Toshiya Koyanagi

Clinical effects of ventricular assist system in end-stage cardiac failure. Advantages of left ventricular blood drainage for recovery from cardiac dysfunction.

OBJECTIVES Heart transplantation is extremely limited currently in Japan. As a consequence ventricular assist system implantation is employed the patient falls into end-stage cardiogenic shock. This preliminary report describes our initial clinical experience with use of 2 kinds of ventricular assist system for 13 Japanese patients. METHODS 7 patients were supported by a left ventricular assist system with blood drainage from the left atrium (LA drainage Group) using a Toyobo ventricular assist system, while another 6 patients were supported by a left ventricular assist system with blood drainage from the left ventricle (LV drainage Group) using the Toyobo ventricular assist system (1 patient) or TCI-LVAS (5 patients). RESULTS The average duration of ventricular assist system support in the LV drainage Group was 112 days including two on-going patients (now at 39 days and 241 days) and in the LA drainage Group was 49 days. The average left ventricular ejection fraction at 3 weeks after ventricular assist system implantation was improved from 12.3 to 54% using the TCI-LVAS and from 14 to 33% using the Toyobo ventricular assist system with drainage from the left ventricle. However, this was decreased from 20 to 10% using the Toyobo ventricular assist system with drainage from the left atrium. The ventricular assist system was explanted in 4 patients (31%) with recovery of cardiac dysfunction and 3 were long survivors. The 2 on-going patients are awaiting heart transplantation. Thus the current survival rate overall is 38%. The survival rate (67%) is excellent in the LV drainage Group including 2 long survivors after explantation. CONCLUSION Ventricular assist system support with drainage from the left ventricle seems to be more advantageous for cardiac functional recovery than from the left atrium for end-stage heart failure.

Redo without transfusion in a patient with idiopathic thrombocytopenic purpura

Mitral valve replacement was able to be carried out at redo operation requiring neither allogeneic platelet nor blood transfusion in a patient with idiopathic thrombocytopenic purpura, by means of preoperative high-dose intravenous gamma-globulin, autologous blood predonation, use of a centrifugal pump, heparin-coated extracorporeal circuits, and simultaneous splenectomy.

Combined coronary intervention in heart-transplant patient with rapidly accelerated cardiac allograft vasculopathy

A 46-year-old man accepted for heart transplantation due to persistent cardiac failure from dilated cardiomyopathy underwent a transplant in Germany on July 13, 1995. The donor heart was suspected of coronary artery disease at explantation, but he could wait no longer because of his rapidly deteriorating hemodynamics. Postoperative coronary angiography revealed 25% stenosis of the left descending artery. He showed several episodes of minimal or moderate rejection postoperatively, and coronary angiography 15 months postoperatively showed rapidly accelerated cardiac allograft vasculopathy demonstrating triple vessel disease with multiple lesions. Percutaneous transluminal coronary angioplasty was successful on 2 coronary vessels, but immediately recurrent stenosis and new lesions involving the left main trunk occurred 6 weeks thereafter. Since he was financially unable to afford a second heart transplantation, quadruple coronary artery bypass grafting was conducted October 25, 1996. A biventricular assist device was used when he could not be weaned from cardiopulmonary bypass. He died of multiple organ failure 3 days after surgery.

Clinical experience of milrinone as a pharmacological bridge to heart transplantation.

A 19-year-old man with idiopathic dilated cardiomyopathy developed cardiogenic shock. A HeartMate left ventricular assist device was inserted as an emergency procedure, but removed after 189 days due to sepsis related to the device. Intravenous milrinone was administered because of recurrence of heart failure, and as a result the symptoms disappeared and the urinary output increased. Echocardiography showed improvement in the left ventricular ejection fraction. Subsequently, the patient successfully underwent heart transplantation. Milrinone was effective as a pharmacological bridge to heart transplantation in this patient with terminal and critical heart failure after removal of a left ventricular assist device.

Reoperative minimally invasive axillocoronary artery bypass to the obtuse marginal branch

A 73-year-old man was admitted with unstable angina, having severe coronary artery disease involving 3 vessels. He had undergone coronary artery bypass grafting to the left anterior descending artery and the obtuse marginal branch using saphenous vein grafts in 1979. Computed tomography showed severe calcium deposition and atherosclerosis in the ascending and descending aorta. We conducted axillocoronary artery bypass to the obtuse marginal branch and left internal thoracic artery as an in situ graft to the left anterior descending artery without cardiopulmonary bypass. Grafts were satisfactory and clinical results good.

Severe diffuse atherosclerotic lesions of right gastroepiploic artery graft.

The incidence of arteriosclerosis of the right gastroepiploic artery (RGEA) has not been widely known. We experienced one patient in whom the RGEA had severe diffuse atherosclerotic lesions and luminal narrowing, and was therefore determined to be unsuitable as a coronary bypass conduit at operation.

Mid-Term Results of the Use of Radial Artery Graft for Coronary Artery Bypass (Radial Artery Graft Versus Saphenous Vein Graft).

術後1年以上経過した左回旋枝もしくは対角枝に橈骨動脈を用いたCABG134例を対象に術後中期遠隔成績を大伏在静脈と比較し検討した.平均観察期間は2年4ヵ月.RAは108本,SVGは42本をこの領域にバイパスした.吻合部位はRA群がPLに69本,OMに29本,DBに10本のバイパスを施行した.SVG群はそれぞれ26本,14本,2本であった.早期グラフト開存率はRA群では97.9%,SVG群では91.7%であった.術後1年ごとのTMTによる評価ではRA群では99.0%が,SVGでは90.9%が陰性であった.冠動脈造影での開存率はRA群では92.9%で,SVG群では50.0%であった.左回旋枝,対角枝に対するCABGのグラフトとしてRAは有用と考えられた.

A new device for insertion of an intraaortic balloon catheter via the ascending aorta

Although transfemoral insertion of a balloon catheter is conventionally utilized, a trans-ascending aortic approach may be selected in patients following failure of or contraindication to femoral artery cannulation. A new device was developed to insert the catheter of an intraaortic balloon pump (IABP) through the ascending aorta to the descending aorta securely. The device consists of three instruments: a needle dilator, a curved sheath, and a balloontipped guide catheter. We successfully inserted and placed an IABP through the ascending aorta in an experimental study in a dog. We anticipate satisfactory results in clinical application of this device.