Noriyoshi Kutsukata

Aortic dissection extending from the left coronary artery during percutaneous coronary angioplasty

A 72-year-old woman with acute aortic dissection as a complication of percutaneous coronary angioplasty was successfully treated. She received a graft replacement of the ascending aorta as well as triple coronary artery bypass grafts. The dissection had extended from the left coronary artery. Although acute aortic dissection is a rare complication of percutaneous coronary angioplasty, physicians and cardiac surgeons should keep its potential occurrence in mind.

Relationship between effect of polymyxin B-immobilized fiber and high-mobility group box-1 protein in septic shock patients.

Direct hemoperfusion (DHP) using a polymyxin B (PMX)-immobilized fiber column has been used for treatment of endotoxemia-induced septic shock in Japan since 1994 and is now an accepted therapy for reducing serum endotoxin levels. Although a reduction in inflammatory cytokines has been reported, the detailed mechanism of DHP-PMX is not known. We investigated the high-mobility group box-1 (HMGB-1) level in septic shock patients treated with DHP-PMX. Subjects (n = 20) were separated into two group: those whose systolic blood pressure increased to more than 30 mm Hg immediately after DHP-PMX (effective [E] group: nine cases) and those whose systolic blood pressure did not increase to more than 30 mm Hg (noneffective [N-E] group: 11 cases). The interleukin-6, plasminogen activator inhibitor-1, and HMGB-1 levels were measured in each group. The Pao2/Fio2 ratio and the Sepsis-Related Organ Failure Assessment (SOFA) score were also evaluated. Pretreatment interleukin-6, plasminogen activator inhibitor-1, and HMGB-1 levels were similar in the E and N-E groups, but mortality rate was significantly higher in the N-E group. Furthermore, posttreatment SOFA score was significantly lower in the E group. In the E group, only the HMGB-1 levels improved significantly after DHP-PMX. Present data suggest that the circulation dynamics of septic shock patients can be improved by reducing HMGB-1 levels by using DHP-PMX.

Effectiveness of continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter after polymyxin B-immobilized fiber column therapy of septic shock.

Septic shock is a condition associated with diffuse coagulopathy and multiple organ failure, and frequently ends in death. Direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) was first developed in Japan in 1994 and has since been used for the treatment of septic shock. On the other hand, the effectiveness of continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (PMMA- CHDF) for critically ill patients has also been reported. We treated 27 septic shock patients by DHP-PMX. The patients, except for the nine in whom CHDF was not performed after DHP-PMX, were divided into two groups: namely, a group in which PMMA-CHDF therapy was added after DHP-PMX (11 cases), and a group in which continuous hemodiafiltration using a polyacrylonitrile membrane hemofilter (PAN-CHDF) therapy was added after DHP-PMX (7 cases). The outcomes in the two groups were compared. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score and the average sepsis-related organ failure assessment (SOFA) score were not significantly different between the two groups. The PMMA-CHDF group showed significantly better outcomes, with significant improvements of the serum PAI-1, protein C, IL-6 and N-arachidonoylethanolamine (AEA) levels. We conclude that PMMA-CHDF may be more effective than PAN-CHDF in the management of septic shock.

Clinical responses and improvement of some laboratory parameters following polymyxin B-immobilized fiber treatment in septic shock.

Direct hemoperfusion using a polymyxin B–immobilized fiber column (PMX; Toray Industries Inc., Tokyo, Japan) was first developed in 1994 and has since been used for the treatment of septic shock. Positive clinical data, such as an increase in systolic blood pressure (SBP) and an improved Pao2/Fio2 ratio, have also been reported. We treated 27 septic shock patients using DHP-PMX. The patients were separated into two groups for analysis: those whose Pao2/Fio2 ratio increased after DHP-PMX (9 cases) and those whose Pao2/Fio2 ratio did not increase after DHP-PMX (18 cases). The patients were also separated into two other groups for analysis: those whose SBP increased by more than 30 mm Hg immediately after DHP-PMX (15 cases) and those whose SBP did not increase by more than 30 mm Hg after DHP-PMX (12 cases). The Pao2/Fio2 ratio increased significantly after DHP-PMX in the groups showing improved 2AG and PAI-1 levels (p = 0.0040). The SBP increased significantly in the group showing improved HMGB-1 levels (p < 0.0001). We observed a relationship between hemodynamic improvement and increase of the serum HMGB-1 levels and between improvement of respiratory functions and increase of the serum 2-AG and PAI-1 levels in septic shock patients treated with DHP-PMX.

Effectiveness of Human Atrial Natriuretic Peptide Supplementation in Pulmonary Edema Patients Using the Pulse Contour Cardiac Output System

Purpose Atrial natriuretic peptide (ANP) has a variety of pharmacologic effects, including natriuresis, diuresis, vasodilatation, and suppression of the renin-angiotensin system. A recent study showed that ANP infusion improved hypoxemia and pulmonary hypertension in a lung injury model. On the other hand, the pulse contour cardiac output (PiCCO™) system (Pulsion Medical Systems, Munich, Germany) allows monitoring of the intravascular volume status and may be used to guide volume therapy in severe sepsis and critically ill patients. Materials and Methods We treated 10 pulmonary edema patients without heart disease with human ANP (HANP). The patients were divided into two groups: a group with normal Intrathoracic Blood Volume (ITBV) (900-1100 mL/m2) (n = 6), and a group with abnormal ITBV (n = 4), as measured by the PiCCO™ device; the extravascular lung water (EVLW) and pulmonary vascular permeability index (PVPI) in the two groups were compared. Results The average patient age was 63.9 ± 14.4 years. The normal ITBV group showed significant improvement of the EVLW (before, 16.7 ± 2.7 mL/kg; after, 10.5 ± 3.6 mL/kg; p = 0.0020) and PVPI (before, 3.2 ± 0.3; after, 2.1 ± 0.7; p = 0.0214) after the treatment. The abnormal ITBV group showed no significant improvement of either the EVLW (before, 16.3 ± 8.9 mL/kg; after, 18.8 ± 9.6 mL/kg; p = 0.8387) or PVPI (before, 2.3 ± 0.8; after, 2.7 ± 1.3; p = 0.2782) after the treatment. In both groups, the EVLW and PVPI were strongly correlated with the chest X-ray findings. Conclusion We conclude that HANP supplementation may improve the EVLW and PVPI in pulmonary edema patients without heart disease with a normal ITBV. The PiCCO™ system seems to be a useful device for the management of pulmonary edema.

Morphological evaluation of areas of damage in blunt cardiac injury and investigation of traffic accident research

PurposeThis study investigated the relation between the cause of blunt cardiac injury and areas of damage. For the purpose of injury prevention, we also examined traffic accident cases in a micro study using engineering-based medicine.MethodsAmong the 2673 patients transported to our facility within the 15-month period from February 2009 to April 2010, there were 12 cases of cardiac perforation. We studied these cases anatomically to evaluate the morphology of the damaged cardiac areas. We conducted a detailed micro-study in two cases regarding the circumstances surrounding the traffic accident and the vehicular damage.ResultsSubjects were nine men (mean age 64 years). The mean Injury Severity Score was 54.0 ± 19.6, and the probability of survival was 0.147. The actual survival rate was 16.7% (2 survivors, 10 deaths). Lesion sites in the 12 cases (21 sites in total) were the right atrium in 8 cases, superior and inferior vena cava in 5 cases, right ventricle in 4 cases, pulmonary artery and left atrium in 1 case each, and pulmonary vein in 2 cases, excluding the left ventricle and ascending aorta. In three cases, the aortic isthmus was also injured.ConclusionBlunt cardiac injury was more common on the right side chamber. The survival rate was extremely close to the calculated survival probability. Proper seatbelt usage is important for the prevention of blunt cardiac injury due to traffic accidents. Increased severity of injury may be associated with accidents involving light motor vehicles.

Relationship between treatment resistance to hemoperfusion using a polymyxin B-immobilized fiber column and oxidative stress.

Recently, the existence of a relationship was reported between the severity of lung injury and the serum level of F2-isoprostane, a known oxidative stress marker. Recent reports have suggested that direct hemoperfusion with a polymyxin B-immobilized fiber column (DHP-PMX) may improve the oxygenation in patients with acute lung injury and acute respiratory distress syndrome. Because cases of septic shock associated with respiratory diseases have poor outcomes, we selected cases of septic shock associated with respiratory disease to review the characteristics of the treatment-resistant cases. We treated 13 septic shock cases due to respiratory disease using DHP-PMX. The patients were separated into 2 groups for analysis from oxygenation effect immediately after DHP-PMX: A group (7 cases) PaO2/FiO2 ratio increased more than 20%; B group (6 cases) PaO2/FiO2 ratio did not increase more than 20%. Factors were measured before DHP-PMX. The average Acute Physiology and Chronic Health Evaluation II score was 31.2 ± 9.4, and the average sequential organ failure assessment score was 15.1 ± 5.3 before DHP-PMX. Four patients survived and 9 died. Only the F2-Isoprostane level was significantly high in B group (p = 0.0228). A relationship between F2-Isoplostane and rebellious cases by DHP-PMX in severe respiratory disease patients became clear.

Combined non-cardiac operations with minimally invasive direct coronary artery bypass grafting

We report two cases in which Minimally invasive direct coronary artery bypass grafting was followed by other non-cardiac operations in the same operative setting. A left internal thoracic artery-to-left anterior descending artery anastomosis was constructed through a left anterior thoracotomy in both patients. Immediately after Minimally invasive direct coronary artery bypass grafting, one patient underwent a pancreatoduodenectomy for a biliary duct carcinoma and the other patient received a prosthetic graft replacement for an abdominal aortic aneurysm. Minimally invasive direct coronary artery bypass grafting is advantageous in patients with significant coronary artery disease who have to undergo other non-cardiac surgeries.

Effectiveness of early start of direct hemoperfusion with polymyxin B-immobilized fiber columns judging from stabilization in circulatory dynamics in surgical treatment patients.

Background: Septic shock remains a major cause of multiple organ failure and is associated with a high mortality rate. In 1994, direct hemoperfusion using a polymyxin B-immobilized fiber column (PMX; Toray Industries Inc., Tokyo Japan) was developed in Japan and has since been used for the treatment of septic shock arising from endotoxemia. Materials and Method: We treated 36 patients with septic shock using direct hemoperfusion with PMX. The patients were analyzed in two groups based on whether they had undergone surgery prior to DHP-PMX treatment (surgical group: surgical treatment before DHP-PMX, medical group: no surgical treatment). In surgical group, DHP-PMX was started within three hours after the surgical treatment. Various factors were measured before and after DHP-PMX. Results: The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 27.4 ± 8.8, and the mean sepsis-related organ failure assessment (SOFA) score was 11.8 ± 4.9 before DHP-PMX. The SOFA score was significantly higher (P = 0.0091) and the PaO2/FiO2 ratio (P/F ratio) was significantly lower (P = 0.0037) in medical group than in surgical group prior to DHP-PMX. A chi-square test showed that the survival rate in surgical group was significantly better than in medical group (P = 0.0027). The survival rate of surgical group (84.2%) was judged to be very good because the predicated survival rate based on the APACHE II score (25.0) was only 46.5%. On the other hand, the survival rate of medical group (35.3%) was almost equal to that predicted by the APACHE II score (30.6; predicted survival rate, 27.4%). Conclusion: The results of this study suggest the utility of early DHP-PMX in surgical group.

Selection of acute blood purification therapy according to severity score and blood lactic acid value in patients with septic shock

Aim: As an alternative method for acute blood purification therapy, continuous venovenous hemodiafiltration (CVVHDF) has been reported as an effective clinical treatment for critically ill patients, but the optimal column for performing CVVHDF remains controversial. Patients and Methods: We used direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) to treat 88 patients with septic shock. To determine the optimal acute blood purification therapy, we subsequently divided the patients into three groups: the first group underwent CVVHDF using a polymethylmethacrylate membrane hemofilter (PMMA) after undergoing DHP-PMX (28 cases), the second group underwent CVVHDF using a polyacrylonitrile membrane hemofilter (PAN) after undergoing DHP-PMX (26 cases), and the third group did not undergo CVVHDF after undergoing DHP-PMX (34 cases). Results: The overall survival rate was 54.5%, and patient outcome was significantly related to the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the sepsis-related organ failure assessment (SOFA) score, and the blood lactic acid value before treatment (all P<0.0001). Only the PMMA-CVVHDF group showed a better outcome (survival rate of 78.6%) compared with the other groups (P = 0.0190). In addition, only the PMMA-CVVHDF group showed a significant improvement in the blood lactic acid level on day 3 (P = 0.0011). Conclusion: Our study suggests that the PMX column might be effective during the early phase of septic shock, before a high level of lactic acid is present. Furthermore, a PMMA column might be the most useful column for performing CVVHDF after DHP-PMX treatment, as suggested by the blood lactic acid value.