Yoshikado Sasako

Clinical Experience of Percutaneous Cardiopulmonary Support

Recently, percutaneous cardiopulmonary support (PCPS) combined with femoro-femoral bypass without reservoir has become valued because of its quick and easy application. We developed a fully preconnected compact integrated cardiopulmonary bypass (CPB) unit (priming volume of 250 ml) with a blind pore membrane oxygenator (Kuraray Menox) for PCPS. From 1990 to 1995, PCPS was performed in 49 patients of whom 26 were weaned from support. In most cases, we applied this CICU in patients with no active bleeding (22 patients); in patients with active bleeding (n = 13), we used Medtron-ics heparin-bonded close chest support pack (CCSP). Of these, PCPS was performed uneventfully for 2 h (median) in 8 elective cases; all of these patients were weaned or were switched to a left ventricular assist system (LVAS). In 8 urgent cases, such as those with low cardiac output syndrome, PCPS was performed for 4 days (median), 1 was weaned, and 2 CICU were cases switched to other procedures. In 32 cases of shock, 5 CICU patients were weaned, and 3 of them survived. Eight patients including 5 CICU patients and 1 CCSP patient were switched to operation or LVAS, and 2 CICU patients remain alive. From these data, PCPS has been shown to support the patients circulation in the acute phase and earn time to switch to operation or LVAS; the quick and easy set-up of the CICU can improve the clinical results. The use of the Medtronic device broadened the indication for PCPS. The CCSP enlarged the indication of PCPS but could not improve the results. To improve the results, a heparin-bonded surface is desired.

Segmental autotransplantation of the pancreas after total pancreatectomy for advanced periampullary carcinoma —A case report—

A case is reported here in which segmental autotransplantation of the pancreas was performed after total pancreatectomy for advanced periampullary carcinoma in an attempt to preserve pancreatic endocrine function. The postoperative course was uneventful. The requirement of insulin decreased after the operation and the daily profile examination, done 5 months following surgery, showed a permissive fluctuation of blood sugar levels without insulin injection. Thus, segmental autotransplantation of the pancreas offers a method of preserving pancreatic endocrine function after total pancreatectomy for periampullary carcinoma in selected patients.

Cardiac calcified amorphous tumor in a hemodialysis patient

We present a case of cardiac calcified amorphous tumor, a rare intracardiac non-neoplastic tumor, in a hemodialysis patient. A 72-year-old woman with no history of thromboembolic, malignant, or inflammatory disease presented with dyspnea. Echocardiography revealed a highly echoic, slightly mobile mass with an acoustic shadow originating from the mitral subvalvular apparatus, extending to the left ventricular outflow tract. She underwent surgical resection of the mass through the aortic valve, which was easily excised from the papillary muscle and chordae tendineae. Histopathologic examination revealed nodular calcium deposits on a background of amorphous degenerated fibrin material, consistent with calcified amorphous tumor.

New Compact Integrated Cardiopulmonary Bypass Unit (CICU) for Percutaneous Cardiopulmonary Support

The cardiopulmonary bypass technique has been used for circulatory support [1] and cardiac resuscitation [2]. Recently, percutaneous cardiopulmonary support (PCPS) with large-bore thin-walled cannulas has become valued because of its easy application in emergency cases [3,4], and because of its use for supported percutaneous transluminal coronary angioplasty (PTCA) [5,6]; it has rapidly achieved widespread popularity. Despite the increased clinical demands, a cardiopulmonary bypass unit specially designed for PCPS has not yet been developed. We have developed a new compact integrated cardiopulmonary bypass unit (CICU) for PCPS, and applied it clinically. Herein, we describe this unit and the results achieved with its initial clinical use.

Influence of Long-Term Support upon the Severely Failing Left Ventricle

It is unclear how long-term support with a left ventricular assist system (LVAS) affects the severely failing left ventricle (LV). From 1994, we applied our LVAS to seven patients with profound heart failure. Of those, six patients were supported for more than 3 weeks. The etiologies of heart failure were valvular heart disease (VHD) in one, ischemic heart disease (IHD) in two, dilated phase hypertrophic cardiomyopathy (DHCM) in one, and dilated cardiomyopathy (DCM) in two. In one patient, biventricular assist was performed because of coexisting severe right heart failure. Each LVAS was installed between the left atrium and the ascending aorta and the pump was positioned paracorporeally. After stabilization of general condition, exercise was started. The natural heart size was examined and systolic heart function was evaluated by the systolic time interval (STI) under LVAS pumping by using echocardiography. This STI was calculated from the equation: ejection time divided by pre-ejection period measured from aortic valve movement. At the beginning of assistance, the STI was low ( 1 and their LVDd decreased to <70mm. Two of them (1CM, 1VHD) are doing well now 2 years after LVAS removal. From these data, the cardiac function of the patient with a severely failing LV may improve when LV dilatation decreases and STI increases through long-term LVAS support.

Valve-Sparing Operation Versus Bentall Operation: Comparison at Medium-Term Follow-Up

The valve-sparing operation has been proposed for aortic regurgitation (AR) in the setting of aortic root dilatation. This method has several advantages over the Bentall operation. Since 1994 a total of 37 patients have undergone either reimplantation of the aortic valve (12 patients) or remodeling of the aortic root (25 patients) in our institution (group R). During the same period 33 patients have had the Bentall operation (group B) as elective surgery. The mean follow-up periods were 323 days (17–1457 days) in group A and 712 days (15–1620 days) in group B. In group R seven patients had Marfan syndrome, five had aortic dissection, and three had aortitis syndrome. In group B nine patients had Marfan syndrome, two had aortic dissection, and eight had aortitis syndrome. There were no differences in preoperative New York Heart Association class or age at operation between the two groups. There was one hospital death in each group and one late death in group B. Two patients in group R required reoperation but none in group B. Actuarial survivals at 4 years were 96.7% in group R and 94.0% in group B. The event-free rates at 4 years were 94.6% in group R and 93.9% in group B. The reoperation-free rates at 4 years were 94.6% in group R and 100% in group B. There was no statistical difference between the two groups for all rates. The valve-sparing operation maintains valve competence during the early postoperative course in our experience, but follow-up data showed deterioration of the valve competence after reimplantation or remodeling, particularly when aortic regurgitation, even mild, was seen after operation. The medium-term survival and cardiac event rates for the valve-sparing operation showed no statistical difference from those of the Bentall operation, although the long-term results of valve competence after the valve-sparing operation are still not known. The aortic root replacement technique should be selected in each clinical setting.

Acute Liver Failure after Fontan Procedure

As the number of patients who require a Fontan-type procedure for complex congenital malformations increases, acute hepatic dysfunction or failure has become a matter of concern as a postoperative complication secondary to high postoperative venous pressure [1]. A retrospective analysis of the patients who underwent this procedure was performed to evaluate the hemodynamic findings in correlation with this potentially lethal complication.