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71歳,男性.68歳時に小嚢性の胸部大動脈瘤(最大径48mm)を指摘された.69歳時に自己免疫性肝炎を発症しステロイドの内服が開始されたため,内科的に経過観察されていた.70歳時,瘤の最大径52mmと拡大傾向を示したため精査したところ遠位弓部大動脈瘤が左鎖骨下動脈にまで及んでいることが判明し,手術適応と考えられた.また,一過性意識障害の既往があったため頸動脈エコーを施行したところ両側の内頸動脈に狭窄病変を有することが判明したが,cold Xe CTにて脳血流の評価を行ったところ,ほぼ正常パターンを示したことから逆行性脳灌流法(retrograde cerebral perfusion: RCP)を併用することで手術可能と判断された.自己免疫性肝炎についても小康状態にありステロイドから離脱していたため,手術方針となった.手術はRCP,no-touch technique, elephant trunkにて上行および弓部大動脈を置換した.術後,重篤な合併症を生じることなく,退院した.本症例のように内頸動脈に狭窄病変を有する症例に対する場合でも,RCPとno-touch techniqueを用いることでより安全に手術を施行しうる可能性が示唆された.

Infection after pacemaker implantation can be the most lethal potential complication, although such infections occur infrequently. In this report, we review our experience with patients who were infected after pacemaker implantation and assess their treatment. The infection rate was 1.3% (9 patients) after 712 operations performed in 588 patients. Four men and five women were infected; their mean age was 74.4 years (range, 66 to 86 years). The infection rates after the initial implantation and the second operation were 0.85% and 2.7%, respectively. Two of the nine patients underwent palliative two-stage operations, which included first removing the generator and subsequent irrigation with temporary pacing before a new pacemaker system was implanted during the second stage. Two patients underwent radical two-stage operations (without abandoning old leads); one of these underwent cardiopulmonary bypass after treatment for generalized septicemia. One patient underwent relocation of the pocket 1 month after the onset of pacemaker infection. The remaining four patients underwent palliative one-stage operations, in which new pacemaker units were implanted in the contralateral sides at the same time the first generator was removed. All of the patients were alive and well postoperatively. No recurrent infections were recognized. Therefore, a palliative one-stage operation (“retain old leads” procedure) might be an effective procedure of choice for patients with localized infections over the pocket. Furthermore, irrigation with function water and systemic antibiotic prophylaxis could be effective as measures against infection.

Two patients had percutaneous cardiopulmonary support (PCPS) used as a bridge to emergency surgery. A 66-year-old man admitted with profound cardiogenic shock underwent direct stenting under PCPS with the diagnosis of acute myocardial infarction of the left main trunk, with the intention of performing revascularization as soon as possible. Subsequently, double coronary artery bypass grafting was successfully accomplished. A 69-year-old woman, admitted with acute heart failure due to critical aortic stenosis, manifested cardiogenic shock while undergoing catheterization. PCPS was immediately instituted until the acute deterioration of her hemodynamic state could be reversed, and was continued uneventfully till aortic valve replacement was performed. These results suggest that the current PCPS system is an effective response to acute circulatory collapse and will contributed to the improved survival of patients.

Successful reconstruction of the aortic annulus for perivalvular leak following combined valve replacement was performed in two patients, 6 and 7 years postoperatively, using Manouguian's operation. A fistula was seen at the junction of the aortic annulus and the superior or inferior margin of the patch used for enlargement. This fistula was closed from both sides; from the left atrium with reinforced Teflon pledgets and from the aorta using a patch. Successful reconstruction of the aortic annulus was made, and no regurgitation was seen after the operation.

According to the literature, the incidence of pannus formation with the St. Jude Medical prosthetic aortic valve has been reported at 0.03% and 0.14% (per patient-year), with no case report of St. Jude Medical prosthetic aortic valve malfunction due to pannus formation. Between 1980 and 1999, 1, 186 patients underwent aortic valve replacement at our institute. We encountered 2 aortic valve malfunctions due to pannus formation, including the case of a 53-year-old woman who suffered a St. Jude medical aortic valve malfunction 13 years after the initial operation. A second aortic valve replacement was successful and the postoperative course was uneventful. The possibility of pannus formation on St. Jude Medical aortic valves must thus be considered and its mechanism clarified.

It is still unclear whether cerebral perfusion is affected during off-pump coronary bypass grafting (OPCABG). We investigated the predictive value of the neurobiochemical markers of brain damage and cerebral perfusion in relation to early neuropsychological outcome after OPCABG.We performed OPCABG in ten patients (mean age, 63.4 +/- 5.5 years). A 5.5 F oximetric catheter was placed in the jugular bulb to continuously measure jugular oxygen saturation (SjO(2)) during OPCABG. We also examined the activity of daily living (ADL) index and performed the Mini-Mental State Examination (MMSE) to assess neuropsychological state preoperatively and 7 days postoperatively. Venous serum levels of neuron-specific enolase (NSE) and brain-specific creatine kinase (CK-BB) were measured preoperatively and 24 h after skin closure.The mean arterial blood pressure and the SjO(2) during anastomosis of the left circumflex coronary artery (Cx) were significantly lower than that of the left anterior descending coronary artery (LAD) (P0.001). None of the patients died. There was no transient or permanent neurologic deficit. Cognitive decline was evident in two patients with a low SjO(2) and a high postoperative NSE level. The postoperative CK-BB value was normal in all patients.Monitoring intraoperative continuous cerebral oxygen desaturation and postoperative NSE levels could be useful for predicting early neuropsychological outcome after OPCABG.

To compare the arch-first technique with conventional aortic arch reconstruction 19 patients were randomly assigned to either procedure. Nine patients underwent the arch-first technique (group A) and 10 underwent the conventional technique (group B). There were no hospital deaths and no significant differences between groups in terms of intraoperative bleeding or the duration of operation cardiopulmonary bypass aortic crossclamping recovery from anesthesia or intensive care. The mean duration of retrograde cerebral perfusion via the superior vena cava was significantly shorter in group A (41.7 ± 10.4 min) than group B (63.9 ± 10 min). Transient neurologic dysfunction was noted in 4 (44%) patients in group A 6 (60%) in group B postoperatively but there was no permanent neurologic dysfunction in either group. The arch-first technique makes it possible to reduce the duration of cerebral ischemia retrograde cerebral perfusion via the superior vena cava reestablish antegrade cerebral perfusion earlier without damaging severely atheromatous arch vessels or conducting retrograde cerebral perfusion via a femoral artery. This technique has the potential to reduce the incidence of neurologic dysfunction.

Purpose. Preoperative autologous blood donation reduces exposure to homologous blood transfusions in cardiac surgery. The purpose of this study was to ascertain the volume of predonated autologous blood needed to avoid homologous blood transfusion in scheduled off-pump coronary artery bypass grafting (off-pump CABG). Methods. Fifty-six patients underwent scheduled off-pump CABG between January 1999 and December 2000. These patients all donated either 400 ml (group 1, n = 33) or 800 ml (group 2, n = 23) of autologous blood before operation. These patients donated at a rate of 400 ml per week. All patients were given an equal volume of saline solution at the time of autologous donation. Results. There were no significant differences in the mean age, mean body weight, mean preoperative hematocrit values, mean graft number, or mean volume of intraoperative blood loss between groups 1 and 2. There was a significant difference in the mean postoperative day-7 hematocrit value (33.6% ± 1.3% vs 39.3% ± 1.3%, P ≪ 0.05). The rates of avoiding homologous blood transfusion were 63.6% in group 1 and 100% in group 2 (P ≪ 0.05). Conclusions. Autologous blood transfusion is effective for reducing the homologous blood requirement. We believe that an 800-ml predonation is sufficient to avoid homologous blood transfusion in scheduled off-pump CABG; furthermore, patients with cardiovascular disease, including severe coronary artery disease, should be administered saline along with the blood donation.

A 52 year-old man underwent aortic valve replacement and ascending aortic replacement (Wheat procedure) for acute dissection (Stanford type A) and aortic regurgitation (grade 3/4). At that time, the aortic root was slightly dilated at about 45 mm and the descending aorta was within a normal range at about 35 mm. Forty months after the initial operation, a follow-up chest enhanced computed tomography showed an aortic root aneurysm about 60 mm in diameter, a thoracic aortic aneurysm about 70 mm in diameter and chronic aortic dissection. First we performed the Bentall procedure, innominate artery and left common carotid artery replacement by 12 mm, and 10 mm Hemashield grafts during selective cerebral perfusion. After 10 weeks, we carried out aortic arch, descending aorta and left subclavian artery replacement. The postoperative course was uneventful and postoperative examination demonstrated a good surgical result. Histological findings of the aortic aneurysm wall showed cystic medial necrosis, but Marfan's syndrome was excluded clinically. We could diagnose aortic root aneurysm by regular follow-up chest enhanced computed tomography (CT) and echocardiography. Therefore, cases with slight dilation of the aortic root in the Wheat procedure should undergo regular follow-up evaluation by chest enhanced CT and echocardiography.

The purpose of this study was to evaluate the clinical outcome of composite valve graft replacement in 193 patients with aortic valve disease and aneurysm of the ascending aorta from January 1980 to June 1999. The clinical outcome was compared between the patients diagnosed with Marfan syndrome (M group) and those without Marfan syndrome (non-M group), between those with aortic dissection (AD group) and without dissection (non-AD group), between 2 different techniques for coronary artery reattachment (modified Bentall [mB] and modified Piehler [mP]), and between the time of operation (1980-1989 and 1990-1999). Long-term outcome of this procedure was almost satisfactory with actuarial survival of 71.5 +/- 4.4% at 10 years and freedom from reoperation of 76.5 +/- 4.4% at 10 years. Freedom from cardiovascular events and freedom from reoperation were significantly lower in the M group and AD group than in the non-M and non-AD groups. Also, actuarial survival was significantly higher in the latter 10 years compared with the former 10 years. It was concluded that the improvement of perioperative management and proper selection of the technique for coronary artery reattachment could have improved the clinical outcome. In patients with Marfan syndrome or aortic dissection, there still remains a higher risk of cardiovascular event and future reoperation. Extensive aortic reconstruction or staged operation should be performed in such patients.

BACKGROUND JTV519 is know to protect cardiomyocytes from calcium overloading-induced damage. The aim of this study was to investigate the potential protective effect of JTV519 on myocardium subjected to prolonged ischemia and the underlying mechanism of such protection. The effect of JTV519 was also compared with that of diltiazem, a 1,5-benzothiazepine derivative. METHODS Isolated rat hearts were randomly divided into three groups. Control hearts were arrested with histidine-tryptophan-ketoglutarat (HTK) cardioplegic solution alone. In the JTV519 group of hearts, cardiac arrest was achieved with JTV519 (10(-3) mmol/L) in the HTK solution. Hearts in the diltiazem group were arrested with diltiazem (0.5 mmol/L) in the HTK solution. All the hearts were then subjected to 6-hour storage in HTK solution at 4 degrees C. RESULTS After a 30-minute reperfusion, the left ventricular developed pressure in the JTV519 and diltiazem groups were improved significantly compared with the control group. There was a significantly lower left ventricular end-diastolic pressure level and higher recovery of coronary flow in the JTV519 group than in the control group. The postischemic intracellular calcium concentration was attenuated by adding JTV519 or diltiazem to HTK cardioplegia. CONCLUSION As an adjunct to cardioplegia, JTV519 showed a significant protective effect on myocardium undergoing 6 hours of ischemia. The beneficial protective effects of JTV519 are correlated with its ability to inhibit the postischemic rise in intracellular calcium.

Mechanisms through which the denervated heart responds to supine exercise were assessed in various ways in seven cardiac transplant recipients, 1–37 months after surgery. The results were compared with those in 15 normal subjects. The heart rate at rest and after exercise in transplant patients was 30% higher than normal (P < 0.01). Although cardiac output at rest was similar in both groups, early in exercise the means by which cardiac output increased in the transplant patients differed from normal. In the transplant recipients during the early stage of exercise, the blood norepinephrine level was significantly elevated, and the percent fraction shortening and velocity of circumferential fiber shortening (Vcf) was also higher than in normal subjects with an approximately similar heart rate. The level of atrial natrium diuretic peptide was also significantly increased during exercise by augmented preload (P < 0.01). These results support the concept that in the transplanted heart, there are increases in cardiac output via mechanisms different from those in normal hearts.

Our experience consisted of 16 patients with end-stage heart failure who needed assist devices as a bridge to transplantation before June, 1996. There were 14 males and two females; aged 15–59 (mean 49.0 ± 2.5) years. Thirteen had ischemic cardiomyopathy; three had idiopathic dilated cardiomyopathy (one was associated with muscular dystrophy). Four types of assist devices were included in this study: 16 Bio-Medicus centrifugal pumps [seven for unilateral left ventricular assist devices (LVAD), six for biventricular assist devices (BVAD), and three for right ventricular assist devices (RVAD) combined with other pumps], four Abiomed pumps (left side), one Novacor pump (left side), and one HeartMate pump (left side). The period of support ranged from 0 to 75 days (mean 10.8 ± 4.5 days). Nine patients had an intra-aortic balloon pump inserted in conjunction with the assist devices. Complications during the support period included bleeding that required reopening of the sternotomy (n = 6), infection (n = 4), neurologic disorders (n = 2), renal failure (n = 1), and respiratory failure (n = 5). Ten patients had cardiac transplantation and six died awaiting a donor heart. One patient was weaned from the LVAD, but died before transplant. Causes of deaths before transplant were right heart failure (n = 3), neurological disorder (n = 2), and respiratory/renal failure (n = 1). After transplantation, there were two early and one late mortalities. The mean survival period was 28.3 ±11.4 months. In conclusion, assist devices may allow for a substantial number of patients with end-stage cardiac failure to receive transplants. Early ventricular assist device implantation and appropriate right ventricular support may reduce patient mortality and improve transplantation outcome.

The purpose of this study was to compare the myocardial protective effect of histidine-tryptophan-potassium and glucose-insulin-potassium cardioplegic solutions in patients with a dilated heart (left ventricular diastolic diameter55 mm, left ventricular systolic diameter45 mm) associated with prolonged cross-clamp time (longer than 200 minutes).We selected 20 patients with dilated hearts due to severe aortic regurgitation. Glucose-insulin-potassium cardioplegia was used in 11 patients and histidine-tryptophan-potassium cardioplegia was used in 9 patients.After operation, the cardiac index was significantly increased in the histidine-tryptophan-potassium group (p0.05). Postoperative percent fractional shortening was 13.4% +/- 3.1% in the glucose-insulin-potassium group and 23.6% +/- 2.6% in the histidine-tryptophan-potassium group (p0.05). Creatine kinase levels were significantly lower in the histidine-tryptophan-potassium group than that in the glucose-insulin-potassium group (p0.05). The incidence of ventricular arrhythmia (higher than Lown's grade 2) was lower in the histidine-tryptophan-potassium group.These data support the superiority of the histidine-tryptophan-potassium method over the glucose-insulin-potassium method for protection of the dilated heart during prolonged ischemia in open heart operations.

A 41-year-old man with aortic stenosis, mitral stenosis, and tricuspid regurgitation due to Maroteaux-Lamy syndrome underwent aortic and mitral valve replacement with tricuspid annuloplasty. The annular diameter of the aortic and mitral valves was extremely small. The valve prostheses were 19 mm in diameter in the aortic position and 25 mm in the mitral position. Histologically, the valves showed thickening and hyalinization of the collagen fibers, and the presence of foamy cells that contained a large quantity of pure acid mucopolysaccharide. On an echocardiographic examination performed 2 years after the surgery, the peak systolic gradient of the trans-aortic valve was 18 mmHg at rest, and 26 mmHg during exercise. Careful observation of the residual pressure gradient will be needed. The patient's present New York Heart Association (NYHA) status is grade I and he has returned to work.

This study was carried out to investigate optimum immunosuppression when xenografts were used as a bridge to allotransplantation. Xenotransplantations were conducted with Golden hamsters as the donors and Lewis rats as the recipients. The animals were assigned to eight groups of differing immunosuppressive protocols and results were compared with a control group that received no immunosuppression. In groups A, B, and C, FK506 was administered at different dosages: 0.75, 1.0, and 1.25 mg/kg per day, respectively. In groups D and E, deoxyspergualin (DSG) was given at 10 and 20mg/kg per day, respectively. group F received cyclosporin (10 mg/kg per day) and groups G and H received combination therapy of FK plus DSG (group G, FK 0.5mg/kg per day + DSG 10mg/kg per day; group H, FK 0.5mg/kg per day + DSG 5mg/kg per day). In a second experiment, to investigate the suppression of hyperacute rejection and bridge use of xenograft, the recipients were sensitized by skin xenografts and allotransplantations were then performed. The mean graft survival (days) of the xenografts was significantly prolonged in groups G and H (P < 0.01). The mean serum anti-hamster titer (IgG; %) 10 days after xenotransplant was 58.3 in the controls; the value was significantly suppressed in group G (5.8) and group H (8.9) (P < 0.01). The combination of FK plus DSG significantly prolonged allograft survival following xeno-sensitization, for up to 35.2 days, in comparison with 0.2 days in the control. In conclusion, the combination of FK plus DSG showed significant suppressive effect in xenografts, making it possible to use xenografts as a bridge to allotransplantation.

We encountered a patient with coronary perforation showing cardiac tamponade and shock that occurred during debulking by directional coronary atherectomy. We successfully performed emergent pericardial drainage and aorto-coronary bypass procedures. Bypass surgery is recommended to avoid perioperative myocardial infarction in cases such as ours since the native coronary artery may be at risk of being occluded or narrowed due to oppression by the hematoma and destroyed intima.

Noninvasive monitoring of cardiac rejection has been the most challenging aspect of cardiac transplantation. Our previous study [1] revealed that the cardiac rejection originates in the right ventricle and shifts to the left ventricle. Therefore, it is possible that the wall motion of the right ventricle could have deteriorated at the initial stage of the rejection process. In this study, we investigated the efficacy of cardiac impedance in assessing the contractility of the right ventricle, and its correlation with cardiac rejection, using a rat model. In experiment 1, seven mongrel dogs were used. The relationship between cardiac impedance and left ventricular wall motion was evaluated using shortening fraction and Emax as an indicator. The amplitude of cardiac impedance was significantly correlated with changes in Emax and the shortening fraction of the left ventricle by modification with isoproterenolol (0.1µg/kg per min) and propranolol (0.2mg/kg) infusion. In experiment 2, to investigate the sensitivity and durability of this method, 35 heterotopic heart transplantations were carried out in rats. The transplanted rats were divided into five groups. To evaluate sensitivity, the cardiac impedance of allografts was compared with that of autografts. In allografts, the impedance declined from day 4, correlating with the histological findings of cardiac rejection. The cardiac impedance was reflected in response the reverse effect, brought about by the infusion of methylprednisolone. This method also had a satisfactory durability for 3 weeks. We concluded that cardiac impedance is a sensitive indicator for detecting the wall motion of the heart. Using this technique, cardiac rejection might be predicted; the method would also be useful in assessing the reverse effect occurring after treatment with steroids.

Background: Intracoronary transfer and expression of recombinant genes in the intact heart is now feasible. In the transplant setting, local modulation of host immune responses by a genetically modified allograft may offer an attractive alternative to systemic immunosuppression. Methods: We tested the efficacy and in vivo effect of intracoronary transfer of two immunosuppressive cytokine genes. First-generation E1-deleted adenoviral vectors expressing the Epstein-Barr virus interleukin-10 (AdSvIL10) or human transforming growth factor—β1 (AdCMVTGF-β) were used. Rabbit cardiac allografts were transduced during cold preservation by slow (1 ml/min) intracoronary infusion of 1010 pfu/gm diluted viral vectors and then implanted heterotopically. Controls included E1-deleted adenovirus (Ad5dl434) and AdCMVLacZ. Beating allografts were collected on day 4 for analysis of gene transfer efficacy and distribution. Additional grafts were used for evaluation of alloreactivity (n = 34). Results: Mean allograft viral uptake was 81% (up to 91%). Polymerase chain reactions and reverse transcription–polymerase chain reactions confirmed the presence and expression of both genes in the grafts. β-Galactosidase staining in AdCMVLacZ-infected grafts demonstrated efficient gene expression, which was highest (100%) in subepicardial regions. More homogeneous transmyocardial distribution of the transgene (in 25% to 40% of cells) could be achieved by pulsatile slow delivery. Allograft survival was 6.9 ± 0.9 days in controls (n = 12), 11.1 ± 1.7 days in AdCMVTGF-β–infected grafts (n = 11, p < 10), and 11.2 ± 3 days in AdSvIL10-infected grafts (n = 11, p < 10). Histologic scores (blinded) showed significantly (p < 0.005) higher regression coefficients for rejection in controls compared with both cytokine-transduced groups. Perioperative administration of cyclosporine A (INN: ciclosporin) to recipients had no effect on survival of AdCMVTGF-β–infected grafts but reduced survival of AdSvIL10-infected grafts. Conclusions: Intracoronary gene transfer of immunosuppressive cytokines to cardiac allografts is efficient and effectively prolongs graft survival. Vectors that would induce long-term expression of such genes may make this approach clinically applicable. (J Thorac Cardiovasc Surg 1997;114:923-33)