Hidenori Gohra

RELATIONSHIP BETWEEN RESPIRATORY DISTRESS AND CYTOKINE RESPONSE AFTER CARDIOPULMONARY BYPASS

The influence of cytokines on the inflammatory response in surgery has recently been the subject of investigations. We measured tumor necrotic factorga (TNF-α), interleukin 1β (IL-1β), interleukin 6 (IL-6), interleukin 8 (IL-8), and granulocyte elastase (GEL) in 26 patients undergoing elective cardiac operations using cardiopulmonary bypass (CPB), preoperatively, immediately after CPB, and on postoperative days (PODs) 1, 3, and 6. To evaluate the effect of these cytokines on pulmonary function, the patients were divided according to whether the oxygenation index (OI) on POD I was > 250 or < 250, into groups A and B, respectively. TNF-α and IL-1 β were undetectable and there were no significant differences in the preoperative IL-6, IL-8, and GEL levels. However, immediately following CPB, the mean IL-6, IL-8 and GEL levels in both groups were significantly higher than the preoperative levels (P < 0.01). Moreover, all these levels were significantly higher in group B than in group A, at 162 ± 150 pg/mlvs 64 ± 53 pg/ml (P < 0.05) for IL-6; 53 ± pg/mlvs 22 ± 20 pg/ml (P < 0.01) for IL-8; and 2477 ± 1642 mg/1vs 1397 ± 774 mg/l (P < 0.01) for GEL. The IL-6 levels returned to the preoperative values in both groups on POD 1; however, the GEL levels remained significantly higher in group B than in group A postoperatively, at 616 ± 326 mg/lvs 378 ± 70 mg/l on POD 1, and at 292 ± 70 mg/lvs 218 ± 62 mg/1 on POD 3 (P < 0.05). Thus high levels of cytokines such as IL-6, IL-8, and GEL may be detrimental to respiratory function.

Increased Serum Interleukin-8: Correlation with Poor Prognosis in Patients with Postoperative Multiple Organ Failure

Abstract. This study investigated whether cytokines and colony-stimulating factors can predict prognosis in patients with postoperative multiple organ failure (MOF). We evaluated 14 patients with postoperative MOF who underwent operation for cardiovascular disease. Seven patients recovered from MOF (survivors) and seven did not recover and died (nonsurvivors). The white blood cell (WBC) count, granulocyte colony-stimulating factor, monocytic colony-stimulating factor, interleukin-6 (IL-6), and IL-8 were measured on the day the patients were judged to be in MOF and each week thereafter until the patients recovered or died. Survivors and nonsurvivors were equivalent in terms of age, gender, proportion of use of extracorporeal circulation, operation time, volume of blood transfusion, time from operation to the onset of MOF, the MOF score, proportion of bacteremia, duration of MOF, and number of failed organs. The mean duration of MOF was less than 2 weeks in both groups; therefore the measurements were compared on the first day of MOF and 1 week later. No significant differences between the two groups in terms of WBC counts, colony-stimulating factors, and IL-6 levels were noted. However, the serum level of IL-8 was significantly higher in nonsurvivors than in survivors. Patients with a high serum levels of IL-8 at the time of MOF had a poor prognosis.

The preoperative administration of lentinan ameliorated the impairment of natural killer activity after cardiopulmonary bypass

The aim of this study was to determine whether the preoperative administration of lentinan, which is used clinically to activate T cell function in cancer patients, prevents the impairment of lymphocyte function after cardiopulmonary bypass (CPB). A total of 25 adults undergoing coronary artery bypass grafting were enrolled in this study. Lentinan (2 mg) was given to 10 randomly selected patients 7 d before surgery, while the other 15 patients were considered as a control. The white blood cell count, percentage of lymphocytes, subsets of lymphocytes, and natural killer cell activity were measured preoperatively, immediately after CPB and 1, 3, and 6 d after surgery. The white blood cell counts and the percentage of lymphocytes were not significantly different between the two groups; however, the percentage of CD4-positive cells in the lentinan group recovered to normal more rapidly than in the control group. Although natural killer cell activity was impaired in the control group after CPB, it maintained a nearly normal level in the lentinan group. The preoperative administration of lentinan for patients undergoing CPB ameliorated the impairment of natural killer activity and promoted the rapid recovery of CD4-positive cells.

Evaluation of brain oxygenation during selective cerebral perfusion by near-infrared Spectroscopy

BACKGROUND Although selective cerebral perfusion (SCP) has been used for cerebral protection in aortic arch operations, the appropriate perfusion conditions of SCP are unclear. METHODS We used near-infrared spectroscopy, which evaluates brain ischemia noninvasively and continuously, to determine whether perfusion with SCP (core temperature, 20 degrees C; flow rate, 10 mL.kg-1.min-1) was acceptable in terms of oxyhemoglobin and deoxyhemoglobin in patients having SCP for aortic arch operations (SCP group, n = 6) versus patients having cardiopulmonary bypass (CPB) for coronary artery bypass grafting (CPB group, n = 6). RESULTS There were no significant differences in age (65 +/- 10 versus 63 +/- 12 years), CPB time (199 +/- 67 versus 199 +/- 52 minutes), changes in hematocrit (-12.9% +/- 3.7% versus -12.5% +/- 6.0%), lowest blood pressure (43 +/- 7 versus 45 +/- 10 mm Hg), or highest central venous pressure (8 +/- 2 versus 9 +/- 4 mm Hg) between the SCP and CPB groups. In the SCP group, the maximum decrease in oxyhemoglobin level and the maximum increase in deoxyhemoglobin level were -5.0 to -11.4 mumol/L and -0.1 to 3.9 mumol/L, respectively; in the CPB group, the respective changes were -3.2 to -14.2 mumol/L and -0.4 to 3.6 mumol/L. Changes of oxyhemoglobin and deoxyhemoglobin levels in the SCP group were almost within the range of those in the CPB group. There were no brain complications in either group. CONCLUSIONS As described here, SCP is acceptable and safe for brain protection in aortic arch procedures.

Right axillary cannulation in the left thoracotomy for thoracic aortic aneurysm

Perfusion from the femoral artery is commonly used in the open proximal method of performing distal aortic arch aneurysm repair or Stanford type B aortic dissection repair under circulatory arrest through left thoracotomy. However, it is associated with a significant risk of retrograde emboli or malperfusion, and with other problems including a restricted time of circulatory arrest to the brain and difficulties in de-airing from the arch branches and proximal ascending aorta. To overcome these problems, we developed a method of performing right axillary perfusion through left thoracotomy.

Nitric Oxide Release from Coronary Vasculature before, during, and following Cardioplegic Arrest

Abstract. Nitric oxide (NO) is known as a vasodilatory molecule synthesized by vascular endothelium. The NO-dependent vasodilatory response of coronary artery is impaired after ischemia and reperfusion. In the present study, the release of NO from coronary vasculature was evaluated before and during cardioplegic arrest and after reperfusion. Nine patients undergoing heart surgery were studied. Multidose crystalloid cardioplegics were used for myocardial protection. The coronary affluent and effluent were obtained simultaneously before cardioplegic arrest, at each cardioplegic administration, and after reperfusion; and the levels of nitrite and nitrate, the stable end-products of NO, were measured. The NO release from the coronary vasculature was determined as the difference in the levels of nitrite and nitrate between the coronary effluent and affluent. The level of nitrite/nitrate release from coronary vasculature was 6.8 ± 3.7 μM before cardioplegic arrest. During cardioplegic arrest the nitrite/nitrate release decreased, reaching 1.3 ± 1.3 μM (p < 0.05, vs. before cardioplegic arrest) at the fourth administration of the cardioplegic. At 3 to 5 minutes after reperfusion, nitrite/nitrate release further decreased to 0.36 ± 0.34 μM (p < 0.05, vs. before cardioplegic arrest). During cardioplegic arrest the NO release decreased and reached significance at approximately 70 minutes of cardioplegic arrest compared to that before cardioplegic arrest. After reperfusion, NO release was further reduced, with statistical significance compared to that before cardioplegic arrest. Our data may indicate that cardioplegic arrest and reperfusion cause endothelial dysfunction.

Stress caused by minimally invasive cardiac surgery versus conventional cardiac surgery: incidence of systemic inflammatory response syndrome.

Abstract. The present study was conducted to evaluate the degree of stress in patients induced by minimally invasive cardiac surgery (MICS) in comparison with that caused by conventional cardiac surgery. We did this by assessing the incidence of systemic inflammatory response syndrome (SIRS). A total of 48 adult patients who underwent surgery for single valve disease were included in this study, 27 of whom underwent conventional surgery and 21 MICS. We evaluated the stress inflicted on the patients in these two groups by analyzing the duration and degree of SIRS and the level of C-reactive protein (CRP). SIRS was assessed by measuring body temperature, heart rate, respiratory rate, and white blood cell counts. There were no significant differences in the operating times, perfusion times, or aorta clamp times between the two groups; and the mean volume of blood transfusion did not differ significantly either. There was no significant difference in the incidence of SIRS or the mean duration of SIRS between the two groups. The CRP levels did not differ significantly between the two groups. Thus although MICS is superior to conventional cardiac surgery in that only a small skin incision is required, the stress experienced by the patient may be the same as that experienced by the patient undergoing conventional cardiac surgery.

A Video - Assisted Thoracoscopic Surgical Technique for Interruption of Patent Ductus Arteriosus

We describe herein a technique for patent ductus arteriosus (PDA) closure using a method of video-assisted thoracoscopic surgical (VATS) interruption derived from video-assisted endoscopic surgery. This technique of repair was performed on five patients with a mean age of 3 years and a mean weight of 13.7 kg during 1994 and 1995. Under general anesthesia, two 10-mm trocars and two or three 5-mm trocars were inserted through the left thoracic wall. A video camera and specially designed surgical tools including scissors, dissectors, and a clip applicator were then introduced. The ductus was dissected, and two titanium clips were applied to interrupt the ductus completely. Successful closure of the PDA by this video-assisted technique was achieved in all patients. The only complication which developed in one patient was hoarseness for 2 weeks postoperatively. The hospital stay ranged from 7 to 12 days and there were no serious complications of deaths. There results indicate that video-assisted thoracoscopic surgical interruption is a safe and effective technique for achieving closure of PDA.

Staged Surgical Repair for Extensive Cardiovascular Damage by Syphilis

A 45-year-old man had aortic regurgitation with a syphilitic true aneurysm of the ascending to transverse arch aorta and a descending aortic aneurysm from chronic Stanford type B aortic dissection. After antibiotic therapy, two-staged surgical repair was performed and there has been no evidence of recurrence in 12 months since the second stage. We describe the successful management of extensive cardiovascular syphilitic damage.

Coronary bypass surgery after renal transplantation.

We report, herein, cases of two renal transplantation patients who underwent coronary artery bypass grafting and discuss the perioperative management of this clinical situation. The first case was a 43-year-old male who underwent coronary artery bypass grafting 50 days after renal transplantation, and the second was a chronic case of a 49-year-old male who underwent coronary artery bypass grafting 17 years after renal transplantation. Prior to the operation, the first patient was continuously administered 2 mg/kg/day of cyclosporin A with the dosage regulated according to the plasma level. The second patient was administered 50 mg/day of cyclophosphamide intravenously instead of an oral dosage of 50 mg/day of azathioprine just prior to the operation. In both patients, perfusion pressure during cardiopulmonary bypass was maintained at approximately 80 mmHg in order to obtain optimal urine output. The CD4/CD8 ratio was monitored for indication of graft rejection, but no remarkable changes were observed perioperatively in either patient. Both patients followed a good clinical course and their postoperative renal function was well maintained. The urine output during cardiopulmonary bypass was 300 ml and 650 ml, respectively. The patients were discharged 15 and 27 days after their operation, respectively. In conclusion, coronary artery bypass grafting can be safely performed in patients who have undergone renal transplantation, if there is appropriate perioperative usage of immunosuppressive agents and maintenance of perfusion pressure during cardiopulmonary bypass.