Hajime Sakurai

Predictors affecting durability of epicardial pacemaker leads in pediatric patients.

OBJECTIVES Despite pacemaker therapy in children and adolescents favoring an initial epicardial approach, predictors of lead failure have not been well clarified. The aim of this study was to assess the long-term outcomes and to determine predictors affecting lead durability in pediatric pacing therapy. METHODS We reviewed the outcomes of 109 consecutive pacing leads implanted in 55 patients (median age, 5.2 years; range, 31 days-15.8 years), including 38 atrial and 71 ventricular leads. They consisted of 58 (53%) fishhooks, 37 (34%) screw-in leads, and 14 (13%) steroid-eluting suture-on leads. Seventy (64%) were implanted in patients with structural heart disease. RESULTS The leads were followed for a median of 6.4 years (range, 3 days-22.9 years). Lead failure occurred in 29 leads (27%; median of 8.4 years after implantation). Exit block or elevation of pacing threshold was the most common cause (n = 18), but failures did not directly cause patient death. The overall 1-, 5-, 10-, and 15-year lead survivals were 100%, 89.0%, 72.5%, and 55.5%, respectively. Multivariate Cox analysis revealed concurrent structural heart disease (relative risk, 2.85; 95% confidence interval, 1.27-6.42; P = .011) to be the only significant predictor of lead failure. CONCLUSIONS Epicardial leads provide a reliable technique for managing rhythmic disturbance problems in the pediatric population. The only significant predictor of lead failure is the presence of structural heart disease.

Cardiovascular surgery in patients on chronic dialysis: effect of intraoperative hemodialysis

To evaluate the operative result and the perioperative management of dialysis patients undergoing elective cardiac surgery, we retrospectively reviewed consecutive adult patients with chronic renal failure dependent on maintenance dialysis. Between April 1994 and March 2002, 20 patients who underwent cardiopulmonary bypass (CPB) procedures were studied. Fourteen patients underwent isolated coronary artery bypass grafting, four valve replacements and two combined procedures. Our strategy for the chronic dialysis patients was as follows: dialysis the day before the operation, intraoperative hemodialysis (HD) during CPB, and no dialysis or hemofiltration (HF) on the operative day. Intraoperative HD produces the optimal fluid and electrolyte balance at the end of the operation. The mean interval between the end of surgery and the commencement of HD was 31.2+/-12.5 h. No patients required any hemocatharsis such as HF or HD on the day of operation. The overall operative mortality was 5.0%. There were six late deaths (30.0%). Overall, including the operative and non-cardiac death, actuarial survival rate was 85.0% at 1 year, 70.0% at 5 years, and 65.0% at 6 years. Intraoperative HD has an advantage in the postoperative period; it avoids the hemodynamic instability and the risk of heparin-associated bleeding associated with the use of HD.

Surgical outcome of Fontan conversion and arrhythmia surgery: Need a pacemaker?

Background Atrial tachyarrhythmias are frequent complications in the late period after the Fontan procedure, and important risk factors for a poor prognosis. The impact of Fontan conversion and arrhythmia surgery in failed Fontan patients has been described in many reports. Objective We evaluated our experience with Fontan conversion procedures, concomitant arrhythmia surgery, and pacemaker implantation. Methods We reviewed the hospital records of 25 consecutive patients who underwent a Fontan conversion procedure from January 2004 to March 2012. Twenty-four patients had arrhythmia surgery using cryoablation and radiofrequency ablation at the time of conversion. A bilateral atrial maze procedure was performed in 6 patients, right-side maze in 15, and isthmus block in 3. Three patients with a diagnosis of corrected transposition of the great arteries underwent simultaneous pacemaker implantation electively. Results There was no early death and one late death during a mean follow-up period of 21.2 months. Three tachyarrhythmia recurrences developed, and there were 4 occurrences of sinus bradycardia. Five of these patients required postoperative pacemaker implantation. Conclusion The mid-term results of Fontan conversion and arrhythmia surgery in our institute were satisfactory. The occurrence of unexpected postoperative pacemaker requirement was high in the patients who underwent a right atrial or bilateral atrial maze procedure. Pacemaker or lead implantation is recommended for patients planned to undergo a right-side or full maze procedure.

Unruptured Left Coronary Sinus of Valsalva Aneurysm Causing Mitral Valve Obstruction

A 77-year-old man was admitted for congestive heart failure. He had started to have palpitations after eating supper 2 days before the admission and had experienced dyspnea on exertion since then. He visited his family physician, who referred him to the cardiology clinic of our hospital. The patient was under the family physicians care for diabetes mellitus, hypertension, and paroxysmal atrial fibrillation. He had never been diagnosed as having any organic heart disease. He was an ex-smoker and drank alcohol on social occasions. The patient was on β-blockers and Coumadin. His cardiovascular physical examination was significant for a 3/6 systolic murmur and a rapid, irregular heart beat. His ECG showed atrial fibrillation with a ventricular rate of 150 bpm. His portable chest x-ray (Figure 1A) showed bilateral pleural effusion and pulmonary edema. An emergency transthoracic echocardiogram showed normal left and right ventricular function. A large mass in the left atrium was seen that was causing functional mitral stenosis. The patient was admitted to the hospital, given digoxin, and started on intravenous diuresis. His ECG on normal sinus rhythm (Figure 1B), which was …

Right Heart Failure Secondary to Compression of the Right Pulmonary Artery by a Large Proximal Aortic Aneurysm

A 73-year-old woman, who was known to have a large proximal aortic aneurysm, was referred from the Gastroenterology Department for reevaluation for possible aortic surgery. At that time, she complained of fatigue and shortness of breath, which corresponded to New York Heart Association class III symptoms. The patient had initially consulted us 1 year before this presentation. She had been diagnosed recently as having gastric cancer at that time, and additional tests revealed that she also had a proximal aortic aneurysm. Although the aneurysm was large, with a maximum diameter of 67 mm, her gastric cancer, classified as being in stage 4, was considered inoperable. The gastroenterologist estimated that she could probably live for ≈1 year. We discussed the options with the patient, and she rationally decided not to undergo aortic surgery at that time. She did not have any cardiac-related symptoms at that time. A chest radiograph showed a right-sided bulge of the mediastinum (Figure 1). Figure 1. A , A chest radiograph taken at the patient’s first visit …

Aortocarotid bypass at the time of central aortic repair for type A acute aortic dissections

retractor (Rultract, Cleveland, Ohio) is secured to the head of the operating table and used to retract the left costal margin cephalad. The abdomen and preperitoneal pump pocket are entered. Dissection is conducted to mobilize the outflow graft screw and the inflow segment screw, displacing these downward into the abdomen, thus enabling detachment of the body of the pump for replacement (Figure 1). Before attempting replacement of the pump, CPB is established and the ascending aorta is vented as described above. Next,

[Two staged Starnes operation for Ebstein's anomaly with pulmonary atresia in early infancy--a report of a successful case].

Severe tricuspid valve regurgitation and decreased pulmonary blood flow in neonatal Ebsteins anomaly with pulmonary atresia, may result in cardiac respiratory failure and hypoxemia. The poor natural course and lack of standard surgical treatment make treatment for neonatal Ebsteins anomaly very difficult. The Blalock-Taussig operation was performed for hypoxemia in Ebsteins anomaly associated with pulmonary atresia and severe tricuspid regurgitation on 36th day after birth. On the 63rd day after birth, tricuspid valve orifice closure and right atrium plication (Starnes procedure) were accomplished under cardiopulmonary bypass. Heart failure became controllable and the patient condition was satisfactory at one year after surgery.

Aortic to right ventricular shunt for pulmonary atresia with intact ventricular septum and bilateral coronary ostial atresia

From the Departments of Cardiovascular Surgery and Pediatric Cardiology, Japan Community Healthcare Organization Chukyo Hospital, Nagoya, Japan. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Jan 8, 2018; revisions received Feb 20, 2018; accepted for publication March 7, 2018; available ahead of print April 5, 2018. Address for reprints: Hajime Sakurai, MD, 1-1-10 Sanjo, Minami-ku, Nagoya 457-8510, Japan (E-mail: hsaku391@gmail.com). J Thorac Cardiovasc Surg 2018;156:e17-20 0022-5223/

Dilated cardiomyopathy associated with elephant trunk in Loeys–Dietz syndrome

36.00 Copyright 2018 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2018.03.047

Surgical Repair of Aortic Regurgitation With Left Ventricular Aneurysm Diagnosed Preoperatively as Aortico-Left Ventricular Tunnel

A 14-year-old boy presented to our institution with a diagnosis of acute type A dissection. He was diagnosed with Loeys-Dietz syndrome and underwent aortic valve sparing repair at the age of 9 years. Emergency total arch repair with elephant trunk (ET) was performed successfully; echocardiogram before discharge showed normal left ventricular function and size. However, he was readmitted 1 month after discharge with significant left ventricular dysfunction and dilatation. The small folded ET caused a pressure gradient between the upper and lower body, which might deteriorate left ventricular function. Urgent balloon arterioplasty was performed to unfold the ET graft, resulting in no improvement of left ventricular function. ET removal and descending aorta replacement with an 18-mm graft was performed eventually. Left ventricular function and brain natriuretic peptide gradually improved after approximately 2 years of follow-up.