Yu Oshima

Clinical outcome of the Fontan operation in patients with impaired ventricular function

OBJECTIVE Although a staged Fontan strategy allows for an excellent outcome in high-risk patients, an impaired ventricular function remains a significant factor of early/late mortality and morbidity. This study evaluated the clinical outcome of the Fontan operation in patients with impaired ventricular function. METHODS A retrospective review was performed on 217 patients who had undergone the Fontan operation between 1991 and 2007. RESULTS Twenty-nine (13%) of the 217 patients had an impaired ventricular function (ejection fraction (EF) <50%). The median age at the time of the operation was 3 (range: 1-31 years) years. There were five adult patients. The ventricular morphology was right in 20 patients (including five hypoplastic left heart syndrome (HLHS)) and others (left and two-ventricle) in nine patients. Heterotaxy syndrome was present in eight patients. Previous surgical interventions included bidirectional Glenn anastomoses in 24, modified Blalock-Taussig shunts in two and pulmonary artery banding in two. The preoperative EF was 43+/-6%. Significant (moderate or severe) atrioventricular valve regurgitation was noted in four patients. The percutaneous oxygen saturation (SpO(2)) was 82+/-5%. The pulmonary artery pressure and pulmonary artery index were 11+/-3 mmHg and 296+/-102 mm(2)m(-2), respectively. All 29 patients underwent the Fontan operation without any early mortality. There were two late mortalities and two re-operations. EF was maintained at 59+/-15% at a median follow-up of 7.5 (range: 1-19) years. The percent normal systemic ventricular end-diastolic volume decreased from 174+/-95% to 124+/-39% (p<0.05). The SpO(2) increased to 92+/-2%. The mean cardiothoracic ratio in chest X-ray and B-type natriuretic peptide were 51% (range: 35-68%) and 22 pgml(-1) (range: 9-382 pgml(-1)), respectively. Three patients developed congestive heart failure, seven had arrhythmia and two developed protein-losing enteropathy. The New York Heart Association (NYHA) class functional class is I in 21 patients, II in five and III in one. CONCLUSIONS Acceptable clinical outcomes were observed at an intermediate follow-up of the Fontan operation in patients with an impaired ventricular function.

Single center experience with a low volume priming cardiopulmonary bypass circuit for preventing blood transfusion in infants and small children.

This retrospective study analyzed the current practice of blood transfusion-free open-heart surgery in 536 children weighing 5–20 kg undergoing surgery between 2004 and 2007. A miniaturized cardiopulmonary bypass (CPB) circuit was used (priming volume; 300 ml for the flow rate <1,500 ml/min; 550 ml for the flow rate of 1500–2300 ml/min). Modified ultrafiltration was routinely performed. Criteria for blood transfusion during CPB included a hematocrit of <20% and/or mixed venous oxygen saturation of <65%. Transfusion during CPB was avoided in 264 (49.3%) of the 536 patients (5–10 kg group, 29.0%; 11–15 kg group, 67.4%; 16–20 kg group, 80.8%). There was no neurological complication related to hemodilution. Multiple logistic regression analysis revealed that body weight, preoperative hematocrit, priming volume of CPB circuit, CPB time, and lowest hematocrit during CPB predict requirement of blood transfusion (p < 0.01). Transfusion rate was lowest in the atrial septal defect group (5.6%) and highest in tetralogy of Fallot group (78.7%), being associated with complexity of diagnosis and procedure required. Blood transfusion-free open-heart surgery may be achieved in the half of the patients weighing 5–20 kg, and further miniaturization of CPB circuit and refinement of perfusion strategy might reduce transfusion rate in patients <10 kg and/or with complex congenital heart disease.

Ultrafiltration of priming blood before cardiopulmonary bypass attenuates inflammatory response and maintains cardiopulmonary function in neonatal piglets.

Blood priming is necessary for cardiopulmonary bypass (CPB) in neonates to avoid excessive hemodilution; however, transfusion-related inflammation affects postCPB outcomes in neonatal open-heart surgery. We hypothesized that ultrafiltration of priming blood before CPB may reduce inflammatory mediators in priming blood and postCPB inflammatory responses, thereby improving cardiopulmonary function. Twelve 1-week-old piglets (3.5 ± 0.2 kg) were divided into two groups. Group U (n = 6) employed the priming blood ultrafiltrated before CPB, but group N (n = 6) used the nonultrafiltrated blood. Cardiopulmonary bypass was performed for 2 hours and then modified ultrafiltration (MUF) was conducted. Data were acquired before CPB and after MUF. The values of K+, serotonin, and IL-8 in priming blood was significantly decreased after ultrafiltration (8.2 ± 2.6 vs. 4.2 ± 0.8 mEq/L, p < 0.01, 234 ± 96 vs. 74 ± 42 ng/ml, p < 0.01, 78.4 ± 5.1 vs. 64.5 ± 59.1 pg/ml, p < 0.05). Group U after MUF had lower thrombin-antithrombin complex levels (23.9 ± 5.1 vs. 33.7 ± 4.6 ng/ml, p < 0.01) and lower IL-8 levels in airway fluid (925 ± 710 vs. 2495 ± 1207 pg/ml, p < 0.05) than group N. Cardiac output and arterial PO2 after MUF in group U were also higher (1.13 ± 0.21 vs. 0.69 ± 0.22, p < 0.01, 340 ± 190 vs. 149 ± 84 mm Hg, p < 0.05). The ultrafiltration of blood priming before CPB attenuated activation of the coagulation pathway and inflammatory responses and preserved cardiopulmonary function in neonatal piglets.

Chronic Kidney Disease Is Positively and Diabetes Mellitus Is Negatively Associated with Abdominal Aortic Aneurysm.

Background and Aims Chronic kidney disease (CKD) and diabetes mellitus (DM) are considered as risk factors for cardiovascular diseases. The purpose of this study was to clarify the relationship of CKD and DM with the presence of abdominal aortic aneurysm (AAA). Methods We enrolled 261 patients with AAA (AAA+) and age-and-sex matched 261 patients without AAA (AAA-) at two hospitals between 2008 and 2014, and examined the association between the risk factors and the presence of AAA. Furthermore, in order to investigate the prevalence of AAA in each group, we enrolled 1126 patients with CKD and 400 patients with DM. Results The presence of CKD in patients with AAA+ was significantly higher than that in patients with AAA- (AAA+; 65%, AAA-; 52%, P = 0.004). The presence of DM in patients with AAA+ was significantly lower than that in patients with AAA- (AAA+; 17%, AAA-; 35%, P < 0.001). A multivariate logistic regression analysis demonstrated that hypertension, ischemic heart disease and CKD were independent determinants, whereas, DM was a negatively independent determinant, for the presence of AAA. The prevalence of AAA in patients with CKD 65 years old and above was 5.1%, whereas, that in patients with DM 65 years old and above was only 0.6%. Conclusion CKD is a positively associated with the presence of AAA. In contrast, DM is a negatively associated with the presence of AAA in Japanese population.

Celsior preserves cardiac mechano-energetics better than University of Wisconsin solution by preventing oxidative stress

OBJECTIVES Identity of the optimal heart preservation solution remains unknown. Because oxidative stress contributes to contractile failure in the ischaemic/reperfused myocardium and the main characteristic of Celsior is its antioxidant effect, it is important to elucidate the relationship between the inhibitory effect on oxidative stress and cardiac mechano-energetics. We therefore evaluated the efficacy of Celsior from both aspects by comparison with the University of Wisconsin solution (UWS). METHODS We used 18 excised cross-circulated canine hearts. Excised hearts were preserved with UWS (n = 6) or Celsior (n = 6) for 3 h at 4 °C; the remaining six served as controls. Hearts were then cross-circulated and rewarmed. The end-systolic pressure-volume ratio (LV Emax) and the ventricular pressure-volume area, which is a measure of total mechanical energy, were assessed after reperfusion. Biopsies were taken from the endocardium after excising the heart, before reperfusion, after reperfusion and 4 h after reperfusion to assess the inhibitory effect of each agent on oxidative stress. Endo-myocardial biopsy samples were studied immunohistochemically for expression of 4-hydroxy-2-nonenal (HNE)-modified protein, which is a major lipid peroxidation product. RESULTS Emax in the UWS group was significantly smaller than in the control group, whereas the Emax in the Celsior group was preserved. Oxygen cost of Emax in the UWS group was significantly higher than in the Celsior group. Myocardial HNE-modified protein levels increased gradually, both under preservation and after reperfusion in the UWS group. Myocardial HNE-modified protein levels in the Celsior group were lower, mainly before and 4 h after reperfusion compared with the UWS group. CONCLUSIONS Celsior may maintain cardiac contractility and conserve oxygen cost by inhibiting oxidative stress.

Ventricular septal defects in an adult with giant membranous septal aneurysm accompanying stroke onset.

© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc aneurysms (MSAs) of 42 37 mm attached to the left ventricle (Fig 1). Aneurysm covered with calcification identified by CT in the right side of the heart oppressed the inferior vena cava (Fig 2). We speculated that the patient’s symptoms were associated with thrombus in the MSA and planned a surgical treatment. Because the large MSA complicated the direct insertion of a venous cannula from the inferior vena cava, a venous cannula was inserted from the right femoral vein. Opening the right atrium (RA) and exposing the MSA, Koch’s triangle had been stretched from the back by the MSA and had extended to the outside of the heart between the RA and an intra-atrioventricular fissure adjunct to the proximal RA. Because the MSA was too large, we opened the MSA both within and outside the RA. This showed a ventricular septal defects (VSD) with a diameter of 10 mm and fibrous tissue covering the edge (Fig 3). The VSD appeared to be a remnant of a large perimembranous VSD with inlets. We closed the VSD with a Hemashield patch and pericardium (MAQUET Cardiovasular LLC, San Jose, CA). The calcified intima was partially excised, and the aneurysm was closed. The postoperative recovery was uneventful, and the patient fully recovered strength and function in her Fig 3.

Reconstruction of the intraparenchymal pulmonary artery aneurysm

Pulmonary artery aneurysms are rare and often arise in the left main trunk. Because they are uncommon, standardized treatment and clinical management are not clearly established. We present the case of a pulmonary artery aneurysm arising intraparenchymally and its surgical reconstruction using autologous pericardium. In terms of preserving pulmonary function, this procedure is effective compared with surgical procedures such as removal of part of the lungs.