Yukiharu Sugimura

Analysis of open heart surgery in patients with liver cirrhosis.

Open heart surgery in patients with liver cirrhosis is considered to be very risky, but the predictors of poor outcomes in such cases have not been established. We report the perioperative results of open heart surgery in patients with liver cirrhosis in our hospital. We reviewed the results of 13 cases in 12 patients with liver cirrhosis who underwent open heart surgery between January 2001 and December 2010. The Child-Turcotte-Pugh classification, the model for end-stage liver disease score, EuroSCORE, and perioperative data were used to identify risk factors for morbidity and mortality retrospectively. Ten patients had postoperative complications. Significant differences in morbidity were evident for Child-Turcotte-Pugh class, cardiopulmonary bypass time, and crossclamp time. Two patients died of liver failure, one at 40 days and the other at 2 years after surgery. Statistically significant differences in liver-related mortality were evident in the model for end-stage liver disease scores and serum cholinesterase levels. We concluded that a high Child-Turcotte-Pugh class was associated with increased morbidity. Cardiopulmonary bypass and crossclamp times were also related to high morbidity, while high model for end-stage liver disease scores and low serum cholinesterase levels predicted liver-related mortality.

Outcome of composite arterial Y-grafts in off-pump coronary artery bypass

The efficacy of using composite arterial Y-grafts in off-pump coronary artery bypass has not been established. We assessed graft patency, long-term clinical outcomes, and the indications for composite arterial Y-grafting by reviewing 53 patients who underwent primary isolated elective off-pump coronary artery bypass with composite arterial Y-grafts between January 2002 and December 2008. Coronary angiography or 64-slice multidetector computed tomographic coronary angiography was used to assess graft patency. Follow-up raged from 18 to 97 months. The rates of mortality, graft failure, and recurrence of ischemic heart disease were 0%, 22.6%, and 13.2%, respectively. Only 4 (7.5%) patients required additional procedures (percutaneous coronary interventions or repeat surgery) because of graft failure. A significantly higher rate of graft failure was evident when one end of the composite graft was anastomosed to a 75% stenosed branch of a native coronary artery and the other end to a branch with >90% stenosis. The long-term patency of composite arterial Y-grafts in off-pump coronary artery bypass requires proper judgment of the indications.

Acute aortic regurgitation due to rupture of an anomalous cord from the raphe

A 73-year-old man was admitted with complaints of back pain and dyspnea. He was asymptomatic until one day before admission. The dyspnea progressed rapidly and resulted in pulmonary edema and cardiogenic shock. Electrocardiography showed ST depression in leads V3–V6. Transthoracic echocardiography revealed severe aortic regurgitation, an ejection fraction of 71%, and a left ventricular diastolic diameter of 35mm, with no evidence of akinesis or pericardial effusion. Aortic dissection and pulmonary embolism were ruled out by computed tomography. No coronary lesion was present on coronary angiography. The cardiogenic shock suggested acute aortic regurgitation. Transesophageal echocardiography showed a bicuspid valve with an anomalous cord and the raphe prolapsing toward the left ventricular cavity during diastole (Figure 1). An emergency median sternotomy was performed. The explanted valve underwent pathologic examination and did not show any signs of infection (Figure 2). The aortic valve was replaced with a 23-mm St. Jude Medical mechanical valve prosthesis. The postoperative course was uneventful.

Surgical treatment of giant innominate artery aneurysm

Innominate artery aneurysms are rare. A 39-year-old male patient, who had chest tightness several years previously, was referred to our hospital because of an upper right mediastinal mass detected from chest X-ray. Computed tomography revealed an innominate artery aneurysm. Cerebral perfusion pressure was monitored with bilateral radial blood pressure and using cerebral oximeter, which is an easy and useful perioperative approach. We successfully performed reconstruction of the innominate artery with a synthetic graft without cardiopulmonary bypass.

Traumatic proximal aortic arch injuries with contralateral aortic disruption.

A previously healthy 48-year-old woman suffered a motor vehicle accident. On admission, chest computed tomography revealed some rib fractures and proximal aortic arch injuries (Figure 1a) with contralateral aortic disruption (Figure 1b), which became gradually worse. Thus she underwent aortic arch replacement under deep hypothermic cardiac arrest. Cardiopulmonary bypass was instituted via the left femoral artery and right atrium. The circulatory arrest time was 59min and the lowest temperature was 20 C. The total cardiopulmonary bypass time was 215min. Operative findings showed an aortic laceration at the proximal arch (Figure 2a) with contralateral disruption (Figure 2b). The patient was discharged 13 days postoperatively in a satisfactory condition without any critical complications. Currently, open surgical repair remains the gold standard therapy for traumatic thoracic aortic injuries. Funding

Surgical repair of unroofed coronary sinus atrial septal defect in an adult

Physical examination a 73-year-old woman with dyspnea revealed a systolic murmur at the 2nd intercostal space along the left sternal border. Chest radiography revealed right heart enlargement. Electrocardiography indicated normal sinus rhythm. Transesophageal echocardiography showed a dilated coronary sinus located at both atria. The pulmonary-to-systemic blood flow ratio was 2.46. Chest computed tomography revealed an unroofed coronary sinus atrial septal defect (Figures 1 and 2). She was diagnosed with unroofed coronary sinus atrial septal defect without persistent left superior vena cava. At surgery, an ostium opening into the right atrium was found (Figure 3). We performed autologous pericardial patch closure of the ostium, leaving the coronary vein draining into the left atrium. The patient was discharged 11 days postoperatively in a satisfactory condition without any critical complications.