Ayumu Masuoka

Importance of luxury flow for critically ill patients receiving a left ventricular assist system

The presence of a significant organ dysfunction does not immediately exclude patients from consideration for treatment with a left ventricular assist system (LVAS). However, in treating morbid circulatory shock patients with multiple organ failure, it is important to know the preoperative and postoperative factor or factors related to the recovery of the damaged organ function. In this study, we retrospectively analyzed patients receiving a LVAS at our institution and tried to determine the important factors related to the survival of patients with multisystem failure. Twenty-seven patients who underwent LVAS placement at Saitama Medical School Hospital between 1993 and 2003 were included in this study. The preoperative risk factors analyzed were renal dysfunction, respiratory dysfunction, hepatic dysfunction, the existence of active infection, and the combination of all four factors. As a postoperative factor, the pump flow index (mean LVAS pump flow during the first 2 weeks after LVAS surgery divided by the body surface area) was analyzed. None of the analyzed preoperative factors could predict survival after LVAS surgery, but a pump flow index of less than 2.5 l/min/m2 had a significant relationship with death after LVAS surgery. Further analysis revealed that all the patients with a pump flow index of 3.0 l/min/m2 or more could overcome preoperative organ dysfunction. Congestive heart failure patients with multisystem failure need luxury pump flow for successful LVAS surgery; this factor could be especially important in device selection and postoperative management.

Influence of Bidirectional Cavopulmonary Anastomosis and Concomitant Valve Repair on Atrioventricular Valve Annulus and Function

BACKGROUND The relationship between atrioventricular valve regurgitation (AVVR) and valve annulus after bidirectional cavopulmonary anastomosis (BCPA) and adequate indications for valve repair are unclear. METHODS We evaluated the size of the valve annulus and the grade of AVVR before and immediately after BCPA, and at the most recent follow-up before the Fontan operation in 37 patients with a functional single ventricle. RESULTS Nine patients underwent concomitant valve surgery. The mean z value of the valve annulus was significantly lower postoperatively than preoperatively in the 28 patients who were not treated by valve surgery (0.45 vs 1.51, p=0.01). However, mean regurgitation scores did not significantly change after BCPA (1.60 vs 1.78, p=0.08). The most recent assessment showed that the mean z value increased compared with that immediately after BCPA (1.36 vs 0.45, p=0.005). This increase was significant in the patients with moderate regurgitation. The mean z value of the valve annulus of the patients treated by concomitant valvuloplasty was significantly lower postoperatively than preoperatively (-0.25 vs 3.9, p=0.0001) and remained low at the latest evaluation. Mean regurgitation scores also significantly decreased after BCPA (2.25 vs 3.37, p=0.007). CONCLUSIONS Unloading the systemic ventricle by BCPA leads to a decrease in the relative size of the atrioventricular valve. However, this decrease does not improve the degree of AVVR in the absence of concomitant valve repair. Concomitant valve repair is justified in patients with moderate or worse AVVR and an abnormal valve structure.

Fifteen-month circulatory support for sustained ventricular fibrillation by left ventricular assist device

1. Pennington DG, McBride LR, Peigh PS, Miller LW, Swartz MT. Eight years’ experience with bridging to cardiac transplantation. J Thorac Cardiovasc Surg. 1994;107:472-81. 2. Peterze B, Lonn U, Jansson K, Rutberg H, Casimir-Ahn H, Nylander E. Long-term follow-up of patients treated with an implantable left ventricular assist device as an extended bridge to heart transplantation. J Heart Lung Transplant. 2002;21:604-7. 3. Bank AJ, Mir SH, Nguyen DQ, Bolman RM 3rd, Shumway SJ, Miller LW, et al. Effects of left ventricular assist devices on outcomes in patients undergoing heart transplantation. Ann Thorac Surg. 2000;69: 1369-75. 4. Sun BC, Catanese KA, Spanier TB, Flannery MR, Gardocki MT, Marcus LS, et al. 100 long-term implantable left ventricular assist devices: the Columbia Presbyterian interim experience. Ann Thorac Surg. 1999;68:688-94. 5. Massad MG, McCarthy PM, Smedira NG, Cook DJ, Ratliff NB, Goormastic M, et al. Does successful bridging with the implantable left ventricular assist device affect cardiac transplantation outcome? J Thorac Cardiovasc Surg. 1996;112:1275-83.

Lethal thrombus in the carotid artery during operation for acute aortic dissection with cerebral malperfusion.

A drowsy patient with acute type A aortic dissection and cerebral malperfusion required emergency operation. Because the right carotid artery was totally obstructed, cerebral perfusion was first restored by cannulating it and the left femoral artery before midline sternotomy. However, a long fresh thrombus was found flowing backward from the obstructed carotid artery. This thrombus was removed, and both arteries were connected through a Y-shaped extracorporeal circulation circuit to reperfuse the brain. During the subsequent aortic procedure, both arteries were used for arterial inflow. Such thrombi can cause grave postoperative neurologic dysfunction. Carotid artery cannulation is mandatory in such cases.

Hybrid Palliation for Interrupted Aortic Arch With Small Aortic Valve

Objectives: Open heart surgery for interrupted aortic arch in the neonatal period is still a high-risk procedure related in part to patient factors such as low birth weight, other morphologic anomalies, and, especially, small aortic valve size. Recently, we performed hybrid palliation with bilateral pulmonary artery banding and ductal stenting as the first-stage palliation for such cases. In this study, the outcomes of this procedure were examined. Methods: Six cases of interrupted aortic arch with a small aortic valve underwent the hybrid procedure in the neonatal period in our institute from 2010 to 2015 (mean age: 6.8 days, mean body weight: 3.2 kg, mean z score of the aortic valve annulus: −8.3). Their postoperative clinical courses and results of the second-stage surgery were evaluated. Results: No mortality or severe morbidity was seen in association with initial hybrid palliation. Five of six patients were discharged from the hospital; the one exception had a significant urinary tract anomaly. None needed an additional catheter intervention or surgical procedure postoperatively. All surviving patients underwent second-stage surgery; three had biventricular repair by the conventional method or Damus-Kaye-Stansel anastomosis with the Rastelli procedure and the other three proceeded toward staged Fontan reconstruction. Growth of the aortic valve was seen in four patients, and increased indexed left ventricle volume was recognized in one after the palliation. Conclusion: Hybrid palliation could be useful not only to avoid high-risk neonatal surgery but also to allow for eventual selection of the second-stage surgery based on the observations of potential interval development of left ventricular structures.

A case of ventricular septal defect and mitral insufficiency after blunt trauma

Few reports have described traumatic heart injury in children. We describe a case of acute mitral regurgitation associated with papillary muscle rupture, traumatic ventricular septal defect, and impending left ventricular free wall rupture due to blunt trauma in a 2-year-old girl. The papillary muscle was sutured to the left ventricular free wall. The septal defect and surrounding ruptured muscle were covered with a pericardial patch, and a Hemashield patch was used to close the ventriculotomy. A residual defect caused by dehiscence of the pericardial patch necessitated reoperation 10 months later. The patient is currently being observed on an outpatient basis.

Cardiopulmonary Bypass through a Left Thoracotomy Using Venous Drainage from the Innominate Vein in Congenital Heart Surgery

Cardiopulmonary bypass (CPB) through a left lateral thoracotomy is a useful approach for some congenital heart procedures, although vascular access for the arterial and venous cannulation can be challenging in the selective patients. Six patients underwent successful extracorporeal circulation through a left lateral thoracotomy using the innominate vein for venous drainage. No operative deaths or major complications occurred. Venous drainage solely from the innominate vein was adequate to establish partial bypass without the need for pericardiotomy. Total bypass was established with combined venous drainage from the innominate vein and the main pulmonary artery. Exposure of the systemic atrioventricular valve was excellent through a left thoracotomy. Venous drainage from the innominate vein without using atrial drainage can safely be used for extracorporeal circulation through a left lateral thoracotomy without compromising the procedure and it is a useful approach to congenital heart surgery in selected patients. doi: 10.1111/jocs.12165 (J Card Surg 2013;28:591–594)

De Novo Migraine With Aura After Surgical Repair of Aortic Coarctation

Coarctation of the aorta (CoA) is reported to be associated with an increased risk for migraine. We describe here the case of a 13‐year‐old female patient who presented migraine with aura after surgical repair of CoA with a stent. As possible reasons for her condition, we postulate host responses to stent placement and/or disturbed cerebral autoregulation related to intracranial hypertension before the surgical repair and hypotension afterward, leading to hypoperfusion. This case demonstrates that de novo migraine with aura can occur after surgical repair of CoA and should be recognized as a potential complication.

A rare case of pediatric primary cardiac tumor in a patient with Down syndrome

Although hematological malignancies are a known complication of Down syndrome, few reports have described cases involving solid tumors. We describe the case of a 3-year-old Down syndrome girl with a primary solid cardiac tumor. Outpatient echocardiography after intracardiac repair of a ventricular septal defect at 6 months of age revealed a highly mobile pedunculated mass (8 × 9 mm) on the free wall of the right atrium. Due to potential incarceration of the mass in the tricuspid orifice, it was excised under extracorporeal circulation and cardiac arrest. Macroscopically, the tumor closely resembled a papillary fibroelastoma, although histopathological tests were inconclusive.

Giant epicardial cyst presenting as acute cardiac tamponade in a 2-year-old boy

Cystic structures within the pericardial cavity are rare. They are divided into epicardial and pericardial variants. Pericardial and epicardial cysts rarely cause symptoms. This report describes a case of epicardial cyst with acute cardiac tamponade in a 2-year-old boy with no previous cardiac history who was transferred to our hospital because of hemodynamic instability. Emergency drainage of the pericardial effusion and complete excision of the cyst were performed through a median full sternotomy.