Takako Nishino

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.

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.

Rare basis of patent ductus arteriosus: Persistence of the fifth aortic arch

Persistence of the fifth aortic arch (PFAA), which appears transiently in normal human embryonic development, is a rare congenital aortic arch anomaly. PFAA usually is asymptomatic, typically being found incidentally on investigation for other cardiac anomalies. Herein we describe the case of a patient with PFAA and a double-outlet right ventricle (DORV) as well as an unusually situated patent ductus arteriosus, and discuss the underlying embryologic events.

Seamless adaptive servo-ventilation therapy after triple-valve surgery

A 70-year-old man with severe multivalvular disease, atrial fibrillation, and kyphoscoliosis, had Cheyne-Stokes respiration with central sleep apnea. After triple-valve surgery with the maze procedure, adjunctive adaptive servo-ventilation therapy was initiated on the first postoperative day and continued seamlessly in the postoperative period. Seamless adaptive servo-ventilation therapy as an adjunct to triple-valve surgery is more likely to prevent heart failure remodeling without worsening of pulmonary hypertension and recurrence of atrial fibrillation.

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.