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ABSTRACT: OBJECTIVES: This study sought to evaluate thoracoscopic stand-alone left atrial appendectomy for thromboembolism prevention in nonvalvular atrial fibrillation (AF). BACKGROUND: Closing the left atrial appendage (LAA) is an efficacious alternative to oral anticoagulation as prevention against AF-induced thromboembolism, provided that the procedure is safe and complete. METHODS: Thirty patients (mean age, 74 ± 5.0 years) who had had thromboembolisms were selected. A subgroup of 21 patients (mean age, 75 years; mean CHA(2)DS(2) VASc score, 4.5) urgently needed an alternative treatment to anticoagulation: warfarin was contraindicated due to hemorrhagic side effects in 13, the international normalized ratio was uncontrollable in 7, and transient ischemic attacks had developed immediately after the warfarin dose was reduced for oncological treatment in 1. The LAA was thoracoscopically excised with an endoscopic cutter. RESULTS: Thoracoscopic appendectomy (mean operating time, 32 min, switched to mini-thoracotomy in 2 cases) led to no mortality and no major complications. Three-month post-operative 3-dimensional enhanced computed tomography, performed with patients' consent, confirmed the completeness of the appendectomy. Patients have been followed for 1 to 38 months (mean, 16 ± 9.7 months [18 ± 9.4 months for the subgroup]). One patient died of breast cancer 28 months after surgery. Despite discontinued anticoagulation, no patients have experienced recurrence of thromboembolism. CONCLUSIONS: Thoracoscopic stand-alone appendectomy is potentially safe and may allow surgeons to achieve relatively simple, complete LAA closure. Further experience may demonstrate this technique to be a viable option for thromboembolism prevention in nonvalvular AF.
Journal of the American College of Cardiology 02/2013; · 14.16 Impact Factor
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ABSTRACT: A 41-year-old man with sudden onset of chest oppression and downslope ST depression was diagnosed as having typeA aortic
dissection with angina pectoris and aortic regurgitation. Intraoperative transesophageal echocardiogram (TEE) showed intimal
flap inverting into the left ventricle through the aortic valve. This case was rare in that transient myocardial ischemia
was induced not by dissection of the aortic root reaching the coronary ostia but by back-and-forth movement of the intimal
flap, covering the coronary ostia and interrupting the coronary artery flow. TEE was important for correct diagnosis.
KeywordsTypeA aortic dissection–Transient myocardial ischemia–Intimal flap inverting into the left ventricle–Transthoracic echocardiogram
Journal of Echocardiography 04/2012; 9(3):112-114.
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Kyobu geka. The Japanese journal of thoracic surgery 04/2011; 64(4):339-40.
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ABSTRACT: : A pedicled prepericardial fat flap was created to augment the pericardial cavity and applied for patients undergoing coronary artery bypass grafting. The efficacy and durability of this method were investigated.
: Between July 2005 and November 2008, the present technique was applied for consecutive 245 patients (165 men and 80 women, aged 67 ± 8.3 years) undergoing isolated coronary artery bypass grafting in which 240 (98.0%) were off-pump cases. The left and/or right internal thoracic artery and the gastroepiploic artery were used in 244 and 160 patients, respectively, and the saphenous vein and the radial artery were used in 51 and 10 patients, respectively. Ninety-seven (40.0%) patients had been diabetic, 18 (7.3%) had had chronic renal failure, and three were redo cases. The prepericardial soft tissue, involving the pedicled thymic gland, was dissected en bloc and sewn with pericardiotomies to wrap the heart and the grafts. Angiography or three-dimensional computed tomography was used to assess the intrapericardial pathways of each graft and a long-term durability of the fat pad.
: Early angiography or three-dimensional computed tomography proved that the graft pathways were unaffected by the encasements. Resternotomies in two patients and sternal treatments for infectious dehiscence in two patients were safely achievable. Five-year postoperative computed tomography showed the intact fat pad in the retrosternal space.
: The present technique can encase the heart not the least jeopardizing each pathway of the grafts, and the durable fat pad functions protectively when the sternotomy is either reopened or infected.
Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery 07/2009; 4(4):206-8.
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ABSTRACT: Although it is well known that valvular lesions show changes in stiffness, this fact has not been studied objectively or quantitatively.
Using a tactile sensor, stiffness of the mitral valve was measured at 11 autopsies and 19 surgically excised specimens. The relationships between stiffness and histological state were investigated in 394 points of resected specimens.
In normal mitral valves, the anterior leaflet was significantly stiffer than the posterior leaflet in all zones. The rough zone had the least stiffness in both leaflets. Mitral stenotic valves were significantly stiffer than normal in all zones, the rough zone had the greatest stiffness. The grade of fibrosis (r=0.862), hyalinosis (r=0.783), and calcification (r=0.464) had positive correlation with the stiffness, respectively. An S score that was composed of these three factors had strong positive correlation (r=0.935). The regression equation was: stiffness=2.882+2.304xS score (r(2)=0.88). With cut-off values of 8 g/cm for severe fibrosis, 10 for focal hyalinosis, 13 for diffuse hyalinosis, 15 for mild calcification and 18 for massive calcification, these changes were accurately (>90%) detected. The grade of myxoid change had mild negative correlation with the stiffness (r=-0.507).
The actual value of stiffness of normal and abnormal mitral valves and the relationships between stiffness and histological changes were obtained. A tactile sensor promptly and accurately shows stiffness of the heart valve indicating its histological state. It can be a useful device for cardiovascular surgery.
Annals of thoracic and cardiovascular surgery: official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia 06/2007; 13(3):178-84. · 0.69 Impact Factor
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ABSTRACT: We employed the Laparolift and Laparofan (Origin Medsystems Inc., CA, USA) and developed a sternum lifting technique to create a sufficient intra-pleural space between the heart and the sternum in which the left internal thoracic artery (ITA) in situ graft could be thoracoscopically mobilized. Between June and December 2004, this technique was applied to 12 consecutive patients (eight men, four women, aged 68.5+/-9.6 years) undergoing minimally invasive coronary artery bypass grafting via a left mini-thoracotomy. The Laparofan, connected to the arm of the lift machine (Laparolift), was introduced through a subxyphoidal entry and opened beneath the sternum. The sternum was elevated by about 5 cm until a sufficient working space was created under the sternum. With left hemipulmonary collapse, the left ITA was thoracoscopically taken down through the axillary ports. There was no procedural conversion to direct harvesting. The mean thoracoscopic harvesting time was 34.5+/-7.7 min. There was no mortality and no instrument-related morbidities. Patency of each ITA graft was angiographically confirmed. In conclusion, despite the limited experience, the present sternum elevation technique using the Laparolift system is a viable method for increasing the intra-pleural working space beneath the sternum during thoracoscopic ITA harvesting.
European Journal of Cardio-Thoracic Surgery 07/2005; 27(6):1119-21. · 2.55 Impact Factor
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ABSTRACT: Traumatic chylothorax is a serious morbidity due to aortic surgery. We treated this complication successfully by supradiaphragmatic thoracic-duct division in five adults (three men, two women, aged 61.5+/-19.5 years) and a 3-year-old male infant after an average interval of 4.1+/-1.8 days following initial aortic surgery: graft-replacement of subclavian or descending aortic aneurysm in the adults, and correction of aortic coarctation in the infant. A right thoracoscopic approach was used in the adults and the left thoracotomy was re-used in the infant. Individual exposure and division of the thoracic duct was accomplished using an ultrasonic coagulator. The operating time was 22+/-5.5 min for the thoracoscopy cases, and 70 min for the infant. There was no mortality and no procedure-related morbidity, and chylous leakage ceased immediately in all patients. There was no recurrence of chylothorax during a mean follow-up period of 17+/-9.7 months. Despite our limited experience, we conclude that the present supradiaphragmatic thoracic duct division technique (right thoracoscopy in adults) is safe and perfectly effective, and therefore prompt application of this method is recommendable for treatment of aortic surgery-related traumatic chylo-leakage, particularly in vulnerable elderly or infant patients.
European Journal of Cardio-Thoracic Surgery 02/2005; 27(1):153-5. · 2.55 Impact Factor
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ABSTRACT: We have been using a mini-thoracotomy localization technique before re-operative minimally invasive direct coronary artery bypass (MIDCAB) to the left anterior descending artery (LAD). This technique was performed during the diagnostic laboratory catheter study, in which the skin portion was marked just above the target LAD site, observing the enhanced LAD by fluoroscopy. In nine patients, a 3-4-cm mini-entry was made by referring to the marked position, the LAD was identified in the minimally dissected epicardium, and anastomoses were performed using the vein in six cases, the left internal thoracic artery in two, and the right gastroepiploic artery in one.
Interactive cardiovascular and thoracic surgery 01/2005; 3(4):551-3.
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ABSTRACT: : A modified maze procedure in which trans-septal cardioscopy was used for cryoablation in the left atrium is described.
: The technique was used in 11 consecutive patients (9 men and 2 women, 56.5 ± 19.8 years) with permanent atrial fibrillation (Af) and concomitant nonmitral cardiac or aortic disease: aortic valvular disease in 4 patients, atrial septal defect (ASD) in 2 patients, tricuspid regurgitation in 2 patients, acute aortic dissection in 1 patient, arch aneurysm in 1 patient, and coronary artery disease in 1 patient. The mean Af duration detected in 7 cases was 18.5 ± 10.1 months. Partial sternotomy was used in aortic valve replacement, ASD closure, and tricuspid valve plasty, and fullsternotomy was used in aortic graft replacement and coronary artery bypass. Cardiopulmonary bypass was established, aortic cross-clamp was performed, a right atriotomy was created, a cryoablation probe and cardioscope (3 mm) were introduced into the left atrium through a 1-cm cut at the fossa ovalis or ASD, and cardioscopic left-atrial endocardial cryoablation was performed. The right-side maze procedure was conducted directly. The atrial appendages were excised in each case.
: Left-atrial cardioscopic cryoablation required 25.0 ± 5.5 minutes, and no deaths or procedure-related morbidities occurred. The mean follow-up period was 12 ± 8.5 months. One patient with tricuspid regurgitation died of liver failure. With the exception of coronary and acute dissection cases, all patients have maintained a sinus rhythm.
: Although experience is limited, videocardioscopic trans-septal left-atrial cryoablation is a viable method for nonmitral Af cases, and the partial sternotomy approach can be performed.
Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery 01/2005; 1(1):48-50.
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ABSTRACT: After it was shown that a rapidly firing focus in a pulmonary vein (PV) can cause atrial fibrillation, percutaneous endocardial PV isolation using radiofrequency began to be used as a method of treatment. However, this technique is time consuming. It requires fluoroscopy and contrast media to identify the PV, and cardiac tamponade and PV obstruction are major complications. To overcome these drawbacks, we developed a hook-shaped cryoprobe to enable circumferential ablation of PV orifices epicardially. The aim of this experimental study in dogs was to confirm the efficacy of this method electrophysiologically.
Five mongrel dogs (32 PVs) were used. Surrounding tissue was dissected to expose all PVs and their orifices into the left atrium. Each PV was stimulated with an electrode to measure the length of PV which has the same pacing threshold as the left atrium.
The mean distance from the PV orifice to the pacing boundary line was 8.9 +/- 1.3 mm. Encircling cryoablation was performed with a hook-shaped cryoprobe to circumferentially ablate each PV orifice epicardially.
Cryoablation by this method created a bidirectional conduction block in all PVs. All PVs were electrically isolated, and the PV isolation was achieved epicardially without atriotomy. This method should enable less invasive treatment of AF clinically.
The Annals of thoracic surgery 10/2004; 78(3):1056-9. · 3.74 Impact Factor
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Journal of Thoracic and Cardiovascular Surgery 06/2004; 127(5):1525-7. · 3.41 Impact Factor
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ABSTRACT: This article describes our clinical experience with a new needle driver (Olympus, Tokyo, Japan), which we have produced to facilitate minithoracotomy or port-access coronary artery anastomosis with the running suture technique.
The needle driver is 21 cm long, weighs 38 g, and has a grip shaft 1.4 cm in diameter. The device is held like a pencil. A side lever and a revolving disk in the shaft are manipulated with the fingers; a fine needle with a 7-0/8-0 monofilament suture can be grasped/released and driven to penetrate the coronary arterial wall. This device was employed in 10 consecutive patients (8 men, 2 women, 73 +/- 7.5 years old), and off-pump bypass to the left anterior descending artery was achieved using the left internal thoracic artery or vein via a minithoracotomy (4.2 +/- 0.6 cm long).
There was no instrument-related injury during each anastomosis. The mean sewing time per anastomosis was 12 minutes (range, 8-18 minutes). Angiography confirmed the patency of the graft in all cases.
Although our experience is limited, we consider the present needle driver to be a viable device for facilitating off-pump, minientry coronary artery anastomosis with the suturing technique.
Heart Surgery Forum 02/2004; 7(6):E559-61. · 0.63 Impact Factor
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ABSTRACT: In minimally invasive coronary artery bypass (MICAB), a video-assisted needle-guided technique was used to make a mini-thoracotomy or an access-port just above the target site in the left anterior descending coronary artery (LAD). After thoracoscopic preparation of the left internal thoracic artery (LITA) and pericardiotomy, a 7-cm, 23-gauge needle was used to examine the skin-point where the needle vertically penetrated the chest wall and thoracoscopically indicated the target site in the LAD. This point was used as the mid-point of the skin incision for a 6-cm thoracotomy (six cases) or a 33-mm access-port (four cases). Consequently, there was no conversion of approach except in the patient with pulmonary dysfunction, and each LITA-LAD anastomosis was completed directly through the mini-entry. There was no mortality and no procedure-related morbidity. Patency of each graft was confirmed within a week after surgery. After a mean follow-up period of 12.5+/-7.8 months, all of the patients except one, who died of stroke 1 year after surgery, are alive with no ischemic events. Although our experience is limited, the present video-assisted needle-guided technique can be a simple method to facilitate appropriate positioning of a mini-entry in MICAB to the LAD with a thoracoscopically prepared LITA graft.
European Journal of Cardio-Thoracic Surgery 11/2003; 24(4):644-6. · 2.55 Impact Factor
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Journal of Thoracic and Cardiovascular Surgery 10/2003; 126(3):904-5. · 3.41 Impact Factor
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ABSTRACT: This report describes a 60-year-old male patient who developed early valvular obliteration of a cryopreserved aortic valve allograft with associated severe valvular leakage. The patient had previously undergone two operations for aortic valve insufficiency resulting from infective endocarditis, and prosthetic valve endocarditis: aortic valve replacement with a mechanical prosthesis was done 4 years ago, and two years later aortic root replacement with a cryopreserved allograft was performed. Perforation through the non-coronary cusp of the aortic allograft was found, and valve replacement was achieved using a mechanical prosthesis. The intraoperative findings, histological, immunological, and bacteriological studies of the resected cusps demonstrated negative for infection and rejection, therefore, the valvular perforation might have been caused by an injury or degeneration during management of the homologous graft. The patient showed neither aortic regurgitation on echocardiography nor recurrence of endocarditis 10 months after surgery.
The Japanese Journal of Thoracic and Cardiovascular Surgery 09/2003; 51(8):384-6.
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Journal of Thoracic and Cardiovascular Surgery 07/2003; 125(6):1537-8. · 3.41 Impact Factor
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ABSTRACT: Left atrial dissection, a rare complication occurring mainly after mitral repair, is reported after double valve replacement in a patient with a connective tissue disease. A 63-year-old woman with systemic sclerosis underwent double valve replacement. Laceration of the tissue between the two mechanical prostheses and dissection of the left atrial wall emerged postoperatively and regurgitation through the dissection caused heart failure, which later improved without surgery. The possible causes of the dissection were thought to be shear forces against the tissue between the two prostheses and tissue fragility due to systemic sclerosis and corticosteroid therapy.
The Annals of Thoracic Surgery 03/2003; 75(2):584-6. · 3.74 Impact Factor
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ABSTRACT: Since Haïssagere and colleagues reported that a rapid firing focus in or close to the pulmonary veins could be the cause of atrial fibrillation, a transcutaneous catheter technique directed at isolating these foci has been developed. How should patients with nonvalvular atrial fibrillation who require cardiac operation be managed? We developed an epicardial technique that uses cryoablation to isolate the left atrial posterior wall and pulmonary veins and used it to treat a patient. Because cryoablation is achieved epicardially, the technique does not require atriotomy and does not prolong aortic cross-clamp time. Isolation of the left atrium was confirmed by electrophyscologic studies, and the patient remains in sinus rhythm 16 months after operation. This concomitant procedure allows treatment of patients with nonvalvular atrial fibrillation.
The Annals of Thoracic Surgery 03/2003; 75(2):590-3. · 3.74 Impact Factor
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ABSTRACT: We assessed the feasibility of beating atrial septal defect (ASD) closure monitored by real-time 3D echocardiography (RT3DE).
RT3DE was developed with prototype ultrasound equipment consisting of a high-speed 3D rendering unit with a frame rate of 5 to 10 frames/s. We also developed a prototype semiautomatic suture device and suture cutting system. In the experiment, 12 mongrel dogs were anesthetized, and after median sternotomy, the echo probe was applied directly to the surface of the right atrium. Three surgical maneuvers (balloon atrial septectomy, enlargement of the ASD, and ASD closure) were performed through the atrial port inserted into the right atrial appendage. The heart was then excised, and the area of the ASD measured by RT3DE was compared with its area measured directly. The ASD was successfully closed in all experimental animals except the first 2. Examination of the excised heart showed that none of the sutures were loose. The mean area of the ASD was 82.5+/-38.6 mm(2) when measured by RT3DE and 81.6+/-38.2 mm(2) when measured directly, and there was a significant correlation between the areas measured by RT3DE and those measured directly (echo measurements=1.007xdirect measurements+0.337; P<0.0001). A Bland-Altman analysis revealed close agreement between the results obtained by the 2 methods (7.807 mm(2) upper and -6.024 mm(2) lower limit of agreement).
Introduction of RT3DE, a semiautomatic suture device, and a suture cutting system made beating ASD closure without cardiopulmonary bypass possible.
Circulation 02/2003; 107(5):785-90. · 14.74 Impact Factor
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ABSTRACT: A successfully-treated case of graft infection after thoracoabdominal aortic repair is reported. A 61-year-old male underwent graft replacement of a Crawford type IV thoracoabdominal aortic aneurysm and developed graft infection due to methicillin-resistant Staphylococcus aureus. After 35 days' open retroperitoneal irrigation, the culture around the graft turned negative, and omental transposition and skin flap transfer were successfully conducted. The long-term open retroperitoneal irrigation could be conducted without significant complications, and it was very effective in controlling the severe infection.
The Japanese Journal of Thoracic and Cardiovascular Surgery 02/2003; 51(1):37-40.
