Yoshinori Takanashi

Clinical efficacy of heparin-bonded bypass circuits related to cytokine responses in children.

BACKGROUND Cardiopulmonary bypass (CPB) induces numerous systemic reactions. This study examined the efficacy of heparin-bonded CPB circuits on inflammatory responses and postoperative status in children. METHODS Thirty-four infants undergoing elective cardiac surgery were randomly divided into two groups: a heparin-bonded CPB group (n = 17) and a non-heparin-bonded group (n = 17). Plasma levels of the inflammatory cytokines were measured before, during, and after CPB, and postoperative status was determined by examining the respiratory index, blood loss, and the post- and preoperative body weight percent ratio. RESULTS Significant differences in tumor necrosis factor-alpha, interleukin-6, and interleukin-8 patterns were observed during and after CPB between the two groups (p < 0.01, p < 0.01, p < 0.05, respectively). All cytokines measured were significantly lower in the heparin-bonded group just after CPB (p < 0.05). There were no differences in duration of intubation, intensive care unit or hospital stay, or postoperative blood loss, but the respiratory index 3 hours after CPB and body weight percent ratio 24 and 48 hours after CPB were significantly reduced in the bonded group (p < 0.05, p < 0.01, p < 0.05, respectively). CONCLUSIONS Our findings suggest that heparin bonding of the bypass circuits affects early postoperative status and reduces cytokine responses in pediatric cardiac surgery.

Pulmonary arterial changes in patients dying after a modified Fontan procedure following pulmonary artery banding

SummaryPulmonary arterial changes were histometrically analyzed in four cases of postoperative death following a modified Fontan procedure in which pulmonary artery banding had previously been performed because of pulmonary hypertension. Case 1 was a 3-year-old girl with corrected transposition of the great arteries (TGA), ventricular septal defect, and double-inlet left ventricle; case 2 was a 6-year-old girl with single ventricle (SV) and complete TGA; case 3 was a 25-month-old boy with SV and doubleoutlet right ventricle; and case 4 was a 21-year-old man with tricuspid atresia. The cause of death in cases 1, 2, and 3 was pulmonary hypertensive crisis due to postoperative vasoconstriction of the small pulmonary arteries. Medial hypertrophy remained in half of the preacinar small pulmonary arteries although it was not observed in all the intraacinar arteries in cases 1 and 2, even after banding. The postoperative course of case 4 was uneventful despite multiple thromboembolism in the small pulmonary arteries. However, the patient died due to a thrombosed artificial valve. The results suggest that residual medial hypertrophy of the small pulmonary arteries was a major risk factor in these cases. Lung biopsy is recommended to determine the indications for the Fontan procedure in these hemodynamically critical cases.

Superior biocompatibility of heparin-bonded circuits in pediatric cardiopulmonary bypass.

BACKGROUND Heparin bonding of pediatric cardiopulmonary bypass circuits may decrease activation of blood compartments as inflammatory responses. We studied the biocompatibility of heparin-bonded circuits in infant cardiac surgery. METHODS Twenty-four infants undergoing elective cardiac surgery were randomly assigned to either a nonheparin-bonded control circuit (n = 12) or a fully heparin-bonded circuit (n = 12) including membrane oxygenator, reservoir, and all tubing. Blood samples were used to identify differences in complement activation and cytokine release between groups during and after cardiopulmonary bypass. The postbypass oxygenation index was also compared. RESULTS The C3 activation product in the heparin-bonded group was significantly lower during (p < 0.01) and just after (p < 0.05) cardiopulmonary bypass. No statistically significant difference in C4 activation products was observed. Lower interleukin-6 and tumor necrosis factor-alpha were found immediately after cardiopulmonary bypass (p < 0.05) and a higher mean postbypass oxygenation index was also seen (p < 0.05) in the heparin-bonded group. CONCLUSION We found that a heparin-bonded cardiopulmonary bypass circuit reduced inflammatory response and improved oxygenation in pediatric cardiac surgery. These results suggest that the superior biocompatibility of the bonded circuit may reduce pulmonary complications.

A CASE REPORT OF INCOMPLETE ENDOCARDIAL CUSHION DEFECT WITH MITRAL STENOSIS IN AN ELDERLY PATIENT

The following paper describes a mitral valve replacement (SJM 27 mm), the patch closure (EPTFE) of an ostium primum atrial septal defect and tricuspid annuloplasty (De Vegas method) in a 64-year-old female patient with an incomplete endocardial cushion defect and mitral stenosis. Surgery revealed thickened, mitral valve leaflets and the presence of a cleft, findings similar to those observed in case of rheumatic degeneration. Investigation of patient hemodynamics confirmed a diagnosis of Lutembacher syndrome and a lower with left ventricle volume. After surgery, the volume of left ventricle increased and the patients clinical course was uneventful.

[Surgical treatment of total anomalous pulmonary venous connection--clinical aspects of pulmonary venous obstruction].

During November 1986 and May 1997, 19 patients with total anomalous pulmonary venous connection (TAPVC) underwent repair surgery. 20 operations including two reoperations were performed. 8 of 19 patients were classified as Darling type Ia, 5 as type IIa, 4 as type III and 2 patients were type IV. Two patients were operated under emergency circumstances within 24 hours after admission, 7 patients were after a short term stabilization of 4.4 days, and the other 11 patients received surgical treatment after a mean of 8.8 days as scheduled cases. For the anostomosis, the common pulmonary venous chamber or the vertical vein was connected with the left atrium in type Ia and III cases; in type IIa and IV cases the cut-back method was performed. Persistent pulmonary hypertension and post-operative pulmonary venous obstruction (PVO) affected the post-operative clinical course. Persistent pulmonary hypertension caused the death of one patient with type IIa and III each, just after operation. One type IV patient died 50 days after operation. The autopsy revealed post-operative obstructions of the remote parts of the pulmonary veins on the anostomosis site. Two patients (type IIa, III) successfully underwent reoperation due to PVO. Post-operative cardiac catheterization was performed after 12 month in 12 cases. Persistent pulmonary hypertension was found in 4 patients, and a type III patient was reoperated because of stenosis of the anostomosis site. The other three patients had persistent pulmonary hypertension without any demonstrable PVO. Persistent pulmonary hypertension and PVO are combined as TAPVC complex. The difficulty to reoperated patients with persistent pulmonary hypertension caused by PVO is one major problem. So preoperative prevention of PVO by normalization the morphologic changes of the pulmonary veins by using drugs could be a different view point in TAPVC therapy after the initial operation.

A successful case report of one and one half ventricle repair for pure pulmonary stenosis in a 4-year-old girl

A 4-year-old girl with pure pulmonary stenosis, hypoplastic right ventricle and atrial septal defect, underwent left modified Blalock-Taussig shunt at the age of 2 year. Her RVEDV was 62.7% of normal and TVD was 64.2% of normal at the age of 3 year. We observed development of right ventricle and performed simultaneously Glenn shunt and right ventricular outflow reconstruction (one and one half ventricle repair). Her general condition after operation became better. The size of tricuspid valve and right ventricle grew on Cardiac ultrasonography and catheterization examined after one year operation. In future, If the size of RV and TV might grow further, we should recommend her biventricular repair.