[show abstract][hide abstract] ABSTRACT: In order to clarify the long-term outcome after surgical repair of a sinus of Valsalva aneurysm, we retrospectively assessed the operative results for patients treated in our institute.
The subjects were 27 patients who had undergone an operation between 1958 and 1996. For associated aortic regurgitation (AR) aortic valve repair was performed in 13 patients, 12 of whom had a ventricular septal defect (VSD); and an aortic valve replacement was performed in 3 patients, 1 of whom had a VSD.
Five of the 13 patients who had aortic valve repair needed aortic valve replacement because AR developed after a period of between 7 and 13 years; those cases were complicated by VSD. Another 2 patients with mild AR also complicated by VSD are currently under observation.
Although the postoperative outcome of the aortic valve repairs was good, cases that were complicated by VSD plus associated AR tended to develop AR later after surgery. Therefore, careful observation of the postoperative course is necessary.
The Annals of Thoracic Surgery 10/2000; 70(3):727-9. · 3.45 Impact Factor
[show abstract][hide abstract] ABSTRACT: Nitric oxide is the most potent vasodilator among inflammation-mediated vasoactive substances. Tepid cardiopulmonary bypass has been known to maintain low vascular resistance and nitric oxide may also be involved. There has been no previous clinical study elucidating a role of nitric oxide in a temperature dependent regulation of systemic vascular resistance in cardiopulmonary bypass.
Thirty-one patients who underwent valvular surgery were randomly divided into two comparable groups; consisting of the hypothermic cardiopulmonary bypass (28 degrees C:14 patients) and the tepid cardiopulmonary bypass group (34 degrees C:17 patients). The serum levels of nitric oxide (NO(2)(-)+NO(3)(-)), prostaglandin E(2), bradykinin, 6-keto PGF1alpha, thromboxane B(2), endothelin-1, systemic vascular resistance index were measured before, 0, 12 and 24 h after cardiopulmonary bypass.
The pattern of change in systemic vascular resistance index and nitric oxide during and after cardiopulmonary bypass were significantly different between the two groups (P=0.0008, P=0.02). The tepid group showed significantly lower levels of systemic vascular resistance index after cardiopulmonary bypass than the hypothermic group (0 h: 2278+/-735 vs. 4387+/-1289, 12 h: 1827+/-817 vs. 2817+/-1146 and 24 h: 1690+/-548 vs. 2761+/-641 dyne s cm(-5) m(2), P=0.0001, P=0.03, P=0. 0006). The nitric oxide levels were significantly higher at 0, 12 and 24 h after cardiopulmonary bypass in the tepid group than those in the hypothermic group (84.7+/-33.3 vs. 46.3+/-18.1, 69.8+/-31.1 vs. 40.1+/-17.5 and 80.1+/-38.5 vs. 39.1+/-15.6 micromol/l, P=0.008, P=0.03, P=0.01). The prostaglandin E(2) levels in the tepid group was significantly higher just after cardiopulmonary bypass than that in the hypothermic group (37.3+/-20.0 vs. 15.8+/-8.6 pg/ml, P=0.02). The bradykinin level in the hypothermic group was significantly higher just after cardiopulmonary bypass than that in the tepid group (2.40+/-0.32 vs. 1.85+/-0.21 log(10) (pg/ml), P=0.005). Only nitric oxide showed a significant negative correlation with the systemic vascular resistance index both during and after cardiopulmonary bypass (r=-0.60, P<0.0001) as compared with prostaglandin E(2) and bradykinin.
These findings demonstrated that serum nitric oxide levels in tepid cardiopulmonary bypass were significantly higher than those in hypothermic cardiopulmonary bypass. Nitric oxide correlated with systemic vascular resistance. Thus, nitric oxide may play a pivotal role in a temperature dependent regulation of systemic vascular resistance in cardiopulmonary bypass.
European Journal of Cardio-Thoracic Surgery 10/2000; 18(3):342-7. · 2.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: We assessed the appropriate length of an elephant trunk prosthesis based on our experience with 9 patients experiencing extensive thoracic aneurysms. There were 3 patients with a true aneurysm, 5 patients with a dissecting aortic aneurysm, and 1 patient with a true plus dissecting aortic aneurysm. The subjects were 4 men and 5 women and, at the time of operation, were from 38 to 74 years old. The second-stage operations were performed on 6 patients from 9 days to 6 months after the first-stage operation. In the first-stage operation, one patient died of pneumonia during the hospital stay and another died of multi-organ infarction after 15 months. In the second-stage operation, two patients died of brain hemorrhage in the chronic stage after the operation. The length of the elephant trunk prosthesis was 3 cm in the three early patients, and in one of them the elephant trunk could not be utilized due to its insufficient length. In the next three patients, the length was extended to 5 cm, but one of patient experienced an expansion of the aneurysm in the descending aorta due to a graft of insufficient length which could not decompress the aneurysmal wall. Therefore, in the last three patients, the length was further extended to 10 cm, and the second-stage operation was performed uneventfully on the 64th, 9th and 45th day, respectively after the first-stage operation within a continuous hospital stay. Neither expansion of the aneurysm nor thromboembolism was found during the waiting period for any of the second-stage operations. Accordingly, we recommend using a 10 cm elephant trunk prosthesis.
The Japanese Journal of Thoracic and Cardiovascular Surgery 01/2000; 47(12):607-10.
[show abstract][hide abstract] ABSTRACT: To clarify the mechanisms of structural changes underlying vein graft stenosis that limits efficacy of bypass grafting operation, we examined the accumulation and distribution of various extracellular matrix (ECM) components during neointima formation in rabbit vein grafts and analyzed their correlation with proliferation and phenotypic modulation of smooth muscle cells (SMCs).
An autologous external jugular vein graft was transplanted into the carotid artery in 25 rabbits. After the restoration of blood flow, the graft was markedly dilated. Medial SMCs in the graft appeared to be injured, and they began to proliferate at day 4 and subsequently migrated and formed the neointima at day 7. The neointima observed at days 7 and 14 contained ECM components, including type I collagen, heparan sulfate, and chondroitin sulfate, and the intimal SMCs were phenotypically modulated from the differentiated-type (SM2-positive and SM embryonic-negative) to the dedifferentiated-type (SM2-negative and SM embryonic-positive) as determined with immunostainings for myosin heavy chain isoforms. The intimal SMC proliferation was maximal at 2 weeks and then decreased rapidly. However, the neointima continued to thicken thereafter throughout the 6-month period of the experiment, and ECM accumulation, such as type I collagen and decorin, a small dermatan sulfate proteoglycan, was a prominent feature observed in the hypocellular region of the deep intima from 2 months after the transplantation. The phenotype of the intimal SMCs gradually returned to the differentiated-type from the deep intima after 2 months, but a small number of the intimal SMCs remained in the dedifferentiated phenotype even at 6 months after the operation.
The neointima in the vein graft was formed initially by means of migration and proliferation of the phenotypically modulated, dedifferentiated-type SMCs and continued to thicken by means of sustained ECM accumulation, including type I collagen and decorin, in association with the prolonged presence of the dedifferentiated-type SMCs. These chronologic features in cell kinetics and ECM accumulation may contribute to the frequent occurrence of graft wall thickening that occurs in the vein grafts.
Journal of Vascular Surgery 08/1999; 30(1):169-83. · 2.88 Impact Factor
[show abstract][hide abstract] ABSTRACT: The administration of an ultra-short-acting beta-adrenergic antagonist, esmolol, has been introduced as a novel method for beating-heart surgery. In the present study, a new ultra-short-acting beta-blocker, ONO-1101, was administered during cardiopulmonary bypass (CPB) to investigate its effects on cardiac function and hemodynamics. Nine adult mongrel dogs underwent 60 min of CPB during which they were given either ONO-1101 (ONO group; n = 4) or saline (control group; n = 5). In the ONO group, the hearts became flaccid enough for surgery to be performed without cardiac standstill within 10 min after the commencement of ONO-1101 with significant decreases in the heart rate, the preload recruitable stroke work (PRSW), and the slope of the end-systolic left ventricular pressure-volume relationship (Emax). The mean arterial pressure and systemic vascular resistance also decreased, but were maintained above 50 mmHg during CPB without catecholamine. These indices increased to the control group level 20 min after the discontinuation of ONO-1101. The serum concentration of ONO-1101 decreased from the maximum level of 121 +/- 15 microg/ml soon after infusion to 11 +/- 5 microg/ml within 30 min after discontinuation. These data suggest that ONO-1101 may be useful to enable beating-heart surgery to be performed without aortic cross-clamp as an ultra-short-acting beta-adrenergic blocker.
Surgery Today 02/1999; 29(3):248-54. · 0.96 Impact Factor
[show abstract][hide abstract] ABSTRACT: The outcome of the Fontan-type operation for complex heart disease has been significantly improved, and low morbidity and mortality rates are reported. However, some problems still occur in late follow-up, including ventricular failure, hepatic congestion, supraventricular arrhythmia, cerebrovascular events, exercise intolerance, and residual or new cardiac lesions. Reinterventions after the Fontan-type operation for complex cardiac defects in 43 patients are reviewed. In addition to catheter interventions, the main reasons for reoperation were subaortic stenosis, pulmonary artery and vein obstructions, and interatrial shunt. Early intervention, particularly for subaortic obstruction, is recommended, and the Damus-Kay--Stansel anastomosis appears to be the procedure of choice. Reoperation was required in 6 of the 43 patients, with one operative death. The total event-free survival rate after 10 years of follow-up was 53%. The need for reoperation appears to be reduced after performing the total cavopulmonary shunt procedure compared to that after atriopulmonary connection. However, late arrhythmia remains a significant problem in this group of patients, and further assessment of the results of reintervention for arrhythmia is required.
[show abstract][hide abstract] ABSTRACT: It is still difficult to evaluate myocardial damage in the acute phase of reperfusion in cardiac operations. We investigated the clinical significance of human heart fatty acid-binding protein (HH-FABP) for detecting myocardial damage after cardiac operations earlier than creatine kinase MB isoform or troponin-T.
Blood samples from 20 patients who underwent coronary artery bypass grafting were collected serially after reperfusion to measure serum levels of creatine kinase-MB, troponin-T, and HH-FABP.
Serum HH-FABP levels peaked earliest after reperfusion. In addition, the maximum serum HH-FABP level was predictable immediately after reperfusion. The maximum serum HH-FABP level correlated with the maximum serum creatine kinase-MB or troponin-T level, as well as with the aortic cross-clamp time or the maximum dose of catecholamines administered after reperfusion.
Measurements of HH-FABP allow for earlier evaluation of myocardial damage in the acute phase of reperfusion. Human heart fatty acid-binding protein may be a useful indicator of myocardial damage after cardiac operations.
The Annals of Thoracic Surgery 02/1998; 65(1):54-8. · 3.45 Impact Factor
[show abstract][hide abstract] ABSTRACT: NFkappaB, an important transcriptional factor, has been reported to play a significant role in the coordinated transcription of cytokine and adhesion molecule genes. Therefore, blocking the NFkappaB may attenuate ischemia reperfusion injury in the myocardium. For blocking transcriptional factors, gene therapy, such as cis element "decoy," appears to be an innovative and useful therapy. This study aimed to prove the efficacy of cis element decoy against NFkappaB binding site for myocardial protection.
Rat hearts were transfected with fluorescence isothiocyanate-labeled cis element decoy against NFkappaB (NF)-binding site (NF group, n=6) and scrambled decoy (SD) group (n=6) by coronary infusion of hemagglutinating virus of Japan (HVJ)-liposome during cardioplegic arrest. Both the NF and SD groups showed marked FITC-staining in the nuclei of myocytes, demonstrating the efficacy of gene transfer into the nuclei of cardiac myocytes as compared with the control group transfected with empty liposomes. After 3 days of transfection, the NF group showed significantly higher percentages of recovery of left ventricular developed pressure (NF versus SD, 87+/-11 versus 54+/-12%) and coronary flow (97+/-16 versus 61+/-15%) than did the control hearts when exposed to ischemia (30 minutes, 37 degrees C) and reperfusion (30 minutes, 37 degrees C). The NF group showed a significantly lower percentage of neutrophil adherence to endothelial cells (38+/-6 versus 81+/-3%) and a lower tissue level of interleukin-8 (109+/-48 versus 210+/-55 ng/mg) than did the SD group.
The hearts transfected with cis element decoy against NFkappaB binding site showed significant improvement in tolerance against ischemia-reperfusion injury in association with the inhibition of neutrophil adherence and tissue IL-8 production. This suggests that NFkappaB plays a significant role in ischemia-reperfusion injury. This method, using in vivo gene transfection of cis element decoy against NFkappaB binding site, appears to be a novel and future strategy for myocardial protection.
[show abstract][hide abstract] ABSTRACT: Arterial aneurysms are very rare in children, especially those who have no history of cardiac or vascular malformation, connective tissue disorder, or trauma. We describe a 3-year-old boy who had multiple arterial aneurysms of the left external iliac artery with a maximal diameter of 67 mm, with no history of these disorders. The iliac artery distal to the aneurysm and superficial femoral artery were occluded causing the growth disturbances of his left leg. He underwent graft replacement of the left iliac artery using a ringed Gore-Tex graft (6 mm in diameter). Postoperative angiogram showed a patent graft without any residual aneurysm in the left iliac artery. His ankleibrachial index improve from 0.2 to 0.6 after surgery.
Journal of Pediatric Surgery 11/1997; 32(10):1519-21. · 1.38 Impact Factor
[show abstract][hide abstract] ABSTRACT: We evaluated the usefulness of noninvasive hemodynamic assessment of internal thoracic artery grafts (ITAGs) using duplex Doppler echocardiography from the supraclavicular fossa (transcutaneous pulsed Doppler method: PD method). Eighteen ITAGs were examined by PD method in comparison with Doppler catheter method using Doppler flowire (DC method). The hemodynamic indices used were the diastolic/systolic peak velocity ratio (DSVR) and the diastolic fraction of time-velocity integral (DF) in the ITAGs. A significant linear correlation was seen both in DSVR and DF between these two methods (p < 0.01). The subjects were assigned to two groups according to angiographic findings Group A (Gr-A: 5 grafts) with string sign including significant graft stenosis and group B (Gr-B 13 grafts) with good patency. In both PD and DC methods, DSVR and DF were significantly lower in Gr-A than in Gr-B (p < 0.01). The blood flow pattern was thus systolic dominant in the grafts with string sign, while it was diastolic dominant in the grafts with good patency. In some grafts in Gr-B, however, both DSVR ad DF were as low as that in Gr-A. Responding to pacing, Gr-B further increased both DSVR and DF, but Gr-A did not. As a result, the difference between both groups was further distinguished. In summary, ITAG function can be assessed by the noninvasive PD method. Interventions such as exercise, dobutamine infusion may make it more accurate, particularly in evaluating borderline data.
[show abstract][hide abstract] ABSTRACT: Cardiopulmonary bypass (CPB) causes inflammatory reactions and abnormal responses of vascular resistance. Theoretically, the difference in the blood temperature during CPB may influence the degree of CPB-induced inflammatory reactions.
To elucidate the effect of the perfusate temperature during CPB, serum levels of inflammatory cytokines, neutrophil elastase, complements, and vasoactive substances were measured in 18 patients undergoing elective coronary artery bypass grafting under tepid temperature (34 degrees C) and moderate hypothermia (28 degrees C). Respiratory index and systemic vascular resistance index during and after CPB and intubation time after postoperative course were also analyzed.
The patterns of the change in interleukin-8 and neutrophil elastase were significantly different between the two groups. The tepid group showed an earlier decrease in interleukin-8 and neutrophil elastase levels as compared with the hypothermic group. The prostaglandin E2 level just after CPB was significantly higher in the tepid group than in the hypothermic group. Systemic vascular resistance index and respiratory index and intubation time were significantly lower in the tepid group than in the hypothermic group.
These results demonstrated that tepid CPB affected the inflammatory cytokine release and neutrophil activation compared with hypothermic CPB, resulting in the attenuation of respiratory dysfunction. This may suggest a beneficial effect of tepid temperature in CPB with possible attenuation of the postperfusion syndrome.
The Annals of Thoracic Surgery 08/1997; 64(1):124-8. · 3.45 Impact Factor
[show abstract][hide abstract] ABSTRACT: In this study, we evaluated the biocompatibility of heparin-coated circuits in pediatric cardiopulmonary bypass (CPB). Eight patients were divided into 2 groups: the control group (Group C) and heparin-coated group (Group H). In Group H, CPB circuits, including the arterial pump, oxygenator, and cannulas were heparin-coated. Before, during, and after CPB, blood samples were obtained to assess the platelet counts (Plat), alpha 2-plasmin plasminogen inhibitor complex (PIC), thrombin-antithrombin III complex (TAT), C3 activation products (C3a), interleukin (IL)-6, IL-8, and polymorphonuclear neutrophil leukocyte (PMN) elastase. There was no significant difference in Plat, PIC, or TAT between groups. Group H showed significantly low levels of C3a (during and after CPB), PMN elastase (during CPB), and IL-6 (after CPB). These data demonstrated that in pediatric CPB, heparin-coated CPB circuits reduced the activation of complements and the production of PMN elastase and IL-6, suggesting the superior biocompatibility of the heparin-coated circuits.
[show abstract][hide abstract] ABSTRACT: Late rupture of the left ventricle after repeat MVR was successfully repaired by patch closure through the right atrium. We recommend early elective repair of such lesions before cardiac function is compromised.
European Journal of Cardio-Thoracic Surgery 06/1997; 11(5):991-3. · 2.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: We report the surgical treatment of a rare case of true aortic aneurysm in a right-sided aortic arch. A 49-year-old female patient with obstructive respiratory problems demonstrated a true aneurysm with a diameter of 58 mm located at the right-sided aortic arch between the right carotid artery and right subclavian artery. Surgery was successfully performed by replacing the arch including the aneurysm with a prosthetic graft. The positions of true aneurysms in the right-sided aortic arch can be divided into two subtypes: first, the transverse arch between the right carotid artery and right subclavian artery, and second, the base of the subclavian artery, the Kommerell's diverticulum. The region is informative for consideration of the surgical approach toward aneurysms of this entity.
Journal of Vascular Surgery 06/1997; 25(5):941-4. · 2.88 Impact Factor
[show abstract][hide abstract] ABSTRACT: A 54-year-old man with AR due to AAE underwent the replacement of ascending aorta by sparing an aortic valve (David operation). Under cardiopulmonary bypass, the aneurysmal aorta and the all three sinuses of valsalva were excised, leaving 5 mm of arterial wall attached to the aortic valve. The aortic valve was reimplanted inside a Dacron graft (28 mm Hemashield) which was calculated by aortic valve leaflet height as well as from the size of LVOT. The patient has survived the operative procedure and showed uneventful recovery. We believe this new procedure preserving the native aortic valve is useful for preventing from some complications associated with an artificial heart valve and improvement of QOL of patient.
[show abstract][hide abstract] ABSTRACT: To confirm gene transfer techniques especially into the whole heart, we tried out a gene transfer method involving liposome with the viral envelope hemagglutinating virus of Japan liposome as an alternative to existing techniques such as cationic lipofection or other viral vectors.
For this study, hemagglutinating virus of Japan liposome (H group) or cationic liposome (L group) was used to compare the efficacy of gene transfection of oligonucleotide labeled with fluorescein isothiocyanate and cDNA of beta-galactosidase and human manganese-superoxide dismutase. Fluorescein-labeled oligonucleotide, cDNA of beta-galactosidase, or manganese-superoxide dismutase was complexed with liposomes, DNA-binding nuclear protein, and the viral protein coat of hemagglutinating virus of Japan. After donor rat hearts arrested by cardioplegia had been harvested, the coronary artery during cardioplegic arrest was infused via an aortic cannula with the liposome-gene complex. Next, the hearts were transplanted into the abdomen of recipient rats of the same strain, and all recipients were put to death after 3 days of transfection.
Fluorescein isothiocyanate was detected in the nuclei of more than 70% of the myocytes (75% +/- 14%, n = 5) in the H group compared with fewer than 10% in the L group (7% +/- 5%, n = 5). The intensity of fluorescein isothiocyanate was significantly higher in the H group (979 +/- 112 FI) than in the L group (116 +/- 68 FI). beta-Galactosidase was expressed in the cytosol of more than 50% of the myocytes in the H group (61% +/- 7%, n = 5) compared with none in the L group (0%, n = 5). After 3 days of gene transfection, and when exposed to ischemia (30 minutes, 37 degrees C) and reperfusion (30 minutes, 37 degrees C) with Langendorff apparatus, the hearts transfected with manganese-superoxide dismutase (S group, n = 5) showed a significantly higher percentage of recovery of left ventricular end-diastolic pressure (S vs C, 86% +/- 3% vs 54% +/- 12%) and coronary flow (98% +/- 2% vs 66% +/- 12%) than did the control hearts (C group, n = 5). Western blotting analysis showed an apparent increased expression of manganese-superoxide dismutase in the hearts transfected with manganese-superoxide dismutase compared with the control hearts. These results clearly demonstrated that the donor hearts were transfected with fluorescein-labeled oligonucleotide and the beta-galactosidase gene as a result of coronary infusion of the hemagglutinating virus of Japan liposome during cardioplegic arrest at the time of harvest. Furthermore, the hearts transfected with manganese-superoxide dismutase showed significant improvement in tolerance against ischemia reperfusion injury.
We believe that this method represents a novel in vivo gene transfer technique for the heart and thus may provide a new tool for research and therapy of heart transplantation.
Journal of Thoracic and Cardiovascular Surgery 04/1997; 113(3):512-8; discussion 518-9. · 3.53 Impact Factor
[show abstract][hide abstract] ABSTRACT: Mitral annuloplasty has long been considered as the basic procedure for mitral regurgitation (MR). However, it is increasingly advisable to avoid foreign material and to use a method that provides greater adjustment for control of annular size. In this study, the semicircular suture annuloplasty (Paneth-Burr method) was evaluated for its efficacy and durability; the optimum size of the mitral annulus was also assessed.
The Paneth-Burr method was modified using Gore-Tex suture, a crossing suture technique, and obturator for temporary annulus size adjustment. Between 1992 and 1994, 21 patients with an average age of 45 years (range: 8 months to 67 years) underwent such annuloplasty combined with various valvuloplasties and chordal reconstruction. The etiologies were degenerative in 11 patients, congenital in five, ischemic in three and endocarditis in two.
Mean MR grades (0-4) decreased from 3.3 +/- 0.6 to 0.2 +/- 0.4 after surgery. At an average 24 months follow up (range: 12 to 41 months), 16 patients showed no increase in MR, but five showed increased MR grades (all grade 3 or less: three grade 3 and two grade 2). Only one patient with ischemic MR required reoperation. Patients with increased MR grade during follow up had a larger intraoperative annular size (> 90% of normal), while those with < 90% of normal mitral annular size showed no increase in MR beyond grade 2, except one with ischemic etiology.
A measured semicircular suture annuloplasty appears to be useful for MR, with acceptable efficacy and durability. In addition, the annular size to be adjusted at surgery is proposed to be < or = 90% of normal mitral annular diameter.
The Journal of heart valve disease 01/1997; 6(1):48-53. · 1.07 Impact Factor
[show abstract][hide abstract] ABSTRACT: The key to the successful implantation of a left ventricular assist system (LVAS) for patients with end stage cardiac disease is whether the functions of other vital organs are irreversibly damaged or not. The portable cardiopulmonary support system (PCPS) is not only as convenient as, but is more powerful than, the intra-aortic balloon pump (IABP) in resuscitating impaired end organ function. To investigate the efficacy of PCPS in end stage cardiac disease, end organ function before and after the application of PCPS was retrospectively analyzed for end stage cardiac disease. From 1992 to 1996, five cardiomyopathy patients with deterioration in end organ function, despite application of IABP, underwent PCPS support before implantation of LVAS. Urine volume and levels of liver enzymes (sAST and sALT) and serum creatinine were determined before and after institution of PCPS. After the start of PCPS, the urine output increased significantly (1,840 +/- 450-4,340 +/- 470 ml/day, p < 0.01), and levels of sAST, sALT, and serum creatinine decreased significantly (630 +/- 220-150 +/- 50 IU/L, 630 +/- 260-260 +/- 130 IU/L, and 2.9 +/- 0.5-1.2 +/- 0.1 mg/dl, respectively; p < 0.05). All five patients were successfully bridged to LVAS implantation, and none died of multiple organ failure caused by pre-existing cardiac failure. These results indicate that PCPS before LVAS implantation is useful in resuscitating impaired end organ function and improving the survival rate with LVAS implantation for end stage cardiac disease.