Hiroomi Murayama

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.

Midterm results for endovascular stent grafts via median sternotomy for distal aortic arch aneurysm

Dislocation or perigraft leakage is a major problem during the follow-up period for endovascular stent graft (EVG) implantation via median sternotomy for distal aortic arch aneurysm. Anchoring sutures have been applied for the prevention of these complications. Here, we evaluate the midterm results and the efficacy of anchoring sutures. There were 21 male and 2 female patients enrolled in the study with an average age of 70 years (59–83). Aneurysm types were 21 true aneurysms (13 fusiform, 8 saccular), 1 chronic dissection, and 1 penetrating aortic ulcer. Total arch replacement was performed in two patients and aortocoronary bypass grafting was combined in four patients. Anchoring sutures to fix the EVG via median sternotomy were applied for 11 recent patients. The average follow-up period was 44 (22–79) months. There were no operative mortalities, but one case of paraplegia, one of stroke, and two of temporary spinal cord dysfunction. Complications related to EVG via median sternotomy occurred in five patients who had not received anchoring sutures, but the 11 patients with anchoring sutures showed no EVG-related complications. A chronic type B dissection revealed impending rupture due to false lumen infection 1 year after operation and repeat surgery was performed. Stent dislocation occurred in four patients, two of whom required repeat surgery via left thoracotomy due to endoleakage 3 and 4 years after surgery. One died from aneurismal rupture 5 years after surgery. One required emergency graft replacement because of graft perforation 5 years after surgery. The proportion of patients free from EVG-related events at 5 years after surgery was 75%. Anchoring sutures (P = 0.0155) and a large aneurysm of more than 80 mm (P = 0.0190) were predictors of late EVG-related complications. There were five late deaths: two were from stroke, one from rupture, one from cancer, and one from multiple organ failure after repeat surgery. EVG shortens postoperative recovery with relatively lower mortality, but spinal cord injury is a complication occurring with a relatively high rate. Patients with large aneurysms are not good candidates for EVG implantation via median sternotomy Anchoring sutures to fix the EVG to the aortic wall should help prevent EVG-related events and improve the durability of EVG.

Peripheral Veno‐Arterial Extracorporeal Membrane Oxygenation as a Bridge to Decision for Pediatric Fulminant Myocarditis

It is essential to establish an appropriate initial treatment strategy for pediatric fulminant myocarditis. We reviewed eight cases of pediatric fulminant myocarditis that required extracorporeal membrane oxygenation (ECMO) from 2012 to 2015. The median age was 8 years (range 3 months-13 years), and the median body surface area was 0.89 m(2) (range 0.35-1.34 m(2) ). Peripheral veno-arterial ECMO was initially applied, and we evaluated whether heart decompression was sufficient. If the pump flow was insufficient, central cannulation was performed via median sternotomy (central ECMO). The need for subsequent ventricular assist device (VAD) support was determined 72 h after ECMO initiation. Six patients were bridged to recovery using peripheral ECMO support only (for 3-11 days), whereas two required VAD support. One patient was switched to central ECMO before VAD implantation. Three patients died of multiorgan failure, even though cardiac function recovered in two of those patients. The duration from hospital arrival to ECMO initiation was shorter in the survival (3.3 ± 1.3 h; range 1.6-4.7 h) than in the nonsurvival group (32 ± 28 h; range 0.7-55 h). Peripheral ECMO can be useful as a bridge to decision for pediatric fulminant myocarditis, which is frequently followed by a successful bridge to recovery. It is important to determine whether ECMO support should be initiated before organ dysfunction advances to preserve organ function, which provides a better bridge to subsequent VAD therapy and heart transplant or recovery.

Successful removal of an infected pacemaker lead using cardiopulmonary bypass in an 89-year-old patient.

We report the case of an 89-year-old patient suffering from endocarditis with septicemia caused by a growth on a pacemaker lead. The entire pacemaker system was successfully removed using cardiopulmonary bypass. Although the patient was an octogenarian in poor condition with a systemic infection, an aggressive operation with careful perioperative management gave a good clinical result. As far as we know, this is the oldest patient in whom a pacemaker system has been removed using cardiopulmonary bypass.

Nonmycotic False Aneurysm of Aortic Cannulation Site Presenting 26 Years Postoperatively

We report the case of a 64-year-old woman who presented with a false aneurysm in the ascending aorta where arterial cannulation was done in an operation 26 years earlier. The aneurysm was excised with the ascending aorta and successfully replaced with a prosthetic graft during deep hypothermic circulatory arrest and retrograde cerebral perfusion, accompanied with concomitant procedures of mitral valve replacement and maze procedure. When the aneurysm, 3.5 x 3.0 x 4.5 cm, was removed, it showed a remarkable sharp line of demarcation between the normal aorta. Microscopic examination of the specimen was consistent with the features of a pseudoaneurysm.

The case of an explanted 16-year-old mitral Carpentier-Edwards pericardial bioprosthesis.

We report the case of a mitral Carpentier-Edwards pericardial bioprosthesis that was explanted from a 43-year-old female patient because of structural valve deterioration 16 years following implantation. Upon removal, the prosthesis was found to be discolored and all leaflets were stiff and hard, showing extensive calcification, pannus overgrowth, leaflet hematoma, and multiple disruptions. One leaflet presented a wavy free margin due to commissural disruptions, leading to incomplete cusp coaptation. The accumulated physical symptoms of the patient were consistent with these findings.

Iatrogenic aortic dissection in an infant with persistent fifth aortic arch and congenital heart defects.

From the Department of Cardiovascular Surgery, Aichi Children’s Health andMedical Center, Obu, Aichi, Japan. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Aug 13, 2015; revisions received Oct 1, 2015; accepted for publication Oct 7, 2015; available ahead of print Nov 11, 2015. Address for reprints: Noritaka Okada, MD, PhD, 7-426 Morioka-cho, Obu, Aichi, Japan 474-8710 (E-mail: cvsoka@gmail.com). J Thorac Cardiovasc Surg 2016;151:e55-7 0022-5223/

Optimal Surgical Management Using a Classic Blalock-Taussig Shunt for an Infected Pseudoaneurysm After a Modified Blalock-Taussig Shunt Procedure

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.10.033

Right ventricular centripetal plication: an aggressive right ventricular exclusion technique

We present 2 cases of a 3-month-old girl and boy who were diagnosed with an infected pseudoaneurysm 2 months after undergoing left-sided modified Blalock-Taussig shunt (mBTS) operations for pulmonary atresia. Because the shunts in both cases were nearly obstructed, they underwent a 2-stage surgical approach: classic BTS operations through a right thoracotomy to establish sufficient pulmonary flow and infected graft removal through a median sternotomy after close observation of the state of the aneurysms. By utilizing autologous tissue from a different thoracic entry, both patients were successfully managed and recovered without any recurrence of infection.