Takehiro Inoue

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.

Spherical sulfated cellulose adsorbs high-mobility-group box chromosomal protein 1 in vitro and in vivo.

High-mobility-group box chromosomal protein 1 (HMGB1) has recently been identified as a late mediator of various kinds of acute and chronic inflammation. A method for efficiently removing HMGB1 from systemic circulation could be a promising therapy for HMGB1-mediated inflammatory diseases. It is well known that the cationic portion of HMGB1 binds to heparin, which has abundant sulfates in its structure. In this study, we determined whether spherical sulfated cellulose (SC) efficiently adsorbed HMGB1, as well as other inflammatory mediators, in vitro. Then, we investigated the efficacy of hemoperfusion with the SC (SC group) or cellulose beads (control group) at adsorbing endogenous mediators, including HMGB1, in vivo. We have demonstrated that the SC adsorbed significantly larger amounts of HMGB1, interleukin (IL)-4, and IL-8 when compared with cellulose beads, in vitro. Hemoperfusion with the SC for 30 minute, starting 2 hour after an abdominal opening and closure operation, significantly reduced serum HMGB1 levels (p = 0.004) and consistently increased serum IL-10 levels, in vivo. These data suggest the potential benefits of hemoperfusion using the SC in treating HMGB1-mediated inflammatory diseases.

Hemoadsorption of High-Mobility Group Box Chromosomal Protein 1 Using a Column for Large Animals

Background: High-mobility group box chromosomal protein 1 (HMGB1) has recently been identified as an important mediator of various kinds of acute and chronic inflammation. A method for efficiently removing HMGB1 from the systemic circulation could be a promising therapy for HMGB1-mediated inflammatory diseases. Materials and Methods: In this study, we produced a new adsorbent material by chemically treating polystyrene fiber. We first determined whether the adsorbent material efficiently adsorbed HMGB1 in vitro using a bovine HMGB1 solution and a plasma sample from a swine model of acute liver failure. We then constructed a column by embedding fabric sheets of the newly developed fibers into a cartridge and tested the ability of the column to reduce plasma HMGB1 levels during a 4-hour extracorporeal hemoperfusion in a swine model of acute liver failure. Results: The in vitro adsorption test of the new fiber showed high performance for HMGB1 adsorption (96% adsorption in the bovine HMGB1 solution and 94% in the acute liver failure swine plasma, 2 h incubation at 37°C; p < 0.05 vs. incubation with no adsorbent). In the in vivo study, the ratio of the HMGB1 concentration at the outlet versus the inlet of the column was significantly lower in swine hemoperfused with the newly developed column (53 and 61% at the beginning and end of perfusion, respectively) than in those animals hemoperfused with the control column (94 and 93% at the beginning and end of perfusion, respectively; p < 0.05). Moreover, the normalized plasma level of HMGB1 was significantly lower during perfusion with the new column than with the control column (p < 0.05 at 1, 2, and 3 h after initiation of perfusion). Conclusion: These data suggest that the newly developed column has the potential to effectively adsorb HMGB1 during hemoperfusion in swine.

Physiologic atrial cardiac pacing for the prevention of chronic atrial fibrillation associated with sick sinus syndrome.

Long-term results of physiologic atrial pacing have been analyzed for the possibility of avoiding the recurrence of paroxysmal atrial fibrillation and the progression to chronic permanent atrial fibrillation in patients with paroxysmal atrial fibrillation related to sick sinus syndrome. Seventy four patients were evaluated and divided into two groups; 39 patients underwent atrial pacing (AAI, 53%) and 35 had ventricular pacing by single-lead pacing (VVI, 47%). All patients had been evaluated periodically on an out-patient basis by 24 hour Holter monitoring. Basic rhythms in all AAI patients were based on atrial pacing, resulting from the suppression of paroxysmal atrial fibrillation. Basic rhythms in the VVI paced patients were variable, consisting of regular sinus rhythm, transient atrial fibrillation, and ventricular pacing in 30 of 35 patients in the VVI group. The remaining five patients progressed to chronic permanent atrial fibrillation (0% in AAI vs. 14% in VVI, p < 0.05). Thromboembolic complications were not observed in the AAI pacing group. Three patients demonstrated thromboembolic complications (0% in AAI vs. 8.6% in VVI, p < 0.05). The effect of preventing paroxysmal atrial fibrillation and the progression to chronic atrial fibrillation was evident in the AAI paced group, but VVI pacing cannot prevent paroxysmal atrial fibrillation and chronic atrial fibrillation. In addition, potential risks of thromboembolic complications caused by atrial fibrillation were not decreased in VVI paced patients.

Long-Term Survival After Coverage With Prevertebral Fascia for Abdominal Aortic Stump Closure.

Abdominal aortic graft-enteric fistula is an uncommon but grave complication. Acceptable early results of its management have been reported in recent years, but aortic stump disruption remains a dreaded problem in the remote period. This report describes a case of a 71-year-old male with graft-enteric fistula following after a distant abdominal aortic aneurysm repair. The patient underwent 1-stage operation with extra-anatomic bypass preceding the complete removal of the infected aortic graft and intestinal repair. For coverage of the aortic stump closure, the prevertebral fascia was harvested as a flap and was successfully used to buttress the closure. Additionally, omental wrap was secured around the stump and around the area after complete graft removal. Postoperative intravenous antibiotic with meropenem was administered for 8 weeks, followed by suppression with ongoing oral antibiotic with trimethoprim–sulfamethoxazole for 6 months. Although sigmoidectomy and the left ureteral reconstruction were required, the patient is doing well without recurrent infection and without stump disruption after 8 years of follow-up.

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.

Follow-up Study of Coronary Artery Bypass Grafting in Patients with Kawasaki Disease

Background: The purpose of this study was to assess the long-term clinical outcome of coronary artery bypass grafting in pediatric patients with Kawasaki disease. Methods: Six patients (mean age, 9.3±1.6 years) underwent coronary artery bypass graft ing be tween September 1985 and December 1992. The number of bypass grafts placed was 1-2/patient(mean of 1.3±0.5). The left internal mammary artery (IMA) was used as a bypass graft in 3 patients, bilateral IMA in 1 and saphenous vein in 3. All pa t ients underw e nt postoperative evaluations after one month, and between 5 and 10 years.Results: Follow-up ranged between 9 and 16 years (mean,12.6±2.7 years). Stress myocardial scintigraphy identified two patients with transient ischemia, one o f w hom died suddenly a ft er 16 postoperative years. Coronary angiography demonstrated that the grafts of 5 patients were patent at both the short- and long-term follow-ups. However, in one patient, the IMA that was grafted to the diagonal artery was occ l ude d one month after su rgery. Five survivors are in good health without clinical angina. Conclusions: We consider that coronary revascularization using bilateral IMA grafts may provide a more favorable prognosis in patients with severe Kawasaki coronary artery disease. Stre ss myocardial scintigraphy and echocardiography can be used effectively to follow such patients.