Hideki Sasaki

Delayed Presentation of Injury to the Sinus of Valsalva with Aortic Regurgitation Resulting from Penetrating Cardiac Wounds

Abstract A 39‐year‐old man had attempted to commit suicide using a small knife to penetrate the anterior chest wall. An emergency operation was performed successfully to repair the penetrating cardiac injury of the right ventricular outflow tract without using cardiopulmonary bypass. Two years after the operation, he was complained of dyspnea and a continuous murmur was detected. Echocardiography and cardiac catheterization revealed aorto‐right ventricular fistula in the sinus of valsalva with aortic regurgitation. In operation, the healed laceration of the right coronary cusp and the fistula between aorta and right ventricle were identified. The fistula was closed using a Dacron patch and the aortic valve was replaced with a mechanical valve. Long‐term follow‐up of penetrating thoracic injuries is important for detecting underlying intracardiac lesions. (J Card Surg 2003;18:236‐239)

Chordal-sparing mitral valve replacement: pitfalls and techniques to prevent complications

When feasible, mitral valve repair is the usual treatment of choice for correction of chronic mitral insufficiency. When valve replacement is required, chordal sparing is the preferred technique. Many investigators have pointed out the merits of preserving the subvalvular apparatus during mitral valve replacement. However, many surgeons hesitate to perform chordal-sparing mitral valve replacement because of its technical complexity and potential interference with mechanical valve leaflet motion. We present a modified technique of chordal-sparing mitral valve replacement to avoid these problems.

Bridge to Heart Transplantation with Left Ventricular Assist Device Versus Inotropic Agents in Status 1 Patients

Abstract  Objective: Left ventricular assist devices (LVADs) are commonly used for critically ill patients awaiting heart transplantation, although their effect on long‐term outcomes, relative to inotropic support alone, is still debated. Method: Data from Status 1 patients who underwent heart transplantation at our institution between 1990 and 2005 were reviewed (n = 180). They were divided into two groups: those who underwent LVAD implantation as a bridge to transplant (n = 31) and those treated with inotropic agents without the support of LVAD (n = 149). They were compared in terms of demographics and clinical outcome. Results: Both groups were similar in terms of patient and donor demographics. Relative to the inotrope group, the LVAD group did have a longer ischemic time (p = 0.032), a greater incidence of pretransplant transfusion (p < 0.00001), and a greater maximum level of pretransplant panel reactive antibodies (p < 0.001). Creatinine at listing significantly improved in LVAD patients awaiting transplantation (p < 0.0001). Comparisons of 5‐year survival in addition to freedom from posttransplant infection, malignancy, revascularization, and acute rejection did not show significant difference between the two groups. The LVAD group did benefit from increased freedom from chronic rejection compared to the inotrope group (p = 0.049). Stepwise Cox Regression did not identify any independent factors affecting patient survival during the first 5 years after transplant. Conclusions: Status 1 patients successfully bridged to heart transplantation with LVADs had similar long‐term clinical outcomes compared to those treated with inotropic agents.

Hypothermic extracorporeal circulation in immature swine: a comparison of continuous cardiopulmonary bypass, selective antegrade cerebral perfusion and circulatory arrest.

OBJECTIVE Selective antegrade cerebral perfusion (SCP) has been widely used during complex congenital heart surgery and theoretically affords some degree of neuroprotection. There are limited data to support this claim, however. This study was designed to compare, at profound hypothermia, continuous cardiopulmonary bypass, SCP and circulatory arrest in a survival model of extracorporeal circulation in immature swine. METHODS Fifteen piglets (5.9+/-1.1 kg) were placed on cardiopulmonary bypass (CPB), cooled to a rectal temperature of 15 degrees C and subjected to 90 min of hypothermic circulatory arrest (HCA), selective cerebral perfusion (30 ml kg(-1)min(-1)) (SCP) or systemic full-flow perfusion (FF; 100 ml kg(-1)min(-1)). Piglets were weaned from CPB and extubated. Daily neurologic assessments were performed for 5 days using neurologic deficit scoring (NDS) and overall performance categories (OPC). On postoperative day (POD) 5, all brains were perfusion-fixed and assigned a total histologic score (THS) of neuronal injury by a neuropathologist blinded to the study groups. RESULTS The median POD 1 NDS/OPC was 0 (range 0-115)/1(range 1-2) for FF, 130 (range 0-195)/2 (range 1-3) for HCA and 0 (range 0-30)/1 for SCP. Although there was a trend for the neurologic status in the HCA group to be worse on POD 1, this did not achieve significance, and both NDS and OPC scores for HCA animals normalised by POD 5. Median THS was 9 (range, 0-11) for FF, 12 (range, 4-14) for HCA and 9 (range, 0-11) for SCP with no statistically significant difference between the groups. CONCLUSIONS In this survival model of hypothermic extracorporeal circulatory support in immature swine, histologic brain injury was similar in piglets subjected to FF, SCP or HCA. Although the HCA group tended to have worse early neurologic outcome, any difference clearly disappeared by POD 5. These data raise the possibility that profound hypothermia alone during extracorporeal support may produce this observed brain injury. Additional study is required to define the precise aetiology of the brain injury observed in this animal model.

Coronary artery bypass grafting without full sternotomy

Coronary artery bypass grafting is performed without full sternotomy in selected patients because it is less invasive. Left internal thoracic artery-left anterior descending artery bypass (LITA-LAD bypass) via a small left anterior thoracotomy is a well established procedure, which achieves good graft patency with low mortality and morbidity rates. Multiple revascularization is possible with a limited lateral thoracotomy or L-figure approach. Axillary-coronary bypass and right gastroepiploic artery-right coronary artery bypass (RGEA-RCA bypass) are alternative methods, especially for redo surgery, in selected patients.

Mechanical Support for Patients with Fulminant Acute Myocarditis: Strategy for Biventricular Failure and Respiratory Failure

Abstract  Acute fulminant myocarditis can cause left ventricular dysfunction that predisposes the patients to critical condition. Left ventricular assist device (LVAD) is a useful option for the patient whose condition is resistant to medical therapy. However, when right ventricular dysfunction with hypoxia is complicated with left ventricular dysfunction, it can be difficult to make a prompt decision in order to achieve better outcome. We present our case in which the support on LVAD and extracorporeal membrane oxygenation (ECMO) was effective to treat critically ill patients.

A Case of Acute Aortic Dissection with Intimal Tear Found at 1 cm Above Previous Aortotomy

Although it is rare, acute aortic dissection after cardiac surgery predisposes the patients to critical condition such as rupture, tamponade and death. Prompt diagnosis and treatment is mandatory for this fatal complication. We present our case in which acute aortic dissection occurred 7 years after aortic valve replacement.

Momentary and wide aortic regurgitation as an indicator of aortic dissection

A 55-year-old female with a history of hypertension was admitted for dyspnea, epigastralgia and nausea. A chest X-ray showed pulmonary congestion. Transthoracic echocardiography (TTE) revealed severe left ventricular dysfunction with akinesis of the infero-posterior wall and Doppler color-flow mode showed mild aortic regurgitation (AR). Noninvasive positive pressure ventilation, intravenous heparin and diuretics were administered. Follow-up TTE revealed a dissection flap as well as momentary and wide AR only during isovolumetric relaxation. Contrast-enhanced computed tomography of the chest revealed Stanford type A aortic dissection. A momentary and wide AR in echocardiograms might serve as an important and useful indicator of aortic dissection in patients with acute myocardial infarction and congestive heart failure.

Biatrial myxomas with Carney complex.

A 30-year-old man presented with chest pain and was diagnosed with biatrial myxomas and pulmonary embolism. He underwent resection of the biatrial myxomas and tumor embolectomy from the pulmonary artery. The histological diagnosis was multiple cardiac myxomas. Further examination showed that this patient also had spotty pigmentations, cutaneous myxomas, and acromegaly. He was diagnosed with Carney complex.

Subannular ring in Behcet's disease §

complex complicated empyema as reported in the Divisi’s letter). The American College of Chest Physicians (ACCP) has staged patients with pleural empyema according to the risk of a poor outcome into four categories (I—IV) and the American Thoracic Society (ATS) has staged empyema in three steps (I, exudative; II, fibrinopurulent; and III, chronic organization) according to the natural course of the disease: ATS stage III, ACCP category IV, and Light class VII are equivalent, as well as ATS II, ACCP III, and Light IV—VI. According to our experience and as presented in a recently published best-evidence topic, which evaluated 68 articles during the period March 1950—February 2010, the videothoracoscopicapproachoffersequivalent outcomescomparedwith open approach in terms of resolution of disease [3—5]. The most recent articles also highlighted superior outcome for video-assisted thoracoscopic surgery (VATS) in termsof hospital stay, postoperative pain, and postoperative complications. The issue of the stage of empyema should never discourage surgeons from the thoracoscopic approach. The 5.9% overall conversion rate of our series becomes as high as 16.4% when referred to 67 patients in stage III empyema, which signifies advanced stage. Nevertheless, this value that takes into account the overall learning curve of our Institution becomes acceptable to avoid a policy of thoracotomy in all advanced stages. VATS should represent the beginning of every empyema procedure, no matter what the stage, with thoracotomy being the alternative when the minimally invasive approach fails. Furthermore, there is absolutely no greater risk of iatrogenic lung injury during VATS decortication than during thoracotomy. As regards the proposed use of carbon dioxide (CO2) insufflation during thoracoscopy to facilitate decortications, we have no experience even if it can be interesting from a theoretical point of view. Low-flow CO2 insufflation with an intrapleural pressure of 8—10 mmHg should be safe even if some catastrophic complications have been reported.