Teiji Asakura

Left atrial function after Cox's maze operation concomitant with mitral valve operation

BACKGROUND This study examined whether the atrial fibrillation that commonly occurs in patients with a mitral valve operation could be eliminated by a concomitant maze operation. METHODS Left atrial function after Coxs maze operation performed concomitantly with a mitral valve operation was evaluated in 10 patients ranging in age from 38 to 67 years (mean age, 54 years). Seven patients who had had coronary artery bypass grafting served as the control group. Using transthoracic echocardiography, the ratio between the peak speed of the early filling wave and that of the atrial contraction wave (A/E ratio) and the atrial filling fraction (AFF) were determined from transmitral flow measurements. These two indices have been considered to represent the contribution of left atrial active contraction to ventricular filling. RESULTS The A/E ratio and the AFF were significantly lower in the maze group (0.35 +/- 0.17 versus 0.97 +/- 0.28 [p < 0.01] and 17.6% +/- 8.8% versus 36.8% +/- 6.4% [p < 0.01], respectively). The A/E ratio and the AFF correlated inversely with age (r = -0.72, p < 0.05 and r = 0.76, p < 0.05, respectively) in the maze group. In an angiographic study, the mean left atrial maximal volume index in the maze group was approximately three times larger than that in the control group (117.5 +/- 24.3 mL/m2 versus 35.3 +/- 6.6 mL/m2 [p < 0.01]). The left atrial active emptying volume index was significantly smaller in patients in the maze group (7.2 +/- 2.5 mL/m2 versus 13.1 +/- 4.6 mL/m2 [p < 0.01]). CONCLUSIONS After the maze procedure performed concomitantly with a mitral valve operation in patients with a dilated left atrium, left atrial contraction is detectable but incomplete in the elderly.

Clinical application of total body retrograde perfusion to operation for aortic dissection

The use of profound hypothermia and total circulatory arrest in the surgical treatment of aortic dissection has previously been reported. However, the safe period of prolonged circulatory arrest with hypothermia remains controversial. We have developed a technique of hypothermic total body retrograde perfusion to achieve systemic organ protection: cerebral protection by continuous retrograde perfusion through the superior vena cava, myocardial protection by coronary sinus infusion, and abdominal visceral organ perfusion by continuous retrograde perfusion through the inferior vena cava. Our technique yields a relatively bloodless operating field and avoids hypoperfusion of vital organs through a false lumen.

Selective jugular cannulation for safer retrograde cerebral perfusion

Hypothermic retrograde cerebral perfusion is a new technique for protecting the brain. Satisfactory cerebral protection should be possible even for periods of retrograde perfusion greater than 60 minutes. However, there are some concerns that functioning venous valves at the jugular-subclavian junction may impede retrograde flow to the brain and consequently cerebral protection may not be adequate. To overcome this obstacle, we have developed an easy and safe technique of selective jugular cannulation through the right atrium using a central venous catheter and a guidewire. We have employed this technique successfully in 15 patients who underwent operation on the aortic arch.

Resection of aortic aneurysms without aortic clamp technique with the aid of hypothermic total body retrograde perfusion

Aneurysms involving either the aortic arch or the proximal descending thoracic aorta in five patients were resected with the aid of profound hypothermic total body retrograde perfusion. Traditional surgical management of the aortic arch and the descending thoracic aorta necessitates clamping of the aorta. However, this technique may be associated with rupture or atheroembolism. Rupture occurring at the clamping site may be difficult to repair. Atheroembolism to the brain compromises the neurologic system, and multiple organ embolism is associated with disseminated intravascular coagulopathy. Atheroembolism in cardiovascular surgery has become increasingly prevalent. It is necessary to prevent clamp injuries and to preserve the function of the vital organs, such as the brain, heart, and liver, during aortic reconstruction. We applied a total body retrograde perfusion technique to operations for aortic aneurysms. Total body retrograde perfusion consists of cerebral protection by continuous perfusion through the superior vena cava, intermittent retrograde coronary perfusion through the coronary sinus, and continuous abdominal visceral perfusion through the inferior vena cava. It can yield a relatively bloodless operating field without the need for aortic clamping. We believe this new adjunct offers excellent results in the surgical treatment of aneurysms of the aortic arch or adjacent structures.

Coronary artery bypass grafting in cases with poor left ventricular function

From January 1987 through June 1992, 18 patients with poor left ventricular function (left ventricular ejection fraction [LVEF] less than 0.3) underwent elective isolated primary coronary artery bypass surgery. The mean age was 56.4 years (range, 46 to 72 years), and 15 were males and 3 were females. Mean pre-operative LVEF measured by ventriculography was 0.26 +/- 0.03 (range, 0.19 to 0.30). Sixteen patients (88.9%) had a prior myocardial infarction and 9 (50%) had a history of congestive heart failure. Complete revascularization was the goal for all patients, and the mean number of bypass grafts was 3.0 +/- 0.8 per patient. The left anterior descending coronary artery (LAD) was revascularized in all patients. There were no operative deaths. Post-operative LVEF improved significantly from 0.26 +/- 0.03 to 0.42 +/- 0.11 (p = 0.0002), and the regional left ventricular wall motion improved in the diaphragmatic and posterobasal regions (p < 0.01). The patency of the grafts was 93.9% in all, and 100% for LAD. The mean follow-up period was 77 months, and the overall actuarial survival rate was 88.9% at 10 years. During follow-up periods, two patients died of congestive heart failure (CHF), and two required three rehospitalizations because of CHF. The overall cardiac event free rate was 75.8% at 10 years. In patients with poor left ventricular function, surgical revascularization can be performed safely, but congestive heart failure sometimes occurs during follow-up periods and may be the cause of death. Therefore alternate forms of therapy such as cardiac transplantation and/or TMLR should be considered in selected patients.

Surgical Treatment of Infective Endocarditis.

最近9年間に当院および関連施設で手術を行った感染性心内膜炎37例について治療上の問題点につき検討した. 罹患部位は大動脈弁位17例, 僧帽弁位10例, 大動脈弁+僧帽弁10例, 2例は人工弁感染で, 他の35例は自然弁感染であった. 起炎菌は Streptococcus が最も多く20例, Staphylococcus 5例, グラム陰性桿菌3例で10例は培養陰性であった. 術式に大きな影響を及ぼす弁輪部膿瘍は大動脈弁位で10例に認めた. 弁輪の再建は欠損の小さな4例ではマットレス縫合で縫合し, 欠損の広範な4例では自己心膜パッチを縫着し良好な結果を得た. 人工弁付人工血管で translocation を行ったPVEの2例は救命できなかった. 最近は逆行性冠灌流法を採用し顕著な術後LOSの発生をみていない. 術後早期死亡を4例に, 遠隔死亡を3例に認めたが, 感染性動脈瘤破裂による脳出血が2例であり, 今後の検討を要する課題である.

Recurrent Hemoptysis due to Aortobronchopulmonary Fistula of False Aortic Aneurysm Associated with Repair of Rupture of the Sinus of Valsalva.

A 54-year-old man presented with recurrent hemoptysis of one year duration. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a saccular aneurysm of the ascending aorta. The aneurysm was intraoperatively found to have formed on the superior surface of the site of aortotomy suture placed during previous repair of rupture of the sinus of Valsalva and to have a fistulous communication to the lung. CT and MRI were very useful in the diagnosis of the aneurysm as the cause of hemoptysis.