Correction of tetralogy of Fallot in an adult using a stented bioprosthetic valved conduit.

A 55-year-old man with tetralogy of Fallot successfully underwent correction using a valved conduit. He was diagnosed as having congenital heart disease during childhood, but no surgical intervention was performed. Cyanosis and dyspnea on effort had progressed gradually. Catheterization showed a left ventricular end diastolic volume of 126 ml, and the pulmonary arteries had sufficient diameters. To prevent postoperative pulmonary regurgitation, we planned to use a bioprosthetic valved conduit for right ventricular outflow tract reconstruction. At 4.5 years after the operation he is in New York Heart Association functional class I. The catheterization performed 1.5 years after the surgery showed no pressure gradient between the right ventricle and the pulmonary artery. Thus, total correction of tetralogy of Fallot in an adult can be achieved safely, and the use of a bioprosthetic stented valved conduit can be beneficial.

The role of N-terminal pro-B-type natriuretic peptide in the diagnosis of congestive heart failure in children. - Correlation with the heart failure score and comparison with B-type natriuretic peptide -.

BACKGROUND: Both B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) are useful biomarkers for the assessment of congestive heart failure (CHF) in adults. The purpose of this study was to determine whether BNP and NT-proBNP levels could be used to stratify the severity of CHF in children. METHODS AND RESULTS: The study comprised 181 children with CHF and 232 healthy children aged from 4 months to 14 years who were categorized into CHF grades I, II, III and IV according to the modified Ross scoring system. The plasma BNP and serum NT-proBNP levels were significantly correlated with increasing CHF grades. The NT-proBNP levels were significantly different among the 4 CHF grades. However, only 2 significant differences were observed in the BNP levels between each CHF grade. NT-proBNP testing with cut-off points of >438 pg/ml (> or =grade II), >1,678 pg/ml (> or =grade III) and >7,734 pg/ml (grade IV) in the patients below 3 years of age, and >295 pg/ml (> or =grade II), >1,545 pg/ml (> or =grade III) and >3,617 pg/ml (grade IV) in those above 3 years of age was determined to be highly sensitive and specific by receiver operating characteristic analysis. CONCLUSIONS: The blood levels of BNP and NT-proBNP therefore reflect the severity of CHF in children. In particular, NT-proBNP is a useful biomarker for evaluating CHF in children.

Cardioprotective effects of normothermic reperfusion with oxygenated potassium cardioplegia: a possible mechanism.

Na(+)/K(+) pump activation induced by normothermic reperfusion with high potassium cardioplegia may exert a protective effect on reperfusion-induced myocardial damage. We investigated (1) temperature dependency and extracellular potassium dependency of the Na(+)/K(+) pump current (Ip), (2) effects of high potassium or ouabain during reperfusion on the post-ischemic left ventricular (LV) function. Ip-voltage relation was constructed at 5.0 and 20 mM of KCl (37 degrees C) using a whole-cell clamp technique in guinea pig myocytes. Ip at -40 mV was measured at 37, 27 and 18 degrees C (KCl: 5.0 mM). Isolated rat hearts were Langendorff-perfused and subjected to 20 min of global ischemia (37 degrees C) followed by 35 min of reperfusion (37 degrees C). The post-ischemic recovery of LV developed pressure (%LVDP) was assessed in the four reperfusate groups (4.8 mM KCl, 10 mM KCl, 20 mM KCl, or 4.8 mM KCl plus 50 microM ouabain during the first 10 min of reperfusion). The 4.8 mM KCl and 10.0 mM KCl groups were compared under metabolic inhibition (glucose-free, NaCN, or hypoxia) during reperfusion. The Ip-voltage relation shifted upward when extracellular KCl was increased from 5.0 to 20 mM. Ip was significantly greater at 37 degrees C than at 18 degrees C (114.3+/-17.2 vs. 22.7+/-1.2 pA, respectively). %LVDP was significantly greater at the 10.0 mM KCl group than at the 4.8 mM KCl group (54.9+/-5.5% vs. 34.2+/-5.9%, respectively). Metabolic inhibition abolished the difference between the two groups. Ouabain significantly decreased %LVDP (15.9+/-1.6%). Potassium-induced cardiac arrest during normothermic reperfusion may exert a cardioprotective effect by inducing Na(+)/K(+) pump activation, which may be supported by aerobic metabolism during reoxygenation rather than by energy saving during cardiac arrest.

Vacuum-assisted closure for pediatric post-sternotomy mediastinitis: are low negative pressures sufficient?

We present 3 cases of pediatric post-sternotomy mediastinitis treated by a vacuum-assisted closure (VAC). The patients 2 girls, aged 6 months and 10 months, and a 2-year-old boy. The onset of infection was at 9, 14, and 32 postoperative days. The culture examination detected coagulase-negative Staphylococci strains in 2 cases, and Staphylococcus aureus in 1 case. A VAC was performed at -50 mm Hg for 10, 12, and 7 days. The wounds were closed without vascularized soft tissue. A VAC under a low negative pressure is a useful and safe procedure for the management of pediatric post-sternotomy mediastinitis.

Perforation of the ascending aorta with a hematoma extending into the left-side upper extrapleural cavity.

We herein present an extremely rare case of a perforation of the ascending aorta with a hematoma extending into the left-side upper extrapleural cavity. A 62-year-old male with a sudden onset of severe chest pain was referred to our institution because of an abnormal shadow in the left-side upper lung field. Computed tomography revealed a small fusiform aortic arch aneurysm and a hematoma extending to the left-side upper extrapleural cavity. We diagnosed the patient to have acute aortic syndrome and urgent surgery was thus performed. Major bleeding which might be caused by a progression of the perforation was seen during a dissection of the aorta. The aortic arch was transected and a total arch replacement was performed with a 26 mm Dacron graft. No findings of a rupture of the aortic arch aneurysm or dissection were observed. The histopathology of the aorta revealed a severe atheromatous lesion with calcification and thinning disarrayed elastic fibers. The postoperative course was essentially good except for the development of pericardial effusion which required drainage.

Staged repair for a chronic dissecting thoracic aortic aneurysm with no transfusion in a Jehovah's Witness patient.

We present the case of a 59-year-old male Jehovah's Witness who underwent staged repair for a thoracic aortic aneurysm with no transfusion. The primary operation to replace the distal portion of the aortic arch and left subclavian artery reconstruction were performed. We applied axilla femoral artery temporary external bypass. A second operation was carried out 8 months later. We replaced the descending aorta and reconstructed the intercostal arteries under temporary bypass in the same manner as was done during the previous operation. The blood losses and minimum hemoglobin values during the two operations were 2235 and 13,941 ml, respectively, 8.8 and 5.9 g/dl, respectively. Administration of erythropoietin and a drainage blood recovery device were useful. Surgical repair for a thoracic aortic aneurysm using a temporary bypass is thus considered a viable surgical option in such situations and is important for conducting effective perioperative management.

Total arch replacement for a distal aortic arch aneurysm with right aortic arch.

Right-sided aortic arch accompanied by an aberrant origin of the left subclavian artery is rare and seen in 0.05% approximately 0.1% of the population. A 73-year-old woman with this anomaly was admitted to our institution because of the enlargement of the distal aortic arch aneurysm. She also had mild dysphagia. The size of the aneurysm was 70 mm in diameter and she underwent total arch replacement using selective cerebral perfusion through a median sternotomy. Additional right thoracotomy was not required and four cervical vessels were reconstructed. The postoperative course was uneventful. This case report shows median sternotomy alone may provide sufficient access for this pathology.

Isolated iliac artery aneurysm caused by fibromuscular dysplasia: report of a case.

Fibromuscular dysplasia (FMD) can develop in many different arteries, but iliac artery aneurysms are rare. A 69-year-old Japanese woman was admitted to our hospital for treatment of a right common iliac artery aneurysm. Aortography revealed aneurysms in both the right common iliac artery and the left internal iliac artery. Notably, the right common iliac artery aneurysm had a "string-of-beads" appearance. At surgery, the aneurysms were resected, and replaced with Y-shaped vascular prostheses. The histopathological diagnosis was fibromuscular dysplasia (FMD). We report this case of common iliac artery aneurysm caused by FMD due to its rarity.

Novel anastomotic method enables aortofemoral bypass for patients with porcelain aorta.

PURPOSE: Porcelain aorta is an indication for axillofemoral bypass. However, the procedure has definitive flaws. We present a new method for achievement of aortofemoral bypass. METHODS: The portion of the distal aorta for anastomosis is wrapped with a double polytetrafluoroethylene mesh and fixed to the adventitia with continuous sutures. The adventitia of the anastomotic site is cut over the mesh until the calcified surface is disclosed. Margins of the mesh and the peeled adventitia are fixed along the anastomotic margin with continuous sutures. After the aorta and distal arteries are occluded with balloon catheters, an opening on the bared calcification is made with an airdrill and enlarged with a laminectomy rongeur. The anastomosis is performed between a graft and the mesh-reinforced adventitia with continuous sutures. Over 6 years, this method has been applied to nine patients with porcelain aorta who are diabetic or undergoing dialysis. The indications were disabling claudication in three patients and limb salvage in six patients. RESULTS: No anastomotic complications or operative deaths were seen, and satisfactory mid-term results were obtained, with follow-up ranging from 3 to 62 months after surgery. One patient died of coronary heart disease 3 years after surgery, but the grafts retained a good function. CONCLUSION: This method is safe and effective, and more liberal application of this method may help improve outcome and quality of life.