Norihiro Kondo

Left atrial maze procedure: A useful addition to other corrective operations

BACKGROUND The left atrial maze procedure is performed to treat atrial fibrillation (AF), mainly in patients with mitral valve disease. In this study, we assessed the midterm results of this procedure and clinically analyzed predicting factors for postoperative persistent AF. METHODS From June 1997 to May 2001, the left atrial maze procedure was performed on 31 patients (29 with mitral valve disease and 2 lone AF). For purposes of analysis, patients were divided postoperatively into those with persistent atrial fibrillation (AF) and those with sinus rhythm (SR), except 2 patients who required pacemaker implantation for sinus node dysfunction. Over a follow-up period of more than 12 months, patients were compared based on their preoperative and intraoperative variables. RESULTS At discharge, the success rate was 89.7%. The midterm rates (total of 94.9 patient-years of follow-up) of sinus rhythm and freedom from AF were 72.4% and 79.3%, respectively. There were significant differences in duration of AF, voltage of f-wave at first precordial lead of electrocardiogram, and cardiothoracic ratio between the SR and AF groups. CONCLUSIONS Our midterm results suggest that the left atrial maze procedure is an effective alternative adjunct procedure for elective open heart surgery to treat AF, depending upon the patients clinical condition.

Coronary artery bypass surgery by the transdiaphragmatic approach.

BACKGROUND The transdiaphragmatic approach is useful for reoperative coronary artery bypass grafting involving the right coronary artery because it does not require median sternotomy or cardiopulmonary bypass. METHODS Twenty-one patients underwent coronary artery bypass surgery by the transdiaphragmatic approach. The ratio of first operations to reoperations was 7:14. The cause of reoperation was occlusion of a saphenous vein graft in 4 patients, right gastroepiploic artery graft failure in 3 patients, and a new sclerotic lesion in the right coronary artery in 7 patients. When the radial artery or saphenous vein was used, grafting extended from the origin of the gastroduodenal artery to the right coronary artery. RESULTS None of the patients died during surgery. The sites of anastomoses were as follows: right coronary artery in 11 patients, right posterior descending artery in 9 patients, and the atrioventricular node artery in 1 patient. The following types of grafts were used: right gastroepiploic artery in 17 patients, saphenous vein in 2 patients, and radial artery in 2 patients. CONCLUSIONS When reoperative coronary surgery involving the right coronary artery is necessary, the transdiaphragmatic technique is effective because it does not damage patent grafts placed during the primary operation.

Left thoracotomy approach in reoperative off-pump coronary revascularization: bypass grafting from the left axillary artery or descending thoracic aorta.

OBJECTIVE Reoperative coronary bypass grafting is at high risk. Particularly in redo cases where the patent graft is running near the midline of the sternum, the graft may be exposed to injury by a median sternotomy and subsequent dissection. Whereas, off-pump bypass grafting from the left axillary artery or descending thoracic artery by a left thoracotomy approach is safe for preventing graft damage. METHODS From March 1998 to February 2002, we performed off-pump coronary artery bypass grafting by a left thoracotomy approach in 9 patients. The left axillary artery was used as the inflow vessel in 4 cases, and the descending thoracic aorta in 5. RESULTS The radial artery was anastomosed proximally to the axillary artery in 4 cases and the descending thoracic aorta in one case. The saphenous vein graft was anastomosed proximally to the descending thoracic aorta in 4 cases. Transdiaphragmatic minimally invasive bypass grafting for the right coronary artery was simultaneously performed in 3 cases. Postoperative cardiac events were ventricular arrhythmia in 6 cases and supraventricular arrhythmia in 3 cases. There was no damage to the patent grafts. Postoperative coronary angiography performed in 8 cases revealed all the grafts to be patent without stenosis. Cardiac symptoms were not found after the operation in any of the cases. CONCLUSIONS These procedures can prevent the injury to patent grafts caused by a median sternotomy, and will be one of the useful strategies for reoperative off-pump coronary artery bypass grafting.

Surgical Repair of Arteriovenous Fistula Associated with Iinfrarenal Aorto-iliac Aneurysm: Report of Two Contrasting Cases.

We present two cases of arteriovenous fistulas associated with aneurysms of the infrarenal aorta or common iliac artery. A definitive diagnosis is sometimes difficult given the varied and unclear presentation. However, with the correct preoperative diagnosis, mortality can be reduced. Both cases, being reported here, were diagnosed preoperatively and underwent alternate surgical repairs. One case was treated by aortic exclusion, whereas the second case was treated by primary closure of the fistula. Repair techniques were chosen based on acuity of presentation. Given our experience with these two cases, we conclude that direct closure is possible but dependent on the chronicity of the lesion.

Coronary artery bypass via diaphragmatic approach with free graft.

To avoid injury to patent bypass grafts or myocardium during median sternotomy in coronary artery bypass graft reoperation, we performed modified minimally invasive direct coronary artery bypass to the right coronary artery via diaphragmatic approach using the right gastroepiproic artery. In cases in which the right gastroepiproic artery cannot be used, this technique is performed with a free graft from the gastroduodenal artery. This approach is very useful for reoperation in these circumstances.

Reoperative Coronary Artery Bypass Surgery: Avoiding Repeat Median Sternotomy

BACKGROUND Mortality and morbidity in reoperative coronary artery surgery are considered to be higher than those for initial surgery. Contributing factors include cardiac injury and damage to patent grafts in repeat median sternotomy. To avoid these complications, reoperative cases were performed off pump to avoid repeat median sternotomy. METHODS The study subjects were 79 patients who underwent reoperations while utilizing off-pump coronary artery bypass grafting to avoid the need for repeat median sternotomies. All operations were performed by the same surgeon in the period from January 1996 to December 2010. RESULTS The mean duration from initial surgery to reoperation was 6 years and 5 months. Reported reasons for reoperation were de novo coronary lesion in 16 patients, graft failure in 33 patients, and de novo coronary lesion plus graft failure in 47 patients. All cases underwent surgery off pump. The approach was left anterior small thoracotomy (35 patients), transdiaphragmatic approach (21 patients), left posterolateral thoracotomy (9 patients), left anterior small thoracotomy plus transdiaphragmatic approach (9 patients), left posterolateral thoracotomy plus transdiaphragmatic approach (4 patients), and small median sternotomy plus left anterior small thoracotomy (1 patient). There were no deaths among the 79 patients in whom repeat median sternotomy was avoided, and all grafts were patent. CONCLUSIONS Reoperative coronary artery surgery that avoids repeat median sternotomy can prevent cardiac injury and damage to patent grafts. Furthermore, it does not require blood transfusion. Thus, it is an effective method of reducing mortality and morbidity even in reoperative cases.

Improved Outcomes for Ruptured Abdominal Aortic Aneurysms Using Integrated Management Involving Endovascular Clamping, Endovascular Replacement, and Open Abdominal Decompression

Objective: Endovascular repair has become the treatment of choice for ruptured abdominal aortic aneurysms (RAAAs). To improve surgical outcomes, preoperative management is important. In 2011, we introduced integrated management, which involves endovascular aneurysm repair, stabilization of hemodynamics by endovascular clamping, and open abdominal decompression to address abdominal compartment syndrome (ACS). Methods: To evaluate the efficacy of this management strategy, 62 patients who had undergone emergency surgery for an RAAA were analyzed retrospectively: group A (n=39), where an old strategy was used, and group B (n=23), where integrated management was introduced. Patient characteristics and 30-day mortality rates were compared between the two groups. Results: The average patient age was 67.7 years and 74.7 years for groups A and B, respectively (P=0.032). Group B patients required more frequent use of vasopressors (P=0.035). Other patient characteristics did not differ between the two groups. The duration of surgery was significantly shorter in group B than in group A (P=0.001). The total amount of transfused blood did not differ between the two groups. No patients showed symptoms of ACS. Early mortality rates were 12.8% and 8.7% in groups A and B, respectively. The number of wound infections was significantly fewer in group B than in group A. Conclusion: Although group B patients were significantly older and had a higher rate of vasopressor use, early mortality was improved in both groups. Morbidity was significantly better in group B with respect to the duration of surgery and number of wound infections than in group A.

Selection and Determination of Treatment for the Spontaneous Isolated Dissection of the Superior Mesenteric Artery

Objective: This study aimed to clarify the selection and determination of appropriate treatment for acute symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). Methods: Data from 10 consecutive patients, who were diagnosed with symptomatic SIDSMA using computed tomography angiography and were managed in our hospital from January 2010 to October 2015, were retrospectively collected and analyzed. Results: There were nine males and one female; mean patient age was 50.3 (range, 35–64) years. All patients experienced acute abdominal pain, and three patients experienced concomitant vomiting. Only one patient exhibited symptoms of suspected peritonitis and intestinal ischemia. Three patients showed improved abdominal pain before admission to our hospital. One patient experienced severe abdominal pain that could not be managed using morphine; he underwent right external iliac to superior mesenteric artery bypass with a great saphenous vein graft. No patient presented with intestinal necrosis. All patients survived, and no patient developed complications during the follow-up period of up to 42 (24.5±16.5) months. Conclusion: Conservative management appears to be the most feasible treatment for SIDSMA. However, open surgery can be performed in patients presenting with any symptoms of intestinal ischemia.

Surgical Management of Mycotic Aortic Aneurysms

Purpose: A mycotic aneurysm is an uncommon disease associated with a high mortality rate when managed surgically. This study reviewed our experiences in the surgical management of mycotic aortic aneurysms. Methods: In total, 26 patients who underwent surgery for a mycotic aneurysm were retrospectively reviewed. The mycotic aneurysms involved the thoracic aorta in 9 patients, the thoracoabdominal aorta in 4 patients, and the abdominal aorta in 13 patients. An overt aortic rupture in the mediastinum or retroperitoneal space was detected in 4 patients. Patients were classified into one of two groups, febrile or afebrile, and background characteristics, surgical intervention, and early and late mortalities were all compared. Results: There were 19 patients who underwent open surgery, and 7 patients underwent endovascular repair. No significant differences in the clinical characteristics were found between the two groups; however, the incidence of postoperative complications was significantly higher in the febrile group than in the afebrile group (P=0.024). Overall mortality was 15.4% (4/26), and 30-day mortality was 7.7% (2/26). Conclusion: Although febrile patients had a higher incidence of postoperative complications, surgical mortality from a mycotic aneurysm was within an acceptable range. Each patient should be thoroughly evaluated and treated on a case-by-case basis, using conventional open repair, endovascular repair, or a combination of both approaches.

A durable iliac-axillary and axillary-carotid bypass for cerebral ischemia due to Takayasu arteritis allowed successful pregnancies and deliveries

A 24-year-old Japanese woman underwent ilioaxillary bypass with an expanded polytetrafluoroethylene graft and axillocarotid bypass with an autologous saphenous vein graft for severe brain ischemia due to Takayasu arteritis. A method that involved wrapping strips of the graft around the artery was used to prevent stretching of the anastomotic site. Her general condition and symptoms improved remarkably. She became pregnant three times and delivered the infants without any complications caused by the operation. The present case contributes to proof of patency, effectiveness, and durability of these bypass grafts.