ino K

Single-stage repair of aortic coarctation with ventricular septal defect using isolated cerebral and myocardial perfusion

OBJECTIVE To avoid hypothermic circulatory arrest, we have repaired aortic coarctation with ventricular septal defect (VSD) in a one-stage procedure using an isolated cerebral and myocardial perfusion technique, and retrospectively compared this novel approach to the conventional two-stage approach. METHODS Between October 1991 and February 1999, 24 infants, aged 4-137 days (median, 27 days) and weighing 1.7-4.3 kg (median, 3.0 kg), underwent the repair of aortic coarctation with VSD either in one (group I, n=11) or two stages (group II, n=13). In Group I, an arterial cannula for cardiopulmonary bypass was inserted into the ascending aorta in six patients with coarctation only, or into a polytetrafluoroethylene (PTFE) graft which was anastomosed to the innominate artery in the remaining five who had hypoplastic arches. A cross-clamp was placed between the innominate and left carotid arteries. The bypass flow was reduced to 30-50% of full flow at 28 degrees C, thereby maintaining a radial artery pressure of 30-45 mmHg. At this point, the aortic coarctation was repaired by an end-to-end arch anastomosis, while maintaining brain perfusion and with the heart still beating. In five patients with hypoplastic aortic arches, the innominate artery proximal to the graft was then secured down and the arch anastomosis was extended to the distal ascending aorta, while providing isolated cerebral perfusion and cardioplegic arrest. After arch reconstruction was performed, the clamp was moved onto the ascending aorta, and the VSD was closed with systemic perfusion. In contrast, for group II patients, coarctation repairs were performed through a posterolateral approach, and existing VSDs were closed as secondary procedures. RESULTS The mean isolated cerebral and myocardial perfusion time for group I was 13 min (range, 7-20 min). The myocardial ischemic time did not differ between groups I and II (43+/-4 vs. 42+/-5 min, not significant). There were no hospital mortalities or neurological complications in either group, but one late death in each group. CONCLUSION Single-stage repair of aortic coarctation with VSD does not increase myocardial ischemic time compared to the traditional two-stage approach. The isolated cerebral and myocardial perfusion technique may offer substantial brain and myocardial protection during aortic arch reconstruction.

Late aneurysm after subclavian flap aortoplasty for coarctation of the aorta

Late aneurysms are common after repair of coarctation of the aorta by prosthetic patch aortoplasty but are rare after subclavian flap aortoplasty. We present the case of a 14-year-old boy who underwent a grafting procedure for a descending thoracic aortic aneurysm after subclavian flap aortoplasty for coarctation of the aorta when he was 2 years old. This is the fifth report of late aneurysm formation after subclavian flap aortoplasty.

The use of a biventricular assist device for postcardiotomy profound biventricular failure.

A 58-year-old woman who could not be weaned from cardiopulmonary bypass was treated with a biventricular assist device (BVAD) using a centrifugal pump for the left side and a pneumatic pulsatile pump for the right side. At the initiation of the BVAD support, predominant right ventricular failure was recognized and therefore weaning was begun from the left side. The left ventricular assist device was discontinued after 87 h and the patient was finally weaned from the right ventricular assist device after 205 h. Despite the complete recovery of cardiac function, the patient developed renal failure followed by an intractable infection and died of multiple organ failure on the 59th postoperative day (POD).

Multivessel coronary revascularization with bilateral internal thoracic artery grafts

Sixteen patients underwent coronary revascularization with bilateral internal thoracic artery (ITA) grafts between 1988 and 1989 at the Okayama University Hospital. A total 39 coronary grafts were performed, being an average of 2.4 grafts per patient. Each patient received bilateral ITA grafts, and in 5 patients an additional 7 grafts were constructed with 5 autologous veins and 2 gastroepiloic arteries. The right ITA was grafted as a free graft in 4 patients. The ITA graft patency rate was 96.8 per cent (31/32) at the time of hospital discharge. The postoperative morbidity included one reoperation for bleeding and one myocardial infarction. Coronary artery bypass grafting with bilateral ITA grafts can be safely performed and its application facilitates complete revascularization with arterial grafts.

Cardiac Functions in Long-Term Survivors of Mechanical Circulatory Support

Over the last 5 years, 12 patients (7 males and 5 females, aged 22–73 years; mean age, 54) in our institutions received ventricular assist devices (VADs) while in post-car diotomy shock. Eight patients underwent surgery for valve replacements, three for coronary artery bypass graftings and one for ventricular septal rupture (VSR) closure. The duration of VAD support ranged from 6 h to 9 days (mean, 4.2 days). Ten patients were weaned from the VADs and six survived. The six survivors were followed-up for 4–42 months (mean, 25 months); five were in New York Heart Association (NYHA) class I and one in class II. The cardiac functions in five patients who lived for more than 1 year were assessed by ultrasonic echocardiography (UCG). Pre- and postoperative UCG revealed that the ejection fraction (EF) increased from 41.7 ± 6.4% to 57.5 ± 11.3 (P < 0.01), the mean velocity of circumferential fiber shortening (mVcf) increased from 0.76 ± 0.26c/s to 0.92 ± 0.35 (P < 0.01), the left ventricular diastolic dimension (LVDd) decreased from 63.0 ± 16.4mm to 52.4 ± 10.3 (P < 0.05), and the left ventricular systolic dimension (LVDs) decreased from 48.8 ± 16.6mm to 36.8 ± 9.6 (P < 0.05). However, the patients did not show further changes in these parameters during exercise. Eight patients who had double valve replacements were observed for comparison (control group). In the control group, exercise improved cardiac output, from 4.63 ± 0.791/min to 8.05 ± 1.34 (P < 0.01), and mVcf, from 1.02 ± 0.19c/s to 1.72 ± 0.41 (P < 0.01). We concluded from these findings that VAD patients, as compared to the control patients, exhibited improvement in postoperative cardiac functions, but had lower tolerance in exercise tests.