Makoto Hibino

Simplified Management of Hemodialysis-Dependent Patients Undergoing Cardiac Surgery

BACKGROUND The mortality and morbidity rates are high after cardiac surgery in hemodialysis (HD)-dependent patients. To improve their outcomes, optimal perioperative managements should be discussed. METHODS A retrospective analysis of 245 HD patients who underwent cardiac surgery between 1994 and 2007 was conducted. The basic management strategies were (1) low-potassium HD for 2 days before surgery, (2) only hemofiltration during cardiopulmonary bypass, and (3) start of regular intermittent HD on the first postoperative day. Continuous venovenous hemodiafiltration was applied only for patients with hemodynamic instability. RESULTS The causes of renal failure included diabetic (n = 89, 36%), glomerulonephritis (n = 49, 20%), and unknown (n = 75, 31%). The history of HD was 9.7 +/- 7.6 years. The operative procedures included coronary (n = 135), valve (n = 103), and others. The amount of intraoperative ultrafiltration was 6,123 +/- 324 mL during cardiopulmonary bypass for 197 +/- 67 minutes. Two hundred eight patients (85%) were managed with only intermittent HD, whereas 36 patients (15%) needed continuous venovenous hemodiafiltration. The use of continuous venovenous hemodiafiltration significantly declined during the year (26% before 2003 and 3% after 2003; p < 0.001). The amount of fluid removal on the first postoperative day was 1,297 +/- 81 mL. The hospital mortality was 9.7% with the causes including infection (n = 11), cardiac events (n = 6), gastrointestinal events (n = 5), and stroke (n = 2). A multivariate logistic regression analysis revealed that selection of intermittent HD or continuous venovenous hemodiafiltration was not related to the hospital mortality. CONCLUSIONS Simplified management only with intermittent HD can be safely performed in most HD-dependent patients undergoing cardiac surgery.

Predictors for early and late outcomes after coronary artery bypass grafting in hemodialysis patients.

BACKGROUND Markedly higher hospital and long-term mortality after coronary artery bypass grafting (CABG) have been reported in hemodialysis (HD)-dependent patients. We tried to identify the predictors for short-term and long-term outcomes after CABG, which have not been well studied. METHODS Between 1993 and 2010, 152 patients undergoing HD (117 men; HD duration of 8.7±8.0 years) underwent isolated CABG. Our strategies included use of a single internal thoracic artery (ITA) in patients with diabetes mellitus (DM), bilateral ITAs in patients without DM, and possible avoidance of cardiopulmonary bypass (CPB) after 2003. RESULTS Thirty-six percent of patients underwent conventional CABG: 20% had on-pump beating heart procedures and 44% had off-pump procedures, with 2.8±1.0 anastomoses. Hospital mortality was 10.6% with improvement to 6.8% after 2003. Predictors for hospital death were left ventricular ejection fraction (LVEF) less than 0.40 (p=0.042), use of CPB (p=0.046), and postoperative need for continuous hemofiltration (p=0.037). After follow-up of 49±42 months, the overall survival rates were 76.9%, 60.0%, 43.9%, and 36.2% and the cardiac events-free rates were 77.0%, 70.1%, 55.9%, and 44.8% at 3, 5, 8, and 10 years, respectively, in the Kaplan-Meier model. A multivariate Cox proportional hazard model identified age older than 63 years (p=0.014), DM (p=0.036), and peripheral artery disease (PAD) (p=0.044) as predictors for late death, and DM (p=0.038) and LVEF less than 0.40 (p=0.027) as predictors for late cardiac events. CONCLUSIONS Although early outcomes have been improved by off-pump techniques, late outcomes are not satisfactory in patients who rely on HD and undergo CABG. To improve late outcomes we may need aggressive management of DM, PAD, and low LVEF in those patients.

Can we predict the site of entry tear by computed tomography in patients with acute type a aortic dissection

In patients with acute type A aortic dissection (AAD), localization of the primary entry tear to be excluded is of major importance for intervention.

Valve Selection for the Aortic Position in Dialysis Patients

BACKGROUND Prosthetic valve selection in dialysis patients remains controversial because of the limited data available. This study aimed to clarify late clinical outcomes and discuss strategies for optimal valve selection in dialysis patients. METHODS We retrospectively analyzed the data obtained from 406 consecutive patients who underwent aortic valve replacement between 1995 and 2010. We compared valve-related outcomes among 89 dialysis and 317 nondialysis patients. We selected bioprostheses for all patients older than 65 to 70 years, irrespective of the renal function. RESULTS Dialysis was found to be a significant risk factor for bleeding events (hazard ratio, 3.98; 95% confidence interval, 2.51 to 6.30; p < 0.001), however, no significant differences were observed according to the type of prosthesis. The overall survival was significantly worse in the dialysis patients (63% versus 85% at 5 years; p < 0.001), and freedom from structural valve deterioration was also lower in the dialysis patients (82% versus 100% at 5 years; p < 0.001). Among the dialysis patients, an advanced age (≥ 70 years; hazard ratio, 3.53; p = 0.011), diabetes mellitus (hazard ratio, 2.48; p = 0.041), and concomitant coronary artery bypass grafting (hazard ratio, 1.99; p = 0.071) were independent predictors for late death based on a multivariate analysis. CONCLUSIONS Our valve selection criteria in dialysis patients, which are the same as the current practice guidelines for nondialysis patients, are acceptable. Bioprostheses can be considered in all dialysis patients with diabetes or coronary artery disease.

Effects of the side of arteriovenous fistula on outcomes after coronary artery bypass surgery in hemodialysis-dependent patients.

OBJECTIVE The aim of the study was to determine whether using the in situ internal thoracic artery (ITA) graft ipsilateral to the arteriovenous fistula adversely affects the outcomes after isolated coronary artery bypass grafting (CABG) in the dialysis-dependent patients to answer the concerns of a possible steal and consequent myocardial ischemia. METHODS We categorized 155 dialysis patients undergoing isolated CABG between January 1993 and December 2011 into 108 patients (70%, ipsilateral group) whose left anterior descending artery (LAD) was revascularized with the ITA ipsilateral to the arteriovenous fistula and 47 patients (contralateral group) whose LAD was grafted with the ITA opposite to the fistula, to compare their early and late outcomes. RESULTS While 94% of the ipsilateral group had left fistula, 55% of the contralateral group had left fistulas. The LAD was grafted with the left ITA in 94% of the ipsilateral group, whereas it was grafted with left (49%) or right (51%) ITAs in the contralateral group. There was no significant difference in hospital mortality between the groups (ipsilateral 10.2% vs contralateral 10.6%). After follow-up for 55 ± 42 months, the overall survival (ipsilateral 58% vs contralateral 65% at 5 years) and cardiac event-free rates (ipsilateral 74% vs contralateral 68% at 5 years) were also similar between the groups by log-rank tests (P = .90 and P = .07). CONCLUSIONS Revascularization of the LAD using the in situ ITA graft ipsilateral to the arteriovenous fistula increases neither the operative mortality nor the risks of late death and cardiac events after isolated CABG in dialysis patients.

Long-term size follow-up of knitted Dacron grafts (Gelseal™) used in the ascending aorta

There is limited information about the size change of a knitted Dacron graft (Gelseal™) used in the thoracic aorta. We evaluated the diameters of the Gelseal™ grafts at a long-term follow-up for 3.7 ± 1.3 years (1-5.9 years; median, 4.0 years), which were used for replacement of the ascending aorta in 59 patients with acute aortic dissection. The early and late dilatation rates (LDRs) of the prosthetic grafts were calculated retrospectively based on the graft diameter at the level equivalent to the ascending aorta on the pre-discharge computed tomography (CT) scans and follow-up CT scans performed every year after surgery. Immediately after surgery (15 ± 7 days), the early dilatation of the Gelseal™ grafts was 26.0 ± 6.0% with significant correlations with the number of post-operative days (R = 0.500, P = 0.003). At the follow-up for 3.7 ± 1.3 years, the LDR was 10.5 ± 6.6%, which was also significantly correlated with the number of the post-operative years (R = 0.608, P = 0.001). Linear regression analysis indicated that the annual dilatation rate was ≈ 3.23%. During the follow-up, we have experienced no redo surgery due to graft fracture or false aneurysm formation at the anastomosis sites associated with the graft dilatation. In conclusion, the Gelseal™ graft used in the ascending aorta demonstrates a small but continuous increase in the diameter, up to 5 years after implantation, without any adverse events.

Extended total arch replacement via the L-incision approach: single-stage repair for extensive aneurysms of the aortic arch

OBJECTIVES Total arch replacement via the L-incision approach (a combination of left anterior thoracotomy and upper median sternotomy) can be used to achieve more extensive replacement. METHODS In the period between 2002 and 2014, 279 total arch replacement procedures were performed. After excluding cases of acute aortic dissection and cases involving concomitant, hybrid or frozen elephant trunk procedures, patients who underwent isolated total arch replacement via an L-incision (n = 29) and via median sternotomy (n = 143) were identified and the data pertaining to their cases were analysed. RESULTS Operative mortality was higher in the L-incision group than in the median sternotomy group (6.9 vs 2.1%); however, the difference was not statistically significant. The L-incision group displayed a higher rate of respiratory complications, including pneumonia (28 vs 7.0%, P = 0.0034), the need for tracheostomy (17 vs 2.1%, P = 0.0038) and pulmonary haemorrhage (6.9 vs 0%, P = 0.028). The rate of paraplegia was similar between the groups (0 vs 1.4%, P = 1.00), despite the wider range replaced via the L-incision approach (7.3 ± 1.5 vs 4.7 ± 0.8 anatomical zones, P < 0.001). The rates of other complications and functional recovery were similar. The long-term survival (73 vs 84% at 5 years) and aortic event-free rates (94 vs 96% at 5 years) were similar in both groups. CONCLUSIONS A combination of left anterior thoracotomy and upper median sternotomy can be applied to the single-stage repair of extended aneurysms with acceptable results in appropriately selected patients.

Superior mesenteric artery plasty for type A acute aortic dissection with visceral ischemia

Treatment of visceral ischemia complicated with acute type A aortic dissection is controversial. We had two cases of acute type A aortic dissection complicated by superior mesenteric artery (SMA) ischemia and successfully treated them with direct SMA perfusion during central aortic repair followed by SMA plasty. The presented procedures can be an option to treat visceral ischemia with a standard operative theater and equipment.

Ascending Aortic Aneurysm in a Child With Fibulin-4 Deficiency

EFEMP2 (alias FBLN4) encodes extracellular matrix protein fibulin-4, and its mutation is associated with autosomal recessive cutis laxa type 1B and leads to severe aortopathy with aneurysm formation and vascular tortuosity. A 4-month-old child presented with a large ascending aortic aneurysm, and genetic testing revealed an EFEMP2 mutation. We achieved successful repair of the ascending aortic aneurysm at 33 months of age and report the macroscopic and microscopic findings.

Entire Circumferential Reconstruction of the Right Atrium Surrounded by Angiosarcoma

Primary cardiac angiosarcomas are frequently found at a large size with infiltration into the adjacent heart structure owing to their asymptomatic characteristics until an advanced stage. Therefore, extensive resection is often required to achieve a good prognosis. We herein report a case of entire circumferential resection of the right atrium surrounded by angiosarcoma and excellent three-dimensional reconstruction of the right atrium.