Takeo Tedoriya

Living-donor lobar lung transplantation for various lung diseases

OBJECTIVE We report on our early experience in living-donor lobar lung transplantation for patients with various lung diseases including restrictive, obstructive, septic, and hypertensive lung diseases. METHODS From October 1998 to March 2002, living-donor lobar lung transplantation was performed in 14 patients with end-stage lung diseases. There were 11 female patients and 3 male patients, with ages ranging from 8 to 53 years, including 4 children and 10 adults. Diagnoses included primary pulmonary hypertension (n = 6), idiopathic interstitial pneumonia (n = 2), bronchiolitis obliterans (n = 2), bronchiectasis (n = 2), lymphangioleiomyomatosis (n = 1), and cystic fibrosis (n = 1). Bilateral living-donor lobar lung transplantation was performed in 13 patients and right single living-donor lobar lung transplantation was performed for a 10-year-old boy with primary pulmonary hypertension. RESULTS All the 14 patients are currently alive with a follow-up period of 4 to 45 months. Although their forced vital capacity (1327 +/- 78 mL, 50.2% of predicted) was limited at discharge, arterial oxygen tension on room air (98.5 +/- 1.8 mm Hg) and systolic pulmonary artery pressure (24.8 +/- 1.6 mm Hg) were excellent. Forced vital capacity improved gradually and reached 1894 +/- 99 mL, 67.4% of predicted, at 1 year. All donors have returned to their previous lifestyles. CONCLUSIONS Living-donor lobar lung transplantation can be applied to restrictive, obstructive, septic, and hypertensive lung diseases. This type of procedure can be an alternative to conventional cadaveric lung transplantation for both pediatric and adult patients who would die soon otherwise.

Total Right Ventricular Exclusion Improves Left Ventricular Function in Patients With End-Stage Congestive Right Ventricular Failure

Background—We developed a total right ventricular (RV) exclusion procedure for the treatment of isolated congestive RV failure. The objective of the present study was to elucidate the effects of a complete removal of RV volume overload (RVVO) on the surgically created single left ventricle (LV). Methods and Results—Three adults (2 arrhythmogenic RV dysplasia, 1 Ebstein) and 5 children (all Ebstein) in NYHA class IV underwent the procedure. The RV free wall was resected from the heart, and the tricuspid orifice was closed. Pulmonary blood supply was obtained by a cavopulmonary connection in 6 patients and a systemic-pulmonary shunt in 2. The LV function was evaluated by 2-dimensional echocardiography 1 month after the surgery. All patients are alive. The paradoxical movement of the interventricular septum and geometry of the LV expressed by its eccentricity (2.1 to 1.2, P <0.01) were normalized after the operation in all 8 patients. LV end-diastolic volumes (59% to 109% of normal value, P <0.01), indexed maximal left atrial area (6.5 to 10.5 cm2/m2, P <0.01), LV ejection fraction (27% to 62%, P <0.01), and cardiac index (2.1 to 3.3 L/min/m2, P <0.05) all significantly increased. Conclusion—Removal of the RVVO by means of the total RV exclusion procedure provides effective volume loading, restores a cylindrical shape, and improves contractile function of the LV, thus leading to increased systemic output.

Apico-aortic conduit for aortic stenosis with a porcelain aorta; technical modification for apical outflow

A successful apico-aortic bypass for a patient with a porcelain aorta suffering from aortic stenosis is reported. A sewing cuff with an outflow graft to the apex and a hand-made composite graft were used instead of a rigid apical connector.

Significance of mitral valve repair for active-phase infective endocarditis.

Mitral valve repair is preferred to replacement in infective endocarditis, but in the active phase, it often requires extensive debridement of infected tissue and complex reconstruction. We investigated 22 consecutive native mitral valve operations during active-phase infective endocarditis. The time from initiation of medical treatment to operation was 16.8 ± 16.4 days. Mitral valve repair was performed in 15 (68.2%) patients, using prosthetic annuloplasty in 14, an autologous pericardial patch in 11, and artificial chordal replacement in 9. Hospital mortality was 9.1% (2 patients), due to subarachnoid hemorrhage and pneumonia. One patient died 26 months after valve replacement due to congestive heart failure. The postoperative left ventricular end-diastolic dimension was significantly smaller (45.7 ± 5.6 vs. 53.3 ± 10.2 mm) and ejection fraction was significantly higher (57.0% ± 14.7% vs. 40.1% ± 8.2%) in patients who underwent valve repair compared to those who had valve replacement. Mitral regurgitation requiring reoperation occurred in 3 patients during follow-up. Mitral valve repair is feasible in active-phase infective endocarditis, and results in improved regression of left ventricular dimensions compared to valve replacement. However, complex mitral valve repair with extensive leaflet resection may not have long-term durability.

Mitral-aortic intervalvular pseudoaneurysm with ventricular septal defect.

A 35-year-old woman was found on echocardiography to have a pseudoaneurysm of the mitral-aortic intervalvular fibrosa, residual ventricular septal defect, and aortic regurgitation. She had undergone surgical closure of a ventricular septal defect at age 7 and was found to have residual shunt several years later. She had been followed nonsurgically and had symptoms of cardiac failure during her 2 pregnancies. The pseudoaneurysm and the septal defect were successfully repaired.

Post-mortem tissue-type plasminogen activator preserves graft function of hearts harvested from non-pre-treated non-heart-beating donors.

BACKGROUND Intracoronary microthrombi may cause primary graft failure of hearts harvested from non-pre-treated non-heart-beating donors (NHBDs). We examined the extent of functional recovery to compare the protective effects of post-mortem tissue-type plasminogen activator (t-PA) and heparin pre-treatment. METHODS Heparin pre-treatment was systemically administered before hypoxic cardiac arrest in 6 mongrel dogs (Group A). No pre-treatments, including heparin, were administered in 8 dogs (Group B). After 60 minutes of ischemia, intracoronary microthrombi were flushed by retrograde blood cardioplegia with t-PA. After 120 minutes of controlled reperfusion, pre-load was increased for ejection against an after-load of 80 mm Hg. Pressure-volume loops were recorded to obtain the end-systolic pressure-volume relationship (ESPVR) and end-diastolic pressure-volume relationship (EDPVR). Stroke volume at a given pre-load was calculated from averaged ESPVR, EDPVR, and after-load identical to the averaged baseline value. The Frank-Starling relationship was obtained, and cardiac status was classified using the Forrester hemodynamic sub-set. RESULTS There were no significant differences between Group A and Group B in post-resuscitated end-systolic elastance (3.1 +/- 0.7 vs 3.0 +/- 0.8 mm Hg/ml), time constant of isovolumic relaxation (40 +/- 7 vs 40 +/- 6 msec), LV max +dP/dt (1133 +/- 131 vs 1090 +/- 105 mm Hg/s), and LV max -dP/dt (732 +/- 131 vs 752 +/- 122 mm Hg/s). The post-resuscitated cardiac index was decreased to about 50%, and cardiac status was classified as Forrester III or IV sub-set. CONCLUSIONS Post-mortem t-PA preserves graft function of hearts harvested from non-pre-treated NHBDs. This pharmaceutical intervention may be an alternative to heparin pre-treatment, which could increase the number of cardiac allografts harvested from potential non-pre-treated NHBDs.

Hypothermic circulatory arrest: renal protection by atrial natriuretic peptide.

Moderate hypothermic circulatory arrest with selective cerebral perfusion has been developed for cerebral protection during thoracic aortic surgery. However, visceral organs, particularly the kidneys, suffer greater tissue damage under moderate hypothermic circulatory arrest, and acute renal failure after hypothermic circulatory arrest is an independent risk factor for early and late mortality. This study investigated whether atrial natriuretic peptide could prevent the reduction in renal perfusion and protect renal function after moderate hypothermic circulatory arrest. Twelve pigs cooled to 30°C during cardiopulmonary bypass were randomly assigned to a peptide-treated group of 6 and a control group of 6. Moderate hypothermic circulatory arrest was induced for 60 min. Systemic arterial mean pressure and renal artery flow did not differ between groups during the study. However, renal medullary blood flow increased significantly in the peptide-treated group after hypothermic circulatory arrest. Myeloperoxidase activity was significantly reduced in the medulla of the peptide-treated group. Renal medullary ischemia after hypothermic circulatory arrest was ameliorated by atrial natriuretic peptide which increased medullary blood flow and reduced sodium reabsorption in the medulla. Atrial natriuretic peptide also reduced the release of an inflammatory marker after ischemia in renal tissue.

Mitral valve repair for infective endocarditis

ObjectiveThis study investigated the feasibility of mitral valve (MV) repair in patients with active or healed infective endocarditis (IE) with mitral regurgitation and evaluated effects on left ventricular (LV) function and structure.MethodsSubjects comprised 19 patients who underwent MV operations for IE between December 2004 and September 2007. MV repair was performed for acute IE in 10 of 15 patients (67%) and for healed IE in 4 of 4 patients (100%).ResultsNo early or late postoperative deaths were encountered. One patient underwent redo MV repair owing to severe mitral regurgitation 1 month postoperatively. Postoperative echocardiography after MV repair demonstrated less than trivial (acute IE in seven, healed IE in three) or mild (acute IE in three, healed IE in one) mitral regurgitation. In patients with MV replacement, the postoperative left atrial dimension (LAD) was decreased (51.5 ± 39.2 vs. 39.2 ± 1.9 mm, P = 0.007); however LV end-diastolic dimension (LVDD) and LV end-systolic dimension were unchanged. In patients with MV repair, LVDD (57.5 ± 6.5 vs. 46.0 ± 5.6 mm, P < 0.001), LV end-systolic dimension (36.1 ± 5.2 vs. 32.4 ± 6.2 mm, P = 0.04), LAD (43.1 ± 8.1 vs. 33.6 ± 7.7 mm, P = 0.003) were reduced. Postoperative ejection fraction (55.3 ± 13.5% vs. 41.8% ± 10.0%, P = 0.03) and fraction shortening (30.1% ± 9.2% vs. 20.7% ± 5.5%, P = 0.03) were better in patients with MV repair than those with MV replacement.ConclusionsMV repair is feasible in patients with both active and healed IE. MV repair preserves better LV function and structure postoperatively.

Granulomatous endocarditis in a patient with Wegener's granulomatosis

Echocardiographic examination of patients with granulomatous endocarditis in patients with Wegeners granulomatosis (WG) reveals vegetation-like lesions that may be misdiagnosed as infective endocarditis resulting in inappropriate therapy. Three-dimensional transesophageal echocardiography aids differential diagnosis. Here, we report the case of a WG patient with associated mitral and aortic granulomatous endocarditis. Although the patient was treated with prednisolone and cyclophosphamide, serial echocardiography did not reveal any significant changes in disease course.

Large primary cardiac sarcoma on the left ventricular free wall: is total excision contraindicated?

A case of a large primary cardiac sarcoma on the left ventricular free wall is reported. Although the definitive diagnosis of this tumor was not made preoperatively, total excision was planned for rapid diagnosis and optimal procedure. However, the operation was discontinued due to intraoperative diagnosis of malignancy. As a result, the patient suffered from the symptoms of cardiac tamponade caused by the large tumor. We discuss the surgical strategy to provide therapeutic benefit for possible patients in the future. In conclusion, an aggressive attempt at volume reduction such as cardiac autotransplantation may relieve the symptoms, even though such surgery would only be palliative.