[Show abstract][Hide abstract] ABSTRACT: Surgical site infection (SSI), particularly deep sternal wound infection (DSWI), is a serious complication after cardiovascular surgery because of its high mortality rate. We evaluated the effectiveness of an SSI bundle to reduce DSWI and identify the risk factors for DSWI.
During the period January 2004 to February 2012, 1374 consecutive patients undergoing cardiovascular surgery via sternotomy were included. The cohort was separated into periods from January 2004 through February 2007 (period I, 682 patients) and March 2007 through February 2012 (period II, 692 patients). During period II, all preventive measures for DSWI were completed as an SSI bundle. We compared the DSWI rate between the 2 periods. Univariate and multivariate analyses were performed for the entire period to identify the risk factors for DSWI.
DSWI occurred in 13 patients (1.9%) during period I and in 1 patient (0.14%) during period II. The DSWI rate during period II was significantly decreased by 93%, compared with period I (P = .001). Independent risk factors for DSWI included obesity (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.00-11.75; P = .049), the use of 4 sternal wires (OR, 8.2; 95% CI, 1.39-48.14; P = .020), long operative time (OR, 4.4; 95% CI, 1.20-16.23; P = .026), and postoperative renal failure (OR, 9.0; 95% CI, 2.44-33.30; P = .001).
Complete implementation of simple multidisciplinary prevention measures as a bundle can greatly decrease the incidence of DSWI.
Full-text · Article · Apr 2014 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: Background:
The efficacy of retrograde cardioplegia for myocardial protection is still controversial. In our institution, we exclusively use intermittent administration of tepid, undiluted blood supplemented with potassium and magnesium for the cases with aortic insufficiency, requiring aortotomy, or undergoing mitral valve repair. In using this retrograde technique, we make a point of cannulating a retrograde perfusion catheter under direct vision following right atriotomy. The purpose of this retrospective study is to evaluate the clinical outcome of using this technique.
This study comprises 49 patients who underwent elective valve surgery using direct-vision retrograde cardioplegia exclusively, requiring more than 3h aortic cross-clamping. Their clinical outcome was reviewed retrospectively.
There was no hospital mortality in this study. No patient was noted to have evidence of mediastinitis, myocardial infarction, or cerebral complications in the postoperative period. The case requiring the longest aortic cross-clamping time (380 min) survived the operation without the use of intra-aortic balloon pumping or percutaneous cardiopulmonary support, and the postoperative course was uneventful.
Our result suggests that direct-vision retrograde cardioplegia is a safe and effective method of cardioplegia delivery, and provides a longer period of myocardial protection than previously thought.
No preview · Article · Mar 2013 · Heart, Lung and Circulation
[Show abstract][Hide abstract] ABSTRACT: We performed descending thoracic aortic repair via posterolateral thoracotomy using retrograde cerebral perfusion with direct cannulation into the left internal jugular vein. No postoperative neurological dysfunction was observed. This patient was discharged without any adverse events.
No preview · Article · Apr 2011 · General Thoracic and Cardiovascular Surgery
[Show abstract][Hide abstract] ABSTRACT: Adverse effects of cardiopulmonary bypass on cancer prognosis are expected but have not been confirmed. Seventy-four cancer patients who underwent cardiac surgery before cancer therapy were followed up for 42 ± 37 months; 45 had cardiac surgery with cardiopulmonary bypass. There was no significant difference in cancer recurrence (40.0%) and deaths (26.7%) among patients who had cardiopulmonary bypass and those who underwent off-pump cardiac surgery (27.6% and 24.1%). There were no significant differences in freedom from cancer-related death at 2 and 5 years after cardiac surgery (78.4% and 68.5%) in the cardiopulmonary bypass group compared to the 29 off-pump group (81.8% and 58.3%). Despite some limitations, this study detected no significant adverse effects of cardiopulmonary bypass on cancer prognosis. Although these results do not verify the safety of cardiopulmonary bypass from an oncologic aspect, they suggest it can be applied in cancer patients who require cardiac surgery.
No preview · Article · Dec 2010 · Asian cardiovascular & thoracic annals
[Show abstract][Hide abstract] ABSTRACT: For coronary artery bypass grafting, the use of free gastroepiploic artery is unpopular because of its tendency to vasospasm. We assessed the en-bloc free gastroepiploic artery graft, which has the gastroepiploic vein anastomosed to the right atrial appendage to prevent graft spasm, and compared it to the skeletonized free gastroepiploic artery graft. A retrospective review was conducted in 57 patients who received en-bloc grafts and 29 who had skeletonized grafts. Kaplan-Meier analysis demonstrated the superiority of the en-bloc free gastroepiploic artery graft with an 80-month patency rate of 96.6% compared to 66.7% with skeletonized grafts. We selected 13 cases from each group, using propensity-score matching, and compared the long-term patency rates. Propensity-score matched analysis showed 80-month patency rates of 100% for en-bloc grafts and 60% for skeletonized grafts. Coronary artery bypass using free gastroepiploic artery grafts with venous drainage seems to provide good long-term results.
No preview · Article · Jun 2010 · Asian cardiovascular & thoracic annals
[Show abstract][Hide abstract] ABSTRACT: We report a case of 72-year-old man with severe manifestations of coronary artery spasm immediately after aortic valve replacement (AVR), which was associated with hemodynamic and arrhythmic instability. The AVR was performed under mild hypothermic cardiopulmonary bypass (34 degrees C), and retrograde blood cardioplegia was intermittently delivered at the same temperature. Immediately after the operation, the patient suddenly developed severe bradycardia and hypotension, and repeated ventricular fibrillation. Percutaneous cardiopulmonary support system (PCPS) and intra-aortic balloon pumping (IABP) were required for this circulatory collapse. Echocardiography revealed left ventricular segmental dysfunction, and coronary artery bypass grafting (CABG) to the right coronary artery and the left ascending artery was performed [during CABG, coronary spasm was strongly suspected by repetitive ST elevation and depression on electrocardiogram (ECG) monitor]. Eventually, the spasm subsided with the intravenous infusion of nitrates, nicorandil, and diltiazem. The remaining postoperative course was uneventful and the patient was discharged on the 24th postoperative day in good clinical condition.
No preview · Article · Feb 2010 · Kyobu geka. The Japanese journal of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: A 66-year-old woman presented with cardiac tamponade. Pericardiocentesis revealed purulent pericarditis. Enhanced computed tomography showed a saccular aneurysm of the aortic arch. An irregularly shaped and partially enhanced mass was seen adjacent to the aneurysm, which suggested development of a mycotic pseudoaneurysm. Surgical drainage was performed through a subxiphoid incision, and continuous irrigation was commenced. On the following day, however, massive bleeding was recognized through the drains. The patient was immediately transferred to the operating theater, and extracorporeal circulation was established. A perforation 1 cm in diameter was found on the anterior surface of the pulmonary trunk, and a large amount of pus came out from the tear. The ascending aorta and the arch were found to be infected. Surgical repair was impossible due to extensive infection, and the patient died. Methicillin-resistant Staphylococcus aureus was isolated from the pericardial effusion, blood, and intraluminal thrombus of the aortic aneurysm.
No preview · Article · Jun 2009 · General Thoracic and Cardiovascular Surgery
[Show abstract][Hide abstract] ABSTRACT: A 51-year-old man who had been suffering from depression stabbed himself in the chest with an ice pick. At presentation, an ice pick lodged in the left fifth intercostal space was moving synchronously with his heartbeat. Echocardiography revealed that the tip was penetrating the anterior wall of the right ventricle. Because the patient was tamponading, an emergency operation was carried out. The ice pick was removed following the establishment of a cardiopulmonary bypass and pericardiotomy. The perforation of the right ventricle was closed with a pledget-reinforced mattress stitch. On postoperative day 12, a holosystolic murmur was detected on auscultation. Transthoracic echocardiography revealed a ventricular septal defect 5 mm in diameter located near the apex. The pulmonary-tosystemic flow ratio was 1.1 by echocardiographic measurement. No sign of heart failure was present. Although it was agreed to manage the ventricular septal defect conservatively, careful echocardiographic follow-up is mandatory.
No preview · Article · Apr 2009 · General Thoracic and Cardiovascular Surgery
[Show abstract][Hide abstract] ABSTRACT: Use of the free gastroepiploic artery (GEA) graft for coronary revascularization is not very popular because of its tendency to vasospasm. We hypothesize that the cause of free GEA spasm is graft damage caused by an interruption of venous drainage from the graft. To overcome this problem, we anastomosed the accompanied gastroepiploic vein to the right atrial appendage simultaneously with the GEA grafting in the aortocoronary position. We here assess the clinical result and the angiographic patency of the free GEA graft in our method in the late postoperative period.
Between January 1997 and April 2001, 57 patients underwent coronary artery grafting with a free GEA using our method. A total of 169 distal anastomoses (average 2.96) were constructed. The free GEA grafts were anastomosed to the main right coronary artery in 26 patients, right coronary artery branch in 27, left anterior descending artery in 1 patient, high lateral branch in 2 patients, and circumflex branch in 2. The mean clinical follow-up is 77 months (range, 35 to 110) in 57 cases, and the angiographic follow-up averages 77 months (range, 37 to 110) in 46 cases.
There was no cardiac death, and all patients were in Canadian Cardiovascular Society class II or less. The mean 77-month patency rate of the free GEA in our method was 95.7%. The patency rates of internal thoracic artery, radial artery, and saphenous vein graft in the same period were respectively 93.2%, 100%, and 81.3%.
Free GEA grafting with venous drainage for myocardial revascularization provided excellent long-term performance.
Full-text · Article · Apr 2008 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: The mortality of conventional coronary artery bypass grafting after acute myocardial infarction remains high. This study compared the clinical outcomes of patients undergoing conventional and on-pump beating-heart coronary artery bypass grafting and evaluated the efficacy of an on-pump beating-heart technique for the surgical treatment of these critically ill patients.
Between January 1999 and March 2005, 61 patients underwent emergency coronary artery bypass grafting for acute myocardial infarction. In the first 23 patients, the conventional cardioplegic method was performed. In the most recent 38 patients, the on-pump beating-heart procedure was used without cardioplegic arrest.
A significant reduction occurred in the observed mortality between the conventional and on-pump beating groups (21.7% vs 2.6%, P = .04), despite a higher predicted mortality risk calculated by using EuroSCORE (9.0 +/- 1.6 vs 9.6 +/- 1.6, P = .048) and a greater use of a preoperative intra-aortic balloon pump (43.5% vs 78.9%, P = .005). On-pump beating-heart patients received fewer bypass grafts than conventional patients (2.0 vs 2.9, P = .001), but the internal thoracic artery was used more often in on-pump beating-heart patients (P = .014). Three patients in the conventional coronary artery bypass grafting group required new insertion of an intra-aortic balloon pump, whereas no patients required this in the on-pump beating-heart group (P = .220). Postoperative renal failure requiring hemodialysis occurred in 2 patients in the conventional coronary artery bypass grafting group but in no patients in the on-pump beating-heart group (P = .138).
On-pump beating-heart coronary artery bypass grafting is the preferred method of emergency myocardial revascularization for patients with acute myocardial infarction who might tolerate cardioplegic arrest poorly. It has lower postoperative mortality and morbidity than conventional coronary artery bypass grafting.
No preview · Article · Apr 2008 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: It remains unclear how cardioplegic arrest affects surgical results after coronary artery bypass grafting surgery (CABG). This study compares early outcomes after on-pump beating-heart CABG and conventional CABG.
From 2002 to 2005, 114 patients underwent on-pump beating-heart CABG. Multivariate logistic regression revealed five characteristics according to which technique is liable to be used: history of cerebral infarction, urgent or emergent operation, lower ejection fraction, preoperative creatine kinase, and lower number of diseased vessels. The early clinical outcome for these patients was compared against 114 conventional CABG patients, matched using a propensity score constructed with these five significant variables and with two nonsignificant variables: history of diabetes mellitus and hypertension.
On-pump beating-heart CABG significantly reduced the duration of operation and cardiopulmonary bypass, total blood loss, and peak creatine kinase (p < 0.05). The number of patients requiring additional intra-aortic balloon pump support was significantly lower in the on-pump beating-heart CABG group (2 versus 13, p < 0.01). No patients required percutaneous cardiopulmonary support after on-pump beating-heart CABG, whereas 4 patients needed it after conventional CABG. Complete revascularization was significantly lower (42.1% versus 77.2%, p < 0.0001), but in-hospital mortality was less in the on-pump beating-heart CABG group (2.6% versus 9.6%, p < 0.05). No significant difference was found in morbidity including stroke, renal failure, mediastinitis, and prolonged ventilation.
On-pump beating-heart CABG can be performed safely, including on high-risk patients. Use of cardiopulmonary bypass and the elimination of cardioplegic arrest may be of most benefit to hemodynamically unstable patients.
Full-text · Article · May 2007 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: Heartstring is a useful device. However, the device failure at the time of loading the seal into the delivery device is a troublesome issue. To avoid this problem, we invent a new method using 2 tourniquets made of 5 mm-wide woven Teflon tapes and plastic tubes. Using our method, the loading procedure became easier and more reliable.
No preview · Article · Oct 2006 · Kyobu geka. The Japanese journal of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: Management of the small aortic root is a significant problem for the surgeon with regard to operative technique and selection of the prosthesis. We report on four adults with a small aortic root who underwent aortic valve replacement with a 16-mm CarboMedics bileaflet valve. All patients now lead normal lives. Postoperative Doppler measurements demonstrated an acceptable transprosthetic gradient.
No preview · Article · Jul 2006 · The Japanese Journal of Thoracic and Cardiovascular Surgery
[Show abstract][Hide abstract] ABSTRACT: A 62-year-old man with supraventricular/ventricular tachycardia associated with myocardial infarction developed tachycardia during beating coronary artery bypass grafting (CABG). Intravenous administration of an ultra short acting beta-blocker, landiolol hydrochloride, controlled heart rate and improved tachyarrhythmia without significant change of blood pressure. Landiolol hydrochloride is effective and useful for the treatment of tachyarrhythmia during beating CABG.
No preview · Article · Apr 2004 · Kyobu geka. The Japanese journal of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: As total arterial revascularization in coronary artery bypass grafting (CABG) has been recommended, a sequential bypass technique using arterial grafts has been induced. We evaluate whether a sequential bypass graft can be functioned or not by using a simple simulation model for coronary circulation analogous to the electrical circuit based on Ohm law. The ratio of flow between graft and native coronary artery was determined by the severity of stenosis in the bypassed vessels and the graft diameter. In selection for sequential bypass technique, these factors should be taken into consideration.
No preview · Article · Aug 2003 · Kyobu geka. The Japanese journal of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: Various types of assist devices have been developed for severe heart failures. Among them, intra-aortic balloon pumping (IABP) has achieved popularity, mainly in the treatment of patients with either severe cardiac infarction or low cardiac output syndrome (LOS) after open-heart surgery. However, IABP has a limitation in that although it acts as a pressure support, it cannot directly support flow volume. In cases of severe pump failure, stronger pump support would be required. However, there is a limit in the clinical use of temporary mechanical support using a pump because of the costs of the expensive equipment. With this in mind, we came up with a new idea in which the motion of a balloon in IABP system is converted into a power source for creating a one-way stream. In order to realize our idea, we made a J-shaped sample model of pulsating chamber incorporating two ball valves. In the hydrodynamic experiment using our new device, flows over 2500 ml/min (Max. 3475 ml/min) were obtained. The percent changes in parameters such as TTI, DPTI and bypass flows obtained by the experiment of left ventricular bypass have demonstrated that our assist system is effective for reducing cardiac work.
No preview · Article · Mar 2003 · The Thoracic and Cardiovascular Surgeon
[Show abstract][Hide abstract] ABSTRACT: A 77-year-old woman was admitted to our hospital with transient dysarthria. The patient had atrial fibrillation without a history of valvular disease. Echocardiographic examination showed evidence of a floating mass going and returning between the left atrium and the mitral orifice. With this finding, the cause of the brain embolic episode was found to be due to the thrombus in the heart. Under surgery, a ball thrombus was removed, the size and weight of which were 40x30x25 mm and 15 g, respectively. The patient's postoperative course was uneventful, and she was discharged from the hospital on the 16th postoperative day.
Full-text · Article · Nov 2002 · Annals of thoracic and cardiovascular surgery: official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia