Moderate vasomotor response to acetylcholine provocation test as an indicator of long-term prognosis.

The acetylcholine (ACh) provocation test (ACh-test) is used for the diagnosis of vasospastic angina (VSA). However, subjects often show a moderate spasm (MS) response for which diagnosis of VSA is not definitive, and the clinical significance of this response is unknown. We assessed moderate coronary vasomotor response to the ACh test as an indicator of long-term prognosis. A total of 298 consecutive patients who underwent the ACh test for suspected VSA were retrospectively investigated. Coronary spasm severity after intracoronary administration of isosorbide dinitrate was evaluated by measuring epicardial coronary artery diameter reduction after ACh injection. Patients were divided into three groups according to the diameter reduction during the ACh test: severe spasm (SS) showing ≥75 % diameter reduction, MS showing ≥50 % diameter reduction, and others (N). In Kaplan-Meier analysis, the major adverse cardiac event (MACE) rates with a median follow-up of 4.6 years were significantly worse in SS (11.1 %) and MS (8.5 %) than N (1.9 %), (SS vs N; P = 0.009, MS vs N; P = 0.029). Significant difference in MACE rates was not observed between SS and MS (P = 0.534). Cox regression analysis revealed that MS remained an independent predictor of MACE after adjustment for other confounders (HR: 7.18, 95 % CI 1.42-36.4, P = 0.017). Patients with MS by ACh test had a cardiac event rate comparable with that of patients with SS and significantly worse than that of patients with normal vasomotor responses.

Antegrade selective cerebral perfusion combined with deep hypothermic circulatory arrest on cerebral circulation: comparison between pulsatile and nonpulsatile blood flows.

PURPOSE: In aortic arch surgeries, antegrade selective cerebral perfusion (SCP) combined with deep hypothermic circulatory arrest (DHCA) has been recently widely used in institutions as one of the most reliable methods for cerebral protection. However, some studies reported a 3.7-9.3% incidence of postoperative cerebral complications. To perform antegrade SCP more safely, we sought to examine the impact of pulsatile flow perfusion during DHCA on cerebral tissue metabolism, focusing on physiological effects of pulsatile flow perfusion. MATERIALS AND METHODS: Sixteen pigs were divided into 2 groups. In each group, antegrade SCP combined with DHCA was conducted. During circulatory arrest, for SCP, a pulsatile flow (group P) and a nonpulsatile flow (group N) were used. We compared results between group P and group N. Jugular venous oxygen saturation (SjO(2)) and cerebral tissue oxygen partial pressure (PtO(2)) were measured at baseline, and continuously throughout the extracorporeal circulation. Hematocrit (Ht), and concentrations of S-100 protein and CK-BB in blood and the cerebrospinal fluid (CSF) were measured at baseline (before the beginning of extracorporeal circulation), following SCP, and after rewarming. Following rewarming, each brain under perfused fixation was removed, and histopathological examinations were conducted using Kluver-Barrera and Tunnel staining methods, electron micrograph. RESULTS: SjO(2) was found to be within normal ranges until after SCP, but decreased with rewarming in both groups. In Group N, changes in SjO(2) were significant, with a decrease to < or =50%. In Group N, concentrations of S-100 protein and CK-BB in CSF after SCP and after rewarming were significantly higher than those in Group P. The time needed for rewarming to 36 degrees C in Group P was shorter than that in Group N. CONCLUSION: Our results suggest that the pulsatile flow circulation method shows cerebral protection effects with increasing blood flow in small cerebral tissues. In addition, it is effective for improving the imbalance between oxygen supply and demand, especially in the process of rewarming from hypothermic conditions. This method seems to be useful as an adjunct in hypothermic circulatory arrest procedures.

40 Years experience in mitral valve replacement using Starr-Edwards, St. Jude Medical and ATS valves.

BACKGROUND: We have used the Starr-Edwards ball (S-E) valve since 1963, the St. Jude Medical (SJM) valve since 1978, and the ATS valve, since 1993 as the first choice of mechanical valve. In this study, the results with each valve during the 40 years were investigated in single mitral valve replacement (MVR) cases. PATIENTS AND METHODS: The mean age for S-E valves was 32.8+/-11.1 years old (y.o.), for SJM it was 47.2+/-12.6 y.o. and for ATS it was 56.3+/-11.4 y.o., indicating the aging of patients over time. The operative mortality decreased over the same time from 10.3% to 5.2% then 1.4% respectively. A significant difference was observed among the 3 groups with regards to the valve-related complication-free rate and cardiac event-free rate. However, there was no significant difference among the 3 groups with the other complications. CONCLUSION: Although there are many cases of valve-related complications with S-E valves, they have a role as an initial stage mechanical valve. In view of the long-term results extending over 20 years, the SJM valves is considered as the most reliable valve. The ATS valve is expected to achieve favorable results in the future because it may improve the quality of life (QOL) of patients and produce fewer valve-related complications.

Radial artery harvest using the sharp scissors method for patients with pathological findings on Allen's test.

PURPOSE: The pathological findings on Allen's test tend to be contraindicative for radial artery (RA) harvest. However, the employment of a meticulous harvest technique might help protect the collateral vessels from the interosseous arteries and thus help to maintain forearm circulation. We herein report successful RA harvest using the sharp scissors method in patients with pathological findings on Allen's test. METHODS: Ten patients with pathological findings on Allen's test underwent RA harvest using only sharp scissors and metal clips. The distal end of the RA was left approximately 5 cm from the wrist. Using forearm thermography, the skin temperature of the harvest site was compared with that of the non-harvest site. All patients underwent postoperative forearm angiography one month after surgery. RESULTS: No ischemic events in the forearm or harvest site complications were observed. Thermography showed no difference in the skin temperatures between the harvest and non-harvest sites in all patients. Moreover, forearm angiography 1 month postoperatively showed that the interosseous arteries to be well developed and connected to the distal end of the RA in all patients. CONCLUSIONS: These results suggest that a meticulous RA harvest using sharp scissors and clips can help to protect from collateral perfusion of the interosseous arteries. Using this method, RA harvest is therefore considered to be acceptable even for patients with pathological findings on Allen's test.

Efficacy of continuous low-dose human atrial natriuretic peptide given from the beginning of cardiopulmonary bypass for thoracic aortic surgery.

PURPOSE: Cardiac surgery performed under cardiopulmonary bypass (CPB) causes abnormalities of the renin-angiotensin-aldosterone system, resulting in decreased urine output and an accumulation of water in the third space. We studied the efficacy of continuous low-dose human atrial natriuretic peptide (hANP) in patients undergoing thoracic aortic surgery. METHODS: We divided 40 patients undergoing thoracic aortic surgery into two groups: the hANP group, which received 0.02 microg/kg per minute of hANP and the non-hANP group, which did not. The hemodynamics, urine output, intensive care unit (ICU) and hospital stay, bleeding volume, homologous blood transfusion volume, furosemide dose, corrected KCl volume, and postoperative respiratory, hepatic, and renal function were compared in the two groups. RESULTS: The urine output during CPB and from CPB weaning to return to ICU was significantly better in the hANP group. The bleeding volume, homologous blood transfusion volume, furosemide dose, and corrected KCl volume were all significantly less in the hANP group. CONCLUSIONS: These findings support the consensus that hANP exerts its diuretic effects to their full potential when administered continuously at low doses during thoracic aortic surgery. We found it to be effective for postoperative hemostasis and for preventing ischemic reperfusion injury.

Risk analysis for depression and patient prognosis after open heart surgery.

BACKGROUND: The aim of the present study was to determine the predictors of depression as a complication after open heart surgery and influence of depression on the patients' prognosis. METHODS AND RESULTS: During the last 3 years, 97 patients (21.5%) of the 452 adult patients who had open heart surgery at our institute experienced depression after the operation. Patients who scored over 16 points using a Center for Epidemiological Studies Depression Scale were diagnosed with significant symptoms of depression. Depressed patients (group I, n=97) and non-depressed patients (group II, n=355) in terms of mortality and length of hospital stay were compared. Predictors for depression were identified by logistic regression analysis. The postoperative hospital stay was significantly longer in group I. Hospital mortality was also significantly higher in group I. Female gender (odds ratio (OR): 5.15, p<0.0001), emergency surgery (OR: 4.46, p<0.0001), and being over 70 years of age (OR: 4.67, p<0.0001) were found to be significant predictors for postoperative depression. CONCLUSION: The prognosis for patients who had depression developed after open heart surgery was poor. It might be important to start prophylactic medication as soon as possible after the operation, particularly for patients at risk of having depression.

A successfully operated case of prosthetic valve thrombosis during planned pregnancy.

The patient was a 29-year-old woman who, when she was an 8-year-old, had undergone atrial septal defect (ASD) closure and mitral valve replacement (MVR) using a Björk-Shiley valve (25 mm) for Lutembacher syndrome. Because of a planned pregnancy, warfarin had been replaced by heparin. During the 7th week of pregnancy, she was admitted to our hospital because of dyspnea. She was diagnosed with acute heart failure due to prosthetic valve thrombosis. Following termination of pregnancy, the mitral valve was replaced with an ATS valve (25 mm). She was discharged 10 days after surgery without complications.

Comparative study of harvest-site complications following coronary artery bypass grafting between the radial artery and the saphenous vein in identical patients.

PURPOSE: The aim of this study was to assess the early outcome for complications associated with the radial artery harvest site, in comparison to using the saphenous vein, in patients harvested for both vessels. METHODS: During the last 2 years, 134 radial arteries were used in 133 patients, and the saphenous vein was also concomitantly used in 94 patients. We assessed the post-harvest forearm perception using a questionnaire that contained two statements regarding pain and numbness in those 94 patients. The incidences of the harvest-site hematoma and infection were also compared between both the arms and legs where the grafts were harvested. RESULTS: Numbness of the harvest site was indicated in 26.6% (radial artery) and 33.0% (saphenous vein), respectively (P = 0.4252). Hematoma was found in 6.4% and 12.8%, respectively (P = 0.2152). On the other hand, the incidences of pain and wound infection were significantly lower in the radial artery sites (pain: 1.1% vs 23.4%, P = 0.0002; infection: 2.1% vs 11.7%, P = 0.0182). CONCLUSIONS: Our early experience suggests that the use of the radial artery is safe and also demonstrates a lower incidence of harvest-site complications than saphenous vein harvesting in patients where both vessels are used as harvest sites.

Effects of pulsatile CPB on interleukin-8 and endothelin-1 levels.

Studies on pulsatile and nonpulsatile perfusion have long been performed. However, investigators have not reached a conclusion on which is more effective. In the present study, pulsatile cardiopulmonary bypass (CPB) was investigated in terms of the effects on cytokines, endothelin, catecholamine, and pulmonary and renal functions. Twenty-four patients who underwent coronary artery bypass grafting were divided into a pulsatile CPB group and a nonpulsatile CPB group. Parameters examined were hemodynamics, interleukin-8 (IL-8), endothelin-1 (ET-1), epinephrine, norepinephrine, lactate, arterial ketone body ratio, urine volume, blood urea nitrogen, creatinine, renin activity, angiotensin-II, lactate dehydrogenase, plasma-free hemoglobin, tracheal intubation time, and respiratory index. The IL-8 at 0.5, 3, and 6 h after CPB, and ET-1 at 3, 6, 9, and 18 h after CPB were significantly lower in the pulsatile group. Both epinephrine and norepinephrine were significantly lower in the pulsatile group. The respiratory index was significantly higher in the pulsatile group. In the present study, inhibitory effects on cytokine activity, edema in pulmonary alveoli, and endothelial damage were shown in addition to the favorable effects on catecholamine level, renal function, and peripheral circulation that have already been documented.

Determining the best procedure for radial artery harvest: prospective randomized trial for early postharvest complications.

OBJECTIVE: Although useful procedures for radial artery harvest have been reported, forearm circulation and collateral perfusion after radial artery harvesting remain unknown. To assess an optimal radial artery harvest technique for forearm circulation, we designed a prospective randomized trial. METHODS: Ninety patients were divided into 3 groups of 30 patients. Electrocautery, an ultrasonic scalpel, or sharp scissors and hemoclips were used to harvest radial arteries in groups 1, 2, and 3, respectively. The incidences of harvest site pain, numbness, swelling, discomfort, hematoma, and infection were compared. With forearm thermography, recovery times from cooled down 5 degrees back to rest temperature were compared between groups. All patients had postoperative forearm angiography at 1 and 12 months. RESULTS: Although there were no differences in the incidences of pain, swelling, and discomfort, the incidence of numbness was significantly lower in group 3 (P = .003). The temperature recovery time was significantly shorter in group 3 (P = .0009). On postoperative angiography at 1 month, the incidence of the development of interosseous arteries was significantly higher in group 3 (86.7%) than in groups 1 (23.3%) and 2 (36.7%). The 12-month study, however, showed that there was no difference among groups (73.3%, 80.0%, and 93.3% in groups 1, 2, and 3, respectively). CONCLUSIONS: These results suggest that sharp dissection with scissors and clips may be better for early postharvest forearm circulation and can decrease the incidence of hand numbness. However, there were no differences among the 3 methods with respect to forearm circulation 12 months after radial artery harvest.

Prospective randomized trial for optimal prophylactic treatment of the upper gastrointestinal complications after open heart surgery.

BACKGROUND: Upper gastrointestinal bleeding is a lethal complication after open heart surgery. We designed a prospective randomized trial to test the efficacy of different antisecretory agents to prevent upper gastrointestinal disease after operation. METHODS AND RESULTS: A total of 210 patients were divided into 3 groups: group I had 70 patients who had mucosal protection (teprenone 150 mg/day), group II had 70 patients who had histamine2-receptor antagonist (ranitidine 300 mg/day), and group III included 70 patients who had a proton pump inhibitor (rabeprazole 10 mg/day). Gastric fiberscopy was used in all patients postoperatively during days 5 to 7. We compared the 3 groups in terms of endoscopic findings. Four patients (5.7%) had gastric bleeding complications in each of groups I and II; 2 died of coagulopathy. In group III no patients had gastric bleeding. The incidence of hemorrhagic gastritis was significantly higher in groups I (22.9%) and II (15.7%) than in III (2.9%) (p=0.0003). The incidence of active ulcers was also significantly higher in groups I (28.6%) and II (21.4%) than in III (4.3%) (p=0.0001). CONCLUSIONS: Early medication postoperative by a proton pump inhibitor was shown to be the most effective treatment and indeed might be described as mandatory to prevent upper gastrointestinal diseases after open heart surgery.

A case of transient bioprosthetic valve regurgitation and hemolysis devoloping early after surgery using Carpentier-Edwards valve.

The Carpentier-Edwards pericardial bioprosthesis has been markedly improved in the long-term results and valve-related complications including valve dysfunction, compared to the previous generation bioprosthesis. We report a patient in whom transient prosthetic valve regurgitation and hemolysis occurred early after mitral valve replacement using a Carpentier-Edwards pericardial bioprosthesis and were resolved by preservative therapy. The patient was a 77-year-old female diagnosed with severe mitral valve stenosis and insufficiency. She underwent mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis. Opening and closing of the three leaflets looked good on intraoperative transesophageal echocardiography (TEE). The only prosthetic valve regurgitation was evident at the central region where the leaflets form coaptation, and no abnormal findings were seen. Serum lactate dehydrogenase (LDH) was decreased to 405 U/l after surgery. However, LDH again began to increase on the 3rd day after surgery and it increased to 1,830 U/l on the 14th day after surgery. Hemolytic urine was detected on 10th day after surgery. PVL was not detected, but moderate abnormal regurgitation from the outside of the stent pocket was detected on TEE. Revision of valve replacement was considered, but LDH thereafter to 393 U/l on 41st day after surgery. The TEE was repeated, and only a trace of central jet was detected without abnormal regurgitation, unlike the previous examination. The patient did not develop any complications thereafter and was discharged on 47th day after surgery. LDH was nearly normal at the time of discharge.

Efficacy of continuous cleansing with teicoplanin on post-CABG methicillin-resistant staphylococcus aureus (MRSA) mediastinitis: report of a case.

The patient was a 48-year-old male who was diagnosed with unstable angina. He had worsening cardiogenic shock during coronary angiography. Emergency coronary artery bypass grafting (CABG) was performed. He had a methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis on day 22 after CABG. Drains were placed in the anterior mediastinum, left thoracic cavity, and abscess cavity, and another drain was placed in the mediastinal space for continuous cleansing with povidone iodine, oxydol. For antibiotics, teicoplanin (TEIC) was administered intravenously and to the local site via the cleansing drain for about one month. No MRSA was detected by culture in discharges from the mediastinal drain. Inflammatory findings were improved, and the patient was discharged and resumed everyday life without recurrence of inflammation as of eight months. Although the number of cases of MRSA mediastinitis is small and accumulation of cases is necessary to investigate therapeutic methods and selection of antibiotics, our department will select closed continuous cleansing and TEIC for antibiotics as the first choice for MRSA mediastinitis, and accumulate cases to investigate its efficacy.