Takaki Sugimoto

Long-term evaluation of treatment for functional tricuspid regurgitation with regurgitant volume: characteristic differences based on primary cardiac lesion

OBJECTIVES The aim of this study was to characterize differences in the long-term effects of treatment for functional tricuspid regurgitation based on the primary cardiac lesion. METHODS Ninety-six patients with valvular heart disease and 32 patients with atrial septal defects associated with tricuspid regurgitation were studied. The tricuspid annular diameter was associated with evidence of right heart failure. In valvular heart disease, a Kay annuloplasty was performed in 33 patients with a tricuspid annular diameter of >/=40 mm to 44 mm, a modified De Vega annuloplasty in 12 patients with a tricuspid annular diameter of >/=45 mm to 49 mm, and a modified De Vega annuloplasty, annuloplasty using a Carpentier ring, or tricuspid valve replacement in each of 4 patients with a tricuspid annular diameter of >/=50 mm. In atrial septal defects, a Kay annuloplasty was performed in 11 patients with a tricuspid annular diameter of >/=45 mm to 49 mm, and a modified De Vega annuloplasty was performed in 5 patients with a tricuspid annular diameter of >/=50 mm. A mean follow-up period was 79 months after operation. RESULTS In the patients with a tricuspid annular diameter of <50 mm, the hemodynamic and clinical findings and tricuspid regurgitation remarkably improved. In the patients with valvular heart disease with a tricuspid annular diameter of >/=50 mm, however, the right heart parameters also showed improvement but less so when compared with those patients with a tricuspid annular diameter of <50 mm. In addition, 4 patients undergoing a modified De Vega annuloplasty have had a gradual increase in tricuspid regurgitation and clinical manifestations late after the operation. In contrast, all 5 patients with atrial septal defects with a tricuspid annular diameter of >/=50 mm have shown remarkable improvement, similar to those with a tricuspid annular diameter of <50 mm. Preoperative analyses revealed that the right heart function in atrial septal defects had not deteriorated to the same extent as in valvular heart disease. CONCLUSION In the patients with a severely dilated tricuspid anulus (>/=50 mm), the postoperative change of tricuspid regurgitation differed between those patients with valvular heart disease and atrial septal defects.

Intravenous Leiomyomatosis Extending into the Right Ventricular Cavity: One-Stage Radical Operation Using Cardiopulmonary Bypass: A Case Report

The authors describe a 47-year-old woman with intravenous leiomyomatosis (IVL) extending into the right ventricular cavity. This rare entity is a neoplasm originating from smooth muscle of the uterus, with vermiform extensions into the inferior vena cava. The patient underwent a one-stage operation under simultaneous sternotomy and laparo tomy, and radical excision of the tumor was successfully achieved with use of normoth ermic cardiopulmonary bypass. Although this tumor is histologically benign, it sometimes extends into the cardiac cavity and causes sudden death due to incarceration into the atri oventricular orifice. Moreover, recurrence or lung metastasis of IVL has been reported. The authors recommend a one stage-radical resection of the tumor or a two-staged operation within a short interval. In the literature, 24 surgical cases of the intravenous leiomyomatosis with intracardiac extension have been reported. The diagnosis and surgical treatment of this tumor are reviewed and discussed.

Right ventricular ejection fraction in the preoperative risk evaluation of candidates for pulmonary resection

The major determinants of postoperative morbidity and mortality after lung resection are the physiologic and functional statuses of the pulmonary and cardiac systems. In our previous study, serial measurements of right ventricular performance after pulmonary resection demonstrated significant right ventricular dysfunction in the postoperative period. This study evaluates the preoperative measurement of right ventricular ejection fraction as a predictor of postoperative complications. In addition to conventional cardiopulmonary functional tests, right ventricular function was assessed with a thermodilution technique at rest and during exercise in 18 patients before and 3 weeks after lobectomy or pneumonectomy. The patients were grouped according to severity of right ventricular functional defect: right ventricular ejection fraction of at least 45% (group Ia, n = 8), right ventricular ejection fraction less than 45% (group Ib, n = 10), exercise-induced increases in right ventricular ejection fraction (group IIa, n = 8), and exercise-induced decreases in right ventricular ejection fraction (group IIb, n = 10). Postoperative cardiopulmonary morbidity was recorded for two patients (25%) in group Ia, three patients (30%) in group Ib, no patients (0%) in group IIa, and five patients (50%) in group IIb. Postoperative hospital stay was 28.9 +/- 8.5 days in group Ia, 29.9 +/- 20.2 days in group Ib, 19.4 +/- 8.0 days in group IIa, and 37.5 +/- 15.9 days in group IIb (p < 0.05, group IIa vs group IIb). Although resection-induced changes in forced expiratory volume in 1 second did not differ significantly between group Ia and group Ib, these values appeared to be increased in groups IIa (not statistically significant) and IIb (significantly, p < 0.05). The measured postoperative values of forced expiratory volume in 1 second and vital capacity were significantly higher than the predicted postoperative values (p < 0.05) in group IIa, but not in groups Ia, Ib, and IIb. We conclude that evaluation of right ventricular performance is useful in determining which patients are at increased risk for medical complications after lung resection. Exercise-induced change in right ventricular ejection fraction may be a better indicator of high risk among candidates for pulmonary resection than the absolute value of this parameter.

Influence of functional tricuspid regurgitation on right ventricular function

BACKGROUND Although right ventricular (RV) function has been extensively studied during the past decade, few reports have described the influence of functional tricuspid regurgitation (TR) on RV function. METHODS One hundred forty-two patients with left-side valvular heart disease associated with TR were enrolled in the study and divided into three groups according to tricuspid annular diameter: group 1 (n = 66), tricuspid annular diameter less than 40 mm; group 2 (n = 58), tricuspid annular diameter of 40 to 50 mm; and group 3 (n = 18), tricuspid annular diameter greater than or equal to 50 mm. In groups 2 and 3, the right heart parameters had deteriorated to the point that TR repair was necessary. The mean follow-up period was 102 months after the operation. RESULTS In each of the three groups, as pulmonary arteriolar resistance index increased, RV forward stroke work index increased in a linear fashion. The slope of the linear regression line was progressively less in group 1, 2, and 3 preoperatively. Postoperatively, this line moved in a parallel manner in group 1 and became steeper in group 2, consequently becoming similar in both groups. However, in group 3, although the slope became steeper in spite of a remarkable decrease of TR, it remained less when compared with groups 1 and 2. In addition, the right heart parameters also improved, but still remained worse in group 3 than group 2; 7 patients undergoing a flexible annuloplasty have shown gradual aggravations in TR and late postoperative clinical manifestations. CONCLUSIONS Functional TR with severely dilated annulus may produce an irreversible deterioration of RV function. The preoperative relationship between pulmonary arteriolar resistance index and RV forward stroke work index, that is, RV systolic function to pressure afterload, might predict a postoperative fate of the right heart function.

Surgical treatment for transvenous tumor extension into the heart: Four cases

From 1984 to 1996, four patients with transvenous intracardiac tumor extension underwent operations in the Kobe University Hospital. The primary tumors of two were intravenous leiomyomatoses originating from the uterus; a third patient had invasive thymoma, and the fourth patient had clear cell sarcoma of the kidney. In 1985, one patient had a curative, staged resection. One-stage operations were carried out in three patients, and all intracardiac tumors were successfully resected en bloc with the primary tumors under conditions of electrical ventricular fibrillation and mild hypothermia. Combined venous reconstructions were necessary for en bloc resection in three cases. Two patients with malignancy received postoperative chemoradiotherapy, and all four patients were discharged uneventfully from our hospital. We consider radical resection with curative intent only for patients with tumors extending into the heart. In these cases, a one-stage operation is preferable, and electrical ventricular fibrillation with mild hypothermia is a recommended method of circulatory assist because of its simplicity.

Foot venous pressure measurement for evaluation of lower limb venous insufficiency

PURPOSE Foot venous pressure measurement is considered to be useful for assessing lower limb venous insufficiency, because venous hypertension is the main factor predisposing to venous insufficiency. In this study, we investigated the utility of foot venous pressure measurement in the evaluation of venous insufficiency. METHODS A total of 148 limbs of 101 patients with venous insufficiency associated with varicose veins and treated over 5 years were studied. The measurements assessed were percentage decrease in foot venous pressure with manual calf compression (%drop), rate of increase in foot venous pressure during a 4-second period after release of compression (4SR%), and time to 50% recovery of foot venous pressure (RT50). RESULTS A higher incidence of skin changes (clinical, etiologic, anatomic, and pathophysiologic classification classes 4 to 6) caused by venous insufficiency was associated with %drop, 4SR%, and RT50 values. Skin changes were found in more than 50% of the limbs with a %drop less than 50%, 4SR% more than 50%, or RT50 less than 4 seconds. After tourniquets were applied to occlude the superficial veins, limbs with severe below-knee deep venous reflux (%drop 60.3 +/- 14.6, 4SR% 36.7 +/- 30.2, RT50 13.9 +/- 14.7) showed significantly worse values than those with no reflux (%drop 79.9 +/- 3.2, 4SR% 8.1 +/- 3.1, RT50 48.9 +/- 17.9) or with mild above-knee reflux (%drop 77.0 +/- 5.0, 4SR% 7.1 +/- 3.2, RT50 46.9 +/- 26.7). After sclerotherapy or surgical treatment, including deep venous reconstruction for severe below-knee reflux, all limbs showed significant improvement in clinical manifestations and foot venous pressure values (%drop 68.1 +/- 7.5 to 76.5 +/- 5.8, 4SR% 33.1 +/- 12.9 to 12.7 +/- 7.6, RT50 7.5 +/- 4.2 to 20.1 +/- 6.5). CONCLUSION Foot venous pressure measurements showed a good correlation with clinical severity and degree of venous reflux and were very useful for evaluating the outcome of therapy for venous insufficiency.

An Abdominal Aortic Rupture Due to Seatbelt Blunt Injury: Report of a Case

A 66-year-old man, who was a passenger in a car involved in a low-speed head-on motor vehicle accident, was rushed to our hospital. His abdomen was tender and distended. An enhanced computed tomography scan showed a massive retroperitoneal hematoma, and its three-dimensional imaging revealed an active leak of the contrast medium from the aortic bifurcation. He went into shock, and was immediately transferred to the operating theater. Through a median laparotomy, a ruptured site measuring 5 mm in diameter was found at the aortic bifurcation and it was closed with sutures under a proximal aortic control. The other organs showed no evidence of injury. Because of the remarkable edema of the bowel, mesentery, and retroperitoneum, the abdomen was temporarily closed with a mesh sheet to prevent the occurrence of abdominal compartment syndrome. A delayed closure was then successfully performed 4 days later, and he was discharged with no residual sequelae 17 days after the initial operation.

Leriche Syndrome Surgical Procedures and Early and Late Results

During the past thirteen years, 29 patients underwent surgical intervention for Leriche syndrome. Fifteen patients (aged forty-two to seventy-two years, average 60.7 years) underwent anatomical bypass, and 9 of them whose thrombus was confined to the infrarenal aorta received a routine graft insertion. In the other 6 whose thrombus extended to the level of the renal arteries, an open thrombectomy of the juxtarenal aorta was first performed through a transection of the infrarenal aorta under renal ischemia (4-14 minutes, average 7). Twelve elderly or high-risk patients (aged sixty-eight to eighty-four years, average 75.3 years) underwent an axillobifemoral bypass, and another (continued on next page) 2 (fifty-eight and sixty years old, respectively) who had been operated on at an earlier time received an ascending aortobifemoral bypass. In cases of anatomical bypass, no graft has occluded and all patients but 1, who died of cerebral infarction, have an active life now. In cases of extraanatomical bypass, 5 of the 28 grafts occluded and only 6 patients have survived. The other 8 patients died of malignancy, atherosclerotic complications, or unknown causes. The 10-year survival rate was 92.9% and 29.5% in the anatomical bypass and extraanatomical bypass group, respectively. In Leriche syndrome, anatomical bypass is preferred to extraanatomical bypass if conditions permit. In the juxtarenal type, an open thrombectomy under renal ischemia is mandatory for anatomical bypass, and a transection of the infrarenal aorta facilitates this procedure. Because the patients with Leriche syndrome are elderly and harbor arte riosclerotic lesions, a careful follow-up is mandatory.

Large perigraft seroma after aortoiliac bypass with an expanded polytetrafluoroethylene graft: report of a case.

A 63-year-old man who had undergone aortoiliac bypass with an expanded polytetrafluoroethylene (PTFE) graft was referred to our hospital for investigation and treatment of a possible pseudoaneurysm of the abdominal aorta. A tender, pulsatile, and bulging mass, about the size of an adult fist, was palpated around the navel. Enhanced computed tomography (CT) showed a large low-density area around the abdominal aorta and PTFE graft, and aortography showed a patent graft with no anastomotic leakage. Operative inspection revealed that the pulsatile mass was a large perigraft seroma, and we replaced the PTFE graft with a new woven Dacron graft. The patient has been well with no sign of recurrence for 1 year, although close long-term follow-up is mandatory.

Usefulness of polyurethane for small-caliber vascular prostheses in comparison with autologous vein graft

Abstract For long-term patency of small-caliber vascular prostheses, antithrombogenicity and microporous structure are very important. We have developed a new technique to give a microporous structure to a polyurethane vascular prosthesis that has favorable antithrombogenicity. A solution of tetrahydrofuran/dimethylformamide (1 : 1) containing 13 wt% of segmented polyurethane (PTMG + MDI) and calcium carbonate (mean particle size, 8 μm) was dipcoated on a glass mandrel 3 mm in diameter and placed into distilled water. After the glass mandrel was removed, the polyurethane tube was placed into hydrochloric acid, and a microporous polyurethane vascular prosthesis was produced. Prostheses made in this fashion, and autologous jugular vein grafts were implanted into the femoral artery and the carotid artery of mongrel dogs. Patency was recognized on the arteriogram and duplex scanning (ultrasonography), and the removed grafts were inspected macroscopically and microscopically. This prosthesis was similar in elasticity to a vein graft. Patency was defined 8 weeks after implantation, and this prosthesis showed less intimal hyperplasia than the autologous vein graft. The new polyurethane prosthesis might be useful for small-caliber vascular reconstruction.