Susumu Nakamoto

Antegrade selective cerebral perfusion with mild hypothermic systemic circulatory arrest during thoracic aortic surgery

Objective Antegrade selective cerebral perfusion (ASCP) and retrograde cerebral perfusion (RCP) have proven to be reliable methods of brain protection during aortic surgery. These techniques are usually accompanied by systemic circulatory arrest with moderate hypothermia (24–28°C) or deep hypothermia (18–24°C). However, hypothermia can lead to various problems. The present study therefore reports results for thoracic aorta replacement using ASCP with mild hypothermic systemic arrest (28–32°C). Design Between 1995 and 2003, 68 consecutive patients underwent repair of the ascending aorta and/or aortic arch. Mild hypothermic ASCP was utilized in 31 cases, moderate hypothermic ASCP in 20, and deep hypothermic RCP in 17. Various parameters were compared between the mild hypothermic ASCP, moderate hypothermic ASCP, and RCP. Results Hospital mortality was 10.3%, with no significant differences observed between any groups. Permanent neurological dysfunction was 8.8%, and no significant differences were observed between any groups. Mild hypothermic ASCP displayed significantly decreased transfusion volume, intubation time, and ICU stay. Conclusions Use of ASCP with mild hypothermic systemic circulatory arrest during aortic surgery resulted in acceptable hospital mortality and neurological outcomes. ASCP with mild hypothermic arrest allows decreased transfusion volume and reduced duration of intubation and ICU stay.

Intravascular Extraction of Permanent Pacemaker Leads

Abstract.Purpose: Cardiac leads that became infected, fail, or are otherwise problematic present difficulties in the management of patients. In this report, we assess our intravascular countertraction technique. Method: Between February 1990 and January 2001, 13 leads were removed from 11 patients using the intravascular countertraction technique. The reasons for lead extraction were pacemaker infection and lead dysfunction. Results: In two of these patients, the ventricular leads could not be completely removed. The complete success rate was 85% and the overall success rate was 92%. There were no serious complications such as cardiac rupture, vein injury, or death, and there were no clinical signs of pulmonary embolism. In one of the patients whose ventricular leads could not be removed completely, the ventricular lead was stretched from its previous round shape, but tricuspid valve regurgitation did not occur during the 3-year follow-up period. In the other patient, the distal electrode was left in the subclavian vein. However, this residual distal electrode did not migrate, and there were no clinical signs of any recurrence of infection. Conclusions: The present study suggests that to remove leads successfully, the largest locking stylet that can be easily passed to the leads tip through the coil lumen should be chosen in order to avoid valve injury, which can sometimes occur when a ventricular leads locking stylet is left in the coil lumen.

Disseminated Cholesterol Embolism After Coronary Artery Bypass Grafting

Blue toe syndrome caused by cholesterol emboli is a relatively benign disease. However, disseminated cholesterol embolism is a life‐threatening condition. We describe here the case of a 71‐year‐old female admitted because of anterior chest pain and intermittent claudication. Following cardiac catheterization, warfarin potassium was administered. However, the patients toes soon darkened bilaterally, and BUN and creatinine levels increased from the normal value. Skin discoloration and renal failure were improved after stopping warfarin potassium administration. The patient underwent coronary artery bypass grafting and left femoropopliteal bypass. Cerebral infarction and renal failure occurred postoperatively due to disseminated cholesterol embolism. The patient died from renal failure on the 16th postoperative day without regaining consciousness following surgery. For high risk patients, interventional procedures to the ascending aorta must be avoided. When CABG cannot be avoided for coronary revascularization, off‐pump bypass and use of arterial grafts are recommended.

Surgical Treatment of Pacemaker Induced Left Innominate Vein Occlusion Using a Spiral Vein Graft

INOUE, T., et al.: Surgical Treatment of Pacemaker Induced Left Innominate Vein Occlusion Using a Spiral Vein Graft. Superior vena cava syndrome due to transvenous pacing leads is an uncommon but potentially life‐threatening complication. This case involves a 54‐year‐old man who developed left innominate vein occlusion due to a pacemaker lead. This complication induced a progressive swelling on the left side of his face, neck, arm, and upper chest. The left innominate vein occlusion was surgically treated using a composite spiral saphenous vein graft. Postoperatively, the patient has received anticoagulation therapy with warfarin to prevent thrombosis and, thereby, the long‐term patency of the graft. He has undergone follow‐up on a regular outpatient basis without showing any recurrence of clinical symptoms.

Small right vertical infra-axillary incision for minimally invasive port-access cardiac surgery: a moving window method

Port-access cardiac surgery has been developed to minimize skin incision and improve cosmetic outcomes. Using this method, a skin incision is generally made just above where the thoracotomy will be placed, horizontally along the intercostal space at the anterolateral submammary position. However, this type of incision can affect the frontal view and shape of the breast. Here, we report our experience with minimally invasive cardiac surgery using a port-access approach via a small vertical right infra-axillary incision and a moving window method. Twenty patients underwent surgical procedures with this approach from December 2010 to January 2012. Thirteen patients underwent mitral valvuloplasty, four mitral valve replacement, one mitral and tricuspid valve replacement and atrial septal defect closure and two atrial septal defect closure. All surgical procedures were completed using this minimally invasive method. All patients had an uneventful recovery and indicated that they were satisfied with the cosmetic results during the follow-up. Our experience suggests that this technique can effectively minimize skin incision and improve cosmetic outcomes.

Early and Late Results of Surgical Treatment for Ventricular Septal Rupture With and Without Use of the Infarction Exclusion Technique—Experience With Two- and Three-Sheet Modification

Abstract  Background: Ventricular septal rupture (VSR) is an infrequent but life‐threatening situation. Although outcomes have improved with the introduction of infarction exclusion, we have experienced difficulty in determining the optimal patch size and shape for obtaining good outcomes. Therefore, we modified the infarction exclusion technique. Herein, we review our experience on the basis of early closure of VSR with and without use of the infarction exclusion technique. Methods: We retrospectively analyzed the hospital records of 33 patients who underwent surgical treatment for VSR. We employed Daggets method from 1982 to 1995, and then introduced the infarction exclusion technique in 1995. We have developed two modifications: the two‐sheet single‐patch technique and the three‐sheet double‐patch technique. Results: Overall hospital mortality was 41.9% and that of the infarction exclusion group was significantly lower than the hospital mortality rate of the noninfarction exclusion group (21% and 63%, respectively, p = 0.0266). Late mortality of survivors was low in all groups during the observation period. The three‐sheet double‐patch group showed no residual shunt. This difference in outcomes between the single‐patch and double‐patch groups was statistically significant (p = 0.0174). Conclusions: The two‐sheet method facilitates the restoration of ventricular geometry. A double‐patch using the three‐sheet method may be useful for reducing residual shunt. (J Card Surg 2012;27:34–38)

Stent Graft Repair of a Ruptured Aberrant Right Subclavian Artery after Open Repair

An aberrant right subclavian artery arising from the proximal portion of the descending thoracic aorta is the most common congenital anomaly of the aortic arch. Open repair is typically performed in such cases; however, it may be associated with a high rate of neurological complications and mortality, particularly in patients contraindicated for major open vascular reconstruction. We successfully treated a ruptured aberrant right subclavian artery using stent grafts in an 81-year-old female patient who had previously undergone open aortic arch repair. The stent graft technique is useful for patients without vascular ring symptoms who require repeat thoracotomy.

Intravenous pacemaker lead implantation for a pediatric patient: A 16-year follow-up study

Intravenous pacemaker lead implantation for small children is not performed routinely. Here, we report the case of a pediatric patient who underwent endocardial lead implantation and follow‐up for 16 years. The patient was a 4‐year‐old boy who underwent total correction of pulmonary atresia with ventricular septal defect following several palliative operations. After the patient underwent total correction, atrial flutter was noted. Atrial flutter was successfully terminated by overdrive pacing. However, atrial flutter occurred again immediately after overdrive pacing. To treat atrial flutter caused by sick sinus syndrome, a screw‐in type lead was attached to the free wall of the right atrium and an excess loop was left to allow for the patients growth. During the 16‐year follow‐up, no adverse effects were observed except for a gradual increase in pacing threshold. The selection of a small‐sized endocardial lead and an appropriate entry vein, with meticulous management of the leads, makes implantation of an endocardial lead for small children easier and safer.

Cardiac Resynchronization for Corrected Transposition of the Great Arteries with Systemic Right Ventricle Failure after Tricuspid Valve Replacement and Ventricle Septal Defect Closure

A 32‐year‐old man developed systemic right ventricular (RV) heart failure after ventricular septal defect (VSD) closure and tricuspid valve replacement for corrected transposition of the great arteries with VSD and Ebstein anomaly. He subsequently experienced RV failure with wide QRS and atrial fibrillation (AF). Because corrective surgery for this condition seemed over risky, we decided to perform cardiac resynchronization therapy with implantation of an implantable cardioverter defibrillator (CRT‐D). After CRT‐D device implantation, the patient showed improved performance status in terms of New York Heart Association functional class, B‐type brain natriuretic peptide levels, RV ejection fraction and cardiac electrical rhythm. CRT‐D implantation is a useful approach for systemic RV failure with wide QRS duration showing right bundle branch block and AF.

Refractoriness to Platelet Transfusion Following Double Valve Replacement in an ITP Patient Who Had Undergone Splenectomy

Abstract Reports of patients with idiopathic thrombocytopenic purpura (ITP) undergoing cardiac surgery are rare, and almost all of the reported cases required platelet transfusion. ITP patients, especially those having a history of splenectomy or a history of heavy bleeding, may have to undergo multiple platelet transfusions. Such transfusions may induce al‐loimmunization against the human leukocyte antigen (HLA) and result in refractoriness to subsequent platelet transfusions. We report a case of a 63‐year‐old female with ITP, with a history of splenectomy and multiple platelet transfusions, who underwent aortic and mitral valve replacement. Although corticosteroid administration, high‐dose immunoglobulin therapy, and repeated platelet transfusion led to a temporary increase in platelet count and successful hemostasis, refractoriness to platelet transfusion occurred postoperatively because of the presence of the anti‐HLA antibody. In addition, the patient showed complications of pyothorax. Corticosteroids might have exerted an inhibitory influence on the occurrence of pyothorax.