Hideyuki Kashikie

Effects of intraoperative administration of atrial natriuretic peptide

BACKGROUND Biological activity of endogenous atrial natriuretic peptide (ANP) may decrease during cardiopulmonary bypass. To evaluate the effects of intraoperative administration of exogenous ANP in patients undergoing cardiopulmonary bypass, we conducted a prospective randomized study. METHODS Eighteen patients undergoing mitral valve surgery were randomized to receive either ANP treatment (ANP group; n = 9) or no ANP treatment (control group; n = 9). Atrial natriuretic peptide was given immediately after initiation of cardiopulmonary bypass for 6 hours (0.05 microg x kg(-1) x min(-1)). Plasma ANP, brain natriuretic peptide and cyclic guanosine monophosphate (cGMP) levels, hemodynamic variables and renal function were assessed perioperatively. RESULTS Administration of ANP increased plasma cyclic guanosine monophosphate levels, urine output and fractional sodium excretion, and decreased preload, afterload and plasma brain natriuretic peptide levels significantly (p < 0.05). Plasma cyclic guanosine monophosphate levels correlated with plasma ANP levels (r = 0.95, p = 0.0001), correlated with fractional sodium excretion (r = 0.53, p = 0.02), and correlated inversely with systemic vascular resistance (r = -0.54, p = 0.02). CONCLUSIONS Intraoperative administration of ANP had potent effects on natriuresis and systemic vasodilation by elevating cyclic guanosine monophosphate levels. The results suggest that the technique is useful for the management of hemodynamics and water-sodium retention after cardiopulmonary bypass.

A New Hydrocolloid Dressing Prevents Surgical Site Infection of Median Sternotomy Wounds

PurposeThis prospective and semi-randomized study was conducted to clarify the effectiveness of a new hydrocolloid dressing placed over median sternotomy wounds using an occlusive dressing technique.MethodsThe subjects were 253 patients undergoing coronary artery bypass grafting (CABG), who were randomized to receive either the new hydrocolloid dressing (Karayahesive, n = 117) or a polyurethane foam dressing (Tegaderm plus Pad, n = 136) immediately after sternal wound closure. Karayahesive was left in place for 7 days, whereas the Tegaderm plus Pad was removed on postoperative day (POD) 2 and replaced with an adhesive wound dressing until POD 7.ResultsIn the Karayahesive group, complete integrity of the wound was achieved in 91% of the patients, with an infection developing in 3.4%: as a superficial surgical site infection (SSI) in three and as a deep SSI in one. On the other hand, in the Tegaderm plus Pad group, an infection developed in 10.3% (14 patients) of the patients: as a superficial SSI in nine and as a deep SSI in five (P < 0.05). The total treatment costs from the application of the dressing until completion of treatment was 699 yen for the Karayahesive and 910 yen for the Tegaderm plus Pad (P < 0.001).ConclusionsThe new hydrocolloid dressing, applied with an occlusive dressing technique to median sternotomy wounds, prevented SSI and was cost effective.

Left atrial thrombus without mitral valve disease in a patient with nephrotic syndrome: Report of a case

Abstract.Left atrial (LA) thrombi are rarely seen in patients without mitral valve disease. We report the case of a 71-year-old man found to have a large LA thrombus without mitral valve disease. The patient also suffered from atrial fibrillation and nephrotic syndrome (NS), and had a history of transient ischemic attack. Transesophageal echocardiography showed an LA thrombus attached to the LA wall, and a normal mitral valve. Blood chemistry revealed a total serum protein of 4.6 g/dl, with 2.0 g/dl of albumin and a total cholesterol level of 453 mg/dl. The plasma fibrinogen level was 366 mg/dl and the antithrombin III was 103%. An emergency operation was performed to remove the LA thrombus and a normal mitral valve was confirmed. We believe that several factors, including changes in coagulability related to the NS, steroid therapy, and diuretics, in addition to the dilated LA with atrial fibrillation, may have caused the LA thrombus formation in this patient.

Long-distance transportation of patients with a paracorporeal left ventricular assist system

In Japan, the heart transplantation program is specialized in only three institutions in Osaka and Tokyo. Therefore, a patient must be transferred to these hospitals for extended treatment, regardless of the distance. Trans-portation of the patient with a paracorporeal left ventricular assist system (Toyobo LVAS) is difficult because of its extremely large consumption of electric power. We planned to transfer a patient with a Toyobo LVAS for 600 km, but the patient was not transferred because he had a stroke. In order to find the best transportation method, various possi-bilities are evaluated; special ambulance car, Shinkansen (Super express train), fiexed-wing aircraft, medium-sized helicopter (belonging to private company or public aviation corps), and large helicopter (belonging to the Self-Defense Force). The special ambulance car the medium-sized helicopter may not be able to provide a stable electric power supply. There is a connecting traffic problem with the Shinkansen and the aircraft, depsite their sufficient electric power supply. The large Self-Defense Force helicopter seems to be the best option for us. Some aspects of the logistics and complexity of long-distance transportationare also commented on.

Simultaneous aortic valve replacement and pectus excavatum correction in a 76-year-old man.

A 76-year-old man was admitted to our department to undergo surgical treatment for aortic valve regurgitation. On physical examination, a bowl-shaped concavity was noted. Chest computed tomography revealed left-sided heart displacement by severe pectus excavatum with a Haller index of 6.40. Considering the postoperative cardiopulmonary complications that may result from mechanical compression due to uncorrected sternal deformities, we decided to perform a simultaneous aortic valve replacement and pectus excavatum correction. The operation time was long (570 min) and involved a high-volume transfusion due to excessive bleeding caused by resection of the deformed costal cartilages and sternal osteotomy under the use of heparin. The endotracheal tube was removed on the fifth postoperative day, but reintubation was required because of hypercapnea and difficulty in sputum discharge. With the aid of tube feeding for nutritional management, his cardiopulmonary function gradually ameliorated and his general condition improved. Consequently, he was weaned from mechanical ventilation on the 14th postoperative day. The patient is doing well 1 year after surgery. We report on the surgical management for pectus excavatum in adult patients.

Coronary artery bypass grafting in patients with pulmonary aspergillosis

Cardiovascular surgery in patients with pulmonary aspergillosis has been rarely reported. Coronary artery bypass grafting (CABG) for three cases of angina pectoris with pulmonary aspergillosis was successfully performed. Patients were discharged from our hospital without any complications of invasive Aspergillus cardiovascular infection. Careful perioperative management for preventing pulmonary complications is important.