The Immunosuppressive effects of prostaglandin E₁ (PGE₁) used in cardiopulmonary bypass (CPB) operation were studied. We examined 30 patients, with ischemic heart diseases. The patients were divided into 3 groups: 11 patients given PGE₁ in group PG (G-PG), 10 patients given amurinon, a phosphodiesterase inhibiter, in group A (G-A), and 9 patients not given either of those drugs in the control group (G-C). Immunologically, lymphocyte subpopulations, and adhesion molecule expression on cell membrane and phagocytosis of neutrophils were analyzed before, at the time of, and after the operation until POD 7. The prominent effects of PGE₁ were observed on neutrophils. The expression of CD 62L, an adhesion molecule designated as L-selectin, on the cell surface membrane of neutrophils significantly increased during and after CPB in G-A and G-C, but it remained unchanged in G-PG during the observation period. Moreover, CPB caused an enhancement of the phagocytic activity of neutrophils in all groups, but its degree was much less in G-PG than in the other two groups. Among lymphocyte subpopulations, the number of CD 3⁺T-cells in G-PG rather than that of CD 20⁺B-cells reduced more greatly than those values observed in G-A and G-C. The decrease of T-cell number, throughout the observation period, in G-PG seemed to be mainly due to the decrease of the number of CD 4⁺T-cells designated as helper T-cells, although the number of CD 8⁺T-cells esignated as killer/suppressor T-cells slightly decreased on PODs 3 and 7. Amurinon, as a whole, did not exert any significant effect either on lymphocytes or on neutrophils in our experiments. Taken together, these results show that the treatment of patients with PGE₁ during CPB causes suppressive effects on immunorelevant cells. It may mitigate the activity of neutrophils, which are suspected as a possible culprit causing reperfusion injury. However, these suppressive effects, including the lowered numbers of CD 4⁺T-cells, may render the patients more vulnerable to infection. Much more intensive cares is required in these patients after operations.

View full abstract

Recently we reported that tumor necrosis factor-α (TNF-α) mRNA expression and the development of postoperative intimal hyperplasia (IH) is different in rat epigastric vein interposition graft, compared to femoral artery re-anastomosis. We evaluated whether a TNF-α suppressive agent, FR-167653 (Fujisawa Pharm. Co., Ltd., Osaka) could suppress IH or not. Eleven Lewis male rats (480±8g) were studied. The epigastric vein graft was interposed into the common femoral artery. They were divided into two groups: group FR (n=5) with 2.0μg/g of FR-167653, and group C (n=6) with same dose of saline instead of FR-167653. The intimal areas of vein grafts were measured at 4 weeks postoperatively. The mean intimal area in group FR was significantly decreased, compared with group C (0.160±0.057mm² vs. 0.434±0.045mm², p<0.01). These results suggest that the TNF-α suppressive agent FR-167653 may suppress the postoperative intimal hyperplasia that occurs on the interposition vein graft in rats.

View full abstract

We evaluated long-term results of 126 consecutive bypass surgeries for chronic limb ischemia including 54 aorto-femoral (AF), 26 femoro-femoral crossover (FF), 7 axillo-femoral (AxF), and 39 femoro-above the knee popliteal (FP) bypasses. Patients who had undergone FF bypasses were significantly older than those who received AF bypasses (p<0.01). Preoperative ankle brachial pressure indices (ABI) of the AxF and FF patients were significantly lower than those of AF patients (p<0.05). Compared with AF patients, the AxF and FF groups included significantly higher percentages of Fontaine III and IV limbs treated by limb salvage surgery (p<0.05). The cumulative graft patency rates 5 years after AF, FF, and FP bypasses were 94.7%, 91.3%, and 64.3%, respectively. In the FP group, patients with intermittent claudication before surgery showed a 5-year graft patency rate of 82.5%, while that in patients who underwent surgery for limb salvage was 43.3%. The secondary graft patency rates 5 years after AF, FF, and FP bypasses were 94.6%, 91.3%, and 83.3%, respectively. All patients whose bypass grafts were occluded were male and were smokers. Poor run-off and insufficient anticoagulation therapies were also associated with graft occlusion. Two of the 12 patients who developed graft occlusion underwent limb amputation.

View full abstract

The valvular function after aortic valve replacement was examined using Doppler echocardiography and changes in serum lactate dehydrogenase (LDH) and free hemoglobin levels were assessed. Data for the ATS Medical open pivot prosthetic valve were compared with those of the St. Jude's Medical prosthetic (SJM) valve, a similar bileaflet valve. These have been used in the past 5 years. There were 23 patients with ATS valves (13 men and 10 women, with a mean age of 60.4±13.8 years) and 16 patients with SJM valves (10 men and 6 women, with a mean age of 61.4±8.7 years). The left ventricular diastolic diameter index (LVDdI), left ventricular systolic diameter index (LVDsI), % fractional shortening (%FS) and left ventricular mass index (LVMI) were determined by echocardiography. The peak pressure gradients of the aortic prosthetic valves were calculated by a simplified Bernoulli equation. Postoperative LVDdI, LVDsI and LVMI were not significantly different in the ATS group and the SJM group. However, the %FS of the ATS group was significantly higher than that of the SJM group with aortic stenosis. The pressure gradients at the aortic prosthetic valve position were not significantly different between ATS and SJM valve in the 19-mm, 21-mm and 23-mm size. Postoperative improvement or recovery of the serum LDH level was observed significantly more frequently in the ATS group than the SJM group (p<0.005). The free hemoglobin level of the ATS group was also lower than that of the SJM group (p<0.005). We demonstrated satisfactory valvular function of the ATS valve compared with the SJM valve. Postoperative improvement of hemolysis was observed significantly more frequently and more rapidly in the ATS valves.

View full abstract

A 51-year-old woman suffered from a sudden onset of anterior chest pain and was referred to our hospital on the suspicion of an anginal attack. The exercise ECG showed findings of an anterior lesion and ischemia. Coronary angiography also revealed left anterior descending branch fistula and circumflex branch fistula connecting to the main pulmonary artery trunk. Direct closure was performed for both intra-pulmonary openings under cardiopulmonary bypass. The postoperative course was uneventful and the patient did not show any precordial pain. Coronary angiography showed no coronary organic narrowing, but contrast medium remained in the fistulae although there was no left to right shunt. Ligation of the fistulae had to be performed simultaneously to confirm complete obstruction of the coronary-pulmonary arterial fistulae. The antiplatlet agent is administered to the patient to prevent occurring myocardial infarction caused by thrombus which might be formed in fistulae.

View full abstract

A 63-year-old man was admitted because of sudden hematemesis and melena. Seven years previously, he had had a woven Dacron aorto-biiliac graft inserted for abdominal aortic aneurysm. Aorto-enteric fistula was diagnosed based on the clinical findings and enhanced computed tomography. It was not clear whether the insected Y graft was infected. We first reconstructed the axillo-bifemoral bypass and then removed the Y graft. Good result can be obtained with prompt surgical intervention.

View full abstract

A 60-year-old man with impending rupture of abdominal aortic aneurysm was transferred to our hospital. The patient entered a state of shock because of rupture during a CT scan examination. Emergency in site reconstruction with a dacron Y-graft was performed. There was massive intraperitoneal bleeding but no apparent abscess formation around the aneurysm. No drain was placed. A subcutaneous abscess that developed postoperatively was cured by open drainage and local antibiotic administration. Culture from both the aortic wall and the subcutaneous abscess revealed Salmonella infection. After subsequent intravenous antibiotic therapy for 45 days, the patient was discharged without any evidence of remaining infection.

View full abstract

A 36-year-old man was admitted to our hospital due to infectious endocarditis and severe mitral regurgitation caused by a prolapsed anterior leaflet. Mitral valve repair with chordal replacement using expanded polytetrafluoroethylene was performed and the post operative course was uneventful. One year after the first operation, he was readmitted with a high fever and lumbargo. Echocardiography revealed vegetation on the anterior mitral leaflet and computed tomography of the brain showed cerebral infarction. Blood culture was positive for Staphylococcus aureus. Inflammatory symptoms improved following multiple antibiotic medication and the blood culture became negative. Echocardiography demonstrated the disappearance of the vegetation, but moderate grade mitral regurgitation remained. We performed mitral valve replacement instead of repair because the infectious lesion extensively destroyed the anterior mitral leaflet. In order to determine the appropriate time for surgical treatment of infectious endocarditis, we must consider several factors, such as the effectiveness of antibiotic treatment, potential cerebral complications, and the degree of damage to the valve and surrounding structures.

View full abstract

The patient was a 15-month-old girl with Down's syndrome. She had a heart murmur on the first day after birth. The echocardiogram revealed that she had the tetralogy of Fallot (TOF) and mitral insufficiency (MI). She was observed because she had no heart failure or cyanosis. However, she developed heart failure with progressive MI. Then, she was admitted to our medical center for surgical treatment. During the operation, it was confirmed that the primary septum was intact and a large ventricular septal defect was located at the inlet to outlet portion with anterior malalignment. Each leaflet of the atrioventricular valve were attached to the same level and the ventricular septum was scooped out. TOF with endocardial cushion defect (ECD) without primary septal defect was diagnosed based on the operative findings. Surgical repair was performed through the right atrium and pulmonary artery. She was discharged 17 days after operation without any complications. This was a very rare combination of TOF with ECD without a primary septal defect. We discussed this rare condition with a review of the literature.

View full abstract

A 36-year-old man underwent partial left ventriculectomy (PLV) to treat end-stage dilated hypertrophic cardiomyopathy. Mitral valve replacement and tricuspid valve annuloplasty were performed to correct the mitral and tricuspid valve insufficiency. The patient suffered ventricular tachycardia and ventricular fibrillation (VT/VF) soon after surgery, but antiarrhythmic-drug therapy was sufficiently effective to treat the VT/VF. On the third postoperative day, an implantable cardioverter-defibrillator (ICD) was implanted to prevent these arrhythmias. Two months later after his discharge from the hospital, recurrent VT/VF appeared and was supposedly associated with renal failure. Continuous hemodialysis was efficacious to ameliorate the systemic circulation, and ventricular arrhythmias disappeared. He survived due to 18 ICD shocks. In appropriately selected patients, ICDs have been recognized as one of the cost-effective therapeutic options. ICDs might be recommended for patients in the postoperative period of PLV who have potentially lethal ventricular arrhythmias resistant to antiarrhythmic-drug therapy.

View full abstract

A 34-year-old man had been in a motor vehicle accident at age 21. Thirteen years later, he complained of fatigue and palpitations, and was evaluated at an outside hospital. Echocardiography revealed severe tricuspid regurgitation and the patient was referred to our institution for treatment. The anterior leaflet of the tricuspid valve was torn and the attached chorda was also torn. The torn anterior leaflet was sutured directly, and an artificial chorda was created using an e-PTFE suture. An annuloplasty was performed with a 34mm Carpentier-Edwards ring. The patient's recovery was uneventful, and postoperative echocardiography revealed no regurgitation.

View full abstract

A 2-month-old boy developed Methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after bidirectional Glenn anastomosis for hypoplastic left heart syndrome. After reexploration, only the skin was closed but the sternum left open, and continuous mediastinal irrigation using saline containing isodine was commenced at an infusion rate of 20-40ml/h. The sternum was closed on day 7 and irrigation was stopped on day 21. The patient was weaned from the ventilator 4 days later, and is currently in a good condition awaiting a Fontan operation.

View full abstract

Reoperations after operations for acute type A aortic dissection were performed in two cases under deep hypothermic circulatory arrest. In case 1, the aortic arch replacement was performed with an inclusion technique seven years ago. The reason for reoperation was the leak from the suture lines of all anastomosis sites. Three sites of leak were closed putting sutures with pledgets. In case 2 the graft replacement of the ascending aorta was performed five years ago. The reason for reoperation was the persistent dissection from the aortic arch to the thoracic descending aorta due to the new entry formation at the site of the aortic clamp. At first the graft replacement of the thoracic descending aorta was performed, followed by arch replacement. As these conditions are preventable, we should perform the open distal anastomosis technique without using a clamp and graft replacement of aortic arch with the branched graft. Moreover, deep hypothermic circulatory arrest may appear to be a valuable adjunct for reoperation after operation on acute type A dissection.

View full abstract

We report a 25-year-old man with ventricular septal perforation due to blunt chest trauma. He was transferred by ambulance to our hospital following a traffic accident. On admission, he had no cardiac murmur. Two days later, a pansystolic murmur appeared over the left lower sternal border. Doppler echocardiogram revealed a large left-to-right shunt through a ventricular septal perforation. We postponed surgical treatment as long as possible because he also exhibited bronchial bleeding due to a lung contusion. Surgical repair of the ruptured ventricular septum was performed 8 days after the chest trauma, because the pulmonary to systemic flow ratio was elevated to 4.6 and cardiac function had deteriorated. During the operation, the site of the septal perforation was easily detected by epicardial echocardiography. A 4-cm tear in the muscular septum was closed through a right ventriculotomy using a pericardial patch reinforced with a Dacron patch. Postoperative recovery was uneventful with the exception of transient right ventricular failure. There was no residual shunt.

View full abstract

Retroperitoneal lymphocele is a very rare complication of abdominal aortic aneurysm repair. An abdominal aortic aneurysm 5cm in diameter was repaired with the retroperitoneal approach in a 70-year-old man. On the 17th postoperative day, mild abdominal distention was reported and a fever of 38°C had developed. A computed tomography scan demonstrated massive fluid collection in the retroperitoneal cavity. Total parenteral nutrition with complete fasting was initiated. A pigtail catheter was inserted into the cavity, and 1, 000ml of milky, odorless, alkaline and sterile fluid was drained. Subsequently, a retroperitoneal lymphocele following abdominal aortic surgery was diagnosed. The leaking lymph tract was ligated because the lymphocele did not improve with long term drainage. Administration of ice cream through the nasogastric tube was used to detect the leaking lymph tract, and we ligated the leaking lymph tract completely. We believe that surgical repair is an alternative strategy when conservative treatments, i. e., fasting, intravenous hyperallimentation and drainage are not effective.

View full abstract

Concomitant occurrence of acute aortic dissection and atherosclerotic aneurysm is rare. In such a circumstance, rupture of the existing aneurysm is the more likely scenario. In general, atherosclerotic plaque frequently serves to terminate the dissection process. A 65-year-old man with an abdominal aortic aneurysm was admitted due to severe back pain. Emergency CT showed acute aortic dissection (Stanford B) with a partially thrombosed pseudo-lumen and fusiform abdominal aortic aneurysm. Hemolysis occurred due to compression of the true lumen by the thrombosed pseudo-lumen. Emergency abdominal aortic graft replacement was performed successfully.

View full abstract

We present a case of ruptured aneurysm of the sinus of Valsalva with congenitally bicuspid aortic valve and aortic regurgitation. A 50-year-old woman was admitted with congestive heart failure. Transesophageal echocardiography demonstrated that an aneurysm originating from the anterior sinus of Valsalva had ruptured into right ventricular outflow tract. With the aid of cardiopulmonary bypass, the aneurysm was repaired with direct closure through an aortotomy and aortic valve replacement with a Carbomedics 21mm was successfully performed. Because of the marked calcification of her cusps and shortening and thickening of the free-edge, valvuloplasty for the insufficient bicuspid valve was not applied in this case. However, valvuloplasty should be considered as the first surgical procedure of choice, even in cases of bicuspid aortic valve associated with ruptured aneurysm of the sinus of Valsalva and aortic regurgitation.

View full abstract

A 76-year-old man was admitted with a diagnosis of mitral valve regurgitation and angina pectoris. Cardiac catheterization demonstrated grade III mitral valve regurgitation with elevated pulmonary pressure and stenosis in the LAD. Severe stenosis in the left internal carotid artery and multiple cerebral infarctions were also recognized. Mitral valve repair with coronary artery bypass was performed at one month after the left carotid endarterectomy. The ascending aorta contained fragile atheroma, so an arterial cannula was inserted into the graft anastomosed to the right axillary artery. Mitral valve repair with coronary artery bypass was performed under moderately hypothermic ventricular fibrillation. Air embolism in the right coronary artery was recognized during systemic rewarming. Mitral valve repair with coronary artery bypass was performed safely under moderately hypothermic ventricular fibrillation in this case of an atherosclerotic ascending aorta. Axillary artery cannulation is useful to avoid cerebral complications in such cases. The de-airing procedure should be completed before the initiation of the heart beating.

View full abstract

An 11-year-old boy, who underwent a Rastelli operation using a 14mm artificial graft and left pulmonary artery (PA) plasty with an autologous pericardium patch 7 years previously, had severe recurrent left pulmonary stenosis. Reoperation was performed including right ventricular outflow tract reconstruction and left PA plasty. The PA at the most stenotic site was only 2mm in diameter; it was enlarged to 10mm by good exposure and an incision on the pulmonary intima. A bovine pericardium patch with a handmade ePTFE valve was sutured onto the autologous tissue not onto the pulmonary intima to avoid restenosis and in expectation of the growth of the pulmonary orifice. On postoperative 3-D CT, the left pulmonary artery was patent and 9mm in diameter. Pulmonary scintigraphy showed an improvement in the left pulmonary perfusion. This sutureless technique was useful in this case of severe pulmonary stenosis.

View full abstract

A 60-year-old man, who had undergone mitral valve repair with quadrangular resection of the posterior mitral leaflet and ring annuloplasty with a Cosgrove-Edwards ring, developed severe mechanical hemolytic anemia. Doppler echocardiography showed only mild residual mitral regurgitation, but turbulent jet was directed toward the annuloplasty ring. Because of unremitting hemolysis requiring multiple transfusions and the occurrence of renal dysfunction, he underwent replacement of the mitral valve with a St. Jude Medical valve. Inspection of the annuloplasty ring at operation showed no evidence of dehiscence, but the area of the annuloplasty ring adjacent to the posteromedial commissure showed no endothelization. After the reoperation, the hemolysis and general condition immediately improved. This experience made us realize the possibility that a high-velocity regurgitant jet toward the cloth-covered annuloplasty ring, even if it mild, can cause severe hemolysis.

View full abstract