Direct and transapical central cannulation for acute type a aortic dissection.

OBJECTIVE: The choice of cannulation site for the treatment of acute Stanford type A aortic dissection is much debated. We believe that central cannulation is quick to perform, easy to use, and safe to manage acute type A aortic dissection. MATERIALS AND METHODS: We retrospectively investigated 26 cases of acute aortic dissection performed using two different central cannulation methods between April 2011 and March 2012. Direct ascending aortic cannulation was performed using the Seldinger technique in 20 patients, and transapical ascending aortic cannulation was performed in six patients in whom puncture was difficult. RESULTS: Patients were 21-86 years old (mean age, 67 years). The surgical techniques used to treat aortic dissection were hemiarch repair in 21 patients and total arch replacement in 5 patients. The mean length of surgery was 393 min. One death (3.8%) was attributed to intestinal ischemia. CONCLUSION: During surgery for acute aortic dissection, central cannulation using either transapical or direct puncture can be performed quickly and safely, and satisfactory short-term outcomes can be obtained. Because acute aortic dissection can present with various conditions, there is no single perfect surgical or cannulation method; therefore, the choice of surgical procedure should be individualized for each patient.

Preventive effect of intraoperative landiolol administration on atrial fibrillation after off-pump coronary artery bypass grafting.

INTRODUCTION: Postoperative atrial fibrillation (AF) is a common complication of cardiac surgery that is associated with an increased incidence of other complications. This study evaluated the safety and efficacy of landiolol hydrochloride--an ultrashort-acting ß1-selective blocker and highly regulated drug, positioned as a class 1 antiarrhythmic in Japan guidelines--for the prevention of AF after off-pump coronary artery bypass grafting (CABG). METHODS: Between January 2011 and November 2013, 116 patients underwent CABG at Fukuoka University Hospital. They were divided into two groups: group L consisted of patients who were administered landiolol hydrochloride at 2 µg/kg/min after completion of all distal anastomoses; group C was the control group consisting of patients who were not administered landiolol. Patient backgrounds, intraoperative variables and incidence of postoperative complications were compared. RESULTS: No significant between-group differences were observed in patient backgrounds or incidence of complications other than postoperative AF, which occurred significantly less frequently in group L. After administration of landiolol, heart rate decreased but no change was observed in arterial pressure or other parameters, and patient hemodynamics remained stable. CONCLUSION: Intraoperative and perioperative administration of low-dose landiolol has a preventive effect on the development of AF after CABG surgery.

A case of type-2 endoleak from a bronchial artery after endovascular aortic repair for Kommerell diverticulum.

We describe a case of type-2 bronchial artery endoleak after endovascular aortic repair of Kommerell diverticulum (KD) involving right-sided aortic arch and aberrant left subclavian artery (LSA). A 68-year-old woman underwent an endovascular repair of KD with an aberrant LSA in our hospital. Follow-up computed tomography (CT) at 6 months after the procedure showed an endoleak. Digital subtraction angiography revealed a type-2 endoleak from a bronchial artery, but no type-1 or type-2 endoleak from the aberrant left subclavian artery. We performed coil embolization of the KD and the left subclavian artery. The endoleak disappeared in the postoperative CT.

Safety and efficacy of ascending aorta cannulation during repair of acute type A aortic dissection (PA29-04): "Presented at the 65th Annual Scientific Meeting of the Japanese Association for Thoracic Surgery".

OBJECTIVE: Antegrade central perfusion for acute Stanford type A aortic dissection prevents malperfusion and retrograde cerebral embolism during cardiopulmonary bypass. Prompt establishment of antegrade perfusion via the ascending aorta may improve surgical results of type A dissections, especially in situations of hemodynamic instability. Thus, we evaluated the safety and efficacy of cannulation of the dissected ascending aorta in acute type A dissection. METHODS: We reviewed the medical charts of patients undergoing repair of acute ascending aortic dissection (n = 52) from April 2010 to April 2013. Cannulation was accomplished in 29 patients via the ascending aorta (central) and in 23 patients via the femoral or axillary artery (peripheral). The ascending aorta was routinely cannulated using Seldinger technique under epiaortic ultrasound guidance. Comorbidities, mortality, complications, and durations of hospital stays were compared for the groups. RESULTS: In all cases, routine cannulation of the ascending aorta was safely performed with no resultant malperfusion or thromboembolism. Mean operative duration, cardiopulmonary bypass time, intubation time, and intensive care unit stay were significantly shorter in the central group. Two patients (6.8 %) in the central group died compared with four patients (17.3 %) in the peripheral group (P = 0.005). CONCLUSIONS: Antegrade central perfusion via the ascending aorta, a simple and safe technique that enables rapid establishment of antegrade systemic perfusion, was as safe as peripheral cannulation in patients with type A acute aortic dissection.

Off-pump coronary artery bypass: techniques, pitfalls, and results.

In coronary artery bypass grafting (CABG), coronary artery anastomosis is generally performed under cardiac arrest using cardiopulmonary bypass (CPB). To avoid the invasiveness of CPB, off-pump coronary artery bypass (OPCAB) is currently also used. In Japan, in particular, OPCAB now accounts for 60 % of all CABG operations and has become a standard surgical procedure. We herein provide a discussion of OPCAB. The goals of coronary artery bypass surgery are to achieve complete revascularization and maintain a high rate of graft patency for the long term. This requires stable exposure of the coronary arteries, including those located on the posterior surface of the heart and the formation of good-quality anastomoses. Achieving this depends not only on the competency of the individual surgeon, but also on smooth and effective teamwork among everyone involved, including the other surgeons, anesthetists, clinical technicians, and nurses. It is important for surgeons and surgical teams to examine their own outcomes and engage in self-scrutiny in an endeavor to improve these outcomes.

Safety and efficacy of an ultrashort-acting ß1-blocker on left ventricular dysfunction.

Landiolol hydrochloride, an ultrashort-acting ß1-selective blocker, is a highly regulated drug. This study evaluated the safety and efficacy of this drug for cases of coronary artery bypass grafting (CABG) with left ventricular dysfunction. Between September 2006 and August 2009, 32 patients with a left ventricular ejection fraction of <40% underwent CABG. Two groups of patients, a group administered landiolol hydrochloride and a control group not administered this drug, were compared. The administration of landiolol hydrochloride was initiated at 1 µg/kg per minute (γ) after cardiopulmonary bypass in on-pump cases and after completion of all the distal anastomoses in off-pump cases. We observed no significant differences between the groups with respect to preoperative patient background or incidences of complications, except for postoperative atrial fibrillation. The heart rate decreased significantly 30 minutes after landiolol hydrochloride administration, but no change was observed in arterial pressure. No change was observed in other parameters; the hemodynamics were stable. The occurrence of atrial fibrillation during the intensive care unit stay (during landiolol hydrochloride administration) was significantly lower in the administration group. The difference remained significant after multiple logistic regression analysis; landiolol hydrochloride was the sole inhibitory factor.

[Current strategy of surgical treatment for ischemic heart disease].

Coronary artery bypass grafting (CABG) surgery is the gold standard therapy for the complete revascularization of patients with multivessel coronary artery disease. Since off-pump CABG (OPCAB) began to be performed, to avoid any side effects from cardiopulmonary bypass, OPCAB is now performed in 66% of all isolated CABG in Japan, and this situation is markedly different from the procedures performed in North America and Europe. Furthermore, percutaneous coronary intervention (PCI) using drug eluting stents (DES) is now being increasingly performed for the treatment of patients with either left main trunk, diffuse or multivessel lesions. Under these circumstances, both the surgical treatment and indications for ischemic heart disease has also changed, and therefore what is asked of surgeons is how they can provide high quality treatment that maintains surgical quality. The strategy to be pursued by surgeons in the future is to perform treatment that is less invasive and provides maximum effects and it is believed that the following issues will become more important. (1) Using arterial grafts for various purposes to maintain high rates graft patency. (2) Successfully performing multivessel bypass procedures and achieving good complete revascularization rates. (3) Careful postoperative management and its complications.

Off-pump coronary artery bypass vs percutaneous coronary intervention. Therapeutic strategies for 3-vessel coronary artery disease: OPCAB vs PCI(PCI-Side).

Coronary artery bypass graft (CABG) surgery is still the best therapy for patients with multivessel and left main coronary artery disease. Recently, the introduction of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in these patients has improved the restenosis rate compared with bare metal stents. Furthermore, according to the results of the SYNTAX trial, no differences were found in the frequencies of mortality or myocardial infarction between CABG and PCI patients. PCI with DES is being increasingly performed for the treatment of patients with either left main trunk, diffuse, or multivessel lesions. In Japan, to avoid any side effects from cardiopulmonary bypass, off-pump coronary artery bypass (OPCAB) was performed in 66% of the total isolated CABG procedures in 2009, and is markedly different from the procedures performed in North America and Europe. However, the comparative effectiveness of PCI and OPCAB remains uncertain. In the present study, the current evidence from randomized trials, a meta-analysis and several observation studies are reviewed.

Efficacy of propafenone hydrochloride in preventing postoperative atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Atrial fibrillation (AF) is one of the most common complications after coronary artery bypass grafting (CABG), and the incidence of postoperative AF (PAF) is estimated to range from 10% to 40%. PAF is a serious complication that is related to unstable hemodynamics, development of embolisms, patient discomfort, and increased medical costs associated with the prolongation of hospital stay. Sometimes, immediate attention is also necessary. In this study, we assessed the efficacy of treatment with the antiarrhythmic drug propafenone hydrochloride, which was administered in the early postoperative period, in preventing the development of PAF, and we attempted to identify risk factors for PAF. MATERIALS AND METHODS: The subjects were 78 patients who underwent isolated off-pump CABG between July 2007 and October 2008. We conducted the study by dividing the patients into 2 groups, a group of 26 patients who received propafenone hydrochloride (P group) and a control group of 52 patients who did not receive this drug (C group). The patients in the P group were given propafenone hydrochloride (150-450 mg/day orally) for 10 days, starting on the day after surgery, and were observed for the development of AF by means of continuous 12-lead electrocardiographic monitoring. Development of AF was defined as AF that lasted

Right ventricular rupture induced by cardiopulmonary resuscitation.

Right ventricular rupture is a rare complication of cardiopulmonary resuscitation and could be fatal. We report a survival case of right ventricular rupture induced by cardiopulmonary resuscitation in a patient with acute myocardial infarction. A 57-year-old man was admitted to our hospital with ventricular fibrillation. Although chest compression and defibrillation were performed, ventricular fibrillation continued. We inserted a percutaneous cardiopulmonary system and performed coronary angiography, which revealed occlusion of the left anterior descending artery. After coronary stenting and intra-aortic balloon pumping, we succeeded in defibrillation and vital signs became stable. Twenty hours after the intervention, systolic blood pressure dropped to 60 mmHg. Ultrasonic cardiogram at that time revealed massive pericardial effusion. We diagnosed cardiac tamponade, and 8Fr drainage tube was placed in the pericardial space. We determined that emergent operation was necessary because we suspected left ventricular rupture due to acute myocardial infarction or coronary rupture induced by percutaneous coronary intervention. However, operative findings revealed right ventricular free wall rupture, which could have been induced by chest compression. In these cases, we should consider the possibility of not only the rupture of left ventricle and coronary artery but also the rupture of right ventricle induced by cardiopulmonary resuscitation.

Endoscopic radial artery harvesting for coronary artery bypass grafting: the initial clinical experience and results of the first 50 patients.

BACKGROUND: The radial artery (RA) is a commonly used arterial conduit in coronary artery bypass grafting (CABG). Traditional open-vessel harvest often leads to postoperative wound complications and cosmetic problems. Endoscopic RA harvesting (ERAH) has been widely used to prevent these problems. The purpose of this study was to assess these problems and graft patency in the first 50 patients who underwent ERAH. METHODS: Between February 2006 and October 2007, 50 patients underwent ERAH with the VasoView system (Boston Scientific). These patients were compared with 50 patients who underwent the traditional open technique. RESULTS: The mean age was 62.8 years in both groups. All RAs were successfully harvested. No conversion was made from ERAH to the traditional open technique. The mean harvesting time (forearm ischemic time) was 27.4 + or - 6.5 minutes, and the mean length of the RA in the ERAH group was 18.5 cm. Neither wound complications, such as wound infection and skin necrosis, nor severe neurologic complications were recorded. The patency rate was 95.9% (95/99) in the ERAH group and 94% (94/100) in the open group. CONCLUSION: ERAH can be performed safely, and the early results are satisfactory. Endoscopic vessel harvesting is therefore recommended as the technique of choice for RA harvesting.

Obstruction of St Jude Medical valves in the aortic position: histology and immunohistochemistry of pannus.

OBJECTIVE: This study aims to reveal the morphological, histological, and immunohistochemical mechanism of pannus formation using resected pannus tissue from patients with prosthetic valve dysfunction. METHOD: Eleven patients with prosthetic valve (St Jude Medical valve) dysfunction in the aortic position who underwent reoperation were studied. We used specimens of resected pannus for histological staining (hematoxylin and eosin, Grocott's, azan, elastica van Gieson) and immunohistochemical staining (transforming growth factor-beta, transforming growth factor-beta receptor 1, alpha-smooth muscle actin, desmin, epithelial membrane antigen, CD34, factor VIII, CD68KP1, matrix metalloproteinase-1, matrix metalloproteinase-3, and matrix metalloproteinase-9). RESULTS: Pannus without thrombus was observed at the periannulus of the left ventricular septal side; it extended into the pivot guard, interfering with the movement of the straight edge of the leaflet. The histological staining demonstrated that the specimens were mainly constituted with collagen and elastic fibrous tissue accompanied by endothelial cells, chronic inflammatory cells infiltration, and myofibroblasts. The immunohistochemical findings showed significant expression of transforming growth factor-beta, transforming growth factor-beta receptor 1, CD34, and factor VIII in the endothelial cells of the lumen layer; strong transforming growth factor-beta receptor 1, alpha-smooth muscle actin, desmin, and epithelial membrane antigen in the myofibroblasts of the media layer; and transforming growth factor-beta, transforming growth factor-beta receptor 1, and CD68KP1 in macrophages of the stump lesion. CONCLUSIONS: Pannus appeared to originate in the neointima in the periannulus of the left ventricular septum. The structure of the pannus consisted of myofibroblasts and an extracellular matrix such as collagen fiber. The pannus formation after prosthetic valve replacement may be associated with a process of periannular tissue healing via the expression of transforming growth factor-beta.

Anomalous origin of the left coronary artery from the pulmonary artery: successful direct reimplantation in a 50-year-old man.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital coronary artery anomaly that is often referred to as Bland White Garland syndrome. Most patients with this anomaly require surgical intervention early in life, and it is extremely rare that patients reach middle age without any symptoms. We present a 50-year-old man with this anomaly, who underwent direct reimplantation of the left main coronary trunk to the ascending aorta. His postoperative course was uneventful, and three and a half years after the operation, he is well and does not require medication. Several surgical procedures can be used to treat this anomaly, but we prefer to use direct reimplantation, whenever technically possible. To our knowledge, this patient is the oldest patient to have undergone a direct reimplantation without any angioplasty.

Spontaneous coronary artery dissection causing myocardial infarction and left ventricular aneurysm.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction (MI). A 66-year-old Japanese man, who had had an anterior wall MI caused by SCAD of the left anterior descending coronary artery, developed left ventricular aneurysm 5 years later, with depressed left ventricular function and thrombus observed on echocardiography. Left endoventricular circular patch plasty according to Dor's technique was performed without coronary artery bypass grafting, because of the absense of significant coronary artery stenosis on the preoperative coronary angiogram. The clinical course of SCAD in the late phase is generally favorable, but because the prognosis of SCAD is uncertain, patients with SCAD should be carefully followed.

Thrombolytic therapy with tissue plasminogen activator for the treatment of nonstructural malfunction of bileaflet cardiac valve prostheses.

This study was conducted to determine the effect of thrombolytic therapy with tissue plasminogen activator (t-PA) for nonstructural malfunction of bileaflet cardiac valve prostheses. Twenty-seven patients with bileaflet prosthetic valve malfunction diagnosed by a combination of cineradiography and transthoracic echocardiography were treated with the administration of intravenous t-PA. The treatment resulted in complete success in 55.6% (15 of 27), partial success in 22.2% (6 of 27), and no change in 22.2% (6 of 27). In the complete success and partial success groups, the condition of the patients in 85.7% (18 of 21) of the cases improved within 24 h after the administration of t-PA. Six cases in whom thrombolytic therapy was instituted more than 1 month (ranged from 1 to 38 months, mean 14.7 months) after the diagnosis of prosthetic valve malfunction showed significantly less effectiveness of thrombolytic therapy with t-PA. Only one patient (3.7%) had a major complication (thromboembolism) after t-PA treatment. The results suggest that thrombolytic therapy with t-PA in patients with nonstructural malfunction of bileaflet cardiac valve prostheses is effective with low incidence of complication when the treatment is instituted early after the diagnosis.