A surgical navigation system for aortic vascular surgery: a practical approach.

In aortic vascular surgery, a navigation system must represent the anatomical map of individual patient in order to detect the important artery. To provide a proper fit for positions along the dorsoventral axis, the spinous process was added to a currently used anatomical point set consisting of four anterior body landmarks. In addition, we attempted to reduce the registration error by compensating for alignment errors resulting from variations in tissue thickness at each landmark. The alignment values were examined using a human phantom consisting of a skeleton model with subcutaneous tissue in the semilateral position. Using this method, a phantom simulation and five clinical trials were performed. Target errors were evaluated at the orifice of the intercostal artery. In the phantom simulation, the error at the target point was 4.1 ± 2.7 mm. However, for one patient undergoing thoracoabdominal aortic aneurysm replacement surgery, the target error was 8.0 mm using the proposed method.

[Surgical results of Konno and Ross procedures in children and Bentall and David procedures in adults].

The surgical management of complex aortic root lesions has developed over 3 decades both in pediatric and adults patients. To avoid permanent anticoagulation and prosthetic materials as much as possible, we had introduced Ross procedure as an alternative to Konno procedure in pediatric patients and David procedures in adults patients. We sought to evaluate the surgical results of Konno, Ross, Bentall and David procedures. The Konno procedure has excellent long term results and anticoagulation-related complication and endocarditis were major causes of re-operation. Ross procedure has excellent long term results, and autograft failure and right ventricular outflow tract (RVOT) obstruction were causes of re-opertion Bentall procedure is certainly effective and has excellent long term results. Pseudoaneurysmal formation in coronary reconstruction was a major cause of reoperation. David procedure is certainly an attractive option especially for young patients. Early result was satisfactory but durability of this operation should be reevaluated.

[Open stent implantation for ascending aorta aneurysm with severe calcification].

A 77-year-old woman had an ascending aortic aneurysm and aortic regurgitation due to aortitis syndrome. Computed tomography showed that ascending aorta was 55 mm in diameter and had severe calcification between the ascending aorta and distal aortic arch involves neck vessels. We performed open stent implantation and aortic valve replacement with bioprostheses valve. No adverse event occurred after the operation and the patient was discharged on the 28th postoperative day. The open stent implantation was useful for the treatment of the aneurysm in high risk patients.

[Dissection of descending aorta with spinal paralysis].

A 56-year-old man had undergone ascending aorta and total arch replacement because of aortic dissection (Stanford type A) in 1997. He had onset of diplegia of the lower limb and vesicorectal disability. Computed tomography (CT) showed serpentine aneurysm in the descending aorta, it was seen between the left subclavian artery and diaphragm level. It was 80 mm of maximum diameter. Magnetic resonance imaging (MRI) was performed for identified Adamkiewicz artery, but we could not identify it. We performed a graft replacement. The 8th intercostal artery was reconstructed with a branch graft. The postoperative course was uneventful. We conclude that graft replacement for spinal ischemia can be effective.

[Mitral regurgitation due to sole punched out lesion of the mitral anterior leaflet in infective endocarditis; report of a case].

Mitral regurgitation (MR) due to only punched out lesion is extremely rare in infective endocarditis. A 31-year-old male was admitted to our hospital due to unusual cause of MR. Echocardiography showed MR due to punched out lesion of the mitral anterior leaflet, which is extremely rare. A round shape punched out lesion (about 16 mm in size) was found intraoperatively in the anterior leaflet of the mitral valve. The surface around the punched out lesion was smooth, and the leaflet displayed good movability. Neither vegetation nor calcification was found. Punched out lesion was successfully closed with autologous pericardial patch and annuloplasty was performed.

[Selection of surgical strategy for abdominal aortic aneurysm coexisting with coronary artery disease; one-stage versus two-stage, and off-pump versus on-pump].

BACKGROUND: In patients having a combination of severe coronary artery disease (CAD) and expanding abdominal aortic aneurysm (AAA), one-stage operation of simultaneous coronary artery bypass grafting (CABG) and AAA repair has been recommended. METHODS AND RESULTS: Of 96 patients (94 men, average 65 year) with AAA and CAD, 21 patients underwent one-stage operation of simultaneous CABG and AAA repair (Group A-1: off-pump CABG in 10 and on-pump in 11), and 75 underwent two-stage operation of CABG followed by AAA with an interval of less than 6 months in 23 patients (Group A-2) and more than 6 months in 52 patients (Group B). Baseline characteristics were similar between the one-stage and two-stage groups, and off-pump and on-pump subgroups, except the proportion of single vessel disease. Mean number of distal anastomoses was significantly lower in the off-pump subgroup than in the on-pump subgroup (p = 0.011) and the two-stage group (p = 0.0057). There was 1 hospital death among on-pump patients but none among off-pump patients. Mortality rate was 4.8% in the one-stage group. Two patients (8.7 &) in the two-stage group, who had AAA was 7.0 cm and 7.5 cm diameter, died of AAA rupture prior to repair. The 10-year all death free rates were 44% in Group A (A-1 and A-2), and 86% in Group B (p = 0.0004). CONCLUSIONS: Our data suggest that one-stage operation with off-pump CABG is an attractive option in selected patients with a large AAA (> 7 cm).

[Off-pump versus standard on-pump reoperative coronary artery bypass grafting].

BACKGROUND: Using standard on-pump procedures, repeat coronary artery bypass grafting (re-CABGs) are associated with a higher morbidity and mortality than first-time CABGs. This retrospective study assessed the clinical outcomes of off-pump re-CABG versus on-pump re-CABG. METHODS: From 1983, 2nd CABG and 3rd CABGs were performed in 162 patients at our institute. The early and late results of 142 patients who received standard on-pump re-CABGs and 20 patients who received off-pump re-CABGs were evaluated. The 2 groups were similar in age, sex, preoperative ejection fraction (EF) and number of coronary lesions. However, mean number of distal anastomoses per patient was significantly higher in on-pump (2.0 +/- 0.8) than in off-pump re-CABG (1.4 +/- 0.6) [p = 0.0009]. RESULTS: Hospital mortality tended to be higher in the on-pump group (5.6%) than in the off-pump group (0%) [p = 0.6]. Morbidity in term of total postoperative complications tended to be higher for on-pump (14.1%) than in off-pump (0%) [p = 0.14]. The 5-year survival rate tended to be higher in the off-pump group (100%) than in the on-pump group (80.8 +/- 3.5%) [p = 0.096]. CONCLUSIONS: In selected patients, off-pump re-CABG can be a reliable and safe option. The mid-term survival and event-free survival rates achievable with the off-pump option are encouraging.

Progress in the treatment of aneurysms of the distal aortic arch: approach through median sternotomy.

AIM: A review of past and current operative procedures for the treatment of aneurysms of the distal aortic arch is presented in conjunction with a series of 43 patients. In this study, distal aortic arch aneurysm refers to an aneurysm involving at least the origin of the left subclavian artery, but not extending beyond the left common carotid artery. We excluded dissection aneurysm and extended aneurysm to the descending thoracic aorta from this study. METHODS: Between January, 1985, and March, 2000, 43 consecutive patients (37 males, 6 females; mean age 67.5 years) underwent repair of aneurysms of the distal aortic arch. The approach to the aneurysm was through a left thoracotomy in 4 patients and a median sternotomy in 39 patients, including an additional left thoracotomy continued to a median sternotomy in 2 patients. The supportive methods during surgery were left heart bypass using a centrifugal pump in 4 patients (LHB group), cardiopulmonary bypass with selective cerebral perfusion in 11 patients (SCP group), and cardiopulmonary bypass with continuous retrograde cerebral perfusion in 28 patients (RCP group). In the RCP group, the "aortic no-touch technique" was applied in 21 patients. The operative methods were patch closure in 4 patients, graft replacement of the distal arch using the inclusion technique in 14 patients, and total arch replacement using the exclusion technique in 25 patients. RESULTS: There were 5 hospital deaths: 1 patient in the LHB group, intractable bleeding; 1 patient in the SCP group, rupture of the distal anastomosis; 3 patients in the RCP group, stroke, rupture of the dissection arising from the distal anastomosis, and perioperative myocardial infarction. Stroke occurred in 1 patient (25%) with LHB, 3 patients (27.2%) with SCP, and 1 patient (3.6%) with RCP. Among the postoperative survivors, a new onset of left recurrent nerve palsy occurred in 2 patients (66.7%) with LHB, 1 patient (10%) with SCP, and in 1 patient (4%) with RCP. No neurological injury or left recurrent nerve palsy occurred in the patients who underwent the "aortic no-touch technique". CONCLUSION: Total arch replacement with the graft exclusion technique under profound hypothermic circulatory arrest using RCP through the median sternotomy is a promising surgical treatment for atherosclerotic distal aortic arch aneurysm. The "aortic no-touch technique" further improved the surgical results of the distal aortic arch aneurysm.

[Total arch replacement for right aortic arch with Kommerell diverticulum and aberrant left subclavian artery].

A 57-year-old man suspected of having angina pectoris underwent coronary angiography and comprehensive examination, which revealed a right-side aortic arch accompanying Kommerell diverticulum and a aberrant left subclavian artery. Esophagography indicated that the esophagus was compressed on its right posterior side and the computed tomography (CT) revealed that the posterior side of the tracheal was compressed, however, the patient experienced no difficulty in breathing, hoarseness of voice or dysphasia. The size of the aortic diverticulum was less than 5 cm and the patient showed no symptom, however, if it was left untreated, there was a risk of rupture in the future. Also the esophagus and tracheal may develop complications due to prolonged compression. Therefore, we decided that the case required surgical operation. Total arch replacement was performed through mediastinotomy and right posterolateral in the 4th intercostal. The postoperative condition was good, and the patient was discharged without any complications.

[Comparative study of hypothermic circulatory arrest and normothermic distal perfusion for thoracoabdominal aortic aneurysm repair].

BACKGROUND: Hypothermic bypass with circulatory arrest for thoracoabdominal aortic aneurysm (TAAA) repair is employed for its protective effect on spinal cord function and because it avoids clamping the diseased aorta. However, organ dysfunction caused by reperfusion injury as well as bleeding tendencies due to deep hypothermia have been described. In this paper we compared the efficacies of the hypothermic and normothermic operations. METHODS: Between February 1996 and June 2000, 28 patients underwent thoracoabdominal aortic repair. Twenty-three patients were men, 5 were women, and the median age was 55.3 (range 23 to 75 years). Fourteen patients had aortic dissection, and 7 had Marfan syndrome. Fourteen patients required reconstruction of visceral arteries. Twelve patients underwent TAAA repair under deep hypothermic circulatory arrest (H group), and 15 under normothermic distal perfusion (N group), while 1 patient underwent a simple clamp procedure. Perioperative data and early outcomes were compared between groups. RESULTS: The overall 30-day mortality rate was 0%, but 3 patients (25.0%) in II group, and 1 patient (6.3%) in N group died during hospital stay. Operation time and bypass time were longer in H group than N group (operative time 793 min vs. 481 min (p < 0.05): cardiopulmonary bypass (CPB) time 255 min vs. 102 min (p < 0.05). Also, more intraoperative bleeding was found in H group than in N group (3,506 ml vs. 1,220 ml). Spinal cord neurologic deficit did not occur in either group. Respiratory failure occurred in 3 patients (25.0%) in H group and one (6.3%) in N group. Renal failure occurred in 3 (25.0%) in H group, and none in N group. CONCLUSION: Early and mid-term outcome of TAAA repair was almost satisfactory and without neurospiral complications. The deep hypothermic operation is more likely to induce postoperative respiratory and renal dysfunction than the normothermic operation. TAAA repair using deep hypothermic circulatory arrest should be limited to patients with TAAA involving the distal arch or a severely calcified aortic wall.

Long-term results after De Vega's tricuspid annuloplasty.

BACKGROUND: Although some surgeons prefer to use artificial valve rings for tricuspid valve annuloplasty, we have mainly performed De Vega's tricuspid annuloplasty for functional tricuspid regurgitation, because it is a simple and effective technique for reducing tricuspid regurgitation due to annular dilatation. We evaluated long-term results of the De Vega's tricuspid annuloplasty up to 19 postoperative years. METHODS: Between January 1980 and June 1999, 408 patients underwent De Vega's tricuspid annuloplasty. Long-term results after De Vega's tricuspid annuloplasty were analyzed. RESULTS: There were 14 (3.4%) early deaths within 30 postoperative days. There were 63 (15.4%) late deaths during the follow-up period. The actuarial survival rate at 15 years after operation was 74.0%, the 15-year freedom from re-operation was 91.6%, and the 15-year freedom from all events was 58.7%, respectively. CONCLUSIONS: These results suggest that De Vega's tricuspid annuloplasty was an effective and reliable procedure of choice for secondary tricuspid regurgitation with annular dilatation.

[Early and mid-term results of all arterial graft coronary artery bypass grafting using bilateral internal thoracic and radial arterial conduits].

From March 1996 to May 2000, 41 patients [age 39-78 (mean 63.5 +/- 8.8) years, 90.2% male] underwent all arterial multiple coronary artery bypass grafting (CABG) using bilateral internal thoracic (BiITA) and radial (RA) arterial conduits. The reason for using RA was that the right gastroepiploic artery (RGEA) was small or occluded on preoperative angiography, a history of upper abdominal surgery or disease, or the right coronary arterial lesion was proximal and mild. The BiITA were used as in situ grafts and the proximal anastomosis of RA was to the ascending aorta in all cases. All patients underwent conventional elective CABG with median sternotomy using cardiopulmonary bypass. The mean number of anastomoses was 3.3 +/- 0.5 branches and complete revascularization rate was 80.5%. Postoperative follow-up averaged 20 months and the longest was 50 months. There was no early death, and overall graft patency 2-3 weeks after surgery was 96.2% (LITA 94.0%, RITA 97.6%, RA 97.6%). Four-year actuarial survival rate was 96.4 +/- 3.5% (1 patient: 9 months, no cardiac death), and cardiac event-free rate after surgery was 89.7 +/- 4.9% [4 patients: percutaneous transluminal coronary angioplasty (PTCA)]. However, once patients were discharged from hospital, cardiac event-free rate was 100%. These excellent results suggest that all arterial graft CABG was satisfactory, and RA can be used as a third suitable arterial bypass conduit, if RGEA cannot be used or is unsuitable for use.

[Surgical treatment of Marfan syndrome; late results and new strategy].

UNLABELLED: Rapid progress has been made in the treatment of Marfan syndrome. Today, the treatment is relatively established and the results have also improved. Even if surgery is performed, however, vascular lesions may recur late after operation and late prognosis is poor considering the age of patients. Issues such as whether a reoperation should be conducted or how the late results might be improved are subjects of debate. Based on an analysis of recent late data, we have performed operations according to the new treatment policy, and here report the results. A total of 203 consecutive operations were conducted in 141 patients with Marfan syndrome who underwent surgery for aortic aneurysm at our department between February 1973 and August 2001. The mean age of patients was 39 (11 years with a male/female ratio of 95:46. At the first operation, 72 patients were diagnosed with annuloaortic ectasia (AAE), 17 patients with AAE + chronic dissection (DeBakey I), 14 patients with AAE + chronic dissection (DeBakey II), 6 patients with AAE + acute dissection (Stanford A), 11 patients with AAE + dissection (DeBakey III), 9 patients with dissection (DeBakey III) only, 3 patients with AAE + abdominal aortic aneurysm only, and 2 patients with abdominal aortic aneurysm only. The cause of reoperation were a new lesion in 17 patients, dissection in 13 patients and a true aneurysm in 4 patients. In 36 patients, an increase in the remaining lesion occurred or a scheduled stage 2 operation was performed. Reoperation was performed following the Bentall operation in 7 patients, dehiscence of the anastomotic region of the coronary artery in 5 patients, aneurysm of the anastomotic region of the coronary artery in 1 patients, and infection of the artificial valve with aneurysm of the anastomotic region of the coronary artery in 1 patient. Hospital deaths were reported in 8 (6%) patients who underwent composite valve graft replacement (including simultaneous arch replacement) for AAE. Hospital deaths also occurred in 8 (13%) patients who underwent a replacement of the aortic arch, descending thoracic or thoracoabdominal aorta, with no cases of paraplegia reported. In all cases, the replacement was extensive. The observed 10-year survival rate was 70% with a freedom from reoperation of 64%. Although dissection did not reduce the observed survival rate, the 10-year freedom from reoperation was significantly decreased at 49% (p = 0.0007). CONCLUSIONS: (1) Surgery is indicated for AAE when the maximum diameter of the aneurysm prior to onset of dissection is 5 cm. In the case of aortic arch without dissection, the Bentall operation with simultaneous arch replacement should be aggressively performed in order to minimize the future risk of vascular events and to eliminate the need for extensive replacement in a reoperation, a procedure which is associated with a high level of risk. (2) Extensive replacement which is associated with poor results should be avoided where possible and, instead, scheduled staged surgery should be aggressively performed in the early stage when the maximum diameter of the aneurysm in the descending aorta is 5 cm or less. (3) By paying adequate attention to patient education, outpatient follow-up using detailed diagnostic imaging, drug therapy, periodic late surveillance, expedition of scheduled surgery, and to the basic approach as well as endeavoring to improve surgical results by the use of new methods of treatment, it is anticipated that further improvement will be observed in late results.

[Dissecting aneurysm of ventricular septum following acute inferior myocardial infarction].

Dissecting aneurysm of the ventricular septum as a complication after myocardial infarction (MI) is very rare. The patient was a 70-year-old women who was diagnosed with acute inferior MI. Three months after MI, catheterization showed a left ventricular aneurysm of the inferior wall, and left-to-right ventricular shunt flow was detected in the aneurysm. Echocardiography showed that the inferior left ventricular free wall was aneurysmal and dissected from the septal wall. Nine months after MI, chronic heart failure was uncontrollable by medication. At surgery, a tear (5 mm long) in the dissecting aneurysm of the ventricular septum was found and closed directly using 2 felt patches, and aneurysmectomy was performed using felt strips. The postoperative course was uneventful and she has been free from any complication for over 1 year.

[Cardiovascular effects of colforsin daropate hydrochloride for acute heart failure after open heart surgery].

Colforsin daropate hydrochloride (COL) is a novel drug for the treatment of acute heart failure. COL stimulates adenylate cyclase directly and produces positive inotropic and vasodilator effects accompanied by the increase in cellular cAMP. We investigated its cardiovascular effects for 9 patients who showed low cardiac index (< 3.0 l/min/m2) after open-heart surgery in ICU. After 2 or 3 hours from administration of COL, heart rate and cardiac index increased, and pulmonary artery pressure and central venous pressure decreased significantly, but blood pressure and systemic venous oxygen saturation did not show significant change. In conclusion, COL improved hemodynamics through positive inotropic and vasodilator effects without hypotension. We should investigate more proper usage of this drug to avoid such side effects as tachycardia and arrhythmia, which occurred in some cases.

[A case report of extended thoracoabdominal graft repair for dissecting aneurysm (DeBakey Type IIIb) with visceral ischemia].

A 62-year-old man diagnosed as dissecting aneurysm (DeBakey type IIIb) with visceral is chemia was transferred to our hospital. He had suffered from abdominal pain and the absence of right femoral pulse. Emergent laparotomy revealed no evidence of visceral infarction. Right axillo-femoral bypass was performed. However, visceral ischemia gradually progressed. Enhanced CT and angiography showed that celiac artery and supramesenteric artery (SMA) were collapsed. He underwent graft replacement of thoracoabdominal aorta involving visceral arteries with femoro-femoral bypass with a centrifugal pump as an ajunct. The visceral arteries were reconstructed. Postoperative CT revealed sufficient flow of branch arteries. He recovered well without complication and then discharged.

Ostial stenosis of coronary arteries after complete replacement of aortic root using gelatin-resorcinol-formaldehyde glue.

Coronary ostial stenosis between an interposition graft and coronary artery is rare and fatal. A 46-year-old woman who had reconstruction of both coronary arteries using interposition grafts for type A acute dissecting aneurysm presented with acute chest pain. Emergent coronary artery bypass grafting was done with saphenous vein grafts. Inappropriate use of gelatin-resorcinol-formaldehyde glue can be associated with ostial stenosis in the long term. Transesophageal echocardiography is useful to diagnose ostial stenosis of the coronary arteries.

Total and partial cardiac sympathetic denervation after surgical repair of ascending aortic aneurysm.

UNLABELLED: Sympathetic cardiopulmonary nerves arise from the cervical sympathetic trunks and travel alongside the great arteries to innervate the ventricles. Because of the proximity of the nerve and artery, cardiac sympathetic denervation may occur in patients who have just undergone surgery for the repair of an ascending aortic aneurysm. METHODS: To evaluate the cardiac sympathetic activity in aortic aneurysm, we performed cardiac 123I-metaiodobenzylguanidine (MIBG) imaging on 12 patients (mean age +/- SD, 47 +/- 17 y) before and after the surgical repair of an aneurysm. Seven patients scheduled for coronary artery bypass grafting also underwent 123I-MIBG imaging as controls for open-chest surgery. Planar images were obtained at 15 min (early) and 4 h (delayed) after injection of 111 MBq 123I-MIBG, and the cardiac 123I-MIBG uptake was graded quantitatively and visually. The quantitative evaluation was based on the heart-to-mediastinum ratio (H/M), and visual evaluation was performed by assigning a score of 0-3 (0 = absent, 1 = severely reduced, 2 = reduced, and 3 = normal). Heart rate variability using 24-h Holter electrocardiography was analyzed before and after the operation to generate a time-domain index of heart rate variability as an index of autonomic balance. RESULTS: In patients with aortic aneurysms, both early and delayed H/Ms were significantly decreased after the operation (early H/M: 1.84 +/- 0.16 before vs. 1.40 +/- 0.16 after, P = 0.001; delayed H/M: 1.79 +/- 0.38 before vs. 1.27 +/- 0.18 after, P = 0.004). Visual analysis of 123I-MIBG accumulation in early images showed absence of 123I-MIBG accumulation in 3 of 12 patients, a score of 1 in 7 patients, and a score of 2 in 2 patients. In contrast, no significant difference between H/M before surgery and H/M after surgery was seen in patients who underwent coronary artery bypass grafting. The time-domain index of heart rate variability was significantly lower after the operation than before (135 +/- 40 after vs. 96 +/- 27 before, P < 0.05). CONCLUSION: Cardiac sympathetic nerves are totally or partially denervated after the surgical repair of ascending aortic aneurysm.

Angiotensin II type 2 receptor mediates vascular smooth muscle cell apoptosis in cystic medial degeneration associated with Marfan's syndrome.

BACKGROUND: Cystic medial degeneration (CMD) is a histological abnormality that is common in the aortic diseases associated with Marfan's syndrome (MFS). Although little known about the mechanism underlying CMD, several recent reports have demonstrated that vascular smooth muscle cell (VSMC) apoptosis could play a substantial role in CMD. On the other hand, angiotensin II (Ang II) has been reported to play an important role in the regulation of VSMC growth and apoptosis via the Ang II type 1 receptor (AT1R) and type 2 receptor (AT2R). METHODS AND RESULTS: To elucidate the role of Ang II signaling via the Ang II receptors in CMD, we investigated AT1R and AT2R mRNA expression and tissue concentration of Ang II in MFS aortas (n=10) and control aortas (n=12). Furthermore, we examined the effects of an ACE inhibitor, an AT1R blocker, and an AT2R blocker on serum deprivation-induced VSMC apoptosis by organ culture system. AT1R expression was significantly decreased (P<0.01) and AT2R expression was significantly increased (P<0.001) in MFS aortas compared with control aortas, and tissue Ang II concentration was significantly higher in CMD than in the control condition (P<0.01). Both the ACE inhibitor and AT2R blocker significantly inhibited serum deprivation-induced VSMC apoptosis (P<0.05), although the AT1R blocker did not inhibit apoptosis in cultured aortic media from MFS patients. CONCLUSIONS: Accelerated ACE-dependent Ang II formation and signaling via upregulated AT2R play a pivotal role in VSMC apoptosis in CMD, and the ACE inhibitor could have clinical value in the prevention and treatment of CMD.

[A re-operative case of bentall operation and aortic arch replacement using a stent graft for a Marfan syndrome, post sternum turnover and post mitral valve replacement].

A 36-year-old male with Marfan syndrome succesfully underwent Bentall operation and aortic arch replacement using a stent graft as an elephant trunk. He had received MVR with sternum turn over 14 years previously. Median sternotomy was performed. Under circulatory arrest with rertograde cerebral perfusion we performed Bentall operation and aortic arch replacement using a stent graft. The sternum was cured well. Retractive breathing was not detected. This surgical procedure was effective for cardiovascular disease with Marfan syndrome.