[Staged carotid artery stent and cardiac surgery under cardiopulmonary bypass].

The presence of carotid disease in patients undergoing cardiac surgery has been known to increase the risk of peri-operative strokes. However, there are some controversies surrounding carotid artery stenting (CAS) in patients undergoing cardiac surgery with carotid disease. We experienced 5 cases of staged carotid artery stent and cardiac surgery under cardiopulmonary bypass. These cases represent 1.7% of the cardiac surgery between August 2006 and June 2009 at our hospital. There were 4 male and 1 female patient whose ages range from 58 to 81 years old (mean 73.0). Two cases were symptomatic and revealed carotid artery stenosis of 50% or more. The remaining 3 asymptomatic cases had 75% or more stenosis. Wallstent RP stents were used in 3 of the cases, and PRECISE stents in the remaining 2. The mean time of carotid angioplasty and stenting was 101 ± 22 minutes. Among the 5 cases, we experienced 2 periprocedural events. One developed bradycardia and cardiac arrest due to severe aortic valve stenosis, which was promptly improved by temporary cardiac pacing. The other experienced transient hemiparesis. The mean period of time between CAS and cardiac surgery was 53 days, with a range of 23 to 78 days. There were no post-operative deaths or strokes. All 5 cardiac operations were performed successfully. Further cooperation among cardiologists, cardiac surgeons and neurosurgeons is suggested for more careful circulatory assessment during CAS in patients with severe cardiac disease.

[Successful repair for impending ruptured subclavian artery aneurysm; report of a case].

Subclavian artery aneurysm is relatively rare. We report a case of an impending rupture of an atherosclerotic aneurysm of the extrathoracic subclavian artery. A 61-year-old male patient with right hemiparesis due to prior cerebral infarction was referred to our hospital for treatment of an enlarging pulsatile mass with continuous pain around the right clavicle. Computed tomography of the chest revealed a fusiform subclavian artery aneurysm with a maximum diameter of 58 mm. An emergency operation was performed following the diagnosis of an impending rupture of the right subclavian artery aneurysm. Using a continuous incision from the supra to sub-clavicular regions, the right subclavian artery aneurysm was replaced with a straight vascular graft, 12 mm in diameter. Although several postoperative complications, such as respiratory insufficiency and renal dysfunction occurred, he was transferred to a rehabilitation hospital on the 110th postoperative day.

[Skeletonized right gastroepiploic artery for coronary artery bypass grafting; evaluation of intraoperative graft flow and postoperative angiographic result].

We evaluated the efficacy of using the skeletonized right gastroepiploic artery (RGEA) in coronary artery bypass grafting (CABG). The RGEA was harvested either as a pedicle (group P, n = 14) or in a skeletonized fashion using a Harmonic Scalpel (group S, n = 14). The free flow of the RGEA was too small to be measured in some cases in group P. On the other hand, the free flow of the RGEA could be measured in all cases in group S, and that value obtained was comparable to the free flow of the left internal thoracic artery. The skeletonization of the RGEA also allowed us to directly visualize this vessel, and thus helped us to evaluate the quality of this artery. Postoperatively, all RGEAs were patent in both groups. The RGEA diameters on the postoperative angiography showed the RGEAs in group S to have a wider caliber, however, the differences in the values for each group did not reach statistic significance. Neither the operation time nor the postoperative hospital stay were substantially lengthened due to the skeletonization of the RGEA. In conclusion, the skeletonization of the RGEA using a Harmonic Scalpel is safe and effective modality which enables surgeons to directly visualize arteries in order to determine their quality and thereby making it easier to perform sequential bypass grafting. The method also demonstrated an excellent quality of the patent graft on postoperative angiography. We therefore consider the skeletonization of the RGEA to be a very useful method for harvesting the RGEA in CABG.

[Mitral valve re-replacement in a patient with occlusion of the left internal carotid artery].

An 83-year-old female patient, who had previously undergone mitral valve replacement using bioprosthesis at 15 years ago, presented symptoms of congestive heart failure. Mitral valve regurgitation was caused by structural deterioration of the bioprosthetic valve, and replacement of the bioprosthesis was indicated. Digital subtraction angiography revealed occlusion of the left internal carotid artery, which put this patient at high risk to cerebral complications during heart valve surgery. Administration of acetazolamide induced a marked decrease in the blood flow in the left cerebral hemisphere. Re-replacement of the mitral valve was successfully performed under high-flow cardiopulmonary bypass. Intra-aortic balloon pumping produced pulsatile blood flow with a peak pressure of 90-100 mmHg during the cardiopulmonary bypass. She recovered after surgery with no neurological complication. We believe the pulsatile cerebral perfusion produced by the intra-aortic balloon pumping with high-flow cardiopulmonary bypass was effective for preventing cerebral complications in this patient with internal carotid artery occlusion.

[Emergency coronary artery bypass grafting for acute coronary syndrome with preoperative intraaortic balloon pumping; comparative surgical outcome and long-term results].

With recent technical improvements in catheter interventional therapy, percutaneous coronary intervention (PCI) has now become the treatment of first choice for acute coronary syndrome (ACS). The objective of the present study was to evaluate critically the timing of coronary artery bypass grafting (CABG) for severe ACS with preoperative intraaortic balloon pumping (IABP). Since 1994, a total of 70 patients have gone emergency or urgent CABG for ACS. Of 70 patients, 50 patients required preoperative IABP. There were 22 patients (17 men, 5 women) with acute myocardial infarction (AMI), with a mean age of 67.7 years, and 28 patients (19 men, 9 women) with unstable angina pectoris (UAP), with a mean age of 69.2 years. There was a significant difference, between AMI and UAP, in the prevalence of emergency operation (95.5% vs 25.0%), in preoperative cardiogenic shock (81.8% vs 17.9%), in the level of preoperative CPK-MB (196.7 IU/l vs 2.0 IU/l) and in preoperative ejection fraction (41.8% vs 47.3%). Two patients in AMI required percutaneous cardiopulmonary support (PCPS). Thirteen patients in AMI and 22 patients in UAP presented left main trunk (LMT) disease. Of the 13 LMT patients in AMI, 4 patients were AMI due to acute occlusion in the LMT. The AMI patients received 2.45 distal anastomoses on average, while the UAP patients 3.14 distal anastomoses (p = 0.019). Excluding the mean number of distal anastomoses, there was no difference in the intraoperative technical factors, such as aortic cross clamping duration, cardiopulmonary bypass duration, rate of complete revascularization, between AMI and UAP. There were postoperative significant differences in low cardiac output syndrome (LOS) [45.6% in AMI vs 3.6% in UAP] and in prolongation of mechanical ventilation (59.1% in AMI vs 14.3% in UAP). The hospital mortality was 9.1% (2/22) in AMI, and 3.6% (1/28) in UAP, with no significant difference. Of these 3 patients, 1 patient died from perioperative cerebrovascular accident (CVA), another from LOS, and the other from postoperative mesenteric ischemia, with an overall mortality of 6.0% (3/50). The overall patency rate of the grafts was 100% in AMI and 96.6% in UAP. The 5-year-survival rate excluding in-hospital death was 72.5% in AMI, and 89.6% in UAP. The 5-year-cardiac event-free rate was 77% in AMI and 89.4% in UAP. The overall survival rate, and cardiac event-free rate, at 5 years was 80.8%, and 83.8%, respectively. In conclusion, for ACS cases, especially UAP cases of LMT, in which symptoms, findings of ischemia and hemodynamics are stabilized by medical intervention including IABP; emergency surgery could be avoided immediately after coronary angiography. Recovery in the ischemic myocardium is intended by IABP, and urgent surgery should be performed after sufficient and precise preoperative examinations. An improvement not only in the perioperative but also long-term results can be expected by performing complete revascularizations.

[Mitral valve repair for a broad prolapse in the high posterior leaflet].

We report a mitral valve repair for a broad prolapse in the high posterior leaflet. Prolapse in the high redundant posterior leaflet with elongation of the chordae had caused the severe mitral valve regurgitation in a 45-year-old man. At operation, the prolapsed portion of the middle scallop was quadrangularly resected in 22 mm wide and 17 mm high. We combined the sliding leaflet technique with the posterior leaflet folding plasty to reduce the height of the posterior leaflet and to lessen the degree of mitral annular plication. Mitral valve regurgitation disappeared after the operation. No left ventricular outflow obstruction associated with systolic anterior motion and no injury to the left circumflex artery were confirmed. These procedures after a broad resection of the high posterior leaflet could successfully prevent systolic anterior motion and injury to the left circumflex artery, and reduce the stress on the suture line of the leaflet.

[Blood conservation in thoracic aortic surgery with total cardiopulmonary bypass].

BACKGROUND: In thoracic aortic surgery, a large number of homologous transfusions sometimes cause systemic inflammatory response, which may lead to pulmonary dysfunction, renal dysfunction and brain edema. To predict the need for homologous blood transfusion in aortic surgery, we use blood transfusion index (preoperative Ht x body weight) to predict the magnitude of homologous transfusion. PATIENTS AND METHODS: From Dec 1997 to May 2000, 59 consecutive patients were underwent thoracic aortic graft replacement with total cardiopulmonary bypass. These patients were divided in 2 groups, who were underwent graft replacement without blood transfusions, and who needed blood transfusions. Each group was compared in age, sex, emergency, Ht, CPB time, blood transfusion index and operative mortality. RESULTS: Forty patients (67.7%) did not required blood transfusion. In elective cases (32 cases), 84.3% were underwent operation without blood transfusion. There was no significant difference between 2 groups in terms of age and mean bypass duration. Blood transfusion index was significantly higher in transfusion group (2,320 +/- 784) compared with that in not transfusion group (1,445 +/- 706). CONCLUSION: Blood transfusion index was useful preoperative parameter to predict the need for homologous transfusion.

[Early operation for acute type a closing dissection].

From March 1997 to January 2000, we operated eleven cases of Stanford type A acute closing dissection. The patients consisted of 4 men and 7 women with a mean age of 71 +/- 9 years. There were 9 cases (81%) of cardiac tamponade and 5 cases (45%) was in the shock state. There were no malperfusion and end organ ischemia. All cases were operated with deep hypothermia and circulatory arrest. Ascending aortic replacement were performed in 9 cases and 2 cases were performed total arch replacement. 6 cases (63%) were not required blood transfusion. There was one operative death and one hospital death. These result suggest that we had better to perform immediate graft replacement for Stanford type A acute closing dissection as soon as possible, even if there were no serious complications.