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Last year, we reported in vitro pump performance, low hemolytic characteristics, and initial in vivo evaluation of a disposable, magnetically levitated centrifugal blood pump, MedTech Dispo. As the first phase of the two-stage in vivo studies, in this study we have carried out a 2-week in vivo evaluation in calves. Male Holstein calves with body weight of 62.4–92.2 kg were used. Under general anesthesia, a left heart bypass with a MedTech Dispo pump was instituted between the left atrium and the descending aorta via left thoracotomy. Blood-contacting surface of the pump was coated with a 2-methacryloyloxyethyl phosphorylcholine polymer. Post-operatively, with activated clotting time controlled at 180–220 s using heparin and bypass flow rate maintained at 50 mL/kg/min, plasma-free hemoglobin (Hb), coagulation, and major organ functions were analyzed for evaluation of biocompatibility. The animals were electively sacrificed at the completion of the 2-week study to evaluate presence of thrombus inside the pump,together with an examination of major organs. To date, we have done 13 MedTech Dispo implantations, of which three went successfully for a 2-week duration. In these three cases, the pump produced a fairly constant flow of 50 mL/Kg/min. Neurological disorders and any symptoms of thromboembolism were not seen. Levels of plasma-free Hb were maintained very low. Major organ functions remained within normal ranges. Autopsy results revealed no thrombus formation inside the pump. In the last six cases, calves suffered from severe pneumonia and they were excluded from the analysis. The MedTech Dispo pump demonstrated sufficient pump performance and biocompatibility to meet requirements for 1-week circulatory support. The second phase (2-month in vivo study) is under way to prove the safety and efficacy of MedTech Dispo for 1-month applications.

Objective Delirium is a common and critical clinical syndrome in older persons. The authors examined whether any abnormalities in the white matter (WM) assessed by diffusion tensor imaging (DTI) predisposes patients to develop delirium after cardiac surgery and also analyzed other risk factors for delirium. Method In 116 consecutive patients who underwent scheduled cardiac operations, fractional anisotropy (FA) values obtained by DTI before the surgery and pre-, peri-, and postoperative factors were evaluated. The postoperative delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for delirium. Results Delirium developed in 19 of 116 patients (16.4%). Eighteen of the patients with delirium (94.7%) were older than 60 years. A multivariate logistic regression analysis showed that advanced age and poor performance on a semantic fluency task (the Word Fluency test animal) were important predictive indicators of the delirium. In addition, a voxel-by-voxel analysis using the Statistical Parametrical Mapping 2 revealed that the FA values of the patients with postoperative delirium were significantly lower than those of the nondelirium patients in the bilaterally widespread deep WMs and bilateral thalamus, whereas the analysis treating age as a nuisance variable indicated a significant change in only four clusters of the brain areas, e.g., the left frontal lobe WM, and left thalamus, when compared with the nondelirium group. Conclusion The abnormalities in the deep WMs and thalamus that were mainly accelerated by aging may account for the vulnerability to postoperative delirium, and the semantic word fluency could be a useful predictive indicator of delirium.

The aim of this observational study was to determine the incidence of atrial fibrillation (AF) after coronary artery bypass grafting (CABG) in patients with or without preoperative pravastatin treatment. Between January 2005 and December 2007, a total of 195 patients (39 women, mean age 66.5 ± 10.2 years) who underwent CABG only were enrolled in this study. Patients were divided into three groups: nonstatin group (n = 111), atorvastatin group (n = 63), pravastatin group (n = 21). The endpoint of the study was the occurrence of new-onset AF during the first 14 days after CABG. Postoperative AF was less frequent in the pravastatin group (9.5%, 2/21 patients) than in the nonstatin group (34.2%, 38/111 patients; P = 0.0025) and the atorvastatin group (34.9%, 22/63 patients; P = 0.0257). C-reactive protein levels were lower in the pravastatin group 72 h after surgery (nonstatin vs. pravastatin, P = 0.0180; atorvastatin vs. pravastatin, P = 0.0383). The Kaplan-Meier analysis showed the protective effect of pravastatin against the risk of developing AF (nonstatin vs. pravastatin, P = 0.0369; atorvastatin vs. pravastatin, P = 0.0378). Multivariable analysis showed that pravastatin treatment conferred a reduced risk of AF (odds ratio 0.22, 95% confidence interval 0.05–0.92, P = 0.0172). Pravastatin treatment before CABG may decrease the incidence of postoperative AF.

A disposable magnetically levitated centrifugal blood pump, which aims to be used for from a few days to a few months, has been developed. An impeller is levitated and rotated without contact using a two-degree-of-freedom radial magnetic bearing and a magnetic coupling. Due to ‘out-of-step’ of the magnetic coupling caused by its insufficient transmittable torque, a previous prototype pump could not yield the required pressure-flow characteristics of 5 L/min against 106 kPa (800 mmHg). The magnetic coupling was redesigned in order to increase the transmittable torque. The stability of the impeller levitation against impact was evaluated through a base excitation test simulating animal experiment and practical use. Applying an impulse excitation of an acceleration of 200 m/s2, the impeller could keep contactless levitation both in the controlled direction and in the passively supported directions. Finally, the animal experiments for one to two weeks showed that no damage and no thrombus formation were found in the pump heads.

MedTech Dispo, a disposable maglev centrifugal blood pump with two degrees of freedom magnetic suspension and radial magnetic coupling rotation, has been developed for 1-month extracorporeal circulatory support. As the first stage of a two-stage in vivo evaluation, 2-week evaluation of a prototype MedTech Dispo was conducted. In in vitro study, the pump could produce 5 L/min against 800 mm Hg and the normalized index of hemolysis was 0.0054 +/- 0.0008 g/100 L. In in vivo study, the pump, with its blood-contacting surface coated with biocompatible 2-methacryloyloxyethyl phosphorylcholine polymer, was implanted in seven calves in left heart bypass. Pump performance was stable with a mean flow of 4.49 +/- 0.38 L/min at a mean speed of 2072.1 +/- 64.5 rpm. The maglev control revealed its stability in rotor position during normal activity by the calves. During 2 weeks of operation in two calves which survived the intended study period, no thrombus formation was seen inside the pump and levels of plasma free hemoglobin were maintained below 4 mg/dL. Although further experiments are required, the pump demonstrated the potential for sufficient and reliable performance and biocompatibility in meeting the requirements for cardiopulmonary bypass and 1-week circulatory support.

Off-pump coronary artery bypass grafting (OPCAB) in patients with acute myocardial infarction (AMI) is difficult because of circulatory deterioration during displacement of the heart. At our institution, we performed minimally circulatory-assisted on-pump beating coronary artery bypass grafting (MICAB) in these patients. During MICAB, support flow was controlled at a minimal level to maintain a systemic blood pressure of approximately 100 mm Hg and a pulmonary arterial systolic pressure of30 mm Hg, providing optimal pulsatile circulation for end-organ perfusion and prevention of heart congestion. From September 2006 to March 2012, MICAB was performed in 37 patients. Either emergent or urgent MICAB was performed in 27 patients following AMI because of hemodynamic instability during reconstruction. Elective MICAB was performed in the remaining 10 patients because of dilated left ventricle (LV) or small target coronary arteries. The details of bypass grafts, perioperative renal function, and early and mid-term morbidity and mortality were compared between the patients who received MICAB and the 37 consecutive patients who underwent OPCAB during the study period at our hospital. The assist flow indices (actual support flow/body surface area) during anastomosis to the left anterior descending artery, left circumflex artery, and right coronary artery were 0.95 ± 0.48 L/min/m

Objective Delirium is a common syndrome in older patients after surgery. Although an atrophic change in the whole brain may be a potential risk factor for postoperative delirium, the anatomically specific change related to the vulnerability still remains a significant issue. Design Prospective study. Setting University hospital. Participants 116 consecutive patients who underwent elective cardiac operations. Measurements Before the surgery, magnetic resonance imaging (MRI) was evaluated. The MRI data were processed to calculate the absolute volumes of the predefined region of interest using Statistical Parametrical Mapping 8 with an atlas-based method. The evaluated volume was expressed as the fraction (%) of the total intracranial volume. Postoperative delirium was diagnosed according to the DSM-IV criteria for delirium. Results Delirium developed in 19 of 116 patients (16.4%) with an age range from 58 to 84 years. Based on a comparison with the age-controlled non-delirium patients (over 57 years; n = 65), a statistically significant reduction in the gray matter volume of the delirium patients was observed in the defined gyri of the temporal and limbic lobes. Moreover, a moderate value (>0.8) of area under the curve to predict postoperative delirium was revealed by receiver operating characteristic curve analysis of the gyri of temporal lobe. Conclusions The decreased volume of gray matter could be associated with the vulnerability to delirium after surgery. The atlas-based method would be a potential tool to pre-screen the brain structure of individual patients for the prediction of postoperative delirium.

While coronary artery bypass grafting (CABG) has been playing a significant role in the revascularization for ischemic heart disease, neurological complications associated with CABG have been a primary concern. Stroke, although the incidence is low, is one of the most devastating complication of CABG. Many studies have identified the risk factors for stroke with CABG, such as prior stroke, carotid artery stenosis, aortic atherosclerosis, atrial fibrillation and cardiopulmonary bypass. Various rational approaches focusing on individual risk factor have been proposed for the stroke. Prophylactic carotid revascularization is an important strategy, and the diagnosis of carotid stenosis has to be established correctly. Prevention of emboli from aortic plaque is also an essential issue. Intraoperative monitoring with transesophageal or epiaortic ultrasound is useful to identify mobile atheromatous plaques and to select appropriate aortic manipulations. Maintenance of cerebral blood flow and blood pressure during cardiopulmonary bypass might be critical issues. Besides, there are conflicting two opinions regarding off-pump CABG; one supports an efficiency for the prevention of stroke while the other advocates no effect. This discrepancy might be explained by the difference of the risk of stroke in the population of the individual study and by the variation of the percentage of aortic clamping or aortic anastomosis in each study. Pharmaceutical therapies such as statin, preventive medication for atrial fibrillation, or antiplatelet are promising methods. Although it is hard to decrease the incidence of the stroke with any single countermeasure, sustained effort should be continued to overcome the stroke associated with CABG.

Background. Arachidonic acid metabolites and platelet-activating factor (PAF) are potentially involved in ischemia-reperfusion (IR) lung injury. A key enzyme regulating their metabolism is cytosolic phospholipase A 2 (cPLA 2 ). Arachidonyl trifluoromethyl ketone (AACOCF 3 ) is reported to be a potent cPLA 2 inhibitor. In the present study, we hypothesized that pharmacological inhibition of cPLA 2 might ameliorate IR lung injury. Methods. To test the hypothesis, we examined the effects of AACOCF 3 in an isolated rat lung model. Three groups were defined (n=6, each): in the vehicle group, lungs were perfused for 2 hours without an ischemic period. In the ischemic groups, 20 mg/kg of AACOCF 3 (AACOCF 3 group) or saline (control group) was i.v. administered 15 min before lung harvest. Lungs were flushed with LPD solution, cold-stored 18 hours, and reperfused for 2 hours. Results. IR increased cPLA 2 activity mainly via alveolar macrophages, sPLA 2 activity, thromboxane and leukotriene formation, and the expression of PAF receptor, whereas AACOCF3 treatment significantly reduced all of these. Compared to the vehicle group, the wet-to-dry ratio, proteins in BAL, and MPO activity increased significantly by twofold, fourfold, and threefold, respectively. Furthermore, the PO 2 dropped from 615.7±31.2 to 452.1±30.9 mmHg at the end of reperfusion (P

Objective To accomplish successful multivessel off-pump coronary artery bypass grafting, safe, reproducible, and effective exposure of all coronary territories is essential. For this purpose, we developed a new, simple, multisuction cardiac positioner. Methods This new cardiac positioner consists of 3 small independent suction cups and suction tubes made of silicone. Unlike an apical suction cardiac positioner, this positioner has no arm. The suction cups can be applied with negative pressure of 300 mm Hg to various surfaces of the ventricle, including not only the apex but also the lateral, inferior, and right ventricular walls, according to surgeon preference. We applied this positioner in 15 clinical multivessel off-pump coronary artery bypass procedures. Results In all cases, all target vessels including those on the lateral or inferior wall were successfully exposed and grafted without hemodynamic compromise. Surgical exposure, especially on the lateral and inferior walls, was quite similar to that of conventional coronary artery bypass graft procedures performed during cardiopulmonary bypass. Conclusions The multisuction cardiac positioner provided reproducible and easy access in multivessel off-pump coronary artery bypass surgery. This simple, variable, and inexpensive cardiac positioner may be used as a new tool to aid in the performance of successful multivessel off-pump coronary artery bypass surgery.

Objective The objective of the present study was to investigate the effectiveness of postoperative oral administration of cibenzoline for the prevention of atrial fibrillation (AF) in coronary artery bypass grafting (CABG). Methods: A total of 39 patients who underwent isolated CABG from September 2000 to February 2001 and who took oral cibenzoline (300 mg per day for 10 days beginning immediately after surgery) were compared to 59 patients who underwent surgery in our department 8 months prior to the study and who did not take cibenzoline for incidence of postoperative AF. Exclusion criteria encompassed age (>80 years), low ejection fraction ( 2.0 mg/dL), and history of supraventricular arrhythmia with or without treatment by anti-arrhythmic drugs. Results: Postoperative AF occurred in 2 patients in the cibenzoline group (2/35, 5.7%) and 20 patients in the control group (20/59, 33.9%). There were significant differences in the incidence of postoperative AF (p=0.002). Multivariate analysis revealed that the administration of cibenzoline reduced the incidence of AF significantly, and that a large number of bypass grafts significantly contributed to postoperative AF in CABG. The number of bypass grafts was significantly larger in the cibenzoline group, indicating that cibenzoline administration significantly suppresses the incidence of AF after CABG in high-risk patients. Conclusions: Postoperative administration of oral cibenzoline for 10 days is one effective method for the prevention of AF after CABG.

The prototype of the miniature vibrating flow pump (VFP) is developed for the external shunt catheter. The cross-slider mechanism is applied to vibrate the tube, which causes the pumping effect. This mechanism results in successful development of the miniature and lightweight VFP. By the use of the prototype VFP, the experiment of the basic pump performance is made in detail based on the authorized procedure in the research field of fluids engineering. The typical H-Q curve of VFP, which is the relationship between the pump head and the flow rate, can be obtained. This result suggests that the miniature VFP developed here can be expected to be used as the booster pump for the external shunt catheter in clinical applications.

Objective: Lipopolysaccharide pretreatment is known to reduce myocardial infarct size, but the mechanism has not been elucidated. We hypothesized that heat shock protein 70, induced by lipopolysaccharide pretreatment, formed complexes with inhibitory κBα, thereby inhibiting degradation and attenuating activation of nuclear factor κB and cellular injury in rat myocardium. Methods: Fifteen Sprague-Dawley rats were given saline solution (control group) or lipopolysaccharide. After 48 hours, 5 hearts in each group were excised without ischemia for examination of heat shock protein 70 and inhibitory κBα levels and detection of heat shock protein 70-inhibitory κBα complexes. Myocardium from the remaining 10 rats in each group was exposed to 30 minutes of ischemia and 30 minutes of reperfusion (n = 5) to evaluate nuclear factor κB activity or to 24 hours of reperfusion (n = 5) to evaluate infarct size. Results: Infarct size was reduced in the lipopolysaccharide group (P

An ultracompact, one piece, totally implantable electromechanical total artificial heart (TAH) has been developed as a permanent replacement for failing hearts. It consists of left and right pusher plate blood pumps (stroke volume 55 ml) made of titanium alloy (Ti-6Al-7Nb) sandwiching a miniaturized electromechanical actuator between them. The diameter of the TAH is 90 mm, with a thickness of 70 mm, yielding an overall volume of 400 ml. It weighs 450 g. Although it is miniaturized, it provided a maximum pump output of 8 L/min against a left afterload of 100 mm Hg. It required approximately 12 watts to provide a pump output of 6.5 L/min with maximum efficiency of 13.5%. To balance left and right flow, the right stroke length was made 10% shorter than the left, and an auxiliary compliance chamber was used to compensate for additional flow differences between them. Motor commutation pulses and a Hall effect pusher plate sensor signal were used in the controller to implement the left master alternate variable rate mode. The calf fitting study revealed excellent anatomic compatibility, and the first successful survivor was obtained in December 2001. Studies of system endurance and biocompatibility are required to ensure long-term reliability. This TAH is promising for permanent replacement of the failing heart as well as for bridge to heart transplantation for the smaller size group of end-stage cardiac patients.

Objectives: Biventricular pacing (BVP) is a new strategy for treating patients with severe congestive heart failure (CHF) and intraventricular conduction delay, but its full potential and technicalities of BVP require further evaluation. We evaluated BVP benefits in 4 patients in whom we implanted a left ventricular lead during primary cardiac surgery.Methods: Four CHF patients treated surgically between October 2000 and August 2001 underwent, at primary surgery, the implantation of leads in the right atrium, right ventricle, and left ventricle (LV) for postsurgical BVP. All patients had severe LV dysfunction and dilatation with intraventricular conduction delay. Surgeries involved CABG alone (n=1), CABG+Dor’s operation (n=2), and tricuspid valve replacement+Maze procedure (n=1). BVP was begun immediately after surgery in all 4 patients. Hemodynamic variables with BVP were compared to those without BVP for each patient, and the utility and technical aspects of implantation were evaluated.Results: BVP increased mean systemic blood pressure by 11% and mean LV stroke work index by 19% in the acute postsurgery period, and reduced mitral regurgitation. Two of the patients were implanted with a generator for permanent BVP, one at 1 month and the other at 6 months after surgery. The threshold of the LV epicardial lead of these 2 patients was below 2 V during follow-up, and BVP was successful.Conclusions: Temporary BVP during the shortterm after cardiac surgery improved cardiac function and decreased mitral regurgitation in all 4 of our patients. Epicardial lead implantation may thus be a useful option during surgical treatment of patients with CHF and intraventricular conduction delay if long-term permanent BVP is indicated.

The Japanese Association for Thoracic Surgery has conducted annual surveys of thoracic surgery throughout Japan since 1987 to determine the statistics regarding the number of procedures according to operative category. Here, we have summarized the results from our annual survey of thoracic surgery performed during 2012. The incidence of hospital mortality was added to the survey to determine the nationwide status, which has contributed to the Japanese surgeons to understand the present status of thoracic surgery in Japan and to make progress to improve operative results by comparing their work with those of others. The Association was able to gain a better understanding of the present problems as well as future prospects, which has been reflected to its activity including education of its members. Thirty-day mortality (so-called ‘‘operative mortality) is defined as death within 30 days of operation regardless of the patient’s geographic location and even though the patient had been discharged from the hospital. Hospital mortality is defined as death within any time interval after an operation if the patient had not been discharged from the hospital. Hospital-to-hospital transfer is not considered discharge: transfer to a nursing home or a rehabilitation unit is considered hospital discharge unless the patient subsequently dies of complications of the operation. The definitions of the Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity of the Society of Thoracic Surgeons and Annual report by The Japanese Association for Thoracic Surgery: Committee for Scientific Affair

To assess the value of procalcitonin (PCT) for the differential diagnosis between infectious and non-infectious systemic inflammatory response syndrome (SIRS) after cardiac operation.Patients diagnosed with SIRS after cardiac surgery and admitted to Department of Cardiovascular Surgery of Tokyo Medical and Dental University Graduate School between April 1st, 2011 and March 31st, 2013 were retrospectively studied. A total of 142 patients with SIRS were included, and they were divided into infectious group (n =47) or non-infectious group ( n =95) according to the diagnostic criteria of the Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock: 2012 (SSCG2012). The patients with infectious SIRS were included, and there were 11 with sepsis, 12 with severe sepsis without shock, and 24 with septic shock respectively.The clinical data of patients were compared, and the receiver operating characteristic curve (ROC curve) was plotted to assess the diagnostic value of infection and non-infectious diseases for PCT, C-reactive protein ( CRP) and white blood cell count ( WBC ) , as well as the diagnosis of the severity of sepsis.PCT, CRP, and WBC were significantly higher in the infectious SIRS group than those in the non-infectious SIRS group [ PCT ( J.Lg/L): 2.80 ( 1.24, 10.20) vs.0.10 (0.06, 0.21), Z=-9.020, P=O.OOl; CRP (mg/L): 158.0 (120.0, 199.0) vs. 58.0 (25.0, 89.0), Z=-7.264,P=O.OOl; WBC ( x 1Q9/L): 15.5 (11.0, 22.6) vs. 9.3 (7.2, 12.6), Z=-5.792, P=O.OOl ]. PCT had the highest sensitivity ( 91.5%) and specificity ( 93.7%) for differential diagnosis, with a cut-off value for infectious SIRS of0.4 7 fLg/L, and the cut-off value of CRP and WBC were 119.5 mg/L and l 0.85 X 1 09/L, respectively. There was no significant difference in WBC among sepsis group, severe sepsis group, and septic shock group (X 109/L: 12.40 (9.10, 24.20),13.30 ( 9.93, 16.93), 20.40 ( 13.45, 28.6), x2=5.638, P=0.060], while PCT, CRP had significant difference (PCT(fLg/L): 1.37 (0.72, 1.85), 3.16 (0.48, 13.24), 3.68 (1.67, 20.96), x2 =7.422, P=0.024; CRP (mg!L): 120.0(74.0, 180.0), 135.7 (81.7, 181.3), 171.1 (151.5, 306.0), x2 =9.524, P=0.009].PCT was more reliable than CRP in diagnosing severe sepsis without shock, but it was ineffective for diagnosing septic shock. The cut-off value of PCT for diagnosing severe sepsis without shock was 2.28 fLg/L, and the sensitivity was 66.7%, specificity was 90.9%.Cut-off value of CRP for the diagnosis of septic shock was 149.5 mg/L, with the sensitivity of 83.3%, and the specificity of 66.7%.PCT was a useful marker for the diagnosis of infectious SIRS after cardiac operation as compared with WBC and CRP. The optimal PCT cut-off value for diagnosing infectious SIRS was 0.47 fLg/L.

Background After restrictive mitral annuloplasty (RMAP) for functional mitral regurgitation (MR), the MR frequently recurs. Papillary muscle relocation (PMR) should reduce the recurrence rate. We assessed the influence of procedural differences in PMR on the postoperative mitral valve configuration. Methods Thirty-nine patients who underwent mitral valve repair for functional MR were enrolled. In limited tethering cases, RMAP alone was performed (RMAP group; n = 23). In severe tethering cases, in addition to RMAP, bilateral papillary muscles were relocated in the direction of the posterior annulus (posterior PMR group; n = 10) or anterior annulus (anterior PMR group; n = 6). We performed pre- and postoperative transthoracic echocardiographic studies, introducing a new index, mitral inflow angle (MIA), to assess the diastolic mitral leaflet excursion. MIA was measured as the angle between the mitral annular plane and the bisector of the anterior and posterior leaflets. Results Postoperative MR grade was significantly reduced in each group (P

A 66-year-old man with a history of diabetes mellitus presented with angina pectoris with 3-vessel disease, and he underwent off-pump coronary artery bypass grafting via median sternotomy. After performing bypass grafting of the left internal thoracic artery to the left anterior descending artery, the appearance of anastomosis configuration appeared to be acceptable. However, transit time flow measurement (TTFM) showed that the mean graft flow was 10 mL/min, which was less than expected despite an acceptable flow curve with a diastolic flow pattern, a pulsatility index (index of resistance) of 2.0, and diastolic filling (proportion of diastole with coronary flow) of 65% (Figure 1). In addition to TTFM, the …

Background This study was performed to assess the value of procalcitonin (PCT) for the differential diagnosis between infectious and non-infectious systemic inflammatory response syndrome (SIRS) after cardiac surgery. Methods Patients diagnosed with SIRS after cardiac surgery between April 1, 2011 and March 31, 2013 were retrospectively studied. A total of 142 patients with SIRS, infectious (n = 47) or non-infectious (n = 95), were included. The patients with infectious SIRS included 11 with sepsis, 12 with severe sepsis without shock, and 24 with septic shock. Results PCT, C-reactive protein (CRP), and the white blood cell (WBC) count were significantly higher in the infectious SIRS group than in the non-infectious SIRS group. PCT had the highest sensitivity and specificity for differential diagnosis, with a cut-off value for infectious SIRS of 0.47 ng/mL. PCT was more reliable than CRP in diagnosing severe sepsis without shock, but it was not useful for diagnosing septic shock. The PCT cut-off value for diagnosing severe sepsis without shock was 2.28 ng/mL. Conclusions PCT was a useful marker for the diagnosis of infectious SIRS after cardiac surgery. The optimal PCT cut-off value for diagnosing infectious SIRS was 0.47 ng/mL.

We have developed a nondepolarizing solution (NDS) that retards myocardial calcium accumulation during cardioplegia. This study compares 1) the membrane resting potential (Em) in Purkinje fibers during cardioplegia induced by NDS or University of Wisconsin solution (UW) at normothermia and hypothermia for 6 h, 2) left ventricular (LV) diastolic function of isolated canine hearts preserved with NDS or UW for 6- and 12 h in hypothermia to elucidate the relationship between diastolic function and myocyte physiology (n = 8, each group), and 3) the effect of Non-depolarizing solution (NDS) compared with Bretschneider's HTK solution on LV diastolic function in isolated rabbit hearts using the Langendorff model in normothermia (n = 10, each group). The membrane resting potential (Em) was as follows: NDS in normothermia, -71 mV (2 min), -65 mV (30 min), and -52 mV (60 min); NDS in hypothermia, -40 mV (1 h) and -32 mV (6 h), while UW in hypothermia 0 mV (6 h). Myocardial calcium accumulation during reperfusion in the NDS groups was minimal and significantly lower than in the UW groups after the 6- and 12 h preservations. Postreperfusion myocardial cyclic adenosin monophosphate (cAMP) and adenosin triphosphate (ATP) concentrations in the NDS groups were closer to normal than in the UW groups after the 6- and 12 h preservations. The postreperfusion myocardial Ca concentration correlated with the cAMP (r = -0.68, n = 25, P = 0.003) and cyclic guanosine monophosphate (cGMP) concentrations (r = -0.69, n = 25, P = 0.003). The left ventricular end-diastolic pressure (LVEDP) after reperfusion correlated with myocardial ATP (r = -0.65, n = 25, P = 0.003) and Ca concentrations (r = -0.68, n = 25, P = 0005). However, the parameter indicating LV elasticity (max LV -dp/dt) correlated with neither the Ca or ATP concentration following reperfusion. NDS prevented stiffness (increased LVEDP) better than HTK during normethermic cardioplegia for 30 min. These results in vitro suggest that NDS prevents myocardial Ca accumulation, depletion of ATP and cAMP, and preserves LV diastolic function, particularly stiffness after reperfusion, for up to 12 h. Furthermore, the myocardial Ca concentration is inversely correlated with the cAMP and cGMP concentrations.

We have evaluated the feasibility of a newly developed single-use, magnetically levitated centrifugal blood pump, MedTech Mag-Lev, in a 3-week extracorporeal membrane oxygenation (ECMO) study in calves against a Medtronic Bio-Pump BPX-80. A heparin- and silicone-coated polypropylene membrane oxygenator MERA NHP Excelung NSH-R was employed as an oxygenator. Six healthy male Holstein calves with body weights of about 100 kg were divided into two groups, four in the MedTech group and two in the Bio-Pump group. Under general anesthesia, the blood pump and oxygenator were inserted extracorporeally between the main pulmonary artery and the descending aorta via a fifth left thoracotomy. Postoperatively, both the pump and oxygen flow rates were controlled at 3 L/min. Heparin was continuously infused to maintain the activated clotting time at 200-240 s. All the MedTech ECMO calves completed the study duration. However, the Bio-Pump ECMO calves were terminated on postoperative days 7 and 10 because of severe hemolysis and thrombus formation. At the start of the MedTech ECMO, the pressure drop across the oxygenator was about 25 mm Hg with the pump operated at 2800 rpm and delivering 3 L/min flow. The PO2 of the oxygenator outlet was higher than 400 mm Hg with the PCO2 below 45 mm Hg. Hemolysis and thrombus were not seen in the MedTech ECMO circuits (plasma-free hemoglobin [PFH]5 mg/dL), while severe hemolysis (PFH20 mg/dL) and large thrombus were observed in the Bio-Pump ECMO circuits. Plasma leakage from the oxygenator did not occur in any ECMO circuits. Three-week cardiopulmonary support was performed successfully with the MedTech ECMO without circuit exchanges. The MedTech Mag-Lev could help extend the durability of ECMO circuits by the improved biocompatible performances.

OBJECTIVES: Surgical ventricular reconstruction (SVR) for patients with severe left ventricular (LV) remodelling due to ischaemic cardiomyopathy is still controversial, because the Surgical Treatment for Ischaemic Heart Failure (STICH) trial demonstrated that SVR not only has no beneficial effect on survival compared with coronary artery bypass grafting (CABG) alone, but also is worse for those with a larger LV. Therefore, we assessed the impact of LV remodelling on the outcomes after SVR for ischaemic cardiomyopathy in Japan, using Di Donato’s LV shape classification. METHODS: From 2000 to 2010, 627 patients underwent SVR for ischaemic heart failure in 11 Japanese hospitals. To assess the patients with an LV ejection fraction (LVEF) of ≤35% like the STICH trial, considering the severity of LV remodelling, the patients with a preoperative LVEF of >35%, no preoperative LV volume assessment and no preoperative LV shape classification were excluded. Finally, 323 patients were selected as the study subjects. The LV shape was divided into three types according to Di Donato’s classification. Types 1 and 3 indicate the aneurysmal and globally akinetic LV, respectively. Type 2 is the intermediate shape. RESULTS: Type 1, 2 and 3 LV shapes were observed in 85 (26%), 104 (32%) and 134 (42%) of the patients, respectively. The preoperative LV volume and diameter increased if the LV became more akinetic (Type 3 > 2 > 1, P< 0.001). LVEF was lower in those with more akinetic LV (P= 0.002). The preoperative LV end-diastolic volume index and LVEF in Type 3 patients were 133 ± 47 ml/m 2 and 22 ± 7%, respectively. Mitral valve repair was more frequently performed for patients with the Type 3 LV shape (65%) than for the others (P< 0.001). The hospital mortality rates were 2.4, 2.9 and 7.4% for Type 1, 2 and 3 patients, respectively (P= 0.16). Kaplan–Meier analysis demonstrated no significant difference in mortality among the three groups (log-rank P= 0.37). The 5-year survival rates were 81, 70 and 73% for Type 1, 2 and 3 patients, respectively. CONCLUSIONS: The severity of LV remodelling did not affect survival after SVR plus CABG. The results of SVR were acceptable even for those with globally akinetic LV due to ischaemic cardiomyopathy.

We developed a control and monitoring unit for pneumatic ventricular assist devices (VADs), which provides optimal fill and empty control and real-time evaluation of pump performance. The flow signal of the inflow cannula is integrated every beat to yield pump filling volume per pump diastole. The ejection signal is triggered when pump filling reaches a preset level. The instantaneous mean flow of each beat (stroke volume/cycle length) is compared with the previous beat, and the threshold level is readjusted to optimize flow. This feedback loop is repeated every beat, and pump filling is immediately adjusted to yield maximum pump flow. Simultaneously the mean flow of every 10 beats is compared with that of the previous 10 beats; then, the ejection time is readjusted to optimize flow. Initial clinical application of this unit supports its effectiveness and reliability.

Intra aortic balloon pumps have been operated inaccurately when used in patients with atrial fibrillation. In 36 pre-operative cardiac surgical patients with atrial fibrillation, the interval between the R wave of the electrocardiogram and the dicrotic notch (R-DCN interval) of the aortic pressure waveform showed significant correlation with the preceding R-R interval by second degree polynomial curves (0.53 < r2 < 0.74, p < 0.01). Based on these results a new algorithm for atrial fibrillation was designed. During brief off periods of the intra-aortic balloon pump in atrial fibrillation, electrocardiograms and aortic pressure waveforms were simultaneously recorded and analyzed to obtain a second degree polynomial curve between the preceding R-R and R-DCN intervals. The precise timing of balloon inflation was controlled using the equation in response to the preceding R-R interval. This new algorithm showed the smallest time lags (SD = 8.5 msec) when compared to other existing algorithms (the Kontron model-10, 53.49 msec; the Aries Medical model-700, 43.69 msec; the Datascope system-90, 25.98 msec; the Mansfield 3000, 19.65 msec; and the Kontron K-2000, 14.89 msec) in mock simulation driving using data obtained from clinically recorded waveforms.

BACKGROUND The relation between infective endocarditis (IE) and renal insufficiency is uncertain. The aim of this study was to investigate active IE with renal insufficiency in cardiac surgery. PATIENTS AND METHODS A retrospective record review was conducted of all cases with IE from January 1998 to July 2009. We identified 38 patients who had undergone surgical intervention (25 males and 13 females, mean age 57.3 ± 15.2 years, range 23-83 years) of IE as defined by the modified Duke criteria. Indications for surgical intervention included new, severe valvular regurgitation with heart failure, intracardiac abscesses, and recurrent embolic events. All patients were divided two groups; one group comprised patients without renal insufficiency (group N, n = 28), the other, those with renal insufficiency (group R, n = 10). RESULTS Mean age of patients in group R was larger than that in of group N (66.3 ± 10.6 vs. 54.1 ± 15.4 years, p = 0.0268), and mean hemoglobin in group R than in group N (8.4 ± 0.9 vs. 10.3 ± 2.5 g/dl, p = 0.0215). In the early outcome, hospital death was greater in group R than in group N (20.0% vs. 0.0%, p = 0.0143). The 8-year survival was significantly worse in group R than in group N (50.0% vs. 96.4%, log rank test: p = 0.0042). Moreover, the 8-year actuarial freedom from cardiac events was significantly worse in group R than in group N (0.0% vs. 60.3%, log rank test: p = 0.0003), too. Renal insufficiency predicted an increase in long-term mortality (OR 12.104, 95%CI 1.349-108.641, p = 0.0259) and morbidity (OR 10.540, 95%CI 2.173-51.129, p = 0.0035). CONCLUSIONS In IE, renal insufficiency may allow for risk stratification of patients undergoing surgical intervention.

Non-ischemic mitral regurgitation( MR) is classified in degenerative MR, infective endocarditis( IE) and rheumatic MR. For degenerative MR, although 100% achievement of successful mitral valve plasty (MVP), it still important to evaluate mitral morphology preoperatively and to select suitable procedure.MR due to IE, the most important thing is to exclude vegetation completely. Then MVP is considered depends on its area of defect. Rheumatic MR is still difficult to accomplish MVP. Mitral valve replacement(MVR) is a main strategy for rheumatic MR.

Basic mechanism of ischemic mitral regurgitation (MR) is augmented leaflet tethering because of the out ward displacement of the papillary muscle by the left ventricular dilation. In 30% of ischemic MR, subvalvular procedure is necessary to eliminate MR. We propose subvalvular procedure aiming at a comprehensive remodeling of the entire mitral complex. This remodeling procedure consists of 3 major concepts; undersized mitral annuloplasty, division and reconstruction of secondary chords, and bilateral papillary muscle relocation. Subvalvular procedure under beating heart is effective to decide the length of artificial chord or papillary muscle relocation.

Last year, we reported in vitro pump performance, low hemolytic characteristics, and initial in vivo evaluation of a disposable, magnetically levitated centrifugal blood pump, MedTech Dispo. As the first phase of the two-stage in vivo studies, in this study we have carried out a 2-week in vivo evaluation in calves. Male Holstein calves with body weight of 62.4–92.2 kg were used. Under general anesthesia, a left heart bypass with a MedTech Dispo pump was instituted between the left atrium and the descending aorta via left thoracotomy. Blood-contacting surface of the pump was coated with a 2-methacryloyloxyethyl phosphorylcholine polymer. Post-operatively, with activated clotting time controlled at 180–220 s using heparin and bypass flow rate maintained at 50 mL/kg/min, plasma-free hemoglobin (Hb), coagulation, and major organ functions were analyzed for evaluation of biocompatibility. The animals were electively sacrificed at the completion of the 2-week study to evaluate presence of thrombus inside the pump,together with an examination of major organs. To date, we have done 13 MedTech Dispo implantations, of which three went successfully for a 2-week duration. In these three cases, the pump produced a fairly constant flow of 50 mL/Kg/min. Neurological disorders and any symptoms of thromboembolism were not seen. Levels of plasma-free Hb were maintained very low. Major organ functions remained within normal ranges. Autopsy results revealed no thrombus formation inside the pump. In the last six cases, calves suffered from severe pneumonia and they were excluded from the analysis. The MedTech Dispo pump demonstrated sufficient pump performance and biocompatibility to meet requirements for 1-week circulatory support. The second phase (2-month in vivo study) is under way to prove the safety and efficacy of MedTech Dispo for 1-month applications.

This study was undertaken in order to clarify the clinical characteristic features and surgical results of coronary artery bypass grafting (CABG) in patients over 65 years of age (group III, n = 43). These patients were compared with 2 other groups of patients, one aged between 50 and 59 years (group I, n = 88) and another aged between 60 and 64 years (group II, n = 54), with respect to mortality, morbidity and late survival. CABG was performed with the saphenous vein under cold K-Mg-cardioplegia with systemic hypothermia. The hospital mortality was 2.3, 3.7, and 4.7 per cent in groups I, II and III, respectively, although no operative mortality was noted in any group. The number of coronary artery lesions increased with age, however, the left ventricular ejection fraction was relatively better preserved in the aged patients than in the younger ones. The 5-year survival rates were 93.4, 95.1 and 96.9 per cent in groups I, II and III, respectively, with most of the late deaths occurring within a year after CABG in each group. In the aged patients, postoperative functional recovery was delayed in the liver and kidney, and postoperative psychosis was not infrequent. The results of this study, indicating a low operative mortality and satisfactory late survival rate, thus strongly support CABG for the aged. Nevertheless, the prevention of postoperative complications is also extremely important for reducing hospital mortality.

Although numerous surgical techniques have been developed for ischemic/functional mitral regurgitation, none has clearly improved patient outcome. We report the clinical application of a new mitral complex remodeling procedure for ischemic/functional mitral regurgitation that allows comprehensive remodeling of the entire mitral complex. The mitral complex remodeling procedure consists of three major concepts: division and reconstruction of secondary chords, undersized annuloplasty, and bilateral papillary muscle relocation.

one month after IR. Result: LVAD+VNS normalized LV end-systolic elastance and decreased LV end-diastolic pressure (EDP) (IR: 14.666.7, VAD: 6.461.5, VAD+VNS: 3.760.4 mmHg, p!0.05), indicating that VAD+VNS fully preserved LV function. NT-proBNP paralleled LVEDP. VAD+VNS strikingly reduced the infarct size (IR: 11.663.1, VAD: 8.762.9, VAD+VNS: 2.960.6%, p!0.05). Conclusions: The combination of VAD with VNS markedly reduces the infarct size and prevents CHF in one month after IR. This treatment would improve the long term mortality resulting from post-infarct chronic heart failure in patients.

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 has become an increasingly popular arterial conduit for coronary artery bypass grafting (CABG). However, the traditional open harvesting technique requires a long incision, and is therefore associated with some wound complications and cosmetic problems. Here, we describe our experience of endoscopic radial artery harvesting (ERAH) through a small incision in 25 patients who underwent CABG.Between February 2, 2004 and January 7, 2005, a total of 25 patients (4 females; mean age: 64+/-10 years) underwent ERAH using the VasoView System (Guidant Corporation, Indianapolis, IN) at our institution. All patients underwent a preoperative Allen test to assess the competence of the palmer arch. Twenty-four radial arteries were harvested from the nondominant arm and one from the dominant arm. The mean clinical follow-up was 8+/-2.9 months.All radial arteries were harvested through a 2-cm incision at the wrist, successfully removed with ERAH and successfully used as CABG conduits. The mean harvest time was 59+/-11 min, and the mean harvested length was 17+/-1.7 cm. No adjunctive procedures were required during vessel harvesting, and no conversions to the open technique were necessary. Harvesting complications included 2 cases of postoperative hematoma and 7 cases of superficial radial nerve paresthesia. Five postoperative angiographies were performed and all radial arteries were patent. Overall, 24/25 (96%) patients were satisfied with the procedure.The ERAH technique was performed as safely as the traditional open technique and the harvested radial arteries were acceptable as CABG conduits. In particular, patient satisfaction with the procedure regarding the cosmetic results was excellent.

A 61-year-old woman suffering from Jarcho-Levin syndrome (JLS) was associated with atrial septal defect and partial anomalous pulmonary venous return and underwent corrective surgery. Pressure controlled postoperative ventilator therapy is preferred in patients with JLS.

Despite wide spread use of the radial artery (RA) graft for coronary artery bypass grafting, the change of hand circulation after RA harvest has not been fully clarified. Severe hand ischemia such as resting pain or gangrene is a rare complication and has been reported in 4 patients. These cases resulted from occlusive artery disease in forearm, which should be carefully explored before RA harvest. Incidence of mild hand ischemia such as hand claudication or fatigue is unknown, but our study suggested that around 10% of the patients developed mild hand ischemia after RA harvest. The blood flow to the forearm territory was decreased by 20% after RA harvest despite the compensatory dilatation of ulnar artery. The presence of low perfusion in the affected hand has been pointed out in some studies. We reported the decreased tissue oxygenation of the affected hand during hand grip exercise. The Allen test is the most popular preoperative screening method, but is associated with considerable numbers of false-positive and false-negative results. Full length scanning of ulnar artery by ultrasonography seems to have a lower false-positive rate. But further clinical experience is necessary to establish a more reliable screening method.