[Inhaled Nitric Oxide Therapy Using High-flow Nasal Cannula in Adults After Open Heart Surgery].

Inhaled nitric oxide( iNO) therapy is commonly used to improve pulmonary hypertension and oxygenation in adult patients undergoing open heart surgery, mostly being applied to mechanical ventilation (MV). We often face rebound of pulmonary artery pressure (PAP) after reduction or discontinuation of iNO therapy, resulting in prolonged MV. Twenty-three cases, to which iNO therapy during MV (MV-iNO) were initiated, then continuously treated with iNO therapy using high-flow nasal cannula (HFNC-iNO) after extubation, were retrospectively investigated. During MV-iNO, mean PAP( mPAP) was significantly lower than before starting iNO therapy (p<0.001). Also, mPAP on HFNC-iNO was significantly lower than mPAP before iNO therapy during MV (p<0.001). There was no significant difference of mPAP between MV-iNO and HFNC-iNO (p=0.38). MV was discontinued in 330 minutes (median), oxygenation was maintained after switching from MV-iNO to HFNC-iNO and there were no cases of reintubation, perioperative mortality, or adverse events due to iNO therapy. HFNC-iNO is considered as useful method in maintaining decreased mPAP and improved oxygenation after extubation in adult patients after open heart surgery.

A Surviving Case of Myocardial Infarction with Ventricular Septal Rupture and Ventricular Aneurysm following Gastrointestinal Bleeding.

A 55-year-old man presented to the emergency department with worsening shortness of breath 1 month after a gastrointestinal bleed. He had congestive heart failure, and an electrocardiogram suggested ischemic heart disease involvement. Echocardiography revealed a ventricular septal defect complicated by a left ventricular aneurysm in the inferior-posterior wall. Conservative treatment was started, but hemodynamic collapse occurred on the third day of admission and coronary angiography revealed a revascularizing lesion in the right fourth posterior descending coronary artery. Subsequently, his hemodynamic status continued to deteriorate, even with an Impella CP® heart pump, so ventricular septal defect patch closure and left ventricular aneurysm suture were performed. His condition improved and he was discharged on day 23 of admission and was not readmitted within 6 months after the procedure. Hemodynamic management of ventricular septal defects requires devices that reduce afterload, and clinicians should be aware of the risk of myocardial infarction after gastrointestinal bleeding.

Mycotic abdominal aortic aneurysm in a patient with systemic lupus erythematosus: A case of critical antinomy.

Mycotic abdominal aortic aneurysms (MAAAs) are rare but life-threatening, and no standard therapy has yet been established. Effective surgery with intensive antimicrobial therapy is crucial; however, this can be fatal in immunocompromised patients. Only a few reports of MAAA with concomitant autoimmune disease exist; therefore, we were concerned about our lack of experience and knowledge about appropriate treatment. We report a 69-year-old male with an MAAA secondary to septic shock after spinal fusion surgery. He had also been on long-term oral immunosuppressants for systemic lupus erythematosus (SLE). After preoperative cephazolin, we performed debridement of infected tissue, graft replacement with a rifampicin-bonded prosthesis, and omentopexy. On the 52nd post-operative day, he was transferred back to the previous attending hospital under oral antibiotics and prednisolone. MAAA in patients with SLE should be treated with in situ replacement using an antimicrobial prosthetic or biological graft with thorough debridement and omentopexy, followed by antimicrobials and immunosuppressants, as needed.

Near-infrared spectroscopy device selection affects intervention management for cerebral desaturation during cardiopulmonary bypass surgery.

OBJECTIVE: Currently, several near-infrared spectroscopy oximetry devices are used for detecting cerebral ischemia during cardiopulmonary bypass (CPB) surgery. We investigated whether two different models of near-infrared spectroscopy oximetry devices affect the assessment of cerebral ischemia and its management during CPB. METHODS: From January 2017 to August 2017, 70 adult cardiovascular surgery cases were randomly assigned to 1 of 2 different near-infrared spectroscopy oximetry devices. The devices were INVOS 5100C (Medtronic, Minneapolis, MN, USA) (group I; n = 35) and FORE-SIGHT ELITE (CAS Medical Systems, Branford, CT, USA) (group F; n = 35). RESULTS: There were no significant differences in patient characteristics. The rSO2 values were significantly higher for patients in group F than for patients in group I. Scalp-Cortex distance showed negative correlations with the mean rSO2 values in group I (P = 0.01). Interventions for low rSO2 during CPB for groups I and F were increase perfusion flow (13:5; P = 0.03), blood transfusion (7:1; P = 0.02), and both (6:1; P = 0.04), respectively. The Scalp-Cortex distance in group I was significantly longer in patients who required intervention than in patients who did not (17.1 ± 2.5 vs 15.1 ± 1.6 mm; P = 0.007). CONCLUSIONS: It is inappropriate to use the same intervention criteria for different near-infrared spectroscopy oximetry devices. Moreover, brain atrophy influence rSO2 values depending on device selection. It is important to note that inappropriate device selection may misguide perfusionists into performing unnecessary or excessive intervention during CPB.

[Extraction of a 36-year-old Pacemaker Lead Using Cardiopulmonary Bypass].

A 78-year-old man underwent pacemaker implantation via the left internal jugular vein 36 years ago. After 30 years, a new device was implanted via the right subclavian vein and the old lead was cut and buried underneath the skin due to infection. This time, the patient presented with persistent lead infection of the left side. We chose open heart surgery to excise the old lead because of severe adhesion and surrounding calcification. The infected lead was completely removed using cardiopulmonary bypass without complication. Old pacemaker leads tend to develop adhesion and calcification within the innominate vein and superior vena cava, and therefore, it is often difficult to remove it with percutaneous technique. It was considered that open heart surgery was useful to excise a very old pacemaker lead.

Resection of a desmoid-type fibromatosis with a CTNNB1 p.S45P mutation using a cervico-thoracic approach: A case report and literature review.

Desmoid-type fibromatosis (DF) is a rare, locally infiltrative, and fibroblastic proliferative disease. DF usually arises from abdominal fascial tissue, but in rare cases, it can occur in extra-abdominal areas. A 73-year-old Japanese male complained of a painless, left anterior neck mass of 3-month duration. Computed tomography revealed the mass measured 9 × 7 × 6 cm and extended to the anterior mediastinum, with invasion of the left clavicle. En bloc resection of the tumor with the left sternoclavicular joint and the medial portion of the left clavicle was performed by cervico-thoracic approach with L-shaped partial sternotomy. Histopathologic examination showed fascicular growth of spindle-shaped cells separated by abundant collagen. Immunohistologic examination revealed nuclear staining of ß-catenin and cytoplasmic staining of vimentin. Genetic analysis of 160 cancer-related genes by next-generation sequencing (NGS) demonstrated only a missense mutation in the CTNNB1 gene (c.133T>C, p.S45P). DF extending from the neck to the anterior mediastinum is rare. We report the complete resection of a large-sized DF with the clavicular invasion. A low-frequency CTNNB1 mutation of DF was identified. Genetic analysis with NGS was beneficial for the diagnosis.

Aortic atresia with transposition of the great arteries.

We describe a rare case of newborn with aortic atresia and transposition of the great arteries who underwent successful surgical repair. To the best of our knowledge, no such case has been previously reported. We demonstrated that, even with a complex diagnosis, the patient could survive after rapid two-stage Norwood procedure.

Early Extubation in the Operating Room after Congenital Open-Heart Surgery.

Early extubation in the operating room after congenital open-heart surgery is feasible, but extubation in the intensive care unit after the operation remains common practice at many institutions. The purpose of this study was to evaluate retrospectively the adequacy of our early-extubation strategy and exclusion criteria through analysis based on the Risk Adjustment in Congenital Heart Surgery method (RACHS-1).This retrospective analysis included 359 cases requiring cardiopulmonary bypass (male, 195; female, 164; weight > 3.0 kg; aged 1 month to 18 years). Neonates and preoperatively intubated patients were excluded. Other exclusion criteria included severe preoperative pulmonary hypertension, high-dose catecholamine requirement after cardiopulmonary bypass, delayed sternal closure, laryngomalacia, serious bleeding, and delayed awakening. The early-extubation rates were compared between age groups and RACHS-1 classes.Overall, 83% of cases (298/359) were extubated in the operating room, classified by RACHS-1 categories as follows: 1, 59/59 (100%); 2, 164/200 (84%); 3, 61/78 (78%); and 4-6, 10/22 (45%). The early extubation rate in categories 1-3 (86%, 288/337) was significantly higher than for categories 4-6 (45.5%, 10/22) (P < 0.001). Because they met one of the exclusion criteria, 61 patients (17%) were not extubated in the operating room. Eight patients (2.7%) required re-intubation after early extubation in the operating room, and longer operation time was significantly associated with re-intubation (P < 0.001).Extubation in the operating room after congenital open-heart surgery was feasible based on our criteria, especially for patients in the low RACHS-1 categories, and involves a very low rate of re-intubation.

Increased systemic cardiac output improves arterial oxygen saturation in bidirectional cavopulmonary shunt.

The low arterial oxygen saturation (SaO2) after bidirectional cavopulmonary shunt (BCPS) predicts poor prognosis. The venous oxygen saturation of inferior vena cava (SivcO2), as well as the pulmonary blood flow/systemic blood flow ratio (Q p/Q s) affects the SaO2. The purpose of this study is to determine whether SivcO2 or Q p/Q s should be increased to achieve better outcomes after BCPS. Forty-eight patients undergoing BCPS were included. Data of patients' age and body weight, SivcO2, Q p/Q s, pulmonary artery (PA) pressure and resistance, PA area index, morphology of ventricle, atrioventricular valve regurgitation, and history of PA plasty were collected. Stepwise multiple logistic regression analyses were used to investigate which of the factors most affected the SaO2 after BCPS. There was a significant correlation between SivcO2 and SaO2 (r = 0.771, P < 0.00001). There was no strong correlation between Q p/Q s and SaO2 (r = 0.358, P < 0.05). Stepwise multiple logistic regression analyses revealed that both SivcO2 (r = 0.49, 95 % confidence interval (CI) 0.37-0.62, P < 0.0001) and Q p/Q s (r = 11.1, 95 % CI 3.3-18.9, P = 0.007) most affected SaO2 after BCPS. Since the SivcO2 has a stronger correlation than Q p/Q s with SaO2, despite the fact that both raising Q p/Q s and raising cardiac output can increase SaO2, raising cardiac output should be considered prior to Q p/Q s to raise the SaO2 after BCPS.

Aortic regurgitation due to fibrous strand rupture in the fenestrated left coronary cusp of the tricuspid aortic valve.

Fenestration-related massive aortic regurgitation is rare. The underlying mechanism is reported to be rupture of the fenestrated fibrous strand, and most ruptured cords have been reported in the bicuspid valve or in the right coronary cusp of the tricuspid aortic valve. We encountered a rare case of acute aortic regurgitation due to fibrous strand rupture in the fenestrated left coronary cusp. Preoperative echocardiography detected left coronary cusp prolapse, and operative findings revealed rupture of a fibrous strand in the left coronary cusp. For cases such as this, preoperative echocardiography would be useful for appropriate diagnosis.

Effect of additional preoperative administration of the neutrophil elastase inhibitor sivelestat on perioperative inflammatory response after pediatric heart surgery with cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) elicits a systemic inflammatory response. Our previous reports revealed that prophylactic sivelestat administration at CPB initiation suppresses the postoperative acute inflammatory response due to CPB in pediatric cardiac surgery. The purpose of this study was to compare the effects of sivelestat administration before CPB and at CPB initiation in patients undergoing pediatric open-heart surgery. Twenty consecutive patients weighing 5-10 kg and undergoing ventricular septal defect closure with CPB were divided into pre-CPB (n = 10) and control (n = 10) groups. Patients in the pre-CPB group received a 24 h continuous intravenous infusion of 0.2 mg/kg/h sivelestat starting at the induction of anesthesia and an additional 0.1 mg/100 mL during CPB priming. Patients in the control group received a 24-h continuous intravenous infusion of 0.2 mg/kg/h sivelestat starting at the commencement of CPB. Blood samples were tested. Clinical variables including blood loss, water balance, systemic vascular resistance index, and the ratio between partial pressure of oxygen and fraction of inspired oxygen (P/F ratio) were assessed. White blood cell count and neutrophil count as well as C-reactive protein levels were significantly lower in the pre-CPB group according to repeated two-way analysis of variance, whereas platelet count was significantly higher. During CPB, mixed venous oxygen saturation remained significantly higher and lactate levels lower in the pre-CPB group. Postoperative alanine aminotransferase and blood urea nitrogen levels were significantly lower in the pre-CPB group than in the control group. The P/F ratio was significantly higher in the pre-CPB group than in the control group. Fluid load requirement was significantly lower in the pre-CPB group.Administration of sivelestat before CPB initiation is more effective than administration at initiation for the suppression of inflammatory responses due to CPB in pediatric open-heart surgery, with this effect being confirmed by clinical evidence.

Effect of the neutrophil elastase inhibitor sivelestat on perioperative inflammatory response after pediatric heart surgery with cardiopulmonary bypass: a prospective randomized study.

Cardiopulmonary bypass (CPB) elicits a systemic inflammatory response. The neutrophil elastase inhibitor sivelestat is known to suppress this systemic inflammatory response, which can eventually result in acute organ failure. The prophylactic effect of sivelestat on acute lung injury, especially in pediatric cardiac surgery, remains unclear. This prospective double-blind, randomized study evaluated the perioperative prophylactic effect of sivelestat in patients undergoing elective pediatric open heart surgery with CPB. Thirty consecutive patients, weighing 5-10 kg and undergoing open heart surgery with CPB, were assigned to sivelestat (n = 15) or control (n = 15) groups. From CPB initiation to 24 h after surgery, patients in the sivelestat group received a continuous intravenous infusion of 0.2 mg/kg/h sivelestat, whereas patients in the control group received the same volume of 0.9% saline. Blood samples were collected, and levels of interleukin (IL)-6, IL-8, tumor necrosis factor alpha, polymorphonuclear elastase (PMN-E), C-reactive protein (CRP), as well as the white blood cell (WBC) count, platelet count, and neutrophil count (NC) were measured. PMN-E levels, IL-8 levels, WBC count, NC, and CRP levels were significantly lower, and platelet count was significantly higher in the sivelestat group, according to repeated two-way analysis of variance. The activated coagulation time was significantly shorter in the sivelestat group, similarly, blood loss was significantly less in the sivelestat group. In conclusion, Sivelestat attenuates perioperative inflammatory response and clinical outcomes in patients undergoing pediatric heart surgery with CPB.

Neutrophil elastase inhibitor sivelestat attenuates perioperative inflammatory response in pediatric heart surgery with cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) evokes activation of a systemic inflammatory response. Sivelestat has been used clinically to treat acute lung injury associated with systemic inflammatory response syndrome. This prospective, doubleblind, randomized study was designed to evaluate the effects of sivelestat in the perioperative period of elective pediatric open-heart surgery with CPB. Twenty-six consecutive pediatric patients weighing between 5 and 10 kg and undergoing open-heart surgery with CPB were divided into a sivelestat group (n = 13) and a control group (n = 13). The patients in the sivelestat group were administered a continuous intravenous infusion of 0.2 mg/kg/hour of sivelestat, and the patients in the control group were administered the same volume of 0.9% saline from the initiation of CPB to 24 hours after surgery. Blood samples were drawn for the measurement of cytokines, polymorphonuclear elastase (PMN-E), white blood cell count (WBC), neutrophil count (NC), and C-reactive protein (CRP). There were no significant differences in cytokine data between the two groups. The peak PMN-E and WBC levels were significantly increased in the control group (P = 0.049, P = 0.039). The WBC and NC levels immediately after surgery in the control group were significantly greater than those in the sivelestat group (P = 0.049, P = 0.044). The peak CRP level in the control group was significantly greater than the sivelestat group (P = 0.04), and the CRP level on postoperative day 4 in the control group was significantly greater than in the sivelestat group (P = 0.014). This study showed that sivelestat attenuates the perioperative inflammatory response in pediatric heart surgery with CPB.

Univentricular heart with bridging bronchus and sling left pulmonary artery.

A bridging bronchus (BB) is a rare congenital heart anomaly. Frequently, BB also is complicated with congenital cardiac malformation, especially with sling (retrotracheal) left pulmonary artery (SLPA). This report presents a patient who underwent a Norwood procedure for a complex congenital heart disease with BB and SLPA.

Surgical strategy for severe aortic hypoplasia and aortic stenosis with ventricular septal defect and normal left ventricle.

At our institution, the strategy for patients with bicuspid aortic valve, aortic valve stenosis (<5 mm), and aortic hypoplasia [hypoplastic aortic arch, coarctation of the aorta (CoA), or interrupted aortic arch (IAA)] with ventricular septal defects (VSDs) as well as normal left ventricular (LV) volume and mitral valve size consists of two parts. The Norwood operation is applied as the first palliation for this group of patients. Second, the decision whether the patients are to undergo the Rastelli operation or a univentricular repair is made depending on the size of the right ventricle after the Norwood operation. This study aimed to examine whether the aforementioned surgical strategy for this group of patients is adequate or not. Seven patients undergoing the Norwood operation as the first palliation for bicuspid aortic valve, aortic valve stenosis (<5 mm), and aortic hypoplasia with VSDs as well as normal LV volume and mitral valve size between February 2005 and March 2010 at Kitasato University Hospital and the Gunma Children's Medical Center were reviewed. Postoperative serum B-type natriuretic peptide (BNP) and central venous pressure (CVP) were measured in the patients undergoing the staged Norwood-Rastelli operation to assess whether the authors' right ventricular end-diastolic volume index (RVEDVI) cutoff (80 % of normal) is adequate. At this writing, all seven patients are alive after a mean follow-up period of 58.8 ± 17.8 months. They all had aortic valve stenosis of <5 mm and a bicuspid aortic valve. Four patients had a diagnosis of CoA with VSD, and three patients had IAA with VSD. Six patients underwent biventricular repair, and one patient had univentricular repair due to the small RVEDVI (74 % of normal). The patients with 80-90 % of normal RVEDVI had higher BNP and higher CVP than those with more than 90 % of normal RVEDVI after the Rastelli operation, whereas the patient undergoing the Fontan operation had a low BNP level. In conclusion, the described strategy for patients with severe aortic hypoplasia and aortic stenosis with VSD as well as normal LV and mitral valve size is reasonable.

[A long-term survival case of biliary tract cancer treated with multimodality therapy].

A 64-year-old man with obstructive jaundice underwent percutaneous transhepatic biliary drainage, and bile cytology diagnosed adenocarcinoma. The operation ended with exploratory laparotomy because of severe cirrhosis, and thus, S-1 therapy was started after radiation therapy (50 Gy) with an endoscopic retrograde biliary drainage (ERBD) tube. After 37 months, an abdominal computed tomography(CT) scan detected dilation of the intrahepatic biliary tract without recurrence, and we therefore detained a biliary expandable metallic stent instead of the causal obstruction of the ERBD tube. Subsequent CT scan and upper gastrointestinal endoscopy detected stenosis and a thickened wall of the duodenum because of recurrence, and thus, we detained a duodenal stent and started gemcitabine therapy. The patient is alive 70 months after the initial consultation. We report herein a long-term survival case of biliary tract cancer treated with multimodality therapy.

Half-turned truncal switch operation for transposition of great arteries with ventricular septal defect and pulmonary regurgitation.

A three-month-old girl weighing 4.2 kg, diagnosed with transposition of the great arteries (TGA) and ventricular septal defect (VSD) was referred to us. She had normal-sized pulmonary annulus and moderate pulmonary regurgitation. Because her pulmonary valve was not suitable for systemic circulation due to valvular incompetence, the half-turned truncal switch operation was selected. The postoperative course was uneventful without left or right ventricular outflow obstructions over a year of follow-up. Our report demonstrated that the TGA and VSD with normal pulmonary annulus is not contraindicated for half-turned truncal switch operation.

For what type of constrictive pericarditis is the waffle procedure effective?

The waffle procedure is performed in patients with marked thickening and calcification of the epicardium and no substantial improvement in hemodynamic parameters after pericardiectomy. We retrospectively investigated the efficacy of the waffle procedure in 6 of 11 patients who underwent pericardiectomy. These 6 patients showed no improvement in central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, or cardiac index after pericardiectomy. After the waffle procedure, all hemodynamic parameters improved, and there were no significant differences compared to those of the 5 patients who did not require the waffle procedure, despite higher pulmonary capillary wedge pressure and lower cardiac index values preoperatively in the waffle group. The waffle procedure was considered effective in patients with persistent epicardial constriction.

The effectiveness of high-flow regional cerebral perfusion in Norwood stage I palliation.

OBJECTIVE: Regional cerebral perfusion (RCP) has been shown to provide cerebral circulatory support during Norwood procedure. In our institution, high-flow RCP (HFRCP) from the right innominate artery has been induced to keep sufficient cerebral and somatic oxygen delivery via collateral vessels. We studied the effectiveness of HFRCP to regional cerebral and somatic tissue oxygenation in Norwood stage I palliation. METHODS: Seventeen patients, who underwent the Norwood procedure, were separated into two groups: group C (n=6) using low-flow RCP and group H (n=11) using HFRCP (mean flow: 54 vs 92mlkg(-1)min(-1), P<0.0001). The mean duration of RCP was 64±10min (range, 49-86min) under the moderate hypothermia. Chlorpromazine (3.0mgkg(-1)) was given to group H patients before and during RCP to increase RCP flow. The mean radial arterial pressure was kept <50mmHg during RCP. To clarify the effectiveness of HFRCP for cerebral and somatic tissue oxygenation, cerebral regional oxygen saturation (rSO(2)) and systemic venous oxygenation (SvO(2)) during RCP were compared between the two groups. Changes in the lactate level before and after RCP, and changes in the blood urea nitrogen (BUN), creatinine, lactate dehydrogenase (LDH), and creatinine kinase (CK) levels before and after surgery, were also compared between the groups. RESULTS: Mean rSO(2) was 82.9±9.0% in group H and 65.9±10.7% in group C (P<0.05). Mean SvO(2) during RCP was 98.2±4.3% in group H and 85.4±9.7% in group C (P<0.01). During RCP, lactate concentration significantly increased in group C compared with that in group H (P<0.001). After surgery, the LDH and CK levels significantly increased in group C compared with that in group H (P<0.05). CONCLUSIONS: Our study revealed that HFRCP preserved sufficient cerebral and somatic tissue oxygenation during the Norwood procedure. The reduction of vascular resistance of collateral vessels increased both cerebral and somatic blood flow, resulting in improved tissue oxygen delivery.