Hemofiltration during cardiopulmonary bypass for high risk adult cardiac surgery.

AIMS: The role of hemofiltration (HF) during cardiopulmonary bypass (CPB) in adult cardiac surgery is controversial. It may be beneficial during prolonged CPB in high-risk surgery. Accordingly, we sought to compare two groups of patients undergoing high-risk cardiac surgery with or without HF. METHODS: One hundred and eighteen patients who underwent complex cardiac surgical procedures during a 12-month period were divided into two groups. Group I (n=61) comprised patients who were treated with hemofiltration during CPB. Group II (n=57) were not filtered. Estimated risk of death, standard demographic, clinical and surgical features were obtained and predetermined outcomes were studied. Statistical comparisons were made. RESULTS: Age, procedure times and mortality rates were similar in both groups. The mean volume of fluid removed in group I was 3.4 L. The preoperative mean Parsonnet score was 24.8 in group I and 22.5 in group II (ns). Postoperative serum hemoglobin, hematocrit, platelet, and albumin levels were all significantly higher in group I patients (p=0.0015) indicating hemoconcentration. Post-operative chest drainage showed a trend toward decreased post-operative bleeding in group I (p=0.065). Postoperative pleural effusions requiring chest tube drainage were significantly less in group I (9.8% vs. 29.8% 6; p = 0.0062). The incidence of lung infection was also decreased from 26.3% to 13.1% (p=0.05). Operative mortality was similar in both groups (11.4% in group 1, 10.5% in group II, ns). CONCLUSION: Hemofiltration during CPB attenuates postoperative anemia, thrombocytopenia and hypoalbuminemia, may reduce post-operative bleeding and appears to decrease post-operative pulmonary complications.

Long lasting spasticity in controlled vasospastic angina.

OBJECTIVE: To evaluate changes in coronary artery spasticity in patients with vasospastic angina who had been stable for years under continuous drug treatment. METHODS: Follow up coronary angiography was performed under intracoronary ergonovine provocation in 27 well controlled patients with vasospastic angina and no organic stenosis; the tests were done > 24 months after the initial coronary angiography, in which occlusive spasm had been induced by the same regimen of ergonovine provocation. RESULTS: The mean (SD) follow up period was 47.2 (21.6) months. All patients had been free from angina attack for more than 24 months under treatment with antianginal drugs. During this follow up period, organic stenosis developed in only one case. Occlusive spasm was observed during follow up coronary angiography in 23 patients. Spasm with 90% narrowing was observed in three other patients, and diffuse significant narrowing was seen in the final patient. No significant difference was found in spasticity (p = 0.75) between the initial and the follow up tests. CONCLUSIONS: Repeated ergonovine provocation during coronary angiography after a controlled period of several years showed that coronary spasm remains inducible in most patients. Discontinuance of drug treatment during the remission from anginal attacks achieved by medication may put the patient at high risk.

[Tricuspid valve closure for pulmonary atresia with intact ventricular septum].

Tricuspid valve closure was performed on four children who had pulmonary atresia with intact ventricular septum. All of them had major right ventricle-coronary communications and severely hypoplastic right ventricle under 30% of normal right ventricle volume. Their coronary circulations were not right ventricle dependent. All of four patients survived tricuspid valve closure. Three children were performed Fontan procedure. One child, with severe change in her coronary arteries preoperatively, once improved her myocardial ischemia in early stage after tricuspid valve closure, however, the myocardial ischemia progrssed in one year later and died suddenly three years and five months after tricuspid valve closure. Three survivors remained good condition in their left ventricle function postoperatively. In this study, we investigated changes in LVEF, LVEDVI, LVEDP and mitral regurgitation as indicators of left ventricle functions through tricuspid valve closure. It revealed that tricuspid valve closure had advantages in preservation of left ventricle function and in preparation for Fontan procedure consequently.

[Roll repair of nonconfluent pulmonary artery].

We reviewed the repair of nonconfluent pulmonary artery using a roll to clarify indication of this operation, operative technique (especially the material and the size of conduit) and possibility of total correction. Eleven patients (mean age: five years) and 13 operations including two reoperations were reviewed. The material of the roll was xenopericardium in nine and artificial graft in four operations. No operative death and late death occurred. Five patients required reoperations from three occlusion and two severe stenosis of the roll. Three of nine xenopericardial roll needed reoperations and in two reoperated cases, the roll had been placed behind the aorta. In contrast, one artificial graft needed reoperation. The diameter of the roll was compared with that of normal pulmonary artery estimated from the body surface area. If the roll was too large (more than 125% normal) or too small (less than 100% normal), the luminal diameter of the roll became significantly smaller than appropriate-sized roll (p = 0.002). The size of nonconfluent side of the pulmonary artery also affect the result of repair. In occluded or stenotic cases, the unilateral PA index was significantly smaller than good patent cases (p = 0.014). Total correction was possible in eight cases (73%) including four Rastelli operation, two right ventricular outflow patch enlargement, and two modified Fontan operations without operative death. Thus preoperative evaluation of the pulmonary artery size and anatomy, selection of roll material and size matching seemed to be important for successful roll repair of nonconfluent pulmonary artery.

[Pericardial effusion following surgery using cardiopulmonary bypass].

Of 156 patients who underwent cardiac or aortic surgery using cardiopulmonary bypass, postoperative pericardial effusion was detected in 89 patients (57%). They were divided into four groups according to the size of pericardial effusion: No effusion (group N, n = 66), small effusion (group S, n = 42), moderate effusion (group M, n = 22) and large effusion (group L, n = 25). In group L, 68% of patients had symptoms and 44% had complications such as subxiphoid drainage and constrictive pericarditis. Fewer patients with perioperative pleurotomy were found in group L than group N (p < 0.05). Postoperative anticoagulation did not affect the size of pericardial effusion. Postoperative amount of drainage were larger in groups, S, M, L than group N (p < 0.05, p < 0.05, p < 0.005). The CRP reelevation rate of each group was equal but the maximum CRP value was higher in group L than group N (p > 0.05). These results suggest that some relationship exists among postoperative drainage, inflammatory response and postoperative pericardial effusion. Since large pericardial effusion is often symptomatic and accompanied by various complications, earlier detection of pericardial effusion and appropriate treatment seems to be essential.

Aortic regurgitation and aneurysm of Sinus of Valsalva associated with osteogenesis imperfecta.

A case of osteogenesis imperfecta with aortic regurgitation is described. The patient had a dilated aortic valve ring and an aneurysm of the Sinus of Valsalva. The patient manifested severe hemodynamic abnormalities and underwent aortic root reconstruction using a valved conduit. The operative problems and the pathological findings are discussed.

[Intracoronary administration of ergonovine maleate for detecting vasospastic angina; one dose method].

Coronary spasm is an important etiologic mechanism in the pathogenesis of myocardial ischemia. Provocative test of coronary spasm during coronary arteriography is clinically useful. The ergonovine test has gained widespread use, and we have examined the efficacy and safety of intracoronary ergonovine application with a fixed dose of 16 micrograms. We studied 119 patients undergoing coronary arteriography. Coronary spasm was induced in 34 cases by intracoronary administration of 16 micrograms of ergonovine maleate. Coronary spasm was readily resolved by intracoronary administration of isosorbide dinitrate. None of the cases negative to the intracoronary ergonovine applications could be induced by additional systemic administration of 0.4 mg of ergonovine. Side effects of ergonovine such as elevation of blood pressure, headache and chest symptoms were infrequent in the intracoronary ergonovine test. We conclude that our method of intracoronary ergonovine application is sensitive and safe for the diagnosis of coronary spasm.

LDL-apheresis and improvement in the coronary atherosclerosis of familial hypercholesterolemia--correlation of computerized quantitative coronary angiography with autopsy findings.

We have evaluated the effects of LDL-aphereses performed over 15 to 62 months, involving both Double Filtration Plasmapheresis (DFPP) and LDL Adsorbent Plasmapheresis (LAPP), for 5 patients with familial hypercholesterolemia (FH) (1; homozygous, and 4; heterozygous) using computer image analysis by coronary angiography, (CAG). Results by CAG showed that in homozygous FH, 9 (75%) of 12 segments demonstrated no progression, 2 (16.7%) segments showed regression, and only 1 (8.3%) segment showed progression. In heterozygous FH, 27 (81.8%) of 33 segments showed progression, and 6 (18.2%) segments showed regression. Aorto coronary bypass was beneficial with obtained patency in 13 (93%) of the 14 grafts. We also performed an autopsy on one patient, with heterozygous FH who died suddenly probably due to fibrillation. The patient had received long-term LDL apheresis for 6 years and 7 months and had shown angiographic regression. The pathological findings showed no typical or new atheroma, significant cicatrization in the thickened intima and an eccentric thickened wall lesion. The serial angiographic findings together with the pathological findings very clearly support the use of LDL-apheresis for producing "true" regression in coronary atherosclerosis in FH.

[Cardiopulmonary support in PTCA for severe coronary artery disease: its efficacy].

Percutaneous transluminal coronary angioplasty (PTCA) assisted by cardiopulmonary femorofemoral bypass was performed in 4 patients who were considered to be candidates for this technique because of their severe coronary artery diseases, including 2 with left main trunk disease, one with cardiogenic shock, and one with severe 3-vessel disease. Here we report the efficacy of cardiopulmonary support in PTCA. Case 1: An 85-year-old man with persistent unstable angina despite maximal doses of medications. Stenosis of the left anterior descending coronary artery (90%) was resolved by PTCA with cardiopulmonary bypass and intraaortic balloon pumping (IABP). Case 2: An 83-year-old man with unstable angina had high grade stenoses in the distal left main, left anterior descending and right coronary arteries. Although IABP was instituted for sustained chest discomfort and ST depression, the patient developed congestive heart failure. PTCA of the left main coronary artery with cardiopulmonary bypass was successfully performed. Case 3: A 64-year-old man with acute myocardial infarction. PTCA of the occluded left anterior descending coronary artery resulted in shock despite IABP, which was resolved by cardiopulmonary bypass with percutaneous insertion of cannulae, the technique we developed. Case 4: A 74-year-old man with unstable angina. He had a severe 3-vessel disease and a thrombus in the right coronary artery.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal coronary angioplasty with cardiopulmonary bypass for stenosis of the most proximal part of the left anterior descending coronary artery.

An 85 year old man with unstable angina pectoris was treated successfully with percutaneous transluminal coronary angioplasty supported by cardiopulmonary bypass and intra-aortic balloon pumping. Coronary angiography had shown stenoses in both the left main stem and left anterior descending coronary arteries. Drug treatment had been ineffective and he was too old for coronary arterial bypass grafting.

[Percutaneous transluminal angioplasty in patients with prior coronary artery bypass grafting].

Seventeen patients with stenosis of bypass grafts or native coronary arteries (NCA) following coronary artery bypass underwent percutaneous transluminal angioplasty (PTCA). Stenoses were located in the saphenous vein graft (SVG) in 11 cases (involving 16 lesions), in the internal mammary artery graft (IMAG) in 2 cases (2 lesions), and in the NCA in 9 cases (13 lesions). All patients had disabling angina pectoris or a post-operative stenosis of more than 50%. PTCA was successful in 75% of all the SVG stenotic lesions, 50% of the IMAG lesions and in 67% of the NCA lesions. There were no complications associated with PTCA. After successful PTCA, restenosis developed in 23% of the SVG cases, 0% of the IMAG cases and in 38% of the NCA cases. Though relief of chest pain was found in 10 patients (59%), PTCA of the NCA was not so effective as PTCA of the bypass grafts.

Angioscopy in transluminal balloon and laser angioplasty in the management of chronic hemodialysis fistulae.

In chronic hemodialysis patients, there is the major problem of occlusion in the arteriovenous fistulae. To investigate this problem, the authors have developed angioscopy for examination and detection of occlusion developing to allow early use of transluminal balloon angioplasty (PTA) or laser angioplasty and prevent occlusions. The authors have examined 27 patients using a 2.7 mm diameter Olympus flexible angioscope and 9F sheath, following-up with a 4 mm balloon catheter (BARD) or SLT Nd-YAG laser. PTA was performed for 25 cases, with 19 demonstrating after one session patency lasting 9 months to date. Three cases revealed restenosis and have each received three PTA sessions. Laser angioplasty was performed in one case of 15 cm chronic occlusion, with subsequent PTA successfully enabling hemodialysis. Angioscopically, the authors were able to observe the various rest-forms within the shunt and detected the mural thrombus attached to the punctured pore. Both circumferential and valvular stenoses were observed. Initially after laser angioplasty, rough irregularity and a mural thrombus in the vessel was observed, but 2 months later, the vessel lumen had become smooth, probably due to intimal growth. Thrombus is acute stenosed cases were clearly observed. Angioplasty enabled new observations in the A-V fistulae, which allows investigation of the mechanism of stenosis or occlusion and enables an extended use of the hemodialysis blood access.

Surgical treatment of coronary aneurysm developed after PTCA.

Two patients who developed coronary aneurysm at the site of Percutaneous Transluminal Coronary Angioplasty (PTCA) in proximal LAD accompanied by severe re-stenosis just proximal to the aneurysm are described. Both patients underwent Coronary Arterial Bypass Grafting (CABG) to distal LAD to stop anginal attacks refractory to any anti-anginal drugs and to prevent a rupture of a coronary aneurysm. After the operation the anginal attacks disappeared and no trace of coronary aneurysm was visible in the coronary angiogram.

Increased subendothelial infiltration of the coronary arteries with monocytes/macrophages in patients with unstable angina. Histological data on 14 autopsied patients.

We report semi-quantitative histological data on coronary arteries, collected at autopsy from Japanese of both sexes (Group I) who had had unstable anginal attacks and transient ST elevation or depression in ECG within 1 month before death. The cause of death in all cases was acute myocardial infarction or coronary sudden death. A control group consisted of 28 autopsied patients (Group II) who had died of causes other than heart disease and who had been free from anginal attacks. The frequency of 51-75% and 76-100% luminal narrowing in the coronary arteries in Group I was statistically higher than that in Group II (P less than 0.01). Subendothelial infiltration of monocytes/macrophages with edematous change was most evident in Group I in all segments of the coronary artery, particularly in the proximal portions of the three main branches, regardless of mural or occlusive thrombotic sites of the coronary artery. The subendothelial infiltration of monocytes/macrophages, in terms of luminal narrowing, was the most frequent in the portions with 0-50% luminal narrowing, followed by portions with 51-75% narrowing. The subendothelial infiltration of mononuclear cells with edematous change, observed mostly in the proximal portions of three main branches of the coronary artery in Group I, was attributed to increased subendothelial permeability and endothelial damage caused by coronary vasospasm of recent occurrence. We propose that repeated vasospasm may lead to further progression of coronary atherosclerosis.

Arterial changes after percutaneous transluminal coronary angioplasty: results at autopsy.

Light and electron microscopic examinations were performed on 20 coronary artery sites from nine patients who had undergone percutaneous transluminal coronary angioplasty. Twelve successfully dilated sites without prior thrombosis showed evidence of a tear in the luminal surface (with or without fracture of an atheroma) even at 140 days after angioplasty. The tear split through a relatively undistensible intima in 9 (75%) of the 12 sites. Two successfully dilated sites with prior thrombosis showed an intraintimal tear with a widely lacerated fibrous cap and thin mural thrombus. After dilation, the occluded prior nonthrombosed site showed marked protrusion of a separated plaque. An occluded prior thrombosed site after dilation revealed intraintimal canal-like hematoma. Four sites that occluded after balloon passage revealed a dissecting hematoma in three and plaque disruption in the other.

Significance of adventitial inflammation of the coronary artery in patients with unstable angina: results at autopsy.

A quantitative analysis of adventitial inflammation of the coronary artery with intimal lesions is described in 12 patients who suffered coronary death and had had unstable angina (crescendo angina) at rest (group 1). After autopsy in these patients we examined epon-embedded cross sections by light and electron microscopy, paying particular attention to the adventitia, and compared these results with those in six patients who had had angina but died of noncardiac causes (group 2) and those in 22 patients who did not have angina (group 3). Of the 132 segments from group 1 patients, 39 (30%) were narrowed 76% to 100% by atherosclerotic plaque (group 2, 27%; group 3, 1%), and 23 (17%) had occlusive thrombi. Of the 264 sections (two from each segment) from group 1 that were examined, 98 (37%) (group 2, 15%; group 3, 9%) revealed clustered infiltration of inflammatory cells in the adventitia, half of which were associated with vascular nerve involvement. These findings in the adventitia may be related to the vasospastic component of unstable angina.