Shinichi Takamoto

A study of brain protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest, with or without retrograde cerebral perfusion: Analysis based on the Japan Adult Cardiovascular Surgery Database

OBJECTIVESnAntegrade cerebral perfusion and hypothermic circulatory arrest, with or without retrograde cerebral perfusion, are 2 major types of brain protection that are used during aortic arch surgery. We conducted a comparative study of these methods in patients undergoing total arch replacement to evaluate the clinical outcomes in Japan, based on the Japan Adult Cardiovascular Surgery Database.nnnMETHODSnA total of 16,218 patients underwent total arch replacement between 2009 and 2012. Patients with acute aortic dissection or ruptured aneurysm, or who underwent emergency surgery were excluded, leaving 8169 patients for analysis. For the brain protection method, 7038 patients had antegrade cerebral perfusion and 1141 patients had hypothermic circulatory arrest/retrograde cerebral perfusion. A nonmatched comparison was made between the 2 groups, and propensity score analysis was performed among 1141 patients.nnnRESULTSnThe matched paired analysis showed that the minimum rectal temperature was lower in the hypothermic circulatory arrest/retrograde cerebral perfusion group (21.2°C ± 3.7°C vs 24.2°C ± 3.2°C) and that the duration of cardiopulmonary bypass and cardiac ischemia was longer in the antegrade cerebral perfusion group. There were no significant differences between the antegrade cerebral perfusion and hypothermic circulatory arrest/retrograde cerebral perfusion groups with regard to 30-day mortality (3.2% vs 4.0%), hospital mortality (6.0% vs 7.1%), incidence of stroke (6.7% vs 8.6%), or transient neurologic disorder (4.1% vs 4.4%). There was no difference in a composite outcome of hospital death, bleeding, prolonged ventilation, need for dialysis, stroke, and infection (antegrade cerebral perfusion 28.4% vs hypothermic circulatory arrest 30.1%). However, hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a significantly higher rate of prolonged stay in the intensive care unit (>8 days: 24.2% vs 15.6%).nnnCONCLUSIONSnHypothermic circulatory arrest/retrograde cerebral perfusion and antegrade cerebral perfusion provide comparable clinical outcomes with regard to mortality and stroke rates, but hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a higher incidence of prolonged intensive care unit stay. Antegrade cerebral perfusion might be preferred as the brain protection method for complicated aortic arch procedures.

Age-specific risk stratification in 13488 isolated coronary artery bypass grafting procedures

Age is a major risk factor in cardiac surgery, however, the precise risks accompanying age have not been fully analyzed. This study aimed to clarify the age-specific risks affecting the short-term outcome after isolated coronary artery bypass grafting (CABG). Data of 13488 procedures were obtained from the Japan Adult Cardiovascular Surgery Database, and the patients were divided into three groups; under 65 years of age (Young, n=4420), 65-75 (Middle, n=5485), and over 75 years of age (Old, n=3583). As a preoperative profile, Old tended to have extracardiac arteriopathy, left main stenosis, and emergency operation, whereas, Young had more coronary risk factors (smoking, diabetes, dyslipidemia) and low left ventricular (LV) function. The 30-day operative mortality rate increased significantly with age (Young: 1.7%, Middle: 2.3%, Old: 4.3%, P<0.0001). Renal dysfunction, arrhythmia, preoperative inotropes, and emergency surgery were the predictors for mortality common to all groups. Besides these, Young only had cardiac factors as additional risks, whereas various factors including cardiac parameters, redo sternotomy, peripheral vascular disease, and chronic lung disease were the additional risks in the elderly. Thus, the elderly population was vulnerable to any kind of factors, and preoperative systemic evaluation was crucial in the elderly to help define the appropriate surgical candidates.

Precise evaluation of bilateral pulmonary artery banding for initial palliation in high-risk hypoplastic left heart syndrome

OBJECTIVESnIn patients with high-risk hypoplastic left heart syndrome (HLHS), the Norwood operation (NW) in the neonatal period still results in high mortality compared with other cardiac surgery. Bilateral pulmonary artery banding (bPAB), a very effective initial procedure for HLHS, for which the specific evaluation is as yet unsatisfactory, was performed, and we report our findings in the present study.nnnMETHODSnWe have performed bPAB since 2006. A total of 17 patients with HLHS or a variant underwent bPAB before the NW. Echocardiography was performed between bPAB and the NW, and the flow acceleration just after bPAB and before NW was evaluated. Before the NW, a catheter examination was also performed.nnnRESULTSnbPAB was performed at 6.6 ± 0.6 days of age, and the NW at 130 ± 88 days. The patients mean body weight (BW) was 2.5 ± 0.4 kg at bPAB and 4.0 ± 1.1 kg at the NW. The length of the tape for bPAB was 9.9 ± 0.6 mm in the right pulmonary artery (RPA) and 9.4 ± 0.6 mm in the left (LPA) because the RPA was usually wider than the LPA. The tape width was 2 mm in all cases. The catheter examination was performed at 95 ± 85 days after bPAB. The arterial oxygen saturation (SaO₂) was 71% ± 8.6%. Multivariate regression analysis revealed that SaO₂ was estimated well using 4 factors: the banding size of the RPA, BW at bPAB, BW at NW, and BW in the period between bPAB and catheter examination (R² = 0.79). Echocardiography just after bPAB showed that the blood flow at the bPAB had accelerated to 3.0 ± 0.8 m/s in the RPA and 3.3 ± 0.8 m/s in the LPA (P = .004). The estimated pressure gradient was 39.2 ± 17.6 mm Hg in the RPA and 46.1 ± 23.0 mm Hg in the LPA (P = .006). The blood flow at bPAB was accelerated to 3.7 ± 0.7 m/s in the RPA and 4.0 ± 0.6 m/s in the LPA before NW (P = .013). The estimated pressure gradient was 62.6 ± 27.6 mm Hg in the RPA and 56.1 ± 19.6 mm Hg in the LPA before NW (P = .014). The catheter examination revealed mean wedge pressures of 18.0 ± 7.2 mm Hg for the RPA and 16.2 ± 4.3 mm Hg for the LPA. The operative mortality rate was 0%. One patient required a repeat operation to adjust the bPAB, and prolonged pleural effusion was observed in 1 case.nnnCONCLUSIONSnThe postoperative SaO₂ after bPAB correlated closely with the banding size and BW at bPAB, NW and during the period after bPAB. Because the mean PA pressure before NW was low enough for single ventricular circulation, the bPAB in this study was an effective option for high-risk patients undergoing HLHS or a variant. We believe the bPAB sizes used were suitable and were determined as follows: BW plus 7 mm for the LPA and BW plus 7.5 mm for the RPA.

Propensity-matched analysis of bilateral internal mammary artery vs single internal mammary artery in 7702 cases of isolated coronary artery bypass grafting

OBJECTIVESnTo evaluate early outcomes of bilateral internal mammary artery (BIMA) compared with single IMA (SIMA) in patients who underwent isolated coronary artery bypass grafting (CABG).nnnMETHODSnPatients who received isolated CABG with SIMA or BIMA were retrospectively reviewed using the Japan Adult Cardiovascular Surgery Database from 210 institutions for 2008 and 2009. We performed a one-to-one matched analysis on the basis of estimated propensity scores for patients receiving either SIMA or BIMA and obtained two cohorts with 3851 patients in each group balanced for baseline characteristics out of 8136 SIMA and 4093 BIMA patients. We compared procedures actually performed, early outcomes including 30-day operative mortality and details of postoperative complications between the groups using Pearsons chi-square test, with P < 0.05 being statistically significant.nnnRESULTSnPreoperative profiles in both groups included 20% females and 50% diabetes mellitus patients with a mean age of 67 years. Off-pump CABG was similar in both groups, being performed 75% of the time, with the mean number of anastomosis being 3.1 and 3.4 in the SIMA and BIMA groups, respectively (P < 0.0001). Thirty-day operative mortality was 1.2% in both groups, and the overall incidence of postoperative complications also was similar, although deep sternal infection was more frequent with BIMA (1.3 of SIMA and 2.3% of BIMA patients; P = 0.0001), while prolonged ventilation and renal failure were more frequent with SIMA (P < 0.05).nnnCONCLUSIONSnThe use of BIMA did not affect either short-term survival as postoperative mortality was low in both groups, or overall morbidity despite higher incidence of deep sternal infection.

Clinical Application of Intermittent Pressure-Augmented Retrograde Cerebral Perfusion

Brain protection is important during aortic arch surgery, especially in patients with cerebral ischemia. We clinically applied the effectiveness of a novel protocol of retrograde cerebral perfusion with intermittent pressure augmentation for brain protection in a canine model, as described in a previous report. Although, in our patient the brachiocephalic artery and left subclavian artery were occluded as a result of aortitis, there was a history of right cerebral infarction, recovery of consciousness, and no neurologic sequelae. Near-infrared oximetry showed recovery of intracranial blood oxygen saturation every time the pressure was augmented.

Outcomes of midterm circulatory support by left ventricular assist device implantation with descending aortic anastomosis

For some patients undergoing left ventricular assist device (LVAD) implantation, the perfusion tube is anastomosed to the descending aorta instead of the currently more prevalently used ascending aorta. Purpose of this study was to assess retrospectively the outcomes of LVAD patients with descending aortic anastomosis. Between March 2007 and March 2010, six patients underwent LVAD implantation with descending aortic anastomosis with Toyobo or Jarvik 2000 LVAD at our institute. Their average circulatory support time was 434xa0(range 82–751)xa0days. Both types of LVAD afforded adequate circulatory support, and inotrope treatment and mechanical ventilation were discontinued relatively early. Echocardiograms of the three patients with Jarvik 2000 LVAD revealed antegrade flow in the ascending aorta during the intermittent low-speed period. Among them, one patient developed infarction in the right brain hemisphere because of thromboembolism, whereas another patient developed pneumonia in the left lung followed by a lethal systemic infection. One patient on Toyobo LVAD support reached heart transplantation without morbidity. Another patient implanted with Toyobo LVAD, whose left ventricular function was too poor to generate forward flow through aortic valve, developed thrombus in the ascending aorta. No embolic events were observed in the organs below the diaphragm. In conclusion, descending aortic anastomosis of the perfusion tube can be used for LVAD implantation for some patients, but considerable risks of morbidities, including thromboembolic events and/or infection, should be recognized.

The national clinical database as an initiative for quality improvement in Japan.

The JCVSD (Japan Cardiovascular Surgery Database) was organized in 2000 to improve the quality of cardiovascular surgery in Japan. Web-based data harvesting on adult cardiac surgery was started (Japan Adult Cardiovascular Surgery Database, JACVSD) in 2001, and on congenital heart surgery (Japan Congenital Cardiovascular Surgery Database, JCCVSD) in 2008. Both databases grew to become national databases by the end of 2013. This was influenced by the success of the Society for Thoracic Surgeons’ National Database, which contains comparable input items. In 2011, the Japanese Board of Cardiovascular Surgery announced that the JACVSD and JCCVSD data are to be used for board certification, which improved the quality of the first paperless and web-based board certification review undertaken in 2013. These changes led to a further step. In 2011, the National Clinical Database (NCD) was organized to investigate the feasibility of clinical databases in other medical fields, especially surgery. In the NCD, the board certification system of the Japan Surgical Society, the basic association of surgery was set as the first level in the hierarchy of specialties, and nine associations and six board certification systems were set at the second level as subspecialties. The NCD grew rapidly, and now covers 95% of total surgical procedures. The participating associations will release or have released risk models, and studies that use ‘big data’ from these databases have been published. The national databases have contributed to evidence-based medicine, to the accountability of medical professionals, and to quality assessment and quality improvement of surgery in Japan.

Anxiety and depression after thoracic aortic surgery or coronary artery bypass

Background: although the outcome of thoracic aortic surgery has improved remarkably, mortality remains high, and mental distress is often present. Psychological outcomes of coronary artery disease have been increasingly researched but few studies have been conducted in thoracic aortic surgery patients. Objective: to compare the psychological outcomes of patients undergoing thoracic aortic surgery with those of patients undergoing coronary artery bypass grafting. Methods: a questionnaire was mailed to 190 patients who underwent thoracic aortic surgery or coronary artery bypass, at 1–5 years postoperatively. Psychological outcomes were assessed using the hospital anxiety and depression scale. Results: 128 patients responded; 49 had aortic surgery and 79 had coronary artery bypass. The incidence of borderline or significant anxiety was 14% in thoracic aortic surgery patients and 16% in coronary bypass patients; depression was present in 28% and 20%, respectively. Psychological outcome scores in the 2 groups did not differ significantly. Emergency surgery was associated with depression after aortic surgery, and symptoms such as chest pain and fatigue were associated with both anxiety and depression after coronary artery bypass. Conclusions: some psychological problems remain in the midterm following thoracic aortic surgery. While we expected a more psychologically compromised outcome in the thoracic aortic surgery group, psychological outcomes were quite similar to those in coronary artery bypass patients. The similarity of the profiles of both groups suggests that thoracic aortic surgery patients have a parallel course of midterm psychological improvement following surgery.

A novel external counterpulsation system for coronary artery disease and heart failure: pilot studies and initial clinical experiences

External counterpulsation (ECP) is a beneficial and noninvasive treatment for coronary artery disease or heart failure; however, it still has a lot of limitations. We used a novel ECP system, Compact CP, the main feature of which is the double-lumen cuff that reduces the impact of cuff inflation and the size of the air compressor. The first lumen was a contact cuff that was attached to the legs with a constant pressure (8xa0kPa). The second lumen was a main cuff that was inflated and deflated with a driving pressure and synchronized to the cardiac cycle. In this report, we describe the results of four pilot studies in a total number of 39 healthy volunteers and initial clinical experiences of this system in three patients. The pilot studies demonstrated that the ECP system provided significant diastolic augmentation and systolic unloading. It also achieved a satisfactory diastolic/systolic pressure ratio (1.00xa0±xa00.06) with a high comfort level at a driving pressure of 40xa0kPa. Higher pressure (50–70xa0kPa) increased the assist performance but decreased the comfort level. ECP was also applied with a patient with chronic refractory angina and two patients with postoperative heart failure following cardiac surgery. The clinical conditions improved. No adverse effect was observed. Our novel ECP system is safe, effective, and promising in the treatment of coronary artery disease or heart failure. Further clinical investigations are needed to support the significance of this system.

Door to balloon time: how short is enough under highly accessible nationwide insurance coverage? Analysis from the Japanese multicenter registry.

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