Use of an ultrasonic surgical aspirator to expose buried coronary arteries.

In coronary artery bypass grafting, the target arteries for grafting can be buried in thick adipose tissue or myocardium, and exposure may be difficult. We used an ultrasonic surgical aspirator to expose buried coronary arteries. Fat tissue or myocardium covering coronary arteries was removed, and target arteries were exposed with little bleeding. No arrhythmia or coronary spastic event occurred during its application, and bypass grafting could be completed. In postoperative angiography, no deformity or shrinkage of coronary arteries was observed at the sites at which the ultrasonic aspirator was applied.

[Simultaneous surgery for left lung cancer and the aneurysm of an aberrant left subclavian artery in a patient with right aortic arch].

A 69-year-old man with right aortic arch was diagnosed as having left lung cancer (cT2aN1M0, cStage IIA) and an aneurysm of an aberrant left subclavian artery. The aneurysm measured 36 mm in diameter and was located 1 cm peripheral from the origin in the area known as "Kommerell's diverticulu Left carotid artery-to-left subclavian artery bypass graft was placed through a left supraclavicular incision prior to thoracotomy. This bypass graft effectively prevented neurological and ischemic complications of the brain and left upper extremity while we safely and successfully performed resection of the aneurysm along with radical surgery for left lung cancer through left thoracotomy. There have been only 10 case reports, including the present case, that have described surgical resection of lung cancer in a patient with right aortic arch. In addition, this is the 1st report to describe simultaneous surgery for both left lung cancer and an aneurysm of an aberrant left subclavian artery in a patient with right aortic arch.

"Initial, continuous and intermittent bolus" administration of minimally-diluted blood cardioplegia supplemented with potassium and magnesium for hypertrophied hearts.

BACKGROUND: Hypertrophied hearts are subject to the deleterious effects of intraoperative ischemia-reperfusion, and stable maintenance of myocardial cardioplegic arrest is essential. Continuous cardioplegia infusion appears an ideal modification to overcome this issue, except for a large amount of crystalloid solution infused into the myocardium. We previously introduced "initial, continuous and intermittent bolus" administration of minimally-diluted blood cardioplegia (mini-BCP) supplemented with potassium and magnesium, and this study was designed to elucidate its efficacy in patients with hypertrophied hearts. METHODS: Thirty patients (M:F=17:13, 69.2+/-7.8 years) with left ventricular mass index greater than 150 g/m(2) who underwent aortic valve replacement between 1996 and 2002 were enrolled, and were allocated to one of the two groups. The same infusion protocol was used for both groups as follows: initial and intermittent (every 20 min) BCP was antegradely infused for 2 min at the rate of 200 mL/min, and continuous retrograde BCP flow rate was set at 60-100mL/min. Group C (n=15) received 4:1-diluted BCP modified with Buckberg solution, and Group M (n=15) were given mini-BCP supplemented with potassium (initial/others: 15.4/9.8 mEq/L) and magnesium (initial/others: 6.5/4.0 mEq/L). RESULTS: Stable cardioplegic arrest was maintained in all study patients, and total amount of crystalloid solution as cardioplegia was lesser in Group M (79.4+/-27.5 mL) than in Group C (937.3+/-372. 1mL, p<0.01). Group M showed a higher incidence of spontaneous heartbeat recovery after aortic unclamping (13 versus 6, p<0.05) and a lower incidence of postoperative atrial fibrillation (0 versus 5, p<0.05). Postoperatively, maximum dopamine dose (3.35+/-2.27 microg/kg/min versus 5.49+/-2.30 microg/kg/min, p<0.05) and peak plasma creatine kinase-myocardial band (CK-MB) (21.7+/-7.2 IU/L versus 28.8+/-8.4 IU/L, p<0.05) were lower in Group M. Early postoperative echocardiography revealed a lower incidence of paradoxical ventricular septal motion (M versus C; 3 versus 10, p<0.05) and greater left ventricular ejection fraction (M versus C; 70.7+/-4.0% versus 67.0+/-5.3%, p<0.05) in Group M. CONCLUSIONS: These results suggest that "initial, continuous and intermittent bolus" administration of mini-BCP, supplemented with potassium and magnesium, is a novel modification for patients with hypertrophied hearts in terms of simplifying the maintenance of cardioplegic arrest with beneficial myocardial protective effects.

Freestyle stentless bioprosthesis for active aortic infectious endocarditis with undetermined causative organism.

A 52-year-old woman developed congestive heart failure and was diagnosed with aortic regurgitation with approximately 20 mm of vegetation located on the noncoronary cusp of the aortic valve. The patient had undergone tooth extraction 3 months earlier, and various antibiotics had been given in the treatment of refractory high fever for 1 month. The damage to the aortic valve extended to the fibrous trigone near the mitral valve, and aggressive debridement of necrotic and infected tissue was done. The excised defect was repaired and reinforced with a pericardial patch, and the Freestyle stentless bioprosthesis was implanted using the full-root technique. Although the causative organism was never isolated, recurrent endocarditis has not occurred during 3 years of follow-up. The Freestyle stentless bioprosthesis was useful in the management of active aortic infectious endocarditis with undetermined causative organism for the prevention of recurrent endocarditis in the early postoperative period.

Left atrial diameter is a simple indicator of a deficiency in atrial natriuretic peptide secretion in patients with mitral stenosis: efficacy of postoperative supplementation with synthetic human alpha-atrial natriuretic peptide.

OBJECTIVE: With regard to a deficiency in atrial natriuretic peptide (ANP) secretion, the relationship between plasma ANP and left atrial diameter measured by echocardiography was examined and the efficacy of postoperative supplementation was evaluated. METHODS: (1) Ninety-six patients with mitral valve disease from 1997 to 2002 (M:F = 65:31, mean-age 65.3 +/- 8.9 years) were studied for relationship analyses. (2) Twenty-six patients with mitral stenosis and left atrial diameter > or = 60 mm undergoing mitral valve replacement (M:F = 17:9, mean-age 67.4 +/- 7.5 years) were randomly allocated to one of two groups; ANP-treated group (n = 13, 0.05 microg/kg/min of synthetic human alpha-ANP was postoperatively administered) and Control group (n = 13). RESULTS: (1) There were significant positive correlations between left atrial diameter and plasma renin-activity (r = 0.690, P < 0.01) and between left atrial diameter and plasma aldosterone (r = 0.757, P < 0.01). The maximum value of plasma ANP was 249.5 pg/mL accompanied with 56.2 mm of left atrial diameter in 29 patients suffering from mitral stenosis. There was a significant negative correlation between left atrial diameter and ANP in patients with left atrial diameter > 56.2 mm (r = - 0.725, P < 0.0001), whereas there was a significant positive correlation in patients with left atrial diameter < or = 56.2 mm (r = 0.529, P = 0.0066). (2) At 24 hours after operation, the ANP-treated group showed significantly lower plasma renin-activity (9.2 +/- 3.3 versus 36.2 +/- 7.4 ng/mL/h) and aldosterone (113.6 +/- 36.9 versus 473.8 +/- 95.8 pg/mL) than the Control group. CONCLUSIONS: Left atrial diameter can be a simple and useful indicator of a deficiency in endogenous ANP secretion in patients with mitral stenosis, and postoperative ANP supplementation contributes to suppressing further activation of renin-angiotensin system during the immediate postoperative period.

Minimally-diluted blood cardioplegia supplemented with potassium and magnesium for combination of 'initial, continuous and intermittent bolus' administration.

BACKGROUND: The present study was designed to examine the hypothesis that minimally-diluted blood cardioplegia (BCP) supplemented with potassium and magnesium provides superior myocardial protection in comparison with the standard-diluted BCP for a combination of 'initial, continuous, and intermittent bolus' BCP administration. METHODS AND RESULTS: Seventy patients undergoing elective coronary revascularization between 1997 and 2001 (M : F =55:15, mean age 67.6+/-7.5 years) were randomly divided into 2 groups: Group C (n=35) was given the standard 4:1-diluted blood-crystalloid BCP, and Group M (n=35) was given minimally-diluted BCP supplemented with potassium-chloride and magnesium-sulfate. The BCP temperature was maintained at 30 degrees C. Cardioplegic arrest was induced with 2 min of initial antegrade BCP infusion, followed by continuous retrograde BCP infusion. Intermittent antegrade BCP was infused every 30 min for 2 min. The time required for achieving cardioplegic arrest was significantly shorter in Group M (47.5+/-16.3 vs 62.5+/-17.6 s, p<0.0001). The number of patients showing spontaneous heart beat recovery after reperfusion was significantly larger in Group M (28 vs 15, p=0.0029), and the number of patients suffering from atrial fibrillation during the postoperative period was significantly smaller in Group M (n=3 vs 11, p=0.034). Both the postoperative maximum dopamine dose (3.57+/-2.46 vs 5.44+/-2.23 microg/kg per min, p=0.0014) and peak creatine kinase-MB (19.5+/-8.5 vs 25.8+/-11.9 IU/L, p=0.0128) were significantly less in Group M. The number of patients showing paradoxical movement of the ventricular septum in the early postoperative echocardiography was significantly smaller in Group M (9 vs 24, p=0.0007). CONCLUSIONS: These results suggest that 'initial, continuous and intermittent bolus' administration of minimally-diluted BCP supplemented with potassium and magnesium is a reliable and effective technique for intraoperative myocardial protection.

Synthetic human alpha-atrial natriuretic peptide improves the management of postoperative hypertension and renal dysfunction after the repair of abdominal aortic aneurysm.

OBJECTIVE: Delayed hypertension (HT) and renal dysfunction (RD) are observed after aortic operations accompanied by infra-renal aortic cross-clamping (AXC). Atrial natriuretic peptide (ANP) has effects on vasodilation and renal protection, and we examined the hypothesis that synthetic human alpha-ANP (hANP) improves the postoperative management for abdominal aortic aneurysm (AAA). METHODS: Fifty patients undergoing elective aneurysmectomy for infrarenal-AAA between 1998 and 2001 (M:F = 43:7, mean age 70.5 +/- 7.7 years) were randomly allocated to one of 2 groups; Group H (n = 24) received hANP immediately after operation (initial dose: 0.025 microg/kg/min), and Group C (n = 26) served as a control group. RESULTS: All patients in Group C required nicardipine hydrochloride (4.41 +/- 1.68 mg/h) for prevention of postoperative HT, whereas only 6 patients in Group H required the increase in hANP dose due to HT (P < 0.0001). Maximum hANP dose was 0.035 +/- 0.019 microg/kg/min. Group H showed significantly smaller furosemide dosage in the initial 3 days (H vs. C; 9.2 +/- 11.0 vs. 58.8 +/- 41.5 mg, P < 0.0001), significantly lower peak-Crn (H vs. C; 1.16 +/- 0.53 vs. 2.58 +/- 1.42 mg/dL, P < 0.0001), and significantly lower plasma renin-activity (7.09 +/- 2.38 vs. 11.52 +/- 4.89 ng/mL/h, P = 0.0002) and aldosterone (51.6 +/- 12.7 vs. 81.2 +/- 34.2 pg/mL, P = 0.0002) on the first postoperative day than Group C did. CONCLUSIONS: These results imply that renin-angiotensin system may play a role in the incidence of postoperative HT and RD, and suggest that hANP infusion is a simple, reliable, and effective method for management during the immediate period after AAA operations.

Synthetic human alpha-atrial natriuretic peptide infusion in management after open heart operations.

Cardiopulmonary bypass (CPB) induces water retention in the third space, and the mechanism is partially associated with the activation of the renin-angiotensin-aldosterone system (RAAS). Atrial natriuretic peptide (ANP) has a gradual but strong diuretic effect and suppresses the RAAS activation. We examined the efficacy of synthetic human alpha-ANP (hANP) infusion in the management of the postoperative water balance control. Thirty patients (male:female = 18:12, 65.2 +/- 9.5 years) undergoing elective open heart operations in 2001 were allocated into one of two groups. Group H (n = 14) received 0.025 microg/kg/minute of synthetic hANP (HANP; Suntory Inc., Zeria Pharmaceutical, Tokyo, Japan) from the termination of CPB; the dose was gradually reduced to 0 until the 72nd postoperative hour. Group C (n = 16) served as control subjects. Twenty-four hours after operation, the central venous pressure, mean pulmonary arterial pressure, and pulmonary capillary wedge pressure were significantly lower in group H than in group C, and the cardiac index was significantly higher in group H. Total volume of plasma solution infused during the initial 24 postoperative hours was significantly smaller in group H. The total dosages of furosemide and potassium-chloride added during the first 72 postoperative hours were significantly smaller in group H. On the first postoperative day, plasma levels of renin activity and aldosterone were significantly lower in group H. These results suggest that postoperative hANP infusion, which provides a sufficient diuretic effect and suppresses CPB induced RAAS activation, may simplify management after open heart operations.