophen group, 15 mg/kg intravenous acetaminophen solution was infused at 30 min after discontinuation of CPB and every 6 h after intensive care unit (ICU) admission.Statistical Analysis Used: The primary outcome was the maximum axillary temperature within 12 h after ICU admission. The effects of acetaminophen on postoperative body temperature were estimated by the standardization and inverse probability weighting using propensity scores.Results: A total of 201 patients were included in the final analysis (acetaminophen group, n = 101; non-acetaminophen group, n = 100). The maximum axillary temperature within 12 h after ICU admission was 37.20 ± 0.54°C in the acetaminophen group and 37.78 ± 0.59°C in the non-acetaminophen group. Acetaminophen lowered the standardized mean of primary endpoint (-0.54°C, 95% confidence interval, -0.69 to -0.38) compared to non-acetaminophen.Conclusions: Perioperative intravenous acetaminophen inhibited body temperature elevation after cardiovascular surgery with CPB, compared with the non-acetaminophen group. [ABSTRACT FROM AUTHOR]

Objective: Heparin resistance is often encountered during cardiopulmonary bypass. Heparin dose and activated clotting time target values for the initiation of cardiopulmonary bypass are not yet universally standardized; further no consensus exists on the management of heparin resistance. This study aimed to investigate the current real-world practice on heparin management and anticoagulant treatment for heparin resistance in Japan., Methods: A questionnaire survey was conducted at medical institutions nationwide with which The Japanese Society of Extra-Corporeal Technology in Medicine members are affiliated, targeting surgical cases with cardiopulmonary bypass performed from January 2019 through December 2019., Results: Among 69% (230/332) of the participating institutions, the criterion for heparin resistance was defined as "the target activated clotting time value not reached even with an additional dose of heparin administration". Cases of heparin resistance were reported in 89.8% (202/225) of the responded institutions. Of note, 75% (106/141) of the responded institutions reported heparin resistance associated with antithrombin activity ≥ 80%. Antithrombin concentrate was used in 38.4% (238/619 responses) or third dose of heparin in 37.8% (234/619 responses) for advanced heparin resistance treatment. Antithrombin concentrate was found to be effective in resolving heparin resistance in patients having normal, as well as lower antithrombin activity., Conclusion: Heparin resistance has occurred in many cardiovascular centers, even among patients with normal antithrombin activities. Interestingly, the administration of antithrombin concentrate resolved heparin resistance, regardless of the baseline antithrombin activity value., (© 2023. The Author(s).)

Introduction: We have been developing a closed-circuit cardiopulmonary bypass (CPB) system ("Dihead CPB") for application during coronary artery bypass grafting (CABG) and valve surgery. To strive for minimal hemolysis during Dihead CPB, we compared the hemolysis caused by three different suction systems and performed a clinical study with the newly applied suction system. Materials & Methods: We evaluated the hemolysis caused by roller-pump suction, the SmartSuction® Harmony® and wall suction systems with respect to suction speed and compared the systems by means of in vitro studies. A clinical study was also performed on 15 volunteers to assess hemolysis and the adequacy of the newly applied suction system with Dihead CPB. Results: Pressure inside the suction cannula was −22.5 ± 0.1 mmHg at a maximum flow of 1.5 L/min for roller-pump suction and −43.4 ± 0.1 mmHg at −150 mmHg of the set vacuum pressure of wall suction. With the SmartSuction, the pressure inside the cannula varied from −76.3 ± 1.0 to −130.3 ± 1.5 mmHg, depending on suctioning conditions. Suction speed (to suction 50 ml of blood) was fastest with the SmartSuction (69.7 ± 3.58 s) whereas, with roller suction, it was 117.3 ± 8.47 s and with wall suction 96.9 ± 7.10 s. The SmartSuction had the highest hemolysis rate (2.00 ± 0.33%) vs. 0.61 ± 0.10% for roller suction and 0.41 ± 0.11% for wall suction (p<0.001). The clinical study with wall suction showed no significant increase in plasma free hemoglobin during or after CPB compared with before surgery. Conclusions: Wall suction had less hemolysis than roller suction or the SmartSuction in the in vitro study and the clinical study with wall suction showed efficient suction speed and acceptable hemolysis, suggesting that Dihead CPB with wall suction is feasible for CABG. [ABSTRACT FROM AUTHOR]

It is important to avoid unnecessary blood cell transfusion. However, the associations of hemodilution and retrograde autologous priming with red blood cell transfusion during and after cardiopulmonary bypass (CPB) in cardiac surgery in Japan are currently unclear. We analyzed these associations using data for 3,090 adults from the Perfusion Case Database of the Japanese Society of Extra-Corporeal Technology in Medicine. Percent hemodilution was calculated by total priming volume and weight. Logistic regression models were used to adjust for covariates including type of surgery, gender, age, hemoglobin concentration before CPB, CPB time, urine volume during CPB, and institution. The percentages of red blood cell transfusions during CPB for patients with <15, 15 to <20, 20 to <25, 25 to <30, and ≥30% hemodilution were 43.0, 51.5, 68.9, 77.3, and 87.7%, respectively. This increase in line with increasing dilution was significant after adjusting for covariates. The percentage of red blood cell transfusion after CPB also increased slightly between 39.0 and 49.4% with percent hemodilution, but the trend after adjusting for covariates was not significant. Use of retrograde autologous priming was significantly associated with blood cell transfusion during CPB after adjusting for covariates, but was not significantly related to blood cell transfusion after CPB. These results suggest that optimizing the percent hemodilution and use of retrograde autologous priming might reduce the use of red blood cell transfusion during CPB in clinical practice in Japan. [ABSTRACT FROM AUTHOR]

Introduction: The substantial interpatient variability in heparin requirement has led to the use of a heparin dose response (HDR) technique. The accuracy of Hepcon-based heparin administration in achieving a target activated clotting time (ACT) using an HDR slope remains controversial. Methods: We prospectively studied 86 adult patients scheduled for cardiac surgery requiring cardiopulmonary bypass. The total dose of calculated heparin required for patient and pump priming was administered simultaneously to achieve a target ACT of 450 s for HDR on the Hepcon HMS system. Blood samples were obtained after the induction of anesthesia, at 3 min after heparin administration and after the initiation of CPB to measure kaolin ACT, HDR slope, whole-blood heparin concentration based on the HDR slope and anti-Xa heparin concentration, antithrombin and complete blood count. Results: The target ACT of 450 s was not achieved in 68.6% of patients. Compared with patients who achieved the target ACT, those who failed to achieve their target ACT had a significantly higher platelet count at baseline. Correlation between the HDR slope and heparin sensitivity was poor. Projected heparin concentration and anti-Xa heparin concentration are not interchangeable based on the Bland–Altman analysis. Conclusion: It can be hypothesized that the wide discrepancy in HDR slope versus heparin sensitivity may be explained by an inaccurate prediction of the plasma heparin level and/or the change in HDR of individual patients, depending on in vivo factors such as extravascular sequestration of heparin, decreased intrinsic antithrombin activity level and platelet count and/or activity. [ABSTRACT FROM AUTHOR]

Background: We designed a non-invasive, observational, real-time study, using near-infrared spectroscopy (NIRS) to assess the in vivo effects of cardiopulmonary bypass (CPB) on patients’ skeletal muscle as well as the effects of hemodilution and hypothermia on tissue oxygen delivery during CPB. Methods: The study included 20 consecutive adult patients undergoing open-heart surgery with CPB. Evaluation parameters for peripheral circulation were measured using the NIRO-200NX and recorded every 30 seconds. To assess how hemodilution influences peripheral circulation parameters, we compared data between a group of patients with hematocrit (Hct) values >22% (high Hct group) and those with Hct values ⩽22% (low Hct group). Results: Changes in the concentration of oxygenated hemoglobin (ΔO2Hb, μmol/L), which flows into the skeletal muscle, was an important factor for deciding the tissue oxygenation index (TOI%), showing the tissue oxygen saturation. The low Hct group showed a significant increase in the normalized tissue hemoglobin index (nTHI), showing the percentage change in the amount of initial hemoglobin and TOI compared to the high Hct group. Changes in the concentration of oxygenated hemoglobin (ΔO2Hb, μmol/L) and deoxygenated hemoglobin (ΔHHb, μmol/L) were significantly less in the low Hct group than in the high Hct group, thus, showing good peripheral circulation despite the low hematocrit levels. Conclusion: Our study indicated the presence of a compensatory mechanism in which increased blood flow of the microcirculation is in compensation for the lack of oxyhemoglobin delivery caused by hemodilution. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to compare the biocompatibility of a new Senko E-Ternal coating (SEC) for cardiopulmonary bypass (CPB) circuits with the well-established poly-2-methoxyethyl acrylate (PMEA) coating. Methods: Forty patients undergoing aortic valve replacement were randomly assigned to either an SEC-coated group (n = 20) or a PMEA-coated group (n = 20). Clinical data and the following markers were analyzed: platelet count, platelet factor (PF) 4, fibrinogen, fibrinogen degradation products (FDPs), antithrombin III (AT III), thrombin-antithrombin complex (TAT), plasminogen, complement hemolytic activity (CH50), complement 3 (C3) and interleukin-6 (IL-6). Blood samples were obtained at five time points in both groups. Results: CPB time, aortic cross-clamp time and blood loss and transfusion were similar in both groups. There were no significant differences between the groups in terms of platelet count, PF4 and all coagulation and fibrinolytic parameters (FDP, AT III, TAT, and plasminogen) at any time points. Inflammatory markers (CH50, C3 and IL-6) were also similar in both groups at all time points. Conclusions: The SEC-coated circuit demonstrated equivalent biocompatibility to the PMEA-coated circuit. SEC-coated circuits are, therefore, favorably comparable to PMEA-coated circuits for clinical use in CPB. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to compare the biocompatibility of a new Senko E-Ternal coating (SEC) for cardiopulmonary bypass (CPB) circuits with the well-established poly-2-methoxyethyl acrylate (PMEA) coating. Methods: Forty patients undergoing aortic valve replacement were randomly assigned to either an SEC-coated group (n = 20) or a PMEA-coated group (n = 20). Clinical data and the following markers were analyzed: platelet count, platelet factor (PF) 4, fibrinogen, fibrinogen degradation products (FDPs), antithrombin III (AT III), thrombin-antithrombin complex (TAT), plasminogen, complement hemolytic activity (CH50), complement 3 (C3) and interleukin-6 (IL-6). Blood samples were obtained at five time points in both groups. Results: CPB time, aortic cross-clamp time and blood loss and transfusion were similar in both groups. There were no significant differences between the groups in terms of platelet count, PF4 and all coagulation and fibrinolytic parameters (FDP, AT III, TAT, and plasminogen) at any time points. Inflammatory markers (CH50, C3 and IL-6) were also similar in both groups at all time points. Conclusions: The SEC-coated circuit demonstrated equivalent biocompatibility to the PMEA-coated circuit. SEC-coated circuits are, therefore, favorably comparable to PMEA-coated circuits for clinical use in CPB. [ABSTRACT FROM AUTHOR]

The viscosity obtained from pressure-flow characteristics of an oxygenator may help to detect factors that change oxygenator resistance. The objective of this study was to model pressure-flow characteristics of a membrane oxygenator with an integrated arterial filter and to quantify their influence on apparent viscosity of non-Newtonian fluids. One Newtonian fluid (glycerin solution) and two non-Newtonian fluids (whole bovine blood and a human red blood cell suspension) were perfused through an oxygenator and their pressure-flow characteristics examined systematically. Four resistance parameters for the pressure gradient characteristics approximation equation were obtained by the least squares method from the relational expression of pressure-flow characteristics and viscosity. For all three fluids, a non-linear flow to pressure change was observed with a coefficient of determination of almost 1 by exponential approximation. The glycerin solution had a higher pressure gradient (10-70%) than the other fluids; the apparent viscosity of the non-Newtonian fluids was around 35% lower than the static one measured by a torsional oscillation viscometer. Overall, our study demonstrated that the influence on the apparent viscosity of non-Newtonian fluids can be quantified by pressure gradient differences in a membrane oxygenator with an integrated arterial filter. [ABSTRACT FROM AUTHOR]

Purpose: Surgical site infection (SSI) increases medical costs and prolongs hospitalization; however, there has been no multicenter study examining the socioeconomic effects of SSI after cardiovascular surgery in Japan. Methods: A retrospective 1:1 matched, case-controlled study on hospital stay and health care expenditure after cardiovascular surgery was performed in four hospitals. Patients selected for the study had undergone coronary artery bypass grafting and/or valve surgery between April, 2006 and March, 2008. Data were obtained for 30 pairs of patients. Results: The mean postoperative stay for the SSI group was 49.1 days, being 3.7 times longer than that for the non-SSI group. The mean postoperative health care expenditure for the SSI group was ¥2,763,000 (US$27,630), being five times higher than that for the non-SSI group. Charges for drug infusion and hospitalization for inpatient care were significantly higher for the SSI group than for the non-SSI group. The increased health care expenditure was mainly attributed to the cost of antibiotics and antimicrobial agents. Conclusion: SSI after cardiovascular surgery not only prolonged the length of hospital stay, but also increased medical expenditure. Thus, the prevention of SSI after cardiovascular surgery is of great socioeconomic importance. [ABSTRACT FROM AUTHOR]

Objectives: A meta-analysis was conducted to investigate the effects of ulinastatin treatment on adult patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). Methods: Seven electronic databases were searched for reports of randomized, controlled trials conducted up to February 2014 in which patients undergoing cardiac surgery with CPB were administered ulinastatin in the perioperative period. Results: Fifty-two studies with 2025 patients were retained for analysis. The results showed that the ulinastatin can attenuate the plasma levels of pro-inflammatory cytokines and enhance the anti-inflammatory cytokine levels in patients undergoing cardiac surgery with CPB. Meanwhile, the ulinastatin had a significant beneficial effect on myocardial injury. The mean differences (MD) and 95% confidence intervals (95% CI) of biochemical markers were −63.54 (−79.36, −47.72) for lactate dehydrogenase, −224.99 (−304.83, −145.14) for creatine kinase, −8.75 (−14.23, −3.28) for creatine kinase-MB, and −0.14 (−0.20, −0.09] for troponin I (all P<0.01). However, neither hemodynamics nor cardiac function improved significantly, except that the MD and 95% CI of mean arterial pressure were 2.50 (0.19, 4.80) (P = 0.03). There were no statistically significant differences in the use of inotropes, postoperative bleeding, postoperative complications, the intensive care unit (ICU) stay, and the hospital stay; however, the frequency of auto resuscitation increased significantly (OR 1.98, 95%CI 1.19 to 3.30, P<0.01), the duration of intubation (MD −1.58, 95%CI −2.84 to −0.32, P<0.01) and the duration of mechanical ventilation (MD −3.29, 95%CI −4.41 to −2.17, P<0.01) shortened significantly in patients who were treated with ulinastatin. Conclusions: Ulinastatin can reduce the plasma levels of pro-inflammatory cytokines and elevate anti-inflammatory cytokine in patients from China and Japan undergoing cardiac surgery with CPB. Ulinastatin treatment may have protective effects on myocardial injury, and can increase the frequency of auto resuscitation, shorten the duration of intubation and mechanical ventilation. [ABSTRACT FROM AUTHOR]

Background Repair of thoracic aortic aneurysm (TAA) is often associated with massive hemorrhage aggravated by dilutional coagulopathy with severe hypofibrinogenemia. Although only fresh frozen plasma (FFP) is available for acquired hypofibrinogenemia in Japan, the hemostatic effect of FFP has not been enough for dilutional coagulopathy in TAA surgery. There are increasing reports suggesting that fibrinogen concentrate may be effective in controlling perioperative bleeding and reducing transfusion requirements. Methods We retrospectively analyzed the hemostatic effect of fibrinogen concentrate compared with FFP in total 49 cases of elective TAA surgery. In 25 patients, fibrinogen concentrate was administered when the fibrinogen level was below 150 mg/dL at the cardiopulmonary bypass (CPB) termination. The recovery of fibrinogen level, blood loss, and transfused units during surgery were compared between cases of this agent and FFP (n = 24). Results We observed rapid increases in plasma fibrinogen level and subsequent improvement in hemostasis by administration of fibrinogen concentrate after CPB termination. The average volume of total blood loss decreased by 64% and the average number of transfused units was reduced by 58% in cases of fibrinogen concentrate given, in comparison with cases of only FFP transfused for fibrinogen supplementation. Conclusions In patients showing severe hypofibrinogenemia during TAA surgery, timely administration of fibrinogen concentrate just after removal from CPB is effective for hemostasis, and therefore in reducing blood loss and transfused volumes. [ABSTRACT FROM AUTHOR]

The article presents a study on the use of a hemoconcentrator as an alternative hemodialysis (ALTHD) and dilutional ultrafiltration (DUF) method in cardiopulmonary bypass surgeries. The study aims to determine the effectiveness of the ALTHD method. The ALTHD method may provide faster electrolyte adjustments compared to DUF because its efficiency depends on both the blood and dialysate flow rates.

Although legislation regarding organ transplantation from brain-dead donors in Japan was approved in 1997, no heart–lung transplantation procedures were performed for some time. Herein, we report the first case of successful heart–lung transplantation in Japan. The recipient was a 35-year-old man with Eisenmenger syndrome, caused by a double outlet right ventricle, who had been suffering hemoptysis and continued NYHA class 3–4 symptoms for 66 months since being registered on the waiting list. He underwent heart–lung transplantation from a 30-year-old donor. The organ ischemic time was 247 min, the postoperative course was uneventful, and the patient was discharged 66 days after the transplant surgery. [ABSTRACT FROM AUTHOR]

Monitoring the blood pump and the oxygen gas flow meter are important maneuvers at the initiation of cardiopulmonary bypass (CPB). We present a novel system, designed to improve safety in the heart-lung machine by linking the control of blood flow and the oxygen gas flow meter. This system uses a mass flow controller to provide and control oxygen flow based on the ventilation-perfusion (V/Q) ratio, using the electronic signal of the blood flow. We tested the system, in vitro and in vivo, and examined the resulting level of blood oxygenation. When extracorporeal circulation was initiated, the oxygen flow was instantly linked to the circulating blood flow, providing an adequate V/Q ratio; the partial pressure of oxygen in the blood was maintained at a normal level. Although we have yet to confirm the safety of this system in clinical trials, the new safety assist device can automatically supply oxygen to the oxygenator at the beginning of CPB. [ABSTRACT FROM PUBLISHER]

Objectives: In Japan, off-pump coronary artery bypass (OPCAB) is more common than on-pump coronary artery bypass. Superior early results of OPCAB have been reported; however, long-term results were still unclear. Purpose of this study is to evaluate the clinical outcomes of OPCAB in Japan using Japan Adult Cardiovascular Surgery Database., Methods: Between 2008 and 2010, 23,633 patients who underwent isolated coronary artery bypass were reported in database. We selected the cases from the hospital with mean annual coronary surgery volume of more than 50. Among the total of 7724 cases at 41 institutions, 2150 (31.2%) on-pump coronary artery bypass (ONCAB) and 5574 (68.8%) OPCAB cases were included. Propensity score (PS) matching was performed using PS developed from patient characteristics and preoperative factors resulting in 2007 cases matched pairs. Long-term follow-up data on patients' mortality and stroke were collected., Results: In-hospital mortality was significantly lower in OPCAB (ONCAB 1.1%, OPCAB 0.4% p = 0.01). Stroke was low in OPCAB group (ONCAB 1.7%, OPCAB 0.8%, p = 0.01). There was no statistically significant difference between OPCAB and ONCAB regarding 7-year overall survival (86.1% vs 88.1% respectively), composite outcomes (72.0% vs 73.9% respectively), or cardiac deaths (97.3% vs 97.1% respectively). Subgroup analysis (more than 75 years old) showed a worse trend in OPCAB group. Only in OPCAB group, incomplete revascularization significantly influenced 7-year survival., Conclusions: OPCAB is associated with early prognostic benefits; however, it might be less favorable outcomes in the long term when patients are older or with incomplete revascularization., (© 2021. The Japanese Association for Thoracic Surgery.)

Background--Extracorporeal membrane oxygenation (ECMO) and percutaneous coronary intervention (PCI) may be useful in cardiopulmonary resuscitation. However, little is known about the combination of ECMO and intra-arrest PCI. This study investigated the efficacy of rapid-response ECMO and intra-arrest PCI in patients with cardiac arrest complicated by acute coronary syndrome who were unresponsive to conventional cardiopulmonary resuscitation. Methods and Results--This multicenter cohort study was conducted with the use of the database of ECMO in Hiroshima City, Japan. Between January 2004 and May 2011, rapid-response ECMO was performed in 86 patients with acute coronary syndrome who were unresponsive to conventional CPR. The median age of the study patients was 63 years, and 81% were male. Emergency coronary angiography was performed in 81 patients (94%), and intra-arrest PCI was performed in 61 patients (71%). The rates of return of spontaneous heartbeat, 30-day survival, and favorable neurological outcomes were 88%, 29%, and 24%, respectively. All of the patients who received intra-arrest PCI achieved return of spontaneous heartbeat. In patients who survived up to day 30, the rate of out-of-hospital cardiac arrest was lower (58% versus 28%; P=0.01), the intra-arrest PCI was higher (88% versus 70%; P=0.04), and the time interval from collapse to the initiation of ECMO was shorter (40 [25-51] versus 54 minutes [34-74 minutes]; P=0.002). Conclusions--Rapid-response ECMO plus intra-arrest PCI is feasible and associated with improved outcomes in patients who are unresponsive to conventional cardiopulmonary resuscitation. On the basis of these findings, randomized studies of intra-arrest PCI are needed. [ABSTRACT FROM AUTHOR]

We report here Japan’s first pediatric perfusion survey. It covers practices from January 2007 through December 2009. Of the 70 congenital heart centers contacted, 53 (76%) completed the survey. They reported performing 3,379 pediatric cardiopulmonary bypass (CPB) procedures in 2009, 3,408 in 2008, and 3,358 in 2007.Twenty-eight percent of all centers used CPB circuits with a priming volume between 151-200 ml. All centers used pre-bypass ultrafiltration and only 6% used retrograde autologous priming. A biomaterial-coated circuit was used by 78% of the centers, a roller pump as the arterial pump by 91%, vacuum-assisted venous drainage by 39%, dilutional ultrafiltration by 48%, and modified ultrafiltration at the end of the procedure by 30%. A regional oxygen saturation monitor was used by 69% of the centers and high flow (150-200 ml/kg/min) management with alpha-stat blood gas control was standard during moderate to normothermic CPBs. Crystalloid cardioplegia solution was used as myocardial protection by 56% of the centers, electronic recording of monitoring data by 51%. The centers performed 98 pediatric extracorporeal membrane oxygenation procedures in 2007, 109 in 2008, and 119 in 2009; 58% of the centers used a centrifugal pump. This survey provides a description of the current practice in Japan. Future surveys will identify trends and rate of change in practice. [ABSTRACT FROM PUBLISHER]

Introduction: Inadequate cerebral oxygen balance during cardiopulmonary bypass may cause neuropsychological dysfunction. Milrinone, a phosphodiesterase III inhibitor, augments cerebral blood flow by direct vasodilatation. We conducted a prospective, randomized study in patients undergoing cardiac surgery with cardiopulmonary bypass to clarify the clinical efficacy of milrinone in the imbalance of cerebral oxygen supply and demand during the rewarming period of cardiopulmonary bypass.Methods: This is a prospective, randomized and placebo-controlled study. After anesthesia, a 5.5 F fiberoptic oximeter catheter was inserted into the right jugular bulb retrogradely for monitoring the jugular venous oxyhemoglobin saturation (SjO2). Patients were randomly assigned to two groups, one receiving a continuous infusion of milrinone, 0.5 µg/kg/min during hypothermic cardiopulmonary bypass, and the other receiving saline as control.Results: Milrinone significantly prevented the reduction of the jugular venous oxyhemoglobin saturation at 10 minutes from the start of rewarming compared with the control group, but did not do so from 10 to 20 minutes after rewarming.Conclusion: Milrinone suppresses the reduction of SjO2 and improves the balance of cerebral oxygen supply and demand during the early rewarming period of hypothermic cardiopulmonary bypass. [ABSTRACT FROM PUBLISHER]

The article discusses research on the effectiveness of a portable and percutaneous cardiopulmonary bypass system for rewarming of patients with accidental severe hypothermia. The study subjects included patients from an emergency medical center and trauma center in Kanagawa, Japan. A Seldinger technique was used to attempt percutaneous cannulation.

Objectives: To evaluate the outcomes of Japanese patients with renal cell carcinoma undergoing surgery for tumor thrombus invading the right atrium., Methods: We retrospectively evaluated 23 patients who underwent extracorporeal circulation-assisted surgery at two institutions. Perioperative outcomes and survival rates were evaluated and compared between two groups of patients, which were set according to the use or not of deep hypothermic circulatory arrest. Data on systemic treatments were assessed., Results: The median age was 64 years; the majority of patients were fit according to the Charlson Comorbidity Index. Five (21.7%) patients had at least one distant metastasis, and 17 (73.9%) received systemic therapy. A total of 16 (69.6%) patients underwent deep hypothermic circulatory arrest. Baseline characteristics were comparable between groups. Patients who underwent deep hypothermic circulatory arrest had a non-significant reduction in blood loss compared with those who did not undergo this procedure (1866.0 vs 3513.0 mL, P = 0.102). The complication rate, both of any grade (43.8% vs 71.4%, P = 0.215) and grade ≥3 (6.3% vs 28.6%, P = 0.162), tended to be lower in patients who underwent deep hypothermic circulatory arrest. The mean 90-day mortality rate was 8.7%, with no difference among groups (6.3% vs 14.3%, respectively; P = 0.545). The overall median cancer-specific and overall survival were both 64.4 months, and did not differ between groups., Conclusions: Renal cell carcinoma patients undergoing extracorporeal circulation-assisted surgery and systemic therapy for right atrial tumor thrombus have acceptable long-term survival rates. Outcomes are comparable regardless of the use of deep hypothermic circulatory arrest., (© 2021 The Japanese Urological Association.)

In Japan, perfusionists who work on other clinical tasks are involved in cardiopulmonary bypass. Moreover, the number of cases they can perform is limited. In view of this situation, valve type semi-closed extracorporeal circulation (VACC) was developed as a system that enables extracorporeal circulation (ECC) regardless of perfusionists' experience. The VACC circuit is based on a conventional open-type ECC circuit. A safety valve is installed at the outlet of the reservoir. It is closed by lowering the reservoir pressure below the venous circuit pressure (Pv), thereby providing a closed-type ECC in which the reservoir is separated from the venous circuit (V-circuit). A closed-type ECC needs means to cope with negative pressure generated in the V-circuit and to remove air mixed in the V-circuit. Water experiments to verify the safety of the VACC were conducted. In experiments simulating low venous return, when the Pv dropped, the safety valve opened so that the V-circuit was connected to the reservoir, and the excessive negative pressure was relieved. In the VACC circuit, a bubble trap is installed in the V-circuit, and the air is degassed to the reservoir by a roller pump (D-pump). A water experiment was conducted to verify the principle of the constant degassing method using the D-pump. It verified that the blood storage volume could be maintained constant even if the D-pump is continuously driven. The VACC system provides handling of air mixed in the V-circuit and safety in the case of low venous return., (© 2021. The Author(s).)

The author suggests the importance of an organized extracorporeal membrane oxygenation (ECMO)-based respiratory program in Japan. He describes ECMO as an expanded clinical application of cardiopulmonary bypass introduced in the 1950s that allowed a longer period of support than other oxygenators. He cites a study in Great Britain which found the efficacy of ECMO in neonates with severe respiratory failure. He also references a study by S. Takeda et al on ECMO for 2009 influenza in Japan.

Objective: Several strategies are employed for administering fresh frozen plasma (FFP) during weaning from cardiopulmonary bypass (CPB). This study evaluated by coagulation function aimed to compare two strategies of administering FFP in cardiovascular surgery: administering 4 units of FFP before separating from CPB or administering it after weaning from CPB., Methods: Thirty patients who underwent CPB and were expected to receive 8 units of FFP and 20 units of platelet concentrate were randomly allocated into group A (8 units of FFP and 20 units of platelet concentrate administered after separating from CPB) and group B (4 units of FFP administered before separation, and 4 units of FFP and 20 units of platelet concentrate administered after separating from CPB). Thromboelastography (TEG6s ® , HAEMONETICS Japan GK, Tokyo, Japan) was conducted at four time points before and after separation. Blood test results, blood loss, and required amounts of blood transfusion were compared. The primary outcome was the difference in coagulation function evaluated by TEG6s 90 min after protamine administration., Results: Twenty-eight patients were enrolled in the study. Coagulation function after separating from CPB was not significantly different between the groups. Additionally, no significant differences were found in intensive care unit outcomes, such as 24-h transfusion requirements., Conclusions: Coagulation function 90 min after separating from CPB was not significantly different between the groups. Prior FFP administration before separation did not provide significant improvement in coagulation function.

Background: In 2011, the Japanese Registry of Acute Aortic Dissection (JRAD) was started in accordance with the model of the International Registration of Acute Aortic Dissection. The aim of this study was to report actual clinical early and midterm outcomes of treatment for acute type A aortic dissection in Japan., Methods: Between 2011 and 2016, 1217 patients (67.9 years-old, 584 male, 241 >80 years old) who had acute type A aortic dissection within 14 days after the onset of symptoms were enrolled., Results: Among 75% patients managed surgically, 68% underwent surgical procedure with cardiopulmonary bypass. Surgery was not indicated in 25% patients. Overall, 12% died in the hospital, 10.8% after surgical treatment and 16.6% after medical treatment. Multivariable analysis of in-hospital mortality revealed the following risk factors: age older than 80 years (odds ratio, 2.37; P < .01); shock vital status on arrival (odds ratio, 1.89; P = .01); disturbance of consciousness, including coma (odds ratio, 3.32; P < .01); and cardiac arrest, for which resuscitation was needed on arrival (odds ratio, 4.86; P < .01)., Conclusions: JRAD data revealed the actual clinical setting for the treatment of acute type A dissection in Japan. Early surgical results were favorable, with a low in-hospital morality rate, and midterm outcomes in selected medically treated patients were equivalent. Preoperative severe conditions, including shock, need for preoperative cardiopulmonary resuscitation, and disturbance of consciousness, as well as advanced age, were risk factors for in-hospital mortality even though the referral interval was brief., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Ventricular septal defect (VSD) after myocardial infarction (MI) is a rare but fatal complication. We report patients' characteristics and operative outcomes after surgical repair of post-MI VSD using a national database of Japan.Methods and Results:This was a retrospective review of the Japan Adult Cardiovascular Surgery Database (JCVSD) to identify adults (age ≥18 years) who underwent surgical repair of post-MI VSD between 2008 and 2014. The primary outcome was operative death. We identified 1,397 patients (671 male [48%], 74.1±9.3 years old) undergoing surgical repair of post-MI VSD among 288,736 patients undergoing cardiac surgery enrolled in the JCVSD during the same period. Of these, 1,075 (77.0%) were supported preoperatively with an intra-aortic balloon pump. Surgical status was urgent in 391 (28.0%) and emergency/salvage in 731 (52.3%). Concomitant coronary artery bypass grafting was performed in 475 (34.0%). Overall 30-day and operative mortalities were 24.3% and 33.0%, respectively. Operative mortality varied according to surgical status: 15.6% in elective, 30.9% in urgent, and 40.6% in emergency/salvage cases. Multivariable analysis identified advanced age and emergency/salvage status as being strongly associated with increased odds of operative death., Conclusions: Post-MI VSD remains a devastating complication in Japan as well as in the USA and Europe.

Objective: The Hepcon Heparin Management System (HMS) facilitates administration of higher heparin and lower protamine doses, which may affect bleeding potential due to heparin rebound. The present study evaluated heparin rebound in patients for whom the Hepcon HMS was used to determine whether point-of-care tests detect residual heparin and residual heparin is associated with postoperative blood loss., Design: Prospective study., Setting: Tertiary care center affiliated with a university hospital., Participants: Adults undergoing elective cardiac surgery requiring cardiopulmonary bypass., Interventions: In blood samples obtained at baseline, at 2 minutes, and at 1, 2, 4, 6, and 24 hours after heparin neutralization, heparin concentrations were measured using an automated chromogenic assay. Activated coagulation time (ACT), activated partial thromboplastin time (APTT), and thromboelastometry 2 hours after heparin neutralization also were examined in the last 22 study patients enrolled., Measurements and Main Results: All 31 patients had measurable heparin levels 2 hours after protamine administration; 22 patients exhibited a primary failure to reverse heparin after protamine administration, and 9 patients had measureable heparin levels 2 hours after complete heparin reversal (ie, heparin rebound). The thromboelastometric variable, INTEM-CT:HEPTEM-CT ratio, correlated with heparin concentration (r=0.72), but ACT (r=-0.12), APTT (r=0.36), and whole blood heparin concentration, determined using the Hepcon HMS, did not. Peak heparin concentration (0.18±0.07 U/mL) at 4 hours was not correlated with mediastinal blood loss., Conclusion: Circulating heparin detected by the chromogenic assay was too low to be clinically significant based on postoperative bleeding, although all 31 patients had residual heparin or heparin rebound at 2 hours after protamine administration with use of the Hepcon HMS., (© 2014 Elsevier Inc. All rights reserved.)

Purpose: We calculated the cumulative sum analysis of an individual surgical learning curve for mitral valve reconstructive surgery to monitor quality control., Methods: Between April 2003 and March 2009, 25 consecutive patients underwent mitral valve reconstructive surgery for mitral regurgitation (MR). All operations were performed by a single surgeon. We analyzed the operative variables, mortality, and major morbidities and calculated the learning curve, using descriptive statistics and cumulative sum analysis based on the Japan SCORE calculator., Results: In this series, the Japan SCORE calculator predicted a 30-day operative mortality rate of 3.07 ± 3.48 % and a 30-day operative mortality and morbidity rate of 14.9 ± 9.58 %s. In reality, there was no operative or in-hospital death and the major postoperative morbidity rate was 6.0 % (two patients). The risk-adjusted cumulative sum analysis revealed that the learning curve for mortality and morbidity shifted downward below the lower confident interval for all the patients, on completion of mitral valve repair. Coefficient analysis revealed a significant negative correlation between the aortic cross-clamp time and the cardiopulmonary time and case load. There was no correlation between the operation time and the case load., Conclusions: Routine reconstructive mitral valve surgery for MR can be performed at the professionally permissive level from the beginning, even in low-volume case loads.

Background: We introduced an initial large dose of modified St. Thomas' Hospital cardioplegic solution with the aim of providing both myocardial protection as well as a smooth intraoperative process., Methods: In 90 cases of isolated aortic valve replacement, we used the modified technique of cardioplegia in 45 (group S) and conventional administration of glucose-insulin-potassium solution in 45 (group G). The patients were selected at random. In group S, we added 4 mEq of potassium to the original St. Thomas' Hospital solution and administered 30 mL·kg(-1) as an initial dose. The temperature was decreased to 2., Results: The mean of reperfusion time after declamping in group S was significantly shorter (16.7 ± 6.4 vs. 21.5 ± 10.0 min; p = 0.007). The average of postoperative maximum creatine kinase-MB was significantly lower in group S (25.6 ± 9.5 vs. 40.6 ± 37.2 IU·L(-1); p = 0.014). On multivariate analysis, use of the modified cardioplegia and aortic crossclamp time were significantly associated with creatine kinase-MB level and reperfusion time after declamping., Conclusions: This modified technique was an acceptable option that provided a bloodless operative field and avoided multiple cardioplegic administrations.

Background: Chronic kidney disease (CKD) is an important risk factor for cardiac surgery. In the most recently reported NU-HIT trial for CKD with CKD patients underwent coronary artery bypass grafting (CABG) as subjects, carperitide was reported to be effective in terms of renal function. In the present study, a subanalysis was performed on patients registered in the NU-HIT trial for CKD from the standpoint of renin-angiotensin system, natriuresis and renal function., Methods: 303 patients with CKD who underwent isolated CABG were divided into a group that received carperitide infusion and another group without carperitide. The renin activity, angiotensin-II, aldosterone, urine-sodium, urine- creatinine, fractional sodium excretion, renal failure index, and BNP levels., Results: There were significant lower in hANP group than the placebo group, in angiotensin-II at one day postoperatively, and in aldosterone from 0 day to one month postoperatively. FENa was significantly lower in the hANP group at 3 day and one week postoperatively., Conclusions: In on pump isolated CABG patients with CKD, carperitide showed a potent natriuretic action and inhibited the renin-angiotensin system, suggesting that it prevented deterioration of postoperative renal function. Our findings raise new possibilities for the perioperative and postoperative management of patients undergoing surgery with cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) elicits a systemic inflammatory response. The neutrophil elastase inhibitor sivelestat is known to suppress this systemic inflammatory response, which can eventually result in acute organ failure. The prophylactic effect of sivelestat on acute lung injury, especially in pediatric cardiac surgery, remains unclear. This prospective double-blind, randomized study evaluated the perioperative prophylactic effect of sivelestat in patients undergoing elective pediatric open heart surgery with CPB. Thirty consecutive patients, weighing 5-10 kg and undergoing open heart surgery with CPB, were assigned to sivelestat (n = 15) or control (n = 15) groups. From CPB initiation to 24 h after surgery, patients in the sivelestat group received a continuous intravenous infusion of 0.2 mg/kg/h sivelestat, whereas patients in the control group received the same volume of 0.9% saline. Blood samples were collected, and levels of interleukin (IL)-6, IL-8, tumor necrosis factor alpha, polymorphonuclear elastase (PMN-E), C-reactive protein (CRP), as well as the white blood cell (WBC) count, platelet count, and neutrophil count (NC) were measured. PMN-E levels, IL-8 levels, WBC count, NC, and CRP levels were significantly lower, and platelet count was significantly higher in the sivelestat group, according to repeated two-way analysis of variance. The activated coagulation time was significantly shorter in the sivelestat group, similarly, blood loss was significantly less in the sivelestat group. In conclusion, Sivelestat attenuates perioperative inflammatory response and clinical outcomes in patients undergoing pediatric heart surgery with CPB., (© 2013 Wiley Periodicals, Inc. and International Center for Artificial Organs and Transplantation.)

Objectives: Cardiac surgery with cardiopulmonary bypass frequently leads to excessive bleeding, obligating blood product transfusions. Because low factor XIII (FXIII) levels have been associated with bleeding after cardiac surgery, we investigated whether administering recombinant FXIII after cardiopulmonary bypass would reduce transfusions., Methods: In this double-blinded, placebo-controlled, multicenter trial, 409 cardiac surgical patients at moderate risk for transfusion were randomized to receive an intravenous dose of recombinant FXIII, 17.5 IU/kg (n = 143), 35 IU/kg (n = 138), or placebo (n = 128) after cardiopulmonary bypass. Transfusion guidelines were standardized. The primary efficacy outcome was avoidance of allogeneic blood products for 7 days postsurgery. Secondary outcomes included amount of blood products transfused and reoperation rate. Serious adverse events were measured for 7 weeks., Results: Study groups had comparable baseline characteristics and an approximately 40% decrease in FXIII levels after cardiopulmonary bypass. Thirty minutes postdose, FXIII levels were restored to higher than the lower 2.5th percentile of preoperative activity in 49% of the placebo group, and 85% and 95% of the 17.5- and 35-IU/kg recombinant FXIII groups, respectively (P < .05 for both treatments vs placebo). Transfusion avoidance rates were 64.8%, 64.3%, and 65.9% with placebo, 17.5 IU/kg, and 35 IU/kg recombinant FXIII (respective odds ratios against placebo, 1.05 [95% confidence interval, 0.61-1.80] and 0.99 [95% confidence interval, 0.57-1.72]). Groups had comparable adverse event rates., Conclusions: Replenishment of FXIII levels after cardiopulmonary bypass had no effect on transfusion avoidance, transfusion requirements, or reoperation in moderate-risk cardiac surgery patients (ClinicalTrials.gov identifier: NCT00914589)., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Open heart surgery in patients with liver cirrhosis is considered to be very risky, but the predictors of poor outcomes in such cases have not been established. We report the perioperative results of open heart surgery in patients with liver cirrhosis in our hospital. We reviewed the results of 13 cases in 12 patients with liver cirrhosis who underwent open heart surgery between January 2001 and December 2010. The Child-Turcotte-Pugh classification, the model for end-stage liver disease score, EuroSCORE, and perioperative data were used to identify risk factors for morbidity and mortality retrospectively. Ten patients had postoperative complications. Significant differences in morbidity were evident for Child-Turcotte-Pugh class, cardiopulmonary bypass time, and crossclamp time. Two patients died of liver failure, one at 40 days and the other at 2 years after surgery. Statistically significant differences in liver-related mortality were evident in the model for end-stage liver disease scores and serum cholinesterase levels. We concluded that a high Child-Turcotte-Pugh class was associated with increased morbidity. Cardiopulmonary bypass and crossclamp times were also related to high morbidity, while high model for end-stage liver disease scores and low serum cholinesterase levels predicted liver-related mortality.

Objective: Total arch replacement has been reported to present high morbidity and mortality. We have introduced a stepwise distal anastomosis technique and modified perfusion strategy, including selective antegrade cerebral perfusion, moderate hypothermia, and separate lower-body perfusion, to minimize organ ischemia and secondary morbidities. We report the operative outcomes of total arch replacement with our modified perfusion strategy., Methods: Between August 2006 and December 2008, 119 patients underwent total arch replacement with the current perfusion strategy. Of these patients, 56 (47%) underwent emergency operation for acute type A aortic dissection (n = 48) or ruptured thoracic aneurysm (n = 8). The mean age of patients was 68 years, and the mean follow-up period was 25 months. We analyzed operative mortality, morbidity, and 4-year survival of this patient group., Results: The mean operation, cardiopulmonary bypass, and circulatory arrest times were 313, 183, and 47 minutes, respectively. Operative mortality was 3.4%. Operative mortality of elective cases was 1.6%. The incidences of permanent neurologic deficit, paraparesis, and renal insufficiency were 5.0%, 1.7%, and 7.6%, respectively. Actuarial 4-year survival was 86.5%., Conclusions: Total arch replacement with our modified perfusion strategy has demonstrated low operative mortality and morbidity., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

We describe an alternative technique through median sternotomy to perform total arch replacement for an extended distal arch aneurysm. After initiating cardiopulmonary bypass, the left pleura is opened widely from the aortic arch to the diaphragm and the left lung is mobilized to the right side with the heart. The descending aorta is visible through the window of the pleural incision. This technique provides excellent exposure, facilitating aneurysm resection, control of the descending aorta and successful completion of the distal anastomosis. In our experience of 26 cases who had distal aortic arch aneurysm with downstream extension, total arch replacement was achieved through a median sternotomy without the need for left anterolateral thoracotomy. This procedure reduced perioperative bleeding and resulted in satisfactory clinical outcomes.

Purpose: Hypothermic circulatory arrest is considered to be a contraindication in acute traumatic aortic rupture (TAR) because full heparinization and hypothermia may lead to fatal bleeding if concomitant hemorrhagic injuries are present. However, in extremely emergent situations, rapid volume infusion via cardiotomy vacuums and the institution of hypothermic circulatory arrest appears to be the only method for saving patients with uncontrollable bleeding. In this study, we evaluate the feasibility of hypothermic circulatory arrest for treating patients with TAR with hemorrhagic shock., Methods: Ten patients (nine men and one woman; mean age, 35 ± 18 years), with acute TAR caused by blunt chest trauma and in a shock state, underwent surgery between 1999 and 2007. All ten patients exhibited rupture of the isthmus, and polytraumatism was frequent. Any life-threatening blood loss from other injuries was surgically treated before aortic surgery. All patients were operated on with standard cardiopulmonary bypass under hypothermic circulatory arrest., Results: All patients received prosthetic graft replacement. The overall hospital mortality was 10.0% (1/10). One patient died of intraabdominal and pulmonary bleeding during surgery, and the other nine were discharged without complications. There was no evidence of any new or increased hemorrhagic complications during heparinization in the nine surviving patients. Mean operation and circulatory arrest times were 305 ± 44 min and 27 ± 7 min, respectively., Conclusion: Hypothermic circulatory arrest is feasible for saving TAR patients with unstable hemodynamics resulting from rupture, provided associated injuries are properly treated in advance.

In total aortic arch replacement (TARCH) using hypothermic circulatory arrest (HCA) and selective cerebral perfusion (SCP), postoperative cerebral complications, including metabolic abnormalities, are by no means rare. Furthermore, there is a lack of international guidelines for the optimal perfusion temperature and flow for SCP. Starting in 2008, TARCH was performed using tepid HCA at 32 °C. In the present study, 27 patients (group C) who underwent TARCH with deep hypothermia at the lowest rectal temperatures of 20-25 °C were retrospectively reviewed and compared with 23 patients (group W) who underwent TARCH with 32 °C tepid hypothermia. Preoperative patient characteristics and intraoperative and postoperative parameters were compared. Preoperative patient characteristics did not differ significantly between the two groups. Circulatory arrest time, cardiopulmonary bypass time, operating time, amount of blood transfused and postoperative neurological complications were significantly reduced in group W compared with group C. Our procedure of TARCH using tepid hypothermia at 32 °C was safe, and it significantly reduced all parameters of extracorporeal circulation time. However, this study has several limitations. To indicate the safety and usefulness of tepid HCA for TARCH, a further multifaceted study should be performed with a greater number of patients.

In cardiac surgical cases such as valve replacement, right ventricular failure caused by intracoronary air embolism sometimes occurs after aortic declamping and during weaning from cardiopulmonary bypass (CPB). The details are reported of a de-airing method which involves simply rotating the arterial cannula towards the base of the heart, with no need for a particular circuit. This method was used in ten patients who, following open-heart surgery, suffered postoperative right ventricular failure due to air embolism in the right coronary artery that did not respond to other de-airing methods. The technique resolved the problem in all patients, who were quickly weaned from CPB and ultimately discharged. Rotation of the arterial cannula may represent a simple means of resuscitating patients who have suffered right ventricular dysfunction that is unrelieved by other, conventional methods.

Purpose: Ventricular septal perforation (VSP) is a rare but life-threatening complication of acute myocardial infarction (AMI). Even with assisted circulation heart failure often progresses quickly, and urgent surgical intervention is required to close the VSP. For several years, we have been performing a double patch closure technique using an equine pericardial patch. In this report, we present details of our patch closure technique and the VSP surgical results; we also examine the problems we encountered., Methods: The present study was a review of nine patients who underwent our patch closure of VSP secondary to AMI. We used a large double-layered equine pericardial patch to close the VSP and did not exclude the infarction area from the left ventricular cavity. No necrotic myocardium was excised to avoid simultaneous excision of stunned myocardium., Results: No patients died within 30 days of the surgery, and there were no in-hospital deaths. Over a mean clinical follow-up period of 4.5 years, no residual shunts were detected, and all patients were alive and had New York Heart Association functional class II., Conclusion: Our patch closure technique was effective for closing VSPs securely. The operating times and cardiopulmonary bypass times were short, and blood loss was minimal. Our patch closure technique may improve the prognosis of VSP.

Objective: Modified ultrafiltration increases blood pressure after cardiopulmonary bypass in children. To investigate the cause of this hemodynamic improvement, we assessed the relationship between increased blood pressure and hematocrit., Methods: We retrospectively assessed 30 consecutive patients who underwent ventricular septal defect closure, and divided them into two groups: group M (modified ultrafiltration, n=15) and group C (conventional ultra-filtration, n=15). We compared the intraoperative transitions of blood pressure and hematocrit, and analyzed the correlations between blood pressure and hematocrit at 15 min after cardiopulmonary bypass (immediately after modified ultrafiltration in group M) and between the percent increases in blood pressure and hematocrit during modified ultrafiltration., Results: Although intraoperative central venous pressure and dopamine dosage were similar, in group M, increases in hematocrit (26.4% +/- 4.9% to 31.9% +/- 5.7%, P < 0.01) and systolic blood pressure (61.1 +/- 10.3 to 75.6 +/- 11.5 mmHg, P < 0.01) occurred during modified ultrafiltration. Furthermore, diastolic and mean blood pressure at 15 min after cardiopulmonary bypass (after modified ultrafiltration) were higher in group M than in group C. However, systolic, mean, and diastolic blood pressure were not correlated with increased hematocrit after modified ultrafiltration, and there was also no correlation between the percent increases in each blood pressure and hematocrit., Conclusion: Modified ultrafiltration increased blood pressure and hematocrit immediately after cardiopulmonary bypass in children. However, no correlations were detected between the increases in blood pressure and hematocrit. These results indicate hemoconcentration is not the major cause of the increased blood pressure during modified ultrafiltration.

Objective: We have developed a surgical method for atrial septal defect repair through a limited right lateral thoracotomy in which the incision line begins 2 cm caudal from the lower angle of the scapula and ends at the midaxial line, thereby improving patient satisfaction with the cosmetic results of treatment., Methods: We performed a retrospective review of 28 patients who underwent isolated atrial septal defect repair through a limited right lateral thoracotomy between January 2002 and August 2004. The mean age and mean body weight at the time of the operation were 85.8 months (range 9-236 months) and 23.0 kg (range 8.0-56.0 kg), respectively. All repaired defects were the ostium secundum type., Results: There was no operative or late mortality and no late morbidity after a mean follow-up of 26 months (range 12-41 months). Echocardiography showed no residual shunt in any of the patients. The mean length of the skin incision was 7.8 cm (range 5.0-11.0 cm), and almost all the patients had satisfactory cosmetic results., Conclusion: The atrial septal defect repair through a limited right lateral thoracotomy in pediatric patients showed satisfactory surgical results and excellent cosmetic results.

The number of coronary artery bypass grafting (CABG) procedures has reached more than 20,000 per year in Japan, and the operative mortality rate has decreased to less than 1.5% including emergent surgery. The mortality and morbidity rates of CABG are still high in patients with risk factors such as cerebrovascular disease, chronic renal failure on hemodialysis, atheromatous and calcified ascending aorta, and older age when cardiopulmonary bypass is used. Minimally invasive direct coronary bypass on a beating heart through a small left lateral anterior thoracotomy, in which the left internal thoracic artery (LITA) is used to revascularize the left anterior descending artery, was introduced for high-risk patients with single-vessel disease in the mid-1990s, although is not widely performed at present. Since the late 1990s off-pump coronary artery bypass grafting (OPCAB) has been widely performed as a treatment for multivessel disease through a median sternotomy with the evolution of stabilizers and apical suction devices, refined anesthetic management, and sophisticated surgical techniques. In 2004, 60% of all CABG procedures in Japan were performed without cardiopulmonary bypass. Due to competition from percutaneous coronary intervention with drug-eluting stents and better long-term outcomes, CABG with arterial grafts alone was carried out in 52% of total cases and in 66% of OPCAB cases. OPCAB is becoming the standard CABG in Japan.