Mycotic aneurysm of the left anterior descending coronary artery after coronary artery bypass graft surgery.

Mycotic aneurysms of the coronary artery are extremely uncommon and can be very difficult to diagnose. We report a unique case of a mycotic aneurysm of the left anterior descending coronary artery with a history of two-vessel off-pump coronary artery bypass graft surgery 9 months previously. The aneurysmectomy was successful.

Tepid hypothermic (32° C) circulatory arrest for total aortic arch replacement: a paradigm shift from profound hypothermic surgery.

In total aortic arch replacement (TARCH) using hypothermic circulatory arrest (HCA) and selective cerebral perfusion (SCP), postoperative cerebral complications, including metabolic abnormalities, are by no means rare. Furthermore, there is a lack of international guidelines for the optimal perfusion temperature and flow for SCP. Starting in 2008, TARCH was performed using tepid HCA at 32 °C. In the present study, 27 patients (group C) who underwent TARCH with deep hypothermia at the lowest rectal temperatures of 20-25 °C were retrospectively reviewed and compared with 23 patients (group W) who underwent TARCH with 32 °C tepid hypothermia. Preoperative patient characteristics and intraoperative and postoperative parameters were compared. Preoperative patient characteristics did not differ significantly between the two groups. Circulatory arrest time, cardiopulmonary bypass time, operating time, amount of blood transfused and postoperative neurological complications were significantly reduced in group W compared with group C. Our procedure of TARCH using tepid hypothermia at 32 °C was safe, and it significantly reduced all parameters of extracorporeal circulation time. However, this study has several limitations. To indicate the safety and usefulness of tepid HCA for TARCH, a further multifaceted study should be performed with a greater number of patients.

Intraradial administration of fasudil inhibits augmented Rho kinase activity to effectively dilate the spastic radial artery during coronary artery bypass grafting surgery.

OBJECTIVES: Radial arteries are increasingly used as conduits for coronary artery bypass grafts. However, vasospasm continues to be a major concern in radial artery grafts. Rho kinase plays a critical role in vascular contraction through phosphorylation of the regulatory subunit myosin phosphatase targeting subunit 1 (MYPT1) of the myosin light chain phosphatase to inhibit myosin light chain phosphatase in vascular smooth muscle. The purpose of this study was to evaluate the inhibitory effects of fasudil, a clinically used Rho kinase inhibitor, on Rho kinase activity, myosin light chain phosphorylation, in vitro contraction, and in situ vasospasm in radial arteries of patients undergoing coronary artery bypass grafting surgery. METHODS: The inhibitory efficacy of fasudil on vasoconstrictor-induced contraction and phosphorylation of MYPT1 was examined in radial artery rings. In situ phosphorylation of MYPT1 was evaluated in nonspastic and spastic radial arteries, and the effects of intraluminal administration of fasudil and verapamil-glyceryl trinitrate (VG) on in situ free blood flow and phosphorylation of MYPT1 and myosin light chain were compared in spastic radial arteries. RESULTS: Both fasudil and VG nearly fully inhibited noradrenaline- and serotonin-induced contraction of radial artery rings. However, fasudil but not VG abolished MYPT1 phosphorylation. In spastic radial arteries phosphorylation of MYPT1 and myosin light chain was increased compared with that seen in nonspastic arteries. Intraradial administration of fasudil induced a much larger increase in in situ free blood flow compared with VG treatment. This antispastic effect of fasudil was accompanied by marked decreases in phosphorylation of MYPT1 and myosin light chain. CONCLUSIONS: Fasudil is a very effective Rho kinase inhibitor that deinhibits myosin light chain phosphatase and powerfully relieves vasospasm in situ in radial arteries.

T-graft technique under antegrade cerebral perfusion for aortic arch aneurysm.

We have devised a T-graft technique for selected extensive aortic arch replacement under antegrade cerebral perfusion. Under hypothermic circulatory arrest using antegrade cerebral perfusion, one graft was island-anastomosed to the supraaortic arteries. The other graft was anastomosed to the descending aorta. Proximal and distal grafts were then end-to-side anastomosed in a T-shape. During rewarming, the ascending aorta and proximal graft were anastomosed. The surgical field was good in the 6 patients included in this report. No perioperative deaths or serious complications were encountered. This procedure was effective for patients with extensive aortic arch aneurysm and relatively intact orifices of the supraaortic arteries.

Inferior vena cava occluder for remote access perfusion in robotic cardiac surgery.

Robotic cardiac surgery requires remote access perfusion. We have developed an inferior vena cava (IVC) occluder that can safely and conveniently drain blood from the IVC. This device has been clinically applied in one patient, as described herein. The framework for this device is made from a single superelastic nitinol wire, 0.30 mm in diameter. Diameter of the spreading site of the device is decided from computed tomographic images. A polyester fabric membrane (thickness 0.10 mm) is set at the tip of this framework. The occluder is deployed through an 18-F sheath. This device was used in a 64-year-old woman with lipoma in the right atrial wall near the IVC-right atrium interface. In this patient, it might not have been possible to completely reset the tumour by conventional IVC occlusion using a snare. The occluder was smoothly and safely deployed and retracted. During placement of the occluder, blood did not flow from the IVC into the right atrium. During extracorporeal circulation, vacuum drainage was performed with no air contamination. The tumour was resected by a three-arm da Vinci Surgical System. The IVC occluder needs to completely block the IVC and avoid obstructing the inflow region of the hepatic vein. This device obviates the need to place a snare on the IVC, and thus should directly improve the safety of robotic cardiac surgery and shorten the operating time.

Use of skeletonized radial artery graft with the PAS-Port proximal anastomotic device.

PURPOSE: We report our initial experience with the PAS-Port proximal anastomosis system (Cardica Inc, Redwood City, CA) using full-skeletonized radial artery (RA) in patients requiring off-pump coronary artery bypass grafting. DESCRIPTION: The PAS-Port system (Cardica Inc) was used in 25 patients undergoing off-pump coronary artery bypass surgery. All patients received at least one RA graft using the PAS-Port system on the proximal anastomosis. The radial arteries were harvested in a fully skeletonized fashion before loading to the PAS-Port system. EVALUATION: Our attempt to use the PAS-Port system for proximal anastomosis of the RA was successful in 25 anastomoses. Postoperative angiography showed 24 grafts to be widely patent. During the mean postoperative follow-up of 9.2 +/- 3.1 months, there was no cardiac-related event in any patient. Mid-term patency collected from the first 8 patients was 87.5% (mean follow-up, 12.8 +/- 2.8 months). CONCLUSIONS: The PAS-Port system does not require aortic clamping and enables the creation of uniform and widely patent anastomosis with use of RA grafts.

[Advanced coronary artery surgery for minimally invasiveness].

Since the development of drug-eluting stents, the conditions of coronary artery surgery have changed. The selection criteria for candidates for coronary artery bypass grafting (CABG) have become more stringent. In this era, surgeons should perform less invasive surgery to save such candidates. Off-pump coronary artery bypass (OPCAB) will become the gold standard surgical procedure for the treatment of ischemic heart disease. This paper describes how to perform less invasive OPCAB with some useful devices and points out the pitfalls of the standard procedure. We have also introduced robotic surgery using the DaVinci system. This procedure decreases the length of dermal incisions. Robotic surgery has other advantages compared with the standard endoscopic surgery. The arm of the robot absorbs the vibrations of human hands and the command function can decrease movement significantly. This arm has five joints, allowing the operator to manipulate the equipment easily inside the body. We have also performed awake CABG with high epidural anesthesia for minimally invasive surgery. This procedure is performed especially in patients with severe cerebrovascular disease and lung injury. In our institution, patients can be discharged only 5 days after this surgical procedure. Less invasive surgery will be the standard procedure in future.

Awake subxyphoid minimally invasive direct coronary artery bypass grafting yielded minimum invasive cardiac surgery for high risk patients.

Off-pump coronary artery bypass graft (CABG) surgery has become a widely used modality and has received recognized as a minimally invasive surgery with few complications. However, for patients with severely impaired pulmonary function, further considerations have to be given to reduce the complications associated with general anesthesia. We have accumulated experience in awake off-pump surgery combined with high thoracic epidural anesthesia. In this report we describe the use of alternative subxiphoid approach in patients with severe pulmonary dysfunction. A catheter for high thoracic epidural anesthesia was inserted one day before surgery. After obtaining an adequate level of anesthesia, a small subxiphoid incision was made and the pericardium was opened to expose the left anterior descending branch. The conduit for bypass, gastroepiploic artery was accessed through a minilaparotomy, and separated under the same surgical field and anatomozed under beating heart. This procedure was performed in three patients. Patency was confirmed by postoperative angiography in all three cases. All patients were discharged after an uneventful postoperative course. Awake subxiphoid approach has the advantages that both thoracotomy and sternotomy can be avoided thus permitting surgery with extremely low invasiveness. This method is recommended for patients with severe pulmonary dysfunction.

Successful aortic valve replacement using dilutional ultrafiltration during cardiopulmonary bypass in a patient with Child-Pugh class C cirrhosis.

Open-heart surgery is a relatively high-risk procedure when performed in patients with Child-Pugh class C cirrhosis. Even though they can tolerate cardiac surgery with cardiopulmonary bypass (CPB), most of them suffer major postoperative complications and prolonged hospital stay. The present report describes a case of a patient with Child-Pugh class C cirrhosis who developed severe heart failure secondary to aortic valve stenosis. The patient underwent successful aortic valve replacement with the use of dilutional ultrafiltration during CPB to reduce adverse effects of CPB. He recovered smoothly after the operation without major postoperative complications. Thus, the use of dilutional ultrafiltration (DUF) during CPB appears to produce beneficial effects for improving outcomes in patients with decompensated cirrhosis who require open-heart surgery.

Lidocaine-magnesium blood cardioplegia was equivalent to potassium blood cardioplegia in left ventricular function of canine heart.

This study evaluated the effects of lidocaine-magnesium blood cardioplegia on left ventricular function compared with potassium blood cardioplegia. Crystalloid cardioplegia which contains lidocaine has been reported but blood cardioplegia is rare. Thirteen dogs received 60 min of global ischemia under hypothermic cardioplumonary bypass (30 degrees C). Potassium blood cardioplegia was administered every 20 min in group A (n=6), and lidocaine-magnesium blood cardioplegia in group B (n=7). We compared the ratio of Emax obtained during IVC occlusion at pre- and post-global ischemia (%Emax) and LVSW (%LVSV). Cardiac function was evaluated prior to CPB and 60 min after reperfusion. There was no difference in time required for cardiac arrest between the two groups (group A: 78+/-3 s, group B: 89+/-9 s). Percentage maximal elastance was significantly better in group B (group A: 63+/-3%, group B: 76+/-4%, P<0.05). Percentage tissue water content of the myocardium after CPB was significantly lower in group B (group A: 82.3+/-4%, group B: 75.5+/-2%, P<0.05). Lidocaine-magnesium blood cardioplegia was equivalent to potassium blood cardioplegia in systolic left ventricular function and reduced myocardial edema in canine heart.

Skeletonized Radial Artery Graft Prepared With Phosphodiesterase-III Inhibitors Indicates Favorable Results Compared With Pedicled Radial Artery Graft in Angiographic Studies.

OBJECTIVES: : The technique used to harvest the radial artery was modified, with improved results. Skeletonized radial artery conduits prepared with phosphodiesterase-III inhibitor were compared with pedicled conduits by angiography. METHODS: : Isolated coronary artery bypass graft surgery that used the radial artery for conduits was performed on 83 consecutive occasions from March 2003 to February 2004. The mean age of the patients was 68 ± 7 years; 65% were male. The radial arteries were harvested randomly for skeletonized (group SPD and group SPa) or pedicled (group PPD). A phosphodiesterase-III inhibitor, olprinone hydrochloride, was used as an antispastic agent during harvesting of the radial artery for both in groups SPD and PPD. Papaverine was used in group SPa. Postoperative angiograms were performed within 1 month. Diameters of the radial artery were scaled at proximal, mid, and distal sections and averaged. Optical stenosis was measured as a percent stenosis value. RESULTS: : There were no significant differences among groups SPD, SPa, and PPD in morbidity or mortality rates. Graft patency rates were 97.4% in group SPD, 98.6% in group SPa, and 95.4% in group PPD (P = 0.67). Diameters of the radial artery conduits were significantly wider in group SPD compared with group PPD (P < 0.001). Spasm and stenosis were less frequent in group PPD (P < 0.05). CONCLUSIONS: : Skeletonized radial artery grafting prepared with a phosphodiesterase-III inhibitor indicated favorable results in angiographic studies.

Rapid formation of the left ventricular pseudoaneurysm after sutureless repair of a subacute left ventricular free wall rupture.

OBJECTIVE: We report a rare, rapid, huge formation of the left ventricular pseudoaneurysm after sutureless repair with GRF glue. METHODS: The case was a 70-year-old male, who received an emergency operation for a subacute left ventricular free wall rupture (LVFWR) complicated by acute myocardial infarction. At that time the left ventricle was wrapped with equine pericardium by using gelatin resorcin formaldehyde (GRF) glue (sutureless repair). The patient had been stable for 13 months but suffered acute heart failure. The left ventricular angiogram (LVG) revealed a huge left ventricular aneurysm and 75% stenosis in the middle segment of the left anterior descending artery (LAD). He had received the LVG one month before. There was a small concavity in the inferior wall of the left ventricle. A huge pseudoaneurysm had formed within one month. RESULTS: A left ventricle direct patch closure, and coronary artery bypass were performed. In the pathological findings, the wall of the aneurysm was almost elastic collagen tissue. CONCLUSIONS: Sutureless repair is an effective technique for subacute left ventricular free wall rupture, a left ventricular pseudoaneurysm has to be cared for the late period.