Seiji Kinugasa

A New Procedure for Chronic Atrial Fibrillation: Bilateral Appendage-Preserving Maze Procedure

BACKGROUND Atrial transport and atrial natriuretic peptide secretion is severely reduced from normal after the maze III procedure. To improve these factors, we developed a bilateral appendage-preserving maze procedure (BAP-maze). METHODS Forty-six patients with chronic atrial fibrillation who underwent the BAP-maze procedure were compared with 40 patients who underwent the maze III procedure. The ratio of the peak velocity of the A and E waves of transmitral flow (transthoracic pulsed Doppler echocardiography), the left atrial appendage ejection fraction (transesophageal echocardiography), and the atrial natriuretic peptide secretory reserve during treadmill exercise test were measured at 6 months postoperatively. RESULTS Sinus rhythm was restored in 44 patients (95.7%) by the BAP-maze procedure and in 39 patients (97.5%) by the maze III procedure. The ratio of the peak velocity of the A and E waves was 0.52 +/- 0.22 in the BAP-maze group and 0.25 +/- 0.19 in the maze III group (p < 0.0001). The left atrial appendage ejection fraction was 44.7% +/- 11.5%, and the atrial natriuretic peptide secretory reserve was greater in the BAP maze group (p = 0.037). CONCLUSIONS The BAP-maze procedure improved atrial transport and atrial natriuretic peptide secretion as well as simplifying the maze operation, without decreasing its effectiveness against atrial fibrillation.

Influence of coronary artery disease on operative mortality and long-term survival after abdominal aortic aneurysm repair.

PurposeThis retrospective study was conducted to evaluate the effects of coronary artery disease (CAD) on short- and long-term survival after abdominal aortic aneurysm (AAA) repair.MethodsOne hundred consecutive patients underwent elective AAA repair between 1991 and 2002. Coronary angiography was performed in all patients, revealing significant coronary artery lesions in 47 (47%). Percutaneous transluminal coronary angioplasty (PTCA) was performed in 11 patients, 20 (median) days before the abdominal surgery. Abdominal aortic aneurysm repair was performed 60 (median) days after coronary artery bypass grafting (CABG) in five patients, and both procedures were performed simultaneously in two patients.ResultsThe in-hospital mortality rate for AAA repair was 1.0%, but there was no cardiac-related operative morbidity or mortality. The 96 patients discharged were followed up for a mean period of 2.9 years (range 3–143 months). The cumulative survival rates after 1, 2, 3, and 5 years were 98%, 95%, 88%, and 77%, respectively. Only one patient (1%) died of myocardial infarction. There was no significant difference in the long-term survival of the CAD and non-CAD patients.ConclusionsThese results emphasize the importance of routine coronary angiography and subsequent coronary revascularization to improve early and late survival rates after AAA repair.

Right ventricular myxoma: report of a case.

We herein report a 36-year-old man who underwent surgical resection for myxoma. Preoperative two-dimensional echocardiography demonstrated a mass in the right ventricle. Intraoperatively, the tumor was found to derive from an anterior papillary muscle of the tricuspid valve. The tumor was successfully excised and the tricuspid valve was repaired with chordoplasty and annuloplasty. A histopathological examination revealed myxoma and a 2-year follow-up has shown no evidence of recurrence or tricuspid valve regurgitation.

Coronary artery bypass graft surgery in dialysis patient

To determine the operative outcome of coronary artery bypass graft surgery (CABG) for severe coronary artery disease in long-term hemodialysis patients, we analyzed a group of 16 patients who underwent CABG over a ten-year period in our institution. Hospital mortality was 12.5% (2 of 16 patients). These two patients died of ischemic colitis and perioperative myocardial infarction, respectively. There were five late deaths: one patient died from myocardial infarction, one from uremia, one from gastro-intestinal bleeding, one from gastric cancer and one from unknown cause. There were four significant postoperative complications (morbidity 25%), consisted of one pulmonary tuberculosis, one sternal dehiscence secondary to mediastinitis, one mediastinal hematoma secondary to late bleeding from the LITA dissection area and one A-V shunt trouble. Graft patency rate within the first two months was 93% (30 to 42 in 13 patients). Hospital survivors experienced complete relief from angina. Actuarial survival was 68.8% at 3 years, 57.3% at 5 years and 28.6% at 7 years. This rate is not significantly different from the survival of all dialysis patients, but seems to be better than that of dialysis patients with not operated coronary artery disease. We concluded that CABG in dialysis patients can be accomplished with acceptable morbidity and mortality and effective relief of symptoms.

Early and late outcomes after reoperation for prosthetic valve endocarditis

OBJECTIVE Prosthetic valve endocarditis remains a challenging complication after heart valve replacement. To identify predictive risk factors, we have reviewed 30 patients who underwent surgery for prosthetic valve endocarditis between March 1986 and May 1999. METHODS There were 15 men and 15 women (mean age 51 years). Prosthetic valve endocarditis was classified as early (< or = 1 year after operation) in 10 cases, and as late in the other 20 cases. The most common indication for surgery was moderate to severe congestive heart failure due to prosthetic valve dysfunction in 21 (70%) patients. The average follow-up period was 6.5 years, with a range of 0.3 to 14.1 years. RESULTS The most common microorganism was Staphylococcus epidermidis in both patients with early (50%) and late prosthetic valve endocarditis (25%). The in-hospital mortality was 13.3% (4/30). There were six late deaths. The actuarial survival at 5 years was 78% and 66% at 10 years. An early onset of prosthetic valve endocarditis was the only significant determinant of both in-hospital mortality (p = 0.005) and overall mortality (p = 0.021). Emergency surgery had a statistically significant relationship with in-hospital mortality (p = 0.045). No significant influence on mortality after reoperation for prosthetic valve endocarditis was found in age, sex, valve position, antecedent native valve endocarditis, or in the type of pathological findings (ring abscess, valve dehiscence, and vegetation). CONCLUSION Early onset of prosthetic valve endocarditis and emergency surgery were important risk factors for mortality due to prosthetic valve endocarditis.

INDICATIONS AND PROBLEMS OF CORONARY ARTERY BYPASS GRAFTING WITHOUT CARDIOPULMONARY BYPASS

As an alternative method of myocardial protection and to obviate the inherent risks of cardiopulmonary bypass (CPB), we have been performing coronary artery bypass grafting (CABG) without CPB in carefully selected patients. Since the first such operation was successfully performed in Junuary 1995 on a patient with angina pectoris and lung cancer, four other patients have subsequently undergone this technique. This series of 5 patients, being 1 man and 4 women ranging in age from 68 to 80 years, is presented in this report. The reasons for the selection of this procedure were concomitant diseases including lung cancer, a calcified aorta, and myocardial infarction. The mean time of ischemia for each anastomosis was 15.3 ± 5.3min, and the maximum cardiac muscle creatine phosphokinase (CPK-MB) was less than 14 unit/l postoperatively. None of the patients required ventilatory support for longer than 24h postoperatively, and oral intake was started within 24h after extubation in all patients. Postoperative angiography confirmed graft patency and none of the patients developed any ischemic symptoms. All the patients were discharged between 1 and 2 months postoperatively. Thus, the off-pump technique is useful when concomitant diseases are present and will become an alternative method of treatment for coronary artery disease in selected patients.

Idiopathic Mediastinal Fibrosis:Report of a Case

We report herein the case of a 28-year-old woman who presented with a mediastinal mass, subsequently confirmed to be idiopathic mediastinal fibrosis. Preoperative chest computed tomography (CT) showed a noncalcified mediastinal mass and surgery was performed to exclude malignancy. The mass was hard and dense, involved the left phrenic nerve, vagus nerve, and left upper lobe, and surrounded the subclavian artery, subclavian vein, superior vena cava, and left pulmonary artery. Pathologic examination showed the findings of mediastinal fibrosis and the mass was partially excised. Postoperative medical treatment was performed with prednisolone and tranilast, and a 3-year follow-up has not demonstrated any complications.

Successful Surgical Treatment for Fungal Endocarditis of the Ascending Aorta after Aortic Valve Replacement

症例は69歳,女性.2001年4月人工弁(Freestyle弁)感染性心内膜炎,僧帽弁閉鎖不全症,陳旧性心筋梗塞に対し再大動脈弁置換術,僧帽弁形成術,冠血行再建術を施行した.2002年1月中旬から下痢,タール便を認め当院消化器科へ入院,絶飲食,高カロリー輸液を行っていた.1月下旬から発熱が持続,抗生剤投与を行い改善傾向にあったが,経食道心臓超音波検査にて上行大動脈に可動性を有する異常エコーを認め,β-Dグルカンの上昇,血液培養検査にてCandida parapsilosisを認め,真菌性心内膜炎の疑いにて4月5日手術を行った.大動脈を切開すると無冠洞近傍の大動脈壁に疣贅の付着を認め,機械弁による再々大動脈弁置換術,および疣贅とともに大動脈壁の一部を切除,大動脈壁欠損部の再建を行った.摘出標本からC.parapsilosisが検出され,抗真菌剤を経静脈的に8週間投与した.術後,意識覚醒遅延,一過性の左半身麻痺の合併を認めたが,術後133日目に脳梗塞後遺症なく退院,抗真菌剤内服を継続し,術後24ヵ月の時点で感染の再燃は認めていない.

Beneficial Effects of Preoperative Coronary Angiography and Coronary Artery Revascularization in Patients Undergoing Surgery for Abdominal Aortic Aneurysm

待機的腹部大動脈瘤 (AAA) 症例に対する術前冠動脈造影 (CAG) と冠血行再建術の有用性を検討した. 1995年1月から1999年11月までの待機的AAA手術53例に術前 routine CAG施行したところ, 23例 (43%) に有意冠動脈狭窄を認め, さらに無症候性心筋虚血を10例 (19%) に認めた. 冠動脈狭窄を有するものには, 負荷心筋シンチを行い, 術前冠血行再建の適応を判断した. 虚血性心疾患合併例の12例に対してCABG 4例, PTCA 8例の術前冠血行再建を施行した. CABGとPTCAによる死亡はなかった. AAA手術死亡を1例 (2%) のみに認め, 原因は腸閉塞より多臓器不全合併による死亡であった. その他, CADに起因する合併症はみられなかった. 以上のことより, 待機的AAA症例では全例にCAGを施行し, 周術期心筋梗塞の合併が危惧される症例には術前冠血行再建を施行することが, 重要であると考えられた.

A Case of Ruptured Aneurysm Complicating Coarctation of the Aorta. Surgical Aspect Using Percutaneous Cardio Pulmonary Support System.

大動脈縮窄症に併発した比較的まれな胸部下行大動脈瘤の破裂例に対し, 経皮的部分体外循環 (PCPS: percutaneous cardio pulmonary support system) を用いて, 人工血管置換術を施行した. 症例は22歳男性, 3年前から胸部下行大動脈瘤を指摘されていたが無症状のため放置. 今回, 胸痛が出現し紹介来院した. 上下肢収縮期血圧差は70mmHg, 大動脈造影などから定型的大動脈縮窄症に併発した胸部下行大動脈瘤と診断した. 発症5日後の胸部レントゲン写真にて多量の左胸水出現, 瘤破裂の診断で緊急手術を施行した. 手術にはPCPSを使用したが, 操作が簡便で血行動態も安定しており, ヘパリンの使用量や出血量も少なく有用であった. 瘤内面は, 大動脈峡部からの血流ジェットが当たる部位に一致して, 長軸方向に4cmの亀裂を認めた. 内膜および中膜は断裂しており, 中膜と外膜の間に血腫が存在した. Open rupture を外膜のみで免れた sealed rupture であった.