Yoshimasa Uno

The role of a staged approach for high-risk Fontan candidates

The preoperative risk characteristics and surgical outcome were reviewed in 24 patients who underwent a one-stage Fontan procedure (One-stage Group) and in 16 patients who underwent bidirectional cavopulmonary shunt as an interim procedure prior to a subsequent Fontan procedure (Two-stage Group) to clarify the role of the staged approach for high-risk Fontan candidates. There were 2 hospital deaths after the one-stage Fontan, and another 2 after the takedown of the fenestrated Fontan to BCPS in patients considered to be less than ideal candidate because of the presence of 3 or more risk factors. In contrast, among the total of 16 patients in the Two-stage Group who had significantly more risk factors than those in One-stage Group (2.8 +/- 1.4, vs 1.1 +/- 1.2 p < 0.001), 14 patients survived after bidirectional cavopulmonary shunt, and a subsequent Fontan procedure was accomplished in 12 patients of these 14, with 2 operative deaths after the takedown to bidirectional cavopulmonary shunt. The rate of final Fontan completion in the Two-stage Group (10/16, 62.5%) was considered to be reasonable, considering the fact that this patient group essentially includes non-Fontan candidates. Additionally, in the category of high-risk with 3 or more risk factors, the rate of successful Fontan completion was higher in the Two-stage Group than in the One-stage Group (50% vs 25%). In the survivors of the Two-stage Group, the average number of risk factor decreased from 2.7 +/- 1.3 (range 0 to 5) to 1.0 +/- 1.0 (range 0 to 4) after bidirectional cavopulmonary shunt with concomitant procedures (i.e., extended pulmonary artery reconstruction in 8, and repair of atrioventricular valve regurgitation in 4), predominantly due to improved Fontan candidacy, relating to pulmonary and/or ventricular characteristics, and eliminated anatomical risks. In conclusion, the two-stage approach with bidirectional cavopulmonary shunt accompanied by concomitant repair of associated anomaly may be useful to lower the risk enough to allow subsequent Fontan completion in high-risk patients.

Scimitar syndrome in an infant with right lung hypoplasia, ventricular septal defect, and severe pulmonary hypertension

A 5-month-old boy was presented for surgical repair of scimitar syndrome associated with right lung hyperplasia, severe pulmonary hypertension, ventricular septal defect (VSD), and atrial septal defect. The calculated shunt fraction (Qp/Qs) was 3.1:1.0, pulmonary vascular resistance was 4.6, and the perfusion lung scan showed a marked decrease (11%) in right pulmonary blood flow. Surgical repair was performed through the right fourth intercostal space with the patient supine. The anomalous vein was divided and interposed with a short azygos vein graft, followed by closure of the VSD. Finally, the interposed azygos vein was anastomosed to the left atrium. Although pulmonary artery pressure was normalized at the 2-year follow-up, cardiac catheterization 6 months after the operation demonstrated right pulmonary vein obstruction.

Double switch operation for congenitally corrected transposition of the great arteries after two-staged pulmonary artery banding

We describe a case of congenitally corrected transposition of the great arteries (cc-TGA) successfully performed by the double switch operation after two-staged pulmonary artery banding (PAB). An eleven-year old boy diagnosed with cc-TGA underwent the first PAB at that age, followed by the second PAB one year later. Because of severe ventricular dysfunction and arrhythmia of the anatomic left ventricle, the intension of one-stage PAB was abandoned. Cardiac catheterization data from after the adequate second PAB provided the surgical indication for the anatomical correction and double switch operation (Senning+Jatene procedure) and this was successfully performed at age 14. Although cardioversion was required to treat supraventricular tachycardia in the early period after surgery, the patient was discharged from hospital and remains in good clinical condition at the last follow-up at 5 years with normal sinus rhythm and good biventricular function.

Hybrid Palliation for Interrupted Aortic Arch With Small Aortic Valve

Objectives: Open heart surgery for interrupted aortic arch in the neonatal period is still a high-risk procedure related in part to patient factors such as low birth weight, other morphologic anomalies, and, especially, small aortic valve size. Recently, we performed hybrid palliation with bilateral pulmonary artery banding and ductal stenting as the first-stage palliation for such cases. In this study, the outcomes of this procedure were examined. Methods: Six cases of interrupted aortic arch with a small aortic valve underwent the hybrid procedure in the neonatal period in our institute from 2010 to 2015 (mean age: 6.8 days, mean body weight: 3.2 kg, mean z score of the aortic valve annulus: −8.3). Their postoperative clinical courses and results of the second-stage surgery were evaluated. Results: No mortality or severe morbidity was seen in association with initial hybrid palliation. Five of six patients were discharged from the hospital; the one exception had a significant urinary tract anomaly. None needed an additional catheter intervention or surgical procedure postoperatively. All surviving patients underwent second-stage surgery; three had biventricular repair by the conventional method or Damus-Kaye-Stansel anastomosis with the Rastelli procedure and the other three proceeded toward staged Fontan reconstruction. Growth of the aortic valve was seen in four patients, and increased indexed left ventricle volume was recognized in one after the palliation. Conclusion: Hybrid palliation could be useful not only to avoid high-risk neonatal surgery but also to allow for eventual selection of the second-stage surgery based on the observations of potential interval development of left ventricular structures.

Inflammatory Response to Hyperoxemic and Normoxemic Cardiopulmonary Bypass in Acyanotic Pediatric Patients

Background: Hyperoxemic management during cardiopulmonary bypass (CPB) is still common, and there is no consensus about physiologic oxygen tension strategy (normoxemic management) during pediatric CPB. In this study, we compared the postoperative conditions and measures of inflammatory response among patients with acyanotic congenital heart disease subjected to either hyperoxemic or normoxemic management strategy during CPB. Methods: We studied 22 patients with a ventricular septal defect and pulmonary artery hypertension. The patients were divided into two groups. Group I (n = 9) received normoxemic management (PaO2 = 100-150 mm Hg) and group II (n = 13) received hyperoxemic management (PaO2 = 200-300 mm Hg) during CPB. There was no difference between groups with regard to age, body weight, duration of CPB, and aorta clamping time or preoperative pulmonary hypertension (pulmonary pressure/systemic pressure [Pp/Ps]). In each group, the blood samples to measure the cytokine levels were collected before and after the CPB. Results: Although we observed no statistically significant differences in postoperative intubation time, alveolar–arterial oxygen difference, creatine kinase MB level, and pulmonary hypertension (Pp/Ps) between group I (10.7 ± 13.4 hours, 197 ± 132 mm Hg, 148 ± 58.6 IU/L, 42.8% ± 22.1%, respectively) and group II (27.8 ± 36.5 hours, 227 ± 150 mm Hg, 151 ± 72.6 IU/L, 50.4% ± 16.0%, respectively), levels of median interleukin 6 and tumor necrosis factor α were lower in group I (129.8 and 17.0 pg/mL, respectively) than that in group II (487.8 and 22.5 pg/mL, respectively). Conclusion: During the CPB in acyanotic pediatric patients, normoxemic management can minimize the systemic inflammatory response syndrome associated with CPB. We can apply this physiologic oxygen tension strategy to surgical advantage during heart surgeries in acyanotic pediatric patients.

Modified Norwood procedure with a handmade down-sizing valved right ventricle-to-pulmonary artery conduit.

First-stage palliation of hypoplastic left heart syndrome has been revolutionized by the recent introduction of a right ventricle-to-pulmonary artery (RV-PA) conduit as an alternative to a systemic-to-pulmonary shunt. However, most conduits are unvalved, and the use of valved xenografts was abandoned during the early era of this operation. We performed a successful modified Norwood operation in a 2-month-old infant with aortic atresia and ventricular and atrial septal defects using a hand-made down-sizing valved graft as an RV-PA conduit. The postoperative course was uneventful with well-balanced pulmonary and arterial perfusion. We believe that minimization of the regurgitant volume from an unvalved prosthetic conduit by utilizing this modification might be of benefit in this particular group of patients.

Two-staged Operation for an Infected Common Illiac Arterial Aneurysm.

細菌感染による感染性腹部動脈瘤は腹部動脈瘤疾患において比較的稀とされており, またその手術時期や血行再建法に関して種々の見解が議論されている. 今回われわれは, 二期的に手術を施行し良好な経過を得た感染性腹部動脈瘤症例を経験したので若干の文献的考察を加え報告する. 症例は56歳, 男性. 糖尿病管理目的にて通院中のところ, 全身倦怠, 発熱が増強. 精査目的にて入院し施行した腹部CT, 腹部大動脈造影検査において, 左総腸骨動脈に曩状の動脈瘤が認められ, また血液培養検査にてサルモネラ菌が検出されたため, 同菌による感染性動脈瘤と診断した. 手術は, 初回術中所見よりまず感染巣の処置と extraanatomical bypass を行い, ついで anatomical grafting とする二期的手術を施行, 術後は6週間抗生剤治療を継続した. 術後経過は良好で軽快退院となり, 術後6カ月を経た現在も感染再燃徴候はみられていないが, 今後も感染症の再燃に対する慎重な経過観察が重要と考えられた.

Clinical advantages and myocardial protection of normothermal CPB —Comparison with hypothermal CPB—

We studied the clinical advantages and myocardial protection of normothermal CPB with comparing to hypothermal CPB. 22-cases of adult CABG were classified under two groups, according to the temperature of CPB. (Normothermal group: 37 degrees C, Hypothermal group: 32 degrees C) In both groups, the assistant CPB time after aortic declamp, the use of cardioversion that meaned the spontaneous recovery to sinus rhythm appeared or not, the dose of cathecholamines in- and post-operation, and the amounts of postoperative bleeding (after 6 h and 12 h) were compared as the clinical results and the data of CPK-MB, Myocin LC-II, and Troponin-T were measured as the effects of myocardial protection. The method of myocardial protection was the intermittent antegrade cold blood cardioplegia with terminal warm blood for all cases. As a result, the assistant CPB time after aortic declamp, the use of cardiovasion, and the amounts of postoperative bleeding (both of 6 h and 12 h) were less in normothermal group rather than in hypothermal group. (p < 0.05). However we had no differences about the dose of cathecholamines in post-operation and the data of three items between two groups. So, it suggests that the sufficient effects of myocardial protection could be obtained in normothermal CPB as in hypothermal CPB. Therefore we conclude that normothermal CPB could provide some clinical advantages, such as shortening CPB time, recovery of sinus rhythm, and prevention of postoperative bleeding, compared to hypothermal CPB and sufficient myocardial protection.