Interstitial fluid shifts to plasma compartment during blood donation.

BACKGROUND: A vasovagal reaction (VVR) occurs in 0.8% to 0.9% of voluntary blood donors in Japan. However, they generally tolerate the acute loss of 400 mL of whole blood rather well, perhaps because several circulatory defense mechanisms compensate for the loss. This study aimed to determine the extent to which an interstitial fluid shift contributes to the development of a VVR. STUDY DESIGN AND METHODS: Blood hemoglobin (Hb) was measured upon admission, at venipuncture, and immediately after collecting 400 mL of whole blood from 736 donors. Shifted fluid volume was calculated using a formula that included Hb levels and estimated total blood volume. RESULTS: By the end of blood collection, 188 ± 80 and 211 ± 82 mL of fluid, which is equivalent to almost half of the total amount of withdrawn blood, had entered the intravascular space in male and female donors, respectively. The difference between the sexes was significant despite the lower body weight and circulating blood volume of the female donors. Body weight increased, whereas age decreased the volume of shifted fluid in female donors. CONCLUSION: Blood loss after donation is quickly compensated by an interstitial fluid shift into the intravascular space and may not be the only direct cause of VVR in the setting of a whole blood donation of 400 mL.

Sternum lifting technique for thoracoscopic internal thoracic artery harvest.

We employed the Laparolift and Laparofan (Origin Medsystems Inc., CA, USA) and developed a sternum lifting technique to create a sufficient intra-pleural space between the heart and the sternum in which the left internal thoracic artery (ITA) in situ graft could be thoracoscopically mobilized. Between June and December 2004, this technique was applied to 12 consecutive patients (eight men, four women, aged 68.5+/-9.6 years) undergoing minimally invasive coronary artery bypass grafting via a left mini-thoracotomy. The Laparofan, connected to the arm of the lift machine (Laparolift), was introduced through a subxyphoidal entry and opened beneath the sternum. The sternum was elevated by about 5 cm until a sufficient working space was created under the sternum. With left hemipulmonary collapse, the left ITA was thoracoscopically taken down through the axillary ports. There was no procedural conversion to direct harvesting. The mean thoracoscopic harvesting time was 34.5+/-7.7 min. There was no mortality and no instrument-related morbidities. Patency of each ITA graft was angiographically confirmed. In conclusion, despite the limited experience, the present sternum elevation technique using the Laparolift system is a viable method for increasing the intra-pleural working space beneath the sternum during thoracoscopic ITA harvesting.

Cardioscopic Trans-septal Cryoablation of Left Atrium in Nonmitral Cases.

BACKGROUND: : A modified maze procedure in which trans-septal cardioscopy was used for cryoablation in the left atrium is described. METHODS: : The technique was used in 11 consecutive patients (9 men and 2 women, 56.5 ± 19.8 years) with permanent atrial fibrillation (Af) and concomitant nonmitral cardiac or aortic disease: aortic valvular disease in 4 patients, atrial septal defect (ASD) in 2 patients, tricuspid regurgitation in 2 patients, acute aortic dissection in 1 patient, arch aneurysm in 1 patient, and coronary artery disease in 1 patient. The mean Af duration detected in 7 cases was 18.5 ± 10.1 months. Partial sternotomy was used in aortic valve replacement, ASD closure, and tricuspid valve plasty, and fullsternotomy was used in aortic graft replacement and coronary artery bypass. Cardiopulmonary bypass was established, aortic cross-clamp was performed, a right atriotomy was created, a cryoablation probe and cardioscope (3 mm) were introduced into the left atrium through a 1-cm cut at the fossa ovalis or ASD, and cardioscopic left-atrial endocardial cryoablation was performed. The right-side maze procedure was conducted directly. The atrial appendages were excised in each case. RESULTS: : Left-atrial cardioscopic cryoablation required 25.0 ± 5.5 minutes, and no deaths or procedure-related morbidities occurred. The mean follow-up period was 12 ± 8.5 months. One patient with tricuspid regurgitation died of liver failure. With the exception of coronary and acute dissection cases, all patients have maintained a sinus rhythm. CONCLUSION: : Although experience is limited, videocardioscopic trans-septal left-atrial cryoablation is a viable method for nonmitral Af cases, and the partial sternotomy approach can be performed.

Fluoroscopic angiography-guided mini-entry localization before minimally invasive redo coronary artery bypass.

We have been using a mini-thoracotomy localization technique before re-operative minimally invasive direct coronary artery bypass (MIDCAB) to the left anterior descending artery (LAD). This technique was performed during the diagnostic laboratory catheter study, in which the skin portion was marked just above the target LAD site, observing the enhanced LAD by fluoroscopy. In nine patients, a 3-4-cm mini-entry was made by referring to the marked position, the LAD was identified in the minimally dissected epicardium, and anastomoses were performed using the vein in six cases, the left internal thoracic artery in two, and the right gastroepiploic artery in one.

A new needle driver for minientry coronary artery bypass.

PURPOSE: This article describes our clinical experience with a new needle driver (Olympus, Tokyo, Japan), which we have produced to facilitate minithoracotomy or port-access coronary artery anastomosis with the running suture technique. METHODS: The needle driver is 21 cm long, weighs 38 g, and has a grip shaft 1.4 cm in diameter. The device is held like a pencil. A side lever and a revolving disk in the shaft are manipulated with the fingers; a fine needle with a 7-0/8-0 monofilament suture can be grasped/released and driven to penetrate the coronary arterial wall. This device was employed in 10 consecutive patients (8 men, 2 women, 73 +/- 7.5 years old), and off-pump bypass to the left anterior descending artery was achieved using the left internal thoracic artery or vein via a minithoracotomy (4.2 +/- 0.6 cm long). RESULTS: There was no instrument-related injury during each anastomosis. The mean sewing time per anastomosis was 12 minutes (range, 8-18 minutes). Angiography confirmed the patency of the graft in all cases. CONCLUSIONS: Although our experience is limited, we consider the present needle driver to be a viable device for facilitating off-pump, minientry coronary artery anastomosis with the suturing technique.

Needle-guided mini-entry in video-assisted coronary artery bypass.

In minimally invasive coronary artery bypass (MICAB), a video-assisted needle-guided technique was used to make a mini-thoracotomy or an access-port just above the target site in the left anterior descending coronary artery (LAD). After thoracoscopic preparation of the left internal thoracic artery (LITA) and pericardiotomy, a 7-cm, 23-gauge needle was used to examine the skin-point where the needle vertically penetrated the chest wall and thoracoscopically indicated the target site in the LAD. This point was used as the mid-point of the skin incision for a 6-cm thoracotomy (six cases) or a 33-mm access-port (four cases). Consequently, there was no conversion of approach except in the patient with pulmonary dysfunction, and each LITA-LAD anastomosis was completed directly through the mini-entry. There was no mortality and no procedure-related morbidity. Patency of each graft was confirmed within a week after surgery. After a mean follow-up period of 12.5+/-7.8 months, all of the patients except one, who died of stroke 1 year after surgery, are alive with no ischemic events. Although our experience is limited, the present video-assisted needle-guided technique can be a simple method to facilitate appropriate positioning of a mini-entry in MICAB to the LAD with a thoracoscopically prepared LITA graft.