[Midterm survival of valve replacement with Carpentier-Edwards pericardial bioprosthesis in young adults].

Biologic prostheses are generally considered to have superior antithrombotic properties but lack durability. We recommend biologic prostheses to elderly patients aged over 65 years old. The purpose of this report is to evaluate the midterm outcomes of aortic or mitral valve replacement with Carpentier-Edwards Pericardial Bioprosthesis (CEP) in patients younger than 60 years old. We performed valve replacement with CEP in 17 patients, aged 60 years or youngers, in the past 10 years. The survival rate and freedom from cardiac death at 9 years was 73.2% and 87.8%, respectively. There was no valve-related thromboembolism, anticoagulant-related hemorrhage, prosthetic valve endocarditis, structual valve dysfunction or re-operation. The midterm durability of the CEP in young patients was excellent. In selection of valve prosthesis, it is important to consider factors such as risk of re-operation as well as taking warfarins, and the patient's life style and wishes.

[Surgical treatment of chronic constrictive pericarditis due to old tuberculosis; report of a case].

We experienced a case of pericardiectomy to treat constrictive pericarditis due to old tuberculosis. A 40-year-old woman was admitted to our hospital with dyspnea on exertion and edema of both legs. The chest computed tomography showed calcification of anterior ventricles. They were tightened up by calcified band. Subtotal pericardiectomy and removal of the calcification were performed without cardiopulmonary bypass. After the operation, symptoms were not disappeared in early phase. However, improvement for the patient was confirmed 3 months later.

Autologous blood donation with recombinant human erythropoietin in anemic patients.

BACKGROUND: Various blood management strategies can be used to reduce the need for allogeneic blood in cardiac surgery. In anemic patients, however, avoidance of allogeneic blood transfusion is difficult to achieve. This study was performed to assess the safety and effectiveness of preoperative blood collection using recombinant human erythropoietin (rHuEPO) for reducing the exposure to allogeneic blood in anemic patients. METHODS: Thirty-two anemic patients undergoing cardiac surgery at our hospital between January 1994 and October 1997 were divided into two groups according to preoperative strategies: 3-week treatment with rHuEPO and blood donation (group 1, n = 16) or iron supplementation alone (group 2, n = 16). RESULTS: There were no statistically significant differences between the two groups in patients' characteristics and surgical data. The number of reticulocytes was increased at just before surgery in group 1, whereas group 2 showed no significant increase. The estimated hemoglobin increases in group 1 were higher at 7 days and just before surgery. The mean number of required allogeneic blood for patients during surgery was 0.59 +/- 1.12 U in group 1 and 5.01 +/- 2.63 U in group 2. In 75% of group 1 patients, allogeneic blood transfusion was successfully avoided, whereas all patients in group 2 received allogeneic blood. CONCLUSIONS: This study suggests that the combination of rHuEPO administration and autologous blood donation can reduce the need for allogeneic blood in anemic patients.

Trapdoor thoracotomy as a surgical approach for aortic arch aneurysm.

Since 1991 ten patients, 9 male and 1 female, with aortic arch aneurysm underwent surgical therapy with trapdoor thoracotomy. The mean age was 67.4 +/- 9.1 (standard deviation) years at operation. In addition to the aortic arch repair, we also performed seven descending aortic replacements. We performed one partial arch replacement, one total arch replacement, and one aneurysmorrhaphy and wrapping of the aortic arch aneurysm. We experienced 1 case of paraplegia, no hospital death, and no long-term mortality.

Safety and efficacy of blood donation prior to elective cardiac surgery in anemic patients.

OBJECTIVE: To determine the safety and effectiveness of blood donation in anemic patients, we harvested blood from cardiac patients with baseline hemoglobin levels below 11.0 g/dl. METHODS: Subjects were 118 patients who underwent elective cardiac surgery between January 1994 and October 1997. We assigned patients to 1 of 2 groups based on their entry hemoglobin level: an anemic group (hemoglobin < 11.0 g/dl, n = 20) and a nonanemic group (hemoglobin > or = 11.0 g/dl, n = 98). All patients received subcutaneous administration of recombinant human erythropoietin, and autologous blood was collected once a week for at least 3 weeks before the scheduled surgery date if the hemoglobin level exceeded 10.5 g/dl. RESULTS: No statistically significant differences were seen between the 2 groups in patient profiles or surgical data. The estimated hemoglobin increase did not differ significantly between groups at any time point. The total collected blood volume per patient was greater in the nonanemic group than in the anemic group (1098 +/- 224 ml vs. 712 +/- 334 ml), but the difference in volume was not statistically significant. The percentage of patients who received allogeneic blood did not differ significantly between groups. No side effects were associated with hemoglobin level prior to donation because the incidence of side effects was similar across hemoglobin levels. CONCLUSIONS: This study suggests that autologous blood donation reduces the need for allogeneic blood in patients with baseline hemoglobin levels below 11.0 g/dl.

Post-parturition infectious endocarditis in a patient with a normal mitral valve.

A 29-year-old woman with no history of heart disease was admitted for the treatment of congestive heart failure. Six months earlier, she had given birth, then 20 days later developed a fever and cardiac failure ensued. An echocardiogram demonstrated severe mitral valve regurgitation. Her blood cultures were positive, and we made a diagnosis of mitral valve regurgitation due to infectious endocarditis. Despite treatment for congestive heart failure and antibiotic therapy, resulting in negative blood cultures, her congestive heart failure did not improve, and vegetation on the mitral valve was observed by echocardiography. We successfully removed the infected tissue with mitral valve plasty.

[Combined erythropoietin and aprotinin use for blood conservation in elderly coronary bypass patients].

Age is one of the predictors of homologous blood transfusion (HBT) in cardiac surgery. To avoid HBT, we have employed pharmacological blood conservation techniques such as the administration of erythropoietin (EPO) in conjunction with autologous blood donation (ABD) and the administration of aprotinin in prime volume. The effectiveness of these methods was evaluted in elderly patients who underwent coronary artery bypass grafting (CABG). Seventy-nine elective coronary bypass patients were classified into two groups by age: group A (> or = 70 y.o., n = 29) and group B (< 70 y.o., n = 46). EPO (24,000 U) was administered once a week subcutaneously starting 3 weeks before the operation. ABDs were carried out as long as the blood hemoglobin levels were above 10.5 g/dl. A significant increase of preoperative blood hemoglobin was observed in both groups. Although the blood hemoglobin levels at the beginning of ABD were lower in group A than in group B, the mean amount of predonated blood per patients was similar in both groups. In 79.3% of group A and in 84.8% of group B, HBT was not required: furthermore, in the prodonated patients, this no-HBT rate could be increased to 84.0% of group A and to 88.1% of group B. These results suggest that CABG in elderly patients can be performed safely without HBT when pharmacological blood conservation techniques are employed.

[Effect of GIK solution on the myocardial metabolism].

Effect of GIK solution (50% glucose 100 ml + insulin 20IU + KCl 20 mEq) infused in an hour on the myocardial metabolism was studied in the postoperative period following the open-heart surgery. Increase of arterial glucose, pyruvate, K+ and PCO2 and the decrease of pH was significant at the end of infusion. Increase of coronary sinus blood PCO2, myocardial oxygen extraction ratio for glucose and carbohydrate and the decrease of pH was highly significant. Myocardial oxygen extraction ratio for carbohydrate correlated significantly with the increase of coronary sinus blood PCO2 and the decrease of pH. Although the cardiac index correlated poorly with the myocardial oxygen extraction ratio for carbohydrate, a significant correlation was observed between the coronary arterial-sinus blood K+ difference and the coronary sinus blood PCO2, pH and myocardial oxygen extraction ratio for carbohydrate. It is suggested that the infused glucose with insulin and K+ was metabolized and degraded to CO2 and H2O quickly in the TCA cycle producing ATP and the rest was stored as glycogen with the uptake of K+ in the myocardium.

[Autologous blood donation with recombinant human erythropoietin prior to elective cardiac surgery in anemic patients].

Despite the reducing exposure to allogeneic blood in cardiac surgery, most of patients with anemia still require allogeneic blood. In this study, we have attempted to harvest the blood from cardiac patients with baseline hemoglobin levels below 11.0 g/dl using recombinant human erythropoietin (rHuEPO). 29 anemic patients undergoing cardiac surgery at our hospital between January 1994 and March 1997 were divided into two groups: 3 weeks' treatment with recombinant human erythropoietin (rHuEPO) and blood donation (group 1, n = 15) and iron supplementation alone (group 2, n = 14). There were no statistically significant differences among the two groups in patients characteristic and surgical data. No serious adverse events after phlebotomy were apparent in patients donating autologous blood. Patients in group 1 had significantly higher hemoglobin levels than patients in group 2 at 7 days before operation. The number of reticulocytes were increased at just before operation in group 1, whereas group 2 showed no significant increase. The estimated hemoglobin increase in group 1 were higher at 7 days and just before operation. In 75% of group 1, allogeneic blood transfusion could be avoided, while all patients in group 2 received allogeneic blood transfusion. This study suggests that the combination of rHuEPO administration and autologous blood donation would be beneficial for anemic patients in elective cardiac surgery. The use of rHuEPO should not be restricted to anemic patients.

[Results of emergency coronary artery bypass surgery after failed coronary angioplasty].

In the past 7 years, 9 emergent or urgent coronary artery bypass operations after failed percutaneous transluminal angioplasty (PTCA) were performed among 947 (PTCA). Since the introduction of coronary perfusion catheter system for the support of coronary perfusion during PTCA we could reduce the number of emergent cases and these patients could be operated on semi-emergently and securely without endangering co-medical staffs in a hurry. It is also unnecessary to be on standby all the time when the PTCA is being undertaken. Two acute myocardial infarction cases died in the early phase of this study (operative mortality 22%) and none after the introduction of coronary perfusion system during PTCA.

[Total removal of infected pacemaker lead with cardiopulmonary bypass; report of a case].

The incidence of infection after pacemaker implant has been reported to occur rarely but it's one of the severe complication. Pacemaker lead sometimes imbedded in the right atrial and ventricular wall, and it seemed to be difficult to remove the pacemaker lead by closed techniques. The optimal treatment is total removal generator and pacing lead, therefore, it is necessary to remove with cardiopulmonary bypass. Septicemia caused by infections retained pacemaker lead developed in an 87-year-old man. Following antibiotic therapy, the lead was successfully removed by cardiotomy on cardiopulmonary bypass. Total removal with cardiopulmonary bypass would be recommended.

[A surgical case report of angina pectoris with multiple coronary giant aneurysms].

A 47-year-old man with sever angina pectoris was referred for surgery. Preoperative coronary angiogram revealed giant multiple aneurysms of RCA (Seg 1-Seg 3) and LCX (Seg 11) and LAD (Seg 6). Stenoses were found distal to aneurysm, 90% in RCA-Seg 4, CX-Seg 11, 100% in LAD- Seg 6 and DX-Seg 9 and OM-Seg 12, with collaterals from RCA to LAD. Left ventlicle contracted poorly with the EF of 36 due to anteroseptal infarction. Coronary artery bypass grafting were performed to LAD using a LITA, to DX and LCX using a SVG in the sequential fashion. Postoperative coronary cineangiogram demonstrated that all grafts were patent and multiple giant coronary aneurysms resembled coronary arterial changes of Kawasaki's disease.

[A case of progressive right coronary ostial stenosis after Carrel patch method using gelatin-resorcin-formalin glue].

A 31-year-old man with type A chronic aortic dissection associated with annuloaortic ectasia underwent the concomitant graft replacement of the total aortic root and the transverse aortic arch. The two coronary arteries were reconstructed using the Carrel patch method. The false lumen of right coronary artery was closed by injection of GRF glue into the dissected space and compressing the dissected layers. Postoperative course was uneventful, and the patient has returned to normal daily life 2 months after surgery. Remarkable progression of the right coronary artery ostial stenosis was observed by coronary angiography 6 months after surgery. The remarkable progression of stenosis may occur in association with injection of GRF glue into the dissected space, although the exact etiology of the progressive stenosis remains obscure.

[Aortic valve operations through an upper partial sternotomy].

The median sternotomy has been accepted as the most common approach to the heart, because this approach is easily opened and closed, and easy access to the entire heart is possible. Following the pioneering work by Cosgrove and colleagues of using a parasternal incision for aortic and mitral valve operations, several reports suggested that modified minimal access procedures are likely to be associated with reduced postoperative discomfort and faster recovery. Since July 1997, we have used an upper partial sternotomy and a limited skin incision for isolated aortic valve replacement (AVR) at our hospital. To demonstrate the benefits of this approach, we compared 14 AVR operations using our minimal access incision (group M) with 19 patients undergoing isolated AVR using a conventional sternotomy (group F). In the minimal access group of patients, a small skin incision was made from the second intercostal space to the fourth rib. The pectralis major and intercostal muscle was freed from the sternum, and then a transverse half sternotomy was made in the fourth intercostal space using a striker without injury to the right internal mammary artery. A median partial sternotomy from the supersternal notch to the level of the fourth intercostal space. Cardiopulmonary bypass was connected through the same access site to avoid cannulation of both groins. Conversion to median sternotomy was not necessary in any patient including reexploration for postoperative bleeding. There was no operative mortality, stroke, aortic dissection and perivalvular leaks due to technical factors. In group F, wound infection occurred in 1 patient. One patient in group M required reoperation to control postoperative bleeding. Although mean duration of operation, cardiopulmonary bypass, and cross clamp time in group M was not prolonged, the initiation of cardiopulmonary bypass and aortic crossclamp was delayed by difficulties of cannulations. The distance between the transverse sternotomy (lower edge of divided sternum) and the midpoint of aortic valve annulus was correlated with mean duration of cardiopulmonary bypass and cross clamp time. Our experience demonstrates that isolated AVR through an upper partial sternotomy allows the same quality operations as the full sternotomy, although more clinical experience is required to clarify the benefits of this approach. Excellent exposure of the aortic valve through a partial sternotomy may be attained, if an adequate approach can be selected by the position of aortic valve.

[Double chambered right ventricle in a 62-year-old female: a surgical case report].

A 62-year-old female was admitted with a chief complaint of transient syncope on exertion. Angiography in right ventricle revealed a defect caused by an anomalous muscle bundle and a pressure gradient of 151 mmHg was observed between the two chambers by cardiac catheterization. Resection of the anomalouse muscle bundle was undertaken using a lower median sternotomy starting at the 2nd intercostal space level and through the outflow tract right ventriculotomy. Patch plasty was also undertaken in the outflow tract. Post-operative course was uneventful and pressure gradient had disappeared at the post-operative catheterization. A rare case of DCRV in a 62-year-old patient with a pressure gradient of 151 mmHg in the right ventricle was reported.

[Benefit of the autoperfusion balloon catheter for emergency coronary artery grafting after failed percutaneous transluminal coronary angioplasty].

A 61-year-old man was operated on an emergent basis because of abrupt closure of left anterior descending coronary artery (LAD) following failed coronary angioplasty. At once abrupt closure occurred, Stack autoperfusion balloon catheter was placed across the coronary lesion to reestablish blood flow to the ischemic myocardial area with intraaortic balloon counterpulsation. Despite a longtime of 12 hours to cardiopulmonary bypass, the patient had been managed with excellent resolution of symptoms and ST elevation. Under a stable hemodynamic state, saphenous vein grafting to LAD was performed with minimal myocardial infarction. Stack catheter made it possible to perform the subsequent coronary bypass operation as a controlled, optimal revascularization procedure because of its passive autoperfusion effect.

[Three-channeled aortic dissection: selection of surgery based on the images].

Three patients with 3-channeled dissection were operated upon. Images of the dissection were enlargement of the false lumens, compression of the true lumen by enlarged false lumens and visceral arteries of false lumen origin. These prevent the use of cardiopulmonary bypass (CPB) and cause malperfusion of the viscera. Three-channeled dissecion is easy to rupture for its peculiar anatomy and total repair of the thoraco-abdominal aorta is mandatory. Fenestration brings functional recovery of malperfused viscera and enables the patients to be placed on CPB for total repair. Two patients underwent infrarenal and descending aorta fenestration followed by the total repair of thoraco-abdominal aorta successfully. A third patient has been placed on the strict CT follow-up following the infrarenal fenestration.

[Re-do surgery with minimally invasive cardiac surgery (MICS): mitral valve replacement 6 years after open mitral commissurotomy].

A 60-year-old man, who had undergone open mitral commissurotomy 6 years ago, underwent re-do surgery (mitral valve replacement) with minimally invasive cardiac surgery (MICS), using lower partial sternotomy to the height of the right side second intercostal space. Cannulation of the heart was carried out placing a cannula directly into the superior vena cava and a second cannula in the inferior vena cava via the right atrium. Arterial return was through the ascending aorta. Cardioplegia was administered directly into the ascending aorta with intermittent perfusion. Valve replacement was performed by opening directly right side left atrium.

[A case report of mitral valve replacement using a parasternal incision (minimally invasive cardiac surgery) with pleuritis tuberculosa and after esophagus operation].

A 68-year-old man underwent mitral valve replacement because of mitral regurgitation (prolaps of anterior mitral leaflet) using parasternal incision (Delos M. Cosgrove, minimally invasive surgery). He had been treated as pulmonary tuberculosis previously and had undergone esophagus operation using stomach role reconstruction beneath the sternum four years before the mitral valve procedure. We could not select median-sternotomy as an approach due to stomach role beneath the sternum, nor left posterolateral thoracotomy because of the heavy left-side pleural adhesion. Cardio-pulmonary bypass cannulations were performed through the same incision, because severe atherosclerosis was found at the distal arteries of the abdominal aorta.

[The comparison of tepid and moderate hypothermic cardiopulmonary bypass in cardiac surgery].

Normothermic cardiopulmonary bypass (CPB) is being increasingly used at some institutions. Patients undergoing normothermic CPB have a higher systemic oxygen demand and may be at higher risk for ischemic injury. This study was designed to confirm the clinical efficacy and safety of tepid hypothermic CPB. Thirty-six patients undergoing open heart surgery between June 1993 and August 1994 were divided into two groups: tepid (n = 18, 32 degrees C) and moderate (n = 18, 26 degrees C) hypothermic CPB. There were no significant differences in preoperative and perioperative patients characteristics between the two groups. The mean aortic cross-clamp time did not differ between two groups, but the mean CPB time was significantly shorter in tepid hypothermic patients. Serum lactate after CPB and lactate/pyrvate ratio during CPB in tepid hypothermic patients were significantly lower than in moderate hypothermic patients. The mixed venous oxygen saturation in tepid hypothermic patients was significantly lower however, it was maintained at levels more than 70% during CPB. This study suggests that tepid hypothermic CPB is a safe and effective alternative to moderate hypothermic CPB for patients undergoing open heart surgery. Previous reports have documented that patients undergoing normothermic CPB are at greater risk for cerebral desaturation. We should evaluate cerebral venous oxygen saturation during tepid hypothermic CPB before the induction of normothermic CPB.