Development of severe string sign in internal thoracic arterial graft during first month.

In the present case, development of the string sign in an internal thoracic arterial graft was observed using transthoracic Doppler echocardiography. Following surgery, the diameter of the internal thoracic graft decreased; however, the diameter of the left anterior descending coronary artery did not change from 1.9 mm. Further, the flow velocity in the internal thoracic artery during the systolic phase became greater than that in the early phase and then decreased on postoperative day 19, and it was not detected on postoperative day 31. Coronary arteriography performed on postoperative day 31 revealed a severely stringed internal thoracic artery.

Changes in left anterior descending coronary artery flow profiles after coronary artery bypass grafting examined by means of transthoracic Doppler echocardiography.

OBJECTIVE: We sought to investigate the changes of velocity profiles in the left anterior descending coronary artery after coronary artery bypass grafting using transthoracic Doppler echocardiography. METHODS: Forty-five patients who received a bypass graft to the left anterior descending coronary artery were studied. Before coronary artery bypass grafting, Doppler velocity profiles of the distal left anterior descending coronary artery were recorded with transthoracic Doppler echocardiography. Peak systolic velocity, mean systolic velocity, peak diastolic velocity, mean diastolic velocity, total velocity time integral, systolic velocity time integral, and diastolic velocity time integral were measured. Three weeks after coronary artery bypass grafting, left anterior descending coronary artery antegrade flow in the distal portion of the anastomosis was obtained by using the same method. Coronary angiography was performed before and 3 weeks after coronary artery bypass grafting. RESULTS: The overall success rate of measuring the left anterior descending coronary artery flow was 60.0% preoperatively and 80.0% postoperatively. In 25 patients, in whom all parameters were obtained both before and after coronary artery bypass grafting, the following increased significantly after coronary artery bypass grafting: peak systolic velocity (14.86 +/- 7.50 vs 25.07 +/- 17.02 cm/s, P =.0045), mean systolic velocity (9.86 +/- 5.42 vs 18.03 +/- 12.94 cm/s, P =.0026), peak diastolic velocity (24.26 +/- 12.54 vs 48.28 +/- 31.66 cm/s, P =.0021), mean diastolic velocity (14.94 +/- 6.65 vs 30.36 +/- 20.71 cm/s, P =.0022), diastolic velocity time integral (7.22 +/- 2.88 vs 15.55 +/- 10.39 cm, P =.0009), total velocity time integral (10.50 +/- 4.48 vs 19.27 +/- 12.63 cm, P =.0034), and diastolic-to-systolic velocity time integral ratio (3.09 +/- 1.53 vs 4.97 +/- 2.75, P =.0044). Angiography showed graft patency and no significant change in left anterior descending coronary artery stenosis in all patients. CONCLUSIONS: Transthoracic Doppler echocardiography showed a significant increase in some parameters in left anterior descending coronary artery flow after coronary artery bypass grafting. Measurement of left anterior descending coronary artery flow by means of transthoracic Doppler echocardiography might be a noninvasive method to evaluate the effect of bypass grafting on the left anterior descending coronary artery.

New strategy for treatment of MRSA mediastinitis: one-stage procedure for omental transposition and closed irrigation.

Mediastinitis due to methicillin-resistant Staphylococcus aureus is a devastating potential complication of cardiac surgery. We treated 4 patients with this condition using a new technique. First we performed an early radical removal of infected tissue and omental transposition with direct primary closure of the sternum and closed continuous irrigation with saline/vancomycin hydrochloride; that was followed by an administration of intravenous antibiotics. We obtained good clinical results, which are reported herein along with the clinical courses.

Noninvasive evaluation of internal thoracic artery and left anterior descending coronary artery anastomotic sites using transthoracic Doppler echocardiography: comparison with coronary arteriography.

OBJECTIVES: This study was designed to evaluate anastomotic sites located between the internal thoracic artery and left anterior descending coronary artery using transthoracic Doppler echocardiography, and then to clarify the accuracy of those results by comparison with coronary arteriographic findings. METHODS: We examined 35 consecutive patients who had undergone bypass surgery. The echocardiographic examinations were performed within approximately 1 week of follow-up coronary arteriography, which occurred at 4.3 +/- 2.2 months after bypass surgery. We measured the diameter using intraluminal flow signals, and we also measured flow velocity. RESULTS: Adequate spectral Doppler recordings of coronary flow in the anastomosis were obtained in 31 (89%) of the 35 study patients. In the normal anastomosis group (n = 25), the diameter and the peak blood flow velocity of the internal thoracic artery and left anterior descending coronary artery were 1.5 +/- 0.3 mm and 2.0 +/- 0.4 mm, and 58 +/- 25 cm/s and 47 +/- 20 cm/s, respectively. Stringed internal thoracic artery was found in 4 patients; the echocardiographic findings revealed a greater amount of information regarding the physiologic state in the area of anastomosis compared with angiographic findings. In a stenotic anastomosis found in 2 patients, the blood flow velocity findings at the anastomotic sites (83 +/- 228 cm/s) were higher than those in normal anastomotic patients (59 +/- 28 cm/s). CONCLUSIONS: Transthoracic Doppler echocardiography enabled an effective evaluation of anastomotic sites between the internal thoracic artery and left anterior descending coronary artery in over 80% of our patients. This totally noninvasive method is thought to be reliable and able to provide a greater amount of information, compared with coronary arteriography, regarding the physiologic state of an anastomosis, such as a competitive relationship.

Advantage of earlier thoracoscopic clipping of thoracic duct for post-operation chylothorax following thoracic aneurysm surgery.

We report that an earlier thoracoscopic clipping of the thoracic duct was advantageous in a case of post-operation chylothorax that occurred following thoracic aneurysm surgery. A 61-year-old man developed chylothorax on postoperative day 2 following graft replacement of the descending thoracic aorta using a left-sided thoracotomy. Since a replaced graft infection is lethal, earlier thoracoscopic clipping of the thoracic duct through the right side chest wall was indicated. The patient underwent thoracoscopic clipping on postoperative day 7 and was successfully treated. The duration of drainage was 2 days and oral intake was started on the seventh day. From our results, we recommend a thoracoscopic procedure through the opposite (right) side chest wall in the early stage of chylothorax development following thoracic aneurysm surgery.

Preoperative intraarterial infusion chemotherapy for advanced gastric cancer--a retrospective review of four cases.

For the purpose of improving operability and curability, we performed intraarterial infusion chemotherapy on four patients with advanced gastric cancer diagnosed pathologically as papillary adenocarcinoma or poorly differentiated adenocarcinoma. Anti-cancer drugs including cis-diamminedichloroplatinum (II), epirubicin, and mitomycin C were administered through catheters whose tips were placed at various sites, as follows: celiac artery, common hepatic artery, right and left gastric artery, accessory left gastric artery, gastroduodenal artery, and right gastroepiploic artery. The therapeutic effect was evaluated by computed tomography (CT) and double contrast X-ray examination of the stomach. A partial response was obtained in one patient, there was no change in two patients, and the fourth patient showed no change and died eight months later. One patient had no recurrence, and recurrence was found in two. The major toxicity was bone marrow suppression, and other side effects such as appetite loss, nausea, and vomiting were all transient. A deep gastric ulcer was found in one patient, but it was cured by intravenous administration of H2 blocker. Although the four patients showed varying responses, intraarterial chemotherapy may prove to be an assistant therapy that enhances the therapeutic effect.

Participation of caspase-3-like protease in necrotic cell death of myocardium during ischemia-reperfusion injury in rat hearts.

This experimental study was designed to determine if caspase-3-like protease is activated during a short period of ischemia - reperfusion (I-R) that did not induce apoptosis, and whether protease-3-protease inhibitor could prevent myocardial I-R injury, especially necrotic cell death. The subjects were 20 isolated rat hearts; 10 were pretreated for 20 min with 100 micromol/L of the protease-3-protease inhibitor, peptide antagonist Asp-Glu-Val-Asp-CHO (DEVD) (Group D), and compared with the 10 no-pretreated hearts (Group C). The hearts were then subjected to 20, 30, 45, and 60 min of normothermic global ischemia followed by 30 min of reperfusion. Caspase-3-like protease was significantly elevated after 45 min and 60 min in ischemic hearts. Group D had reduced levels of caspase-3-like protease activity after 45 min and 60 min (302+/-58%, 378+/-69% of pre-ischemic control, respectively), as compared with Group C (542+/-74%, 689+/-85%, respectively) (p<0.05, p<0.05, respectively). Histological analysis also demonstrated a decrease in cellular damage in Group D, as the count ratio of necrotic cells with total cardiomyocytes was 38%, as compared with 78% in the control group (p<0.05). Caspase-3-like protease participated in I-R injury in rat hearts and inhibition of this protease resulted in a reduction of necrotic cell death.

Improvement of bypass circuit biocompatibility: comparison and combination of heparin-coated circuit and nitric oxide gas infusion.

OBJECTIVES: Nitric oxide (NO) gas infusion to the oxygenator, as well as heparin-coated bypass circuits, have been reported to attenuate blood activation induced by the interaction with the artificial surfaces of an extracorporeal bypass circuit. Using a mock circulation model, we compared the effect of each and also evaluated the effect of their combination on attenuating bypass-induced blood activation. METHODS: A miniature closed bypass circuit was primed with diluted fresh human blood and perfused for 180 minutes using a centrifugal pump. NO gas (0, 50, or 100 ppm) was infused to the oxygenator sweep gas of either a non-heparin-coated or a heparin-coated circuit. Platelet counts, beta-thromboglobulin, platelet factor 4, complement-3 activation products and granulocyte elastase were measured at 0, 30, 60, 120, and 180 minutes after starting the perfusion. RESULTS: One hundred ppm of NO was statistically equivalent to the heparin-coated circuit for attenuating bypass-induced blood activation, and a combination of the two significantly surpassed the results of either modification alone. Fifty ppm of NO alone provided only a slight attenuation of blood activation as compared with the non-heparin-coated circuit, though the difference was not significant. A combination of 50 ppm NO and the heparin-coated circuit did not significantly enhance the effects of the heparin-coated circuit alone. CONCLUSIONS: The combination of NO gas infusion and heparin-coated circuits appears to be a useful and promising modification for enhancing the attenuation of bypass-induced blood activation, though the optimal dose of NO infusion in terms of effectiveness and adverse effects to the whole body remains to be established.