Yoshiharu Takahara

Comparison of coronary hemodynamics in patients with internal mammary artery and saphenous vein coronary artery bypass grafts: a noninvasive approach using combined two-dimensional and Doppler echocardiography.

Blood flow in bypass grafts and recipient left anterior descending coronary arteries was evaluated with combined two-dimensional and Doppler echocardiography in 15 patients with an internal mammary artery graft and in 24 patients with a saphenous vein graft. Comparative studies of coronary hemodynamics were also performed regarding these two different grafting techniques. The graft vessel was detected in 11 (79%) of 14 patients with an internal mammary artery graft and in 20 (87%) of 23 with a saphenous vein graft. The recipient left anterior descending coronary artery was detected in 10 (67%) of the former group and 17 (71%) of the latter. The blood flow patterns obtained were generally biphasic, consisting of systolic and diastolic phases with higher velocity during diastole. The maximal diastolic flow velocity in internal mammary artery grafts was much higher than that in saphenous vein grafts. In patients with an internal mammary artery graft, the flow pattern characteristics within the recipient coronary artery were quite similar to those within the arterial graft, and flow velocities within the recipient coronary artery and the arterial graft were quantitatively almost identical. This outcome may contribute to the long-term patency seen in internal mammary artery grafts. On the other hand, the flow velocity in saphenous vein grafts was fairly low throughout the cardiac cycle. Flow velocity in the recipient coronary artery in patients with a saphenous vein graft was accelerated only in early diastole. As a result, the recipient coronary artery flow pattern and velocity differed substantially from those in the saphenous vein graft.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic Valve Replacement via Left Thoracotomy After an Esophageal Operation

Aortic valve replacement was performed through a left anterolateral thoracotomy using cardiopulmonary bypass in a 59-year-old man who had previously received esophageal resection with substernal reconstruction by gastric tube. Through this approach, injury of the reconstructed tube was avoided and the valve replacement operation was safely performed. We conclude that the lateral thoracotomy approach remains a valuable alternative for certain exceptional cases.

Effect of Sotalol in the prevention of atrial fibrillation following coronary artery bypass grafting.

OBJECTIVE We assessed the efficacy of postoperatively administered oral Sotalol in preventing the occurrence of postoperative atrial fibrillation. METHODS Subjects were 80 consecutive patients undergoing coronary artery bypass grafting (CABG) randomized alternately into a Sotalol group (40 patients) administered 80 mg of oral Sotalol daily starting on the postoperative day 1 and continued for 14 days, and a control group (40 patients) matched for age and gender. RESULTS The incidence of postoperative atrial fibrillation (21 patients) was significantly lower in the Sotalol group (6/40 patients; 15%) than in controls (15/40; 37.5%) (p < 0.05). Significant bradycardia or hypotension, necessitating drug withdrawal, occurred in 3 of 40 (7.5%) patients in the Sotalol group. None in the Sotalol group developed Torsardes de Pointes or sustained ventricular arrhythmias or other severe side effects. The sinus heart rate increased in both groups but less in the Sotalol group. QT, QRS, and QTc durations did not differ between groups. Postoperative hospital stay did not differ between groups. CONCLUSIONS Oral Sotalol administration of 80 mg daily was associated with a significant decrease in postoperative atrial fibrillation in patients undergoing CABG without appreciable side effects. Sotalol should thus be considered in preventing postoperative atrial fibrillation in patients undergoing CABG in the absence of heart failure and significant left ventricular dysfunction.

Aneurysm of the Left Sinus of Valsalva Producing Aortic Valve Regurgitation and Myocardial Ischemia

An aneurysm of the left sinus of Valsalva producing aortic valve regurgitation was treated by excising the aortic root including the aneurysm but leaving the aortic valve leaflets. The aortic valve was reimplanted inside a graft. Postoperative examinations revealed normal aortic valve function. In this case, the cause of aortic valve regurgitation was due to deformity of the aortic annulus. An aortic valve-sparing operation is an appropriate method for such a case.

Medium-term neurological complications after off-pump coronary artery bypass grafting with and without aortic manipulation.

BackgroundThis study aimed to assess the impact of aortic manipulation during off-pump coronary artery bypass (OPCAB) on neurological complications. Methods and resultsOf 336 isolated OPCAB surgeries, the aorta was untouched in 264 cases (group A), whereas it was manipulated by a side-biting clamp in 72 (group B). The average follow-up was 2.9±2.5 years. One patient in each group developed postoperative stroke (P=0.38). The prevalence of triple-vessel disease (group A 40.9% vs. group B 61.1%; P=0.0003) and left main trunk disease (group A 30.7% vs. group B 47.2%; P=0.1) was lower in group A than in group B. The number of bypass grafts (group A 2.18±0.97 vs. group B 3.00±0.97; P=0.0001) was lower in group A than in group B. The prevalence of preoperative atrial fibrillation and the incidence of new-onset postoperative atrial fibrillation were not different between groups (P=0.74 and 0.86, respectively). Survival rate and freedom from major adverse cardiac events were not different between groups (P=0.87 and 0.51, respectively). However, freedom from neurological complications was significantly lower in group A (P=0.0006). The Cox hazard model showed that aortic manipulation (P=0.004; odds ratio, 6.18; 95% confidence interval, 1.8–21.6) and preoperative atrial fibrillation (P=0.001; odds ratio, 14.0; 95% confidence interval, 2.7–72.5) were risk factors for neurological complications. ConclusionAlthough there was no difference in the incidence of immediate postoperative neurological complications, there were fewer medium-term neurological complications in OPCAB cases without aortic manipulation.

Acute type A aortic dissection associated with an aortic annular abscess

We describe a 66-year-old woman who underwent open heart surgery because of congestive heart failure. During operation, we found a Stanford type A dissection and an aortic ring abscess, which had burst into the aortic lumen. No other entries were found. Pathological examination showed excessive neutrophil infiltration in the aortic root. We strongly suspect that the abscess produced the intimal tear to cause the aortic dissection.

Simultaneous coronary arterial bypass surgery using mini-sternotomy and off-pump methods and abdominal aneurysm repair

A technique of combined minimally invasive coronary artery surgery and abdominal aneurysm repair is described. A mini-sternotomy and off-pump coronary artery bypasses to the left descending branch and right coronary arteries are conducted before abdominal aneurysm repair in a simultaneous operation.

Strategy for reduction of stroke incidence in coronary bypass patients with cerebral lesions. Early results and mid-term morbidity using pulsatile perfusion.

OBJECTIVES Cerebral complication is an important factor affecting the outcome after coronary artery bypass surgery under cardiopulmonary bypass. One of the causes for cerebral complication is preoperative cerebrovascular stenotic lesion. Here, we have studied the effect of pulsatile perfusion on the rate of cerebral complication due to a cerebrovascular lesion in patients undergoing coronary arterial bypass graft under cardiopulmonary bypass. METHODS 261 consecutive elective patients underwent operation using cardiopulmonary bypass for management of the atherosclerotic ascending aorta. Group 1 consisted of 62 patients with a cerebrovascular stenotic lesion (> or = 75%) identified on a magnetic resonance angiogram or multiple cerebral infarction diagnosed using a computer tomogram. Group 2 consisted of 199 patients diagnosed with no significant cerebral lesion. In Group 1, the systolic blood pressure during cardiopulmonary bypass was maintained at a level of 80 mmHg by means of pulsatile flow. In Group 2, non-pulsatile perfusion was used as usual. RESULTS The overall hospital mortality was 1.5%, and no mortality was caused by a cerebral event. Only one patient in Group 1 suffered from temporary hemiparalysis. A cerebral complication occurred in only 1.6% in Group 1, and 0.4% overall. The actuarial freedom from cerebrovascular accident after 54 months was 84.4% in Group 1, and 96.2% in Group 2 (p = 0.0011). CONCLUSIONS Management of the atherosclerotic ascending aorta and the use of pulsatile perfusion were helpful in preventing cerebral injury during CABG.

Aortic Dissection complicated With Aorto-Right Atrium Fistula

Aorto-right atrium fistula associated with aortic dissection is a very rare complication. Here report a case of successful surgical repair of ascending aortic dissection complicated with aorto-right atrium fistula. A 65-year-old man was presented with sudden chest pain and dyspnea. Fifteen years ago, he had aortic valve replacement. An aortic dissection with fistula to the right atrium was diagnosed by echocardiography and cardiac catheterization. At operation, dense adhesion of the aortic root due to the previous cardiac operation was confirmed, and this was suggested as the cause for this rare complication.

Extracardiac rupture of a sinus of Valsalva aneurysm

A 73-year-old male presented with back pain. Contrast-enhanced computed tomography (CT) and echocardiography showed a 6.8-cm sinus of Valsalva aneurysm of the non-coronary sinus and a pericardial effusion (Figure 1A and B). The patient arrested upon transfer to the operating room and required cardiopulmonary resuscitation. Cardiopulmonary bypass was emergently established via the right femoral artery and the right atrium. There was a large amount of fresh blood in the pericardium and active bleeding from the perforated sinus of Valsalva aneurysm was observed. Following cardioplegic arrest, the non-coronary sinuswas opened. Therewas no evidence of a dissection flap or any fistulas into any of the cardiac chambers. All the aortic valve leaflets were intact and the valve was competent (Figure 2). After the aneurysm was resected, the defect in the non-coronary sinus was reconstructed with a Dacron graft which was sutured along the annulus and above the attachment of the non-coronary cusp. The patient tolerated the procedure well and made a full neurologic recovery. A postop CT showed an intact patch (Figure 3) and therewas no aortic regurgitation on echocardiography. Histological examination of the aneurysmal wall showed absence of elastic fibers and necrosis, and mucoid degeneration of the media (Figure 4A and B). The patient continues to do well 6 months following surgery.