The Leaving Hospital Program of the Patient with LVAD for Destination Therapy / 日本心臓血管外科学会雑誌

The left ventricle assist device (LVAD) has become an important therapeutic option in the treatment of acute or chronic heart failure. It is usually used as bridge to transplantation or recovery. At present, destination therapy with LVAD has been a therapeutic option in patients with heart failure in whom transplantation is not indicated. We describe a patient, who received destination therapy with LVAD, and was able to go home temporarily. The patient was a 63-year-old man with low output syndrome after acute myocardial infarction. An LVAD (TOYOBO) was implanted at Oita University Hospital, however the patient suffered from MRSA mediastinitis 6 months later. He and his family wished for him to temporarily go home to Ibaraki. The patient, supported by LVAD, was transferred from Oita to Ibaraki by a regular commercial flight and ambulance. Rehabilitation training involved stretching, in-bed muscle strength training, maintaining a standing position, walking on flat ground with a walker and going up and down ramps. All training was measured at the patient's home. The patient was out of hospital for 5 hours, and this period was uneventful upon leaving hospital. The patient also took an active part in rehabilitation after discharge. This program can help to improve the quality of life (QOL) of patients with implanted LVADs for destination therapy.

A Surgical Case of Mitral Regurgitation and Atrial Septal Defect with Myotonic Dystrophy / 日本心臓血管外科学会雑誌

Myotonic dystrophy (MyD) is a rare progressive multisystemic-inherited neuromuscular disease. It is often associated with cardiovascular disorders which require surgical procedures. However, it high sensitivity to anesthetic and neuromuscular blocking agents may result in respiratory complications. Myotonic dysorder due to hypothermia and conductive disorder following open-heart surgery are also risk-factor of perioperative management, thus open-heart surgery for MyD has rarely been reported. We describe the perioperative management for a MyD patient with an atrial septal defect (ASD) and mitral regurgitation (MR), who successfully underwent cardiac surgery. Minimally invasive cardiac surgery (MICS) with reverse-L-shaped partial sternotomy were useful method to minimize postoperative respiratory problems.

A Case of Traumatic Aortic Dissection Associated with Multiple Trauma / 日本心臓血管外科学会雑誌

A 59-year-old woman with blunt multiple trauma was transferred to our emergency unit. A computed tomography revealed both an intimal flap of the descending aorta and cerebral bleeding. Immediate aortic surgery was considered, however full heparinized cardiopulmonary bypass (CPB) was not suitable because of acute brain hemorrhage. We performed surgery 55 days after the trauma. On operation 75% of the intima at the descending aorta was disrupted circumferentially. The descending aorta was replaced by a prosthetic graft under CPB. The postoperative course was uneventful and the patient has been well for 30 months after surgery. In treating aortic dissection associated with blunt trauma, emergency surgery should be performed immediately when possible, however there can be some limitations because of other acute organ injury. Accurate information concerning other injured organs, obtained by careful examination, may help an appropriate decision to be reached.

Factors Affecting Survival after Surgical Treatment for Ruptured Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

To identify the factors affecting the high mortality rates associated with ruptured abdominal aortic aneurysm (rAAA), a review was made of the records of 35 consecutive patients (33 males, 2 females, mean age 69.9yr.) treated surgically between 1988 and 1997. Preoperatively profound shock (systolic pressure less than 70mmHg) was seen in 19 patients and loss of consciousness in 9. Maximum diameter of the AAA was 79±20mm and the preoperative hemoglobin level was 9.1±2.4g/dl. Proximal aortic clamp was performed at the intrathoracic aorta in 3 cases, the suprarenal aorta in 6, balloon occlusion in 4, and the infrarenal aorta in 22. Since 1994, diltiazem and nitroglycerin have been routinely given for latent myocardial ischemia and early induction of continuous hemodialysis for renal failure was attempted postoperatively. The overall hospital mortality rate was 20%. Multisystem failure was the most frequent cause of hospital death (57.1%), followed by pneumonia with sepsis in 28.6%, and intraoperative cardiac arrest (14.3%). By univariate analysis of various factors associated with the mortality rate, loss of consciousness, abnormality on electrocarciogram (ECG) and duration of shock for more than five hours were statistically significant. Multivariate analysis with stepwise logistic regression demonstrated that an ECG abnormality and duration of shock more than five hours were associated with high mortality, but not at statistically significant levels. These findings suggest that factors that are predictive of death (loss of consciousness and ECG abnormality) may be a reflection of shock in this patient population.

Surgical Treatment of Acute Aortic Dissection (Stanford type A) Associated with Myocardial Ischemia / 日本心臓血管外科学会雑誌

Immediate surgical intervention is required for Stanford type A aortic dissection. However, the surgical results of emergency surgery are still poor, especially in patients associated with myocardial ischemia. This study was undertaken to evaluate the surgical results of acute type A aortic dissection in association with myocardial ischemia. In the past six years 7 cases of acute type A aortic dissection underwent surgical repair with simultaneous coronary-artery bypass grafting (CABG). There were 5 male and 2 female with a mean age of 47±16 year-old. The causes of myocardial ischemia were proximal progression of dissection into the coronary orifice in 5 and association of atherosclerotic coronary heart disease in 2. Six patients developed cardiogenic shock before surgery. Bentall's type of operation was performed on 4 patients and prosthetic graft replacement of ascending aorta was performed on 2 patients. Single bypass grafting was performed on 5 patients and double bypass grafting was performed on 2 patients. One patient died due to brain damage and acute renal failure on the tenth postoperative day, and another patient required left ventricular assist device for 9 days due to postoperative low cardiac output syndrome. Ultimately 6 patients (86%) survived and were discharged. In conclusion, surgical management is not easy for the emergency patients with type A acute aortic dissection in association with myocardial ischemia, however, reasonable surgical results can be obtained with supplemental CABG and mechanical support of the left ventricle.

Selective Cerebral Perfusion with Cold Blood for Repair of Aortic Arch Aneurysm / 日本心臓血管外科学会雑誌

Cerebral protection during surgical procedure of aortic arch aneurysm is one of the most important factor which limits the time of surgical repair of the aortic arch and arch branches. We introduced the selective cerebral perfusion system by gravity with cold blood for repair of aortic arch aneurysm from 1988. This study was undertaken to determine whether this new selective cold blood cerebral perfusion system is usefull for repair of aortic arch aneurysm. From July 1988 to May 1991, twenty-three patients with aortic arch aneurysms were repaired using the selective cerebral perfusion system with cold blood. Both carotid arteries were selectively perfused with oxygenated cold blood (16°C) via the reservoir combined with heat-exchanger fixed 1.5 meter high from the head of the patient. Surgical repair was performed under moderate core hypothermia (20-25°C) avoiding prolonged cardiopulmonary bypass to rewarm the patient. Cerebral perfusion pressure was 45 mmHg (mean) and perfusion flow via the carotid arteries was 400ml/min. Mean selective cerebral perfusion time was 60min and mean cardiopulmonary bypass time was 193min. Emergency operations were performed in seven of 23 patients because of ruptured aortic arch aneurysms. There was no intraoperative death. Three of 23 patients (13%) died due to postoperative complication. Nineteen of 20 survivors discharged from the hospital and are good clinical condition. One patient needs the care for rehabilitation in the hospital due to cerebral infarction. Although our experience is limited, successful cerebral protection and avoidance of prolonged cardiopulmonary bypass were achieved. Selective low pressure cerebral perfusion with cold blood may be a useful method for repair of aortic arch aneurysm.