Managing postoperative atrial fibrillation after open-heart surgery using transdermal ß1 blockers.

BACKGROUND: Postoperative atrial fibrillation (POAF) after open-heart surgery is a non-negligible complication. We aimed to describe the efficacy of a transdermal patch of bisoprolol for managing POAF and flutter in thoracic surgical procedures. METHODS: We analyzed the data of 384 patients who underwent open-heart surgery at our hospital and received oral bisoprolol to prevent POAF. Among them, 65 patients (16.9%) also received a 4-mg transdermal patch of bisoprolol to control the heart rate due to POAF. We applied the bisoprolol transdermal patch when the heart rate was > 80 bpm and removed it at ≤ 60 bpm; an additional patch was applied when the heart rate was > 140 bpm. Heparin calcium injections were administered twice daily for anticoagulation between 2 and 6 days postoperatively. RESULTS: The average number of prescriptions for transdermal patches of bisoprolol during hospitalization was 1.8 ± 1.1 (1-5). The median first prescription date was on postoperative day 2 (range: days 0-37). Sinus rhythm recovered within 24 h in 18 patients (27.7%). Eight patients (12.3%) were switched to continuous landiolol infusion because of persistent tachycardia. In three patients, the transdermal patch was removed owing to severe bradycardia. Fifteen patients experienced persistent atrial fibrillation and were treated with electrical cardioversion during hospitalization. We did not observe any serious complications that could be directly attributed to bisoprolol transdermal patch use. CONCLUSIONS: Single-use bisoprolol transdermal patch may help control the heart rate during the initial treatment of POAF after open-heart surgery.

A strategy to enable rapid healing and prevent recurrence of venous ulcers.

INTRODUCTION: Venous ulcers are often intractable. OBJECTIVE: The aim of this study was to retrospectively analyze the effectiveness of endovenous ablation, compression therapy, moist wound healing, and skin care in the management of venous ulcers. MATERIALS AND METHODS: Twenty-eight consecutive patients (10 male, 18 female; mean age, 70.1 years) with Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class C6 venous ulcer underwent endovenous ablation between December 2014 and August 2020. The main treatment strategies were radiofrequency ablation and varicectomy (including stab avulsion of incompetent perforating veins), use of compression therapy until complete healing was achieved, moist wound healing (washing the ulcer site and covering it with dressings twice daily), and skin care, taking into consideration the balance of the microbiome. RESULTS: Active venous leg ulcers (CEAP class C6) were diagnosed in 36 patients at the first visit. In 7 of these patients, compression therapy and use of strategies to promote moist wound healing resulted in ulcer healing by the day of the planned surgery. One patient was unable to quit smoking and, therefore, could not undergo surgery. After excluding these 8 patients, the authors analyzed the data from 28 patients who underwent endovenous ablation. The mean surgical time was 38.9 minutes, and the mean number of stab avulsion incision sites was 9.7. All ulcers healed within a median of 55.5 days (range, 13-365 days). Ulcer healing was achieved by 1 year in all 28 patients (100%). No ulceration recurred as of the final follow-up (median, 24.5 months [range, 3-66 months]). CONCLUSIONS: Endovenous ablation, adequate varicectomy (stab avulsion [maximum number of sites in 1 patient, 43]), compression therapy, moist wound healing, and skin care are effective in treating and preventing recurrence of venous ulcers.

Feasibility of incompetent perforator vein excision using stab avulsion.

OBJECTIVES: Whether incompetent perforator veins (IPVs) require treatment remains controversial. We retrospectively evaluated the feasibility of IPV excision performed using the stab avulsion technique without ligation and sutures in patients undergoing endovenous ablation (EA). METHODS: This was a single-center, retrospective, observational cohort study. EA was performed in 1503 consecutive patients, including 33 patients with ulcers, between December 2014 and May 2021. Varicectomy was performed using the stab avulsion technique; IPV cases were included. RESULTS: Stab avulsion was performed at a mean number of 11.4 ± 7.8 sites. No deep vein thromboses or pulmonary emboli were noted. The incidence of nerve injury was 0.3%. All 33 (100%) patients with ulcers achieved healing by 1 year (median: 55.5 days; range: 13-365 days). CONCLUSIONS: IPV excision via stab avulsion may be a viable option for treating varicose veins and ulcers. This technique offers multiple advantages, including simplicity, safety, and reduced healthcare costs.

Strategy to prevent nerve injury and deep vein thrombosis in radiofrequency segmental thermal ablation of the saphenous veins using a new objective pain scale.

OBJECTIVE: We evaluated the benefit of local anesthesia including tumescent anesthesia and active walking soon after surgery in preventing nerve injury and deep vein thrombosis caused during endovenous ablation. METHODS: Endovenous ablation was performed in 1334 consecutive patients. Varicectomy was performed using the stab avulsion technique. After surgery, patients were encouraged to walk 100-200 m inside the ward for 3-5 times/h. The pain was evaluated objectively using the Okamura pain scale and subjectively using the numerical rating scale. RESULTS: Stab avulsion was performed at 11.8 ± 8.0 sites and the mean operative time was 33.9 ± 15.2 min. The mean Okamura pain scale and numerical rating scale scores were 1.6 ± 1.3 and 3.0 ± 2.0, respectively. Deep vein thrombosis and pulmonary embolism were absent. The incidence of nerve injury was 0.3%. CONCLUSIONS: Endovenous ablation should be performed with the patients under local anesthesia to prevent nerve injury and deep vein thrombosis.

Re-expansion of Thrombosed False Lumen after Aortic Dissection Due to Collateral Retrograde Flow from the Aortic Branches.

Re-expansion of thrombosed false lumen after aortic dissection due to collateral retrograde flow from the aortic branches has rarely been reported. Surgical or endovascular local management such as ligation or occlusion of culprit arteries may not be effective in case retrograde blood flow to the false lumen might occur again from another branch after the operation. Here, we report a 68-year-old woman with re-expansion of the thrombosed false lumen after acute type B aortic dissection due to collateral retrograde flow from the aortic branches successfully treated with tranexamic acid therapy and antihypertensive therapy.

Percutaneous Continuous Irrigation and Drainage for Infected Obturator Bypass Graft.

The treatment for obturator bypass graft infection has been rarely reported and is a surgical challenge because it is difficult to debride infected tissue around the graft located in the deep route and to ensure an alternative revascularization route in patients with a history of inguinal infection. Percutaneous continuous irrigation and drainage is an effective and less invasive definitive therapy for obturator bypass graft infection.

Reexpansion Pulmonary Edema After Atrial Septal Defect Closure Through Right-Sided Minithoracotomy.

We describe a patient with reexpanded pulmonary edema after atrial septal defect closure through a right-sided minithoracotomy. After reexpansion of the right lung after weaning from cardiopulmonary bypass, a large amount of serous slight-hemorrhagic bronchial secretions spilled out from the right bronchus. Positive pressure ventilation and differential ventilation were used. We found no bleeding and decreased secretions 24 hours after the onset of reexpanded pulmonary edema. The patient was extubated 42 hours after the operation. To the best of our knowledge, this is the first case report of the development of reexpansion pulmonary edema during a routine minimally invasive operation for atrial septal defect.

[Graft Pseudoaneurysm after Ascending to Abdominal Aorta Bypass for Atypical Coarctation Due to Aortitis Syndrome;Report of a Case].

We present a case of a 44-year-old woman, with pseudoaneurysm formation at the middle of the prosthetic graft, 60 mm in diameter. She had been diagnosed with atypical coarctation due to aortitis 27 years before, and had undergone a bypass operation with 14 mm-diameter Cooley double velour graft from the ascending aorta to the abdominal aorta. This time, endovascular aortic repair was performed to prevent rupture of the pseudoaneurysm. Though a knitted Dacron graft has a risk of psuedaneurysm formation long patency could be obtained when used in ascending aorta-abdominal aorta bypass.

Five-Year Clinical Outcome of Asymptomatic vs. Symptomatic Severe Aortic Stenosis After Aortic Valve Replacement.

BACKGROUND: There is discordance regarding the effect of symptom status before aortic valve replacement (AVR) on long-term outcome after AVR in severe aortic stenosis (AS).Methods and Results:The CURRENT AS registry is a multicenter retrospective registry enrolling 3,815 consecutive patients with severe AS. Among 1,196 patients managed with the initial AVR strategy, long-term clinical outcomes were compared between the symptomatic patients (n=905), and asymptomatic patients (n=291). Median follow-up interval was 1337 days with a 91% follow-up rate at 2 years. AVR was performed in 886 patients (98%) in the symptomatic group and in 287 patients (99%) in the asymptomatic group. Symptomatic patients were older and more often had comorbidities than asymptomatic patients with similar echocardiographic AS severity. The cumulative 5-year incidences of all-cause death and heart failure (HF) hospitalization were significantly higher in symptomatic patients than in asymptomatic patients (25.6% vs. 15.4%, P=0.001, and 14.2% vs. 3.8%, P<0.001, respectively). On landmark analysis at 30 days after AVR, the differences in mortality and HF hospitalization between the 2 groups were mainly observed beyond 30 days. CONCLUSIONS: When managed with the initial AVR strategy, the long-term outcomes of symptomatic severe AS were worse than those of asymptomatic severe AS. Early AVR strategy might be recommended in some selected asymptomatic severe AS patients with reasonable operative risk.

Continuous carbon dioxide partial pressure monitoring in lung transplant recipients.

BACKGROUND: Living-donor lobar lung transplantation (LDLLT) recipients often have hypercapnia preoperatively, which confers a risk of worsened hypercapnia intraoperatively. We reviewed our experience with continuous carbon dioxide partial pressure (PtcCO2) monitoring in LDLLT to evaluate its accuracy and feasibility. We also assessed preoperative and intraoperative carbon dioxide levels in LDLLT recipients. MATERIAL AND METHODS: Twenty-six LDLLT recipients without pulmonary hypertension underwent preoperative nocturnal and intraoperative PtcCO2 monitoring, determined with a TOSCA-500 monitor. RESULTS: Maximal preoperative nocturnal PtcCO2 (72.7 ± 19.3 mmHg) was significantly correlated with preoperative resting arterial carbon dioxide partial pressure (PaCO2; 55.1 ± 11.6 mmHg, r(2)=0.84). PtcCO2 was more correlated with PaCO2 (range, 39-192 mmHg) during LDLLT (r(2)=0.93) than with end-tidal carbon dioxide partial pressure (r(2)=0.38). Intraoperative continuous PtcCO2 monitoring was useful for evaluating real-time carbon dioxide levels. Intraoperative PtcCO2 did not exceed maximal preoperative nocturnal PtcCO2 in 13 recipients (50%) but temporarily exceeded it in 11 recipients (42%). PtcCO2 was further elevated in 2 recipients (8%) requiring the early establishment of cardiopulmonary bypass. There were no complications related to PtcCO2 monitoring. CONCLUSIONS: PtcCO2 monitoring in LDLLT recipients is useful as a means for determining intraoperative carbon dioxide levels, which increase dramatically and can be predicted preoperatively and assessed in a timely manner.

Protective effect of cardioplegia with poly (ADP-ribose) polymerase-1 inhibitor against myocardial ischemia-reperfusion injury: in vitro study of isolated rat heart model.

Poly(ADP-ribose) polymerase (PARP)-1 inhibitor has been suggested to attenuate the ischemia-reperfusion injury. We investigated the protective effect of the cardioplegia with a PARP-1 inhibitor, 4-hydoxyquinazoline (4-HQ), against myocardial ischemia-reperfusion injury. Isolated rat hearts were perfused on a Langendorff apparatus and cardioplegically arrested for 90 min by perfusion with St. Thomas' Hospital solution (ST-solution). In the Group ST (n = 8), the hearts were arrested with the ST-solution alone. The Group HQ (n = 8) were treated with the ST-solution containing 4-HQ (10 µM) for cardioplegia. During reperfusion, the Group HQ showed significantly greater functional recovery of +dp/dt(max) (p = 0.005) and lower enzymatic leakage (p < 0.01). NAD(+) levels were also preserved higher in the Group HQ (p < 0.01). Immunohistochemical study revealed lesser extents of oxidative stress and apoptosis, in the Group HQ. Thus, addition of 4-HQ in the cardioplegia may provide a new intervention for myocardial protection against ischemia-reperfusion injury by decreasing NAD(+) consumption and suppressing oxidative stress.

Pulmonary arterioplasty for the remaining arterial stump of the donor and the arterial cuff of the donor graft in living-donor lobar lung transplantation.

In living-donor lobar lung transplantation (LDLLT), donor surgeries are conducted in ways that ensure proper dissections for both donors and recipients. We report a case of LDLLT, in which pulmonary arterioplasties with autopericardial patch were performed on both a donor and a recipient. Since excision of the lingular branch of the pulmonary artery was carried out far lower than that of the upper segment of the left lower lobe branch, pulmonary arterioplasty was performed to avoid potential stricture of the remaining lingular branch. Also, because of the oblique stump of the graft pulmonary artery, pulmonary arterioplasty with autopericardial patch was required in the recipient.

Stent angioplasty for a kink in the pulmonary artery anastomosis soon after living-donor lobar lung transplantation.

Herein, we report a case of stent angioplasty for a kink in the pulmonary artery (PA) anastomosis soon after living-donor lobar lung transplantation (LDLLT). A 64-year-old man with idiopathic pulmonary fibrosis underwent bilateral LDLLT with lung donations from his daughters. After reperfusion, the left PA anastomosis showed a kink, which could not be corrected completely during surgery. Due to the kink in the left PA, and the relatively small donor grafts, the patient required extracorporeal membrane oxygenation) after LDLLT. Approximately 24 hours after reperfusion, stent angioplasty was performed, resulting in the patient being successfully weaned from extracorporeal membrane oxygenation on postoperative day 4.

[Surgical treatment for ischemic mitral regurgitation].

BACKGROUND: Ischemic mitral regurgitation (IMR) is characterized by annular dilation and restricted leaflet closure with increased leaflet tethering caused by displaced attachment of the papillary muscles. Our surgical strategy for IMR consists of mitral annuloplasty (MAP) and additional left ventricular restoration procedures as needed. When the left ventricular dilation and mitral tethering are mild, we perform MAP alone. On the other hand, we add papillary muscle approximation (PMA) through left ventriculotomy with or without infero-posteiror wall exclusion (the Batista procedure) when left ventricular dilatation and leaflet tethering are severe. METHODS: From November 2007 to April 2011, we surgically treated 19 patients with IMR at our institution. Of those, 13 patients underwent MAP alone (group M) and 6 patients underwent MAP and PMA (group P). RESULTS: There were no hospital deaths. Postoperatively, echocardiography showed no or mild mitral regurgitation (MR) in all patients except 1 patient in group M. There was significant improvement in left ventricular ejection fraction (LVEF) in both groups. Moreover, left ventricular size decreased significantly in both groups. In group P, the tethering height, area and papillary muscle distance also decreased significantly. There were no patients who developed recurrent MR postoperatively. However, in group P, there were 2 late deaths caused by congestive heart failure and sepsis, and remaining 3 patients suffered from congestive heart failure. In group M, there were no late deaths and all patients were in New York Heart Association (NYHA) class I or II. CONCLUSION: Our surgical strategy for IMR yields excellent reduction of MR. Especially the PMA provides promising effect on tethering reduction. However, the absence of recurrent MR was not associated with an improvement in symptoms and survival in patients who presented with severe left ventricular dilatation and leaflet tethering.

Topical application of a biodegradable disc with amiodarone for atrial fibrillation.

BACKGROUND: Amiodarone is a potent anti-atrial fibrillation (AF) agent; however, its systemic administration induces serious side effects such as interstitial pneumonia. To avoid such effects, we developed a local sustained-release system for amiodarone. METHODS: A biodegradable, cross-linkable dextran disc was developed as a sustained-release carrier for amiodarone. Under general anesthesia, Japanese white rabbits underwent median sternotomy and the biodegradable disc with or without amiodarone (30 mg) was implanted onto the surface of the right atrium. Three days after implantation, we measured tissue amiodarone concentrations (n = 5), the AF threshold, and the atrial effective refractory period of the left atrium by using the Langendorff apparatus. The incidences of induced AF evoked by rapid pacing were measured and compared. RESULTS: The right atrial concentration of amiodarone was far higher than that in the lungs, ventricles, or other organs (p < 0.01). The blood concentration of amiodarone was below detectable levels. The amiodarone biodegradable disc significantly increased the AF threshold (amiodarone group, 6.9 ± 4.6 mA versus control group, 0.5 ± 0.6 mA; p < 0.01) and the effective refractory period (amiodarone group, 53.9 ± 8.9 milliseconds versus control group, 43.9 ± 9.5 milliseconds; p = 0.035) of the left atrium, indicating the electrophysiologic effect of the amiodarone biodegradable disc on the left atrium. Further, the amiodarone group was significantly less likely to experience AF, as compared with the control group (p < 0.01). CONCLUSIONS: This approach may be a less invasive and effective therapeutic option for preventing postoperative AF.

Coronary revascularization in patients with liver cirrhosis.

BACKGROUND: Liver cirrhosis is a major risk factor for cardiac surgery using cardiopulmonary bypass. However, percutaneous coronary intervention (PCI) or off-pump coronary artery bypass graft surgery (OPCABG) may be a less invasive alternative strategy. METHODS: Among the 9,877 patients undergoing first PCI or CABG enrolled in the CREDO-Kyoto Registry (a registry of first-time PCI and CABG patients in Japan), 332 patients diagnosed with liver cirrhosis were entered into the study (age 67.1±9.4 years; 246 male). Liver cirrhosis was diagnosed by liver biopsy or signs of portal hypertension with characteristic morphologic liver and spleen changes. RESULTS: A total of 233 patients received PCI, 58 conventional on-pump CABG (CCABG), and 41 OPCABG. Median follow-up was 3.3 years. The PCI group included less complex coronary lesions such as triple vessel and left main disease (p<0.01 each). Propensity score adjusted in-hospital mortality after CCABG or OPCABG was higher than that after PCI; however, the differences were not significant (odds ratio [95% confidence interval]: 6.84 [0.52 to 90.8], p=0.14 for CCABG versus PCI; and 1.86 [0.08 to 45.8], p=0.71 for OPCABG versus PCI). Adjusted overall mortality after CCABG or CABG was lower than that after PCI, but the differences were not significant (0.66 [0.31 to 1.40], p=0.28; and 0.64 [0.28 to 1.49], p=0.31, respectively). Approximately two thirds of patients died of noncardiovascular morbidities (malignancies, including hepatocarcinoma, or hepatic decompression). CONCLUSIONS: Because overall noncardiovascular mortality is high among patients with liver cirrhosis, complete revascularization may not be associated with better survival outcomes. Further study is warranted to determine the impact of a coronary revascularization strategy for liver cirrhosis patients.

Living-donor lobar lung transplantation with sparing of bilateral native upper lobes: a novel strategy.

A 44-year-old man became wheelchair-bound due to sever bronchiolitis obliterans caused by peripheral blood stem cell transplantation for acute myelogenous leukemia. His lung donors, his sister and his wife, were 17 cm shorter than him. He successfully underwent living-donor lobar lung transplantation with sparing of the bilateral native upper lobes to address the size mismatch. Ten months after the transplantation, the patient has returned to a normal lifestyle without supplemental oxygen.

Effect of edaravone, a novel free radical scavenger, supplemented to cardioplegia on myocardial function after cardioplegic arrest: in vitro study of isolated rat heart.

Cardioplegic arrest has been the main mechanism of myocardial protection during open-heart surgery; however, it causes myocardial injury during ischemia-reperfusion. Free radical scavengers are widely known to attenuate ischemia-reperfusion injury in various settings. We investigated the effects of edaravone, a novel free radical scavenger that was originally used for cerebral protection, on myocardial function during ischemia-reperfusion after cardioplegic arrest. Rat hearts were excised and perfused using Langendorff apparatus. The hearts were cardioplegically arrested for 90 min using St. Thomas' Hospital cardioplegic solution (ST solution) at 4 degrees C every 45 min and then reperfused for 20 min. The hearts were divided into 4 groups (n = 13 in each group). In Group ST, the hearts were arrested using the ST solution alone. In Groups L, M, and H, the hearts were arrested using the ST solution supplemented with a low-dose (1 microM), moderate dose (10 microM), and high dose (100 microM) of edaravone, respectively. Left ventricular function (+dp/dt (max)) and the levels of the cardiac enzymes released were measured before and after cardioplegic arrest. At the end of the study, the water content and the tissue oxidative stress (8-hydroxy-2'-deoxyguanosine) of the heart were measured. During reperfusion, the edaravone-treated groups showed a greater functional recovery with regard to the +dp/dt (max) (P < 0.05). The lactate level was the lowest (P < 0.01) in Group M. The water content of the hearts in the edaravone-treated groups was significantly lower (P < 0.05) than that in Group ST. Oxidative stress was significantly lower (P < 0.01) in the edaravone-treated hearts than in Group ST, and it was the lowest in Group M. The addition of edaravone to the cardioplegic solution ameliorates the impairment in myocardial function by reducing the oxidative stress after cardioplegic arrest. In this study, the maximum improvement in the myocardial function was achieved by addition of a moderate dose (10 microM) of edaravone.