Toru Sato

Left ventricle restoration in patients with non-ischemic dilated cardiomyopathy: risk factors and predictors of outcome and change of mid-term ventricular function

OBJECTIVE The partial left ventriculectomy (PLV) for end-stage dilated cardiomyopathy (DCM) which worked in some patients has been reported, although the hospital mortality is high. To reduce hospital mortality, we selected operative procedures of left ventricular (LV) restoration to improve the operative results. We analyzed the risk factors and predictors of outcome, and the mid-term changes of the LV function were determined. PATIENTS AND METHODS Between December 1996 and September 2000, 74 patients with non-ischemic DCM received LV restoration. The age ranged from 14 to 76 years (mean, 49.0+/-14.0 years), and there were 63 men and 11 women. The etiology of the DCM was idiopathic DCM in 49 patients, and dilated hypertrophic cardiomyopathy in seven patients and others in 18. The preoperative New York Heart Association (NYHA) functional class was 29 in class III and 45 in class IV, in which 32 patients depended on inotropic support. PLV or septal anterior ventricular exclusion (SAVE) was selected depending on the akinetic lesion of the LV based on the intraoperative echo-test. Fifty-six patients received elective operations, and emergency operations were performed in 18 patients. The risk factors and predictors of outcome were analyzed in 74 patients, and in 35 patients who survived more than 1 year after receiving LV restoration, the mid-term cardiac function was examined by cardiac echogram and catheterization. RESULTS PLV was performed in 62 patients and SAVE in 12 patients. Concomitant mitral surgery was performed in 66 patients (89%) and tricuspid annuloplasty in 42 patients (57%). There were 15 hospital deaths and 13 patients died after discharge from the hospital (cardiac deaths in nine and non-cardiac deaths in four). In the 46 late survivors, the NYHA class was I or II in 42 patients and III in four patients. Selection of the procedure of LV restoration (P<0.01), elective operation (P<0.05), and the preoperative volume of LV (endodiastolic volume index of <180 ml/m(2); P<0.05) were risk factors and predictors influencing hospital and late death. After the operation, the LV function improved significantly and the improvement was maintained at the mid-term period; the LV ejection fraction was 31.8+/-7.9% (P<0.01) at 1 year from 23.0+/-7.3% preoperatively, left ventricular diastolic diameter was 62.8+/-10.9 (P<0.01) from 81.7+/-8.2 mm and the LV endosystolic volume index was 88.5+/-45.8 (P<0.05) from 162.6+/-41.6 ml/m(2). CONCLUSIONS The operative results improved with the selection of the procedures, with elective operation, and mitral plasty for less cardiac dilatation. The mid-term results of clinical status and LV function showed the effectiveness of the operation.

Minimally invasive coronary artery revascularization: off-pump bypass grafting and the hybrid procedure

was safe, effective, and suitable especially in patients with high risks for coronary artery bypass grafting.

Intraoperative coronary artery imaging with infrared camera in off-pump CABG

To achieve high quality off-pump coronary artery bypass grafting (CABG), thermal coronary artery imaging using a new generation infrared camera was used and anastomotic status was assessed intraoperatively. In 12 patients who underwent off-pump CABG, 18 grafts (11 internal thoracic, 2 radial, 2 gastroepiploic arteries, and 3 saphenous veins) were evaluated following completion of anastomoses. All grafts were clearly visualized and anastomotic and flow status were observed with local epicardial cooling by CO2 blower in the normothermic heart. Seventeen grafts had no problems and one internal thoracic artery graft showed anastomotic failure that was successfully revised. All grafts were restudied by conventional catheter angiography postoperatively, and all were patent. Intraoperative coronary imaging with a highly sensitive infrared camera is noninvasive and effective for real time evaluation in the operating room. This results in more successful off-pump CABG.

Use of the Harmonic Scalpel for harvesting arterial conduits in coronary artery bypass

A simple and effective technique is described here for harvesting the gastroepiploic artery (GEA) and radial artery (RA) using the Harmonic Scalpel. The mean time of harvesting GEA was 9 min and that of RA was 17 min. There were no injuries or spasms of those grafts and the postoperative angiograms performed in 28 patients. This shows 100% patency of the conduits. The GEA and RA are safely harvested by using the Harmonic Scalpel and the use of arterial conduits in coronary artery bypass grafting (CABG) seems to be easily achieved.

Partial left ventriculectomy, ventriculoplasty or valvular surgery for idiopathic dilated cardiomyopathy - the role of intra-operative echocardiography.

BACKGROUND The partial left ventriculectomy (PLV) is known to work in some patients with dilated cardiomyopathy (DCM), although this procedure does not work well in all patients and the operative mortality is higher than the other cardiac surgeries. In addition to PLV, left ventriculoplasty to exclude antero-septal wall or valvular surgery without left ventricle (LV) surgery can be also effective in patients with DCM. To improve the surgical results for dilated cardiomyopathy, we introduced echo-guided volume reduction test and evaluated the surgical procedures and the results on the surgery for DCM. METHODS Between December 1996 and July 1999, 56 patients with DCM (50 with idiopathic DCM, six with dilated hypertrophic cardiomyopathy) were surgically treated. Under the standard cardiopulmonary bypass, left ventricular motion was determined with color kinesis of echocardiogram and the lesion of akinetic wall was removed or excluded. RESULTS After the initial PLV in 18 patients (initial group), operative procedures were selected in 21 with PLV, five with LV plasty, or 12 with valve surgery without LV surgery according to the findings of the LV wall motion by intraoperative echogram (select group). There were six hospital deaths and late follow-up deaths within 1 year in initial group, however, the mortality decreased significantly after the selection of the operative procedures; three hospital deaths and two late deaths in the select-group (P<0.05). Significant decrease of left ventricular diameter, the LV ejection fraction and endosystolic volume index were demonstrated after the LV surgery. The survival rate improved significantly after the selection of the operative procedures; 14 months survival rates was 50.0% in initial group and 73.1% in select group (P<0.05). CONCLUSION Operative mortality decreased and late follow-up results improved after the selection of operative procedures according to the intraoperative volume reduction test.

Coronary artery bypass grafting with gastroepiploic artery composite graft

BACKGROUND To achieve better results after coronary artery bypass grafting (CABG), arterial conduits are the first choice in multiple CABG for younger patients. We present here the early results of CABG with gastroepiploic artery (GEA) composite graft with free radial artery (RA) to revascularize right coronary artery or left circumflex artery in addition to internal thoracic artery to left anterior descending artery. METHODS Between July 1997 and June 1998, 13 patients received CABG with GEA (larger caliber than 2.0 mm) composite graft. We have assessed the early results. RESULTS There was no postoperative death or major morbidity. Postoperative angiogram was performed in 11 patients and all conduits were patent. Postoperative exercise stress test was done in 13 cases and showed no ischemia. CONCLUSIONS Multiple CABG with arterial conduit can be performed by this procedure. The free RA functioned from secondary branches derived from proximal GEA. In conclusion, this procedure seems to be safe and effective, and both long-term patency and better quality of life may be expected.

Intermediate Clinical Results of Combined Gastroepiploic and Internal Thoracic Artery Bypass

BACKGROUND To improve the postoperative results of coronary artery bypass grafting (CABG), the internal thoracic artery (ITA) has become the conduit of choice, with a low operative risk. The gastroepiploic artery as a third arterial conduit for grafting was first reported in 1987, and the early results were reported to be as good as those for the ITA graft. In this report, we present the intermediate-term results of combining ITA and gastroepiploic artery grafts up to 7 years after the operation. METHODS Between April 1988 and April 1992, 214 patients received CABG with at least one ITA graft and were followed up for more than 3 years. They were divided into two groups: Group I consisted of 155 patients who had CABG using one ITA with or without saphenous vein grafts, and group II consisted of 59 patients who had CABG using an ITA and a gastroepiploic artery with or without saphenous vein grafts. The duration of follow-up for hospital survivors ranged from 36 to 89 months. RESULTS There were six late cardiac deaths in group I and one in group II. Fifteen patients complained of recurrent symptoms of angina: 13 in group I and 2 in group II. The actuarial survival rate excluding noncardiac deaths was 95.9% in group I and 96.8% in group II at 7 years (p = not significant). The cardiac event-free rate was 75.4% in group I and 92.2% in group II, which was a significant difference (p < 0.05). CONCLUSIONS When using both the ITA and gastroepiploic artery, CABG can be performed with minimal operative risk and seems to offer an improved quality of life at least 7 years postoperatively.

CORONARY ARTERY REVASCULARIZATION CONCOMITANT WITH VASCULAR SURGERY

Patients with vascular disease and coronary disease are usually treated initially by coronary artery bypass grafting (CABG), and vascular surgery is generally performed later. In this study we assessed the feasibility of combined CABG and vascular surgery in a single operation. Between 1988 and 1995, 16 patients received combined operations for vascular and cardiac lesions and the clinical results were assessed. There were no operative or hospital deaths. The mean time for operation was 421 min and the duration of the stay in the intensive care unit (ICU) was a mean of 3.6 days. In one patient with an ischemic left leg, the left internal thoracic artery (ITA) had become a collateral source of the ischemic leg, and the need for preoperative angiography of the ITA in such patients was indicated. The combined operation clearly takes longer than either vascular surgery of CABG alone, but the length of the postoperative intensive care unit stay was essentially the same as that after a single operation and the patient was still managed safely after the combined operation. In patients requiring both operations, the combined procedure therefore appears to be safe and to have a good clinical outcome.

Left Subclavian Artery for Graft Inflow in Off-Pump Bypass

In coronary artery bypass grafting without cardiopulmonary bypass, a suitable alternative source of inflow to the free graft is required when the internal thoracic artery has already been used or the ascending aorta is severely atheromatous. Left subclavian artery was used for proximal inflow to a free radial artery graft in 1 patient and to saphenous vein grafts in 3. The free graft was anastomosed to the left subclavian artery through a small subclavian skin incision and the new pedicled graft was introduced into the pleural cavity. Through a left anterior small thoracotomy, the graft was anastomosed to the left anterior descending artery in 3 cases and to the circumflex artery in 1, without cardiopulmonary bypass. The postoperative course was uneventful and all grafts were patent. This technique may extend off-pump coronary artery bypass grafting to patients requiring reoperation and those with a diseased ascending aorta.

Left ventriculoplasty for end-stage cardiomyopathy

To treat patients who are suffering from chronic progressive heart failure due to end-stage cardiomyopathy, direct left ventricular reconstruction, namely ventriculoplasty, was introduced by Vincent Dor, with endoventricular circular patch plasty, and by Randas Batista, with partial left ventriculectomy, independently. In the last 2 years, we have performed the Dor operation in 27 patients with ischemic cardiomyopathy and the Batista operation in 30 patients with nonischemic, mainly idiopathic, dilated cardiomyopathy. In the former group, the hospital mortality was 5% (1/22) in elective operations and 60% (3/5) in emergency operations. Late death occurred in 3 patients. The mean ejection fraction increased from 23% to 38%, and New York Heart Association (NYHA) class improved from 3.3 to 1.3. In the latter group, the hospital mortality was 9% (2/23) in elective operations and 86% (6/7) in emergency operations. Late death occurred in 4 patients. The ejection fraction increased from 18% to 31%, and NYHA class improved from 3.6 to 1.8. The surgical results have improved recently with experience and modification of surgical strategy. In conclusion, left ventriculoplasty is effective for patients with end-stage cardiomyopathy. Proper patient selection, appropriate timing of the operation, and choice of procedure are important keys to obtaining successful outcomes.