Motoshige Yamasaki

Complement Activation in Cardiopulmonary Bypass, with Special Reference to Anaphylatoxin Production in Membrane and Bubble Oxygenators

Complement activation by cardiopulmonary bypass (CPB) was studied in 82 patients divided into membrane (MOG) and bubble oxygenator groups (BOG). The influence of primed homologous to circulating autologous blood volume (H/A) ratio was also evaluated. C4a increased very slowly during CPB in both groups, maintaining slightly higher levels in the BOG than in the MOG, with the exception of a marked initial rise in the BOG with a high H/A ratio (greater than or equal to 20%). Anaphylatoxin C3a levels increased more steeply in the BOG than in the MOG. An obvious rise in anaphylatoxin C5a production was observed in the BOG alone. The influence of high H/A ratio perfusion on complement activation was milder in the MOG than in the BOG. In 20 monkeys (Macaca fascicularis), continuous intraaortic infusion with bubbled autologous blood increased C4a and C3a levels, while autologous blood extracorporeally contacted with nylon increased C3a levels alone. In vitro studies revealed that human immunoglobulin fractions denatured by oxygen bubbling produced C4a, C3a, and C5a in a dose-dependent manner, although human albumin treated identically as human immunoglobulin did not produce these complements. It was thus inferred that (1) during CPB, complement is predominantly activated via the classical pathway in the BOG and via the alternative pathway in the MOG; (2) higher anaphylatoxin levels in the BOG than in the MOG are related to mode and grade of blood trauma; (3) anaphylatoxin level differences in both groups tend to increase with high H/A perfusion; and (4) immunoglobulin-free sera may reduced classical pathway activation.

Coronary artery bypass grafting in patients on chronic hemodialysis: surgical outcome in diabetic nephropathy versus nondiabetic nephropathy patients

BACKGROUND The presence of diabetes mellitus adversely affects the late survival of patients undergoing coronary artery bypass grafting (CABG). The purpose of this study is to clarify the role of diabetic nephropathy on outcomes of a group of patients on chronic hemodialysis undergoing CABG. METHODS Between April 1984 and July 1999, 45 patients on chronic hemodialysis underwent CABG. Forty-three had conventional CABG and 2 had off-pump CABG. There were 37 males and 8 females, and the mean age was 57 years (43 to 76 years). Twenty-one patients had diabetic nephropathy (group D) and 24 had nondiabetic nephropathy (group ND). Early and late results were determined in both groups. RESULTS Early outcome was not significantly different between the groups. There was no hospital mortality, stroke, or requirement for prolonged mechanical ventilation (>24 hours) in either group. No patients in group D, and only 1 (4.2%) in group ND had low cardiac output syndrome. The difference in the incidence of arrhythmias (23.8% in group D and 25% in group ND), wound infections (9.5% in group D and 8.3% in group ND), and delayed tamponade (5% in group D and 12.5% in group ND) was not statistically significant. However, late results differed significantly between the two groups. Actuarial survival (Kaplan-Meier) at 5 and 9 years was 22.9% and 11.5% in group D and 89.1% and 45.7% in group ND (p = 0.01), respectively. Similarly, the cardiac event-free rate at the same intervals was 50.4% and 0% for group D and 100% and 65.8% for group ND (p = 0.001), respectively. CONCLUSIONS Using present technology, CABG can be done in patients on chronic hemodialysis with acceptable early mortality and morbidity. Late results in patients with diabetic nephropathy on hemodialysis are not as favorable as their nondiabetic cohort.

EuroSCORE predicts postoperative mortality, certain morbidities, and recovery time

EuroSCORE (European System for Cardiac Operative Risk Evaluation) used for calculating the risk of the postoperative mortality rate for patients undergoing open-heart surgery may be able to predict postoperative complications as well. Consecutive cases of isolated on-pump coronary artery bypass grafting (CABG) (n=1552) performed between 1991 and 2006 at our hospital group were placed into a systematic database. Patients were stratified using additive EuroSCORE. Incidence of postoperative mortality, morbidity (bleeding, heart failure, mediastinitis, pneumonia, myocardial infarction, renal failure, and stroke), and recovery time (intubation time, ICU stay, and postoperative length of stay) was assessed in each EuroSCORE group. EuroSCORE was well correlated with mortality, total incidence of major complications, heart failure, renal failure, stroke, pneumonia and mediastinitis, and three parameters of recovery time. Postoperative myocardial infarction and incidence of bleeding were not correlated with EuroSCORE. EuroSCORE can predict not only mortality but also postoperative complications and recovery time.

The Use of Enclose ® II Anastomosis Assist Device for the Proximal Coronary Branch Anastomosis to Vascular Graft

We used the Enclose(®)II anastomosis assist device (Novare Surgical Systems, Inc., CA, USA), which was originally developed as an ancillary device for proximal anastomosis in off-pump coronary artery bypass grafting (OPCAB), to assist anastomosis for the vascular grafts without clamping those conduits in two cases. In these cases, it was difficult to clump vascular graft partially, because vascular graft was short. So we used Enclose(®)II anastomosis assist device for these cases. The advantage of this method is that the Enclose(®)II anastomosis assist device facilitates the anastomosis of arterial side branches to the artificial graft (1) by eliminating the use of partial clamp on the artificial conduits and (2) by providing a plane surface for easy handling for suture.

Repair of complete atrioventricular septal defect with severe pulmonary hypertension -effect of re-pulmonary artery banding and analysis of lung biopsy a case report-

We report a case complete atrioventricular defect with severe pulmonary hypertension. The patient was a girl aged 2 years and 6 months with Downs syndrome who had undergone pulmonary artery banding (PAB) 2 years previously. Postoperative catheterization after PAB showed severe pulmonary hypertension. Pulmonary resistance values were 9.3 and 7.3 units at 1 year and 5 months and 1 year and 9 months respectively. We performed re-PAB and lung biopsy when the patient was 2 years and 6 months old. The biopsy specimen at re-PAB classified as Heath-Edwards grade 3 and had an IPVD score of 1.7, indicating tolerance to radical operation. Six months after re-PAB, pulmonary vascular resistance decreased a level at which radical operation could be performed safely. Radical operation was performed 1 year and 4 months after re-PAB. The post operative course was uneventful, and pulmonary hypertensive crisis did not occur. The lung biopsy at the final operation was classified as Heath-Edwards grade 3, had an IPVD score of 1.1, and showed improvement when compared with the pathological findings at re-PAB.

Surgical outcomes of aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection

OBJECTIVES To evaluate the surgical outcomes of aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection. METHODS Between 2008 and 2015, a total of 300 patients with acute Type A aortic dissection underwent emergency surgery, consisting of 271 hemiarch repairs and 29 total aortic arch replacements, using transapical cannulation and the adventitial inversion technique at a distal anastomosis. The mean follow-up periods were 31.7 ± 25.2 months. Overall, 18% (54/300) of the patients were octogenarians, and 21.7% (65/300) had cardiac tamponade; 25% (75/300) had preoperative malperfusion. RESULTS The in-hospital and 30-day mortality rates were 8.3% (25/300) and 6.7% (20/300), respectively. The 30-day mortality rate was 2.7% (6/225) among patients without preoperative malperfusion and 18.7% (14/75) among patients with malperfusion (P < 0.0001), 7.4% (4/54) among octogenarians and 6.5% (16/246) among patients aged less than 80 years (P = 0.81), and 6.3% (17/271) among patients treated with hemiarch repair and 10.3% (3/29) among patients treated with total aortic arch replacement (P = 0.403). Preoperative malperfusion was an independent predictor of perioperative mortality in a multivariable analysis. During the follow-up period, distal reintervention was performed in 11% (33/300) of the patients. The rates of freedom from reintervention at 1, 3 and 5 years were 95.9%, 88.9% and 80.0%, respectively. The overall survival rates at 1, 3 and 5 years were 88.7%, 86.7% and 82.0%, respectively. The in-hospital mortality rate for elective reintervention was 3.0% (1/33). CONCLUSIONS Aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection provides good early and mid-term results. The safety of elective distal reintervention can be guaranteed. To obtain better operative outcomes, effective treatment for cases with malperfusion is mandatory.

Lower Mini-Sternotomy for Direct Coronary Artery Bypass on the Beating Heart.

小切開心拍動下冠状動脈バイパス術 (MIDCAB) が急速に広まり, 内胸動脈を用いた左前下行枝 (LAD) への1枝バイパス術では左前小開胸 (LAST) アプローチが一般的になった. しかし内胸動脈の剥離, 術野の stabilizing, 術後の疼痛などまだ問題点も多い. 当科では手術をより安全・確実に施行するため, また疼痛の軽減を目的として, 胸骨小切開によるMIDCABを4例施行した. 症例は58歳から75歳の男性で, このうち3例がLAD1枝病変で, 1例が脳血流障害を合併した3枝病変であった. 全例手術中に体外循環への移行もなく, 合併症なく終了し, 術後のグラフト造影は全例良好に開存していた. 疼痛の訴えは軽度で創部の問題もなく, 術後5～11病日に全員退院した. 胸骨小切開法はLAST手術に比べ手術手技が容易で, 痛みも少なく美容上も満足できるものであった.