Japanese Journal of Cardiovascular Surgery Vol.35, No.1

Prevention of Homologous Blood Transfusion by Intraoperative Predonation on Valvular Surgery without Preoperative Autologous Donation

(Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan)

Koichi Sato	Masakazu Sogawa	Osamu Namura
Chizuo Kikuchi	Manabu Isoda	Junzo Watanabe
Takeshi Okamoto	Takehito Mishima	Jun-ichi Hayashi

Though preoperative autologous donation is not acceptable for all cases partly because some are preoperatively in a severe condition, intraoperative predonation is possible in almost all cases. We retrospectively evaluated the major factors related to the prevention of homologous blood transfusion by intraoperative predonation in 25 cases following valvular surgery without preoperative autologous donation. Homologous blood was not transfused in 18 cases ｛Group-(－)｝ but in 7 cases only after CPB ｛Group-(＋)｝. The male/female ratio, type of operation, body weight, CPB dilution, CPB duration, and perioperative change in hematocrit were comparable in the 2 groups. However, the autologous blood pooled before CPB in Group-(－) was significantly more than in Group-(＋)（11.3±2.5 vs 7.3±1.8ml/kg, p＜0.001). In conclusion, homologous blood transfusion may be prevented by appropriate intraoperative predonation during surgery for valvular disease.
　Jpn. J. Cardiovasc. Surg. 35: 1-4 (2006)

A New Index of Intraoperative Transit-Time Flow Evaluation in Coronary Artery Bypass Grafting

(Division of Cardiovascular Surgery, Kasugai Municipal Hospital, Kasugai, Japan) Yoshiyuki Takami Hiroshi Masumoto

It is essential to evaluate the quality of coronary artery bypass grafting (CABG) anastomosis in the operating room. Transit-time flow measurement has been increasingly used for this purpose, because it is less invasive, more reproducible, and less time consuming. The electrocardiogram-gated flow measurement has made it possible to identify the systolic flow (Qs) and diastolic flow (Qd) and to calculate a new index, diastolic filling index （DFI＝100∫Qd／［∫｜Qs｜＋∫｜Qd｜］） for graft flow analysis. In this study, we investigated the clinical significance of DFI, together with other indexes, including mean flow (Qm), pulsatility index (PI)，% insufficiency (INSUF), and F0/H1, where F0 is a power of the fundamental frequency and H1 is a power of the first harmonic in spectral analysis by fast Fourier transformation of the flow curve. We examined the relationships of these intraoperative flow variables of the post-operative angiographic findings of 125 CABG grafts, including 58 in-situ internal thoracic arteries. There were significant differences between patent and non-patent grafts in all of the intraoperative flow parameters (Qm: 47.9±31.8ml/min vs 10.2±3.6ml/min, PI: 3.0±1.4 vs 9.6±2.4, INSUF: 3.3±4.2% vs 29.9±8.1%, F0/H1: 2.8±2.0 vs 0.6±0.2, DFI: 68.5±8.4% vs 38.2±17.2%). Our data suggested that a DFI value of more than 50% can be useful for surgeons to distinguish patent from non-patent grafts in the operating room, in combination with other parameters: Qm＞15 ml/min, PI＜5, INSUF＜15%, and F0/H1 ratio＞1.0. 　Jpn. J. Cardiovasc. Surg. 35: 5-9 (2006)

Surgical Management for the Patients of Mediastinal Malignancy Involving Cardiac Structures with Circulatory Impairments

(Division of Organ Regeneration Surgery, Faculty of Medicine, Tottori University, Yonago, Japan and Department of Cardiovascular Surgery, Hamada Medical Center*, Hamada, Japan)

Yasunori Cho*	Satoru Suzuki	Yoshiyuki Haga
Kenichi Hashizume

Malignant disease in the mediastinum often involves cardiac structures such as the cardiac chamber and great vessels, and causes circulatory impairments that limit therapeutic options and longevity. In the present study, we evaluated curative or palliative surgical management for 6 cases of such malignancy in the mediastinum with circulatory impairment who were operated on between January 2001 and February 2004 (4 men and 2 women aged 17 to 72 years). Procedures included tumor resection with cardiopulmonary bypass (CPB) for mitral strangulation due to left atrial myxosarcoma; pericardiectomy without CPB for constrictive pericarditis due to invasive thymoma; radical nephrectomy for renal cell carcinoma with right atrial tumor thrombus using CPB; two pericardial fenestrations with or without partial tumor resection for cardiac tamponade due to pericarditis carcinomatosis caused by malignant lymphoma or lung cancer; and right ventricular metastatic lesion resection with outflow tract reconstruction for the recurrence of renal cell carcinoma using CPB. The follow-up ranged from 4 days to 30 months. Procedure-related death occurred in the patient with invasive thymoma due to heart failure on postoperative day 4. Five operative survivors had improved quality of life and received other therapeutic options. Although the patient with malignant lymphoma died of sepsis during chemotherapy at three weeks, the remaining 4 patients were discharged from the hospital postoperatively but 3 died during follow-up due to the progression of malignant disease. The cause of death were local recurrence at 20 months after operation in the patient with myxosarcoma, liver metastasis at 13 months in the renal cell carcinoma patient, and carcinomatous cachexia at 8 months in the patient with metastatic lung cancer. The patient with recurrence of renal cell carcinoma is doing well without any symptoms of tumor progression at 30 months after metastatic lesion rsection. Despite poor prognosis of the patients of mediastinal malignancy, surgical management for circulatory impairments can be indicated with acceptable risk to lengthen survival and improve the quality of life.
　Jpn. J. Cardiovasc. Surg. 35: 10-13 (2006)

Effect of Cryopreservation of Human Heart Cells on Cell Proliferation

(Division of Cardiovascular Surgery, Department of Surgery (Omori), School of Medicine, Faculty of Medicine and Department of Biomolecular Science, Faculty of Science*, Toho University, Tokyo, Japan) Hiroki Yokomuro Noritsugu Shiono Tsukasa Ozawa Takeshirou Fujii Muneyasu Kawasaki Yoshinori Watanabe Katsunori Yoshihara Nobuya Koyama Mitsumasa Okada*

Preservation is essential for successful cell transplantation. 1) Control group (n＝13); Cells isolated from human right atrial tissues were cultured for 15 days. 2) Cell-cryopreservation (C.P.) group (n＝23), Tissue-C.P. group (n＝29); Human heart cells and minced tissues were cryopreserved in freezing medium containing 70% IMDM, 20% FBS, and 10% DMSO at a rate of－1℃/min. to －80℃ by a programmed freezer and stored in liquid nitrogen (－196℃) for 1 week. After cryopreservation, the tissues and cells were thawed rapidly at 37℃. The cells, cryopreserved cells and cells isolated from cryopreserved tissues were cultured as passage 1, 2, and 3 for 15 days each. Cell proliferation was compared with a control group by determining growth curves, and 2-day proliferation rates. A growth factor, biochemical features and cell cycle were measured pre and post-cryopreservation. The cryopreserved group proliferated much more than the control group within 15 days at passage 1, 2, and 3 (1.7, 2.1, and 3.1 times, p＜0.0001) respectively. The 2-day proliferation rates of cryopreservation group were higher than the control group in 15 days (p＜0.05). The bFGF release after cryopreservation was on average 46.8 and 6.8 times greater than before cryopreservation for the Cell-C.P. and Tissue-C.P. groups, respectively. The TGF-β1 release was also accelerated by cryopreservation (Cell-C.P. group: 1.78 times, Tissue-C.P. group: 1.45 times in average) after cryopreservation. The cell cycle of human heart cells shifted to G2＋M from the G1＋G0 period by cryopreservation. Human atrial tissues and cells can be cultured and cryopreserved. The cryopreserved cells and cells isolated from cryopreserved tissue proliferate much more than non-cryopreserved cells at all cell ages. Cryopreservation enables human tissues and cells to proliferate more because of the greater release of growth factors and changing cell cycle. 　Jpn. J. Cardiovasc. Surg. 35: 14-20 (2006)

Antero-Lateral Thoracotomy with Partial Sternotomy for Retrograde DeBakey III Type Closing Aortic Dissection

(Department of Cardiovascular Surgery, Chugoku Rosai Hospital, Cerebro-Cardiovascular Center, Kure, Japan)

Masafumi Sueshiro	Saiho Hayashi	Hironori Kobayashi

We report 2 cases of retrograde DeBakey III type (Stanford A type) closing aortic dissection in a state of shock. At the preoperative assessment, we could not confirm the region of entry in either of them. Consequently, to close the entry, we decided to perform antero-lateral thoracotomy with partial sternotomy (ALPS) and good results were obtained. This method has 3 advantages. 1) The wide field of view enables visualization from the ascending to the descending aorta. 2) Because of the good field of view, we are able to suture without difficulty and minimize the volume of bleeding. 3) We can minimize influence on the lung because the upper sternum is not incised, thus we can handle the lung gently while performing the planned incision.
　Jpn. J. Cardiovasc. Surg. 35: 21-24 (2006)

Surgical Treatment for Angiosarcoma Occupying the Bilateral Atrial Cavities and the Atrial Septum

(Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Kawasaki, Japan and Department of Cardiovascular&General Surgery, Faculty of Medicine, Shimane University*, Izumo, Japan) Keita Kikuchi* Haruo Makuuchi Hiroshi Murakami Toshiya Kobayashi Masahide Chikada Takamaro Suzuki Takashi Ando Kiyoshi Chiba

A 48-year-old man complained of hemoptysis. Chest CT scan showed a large cardiac tumor invading the atrial septum and both atria, as well as multiple small nodules in bilateral lung fields. They were diagnosed as a malignant cardiac tumor and its lung metastases. As the tumor in the left atrium was extremely massive, operation was performed to prevent sudden death due to occlusion and to make a pathological diagnosis. The cardiac tumor invaded the atrial septum from the right atrium and occupied the left atrium. After the cardiac tumor was completely removed, the bilateral atria, the atrial septum, SVC, IVC and the right lower pulmonary vein were reconstructed with prosthetic pericardial patches. The tumor was angiosarcoma. During the postoperative period, Interleukin-2 was used as the treatment for angiosarcoma. Unfortunately the patient died of lung failure on the 107th postoperative day. Though IL-2 could not stop the development of lung metastasis in this case, the effectiveness of radiotherapy or IL-2 for angiosarcoma has recently been reported. In such cases where complete resection of the primary cardiac lesion is possible, postoperative radiotherapy or IL-2 administration seems to be effective for cardiac sarcoma. 　Jpn. J. Cardiovasc. Surg. 35: 25-28 (2006)

Staged Operation for a Patient with Ischemic Heart Disease and Abdominal Aortic Aneurysm Complicating Idiopathic Thrombocytopenic Purpura

(Department of Cardiovascular Surgery, Hyogo Brain and Heart Center, Himeji, Japan and Department of Cardiovascular Surgery, Miki City Hospital*, Miki, Japan) Akiko Tanaka Nobuhiko Mukohara Hiroya Minami* Masato Yoshida Hidefumi Ohbo Tsutomu Shida

A 62-year-old man, who had been given a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP), was admitted to our hospital for an operation for abdominal aortic aneurysm (AAA). Preoperative coronary angiography revealed severe triple vessel disease, and we chose to treat this first. The platelet count on his first admission was 2.1×104/μl and preoperative immunoglobulin infusion was introduced for 5 days. Off-pump coronary artery bypass grafting (OPCAB) was performed safely with platelet transfusion, and he was discharged on the 14th postoperative day. Thirty-eight days later, graft replacement of AAA was performed with preoperative immunoglobulin infusion and no platelet transfusion, and he was discharged at the 11th postoperative day. Preoperative immunoglobulin infusion therapy and selection of OPCAB were useful to prevent perioperative bleeding complications. This is the first report of staged cardiac and aortic surgery in a patient with ITP. 　Jpn. J. Cardiovasc. Surg. 35: 29-32 (2006)

Surgical Treatment for an Endovascular Stent Infection in the Descending Aorta

(Department of Cardiovascular Surgery Kurashiki Central Hospital, Kurashiki, Japan and Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital*, Fukuyama, Japan） Shogo Obata* Tatsuhiko Komiya Nobushige Tamura Genichi Sakaguchi Shinji Masuyama Chieri Kimura Taira Kobayashi Hiromasa Nakamura

We report a rare case with infection of a stent-graft. A 82-year-old man, who had undergone endovascular stent grafting to repair the descending aortic aneurysm 2 years previously, was admitted with high-grade fever. The blood culture detected methicillin-resistant Staphylococcus aureus (MRSA). Endoleak due to stent-graft infection was diagnosed and operation for synthetic graft replacement was performed. The synthetic graft was infiltrated in Rifampicin prior to the graft replacement to prevent re-infection. Additionally, the graft was covered with the greater omentum. He was discharged on the 45th day after surgery without any problems. One year follow-up showed no sign of re-infection of the graft. 　Jpn. J. Cardiovasc. Surg. 35: 33-36 (2006)

A Case of Coronary Artery Bypass Grafting in a Patient with Wolff-Parkinson-White Syndrome

(Department of Cardiovascular Surgery, International Medical Center of Japan, Tokyo, Japan and Department of Surgery, Sakakibara Heart Institute*, Fuchu, Japan) Kayo Sugiyama Shigeru Hosaka Toshitaka Kashima Togo Norimatsu Naomi Ozawa* Samu Akita Tadashi Omoto Masato Kume Sosuke Kimura

A 54-year-old man with unstable angina and Wolff-Parkinson-White (WPW) syndrome was admitted. Coronary angiography showed 90% stenosis of the left main trunk and 75% stenosis of the obtuse marginal branch. Coronary artery bypass grafting under cardioplegic arrest was done emergently. The left internal mammary artery graft was anastmosed to the left anterior descending artery, and a saphenous vein graft was used as a sequential bypass graft to the high lateral branch and obtuse marginal branch. Immediately after weaning from cardiopulmonary bypass, paroxysmal supraventricular tachycardia (PSVT) requiring electrical cardioversion was occurred, and catheter ablation was performed on the first postoperative day. There are controversus concerning the strategies of surgical treatment for unstable angina concomitant with WPW syndrome. Coronary bypass operation may trigger PSVT in patients with WPW syndrome. The optimal timing of perioperative catheter ablation needs further discussion. 　Jpn. J. Cardiovasc. Surg. 35: 37-40 (2006)

A Case of AS (Bicuspid Aortic Valve) and Aneurysm of Ascending Aorta Complicated with Intraoperative Aortic Dissection

(Department of Thoracic Surgery, Ome Municipal General Hospital, Tokyo, Japan and Thoracic Cardiovascular Surgery Department, Tokyo Medical and Dental University*, Tokyo, Japan) Naoto Miyagi Nagahisa Oshima Toshizumi Shirai Makoto Sunamori*

A 73-year-old woman was due to undergo elective AVR and aortoplasty because of aortic stenosis (AS) and an ascending aortic aneurysm. During the operation, after the start of cardiopulmonary bypass, the ascending aorta was found to be dilated and discolored. A diagnosis of type A dissection was made by transesophageal echocardiography. Replacement of the ascending aorta and AVR were performed under deep hypothermic circulatory arrest. After the operation, VTR revealed that the ascending aorta was dissected from the cardioplegia injection site. The postoperative course was good and she was discharged on postoperative day 28. Intraoperative aortic dissection is a rare but lethal complication, so it is important to recognize it rapidly and manage it appropriately. 　Jpn. J. Cardiovasc. Surg. 35: 41-44 (2006)

A Case of Anterolateral Papillary Muscle Rupture Caused by a Diagonal Branch Occlusion

(Department of Cardiovascular Surgery, Kikuna Memorial Hospital, Yokohama, Japan) Atsushi Bito Noboru Murata Noboru Yamamoto

We encountered an instructive case of anterolateral papillary muscle rupture after acute myocardial infarction. A73-year-old woman with rapidly progressive dyspnea came to our emergency room. Her symptoms associated with acute heart failure rapidly worsened. We diagnosed anterolateral papillary muscle rupture after acute myocardial infarction due to occlusion of the first diagonal branch, based on transesophageal echocardiogram and coronary angiography. We immediately performed mitral valve replacement and coronary artery bypass grafting (CABG) to the diagonal branch. Although she required postoperative intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS), she eventually recovered. Mitral papillary muscle rupture causes rapidly deteriorating hemodynamics and requires surgical treatment. Because of a serious complication of myocardial infarction, this case emphasizes that early diagnosis and aggressive treatment are required for mitral papillary muscle rupture. 　Jpn. J. Cardiovasc. Surg. 35: 45-48 (2006)

A Case of Left Atrial Myocardial Abscess Complicating Bicuspid Aortic Valve Infective Endocarditis

(The Department of Cardiovascular Surgery, Anjo Kosei Hospital, Anjo, Japan) Hitoshi Suzuki Keizo Tanaka Shinji Kanemitsu Toshiya Tokui Yoshihiko Kinoshita

A 56-year-old man was admitted with fever of unknown origin and congestive heart failure. Blood cultures grew Streptococcus gordonii. An echocardiographic examination showed vegetation attached to the bicuspid aortic valve and severe aortic regurgitation. Despite the aggressive therapy, an emergency operation had to be performed because it was otherwise impossible to control heart failure. Vegetation was attached to the aortic valve leaflets. There was no noticeable lesion on the aortic annulus, but a myocardial abscess was noted in the left atrial wall. Aortic valve replacement was performed after the myocardial abscess was drained. It was assumed that the myocardial abscess was due to the septic state from infective endocarditis because it was recognized at a distant zone from the active valvular infection. 　Jpn. J. Cardiovasc. Surg. 35: 49-52 (2006)

A Case of Malignant Cardiac Lymphoma Presenting with Acute Abdomen: Should We Call This Case Primary Cardiac Lymphoma?

(Department of Cardiovascular Surgery, Kyoto University Hospital, Kyoto, Japan and Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital*, Kyoto, Japan) Takeshi Shimamoto Toshifumi Takeuchi* Akiyoshi Mikuriya* Motoyuki Oda*

A 46-year-old woman who originally presented acute abdomen was reffered to us. Her CT scan and echogram showed no abnormal findings in her abdomen. However, A 25-mm tumor-like mass was observed in her right atrium and right lower lobe. Based on the concern that the cardiac tumor might be a risk for embolic events, the tumor in her right atrium was resected under cardiopulmonary bypass in a semi-emergency manner. It was diagnosed as malignant lymphoma of B-cell type by histological examination. Two days after operation, she started to have abdominal pain and CT scan showed free air and a significant amount of effusion in her abdomen. Emergency laparotomy was performed and a single perforation with a tumor mass was observed in her small intestine. Segmentectomy was performed and her postoperative course since then was uneventful. Fifteen days after her initial operation, she was referred to the regional hematology center for chemotherapy. Primary cardiac lymphoma was classically defined as an extranodal lymphoma involving only the heart and/or pericardium; however the currently accepted definition is lymphoma with the vast bulk of the tumor intrapericardial even with small secondary lesions elsewhere. According to this recent definition, several cases with extensive extracardial involvements have been reported as primary cardiac lymphoma and our case marginally could be considered primary. Certain cutoffs must be proposed to quantify extracardiac disease in defining primary cardiac lymphoma. 　Jpn. J. Cardiovasc. Surg. 35: 53-56 (2006)

Hetzer's Procedure for Ebstein's Anomaly in an Adult

(Department of Cardiovascular Surgery, Miyazaki Medical Association Hospital, Miyazaki, Japan) Hiroyuki Nagahama Yasunori Fukushima Takuya Fukuda Takahiro Hayase Makoto Yoshioka

Ebstein's anomaly is a rare congenital heart disease. A 51-year-old man was hospitalized due to Ebstein's anomaly with severe congestive heart failure. He underwent Hetzer's procedure for tricuspid valve incompetence and right atrial isolation technique to restore the sinus rhythm. The postoperative course was uneventful, he was discharged from the hospital on the 21st day after the operation. The cardiothoracic ratio reduced from 74% before the operation to 60%. And his New York Heart Association functional class also improved from III to I after discharge. Hetzer's procedure for tricuspid valve repair in Ebstein's anomaly restructures the valve mechanism at the level of the true tricuspid annulus by using the most mobile leaflet for valve closure without plication of the atrialized chamber. We thus conclude that Hetzer's procedure, with anatomical evaluation of the malformed tricuspid valves before or during the operation, is beneficial as a simple and reproducible method for the repair of certain cases of Ebstein's anomaly. 　Jpn. J. Cardiovasc. Surg. 35: 57-59 (2006)