Sachito Fukuda

Pharmacological response of internal mammary artery and gastroepiploic artery

Pharmacological response of coronary artery bypass conduit is of great importance. This study was designed to clarify the contractile properties of internal mammary artery and gastroepiploic artery obtained from coronary revascularization. The response to ergonovine, serotonin, and phenylephrine was examined by isometric contraction recording apparatus. The concentration-response relation of both internal mammary artery and gastroepiploic artery to ergonovine, serotonin, and phenylephrine showed similar sigmoid curves. There were no significant differences in developed tension between internal mammary artery and gastroepiploic artery at any concentration for any agent. There were no significant differences in the 50% effective dose value for any agent between internal mammary artery and gastroepiploic artery. Internal mammary artery and gastroepiploic artery are reported to be similar in terms of size, flow capacity, and freedom from atherosclerosis. This study shows their equivalence from a pharmacological viewpoint.

Coronary artery reoperation through the left thoracotomy with hypothermic circulatory arrest

BACKGROUND The left thoracotomy approach to avoid injury of the patent old graft and the myocardium with mid sternal reentry at coronary artery reoperation. METHODS The left thoracotomy approach was used in 13 patients. There were 11 men and 2 women with a mean age of 63 years, ranging from 39 to 75 years. Three patients were having their third coronary bypass operation. In 11 patients, distal anastomoses were performed under circulatory arrest with moderate hypothermia. In the other 2 patients, distal anastomoses were performed on a beating heart. No aortic cross-clamp was applied in all patients. The mean number of distal anastomoses was 1.8; the grafted vessels were 11 anterior descending, 3 diagonal, 8 circumflex, and 1 posterolateral coronary arteries. Used grafts were 17 saphenous veins, 4 left internal thoracic arteries, and 2 gastroepiploic arteries. Inflow sites of the free graft were descending aorta in 10 patients and left subclavian artery in 3 patients. RESULTS All patients were alive and well at the mean follow-up of 16 months, and all grafts were patent. CONCLUSIONS The left thoracotomy approach is safe and effective for reoperation on the left coronary artery system, and circulatory arrest is convenient and safe for performing distal anastomosis.

Availability of the in situ right gastroepiploic artery for coronary artery bypass

The right gastroepiploic artery (GEA) has been successfully used as a coronary bypass graft recently. We examined the in situ GEA graft length required from the pyloric portion to the site of coronary anastomosis at the time of operation. Measured GEA length was 17.0 +/- 1.7 cm for the posterior descending artery anastomosis in 17 patients, 17.8 +/- 1.7 cm for the main right coronary artery anastomosis in 13 patients, 22.0 +/- 2.3 cm for the posterolateral branch anastomosis in 7 patients, and 21.0 cm for the left anterior descending artery anastomosis in 1 patient. We examined 228 randomly selected abdominal angiograms and measured the internal diameter of the right GEA at every 2-cm interval from its origin. Probability of availability of the in situ GEA graft for each site of anastomosis was 97% to the right coronary artery and 88% to the anterior descending or the circumflex artery when the internal diameter of GEA was 1.5 mm or greater. From an anatomical standpoint, we concluded that the GEA can be assumed available without preoperative angiography.

Tricuspid valve supra-annular implantation in adult patients with Ebstein's anomaly

BACKGROUND Tricuspid valve supra-annular implantation (TVSI) has been performed for adult patients with Ebsteins anomaly at our hospital for several decades. TVSI is characterized by reliable reduction of tricuspid annulus size without affecting the conduction system; by prevention of residual tricuspid regurgitation (RTR) through preservation of the native tricuspid valve; and by implantation of the bioprosthesis at a supra-annular site. METHODS Ten adult patients with Ebsteins anomaly underwent TVSI. The right ventricular diameter and residual tricuspid regurgitation were evaluated by echocardiography preoperatively, at discharge, 1 year after the operation, and over the long term (12.4 +/- 5.5 years). Actuarial survival rate, actuarial freedom from structural valve deterioration rate, and postoperative occurrence of arrhythmia were also evaluated. RESULTS The actuarial survival rate at 19 years was 76 +/- 15%. Tricuspid regurgitation disappeared in 8 patients just after operation. Right ventricular diameter was significantly smaller at discharge than preoperatively (63 +/- 11 vs 37 +/- 9, p < 0.01), and there were no significant differences between values at discharge and at follow-up. The actuarial freedom from structural valve deterioration rate and the reoperation rate were both 100%. There were no fatal complications related to arrhythmia or thromboembolism. CONCLUSIONS TVSI is useful for adult patients with Ebsteins anomaly. The absence of complications related to fatal arrhythmia and thromboembolism, good durability of the bioprosthesis, and a simple operative procedure are merits of this therapy.

Gastroepiploic artery graft for anterior descending coronary artery bypass

In 308 right gastroepiploic artery (GEA) grafting procedures performed for myocardial revascularization, 38 GEA, 34 in situ, and four free grafts were used to bypass the left anterior descending coronary artery (LAD). Indications for using the GEA for the purpose of LAD bypass were: unavailability of the internal thoracic artery (ITA) at reoperation, surgical damage to the ITA at the time of the operation, or an apparently better free flow versus that in the left ITA, particularly in patients with diabetes mellitus in whom it was considered inadvisable to use bilateral ITAs. There were 21 male and 17 female patients with a mean age of 62 years (range, 31 to 77 years). Ten patients had undergone a previous myocardial revascularization. The mean number of distal anastomoses was 2.8 (range, 1 to 5). Concomitantly used conduits were the ITA in 27 patients, saphenous veins in 21 patients, the inferior epigastric artery in 4 patients, and the bovine internal thoracic artery in 1 patient. All but 1 patient survived. Follow-up ranged from 3 to 84 months (mean, 27 months). Postoperative angiography was performed in 33 patients. At the short-term evaluation (mean, 1 month), 32 of 33 (97%) GEA grafts were found to be patent; all 4 GEA grafts studied at the long-term evaluation (mean, 25 months) were also found to be patent. In no patients did angina recur postoperatively. In 25 patients who underwent an exercise study postoperatively, the stress test results were negative in 23.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative coronary angiography using fluorescein

Intraoperative coronary angiography using fluorescein was applied to evaluate the patency of saphenous vein grafts just after completion of the distal anastomosis. By this technique, the area of the revascularized myocardium was well estimated in real time. This intraoperative direct-vision examination gives us more timely and precise information during coronary artery bypass grafting.

LIMITATION OF IMPLANTATION OF ENDOVASCULAR STENT-GRAFT: CASE REPORT OF A PATIENT WITH THORACOABDOMINAL ANEURYSM

graft prostheses has offered a largely successful alternative approach to the treatment of thoracic aortic aneurysm, an approach that is less invasive and carries a lower risk than does the standard operative method.1,2 However, cardiac surgeons who use the new method have not fully determined optimum indications for applying this alternative to open repair. We report on the autopsy of a patient with reruptured thoracoabdominal aneurysm after endovascular stent-grafting 6 months previously. Clinical summary. A 76-year-old man was admitted to our hospital with a diagnosis of thoracoabdominal aneurysm. He had undergone distal gastrectomy, a low anterior resection for early-stage gastric and sigmoid colon cancer, and radical neck resection for a soft-palate cancer. His height was 152 cm and his body weight was 39 kg. He had significant psychroesthesia in all 4 limbs and anterior chest pain. A large thoracoabdominal aneurysm, 10.0 × 6.7 cm in diameter, extended to just above the celiac artery. For the prevention of impending rupture, we decided that implantation of an endovascular stent-graft, rather than the usual thoracotomy and graft replacement, was indicated because of the patient’s poor general conditions. The dimensions of the stent-graft were determined by his preoperative computed tomographic and angiographic evaluations. The stent-graft, covered by 32 × 190-mm thin-walled woven polyester, was 34 mm in diameter and 200 mm long. Spinal fluid was drained through a catheter placed in the lumbar space before the operation to ensure spinal cord protection. The endovascular stent-graft was implanted into the descending thoracic aorta from the right femoral artery. Although we attempted to place and fix the distal edge of the stent-graft just above the celiac artery, it moved to the cranial side of the aorta. Because of perigraft leakage seen at the distal edge of the stent-graft on intraoperative angiogram, a second implantation was attempted. The second stent-graft, 35 ×

Stent placement in surgically reimplanted left main coronary artery in patient with anomalous origin of left main coronary artery from pulmonary artery.

Surgical repair of a 29-year-old womans left coronary artery with an anomalous origin from the pulmonary artery was performed by reimplantation of the left main artery into the aorta, together with coronary artery bypass grafting. Subsequent stenosis of the reimplanted left main artery was treated with successful Palmaz-Schatz stent placement.

Repeated mitral valve replacement in a patient with extensive annular calcification

BackgroundMitral valve replacement in the presence of severe annular calcification is a technical challenge.Case reportA 47-year-old lady who had undergone mitral and aortic valve replacement for rheumatic disease 27 years before presented with dyspnea. At reoperation, extensive mitral annular calcification was hindering the disc motion of the Starr-Edwards mitral prosthesis. The old prosthesis was removed and a St Jude Medical mechanical valve was implanted after thorough annular debridement. Postoperatively the patient developed paravalvular leak and hemolytic anemia, subsequently undergoing reoperation three days later. The mitral valve was replaced with an Edwards MIRA valve, with a bulkier sewing cuff, after more aggressive annular debridement. Although initially there was no paravalvular leak, it recurred five days later. The patient also developed a small cerebral hemorrhage. As the paravalvular leak and hemolytic anemia gradually worsened, the patient underwent reoperation 14 days later. A Carpentier-Edwards bioprosthetic valve with equine pericardial patches, one to cover the debrided calcified annulus, another as a collar around the prosthesis, was used to eliminate paravalvular leak. At 7 years postoperatively the patient is doing well without any evidence of paravalvular leak or structural valve deterioration.ConclusionMitral valve replacement using a bioprosthesis with equine pericardial patches was useful to overcome recurrent paravalvular leak due to severe mitral annular calcification.

Papillary Fibroelastoma of the Left Ventricle: Report of Two Cases

Papillary fibroelastoma is a relatively rare cardiac tumor. We report two cases of papillary fibroelastoma. The first case involved a 45-year-old woman who presented with rheumatic valves and three tumors developing from the papillary muscle and left ventricle. The second case involved a 68-year-old man who was asymptomatic and whose tumor was detected incidentally on echocardiogram. Both cases were treated surgically. An additional 71 cases of papillary fibroelastoma reported in the medical literature in Japan are reviewed.