Johji Fukada

Thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography.

OBJECTIVE The outcome of thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the artery of Adamkiewicz (ARM) by magnetic resonance angiography (MRA) was investigated. METHODS Between January 2000 and December 2001, 40 consecutive patients who had aneurysms of the thoracoabdominal or descending aorta underwent preoperative MRA to visualize the ARM. Thirty-two patients underwent replacement of the aneurysms, and 25 patients (TAAA, 11; TAA, 14) underwent replacement of the aneurysms with preoperative detection of the ARM. Only intercostal or lumbar arteries in aneurysms, which were detected as the origin of the ARM, were reattached to the graft. The results of thoracoabdominal aortic aneurysm operations in 11 patients in whom the ARM was preoperatively detected (group I) were compared with the results of TAAA operations in 26 patients in whom the ARM was not preoperatively detected (group II). RESULTS MRA demonstrated the ARM in 29 (73%) of the 40 patients. The laterality of the arteries originated from the left side in 29 (100%) and between Th9 and Th12 in 25 (86%), between Th9 and L1 in 28 (97%) of the 29 patients. No spinal cord injury occurred in patients (TAAA and TAA) in whom the ARM had been preoperatively detected. Major complications following TAAA operations included paraplegia (0% in group I and 8% in group II), respiratory failure (9% in group I and 23% in group II), and renal failure requiring hemodialysis (18% in group I and 22% in group II). Operation times were 439+/-99 min in group I and 620+/-200 min in group II (P=0.008). CONCLUSIONS Preoperative detection of the ARM is possible by MRA and is very useful for reducing the incidence of ischemic injury of the spinal cord and for reducing the time of an operation for repair of an aneurysm of the thoracoabdominal or descending aorta.

Is Atrial Fibrillation Resulting From Rheumatic Mitral Valve Disease a Proper Indication for the Maze Procedure

BACKGROUND There are a few patients without detectable atrial contraction despite restoration of atrial rhythm after the maze procedure for atrial fibrillation (AF) associated with mitral valve disease. METHODS From January 1995 to March 1997, 29 consecutive patients with AF associated with mitral valve disease underwent our modified maze procedure combined with mitral or other valve operations. The causes of mitral valve disease were rheumatic mitral stenosis (n = 22) and nonrheumatic mitral regurgitation (n = 7). The 17 patients with postoperative atrial rhythm were divided into group I with rheumatic mitral stenosis (n = 10), and group II with mitral regurgitation of nonrheumatic origins (n = 7). RESULTS Seventeen patients regained atrial rhythm, 2 patients had junctional rhythm, and another 10 remained in AF. Between the group of patients with restoration of atrial rhythm and that of patients remaining in AF, significant differences were found in the percentage with rheumatic disease, history of AF, and maximum f-wave voltage. The postoperative peak velocity of the atrial filling wave to peak velocity of early filling wave ratio for the left atrium measured using Doppler echocardiography was 0.25 in group I, which was significantly lower than that (0.42) in group II. CONCLUSIONS Reconsideration of the indications for the maze procedure for AF associated with rheumatic mitral stenosis may thus be reasonable, particularly for cases in which replacement using a prosthetic valve is necessary, but we believe that patients with nonrheumatic mitral valve disease, especially those able to undergo reconstructive operations, are the best candidates for the maze procedure.

Influence of Pulmonic Position on Durability of Bioprosthetic Heart Valves

BACKGROUND The insertion of bioprosthetic valves into the pulmonic position is not performed commonly because of uncertainty concerning the necessity and durability of such valves. METHODS We reviewed the long-term outcome of 10 patients who underwent pulmonary valve replacement with bioprostheses between March 1985 and March 1997. A Carpentier-Edwards supraannular bioprosthesis was used in 7 patients, a Hancock II bioprosthesis was used in 2 patients, and a Carpentier-Edwards pericardial bioprosthesis was used in 1 patient. The mean patient age at the time of pulmonary valve replacement was 38.9 +/- 16.3 years (range, 15 to 63 years). The diagnoses were pulmonary valvular regurgitation after corrective surgery for tetralogy of Fallot in 7 patients, right ventricular outflow tract stenosis and absent right pulmonary artery combined with a double-outlet right ventricle in 1 patient, pulmonary valvular regurgitation with pulmonary artery dilatation in 1 patient, and aortic valve stenosis treated with our modification of the Ross procedure using a pulmonary bioprosthesis in 1 patient. Survivors were followed up for a mean of 5 years and 5 months. RESULTS One patient underwent reoperation because of infective endocarditis of the bioprosthesis. No bioprosthetic valve dysfunction has been observed on Doppler echocardiography during a maximum follow-up period of 12.2 years, except in the patient who underwent replacement at 15 years of age. CONCLUSIONS Bioprostheses in the pulmonic position are durable in adult patients because they face a minimal hemodynamic load, but they may undergo early leaflet degeneration in younger patients.

Isolated cerebral perfusion for intraoperative cerebral malperfusion in type A aortic dissection.

Cerebral malperfusion due to expansion of a false lumen can occur acutely during aortic repair when retrograde femoral perfusion is initiated. We detected this catastrophe by a rapid decrease in regional cerebral oxygenation and successfully treated it by immediate isolation of the cerebral circulation from the systemic circulation. The surgical management, including the above technique, for this rare event is described.

A Surgical Method for Selecting Appropriate Size of Graft in Aortic Root Remodeling

We describe a surgical technique for selecting the appropriate size of a tube graft in aortic root remodeling procedures. As the technique has a geometric basis, we believe that our method is more accurate in determining the graft size than others.

Surgical treatment of thoracoabdominal aortic aneurysm after repairs of descending thoracic or infrarenal abdominal aortic aneurysm

OBJECTIVE The outcome of thoracoabdominal aortic aneurysm repair after operations for descending thoracic or infrarenal abdominal aortic aneurysm was investigated. METHODS Between May 1982 and July 2000, 102 patients underwent thoracoabdominal aortic aneurysm repair. Of these patients, 36 had previously undergone operations for descending thoracic or abdominal aortic aneurysm. To evaluate the influence of previous descending thoracic or infrarenal abdominal aortic aneurysm repair on the results of TAAA replacement, patients were divided into two groups: one group of patients who had previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group I, n=36) and one group of patients who had not previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group II, n=66). RESULTS Patients with previous descending thoracic or infrarenal abdominal aortic aneurysm repair had more chronic dissection and extensive thoracoabdominal aortic aneurysm. The distal aortic perfusion time and total aortic clamp time were both longer in group I. The total selective visceral and renal perfusion time and operation time did not differ significantly between the two groups. In 30-day mortality rates were 5.5% in group I and 13% in group II. Major postoperative complications included paraplegia in 14% of patients in group I and 3.1% in group II, renal failure requiring hemodialysis in 22% of patients in group I and 19% of patients in group II, respiratory failure in 36% of patients in group I and 30% of patients in group II, postoperative hemorrhage in 11% of patients in group I and 16% of patients in group II. CONCLUSION The presence of a previous descending thoracic or infrarenal abdominal aortic aneurysm did not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.

Re-replacement for prosthetic valve dysfunction : Analysis of long-term results and risk factors

BACKGROUND Prosthetic heart valve re-replacement still remains a challenging situation. Although some studies have examined the early results, the long-term survival has not yet been well analyzed. The aim of this study was to detect the factors that affect the long-term outcome of operation. METHODS Between April 1964 and September 1996, 231 prosthetic valve re-replacements were performed including 16 cases of third valve replacement. There were 100 men and 131 women with a mean age of 47 +/- 14 years. RESULTS The actuarial survival rate was 65% +/- 4% at 5 years and 41% +/- 7% at 10 years. Multivariate analysis revealed that New York Heart Association class IV and left ventricular ejection fraction were found to be independent predictors of late death. CONCLUSIONS Our study showed that advanced New York Heart Association functional class and lower left ventricular ejection fraction were found to be independent predictors of late death. If operation is performed before patients reach such a deteriorated condition, long-term results are excellent.

Minilaparotomy Abdominal Aortic Aneurysm Repair Versus the Retroperitoneal Approach and Standard Open Surgery

PurposeWe evaluated the surgical results of minilaparotomy abdominal aortic aneurysm (AAA) repair in comparison with those of standard open repair and retroperitoneal approach repair.MethodsBetween February 2000 and January 2003, 30 patients with AAA underwent minimal incision laparotomy repair (MINI) through an abdominal incision 7–12 cm long. Their clinical characteristics and in-hospital outcome were then compared with those of patients who had undergone repair of AAA by a standard open technique (OPEN) or retroperitoneal approach technique (RETRO).ResultsThere were significant differences between the MINI, OPEN, and RETRO groups in the time until the patient was able to resume eating (2.4 ± 1.0 vs 4.4 ± 2.4* vs 2.8 ± 1.9 postoperative days [PODs], respectively; *P < 0.05), the time until ambulation outside the room (2.1 ± 0.7 vs 3.5 ± 1.3* vs 2.5 ± 1.9 PODs, respectively; *P < 0.05), and the operation times (188 ± 43* vs 256 ± 77 vs 238 ± 59 min, respectively; *P < 0.05).ConclusionMinilaparotomy repair is a feasible technique, which combines the benefits of a small incision with those of conventional open repair. With the exception of patients with an iliac artery aneurysm extending to the external or internal iliac artery, MINI repair should be considered for the elective treatment of patients with aortic disease.

The Batista Procedure: Fact, Fiction and its Role in the Management of Heart Failure

End-stage heart failure is associated with high rates of mortality. Obviously, heart transplantation is the ultimate surgical intervention for its treatment. However, this surgical option is severely limited by immunosuppressive drug morbidity and inadequate donor organ availability. Partial left ventriculectomy, the so called Batista procedure, has been proposed for the treatment of dilated cardiomyopathy and other end-stage heart failure. Although initial reports lacked significant information on the safety and efficacy of this procedure, overall clinical impression from the reports is that the operation may serve as a relatively inexpensive bridge to transplantation especially in the patients with idiopathic dilated cardiomyopathy. In order to select an exact procedure to resect appropriate amount of scar tissue, dobutamine echocardiographic study, intraoperative volume reduction test using cardiopulmonary bypass, positron emission tomography, or magnetic resonance imaging scans can be used. To avoid the late deterioration related to the development of significant mitral valve regurgitation, definitive mitral valve repair or replacement at the time of the partial left ventriculectomy may be advised. Further study is required to determine the procedures exact role in the treatment of congestive heart failure. This would have to be a multicenter, randomized, and long-term follow-up study.

Initial Management of Acute Type-A Aortic Dissection with a Thrombosed False Lumen: A Retrospective Cohort Study

PurposeAcute type-A aortic dissection with a clotted false lumen is often managed conservatively; however, we found that surgery has a better outcome.MethodsEnhanced computed tomography (CT) showed a clotted false lumen in the ascending aorta in 38 (33.3%) of 114 patients with acute type-A aortic dissection. After the exclusion of 8 patients whose condition was too critical for comparison, 13 patients who were hemodynamically stable and did not have pericardial effusion, organ ischemia, or a dilated ascending aorta greater than 50 mm in diameter, were managed conservatively (group C) and 17 were managed surgically (group S). We compared the early and late results of both groups.ResultsThe early mortality rates were 23.1% in group C and 0% in group S (P = 0.037). The early deaths in group C were caused by redissection in the acute phase. The actuarial survival rates and dissection-related event-free rates 5 years after onset in groups C and S were 64.1% and 80.8% (P = 0.131) and 46.2% and 92.9% (P = 0.002), respectively.ConclusionThe early mortality rate and dissection-related event-free rate were better after surgery than after conservative treatment. The indications for conservative management should be limited because redissection is usually fatal.