Hajime Kin

Hippocampal neuronal death following deep hypothermic circulatory arrest in dogs: involvement of apoptosis.

This study was undertaken to evaluate the histological nature of brain damage caused by deep hypothermic circulatory arrest during cardiopulmonary bypass. Total body cooling to 15 degrees C and rewarming were performed with a conventional cardiopulmonary bypass technique using the femoral artery and vein. Dogs were assigned to one of three groups. In group 1 (n = 4), cardiopulmonary bypass was maintained in a state of deep hypothermia (15 degrees C) for 90 min, group 2 animals (n = 5) underwent 60 min of deep hypothermic circulatory arrest at 15 degrees C, and group 3 (n = 6) underwent 90 min of deep hypothermic circulatory arrest at 15 degrees C. All dogs were killed by perfusion fixation 72 h after cardiopulmonary bypass. The CA1 regions of the hippocampi were examined by light and electron microscopy. Biotinylated dUTP was used for nick-end labeling of apoptotic cells mediated by terminal deoxytransferase. No morphological change was observed in group 1 dogs, and very little in group 2 dogs. More severe neuronal damage was observed in group 3. The nuclei of many cells were shrunken and showed nick-end labeling. Dense chromatin masses were detected electron microscopically in the nuclei of CA1 pyramidal cells. Neuronal cell death observed in CA1 pyramidal cells 72 h after 90 min of deep hypothermic circulatory arrest at 15 degrees C involves apoptosis. Therefore, according to this model, the maximum duration of deep hypothermic circulatory arrest should not be allowed to exceed 60 min.

Coagulopathy associated with residual dissection after surgical treatment of type A aortic dissection

PURPOSE This study was performed to evaluate the effects of a residual dissection on coagulation, fibrinolysis, and platelet function after surgical treatment of acute type A aortic dissection. METHODS Between 1987 and 1995, 48 consecutive patients underwent emergency surgery for acute type A aortic dissection. Thirty-five of 41 survivors were followed-up for periods ranging from 6 to 112 months (median, 30.3 months). These survivors were classified into three groups by computed tomographic scanning and angiography. Fifteen patients had no residual dissection (group I). Of the 20 patients who had residual dissection, nine had an enlarged aorta greater than 45 mm in maximal diameter (group II), and 11 had an aorta less than 45 mm in maximal diameter (group III). For all patients, blood samples were collected for coagulation, fibrinolysis, and platelet function studies on the same day that the computed tomographic scanning had been performed. RESULTS beta-thromboglobulin, thrombin-antithrombin III complex, D-dimer, and alpha 2 plasmin inhibitor-plasmin complex concentrations were significantly higher in group II than in the other two groups. Strong correlations between the maximal diameter of the dissected aorta and beta-thromboglobulin, thrombin-antithrombin III complex, D-dimer, and plasmin inhibitor-plasmin complex concentrations were evident. In contrast, correlations between the length of the dissected aorta and coagulation/fibrinolysis measurements were weak. CONCLUSIONS Our findings suggest that the coagulopathy worsened in proportion to the degree of dilatation of the dissected aorta.

Aortic valve repair in dominant aortic regurgitation.

OBJECTIVE We studied immediate and mid-term results after aortic valve repair. METHODS Immediate and mid-term results were studied in 63 patients undergoing aortic valve repair, calculating survival and reoperation free rates. RESULTS Subjects were 49 men and 14 women aged 15 to 76 years (mean: 53 +/- 17 years). Mean preoperative aortic regurgitation grading of 1 to 4 was 3.2 +/- 0.7. Mean preoperative New York Heart Association functional class was 1.9 +/- 0.8. Two in-hospital deaths occurred. (3.2%) Mean aortic regurgitation grade at discharge was 1.3 +/- 0.8 (p < 0.0001; vs preoperative grade) and functional class was 1.1 +/- 0.2 (p < 0.0001; vs preoperative class),--significantly improved. Overall follow-up was 98.4%, and mean follow-up continued 41.4 +/- 22.1 months. Mean functional class at follow-up was 1.2 +/- 0.4 (n = 49), improved from preoperative class (p < 0.0001). Mean aortic regurgitation grading at follow-up was 1.8 +/- 0.8 (n = 41), improved from preoperative grading (p < 0.0001). Five-year survival was 95.1 +/- 2.8%. One-year reoperation freedom was 96.6 +/- 2.4% and 5-year 77.9 +/- 6.9%. CONCLUSIONS Survival after surgery was good, while reoperation was comparable to other reports but less satisfactory compared to reoperation freedom after aortic valve replacement. Based on reoperative findings, a change in indication was made. We believe technical refinements could improve postoperative results.

Management of infectious endocarditis with mycotic aneurysm evaluated by brain magnetic resonance imaging

OBJECTIVES Cerebral complications of infective endocarditis (IE) [particularly, mycotic aneurysm, visualized as a hypointense spot on T2*-weighted brain magnetic resonance imaging (MRI)] are associated with a high incidence of postoperative cerebral or subarachnoid hemorrhage. We have adopted a policy of performing elective open heart surgery after performing a MRI enhanced by gadolinium in such patients whenever possible after improvement in inflammatory findings around a cerebral aneurysm. METHODS Fifty-six patients (35 men and 21 women, mean age 56 years) diagnosed with active-phase IE between January 2000 and December 2010 were analysed retrospectively. RESULTS Six patients who had not undergone MRI were excluded. The remaining patients were classified into four groups according to preoperative brain MRI findings-Group A (n = 13): cerebral haemorrhage, cerebral infarction, abscess and encephalitis; Group B (n = 7): simple or multiple black dots ( = hypointensive spots) with cerebral haemorrhage or cerebral infarction; Group C (n = 15): simple or multiple black dots alone; Group D (n = 15): no abnormal MRI findings. None of the 12 patients who successfully underwent elective surgery in Groups B and C developed postoperative cerebral complications. CONCLUSIONS Brain MRI is an important tool for the detection of asymptomatic intracranial abnormalities associated with IE and evaluation of the preoperative bleeding risk of patients. Patients with contrast enhancement around black dots are at high risk for bleeding, and performing open heart surgery in such patients whenever possible after the improvement of inflammatory findings reduces the potential risk of cerebral haemorrhage.

Perioperative Serum Procalcitonin Concentrations in Patients with Acute Aortic Dissection

We investigated the perioperative serum procalcitonin (PCT) concentrations in 5 consecutive patients who underwent surgery for acute aortic dissection (2 men, 3 women; mean age 72 ± 9 years, age range 52–81 years). Surgery used cardiopulmonary bypass with deep hypothermic circulatory arrest. Blood samples were taken prior to surgery, upon arrival in the intensive care unit, and 6, 12, 18, 24, and 48 h after intensive care unit arrival. Prior to surgery, the PCT level was 4.2 ± 3.4 (range 0.8–8.3) ng/ml. The PCT increase was greatest at 24 h (5.8 ± 4.5 ng/ml). Preoperatively, the C-reactive protein concentration was 8.0 ± 8.3 (range 0.9–23.8) mg/dl, and the white blood cell count was 8.5 ± 3.1 × 103. C-reactive protein continued to increase at 48 h, while the white blood cell count peaked at 24 h. In spite of no symptoms of infectious diseases or septicemia, all patients had a significant preoperative PCT elevation. This finding may have something to do with the specific preoperative condition of acute aortic dissection. However, more clinical investigation is needed to clarify the PCT changes during and after surgery for acute aortic dissection.

Cardiac Metastatic Liposarcoma

Metastatic cardiac liposarcoma is extremely rare, with only 2 cases previously reported, to our knowledge; of those, only 5 involved surgical resection of right ventricular liposarcoma. The first such case in Japan involved a 61-year-old woman with metastatic liposarcoma of the right ventricle. Despite emergency resection, the patient died of severe congestive heart failure 6 days after operation. Her history included surgery for liposarcoma in the right knee 11 years previously, although it is very difficult to predict that metastasis would proceed thereafter to the cardiac cavity. This rare case suggests, however, that follow-up including examination for cardiac lesions is necessary long after resection of the primary lesion.

A systematic approach to improve the outcomes of type A aortic dissection

Objectives: The aims of this study are to evaluate the outcomes and trends of contemporary emergency surgery for acute type A aortic dissection on the basis of a systematic approach and to assess the impact of temporary aortic crossclamping during systemic cooling on early and late outcomes. Methods: We retrospectively reviewed 702 consecutive patients who underwent emergency surgery for acute type A aortic dissection between March 2004 and May 2015. Our clinical protocol includes rapid transfer to the operating room, quick establishment of cardiopulmonary bypass, temporary aortic crossclamping during cooling, primary entry resection, and open distal anastomosis. We analyzed the perioperative data, survival, freedom from aortic reinterventions, and impact of aortic crossclamping on early and late outcomes. Results: The median time from hospital arrival to cardiopulmonary bypass establishment was 115 minutes and has decreased over the last decade (trend test P < .001). We perfused the femoral artery in 615 patients (87.6%), placed aortic crossclamping in 616 patients (87.7%), and performed open distal anastomosis in all patients. The operative mortality was 5.4% (38/702), and the incidence of stroke was 10.8% (76/702). The 7‐year overall survival and freedom from aortic reinterventions were 80.4% and 87.5%, respectively. Compared with the nonclamping group, the crossclamping group had a shorter operation time, similar operative mortality, incidence of stroke, and freedom from aortic reinterventions. Conclusions: Emergency surgery for acute type A aortic dissection based on our systematic approach demonstrated excellent early and late outcomes. The temporary aortic crossclamping during cooling decreased the operation time without increasing early and late adverse events.

Successful valve repair in traumatic aortic valve regurgitation

Case 1 was a 20-year-old male who had been involved in a traffic accident and developed aortic regurgitation (AR) eight months later. He was admitted with dilatation of the left ventricle. Transesophageal echocardiography (TEE) showed severe AR with perforation of the right coronary cusp. Case 2 was a 50-year-old male who had fallen from a height four months previously, and was admitted with congestive heart failure due to severe AR. TEE showed severe AR due to rupture of the right coronary cusp. In the former patient, valve repair was performed with a patch of autologous pericardium. In the latter patient, cusp reconstruction was performed with autologous pericardium and the commissural plication technique, achieving successful aortic valve repair.

Critical potential of early cardiac surgery for infective endocarditis with cardio-embolic strokes

BACKGROUND Early cardiac surgery may have a trade-off between stabilized hemodynamics with controlled infection and a risk of peri-operative death in patients with infective endocarditis (IE) complicated with cardio-embolic strokes. METHODS We retrospectively studied clinical characteristics and outcomes in 68 consecutive patients with IE (mean age, 58±3years, 62% male) who admitted in our institute during June 2013 and August 2015. RESULTS Cardio-embolic strokes were noted in 37% of patients (n=25) with IE and overall in-hospital mortality was 4 times higher in IE with cardio-embolic strokes than IE with an absence of strokes (n=43) (20% vs. 4.7%, p=0.045). Bacteremia of Staphylococcus aureus (p=0.021) and a complication of cardio-embolic strokes (p=0.031) were independently associated with in-hospital death in those with IE. However, in-hospital mortality was quite low in 19 with early cardiac surgery compared with 6 with conventional treatment in those with cardio-embolic strokes (11% vs. 50%, p=0.035). Multivariate logistic analysis demonstrated that lack of early cardiac surgery (p=0.014), a complication of cerebral hemorrhage (p=0.002), and a presence of refractory heart failure (p=0.047) were independently associated with in-hospital death in those with IE complicated with cardio-embolic strokes. CONCLUSION Early cardiac surgery may provide clinical advantages overcoming peri-operative risks in those with IE complicated with cardio-embolic strokes.

Aortic translocation using the hemi-mustard procedure for corrected transposition.

The management of congenitally corrected transposition of the great arteries and associated lesions is frequently challenging. Restrictive ventricular septal defect and mild pulmonary stenosis are contraindications to the double switch procedure, including the atrial-Rastelli switch procedure, due to the production of postoperative left ventricular outflow tract obstruction. We describe a case of aortic translocation using the hemi-Mustard procedure after left ventricular training in order to prevent postoperative left ventricular outflow obstruction.