Kenji Minakata

Effect of Different Methods of Internal Thoracic Artery Harvest on Pulmonary Function

BACKGROUND In several clinical studies, internal thoracic artery (ITA) grafting for myocardial revascularization has been identified as increasing the risk of postoperative pulmonary complications. This study was designed to determine whether the technique used to harvest the ITA has an effect on postoperative pulmonary function. METHODS Seventy-nine consecutive patients undergoing coronary artery bypass grafting using the left ITA were compared with patients undergoing coronary artery bypass grafting using saphenous vein grafts only. Two methods of ITA harvesting were used: (1) incision of the endothoracic fascia dissected off the ITA as a skeletonized vessel (group 1, n = 33) and (2) mobilization of the ITA as a wide musculofascial pedicle (group 2, n = 46). Thirty-two patients underwent coronary artery bypass grafting using saphenous vein grafts only (group 3). Pulmonary function tests were performed between postoperative days 20 and 30. RESULTS The postoperative values of forced vital capacity were reduced in patients in all groups (p < 0.0001). The ratios of postoperative to preoperative forced vital capacity were 84% in group 1, 77% in group 2, and 84% in group 3. The reduction in group 2 was significant compared with group 1 (p < 0.05) and group 3 (p < 0.05). CONCLUSIONS Postoperative pulmonary dysfunction was significantly greater in patients who underwent wide musculofascial pedicle dissection of the ITA compared with skeletonization of the artery. Thus, of the two techniques, the latter may be the method of choice with regard to lowering the incidence of postoperative pulmonary dysfunction.

Mycotic aneurysm of the left coronary artery.

We report a 24-year-old man with mitral valve endocarditis complicated by acute myocardial infarction due to coronary embolism. Percutaneous transluminal coronary angioplasty and subsequent mitral valve replacement were performed. Postoperative coronary angiography revealed formation of a mycotic aneurysm of the left anterior descending coronary artery at the site of balloon inflation. The patient then underwent successful resection of the aneurysm with coronary artery bypass grafting.

Two-staged treatment strategy in patients with severe carotid or cerebrovascular diseases undergoing coronary artery bypass grafting

PurposeThere is no clear consensus on how to treat patients undergoing coronary artery bypass grafting (CABG) who have severe concomitant carotidcerebral artery stenosis. The aim of this study was to evaluate our surgical results in patients with severe carotid and/or cerebrovascular disease undergoing CABG.MethodsBetween October 2003 and April 2009, a total of 47 such patients were treated at our institution with the following strategies: (1) protective carotid artery stenting for severe carotid stenosis performed either before (n = 20) or after (n = 5) CABG or (2) a superficial temporal artery-middle cerebral artery anastomosis procedure followed by CABG if indicated (n = 4). Off-pump CABG was performed in 75% of the patients. Results. There were no major perioperative strokes or in-hospital deaths; however, three patients had transient ischemic attacks and two had minor strokes during the early post-CABG period. All of the patients with postoperative cerebrovascular events had had unilateral carotid artery occlusion. There were no late deaths during the follow-up period (up to 6 years, with a mean of 27 months). However, major adverse cardiocerebrovascular events (MACCE) occurred in seven patients (14.9%). The rates of freedom from MACCE at 1 and 3 years were 92% and 74%, respectively.ConclusionIt appears that our two-staged approach is safe and may reduce the risk of postoperative cerebrovascular events.

Treatment of prosthetic valve endocarditis complicated by destruction of the aortic annulus

PurposeIt has been reported that surgical treatment for prosthetic valve endocarditis complicated by destruction of the aortic annulus is associated with high mortality and morbidity. The aim of this study was to evaluate the efficacy of our surgical strategy for this situation.MethodsBetween October 2003 and April 2009, eight patients (mean age 68.6 years) with prosthetic valve endocarditis complicated by destruction of the aortic annulus were surgically treated at our hospital. We use a relatively simple procedure consisting of a patch plasty of the abscess cavity in addition to complete removal of the infected tissue of the abscess cavity followed by standard aortic valve replacement. All patients had active endocarditis and were in New York Heart Association functional class III or IV. Preoperative echocardiography revealed that four patients had moderate or severe aortic regurgitation, and two had mitral valve endocarditis as well.ResultsThere were no operative deaths (≤30 days). Cardiac complications included paroxysmal atrial fibrillation in three patients and transient atrioventricular block in one. One patient died of multiple organ failure 66 days after the surgery. The overall in-hospital mortality was 12.5%. Patients were followed-up for 6–49 months (mean 31 months). There was no recurrent prosthetic valve endocarditis. One patient required reoperation (mitral annuloplasty and redo aortic valve replacement). There were two late deaths: lung cancer in one and multiple organ failure related to pneumonia after the aforementioned redo operation in the other.ConclusionOur simple procedure for complicated prosthetic valve endocarditis yielded excellent early and midterm outcomes.

Predictors of success of the modified maze procedure using radiofrequency device.

The modified maze procedure using radiofrequency devices has become an increasingly common surgical option for patients with atrial fibrillation. Several lesion sets have been proposed and tested, but it remains unclear which yields the best results. We studied 61 patients who underwent the modified maze procedure using radiofrequency devices from March 2005. The pulmonary veins were isolated separately on both sides, and a connecting lesion was made inferiorly in the early series of 30 patients (group 1). In 31 patients (group 2) treated from May 2007, we added a superior connecting lesion between both pulmonary veins (completing a box lesion), and also performed coronary sinus ablation from the epicardial side, using a monopolar device. At 6 months postoperatively, maintenance of sinus rhythm with and without antiarrhythmic medications was 70% and 63%, respectively in group 1, and 94% and 90% in group 2 (both p < 0.05). Multivariate analysis indicated that the box lesion with coronary sinus ablation was an independent predictor of the maintenance of sinus rhythm at 6 months. These 2 lesions should not be eliminated from the modified maze procedure.

COMPARISON OF 5-YEAR CLINICAL OUTCOMES IN ASYMPTOMATIC VERSUS SYMPTOMATIC PATIENTS WITH SEVERE AORTIC STENOSIS UNDERGOING AORTIC VALVE REPLACEMENT

Current guidelines generally recommend the strategy of watchful waiting for aortic valve replacement (AVR) until symptoms emerge in asymptomatic patients with severe aortic stenosis (AS). However, there is no previous large-scale study evaluating the impact of symptomatic status on the long-term

A Case of Penetrating Atherosclerotic Ulcer Treated With Thoracic Endovascular Aortic Repair.

Penetrating atherosclerotic ulcer (PAU) is defined as ulceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media.1–3 PAU accounts for 2% to 7% of all acute aortic syndrome.4 PAU is at risk of intramural hematoma, pseudoaneurysm, aortic rupture, or an acute aortic dissection.5 Symptomatic PAU has to be assumed to indicate an emergency because the adventitia is reached and aortic rupture is expected.5 The rupture rate of symptomatic PAU has been reported to be as high as …

Complete rupture of the anterolateral papillary muscle complicated with acute myocardial infarction due to diagonal branch occlusion

It is well known that post-infarction papillary muscle rupture of the anterolateral papillary muscle is less frequent than that of the posteromedial papillary muscle. This is thought to be due to a difference in blood supply (single vs dual) of the papillary muscles. Recently, we had two cases in which occlusion of the diagonal branch of the left anterior descending artery was found to be the culprit lesion of acute myocardial infarction leading to complete rupture of the anterolateral papillary muscle. Herein, we report on these two rare successful surgical cases with some review of the literature.

Asymptomatic vascular rings of aorta in adult cardiac surgery patients.

A 70-year-old man presented with recurrent exertional chest oppression. His history included insulin-dependent diabetes, systemic hypertension, hypercholesterolemia, minor stroke, and myocardial infarction with a subsequent percutaneous catheter intervention. Coronary angiography showed severe 3-vessel disease with significant left main stenosis. A double aortic arch was identified incidentally by multidetector computed tomography (Figure 1). Both arches arose from the ascending aorta, gave rise to the common carotid and subclavian arteries, encircled the trachea and esophagus, and joined the descending aorta. The distal ascending aorta and Figure 1. Multidetector computed tomography demonstrating double aortic arch. The aortic arches were balanced and gave rise to the common carotid and subclavian arteries on each side.