Yoshio Sudo

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.

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.

Acute type a aortic dissection with leg ischemia

The incidence of lower extremity ischemia secondary to acute aortic dissection is relatively low, however, the presenting symptoms are variable in term of severity. We report here in two cases of such circumstances who were successively differently treated. Case one was a 60 years old male presented with severe left leg pain. Even after the initiation of cardiopulmonary bypass, the leg ischemia did not improve, therefore selective leg perfusion was additionally performed through direct left femoral artery cannulation. The surgery toward dissection was completed by mean of simultaneous graft replacement of ascending aorta and aortic arch. The leg ischemia after the aortic procedure however had persisted, femorofemoral bypass was created to relieve the mal-perfusion. Case two was a 37 years old male admitted with severe left leg pain associated with sensory-motor nerve dysfunction with muscle rigidity. In this particular patient, femoro-femoral bypass was firstly reconstructed as the mean of leg salvage procedure. After we learned there was no serious reperfusion symptom manifested, we performed radical surgery toward the aorta. We believe that the decision making of surgical treatment for acute type A dissection complicated with the presence of lower extremity ischemia is based on the severeness of mal-perfusion.

A Case of Cleft Mitral Valve Associated with Papillary Muscle Abnormality in an Adult

中隔の異常を伴わない僧帽弁前尖のcleftと乳頭筋の異常を合併した成人僧帽弁閉鎖不全症(MR)に対する僧帽弁形成術の1例を報告する.症例は53歳,男性.心不全のため来院,心エコーでMR IV度,三尖弁閉鎖不全IV度,両乳頭筋は基部で連続し,前乳頭筋と僧帽弁前尖が腱索を介さないで直接付着する異常を認めた.心内膜床欠損症とは異なり左右短絡や三尖弁と僧帽弁が同じ高さに付着する異常は認めなかった.また,肺動脈圧92/40mmHg,平均肺動脈楔入圧37mmHg,心係数1.85l/min/m2と高度の肺高血圧を認めた.手術所見では,前乳頭筋は直接前尖に付着していたが,後天性の病変を疑わせるような弁や弁下組織の肥厚,硬化,短縮,断裂などは認めなかった.後乳頭筋からの腱索の中央付近の前尖に両側が索状物でつながった1cmほどのcleftを認めた.Cleftを直接縫合,31mm Duran ringで僧帽弁輪を縫縮,三尖弁輪縫縮術を同時に施行した.術後MRは消失し,日常生活に復帰した.僧帽弁前尖のcleftによる成人のMRはきわめてまれである.また,本症例のような乳頭筋の異常を成人に認めた報告はなかった.

Surgical Treatment for Acute Type A Aortic Dissection Caused by Retrograde Propagation.

急性上行解離 (A型) で entry が下行大動脈に存在する逆行性解離例7例に手術を行った. 急性期致死的合併症を防止する目的で, 上行大動脈リング付きグラフト挿入術を6例行い, 5例を救命した. これら5例の4～67か月遠隔期の解離の状態をX線CTにて検討した. 弓部の解離腔は5例中4例は血栓閉鎖していた. しかし弓部分枝にre-entry をもつ1例では, 術後27か月においても解離が残存した. 一方, 下行大動脈以下の解離の拡大を2例に認めた. これに対して最近の1例は, entry までの拡大上行弓部大動脈置換を施行し経過良好である. 今後は, 急性逆行性上行解離において, 上行弓部大動脈の解離を完全に治癒させ, 下行大動脈以下の解離腔の血栓閉鎖の可能性がある, entry までの拡大上行弓部大動脈置換が適切と思われる.