Hitoshi Suhara

Efficacy of a new coating material, PMEA, for cardiopulmonary bypass circuits in a porcine model

BACKGROUND A new coating material, poly-2-methoxyethyl acrylate (PMEA), was developed to improve the biocompatibility of cardiopulmonary bypass (CPB) circuits. METHODS To investigate the efficacy of the PMEA coating for CPB circuits, we compared PMEA-coated circuits (group P, n = 6) with uncoated circuits (group C, n = 6) and heparin (covalent-bonded heparin, Hepaface)-coated circuits (group H, n = 6) in a porcine CPB model. RESULTS Platelet counts were significantly preserved in groups P and H compared with those in group C (P versus C, p < 0.05). The plasma levels of thrombin-antithrombin complex and bradykinin were significantly lower at 120 minutes in groups P and H than in group C (thrombin-antithrombin: P versus C, p < 0.05; bradykinin: P versus C, p < 0.05). The amount of fibrinogen adsorbed onto the hollow fibers was markedly less in group P than in groups C and H. CONCLUSIONS The PMEA coating was equal to heparin coating in preventing reactions induced by CPB circuits, and might be superior to heparin coating in suppressing the adsorption of plasma proteins such as fibrinogen. Thus, PMEA coating may be a suitable means for improving the biocompatibility of CPB circuits.

P-selectin monoclonal antibody may attenuate the whole body inflammatory response induced by cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) is known to induce an inflammatory response in association with neutrophil mediated lung injury. P-Selectin has been reported to be involved in the initiation of this inflammatory response by promoting the adhesion of neutrophils to endothelial cells in postcapillary venules. However, the role of P-selectin in the inflammatory response induced by CPB has never been clarified. To elucidate its role, we evaluated the effect of an anti-rat specific P-selectin monoclonal antibody (ARP2-4; Sumitomo Pharmaceutical) on the response of inflammatory cytokines and lung injury in a rat-CPB model. Twenty Sprague-Dawley rats underwent CPB for 30 minutes (80 ml/kg per minute, 34 degrees C) under one of two conditions. In group P, ARP2-4 (3 mg/kg) was added to the priming solution of the bypass circuit (n = 10). Saline alone was given to group C (n = 10). Inflammatory cytokines (tumor necrosis factor-alpha [TNF-alpha], interleukin[IL]-1beta, IL-6, and IL-8) and respiratory index (RI) as a marker of pulmonary gas-exchange ability were measured 1) before the initiation of CPB, 2) at the termination of CPB, and 3) 2 hours after the termination of CPB. Neither TNF-alpha nor IL-1beta was detected during the experimental period in either group. The plasma levels of IL-6 and IL-8 increased after CPB in both groups, but they were significantly lower in group P than in group C. The RI value increased in a pattern similar to that of the inflammatory cytokines and was significantly lower in group P. These data demonstrate that the addition of an anti-rat specific monoclonal antibody inhibits the abnormal release of inflammatory cytokines and attenuates CPB induced lung injury in rats. Thus, P-selectin may play a role in the augmentation of CPB induced inflammatory response, and the use of its inhibitory monoclonal antibody seems to be a promising strategy for the treatment of CPB induced lung injury.

Percutaneous cardiopulmonary support with heparin-coated circuits in postcardiotomy cardiogenic shock. Efficacy and comparison with left heart bypass.

OBJECTIVE Percutaneous cardiopulmonary support, a simplified form of venoarterial bypass, using totally heparin-coated circuits, has recently come into clinical use. To clarify its efficacy in postcardiotomy cardiogenic shock to aid weaning from cardiopulmonary bypass, we compared results of percutaneous cardiopulmonary support with those of left heart bypass using a centrifugal pump. METHODS We reviewed 18 patients treated between 1991 and 1998 who could not be weaned from cardiopulmonary bypass. Nine were aided by totally heparin-coated percutaneous cardiopulmonary support (PCPS group), and 9 supported by left heart bypass using a centrifugal pump (LHB group). In both groups, activated clotting time was controlled at 150-200 seconds using minimal doses of heparin as needed. RESULTS Weaning and survival rates were higher in the PCPS group than in the LHB group (100% vs 55.6%, and 66.7% vs 22.2%). The PCPS group had a smaller amount of blood loss and needed a smaller amount of blood components in the immediate postoperative period. One percutaneous cardiopulmonary support patient required surgical re-exploration for postoperative bleeding (11.1%), but no clinical thromboembolic event occurred in the PCPS group. In the LHB group, 5 patients underwent surgical re-exploration for postoperative bleeding (55.6%), and 2 underwent thrombus extirpation in the left ventricle (22.2%). CONCLUSIONS Although this study was retrospective and historical backgrounds could have been involved, our data suggest that totally heparin-coated percutaneous cardiopulmonary support system appears more effective as an aid to weaning from cardiopulmonary bypass and in short-term circulatory support for patients in postcardiotomy cardiogenic shock.

Early Outcomes of Open Abdominal Repair Versus Endovascular Repair for Abdominal Aortic Aneurysm: Report from National Hospital Organization Network Study in Japan

OBJECTIVE Early outcomes of open abdominal repair (OS) versus endovascular repair (EVAR) for abdominal aortic aneurysm were retrospectively analyzed, after commercialized devices for EVAR had become available in Japan. PATIENTS AND METHODS A total of 781 consecutive patients (OS, n = 522; EVAR, n = 259) were treated at ten medical centers between January 2008 and September 2010. The OS group comprised patients with preoperative shock (SOS, n = 34) and without shock (NOS, n = 488). RESULTS Patients in the EVAR group were 3 years older than those in the NOS group. There was greater prevalence of hostile abdomen, on dialysis, chronic obstructive pulmonary disease on inhaled drug, and cerebrovascular disease in the EVAR group than in the NOS group. Surgical mortality was 16 cases (2.0% in all patients, EVAR: 0.8%, NOS: 1.4%, SOS: 21%). Hospital stay >30 days was documented in 52 (11%) with NOS, 11 (33%) with SOS, and 8 (3%) with EVAR. Thirty late deaths included 6 aneurysm related death and 14 cardiovascular causes at a mean follow up of 1.0 year. The survival rates freedom from all cause death at one year, were 95 ± 1% in NOS and 94 ± 2% in EVAR respectively. CONCLUSION Though significant differences in patient characteristics among three groups were noted, early results were satisfactory.

Diabetes mellitus adversely affects mortality and recurrence after valve surgery for infective endocarditis

Background: Although diabetes mellitus (DM) increases the incidence of infective endocarditis (IE), little is known about the outcome of valve surgery for active IE in patients with DM. We evaluated the clinical outcomes of valve surgery for IE in patients with DM. Methods: Between 2009 and 2016, 470 patients underwent valve surgery for definitive left‐sided active IE at 12 affiliated hospitals. We compared the preoperative variables and clinical outcomes between patients without (n = 374) and with DM (n = 96). Results: Staphylococcus and chronic hemodialysis were more prevalent in patients with DM, and these patients had greater preoperative inflammation levels and worse renal function than patients without DM. In‐hospital mortality was 8% in patients without DM and 13% in patients with DM (P = .187). The overall survival rate at 1 and 5 years was 87% and 81% in patients without DM and 72% and 59% in patients with DM (P < .001). The incidence of infection‐related death was greater in patients with DM than in patients without DM (P < .001; hazard ratio 3.74 [1.78‐7.71]). Freedom from the recurrence of endocarditis at 1 and 5 years postoperatively was 98% and 95% in patients without DM, and 89% and 78% in patients with DM (P < .001), respectively. The Cox hazard analysis revealed that the presence of DM was the only independent risk for recurrence (hazard ratio 3.74 [1.45‐9.54], P = .007). Conclusions: The short‐ and mid‐term outcome after valve surgery for active IE in patients with DM is worse because of the greater prevalence of infection‐related death and IE recurrence.

Development of hybrid artificial lung with gene transfected biological cells

Although medical technology has made remarkable advances, there are still limits to the medical and surgical treatment of severe organ failure, and their treatment still involves many unresolved problems. In order to deal with these problems, it will be indispensable to develop new methods of treatment, based on a thorough understanding of each type of organ failure and primary research on the mechanisms of onset of organ failure. Artificial organs provide a new means of treating organ failure. It is no exaggeration to say that the results of primary research concerning artificial organs, accumulated to date, have begun to be applied clinically and are contributing to the advancement of medical care. Conventional basic research intended to advance the prospects of developing artificial organs has been conducted in three fields: physiological research (focusing on hemodynamics), pathological research (focusing on morphological changes of organs), and biochemical research. However, following recent remarkable advances in methodology, medical studies have expanded rapidly beyond the consideration of individuals, organs, and cells to incorporate genetics and molecular biology. It is now possible to study life phenomena and diseases at the molecular level. It is plausible to imagine that techniques from molecular biology and biotechnology will be introduced to the efforts to develop artificial organs, with the goal of creating new

Is Endovascular Aneurysm Repair a Relative Contraindication for Patients with Preoperative Renal Dysfunction

UNLABELLED Whether endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is a relative contraindication in patients with preoperative renal dysfunction (Pre-RD), remains controversial because the contrast medium may induce nephrotoxicity. In this study 1658 patients were treated at ten Japanese medical centers between January 2005 and March 2011 (Open surgery (OS) vs. EVAR: n = 1270 vs. n = 388). They were retrospectively analyzed. Multiple logistic regression analysis (MLRA) with pre- and intra-operative variables was applied to all patients. The endpoints induced onset of new dialysis and postoperative renal dysfunction (Post-RD), were defined as a 50% decrease or more from the preoperative estimated glomerular filtration rate (eGFR) level. RESULTS Early mortality, Post-RD, incidence of new dialysis in all patients were 1.6% (OS: EVAR = 1.9%:0.8%), 6% (OS: EVAR = 8%:2.3%) and 1.4% (OS: EVAR = 1.5%:1.0%) respectively. MLRA identified operation time, clamp of renal artery as risk factors for Post-RD, and operation time and Pre-eGFR level as risk factors for new dialysis. CONCLUSION Although Post-RD was more frequently observed in the OS group, MLRA showed that the choice of OS or EVAR was not a risk factor for Post-RD and new dialysis. It was strongly suggested that using contrast medium during EVAR is not a contraindication to AAA repair in patients with Pre-RD. (This article is a translation of J Jpn Coll Angiol 2014; 54: 13-18.).

Total arch replacement for a subacute type A dissection in a patient with a terminal tracheostoma after total laryngectomy: report of a case

Standard full median sternotomy for total arch replacement in tracheostomy patients may lead to mediastinitis and graft infection. Several approaches for typical cardiac surgery, including a T-shaped sternotomy, have been used in patients with both terminal and transient tracheostomas; however, these procedures offer inadequate surgical exposure of the arch vessels. We herein report the case of a 67-year-old man with a subacute type A aortic dissection with a terminal tracheostoma after total laryngectomy, who successfully underwent total arch replacement by a fourth intercostal thoracotomy performed using an anterior bilateral approach and the arch-first technique. To our knowledge, this is the first report of a case of total arch replacement in a patient with subacute aortic dissection and a terminal tracheostoma.

Mobilization of the posterior leaflet of the mitral valve for resection of a left ventricular tumor producing carbohydrate antigen 19-9.

We report an extremely rare case of a left ventricular tumor producing carbohydrate antigen 19-9 (CA19-9). A 43-year-old man with an episode of right hemiplegia underwent an emergent operation for a left ventricular tumor just beneath the posterior leaflet of the mitral valve. The tumor was successfully resected by mobilization of the posterior leaflet of the mitral valve. The resected specimen was immunoreactive for CA19-9.