Takeshi Yoshii

Impact of the entry site on late outcome in acute Stanford type B aortic dissection

OBJECTIVES This study aimed to investigate whether the entry site of acute type B aortic dissection affects late outcomes. METHODS Inpatient and outpatient records were retrospectively reviewed. RESULTS We identified 224 cases of acute type B aortic dissection between 1998 and 2013. Of these 224 patients, 168 were men and the age was 64.2 ± 12.6 (range 23-94) years, from which 130 presented with the entry at a location downstream of the distal aortic arch, 67 with the entry at the outer curvature of the distal aortic arch and 27 with the entry at the inner curvature. At the initial presentation, 127 patients had descending false lumen thrombosis. The 30-day mortality rate was 2%, and 8% of patients had malperfusion. The entry at the outer curvature was associated with a higher risk of 30-day mortality. Patients with the entry at a location downstream were significantly older, and had a higher chance for primarily thrombosed descending false lumen and a lower risk of malperfusion. At follow-up (6.0 ± 4.1 years), the actuarial survival rates were 97, 83 and 60%, freedoms from open aortic surgery were 96, 91 and 86%, aortic intervention were 73, 66 and 63% and aortic events were 71, 60 and 52% at 1, 5 and 10 years, respectively. Multivariate logistic regression analysis revealed that the outer curvature entry and maximum aortic diameter were correlated with open aortic surgery, aortic intervention and aortic events. Of the 127 patients with primarily thrombosed false lumen, the outer curvature entry was significantly correlated with aortic events. CONCLUSIONS The primary entry at the outer curvature of the distal aortic arch, as well as the large aortic diameter, is associated with a higher risk of late open aortic surgery, aortic intervention and aortic events in acute type B aortic dissection. Thus, the entry site should be taken into consideration in the establishment of an appropriate treatment indication of type B aortic dissection.

Staged repair for aortic arch reconstruction and intracardiac repair following bilateral pulmonary artery banding in 3 critical patients

Bilateral pulmonary artery banding has been performed as a first palliation for hypoplastic left heart syndrome with a poor preoperative condition. We report 3 patients with aortic arch reconstruction and intracardiac repair following bilateral pulmonary artery banding in moribund patients after birth. Our patients successfully received arch reconstruction, pulmonary debanding and patch closure of the ventricular septal defect at the age of 2 or 3 months after birth with a body weight of 3.5 and 4.5 kg, respectively. No postoperative neurological deficits were observed, and postoperative morbidity was significantly reduced. More than 75% of cerebral oxygenation may provide higher urinary output due to higher renal blood flow through collateral circulation. This technique reduces the risk of perioperative neurological damage.

Aorto–Left Ventricular Tunnel Successfully Repaired Immediately After Birth

We describe the unusual case of a patient with an antenatal aorto-left ventricular tunnel (ALVT) diagnosis and severe left ventricular (LV) dysfunction who underwent successful repair immediately after birth. To the best of our knowledge, no such case has been reported in the English literature. Our case demonstrated that neonates at the worst end of the ALVT spectrum can survive and achieve normalization of LV function through a timely and multidisciplinary approach.

Optimal Graft Size of Modified Blalock-Taussig Shunt for Biventricular Circulation in Neonates and Small Infants

The modified Blalock-Taussig shunt (mBTS) is one of the most important palliative procedures in congenital heart surgery. However, in neonates and small infants, operative mortality and morbidity due to excessive pulmonary blood flow or shunt failure remains high. In this study, a small shunt graft (3.0-mm diameter) was estimated to determine the optimal shunt graft size of BTS as an initial palliation for ultimate biventricular circulation. Eighteen patients weighing an average 3.5 kg who underwent mBTS from July 2004 to January 2013 at our institute were reviewed. We divided the study cohort into two groups: group S (n = 10) included patients with 3.0-mm diameter shunt grafts, and group L (n = 8) included patients with 3.5-mm diameter shunt grafts. There were no hospital deaths or shunt occlusion in either group. One group L patient (12.5%) had cardiogenic shock due to excessive pulmonary blood flow. There were no differences in postoperative arterial oxygen saturation (SaO2) between the groups. There were no differences in body weight at intracardiac repair (ICR) between the groups. During the interstage to ICR, body weight gain was significantly greater in group S than in group L (P = 0.008). The small shunt graft (3.0-mm diameter) in BTS was safe, provided adequate pulmonary blood flow, and led to significant weight gain between mBTS and ICR for ultimate biventricular circulation in neonates and small infants with low body weight.

The effectiveness of high-flow regional cerebral perfusion in Norwood stage I palliation §

OBJECTIVE Regional cerebral perfusion (RCP) has been shown to provide cerebral circulatory support during Norwood procedure. In our institution, high-flow RCP (HFRCP) from the right innominate artery has been induced to keep sufficient cerebral and somatic oxygen delivery via collateral vessels. We studied the effectiveness of HFRCP to regional cerebral and somatic tissue oxygenation in Norwood stage I palliation. METHODS Seventeen patients, who underwent the Norwood procedure, were separated into two groups: group C (n=6) using low-flow RCP and group H (n=11) using HFRCP (mean flow: 54 vs 92mlkg(-1)min(-1), P<0.0001). The mean duration of RCP was 64±10min (range, 49-86min) under the moderate hypothermia. Chlorpromazine (3.0mgkg(-1)) was given to group H patients before and during RCP to increase RCP flow. The mean radial arterial pressure was kept <50mmHg during RCP. To clarify the effectiveness of HFRCP for cerebral and somatic tissue oxygenation, cerebral regional oxygen saturation (rSO(2)) and systemic venous oxygenation (SvO(2)) during RCP were compared between the two groups. Changes in the lactate level before and after RCP, and changes in the blood urea nitrogen (BUN), creatinine, lactate dehydrogenase (LDH), and creatinine kinase (CK) levels before and after surgery, were also compared between the groups. RESULTS Mean rSO(2) was 82.9±9.0% in group H and 65.9±10.7% in group C (P<0.05). Mean SvO(2) during RCP was 98.2±4.3% in group H and 85.4±9.7% in group C (P<0.01). During RCP, lactate concentration significantly increased in group C compared with that in group H (P<0.001). After surgery, the LDH and CK levels significantly increased in group C compared with that in group H (P<0.05). CONCLUSIONS Our study revealed that HFRCP preserved sufficient cerebral and somatic tissue oxygenation during the Norwood procedure. The reduction of vascular resistance of collateral vessels increased both cerebral and somatic blood flow, resulting in improved tissue oxygen delivery.

Early Extubation in the Operating Room after Congenital Open-Heart Surgery

Early extubation in the operating room after congenital open-heart surgery is feasible, but extubation in the intensive care unit after the operation remains common practice at many institutions. The purpose of this study was to evaluate retrospectively the adequacy of our early-extubation strategy and exclusion criteria through analysis based on the Risk Adjustment in Congenital Heart Surgery method (RACHS-1).This retrospective analysis included 359 cases requiring cardiopulmonary bypass (male, 195; female, 164; weight > 3.0 kg; aged 1 month to 18 years). Neonates and preoperatively intubated patients were excluded. Other exclusion criteria included severe preoperative pulmonary hypertension, high-dose catecholamine requirement after cardiopulmonary bypass, delayed sternal closure, laryngomalacia, serious bleeding, and delayed awakening. The early-extubation rates were compared between age groups and RACHS-1 classes.Overall, 83% of cases (298/359) were extubated in the operating room, classified by RACHS-1 categories as follows: 1, 59/59 (100%); 2, 164/200 (84%); 3, 61/78 (78%); and 4-6, 10/22 (45%). The early extubation rate in categories 1-3 (86%, 288/337) was significantly higher than for categories 4-6 (45.5%, 10/22) (P < 0.001). Because they met one of the exclusion criteria, 61 patients (17%) were not extubated in the operating room. Eight patients (2.7%) required re-intubation after early extubation in the operating room, and longer operation time was significantly associated with re-intubation (P < 0.001).Extubation in the operating room after congenital open-heart surgery was feasible based on our criteria, especially for patients in the low RACHS-1 categories, and involves a very low rate of re-intubation.

Norwood Procedure Performed on a Patient With Trisomy 13

Trisomy 13 is associated with a variety of congenital anomalies, some of which are life-threatening and related to poor prognosis. Therefore, cardiac surgery is rarely offered to these patients, especially to those with complex cardiac anomalies. We report the case of a neonate weighing 2324 g who was born with severe congenital heart defects. Transthoracic echocardiography revealed the diagnoses of asplenia, single ventricle, aortic stenosis, coarctation of the aorta, hypoplastic aortic arch, and total anomalous pulmonary venous return. She was hemodynamically unstable. Palliative Norwood procedure with right ventricle-pulmonary artery conduit (RV-PA conduit) was performed at the age of 1 day to save her life. On postoperative day 7, chromosome analysis revealed trisomy 13. Echocardiography revealed good heart function; stable hemodynamic status was achieved with minimal amounts of inotropic agents. However, she developed anuria, which did not improve despite situational possible interventions, including peritoneal dialysis and continuous hemodiafiltration. On postoperative day 37, she succumbed to sudden cardiorespiratory failure. Nevertheless, this case indicates that a neonate with trisomy 13 can have a better chance at survival with cardiac surgery such as the Norwood procedure with an RV-PA conduit.

Efforts for Perioperative Care in Children with Congenital Heart Defects

[背景]:近年,先天性心疾患に対する周術期管理は飛躍的に進歩し,手術成績,生命予後の向上の 1つの要 因となっている.[目的]:当院で周術期に行っている,1術中経食道心エコー(ITEE)の使用,2心房中 隔欠損症(ASD),心室中隔欠損症(VSD),ファロー四徴症(TOF),Glenn手術,Fontan手術における 手術室抜管,3ASD,VSDのクリニカルパス導入に関してそれぞれ後方視的にその有用性を検討する.[方 法・結果]:2007年 6月〜2014年 6月までの人工心肺使用(On pump)症例 482例,非人工心肺使用(Off pump)症例 146例を対象とした.On pump 474例,Off pump 102例を適応とし,術中経食道心エコーに よる評価を行った.PICU入室直後に遺残病変を認めた症例はなかった.手術室抜管はおもに肺高血圧症 (PH)のない症例を対象とし,抜管率は ASD 94.7%(54/57),VSD 60.0%(69/115),TOF 50.0%(15/ 30),Glenn 42.5%(17/40),Fontan 45.2%(14/31)であった.ASD,VSDのクリニカルパスは PHがな いもしくは軽度な症例に適応とした.クリニカルパス達成率は ASDで 98.2%(55/56),VSDで 94.2%(65/ 69)であった.パス逸脱の原因は 4例が炎症所見の遷延,1例が家庭の事情であった.[結語]:術中経食道 心エコーは人工心肺離脱時の心機能評価,心内遺残空気の評価,遺残病変の確認に有用であった.手術室抜 管は安全性を考慮していることもあり抜管率は高くなかった.再挿管の症例はなかったため手術室抜管の適 応としては妥当であったと考えられる.ASD, VSDのクリニカルパス達成率は 90%を超えており,パスの適 応は妥当であったと考えられる.日心外会誌 44巻 1号:1-7(2015) キーワード:周術期管理;術中経食道心エコー;手術室抜管;Fast-track;クリニカルパス

Increased systemic cardiac output improves arterial oxygen saturation in bidirectional cavopulmonary shunt

The low arterial oxygen saturation (SaO2) after bidirectional cavopulmonary shunt (BCPS) predicts poor prognosis. The venous oxygen saturation of inferior vena cava (SivcO2), as well as the pulmonary blood flow/systemic blood flow ratio (Qp/Qs) affects the SaO2. The purpose of this study is to determine whether SivcO2 or Qp/Qs should be increased to achieve better outcomes after BCPS. Forty-eight patients undergoing BCPS were included. Data of patients’ age and body weight, SivcO2, Qp/Qs, pulmonary artery (PA) pressure and resistance, PA area index, morphology of ventricle, atrioventricular valve regurgitation, and history of PA plasty were collected. Stepwise multiple logistic regression analyses were used to investigate which of the factors most affected the SaO2 after BCPS. There was a significant correlation between SivcO2 and SaO2 (r = 0.771, P < 0.00001). There was no strong correlation between Qp/Qs and SaO2 (r = 0.358, P < 0.05). Stepwise multiple logistic regression analyses revealed that both SivcO2 (r = 0.49, 95 % confidence interval (CI) 0.37–0.62, P < 0.0001) and Qp/Qs (r = 11.1, 95 % CI 3.3–18.9, P = 0.007) most affected SaO2 after BCPS. Since the SivcO2 has a stronger correlation than Qp/Qs with SaO2, despite the fact that both raising Qp/Qs and raising cardiac output can increase SaO2, raising cardiac output should be considered prior to Qp/Qs to raise the SaO2 after BCPS.