Kazuya Fujinaga

Ultrafiltration of the priming blood before cardiopulmonary bypass attenuates inflammatory response and improves postoperative clinical course in pediatric patients.

ABSTRACT The priming solution using in cardiopulmonary bypass (CPB) for infants undergoing cardiac surgery includes considerable amounts of stored blood. Our objective was to test the hypothesis that ultrafiltration (UF) of the stored blood before CPB reduces the unfavorable effects of stored blood and the production of inflammatory cytokines. Fifty pediatric patients with congenital heart defects took part in this study. The patients were randomly divided into two groups: the UF (27 pediatric patients who received UF) and control (23 pediatric patients who did not receive UF) groups. UF was performed with a polysulphone ultrafiltrator before CPB. Blood samples were collected immediately before, during, and 1 h after CPB. The levels of cytokines (TNF‐&agr;, IL‐1&bgr;, IL‐8), NH3, and bradykinin were determined. The serum concentrations of NH3 and bradykinin decreased significantly after UF. Compared with the control group, the UF group had significantly lower cytokine production. Water balance in UF group was better than that of control group. The UF group received significantly less inotropic support and shorter duration of ventilator support and ICU stay. We conclude that removal of bradykinin and a decrease in the levels of NH3, potassium, and pH play a significant role in reducing water retention and postoperative lung injury. UF of the blood used to prime the circuit for CPB is a safe and efficient method for use in open heart surgery in small pediatric patients.

Biocompatibility of silicone-coated oxygenator in cardiopulmonary bypass

BACKGROUND This study was designed to analyze the biocompatibility of silicone-coated oxygenators using inflammatory response as the outcome measure, and to investigate whether the silicone-coated oxygenators perform better in terms of postoperative organ dysfunction. METHODS The 32 patients who underwent cardiopulmonary bypass (CPB) were divided into 3 groups: group A (n = 10), heparin-coated circuit with silicone-coated oxygenator; group B (n = 11), whole heparin-coated circuit; and group C (n = 11), whole untreated circuit. The plasma concentrations of the proinflammatory markers, made of inflammatory cytokines (tumor necrosis factor-alpha, interleukin-1beta, interleukin-6, interleukin-8), terminal complement complex (C5b-9), and polymorphonuclear elastase (PMN-E), were measured by enzyme-linked immunosorbant assay. RESULTS All proinflammatory markers were significantly lower in groups A and B than in group C, especially C5b-9 and PMN-E concentrations, which were significantly lower in group A than in group B. The alveolar-arterial oxygen gradients (A-aDO2) and the respiratory index were significantly better in group A than in group C. In group B, however, only the A-aDO2 was significantly better than in group C. The duration of intubation and the length of stay in the intensive care unit stay were significantly shorter in groups A and B than in group C. CONCLUSIONS Silicone-coated oxygenators are biocompatible and prevent postoperative organ dysfunction.

Method of cell transplantation promoting the organization of intraarterial thrombus.

Background—Endovascular aortic repairs have been developed as less invasive treatments for aortic aneurysms. Some aneurismal cavities, however, remain without organization, causing a re-expansion of the aneurysms. We studied cell transplantation into the aneurismal sac to promote the organization of thrombus for the complete healing of aneurysms. Methods and Results—Skin fibroblasts and skeletal myoblasts were isolated from rats for cell transplantation. An intraarterial thrombus model was made by ligation of the carotid artery. Culture medium (medium group, n=11), collagen gel (gel group, n=11), fibroblasts with collagen gel (F group, n=15), myoblasts with collagen gel (M group, n=12), or mixture of fibroblasts and myoblasts with collagen gel (F+M group, n=14) were injected into the thrombus. After 28 days, histologically, the arterial lumens of the F and M groups were partly filled with fibrous tissues, whereas in the F+M group organization was almost completed and luminal sizes diminished. Immunohistochemical staining demonstrated that α-smooth muscle actin-positive cells were more abundantly contained in the organized area of the F+M group than in the other groups. We also analyzed cellular function in vitro with immunofluorescence; coculture of fibroblasts and myoblasts showed that the fraction of α-smooth muscle actin-positive fibroblasts increased. This phenomenon accounts for the rapid organization of thrombus in the F+M group in vivo. Conclusions—Cell transplantation accelerated thrombus organization. Especially, myoblasts enhanced differentiation of fibroblasts into myofibroblasts, contributing to rapid thrombus organization. Cell transplantation into unorganized spaces seems applicable to endovascular treatment of aneurysms.

Determinants of recurrent tricuspid regurgitation following tricuspid valve annuloplasty during mitral valve surgery

The purpose of this study was to determine risk predictors for recurrent tricuspid regurgitation (TR) following tricuspid valve annuloplasty during mitral valve surgery.

Use of a new venous cannula for minimally invasive cardiac surgery.

Interest in minimally invasive cardiac surgery (MICS) for cardiac disease continues to increase, because it causes less surgical trauma and produces a better cosmetic appearance. We introduced the transxiphoid approach without sternotomy for correction of congenital heart defects. To improve exposure of the cardiac lesion during MICS, we developed a new venous cannula that is made of wire reinforced silicone, with an inflatable balloon attached at the tip. The advantages of this cannula are its extreme flexibility and that a tape does not need to be placed around the vena cava. During a period of 12 months, eight children underwent closure of atrial septal defects. The approach consisted of a 4 to 5 cm low midline incision with division of the xiphoid only. The new venous cannula was used as the superior vena cava cannula, all the patients survived the operation. This new venous cannula provided better exposure during cardiac surgery through a limited incision and is beneficial for minimally invasive cardiac surgery.

Neuroprotective effect of pressure-oriented flow regulation and pH-stat management in selective antegrade brain perfusion during total aortic arch repair

OBJECTIVES The aim of this study was to assess the safety and effectiveness of our selective antegrade brain perfusion (SABP) strategy, which is characterized by moderate hypothermic and low-pressure management under pH-stat using a completely closed cardiopulmonary bypass circuit with a single centrifugal pump. METHODS Forty-nine consecutive patients (median age, 74) underwent total aortic arch replacement using a 4-branched graft. SABP was conducted with individual cannulation in all arch vessels. The SABP flow rate was monitored, and the flow rates of each arch vessel were also measured in patients with available data. RESULTS One patient died of cerebral infarction, and 7 had transient neurological deficits without apparent findings on postoperative imaging studies and without residual sequels at hospital discharge. The operation, cardiopulmonary bypass, cardiac arrest, circulatory arrest and SABP times were 327 min (interquartile range, 292-381), 211 (184-247), 107 (84.8-138.3), 54.0 (48-68) and 137 (114-158), respectively. The total flow of the SABP was 18.1 ml/kg/min (15.7-20.9). The flow rates of the brachiocephalic, the left carotid and the left subclavian arteries were 9.5 ml/kg/min (7.7-11.5), 4.2 (2.8-5.7) and 4.5 (3.7-5.5), respectively. Only the flow rate of the brachiocephalic artery was significantly correlated with the total SABP flow rate (Spearman rank correlation coefficient, r = 0.58, P < 0.01). CONCLUSIONS The moderate hypothermic, high-flow, low-pressure SABP strategy with pH-stat management can be applied in adult aortic surgery; however, the feasibility and effectiveness of this concept need further evaluation in a prospective controlled study.

Emergency Off-Pump Coronary Artery Bypass Graft Surgery for Patients on Preoperative Intraaortic Balloon Pump

BACKGROUND The aim of this study was to investigate early and long-term outcomes of patients with acute coronary syndrome preoperatively requiring intraaortic balloon pump support who underwent emergency off-pump coronary artery bypass graft surgery. METHODS One hundred and fifteen patients on preoperative intraaortic balloon pump receiving emergency off-pump coronary artery bypass graft surgery over an 11-year period were evaluated. The median age was 71 years (range, 33 to 87). Acute myocardial infarction and unstable angina were present in 54 patients (47.0%) and 61 patients (53.0%), respectively. Left main disease and triple-vessel disease without left main involvement were present in 74 patients (64.3%) and 33 patients (28.7%), respectively. RESULTS There were 3 perioperative deaths. Complete surgical revascularization was accomplished in 82 patients (71.3%), and in situ internal thoracic artery graft was used in 96 (83.5%). Late survival, freedom from major adverse cardiac and cerebrovascular events, and freedom from repeat revascularization rates at 5 years were 83.3%, 73.5%, and 84.2%, respectively. The Cox multivariate prognostic predictors of total mortality were preoperative renal impairment (hazard ratio [HR] 7.90; 95% confidence interval [CI]: 3.06 to 20.4) and low ejection fraction (HR 0.94, 95% CI: 0.88 to 0.99). The multivariate risk predictors of major adverse cardiac and cerebrovascular events were preoperative renal impairment (HR 2.68, 95% CI: 1.00 to 7.19) and peripheral vascular disease (HR 2.81, 95% CI: 1.05 to 7.51), and complete revascularization was protective (HR 0.39, 95% CI: 0.19 to 0.81). The multivariate risk factor of repeat revascularization was previous percutaneous coronary intervention (HR 3.26, 95% CI: 1.14 to 9.33), and complete surgical revascularization was also protective (HR 0.30, 95% CI: 0.11 to 0.85). CONCLUSIONS Off-pump coronary artery bypass graft surgery is a feasible option for patients requiring preoperative intraaortic balloon pump support.

Hemodynamic performance of the Edwards Prima Plus stentless valve at 1 year

PurposeThe Edwards Prima Plus stentless valve bioprosthesis (EPPSV) is a porcine aortic root cylinder with resected coronary ostia, fixed in glutaraldehyde at low pressure, and chemically treated to prevent calcification. Utilization of this valve was approved in January 2005 in Japan. The purpose of this study was to evaluate the early hemodynamic performance of EPPSVs in our experience.Materials and methodsFrom April 2005 to January 2006, a total of 21 patients underwent aortic valve replacement with EPPSVs. The hemodynamic performance of EPPSVs was evaluated at the time of discharge (2 weeks) and at 1 year by transthoracic two-dimensional Doppler echocardiography.ResultsThere was one non-valve-related early death and one non-valve-related late death. Hemodynamic data were available for comparison from the time of discharge and at 1 year postoperatively in 19 patients (mean valve size 22 ± 1 mm). Hemodynamic follow-up showed a significant decrease in the peak and mean transvalvular pressure gradients at discharge (37 ± 16 and 18 ± 8 mmHg, respectively) and 1 year postoperatively (25 ± 7 and 12 ± 4 mmHg, respectively) (P < 0.01). The effective orifice area increased significantly between the time of discharge (1.31 ± 0.31 cm2) and 1 year (1.57 ± 0.37 cm2) (P < 0.05) postoperatively. The left ventricular mass index was significantly reduced from the time of discharge (167 ± 49 g/m2) to 1 year postoperatively (126 ± 47 g/m2) (P < 0.001).ConclusionEPPSVs have been associated with high early transprosthetic gradients. Such gradients tend to regress, with significant improvement at 1 year and concomitant regression of left ventricular hypertrophy.

Cardiovascular surgery in chronic hemodialysis patients

Abstract Renal failure increases the morbidity and mortality of patients undergoing cardiac surgery. To investigate the adequacy of perioperative management and intraoperative techniques for cardiac operations, we retrospectively analyzed data from 25 patients (4 women and 21 men, with a mean age of 57.4 ± 7.7 years) with chronic renal failure who underwent cardiovascular surgery. The hospital mortality rate was 8.0%. Eleven postoperative complications were observed in 25 patients. The main complications were low cardiac output syndrome (with intraaortic balloon pump insertion in 4 cases), postoperative gastrointestinal tract bleeding (3 cases), and mediastinitis (2 cases). These results demonstrate that preoperative chronic renal failure increases mortality and morbidity; however, good operative outcome can be obtained with careful perioperative management.

A Long-term Survival Case After Removal of Synchronous, Multiple, Brain Metastases Followed by Resection of Lung Cancer.

Background. Brain metastases represent the most serious complication in lung cancer, and synchronous multiple brain metastases from lung cancer have been considered to indicate an unfavorable prognosis. Case. A 60-year-old man was seen for evaluation of a severe headache. A CT scan of the brain demonstrated multiple tumors in the right parietooccipital and frontotemporal regions. A chest X-ray revealed an abnormal shadow in the apex of the right lung, and a CT scan revealed a 1.4•~1.2cm mass with spiculation in the right S1 region. The patient underwent right occipitotemporal and frontal craniotomy, and two masses were completely removed. Then, he received wholebrain radiation therapy. Six weeks later, he underwent right upper lobectomy. Histologically, the lesions of both the brain and the lung were squamous cell carcinomas, and brain tumors proved to be metastatic tumors from the lung cancer. He has been well with no evidence of recurrence for 7 years. Conclusion. Synchronous oneset of multiple brain metastasis from lung cancer does not necessarily represent an unfavorable prognosis, and combined resection with radiation therapy can provide long-term survival in selected patients. (JJLC. 2002; 42: 45-49) KEY WORDS-Lung cancer, Synchronous multiple brain metastasis, Combined resection, Long-term survival 1 三 重 大学 医学 部 胸部 外 科. 別 刷 請 求先:藤 永 一 弥,三 重 大 学 医学 部 胸 部外 科,〒514-8507 三 重 県 津 市 江 戸 橋2-714 (e-mail: kazu9911@clin.medic.mie-u.ac. jp). 1 Thoracic and Cardiovascular Surgery , Mie University School of Medicine, Japan. Reprints: Kazuya Fujinaga, Department of Thoracic and Cardiovascular Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu-shi, Mie 514-8507, Japan (e-mail: kazu9911@clin. medic.mie-u.ac.jp). Received October 24, 2001; accepted January 7, 2002. (c) 2002 The Japan Lung Cancer Society Japanese Journal of Lung Cancer-Vol 42, No 1, Feb 20, 2002-www.haigan.gr.jp 45 Long-term Survival Case of Lung Cancer With Synchronous Brain Metastases-Fujinaga et al