Taira Kobayashi

Coronary artery bypass surgery is superior to percutaneous coronary intervention with drug-eluting stents for patients with chronic renal failure on hemodialysis.

BACKGROUND Improvements in the results of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) have been extending their use in patients with all forms of coronary artery disease. The purpose of this study was to compare the midterm clinical results of coronary artery bypass surgery (CABG) and PCI with DES in patients with chronic renal failure on hemodialysis. METHODS From January 2002 to December 2006, 29 patients underwent CABG, and 75 patients underwent PCI with DES. For CABG, 24 patients had off-pump surgery. The mean follow-up was 32.0 +/- 22.0 months for CABG and 23.5 +/- 14.8 months for PCI. Survival, cardiac death, major adverse cardiac events (cardiac death, myocardial infarction, revascularization), and target lesion revascularization were analyzed using the Kaplan-Meier method. RESULTS Preoperative characteristics and risk factors were compatible between the groups except for the European System for Cardiac Operative Risk Evaluation (7.3 +/- 2.7 for CABG and 5.0 +/- 2.4 for PCI, p < 0.0001) and the presence of a left main trunk lesion (53.3% for CABG and 18.7% for PCI). Thirty-day mortality was 3.3% for CABG and 4.0% for PCI. The 2-year survival rate was 84.0% for CABG and 67.6% for PCI (p = 0.0271). The cardiac death-free curve at 2 years was 100% for CABG and 84.1% for PCI (p = 0.0122). The major adverse cardiac events-free rate at 2 years was 75.8% for CABG and 31.5% for PCI (p < 0.0001). During the follow-up period, there were 6 late deaths in the CABG group and 27 late deaths (including 6 sudden deaths) in the PCI group. CONCLUSIONS Coronary artery bypass grafting was superior to PCI with DES in patients with chronic renal failure on hemodialysis in terms of long-term outcomes for cardiac death, major adverse cardiac events, and target lesion revascularization. The DES carried a higher risk for sudden death, which might be associated with stent thrombosis.

Surgical Treatment for Postinfarction Left Ventricular Free Wall Rupture

BACKGROUND Left ventricular (LV) free wall rupture is a catastrophic complication after acute myocardial infarction. The optimal therapeutic strategy is controversial and the midterm results are unknown. METHODS Between June 1993 and May 2006, 32 patients with an average age of 73 years (range, from 55 to 96 years) were surgically treated for LV free wall rupture. Sutureless technique (gluing autologous patch to the tear) was applied in all patients. RESULTS The interval between acute myocardial infarction and the rupture was 33 +/- 42 hours and the interval between the rupture and the operation was 3.6 +/- 2.6 hours. Preoperatively, cardiopulmonary resuscitation was performed in eight cases. Percutaneous cardiopulmonary support was placed in six cases and intraaortic balloon pumping in 20 cases preoperatively. The in-hospital mortality was 15.6%. Two patients died of rerupture within ten days. While there was no rerupture during the follow-up period, five patients developed dyskinetic LV aneurysm and one patient developed LV pseudoaneurysm. CONCLUSIONS The sutureless technique is a simple and effective option for the surgical treatment for LV free wall rupture. The preoperative moribund condition was highly associated with the operative mortality.

Preoperative evaluation of patients with liver cirrhosis undergoing open heart surgery

ObjectiveClinical outcomes after open heart surgery in patients with liver cirrhosis are not satisfactory. For evaluating hepatic function, the Child-Pugh classification has been widely used. It has been reported that open heart surgery can be performed safely in patients with mild liver cirrhosis. In this study, we examined the clinical outcomes after open heart surgery in patients with liver cirrhosis and evaluated the usefulness of the Child-Pugh classification.MethodsThere were 12 liver cirrhosis patients who underwent open heart surgery between January 2002 and December 2006 at our institution. The severity of cirrhosis was graded according to the Child-Pugh classification. We reviewed clinical outcomes, such as postoperative mortality and morbidity, and tried to determine the risk factors. Finally, we assessed the usefulness of the Child-Pugh classification.ResultsSix patients were classified as having Child class A, and the other six patients were classified as B. The overall mortality of group A was 50%, and that of group B was 17%. Postoperative major morbidities occurred in half of the patients of Child class A and in all of the patients of Child class B. Patients who experienced major morbidities had markedly lower levels of serum cholinesterase (106 ± 46 vs. 199 ± 72 IU/l; P = 0.02) and lower platelet level (7.5 ± 2.9 vs. 11.9 ± 3.6 × 104/μl; P = 0.04).ConclusionThe mortality and morbidity rates were high even in the Child class A patients. The Child classification may be an insufficient method for evaluating hepatic function. We have to assess other factors, such as the serum cholinesterase level or the platelet count.

Chronic expanding hematoma in the pericardial cavity after cardiac surgery

We report the successful surgical treatment of a rare case of chronic expanding hematoma in the pericardial cavity that developed into a very large mass over a long period. The patient, who had a history of cardiac surgery for a double-outlet right ventricle 14 years previously and for tricuspid regurgitation 8 years ago, noticed a slowly growing mass near the left atrium and ventricle 5 years ago. The mass, which confirmed a diagnosis of chronic expanding hematoma, was resected by left thoracotomy.

The clinical challenge to reduce the postoperative residual shunt in surgical repair of postinfarction ventricular septal perforation

Postinfarction ventricular septal perforation (VSP) remains a surgical challenge. The present study describes the use of an interrupted suture technique with the goal of reducing the incidence of postoperative residual shunt. Thirty-four consecutive cases of patients who underwent Davids procedure for VSP between 1996 and 2008 were reviewed. A running suture technique was used to close the ruptured septum (C-group: 14 patients) prior to 2002, while the interrupted suture technique (I-group: 20 patients) was used after that point. The overall 30-day mortality was 26.5%, and the mortality rate was not different when comparing the two groups. Postoperative residual shunt was present in five patients (36%) in the C-group and in two patients (10%) in the I-group. In conclusion, use of the interrupted suture technique resulted in a lower incidence of postoperative residual shunt rate. However, the mortality associated with surgical repair of VSP remains high.

Thymic carcinoids in multiple endocrine neoplasia-type 1

We report a case of a 45-year-old man with thymic carcinoids in multiple endocrine neoplasm-type 1. Extended total thymectomy was performed through a median sternotomy, and the mediastinal regional lymph nodes and fibroadipose tissue were dissected. Multiple endocrine neoplasm-type 1 related thymic carcinoids are rare and have a poor prognosis. The efficacy of radiotherapy and chemotherapy for prolonging survival is limited, and an aggressive surgical approach with complete excision of the tumor with resection of the peripheral tissues and dissection of the mediastinal lymph nodes seems to be the best available treatment today. We have found that this practice of thymectomy at an early stage in combination with genetic and effective radiological treatment can be effective for multiple endocrine neoplasm-type 1 patients.

Cusp commissuroplasty for tricuspid valve endocarditis

A 19-year-old woman with a history of drug addiction suffered from sepsis and heart failure. Blood culture was positive for Streptococcus viridans. An operation was indicated because the echocardiography showed massive vegetation on the anterior leaflet of the tricuspid valve and severe regurgitation even though the endocarditis was healed with drug therapy. At operation all of the anterior leaflet of the tricuspid valve was resected with the vegetation. Using the technique of cusp commissuroplasty, the disrupted commissure was reconstructed by approximating the septal and posterior cusps at the level of their normal closure, forming a zone of apposition by using a single stitch. Leaflet apposition resulted in a defect between the apposed leaflets and the tricuspid annulus, which was patched with autologous pericardium. The tricuspid valve was reconstructed to function as a unicommissural bicuspid valve. The patient was stable during the follow-up period of two years without any medical treatment.

Pure Cusp Tear of Trifecta Bioprosthesis 2 Years after Aortic Valve Replacement.

Trifecta is a stented bioprosthetic heart valve with a bovine pericardial sheet externally mounted on a titanium stent. This valve is applied only for aortic valve replacement (AVR), providing excellent hemodynamics and extremely low incidence of structural valve deterioration (SVD). A 76-year-old woman presented with dyspnea on effort 24 months after AVR with a 21-mm Trifecta valve. Echocardiography revealed severe aortic regurgitation with prolapse of a cusp of Trifecta valve, which suggested that she developed acute heart failure due to early SVD. In the operation, Trifecta valve had a cusp tear near the commissure with circumferential fibrous pannus ingrowth only at the inflow side. There was neither calcification nor infection. The Trifecta valve was successfully replaced with a new porcine bioprosthesis.

Treatment of porcine bioprosthetic mitral valve thrombosis with anticoagulation

A 70-year-old man underwent mitral valve replacement using a porcine bioprosthesis for infective endocarditis. Transthoracic echocardiography revealed thickened leaflets with increased transprosthetic pressure gradient and new regurgitation, 6 months after surgery. He was followed up medically with the diagnosis of early valve degeneration. He ultimately presented with worsening orthopnea 13 months after surgery. Transesophageal echocardiography revealed an immobile round mass attached to the ventricular aspect of the leaflets, which hampered valve opening, suggesting bioprosthetic valve thrombosis. Anticoagulation with heparin and warfarin were effective and transthoracic echocardiography showed normal transprosthetic pressure gradient and disappearance of regurgitation 2 months later.

Simultaneous Surgery for Thoracic Aortic Aneurysm with Coronary Artery Disease

Objective: We describe our strategy and the outcomes of simultaneous coronary artery bypass grafting (CABG) during surgery for thoracic aortic aneurysms in patients with coronary artery disease.