Yusuke Ando

Follow-up study of pulmonary artery configuration in hypoplastic left heart syndrome

AbstractObjective. Pulmonary artery (PA) distortion significantly compromises the outcome of the staged approach to the Fontan operation in patients with hypoplastic left heart syndrome (HLHS). This retrospective study was designed to investigate the influence of the initial operation on postoperative PA anatomy. Methods. Forty-nine patients with HLHS and its variant were enrolled in this study. As an initial palliation, the Norwood operation with a modified Blalock-Taussig (BT) shunt was performed in 12, the Norwood operation with a right ventricle to pulmonary artery (RV-PA) shunt in 31, and bilateral PA banding in 6. The incidence and risk factors of postoperative central pulmonary artery stenosis (PS) were investigated, and the PA configuration was followed up until post-Fontan status. Results. Twenty-two patients (51.2%) had developed central PS after the Norwood operation (33.3% with a BT shunt vs. 58.1% with a RV-PA shunt). The RV-PA shunt with a polytetrafluoroethylene (PTFE) patch at the distal pulmonary stump significantly decreased the central PS (P = 0.035). The PA index after the Norwood operation was not statistically different between the BT and RV-PA shunt groups, although in the RV-PA group it was significantly higher in patients with a PTFE patch on the distal PA stump. PA plasty was performed in 16 patients in the second-stage palliation and in 15 with the Fontan completion. Freedom from PA plasty was significantly lower in the RV-PA shunt group than in the BT shunt group (63.5% vs. 31.1% at 5 years, P = 0.034). Six patients initially palliated with bilateral PA banding had no stenosis at the banding site in the Norwood + Glenn operation, and one patient required stent placement for left PS in the Fontan completion. Post-Fontan catheterization (n = 31) showed central venous pressure of 11.5 ± 2.6 mmHg, cardiac index of 3.6 ± 0.8 l/kg/min, and PA index of 194.0 ± 58.4 mm2/m2; there was no difference between the groups. Conclusion. The incidence of central PS after the Norwood operation was significant, and the shunt type and procedure for the distal PA stump influenced the postoperative configuration of the central PA. With an aggressive surgical approach to central PS, PA anatomy was satisfactory with good hemodynamic variables after Fontan completion. Bilateral PA banding did not cause later vascular deformity.

“Spiral-Cuff” Technique for Repair of Anomalous Left Coronary Artery From the Pulmonary Artery

We describe a new technique for coronary transfer in the repair of anomalous origin of the left coronary artery from the pulmonary artery. The left coronary artery is elongated with the native pulmonary artery wall to form a spiral-shaped coronary cuff to construct an unstretched new left coronary artery system from the ascending aorta. A postoperative angiographic scan showed good flow of the left coronary artery without any kinking or narrowing. This technique is considered useful when an anomalous coronary artery arises a long way from the ascending aorta.

An Unusual Manifestation of Brain Tumor: Development of Delayed Hemiplegia After Cardiopulmonary Bypass

Abstract  Cerebral swelling after cardiopulmonary bypass might trigger a critical cerebral consequence resulting from intracranial space‐occupying lesion. We experienced a 75‐year‐old woman who suffered from a delayed left hemiplegia after mitral valve replacement. Urgent diagnostic imaging revealed the presence of a brain tumor with perifocal cerebral edema. Fluid shifts occurring within a few days after the cardiopulmonary bypass, manifesting the focal cerebral edema, played a key role in this unique clinical course.

Bilateral Axillary Artery Perfusion to Reduce Brain Damage during Cardiopulmonary Bypass

Abstract  Background: Theoretically, a multiple perfusion approach, reducing detachment of atheromatous debris from the aortic intima and its flow into the cerebral circulation, should contribute to lessen a stroke, and may be applied to complex cardiac surgery with extensive aortic disease. The aim of the present study was to examine the value of bilateral axillary artery perfusion during thoracic aortic and cardiac surgery, and to evaluate the clinical results with a particular focus on cerebral damage. Methods: From March 2002 through December 2007, 24 patients (16 male and eight female; age range, 43 to 84 years) underwent bilateral axillary artery perfusion through side grafts during cardiopulmonary bypass. Aortic surgery, including total arch replacement, hemiarch replacement, and ascending aortic replacement, was performed in 21 patients. Bilateral axillary artery perfusion was also used in three complicated valve surgeries after expanding its indication to cardiac pathology with a diseased aorta, two redo cases with severe atherosclerotic vascular disease, and one case with a porcelain aorta. Results: Bilateral axillary artery perfusion was successful in all patients. There were no complications related to this procedure except in one patient, who suffered from a local fluid retention in one wound, requiring puncture drainage. There was no hospital mortality. No strokes were identified by either clinical assessments or diagnostic imaging. Conclusions: Bilateral axillary artery perfusion is a useful method for protection of the brain during either thoracic aortic or cardiac surgery when the patients have an extensively diseased aorta. (J Card Surg 2010;25:139‐142)

Aortic valve replacement in a patient with a brain tumor

We report a case of aortic stenosis with a brain tumor in a 67-year-old man. Although he showed no clinical neurological abnormality, a computed tomography scan revealed a brain tumor. We performed aortic valve replacement under several management techniques to avoid cerebral injury. Two biochemical markers for brain injury, S-100β and neuron-specific enolase, were measured perioperatively. The postoperative course was uneventful without neurological complication, and the biochemical markers were within the control ranges.

Missing Left Atrial Thrombus: Dislodgement or Artifact?

Patients with a left atrial thrombus are considered at high risk of thromboembolism. Surgical treatment is generally recommended. We experienced a case of a patient with a history of cerebral embolism related to chronic atrial fibrillation in whom, unexpectedly, no thrombi were found at thrombectomy. Although echocardiography is a useful method for detection of a thrombus in the left atrium, the possibility of a reverberation artifact should be routinely explored.

Sutureless pericardial marsupialization for the repair of congenital right pulmonary veins atresia

We present a very rare case of isolated right pulmonary veins atresia in a 4-year-old girl. As the presence of a pulsatile blind pulmonary venous confluence adjacent to the left atrium was demonstrated by preoperative right pulmonary arterial wedge angiography, we applied sutureless pericardial marsupialization for the repair of right pulmonary veins atresia. She is currently 8 years old without pulmonary veins stenosis.

Surgical repair of ostial obstruction of the coronary artery for quadricuspid aortic valve in an infant

A congenital quadricuspid aortic valve accompanied by ostial obstruction of the left coronary artery is extremely rare and has not yet been reported in an infant. We herein describe an infant with ostial obstruction of the left coronary artery caused by a small left coronary cusp that formed a pouch. The patients cardiac function deteriorated due to progressive myocardial ischaemia, and translocation of the ostium of the left coronary artery was performed. Postoperative coronary angiography revealed good filling of the left coronary artery.