Hitoshi Fukumoto

Coronary Artery Bypass Grafting by Utilizing In Situ Right Gastroepiploic Artery: Basic Study and Clinical Application

The right gastroepiploic artery (GEA) was studied angiographically and histologically to determine its suitability for coronary artery bypass grafting. One hundred celiac angiograms demonstrated that the right GEA has the appropriate size (diameter less than 1.5 mm, 4%; 1.5 to 2 mm, 29%; more than 2 mm, 67%) and length (less than half of the greater curvature, 5%; more than half of the greater curvature, 95%; more than two-thirds of the greater curvature, 34%) for use as an in situ graft. A stenotic lesion of a GEA was observed in only 1 angiogram. Histological examination of a right GEA from 5 patients who had undergone gastrectomy demonstrated no evidence of arteriosclerosis. Encouraged by these results, we performed a coronary artery bypass reoperation utilizing an in situ right GEA graft in 2 women. Postoperative angiograms showed good patency of those grafts. The patients recovered well and were free from angina.

Transcollateral retrograde approach with rendezvous technique for recanalization of chronically occluded tibial arteries.

Purpose To describe a novel technique using an antegrade wire in a retrograde microcatheter advanced through a transcollateral vessel for recanalization of challenging infrapopliteal chronic total occlusions. Technique A 75-year-old diabetic man presented with critical limb ischemia manifested as nonhealing ulcers on the toes. Baseline angiography revealed a blunt, long, total occlusion of the anterior tibial artery. A retrograde microcatheter was advanced over a guidewire tracking the collateral channel from the planter artery. Antegrade and retrograde microcatheters were aligned inside the occluded lesion. An antegrade wire was then advanced further down through the retrograde microcatheter. Final angiography of the anterior tibial artery following balloon dilation demonstrated a satisfactory result, without evidence of significant residual stenoses or flow-limiting dissections. Complete wound healing was achieved at 3 weeks. Conclusion This alternative wire method may be useful when traditional interventional approaches are unfeasible.

Features of intrinsic ganglionated plexi in both atria after extensive pulmonary isolation and their clinical significance after catheter ablation in patients with atrial fibrillation

BACKGROUND The features of intrinsic ganglionated plexi (GP) in both atria after extensive pulmonary vein isolation (PVI) and their clinical implications have not been clarified in patients with atrial fibrillation (AF). OBJECTIVE The purpose of this study was to assess the features of GP response after extensive PVI and to evaluate the relationship between GP responses and subsequent AF episodes. METHODS The study population consisted of 216 consecutive AF patients (104 persistent AF) who underwent an initial ablation. We searched for the GP sites in both atria after an extensive PVI. RESULTS GP responses were determined in 186 of 216 patients (85.6%). In the left atrium, GP responses were observed around the right inferior GP in 116 of 216 patients (53.7%) and around the left inferior GP in 57 of 216 (26.4%). In the right atrium, GP responses were observed around the posteroseptal area: inside the CS in 64 of 216 patients (29.6%), at the CS ostium in 150 of 216 (69.4%), and in the lower right atrium in 45 of 216 (20.8%). The presence of a positive GP response was an independent risk factor for AF recurrence (hazard ratio 4.04, confidence interval 1.48-11.0) in patients with paroxysmal, but not persistent, AF. The incidence of recurrent atrial tachyarrhythmias in patients with paroxysmal AF with a positive GP response was 51% vs 8% in those without a GP response (P = .002). CONCLUSION The presence of GP responses after extensive PVI was significantly associated with increased AF recurrence after ablation in patients with paroxysmal AF.

Application of Ultrasonic Aspirator for Dissection of the Internal Mammary Artery in Coronary Artery Bypass Grafting

The low-power ultrasonic aspirator was used for the dissection of the internal mammary artery (IMA) in 20 patients undergoing coronary artery bypass grafting. Harvesting time was shorter and the amount of bleeding was less than with the ordinary method. The short-term patency rate (1 to 6 months) for those IMA grafts was 95% (19 of 20 remained patent). These results have encouraged us to use the ultrasonic aspirator routinely for IMA dissection.

Combined Revascularization of Coronary and Femoral Arteries: A Proposed Alternative

Two patients with both coronary artery disease and leg ischemia were successfully treated with a combined revascularization procedure. Coronary arteries were bypassed with in situ internal mammary artery grafts, and bilateral femoral arteries were bypassed with expanded polytetrafluoroethylene grafts descended from the ascending aorta through the preperitoneal abdominal wall tunnel. Both patients recovered well and experienced no angina or claudication.

Surgical treatment of traumatic thoracic aorta rupture: a 7-year experience.

OBJECTIVES Traumatic aortic rupture is highly lethal and an ongoing therapeutic challenge. We review our 7-year experience with traumatic aortic disruption. METHODS We treated 12 cases of traumatic rupture of the thoracic aorta (TRTA) from December 1994 to June 2001 at our institution. Of these, 9 were male, and the average age 26 years. Injuries were caused by traffic accidents in 9 cases and falls in 3. Contrast-enhanced helical computed tomography was used to diagnose10 cases and digital subtraction angiography to diagnose 2 at other hospitals. Six of 12 (50%) disruptions were located in the aortic isthms. All surgery was conducted under cardiopulmonary bypass. A percutaneous cardiopulmonary support system (heparin-bonded artificial lung and centrifugal pump) was used in 6 cases since 1998. RESULTS Among the 12 patients, 6 had early surgical repair within 2 days after the accident, and all survived free of neurological problems. Six other had repair delayed more than 2 days and all were doing well. CONCLUSION Immediate repair of aortic lesions should be the rule because the majority of deaths from TRTA occur within 24 hours. We believe, however, that immediate surgery may not be necessary for some patients with severe, multiple associated lesions who survive initial traumatic aortic disruption of the aorta.

Feasibility and safety of a virtual 3-Fr sheathless-guiding system for percutaneous coronary intervention

To evaluate the feasibility and safety of a virtual 3‐Fr system [5‐Fr sheathless‐guiding catheter (GC)] for percutaneous coronary intervention (PCI).

Mechanism of atrial functional mitral regurgitation in patients with atrial fibrillation: A study using three-dimensional transesophageal echocardiography

BACKGROUND Functional mitral regurgitation (MR) can occur in patients with atrial fibrillation (AF) despite having preserved left ventricular (LV) systolic function. This MR is known as atrial functional MR. The aim of this study was to clarify the mechanism of atrial functional MR using real-time three-dimensional transesophageal echocardiography (3DTEE). METHODS Sixty patients underwent transthoracic echocardiography and 3DTEE: 16 patients with AF and significant non-organic MR and preserved LV ejection fraction (>50%) constituted the AF-MR group, 20 patients with AF and no significant MR formed the AF-NSMR group, and 24 normal subjects comprised the control group. RESULTS The left atrial volume index was significantly larger in the AF-MR group (95±41ml/m2) than in the AF-NSMR group (38±13ml/m2, p<0.05) or the control group (21±7ml/m2, p<0.05). The 3D annular circumference was significantly longer in the AF-MR group than in the AF-NSMR group. The annular-anterior leaflet coaptation angle was smaller in the AF-MR group than in the AF-NSMR group (11±6° vs. 18±9°, p<0.05). The annular-posterior leaflet coaptation angle was comparable between the two AF groups (26±12° vs. 28±10°), whereas the annular-posterior leaflet tip angle was larger in the AF-MR group than in the AF-NSMR group (59±13° vs. 44±11°, p<0.05). The posterior leaflet bending toward LV cavity was therefore significantly larger in the AF-MR group than in the AF-NSMR group (32±10° vs. 18±15°, p<0.05). CONCLUSIONS In patients with AF and significant functional MR occurring despite their preserved LV systolic function, the left atrium and mitral annulus were dilated and the anterior leaflet was flattened along the mitral annular plane, whereas the posterior leaflet was bent toward the LV cavity.

Real-time transesophageal echocardiography facilitates antegrade balloon aortic valvuloplasty.

We report two cases of severe aortic stenosis (AS) where antegrade balloon aortic valvuloplasty (BAV) was performed under real-time transesophageal echocardiography (TEE) guidance. Real-time TEE can provide useful information for evaluating the aortic valve response to valvuloplasty during the procedure. It was led with the intentional wire-bias technique in order to compress the severely calcified leaflet, and consequently allowed the balloon to reach the largest possible size and achieve full expansion of the aortic annulus.

Ultra-Early Induction of Brain Hypothermia for Patients with Poor-Grade Subarachnoid Hemorrhage

The potential of hypothermia in reducing neuronal damage has been demonstrated in various neurological emergencies. However, its safety, feasibility, and potential benefits for poor-grade subarachnoid hemorrhage (SAH) are uncertain. We induced brain hypothermia in 35 patients (14 men and 21 women; mean age 58 ± 12 years; range 25–70 years) with SAH classified in Grade V by the World Federation of Neurosurgical Societies and evaluated the outcome. Hypothermia was induced by surface cooling immediately after diagnosis of SAH and was followed by urgent surgical obliteration of the ruptured aneurysm. The core temperature was maintained at 33°–34°C for at least 48 h; subsequently, patients were rewarmed 1°C per day. Median time from onset to arrival, cerebral angiography, and surgery was 31.5, 88.5, and 174.5 min, respectively. The core temperature (mean ± standard deviation) was 35.8° ± 1.0°C on arrival, 34.8° ± 1.0°C just before surgery, 34.0° ± 0.7°C at the beginning of microsurgery, and 33.7° ± 0.8°C immediately after surgery. Hypothermia was completed in all patients without serious complications over a period of 6–22 days, with a mean of 9.4 days. The Glasgow Outcome Scale assessed at 3 months after onset was as follows: 4 (11.4%), good recovery; 6 (17.1%), moderate disability; 17 (48.6%), severe disability; 4 ( 11.4%), vegetative state; 4(11.4%), death. Poor outcome was mostly related to primary brain damage; cerebral vasospasm occurred in four patients. Ultra-early induction of hypothermia is feasible and possibly beneficial in poor-grade SAH without increasing morbidity and mortality.