Yoshito Kawachi

Risk stratification analysis of operative mortality in heart and thoracic aorta surgery: comparison between Parsonnet and EuroSCORE additive model

OBJECTIVE Our purpose was to compare the performance of risk stratification model between Parsonnet and European System for Cardiac Operative Risk Evaluation (EuroSCORE) in our patient database. METHODS From August 1994 to December 2000, 803 consecutive patients have undergone heart and thoracic aorta surgery using cardiopulmonary bypass and scored according to Parsonnet and EuroSCORE algorithm. The population was divided into five clinically relevant risk categories. We compared correlation of predicted mortality and observed mortality between these two models. Score validity was assessed by calculating the area under the receiver operating characteristic (ROC) curve. RESULTS Overall hospital mortality was 4.5%. In Parsonnet model, predicted mortality was 2.4% for 0-4% risk, 6.7% for 5-9% risk, 12% for 10-14% risk, 17% for 15-19% risk, 25% for 20% plus risk, and 10.4% for overall patients. Observed mortality was 2.4, 0.4, 5.9, 8.7, 11, and 4.5%, respectively. The thoracic aorta and valve cohort indicated poor correlation between predicted and observed mortality compared to coronary cohort. In the EuroSCORE model, predicted mortality was 1.4% for 0-2% risk, 4.0% for 3-5% risk, 6.7% for 6-8% risk, 9.7% for 9-11% risk, 13% for 12% plus risk, and 5.3% for overall patients. Actual mortality was 0, 1.5, 6.8, 11, 21, and 4.5%, respectively. Each of the thoracic aorta, valve, and coronary cohort indicated good correlation between predicted and observed mortality. Areas under the ROC curves were 0.72 in Parsonnet and 0.82 in EuroSCORE. CONCLUSIONS The EuroSCORE additive model yielded good predictive value for hospital mortality of Japanese patients undergoing not only cardiac but also thoracic aortic surgery.

The effects of pulsatile and nonpulsatile systemic perfusion on renal sympathetic nerve activity in anesthetized dogs.

It is still controversial whether to pulse or not to pulse for the establishment of ideal extracorporeal circulation. We directly measured the renal sympathetic nerve activity in mongrel dogs (n = 10, weighing from 13 to 21 kg) to determine the effects of pulsatile and nonpulsatile systemic perfusion on the control of the sympathetic nerve activity during left ventricular assistance. Pulsatile perfusion was generated with an air-driven, diaphragm-type blood pump, and nonpulsatile perfusion was generated with a centrifugal pump. Renal sympathetic nerve activity and the blood flow of the descending aorta were then recorded during pulsatile and nonpulsatile systemic perfusion. Other variables, such as mean arterial pressure, central venous pressure, left atrial pressure, and blood gas levels, were kept constant. At the same mean arterial pressure, renal sympathetic nerve activity during pulsatile perfusion decreased significantly to 80% of renal sympathetic nerve activity during nonpulsatile perfusion (26.8 +/- 2.4 vs 33.4 +/- 2.9 spikes/sec, p < 0.01). Total systemic vascular resistance during pulsatile perfusion decreased significantly to 85% of that during nonpulsatile perfusion (5700 +/- 580 vs 6667 +/- 709 dynes.sec.cm-5, p < 0.05). These results suggest that pulsatile systemic perfusion, compared with nonpulsatile systemic perfusion, reduces sympathetic nerve activity and peripheral vascular resistance and thus may improve both microcirculation and organ function.

Comparative study of retrograde and selective cerebral perfusion with transcranial Doppler

BACKGROUND Retrograde cerebral perfusion (RCP) is a simple technique and is expected to provide cerebral protection. However, its optimum management and limitations remain unclear. Transcranial Doppler has been used to monitor cerebral perfusion. Using this Doppler technique, we compared cerebral blood flow for RCP with that for selective cerebral perfusion. METHODS Thirty-two consecutive patients underwent elective surgical repair of an aortic aneurysm involving the aortic arch at Kyushu University Hospital. Retrograde cerebral perfusion was used in 15 patients and selective cerebral perfusion, in 17 patients. Continuous measurement of middle cerebral artery blood flow velocities was performed by transcranial Doppler technique. RESULTS Retrograde middle cerebral artery blood flow velocities during RCP could be measured in only 3 patients, whereas middle cerebral artery blood flow velocities during selective cerebral perfusion could be measured in all but 1 woman. The increase in middle cerebral artery blood flow velocities after RCP was significantly greater than that after selective cerebral perfusion. CONCLUSIONS The measurement of middle cerebral artery blood flow velocities with transcranial Doppler technique is practicable during selective cerebral perfusion but difficult during RCP. The increase in middle cerebral artery blood flow velocities after RCP indicates reactive hyperemia and reflects the critical decrease in cerebral blood flow during this type of perfusion.

Comparative study of cell saver and ultrafiltration nontransfusion in cardiac surgery

Hemoconcentration for the establishment of no-donor blood transfusion in open heart surgery was assessed in regard to both the saving of protein and platelets and the exclusion of free hemoglobin. Two different types of hemoconcentrator were compared: the ultrafilter (group I, 6 patients) and the Cell Saver (group II, 6 patients). The total serum protein level, expressed as the percent recovery of the preoperative value, after hemoconcentration was significantly higher in group I (group I versus group II: total serum protein, 118% versus 87% [p less than 0.05]; fibrinogen, 77% versus 50% [p less than 0.01]; immunoglobulin, 83% versus 60% [p less than 0.01]). The platelets also seemed to be well preserved after hemoconcentration in group I. Although the exclusion of free hemoglobin from plasma was inferior in group I compared with group II, the postoperative plasma free hemoglobin level did not increase in group I. We conclude that use of the Cell Saver in nontransfusion cardiopulmonary bypass might cause a severe depletion of various proteins and that the ultrafilter is both safer and more useful if employed routinely.

Use of Automatic Mode Change Between DDD and AAI to Facilitate Native Atrioventricular Conduction in Patients with Sick Sinus Syndrome or Transient Atrioventricular Block

The benefits of the automatic DDD (DDD/AMC) mode in the Chorus II pacemaker (Chorus 6234; Ela Medical Inc.), which automatically switches the modes between DDD and AAI to respect spontaneous AV conduction as much as possible in AAI while preserving safety pacing in DDD during paroxysmal AV block (AVB) only, remain unproven. This study examined the functions of the DDD/AMC mode in 12 patients with sick sinus syndrome (SSS; n = 10) or paroxysmal complete AVB (n = 2). A short‐term (24 hours) comparative study between simple DDD mode and the DDD/AMC mode was performed in 8 of the 12 patients, and a medium‐term (55.2 ± 54.6 days) follow‐up of the DDD/AMC mode was completed in all 12 patients. A comparative pair of 24‐hour surface Holter ECGs was obtained in 6 of the 8 patients in the short‐term study. Telemetry and built‐in Holter histograms were collected in the outpatient clinic in all 12 patients. Although the percentage atrial pacing of the telemetry increased from 59.2 ± 35.4 in DDD to 70.4 ± 31.8 in DDD/AMC (P < 0.009; n = 8), the percentage ventricular pacing decreased from 64.6 ± 37.7 in DDD to 36.2 ± 43.1 in DDD/AMC (P < 0.027) in the short‐term study. In particular, the reduction of percentage ventricular pacing to < 10% was observed in four patients with SSS not associated with ± first‐degree (1°) AVB on preoperative ECGs. Between the two modes a significant difference in arrhythmic events was not observed by the 24‐hour surface Holter ECGS taken from the six patients in the short‐term study. AAI‐DDD switching associated with automatic modulation of AV delay and AV hysteresis occurred in all patients in the medium‐term study. From the medium‐term study, the total AV delay (AV delay plus AV hysteresis) exceeded 300 ms in 6 of the 12 patients in DDD/AMC, and usually became longest during nighttime. From the short‐ or medium‐term study in the 12 patients, two patients preferred the DDD/AMC mode while one preferred the DDD mode. These results suggest that the DDD/AMC mode is useful, at least in SSS patients without ≥ 1° AVB, by reducing the percentage ventricular pacing.

Inhibition of lipid peroxidation with the lazaroid U74500A attenuates ischemia-reperfusion injury in a canine orthotopic heart transplantation model☆☆☆★★★♢

BACKGROUND The lazaroid U74500A is a 21-aminosteroid that inhibits lipid peroxidation and attenuates ischemia-reperfusion injury. We examined the effect of U74500A on heart preservation with the use of a clinically relevant canine orthotopic heart transplantation model. METHODS AND RESULTS Six donor dogs (group L) were pretreated intravenously with U74500A (10 mg/kg), and the dogs without pretreatment served as a control (group C, n = 6). The donor heart was preserved in cold University of Wisconsin solution for 24 hours. The heart was then transplanted orthotopically. Myocardial biopsy was performed to measure the adenosine triphosphate level at the end of ischemia. Before reperfusion, recipients in group L received another dose of U74500A (10 mg/kg) intravenously. After 3 hours of reperfusion, left ventricular function was evaluated by left ventricular pressure-volume relations with the use of a Millar catheter and conductance catheter, thereby deriving the slope of the end-systolic pressure-volume relation, the slope of the stroke work-- end-diastolic volume relation, and the slope of the maximum dP/dt--end-diastolic volume relation. At the same time, serum creatine kinase MB isoenzyme and lipid peroxide levels were measured. The slopes of the end-systolic pressure-volume relation, the stroke work--end-diastolic volume relation, and the maximum dP/dt--end-diastolic volume relation for group L were significantly higher than those for group C. The adenosine triphosphate levels for group L were significantly higher than those for group C. Serum creatine kinase MB isoenzyme and lipid peroxide levels for group L were significantly lower than those for group C. CONCLUSIONS Inhibition of lipid peroxidation by the administration of U74500A was effective for 24-hour canine cardiac preservation. These results indicate that U74500A is a promising agent for heart allograft preservation.

Arresting donor hearts with extracellular-type cardioplegia prevents vasoconstriction induced by UW solution.

The effects of arresting donor hearts with University of Wisconsin solution was investigated. Donor dogs were divided into two groups according to the technique used for arresting the heart. In group I (n = 6) the heart was arrested with University of Wisconsin solution, whereas in group II (n = 6) extracellular-type cardioplegia (K+ = 20 mmol/liter) was used to induce cardioplegic arrest. Aortic root pressure was measured during the infusion of solution at constant flow. In both groups, the hearts were then flushed and stored in cold University of Wisconsin solution for 6 h. The hearts were transplanted orthotopically and disconnected from cardiopulmonary bypass. Left ventricular function was evaluated by pressure-volume relations using a conductance catheter. Peak aortic root pressure during the infusion was significantly higher in group I than in group II, although post-transplant left ventricular function was similar in both groups. Although there was no difference in cardiac function after implantation, donor hearts should be arrested by extracellular-type cardioplegia to prevent coronary vasoconstriction associated with preservation in University of Wisconsin solution.

The effect of lazaroid (U74500A), a novel inhibitor of lipid peroxidation, on 24-hour heart preservation. A study based on a working model using cross-circulated blood-perfused rabbit hearts.

Lazaroid, an inhibitor of iron-mediated lipid peroxidation, has been shown to reduce free radical-mediated injury after ischemia and reperfusion. We thus examined the efficacy of pretreatment with lazaroid (U74500A) in enhancing functional recovery after 24-hr heart preservation. An isolated rabbit heart model perfused with the blood from a support rabbit was used. Before preservation, either U74500A (4 mg/kg, group L; n = 6) or solvent (group S; n = 7) was given to the donor rabbit. After 24-hr preservation with UW solution at 0 degrees C, all hearts were perfused with cross-circulated blood for 60 min with the Langendorff mode followed by 40 min of the working mode. In group S, ventricular fibrillation (Vf) after reperfusion was observed in all hearts, whereas no Vf was observed in the U74500A-pretreated group. In group L, the serum creatine phosphokinase; its isozyme, troponin-T; and serum lipid peroxide levels after 10 min of reperfusion were all significantly (P < 0.05) lower than those in group S. The Frank-Starling curve (indicating the left atrial pressure-aortic flow relationship) showed a significant left and upward shift in group L compared with that in group S (P < 0.0001). The heart pretreated with U74500A showed less ischemia-reperfusion injury, better ventricular function, and a lower lipid peroxide level. We thus conclude that the inhibition of lipid peroxidation with lazaroid appears to offer some potential benefits for long-term heart preservation.

Postoperative cardiac rhythms with superior septal approach and lateral approach to the mitral valve

BACKGROUND The superior-septal approach provides an excellent view of the mitral valve and therefore has received considerable interest. However, the safety of this approach is controversial because it requires division of the sinus node artery in most cases. METHODS Postoperative cardiac rhythms were analyzed in 152 consecutive patients who underwent mitral valve procedures between January 1992 and February 1995 with a conventional right lateral left atriotomy (group 1, n = 69) or the superior-septal approach (group 2, n = 83). Follow-up ranged from 2 to 38 months, and the mean follow-up was 16.1 months in group 1 and 13.8 months in group 2. RESULTS The mortality rate was similar in the two groups (1.4% in group 1 and 1.2% in group 2), and the causes of death were not related to the left atriotomy. At discharge, 96% of the patients in group 1 who were in sinus rhythm preoperatively and 78% of those in group 2 remained in sinus rhythm. At the last follow-up, 88% of these patients in group 1 and 83% in group 2 remained in sinus rhythm. Among the patients in atrial fibrillation or junctional rhythm before operation, 12% in group 1 and 11% in group 2 had regained sinus rhythm at the last follow-up. There were no significant differences in these values. CONCLUSIONS Although the incidence of dysrhythmias was higher with the superior-septal approach in the early postoperative period, this approach provides an excellent operative view of the mitral valve and similar results in terms of late postoperative cardiac rhythms as the right lateral left atriotomy.

Use of transesophageal echocardiography for postoperative evaluation of right ventricular function.

BACKGROUND No method has been available to assess the right ventricular (RV) pressure-volume relation in the operating room or intensive care unit. Left ventricular cross-sectional area measured by echocardiography using the technology of automated border detection has been used to construct left ventricular pressure-area (P-A) loops. In the human right ventricle, however, this approach has not been validated. METHODS We recorded RV P-A loops in 14 patients in the intensive care unit using transesophageal echocardiography. Multiple RV P-A loops were obtained by reducing preload with intravenous nitroglycerin, thereby elucidating the end-systolic P-A relation. RESULTS With an incremental dose of dobutamine, the slope of the RV end-systolic P-A relation increased (from 4.56+/-2.42 to 7.34+/-3.62 mm Hg/cm2, p<0.01), with no change in the x-axis intercept, which implied increased contractility. Furthermore, in the operating room we validated the use of RV cross-sectional area as a surrogate for RV volume by demonstrating the close correlation between the stroke area (maximal RV area minus minimal RV area) and stroke volume (r = 0.962; p<0.0001). CONCLUSIONS Transesophageal echocardiography with automated border detection is a promising tool for elucidating RV function through the analysis of RV P-A loops.