Yoshiteru Yoshioka

Minimal cardiopulmonary bypass attenuates neutrophil activation and cytokine release in coronary artery bypass grafting.

The minimal cardiopulmonary bypass (mini-CPB) circuit, a closed system with neither cardiotomy suction nor an open venous reservoir and thus no air–blood interface, reportedly reduces blood loss and inflammatory reactions associated with coronary bypass surgery. We evaluated the inflammatory reactions in patients in whom coronary bypass operations were performed with conventional CPB or mini-CPB (n = 15 each). Interleukin (IL)-6, IL-8, and neutrophil elastase levels; the neutrophil count; and the C-reactive protein value were measured before and immediately after surgery and on postoperative days 1 and 2. In addition, intraoperative blood loss and the transfusion volume were evaluated in these groups. Neutrophil elastase levels were lower in the mini-CPB group than in the conventional group on postoperative days 1 (127 ± 52 vs. 240 ± 100 µg/l, P = 0.013) and 2 (107 ± 17 vs. 170 ± 45 µ/l, P = 0.0001), as was the IL-8 level on postoperative day 1 (8.3 ± 6.4 vs. 19 ± 11 pg/ml, P = 0.016). The intraoperative blood loss and transfusion volumes were significantly lower in the mini-CPB group than in the conventional group (510 ± 244 vs. 1046 ± 966 ml, P = 0.012, and 691 ± 427 vs. 1416 ± 918 ml, P = 0.0033). Thus, mini-CPB appears to attenuate neutrophil activation and cytokine release after coronary bypass surgery and, in addition, has some beneficial effects on blood conservation.

Beneficial effects of mini-cardiopulmonary bypass on hemostasis in coronary artery bypass grafting: analysis of inflammatory response and hemodilution.

We compared the inflammatory response, hemodilution, and blood loss in patients who underwent mini-cardiopulmonary bypass (CPB) or conventional CPB during coronary artery bypass grafting (CABG). Ninety-eight consecutive patients with ischemic heart disease were randomly assigned to mini-CPB (n = 34) or conventional CPB (n = 64). Interleukin (IL) −8 and neutrophil elastase levels were measured before and after surgery. Hemodilution during CPB, blood loss during and after surgery were also evaluated. Compared with the conventional group, the mini-CPB group had lower levels of IL-8 on postoperative day 1 (8.3 ± 6.4 vs. 19 ± 11 pg/mL, p = 0.016) and of neutrophil elastase on postoperative days 1 (127 ± 52 vs. 240 ± 100 &mgr;g/L, p = 0.013) and 2 (107 ± 17 vs. 170 ± 45 &mgr;/L, p = 0.0001). The mini-CPB group also has less blood loss during (620 ± 595 vs. 978 ± 658 mL, p = 0.012) and after the operation (578 ± 310 vs. 1,002 ± 651 mL, p = 0.0034) and a hemodilution ratio of 14 ± 2 vs. 25% ± 3%, p < 0.0001. Thus, mini-CPB attenuated the inflammatory response and hemodilution, resulting in blood conservation in patients undergoing CABG.

Long-term results of mitral valve replacement: biological xenograft versus mechanical valves

Abstract We studied 279 patients who underwent mitral valve replacement at the Department of Thoracic and Cardiovascular Surgery, Hyogo College of Medicine, between November 1973 and December 1998. The patients were divided into two groups based on the type of replacement valve (154 patients in the biological xenograft group and 125 patients in the mechanical valve group), and the long-term results were compared. Clinically satisfactory results were obtained in both the biological xenograft group and the mechanical valve group according to the surgical results, long-term survival, and incidence of prosthetic valve endocarditis. At 15 years, fewer patients in the mechanical valve group than in the biological xenograft group were free of bleeding events (92.5 ± 3.7% vs 100% P < 0.05). At 15 years, the biological xenograft group was lower than the mechanical valve group with respect to freedom from thromboembolism (72.2 ± 4.6% vs 93.5 ± 3.6% P < 0.01), freedom from valve failure (22.0 ± 5.2% vs 87.0 ± 4.1% P < 0.005) and freedom from cardiac events (16.5 ± 3.9% vs 47.2 ± 14.5% P < 0.01). Though it has previously been suggested that biological xenografts used in mitral valve replacement do not need anticoagulation, the current study suggests the need for anticoagulation with the use of biological xenografts. Mechanical valves require close monitoring of anticoagulation, but their use has decreased the incidence of valve failure and thromboembolism, as compared with the use of biological xenografts. Therefore, mechanical valves are currently the preferred choice for mitral valve replacement. We believe that biological xenografts are indicated only for the older patient (≧65 years).

Clinical management of lower limb ischemia secondary to a persistent sciatic artery aneurysm: Report of a case

A persistent sciatic artery (PSA) is a rare congenital malformation, frequently complicated by atherosclerotic changes such as aneurysmal formation. Optimal treatment is dependent on the individual situation. We report a case of a PSA aneurysm complicated by lower limb ischemia. Graft interposition with distal balloon angioplasty and thrombectomy from the posterior transgluteal approach was performed successfully, without any complications.

Surgical Treatment of Complications Associated with the Angio-Seal Vascular Closure Device: Report of Three Cases

The Angio-Seal arterial closure device consists of several bioabsorbable components and is used for hemostasis of arterial puncture sites. We report 3 cases of hemorrhagic and ischemic complications related to Angio-Seal use. Two cases were treated successfully by surgical removal of the device. In the third case surgical removal of the device failed and additional intervention was necessary. The unique structure of the Angio-Seal and the most likely cause of failure should be considered when treating device-related complications.

Surgical approach to left subclavian artery aneurysm in Marfan syndrome

We present a case of left subclavian artery aneurysm in a 48-year-old man with Marfan syndrome. Aneurysmectomy and interposition with an artificial graft were successfully performed through an infraclavicular incision by dividing the clavicle at its midshaft. The clavicle bone was reconstructed with a steel plate, and the postoperative course was uneventful. Because the arterial wall is fragile in cases of connective tissue disorders such as Marfan syndrome, our surgical approach was considered to be helpful for gentle maneuvering in an adequate operative field.

Modification of the Bentall operation using the proximal double sewing technique without excision of leaflets.

We present a report on reinforcement of the proximal anastomosis during the Bentall operation. The aortic wall was excised with a 5-mm remnant, and aortic valve leaflets were preserved. Interrupted horizontal mattress sutures (2-0 Polyestel) reinforced with pledgets were placed. The composite graft was placed at the intraannular position inside of the preserved leaflets. The aortic valve leaflets were then pasted to the sewing cuff with fibrin glue. A running suture with 4-0 monofilament was placed between the remnant of the aortic wall and the peripheral side of the sewing cuff wrapped with native aortic valve leaflets.

Simple method of left ventricular assist system exchange from a BVS-5000 to a Toyobo: case report of a patient with fulminant myocarditis

We implanted a BVS-5000 biventricular assist system in a 29-year-old woman in cardiogenic shock due to fulminant myocarditis. Exchange of the left ventricular assist system (LVAS) from the BVS-5000 to a Toyobo LVAS and weaning from the right ventricular assist system were performed successfully without cardiopulmonary bypass. This simple, less invasive method may be useful for patients requiring LVAS exchange for long-term ventricular support.

Ruptured giant aneurysm of the ascending aorta caused by chronic aortic dissection

A 55-year-old man developed acute chest pain and dyspnea. Computed tomography demonstrated a rupture of a giant aneurysm of the ascending aorta. The lesion was 14 cm in diameter--the largest ever reported-and resulted from chronic aortic dissection. The patient did not have aortic insufficiency or aortic dissection around the coronary ostium. Graft replacement of the ascending aorta was performed successfully under deep hypothermia with right hemisphere perfusion.