Association between pre-treatment with statin and its inhibitory effect on the onset of coronary artery disease at the time of coronary computed tomography angiography: a new look at an old medication

Coronary artery stenosis is often advanced by the time coronary computed tomography angiography (CCTA). Statins are the most important anti-lipidemic medication for improving the prognosis of coronary artery disease (CAD) patients. Although lipid-lowering therapy using statins appears to have been established as a method for preventing CAD, there remains the problem that CAD cannot be completely suppressed. In this study, we investigated whether pre-treatment with statin could significantly inhibit the onset of CAD when patients received CCTA for screening of CAD. The subjects were 1164 patients who underwent CCTA as screening for CAD. CAD was diagnosed when 50% or more coronary stenosis was present in the coronary arteries. Patient backgrounds were investigated by age, gender, body mass index, coronary risk factors [family history of cardiovascular diseases, smoking history, hypertension (HTN), diabetes mellitus (DM), dyslipidemia, chronic kidney disease (CKD) or metabolic sydrome] and medications. Patients were classified into two groups according to the presence or absence of statin pre-administration during CCTA [statin (-) group (n = 804) and (+) group (n = 360)]. Compared with the statin (-) group, the statin (+) group was significantly older and had higher rates of family history, HTN, and DM. The statin (+) group had a significantly higher % CAD than the statin (-) group. Serum levels of low-density lipoprotein cholesterol (LDL-C) were significantly lower in the statin (+) group than in the statin (-) group. There was no significant difference in either high-density lipoprotein cholesterol levels or triglyceride levels between the two groups. Age, male gender, HTN, DM and pre-treatment with statin were all associated with CAD (+) in all patients. In addition, factors that contributed to CAD (+) in the statin (-) group were age, male gender, and DM, and factors that contributed to CAD (+) in the statin (+) group were age, smoking, HTN and % maximum dose of statin. At the time of CCTA, the statin (+) group had a high rate of CAD and coronary artery stenosis progressed despite a reduction of LDL-C levels. To prevent the onset of CAD, in addition to strict control of other coronary risk factors (HTN etc.), further LDL cholesterol-lowering therapy may be necessary.

Association between paroxysmal or persistent atrial fibrillation and hyperuricemia in patients who underwent coronary computed tomography angiography: from the FU-CCTA-AF Registry

BACKGROUND

Hyperuricemia (HU) and hypertension (HTN) contribute to atherosclerotic cardiovascular disease, and both are also involved in the onset and development of atrial fibrillation (AF).

OBJECTIVE

In the present study, we investigated the association between risk factors for atherosclerosis [including HU, HTN, blood pressure and serum uric acid (UA) levels] and paroxysmal atrial fibrillation (Paro-AF) or persistent atrial fibrillation (Pers-AF) in patients who underwent coronary computed tomography angiography (CCTA).

METHODS

We enrolled 263 patients from the Fukuoka University-CCTA-AF (FU-CCTA-AF Registry) who underwent CCTA prior to AF ablation therapy. AF was classified as either Paro-AF (≤ 7 days) or Pers-AF (> 7 days). HU was diagnosed by a serum UA level > 7.0 mg/dl, and coronary artery disease (CAD) was diagnosed when CCTA results showed ≥ 50% significant coronary artery stenosis. The number of significantly diseased coronary artery vessels (VD), the Gensini score and the coronary artery calcification score (CACS) were measured. Left atrial morphology was also evaluated.

RESULTS

Diastolic blood pressure and HbA1c in the Pers-AF group were significantly higher than those in the Paro-AF group. The Pers-AF group showed a significantly higher prevalence of HU and higher UA levels than the Paro-AF group. In a multivariate logistic regression analysis, HU was an independent associated factor to Pers-AF (odds ratio: 2.023, 95% confidence interval: 1.055-3.881, p = 0.034), while HTN was not.

CONCLUSION

In patients with AF, HU is associated with Pers-AF.

Association Between the Presence of Coronary Artery Disease or Peripheral Artery Disease and Left Ventricular Mass in Patients Who Have Undergone Coronary Computed Tomography Angiography

Background

Left ventricular mass (LVM) is a critical marker of future cardiovascular risk. We determined the association between LVM measured by coronary computed tomography angiography (CCTA) and the presence of coronary artery disease (CAD) or peripheral artery disease (PAD) in patients who had undergone CCTA for screening of CAD.

Methods

We enrolled 1,307 consecutive patients (66 ± 12 years old, 49% males) who underwent CCTA for screening of CAD at the Fukuoka University Hospital (FU-CCTA registry), and either were clinically suspected of having CAD or had at least one cardiovascular risk factor. Patients with coronary stenosis of ≥ 50% by CCTA were diagnosed as CAD. Patients with an ankle brachial pressure index < 0.9 or who had already been diagnosed with PAD were considered to have PAD. Left ventricular mass index (LVMI), left ventricular ejection fraction (LVEF), end-diastolic volume (EDV) and end-systolic volume (ESV) were measured. The patients were divided into CAD (-) and CAD (+) or PAD (-) and PAD (+) groups.

Results

The prevalences of CAD and PAD in all patients were 50% and 4.8%, respectively. Age, %males, %hypertension (HTN), %dyslipidemia (DL), %diabetes mellitus (DM), %smoking and %chronic kidney disease in the CAD (+) group were significantly higher than those in the CAD (-) group. Age, %males, %HTN, %DM and %smoking in the PAD (+) group were significantly higher than those in the PAD (-) group. CAD was independently associated with LVMI (odds ratio (OR): 1.01, 95% confidence interval (CI): 1.01 - 1.02, P < 0.01) in addition to age, male, HTN, DL, DM, and smoking. PAD was also independently associated with LVMI (OR: 1.01, 95% CI: 1.0 - 1.02, P = 0.018) in addition to age, DM, and smoking.

Conclusions

LVMI determined by CCTA may be useful for predicting atherosclerotic cardiovascular diseases including both CAD and PAD, although there were considerable differences between %CAD and %PAD in all patients.

Association between Major Adverse Cardiovascular Events and the Liver Fibrosis Score in Patients with and without Coronary Artery Disease: From the FU-CCTA Registry

The liver fibrosis score reflects the degree of hepatic scarring and has been reported to be associated with cardiovascular disease. Using a coronary artery computed tomography angiography registry at the Fukuoka University Hospital (FU-CCTA registry), we investigated the association between major adverse cardiovascular events (MACEs) and the liver fibrosis score (fibrosis-4 index (FIB-4I)) in 612 patients who underwent CCTA to screen for coronary artery disease and performed a prognosis survey for up to 5 years. The primary endpoint was MACEs (all-cause mortality, acute myocardial infarction, ischemic stroke, coronary revascularization). FIB-4I in all patients and in patients with hypertension (HTN) was significantly higher in the MACE group than in the non-MACE group. The event-free survival rate of MACEs targeting only patients with HTN was significantly lower in patients with a high risk of liver fibrosis (FIB-4I values of 2.67 or higher) than in those with a low or intermediate risk (less than 2.67). However, no significant difference was observed in all patients or in patients without HTN. Finally, FIB-4I and body mass index were independent factors associated with MACEs in patients with HTN. In conclusion, the liver fibrosis score may be an independent predictor of MACEs in hypertensive patients undergoing CCTA.

Investigating the Association between Coronary Artery Disease and the Liver Fibrosis-4 Index in Patients Who Underwent Coronary Computed Tomography Angiography: A Cross-Sectional Study

Liver fibrosis scores, indicative of hepatic scarring, have recently been linked to coronary artery disease (CAD). We investigated the association between CAD and the fibrosis-4 index (FIB-4I) in patients who underwent coronary computed tomography angiography (CCTA). This study included 1244 patients who were clinically suspected of having CAD. The presence or absence of CAD was the primary endpoint. FIB-4I was higher in the CAD group than in the non-CAD group (1.95 ± 1.21 versus [vs.] 1.65 ± 1.22, p < 0.001). FIB-4I was also higher in the hypertension (HTN) group than in the non-HTN group (1.90 ± 1.32 vs. 1.60 ± 0.98, p < 0.001). In all patients, high FIB-4I (≥2.67) was a predictor of presence of CAD (odds ratio [OR]: 1.92, 95% confidence interval [CI]: 1.30-2.83, p = 0.001), and low FIB-4I (≤1.29) was proven to be a predictor of absence of CAD (OR: 0.65, 95% CI: 0.48-0.88, p = 0.006). In the HTN group, high and low FIB-4I levels, were found to be predictors for CAD (OR: 2.01, 95% CI: 1.26-3.21, p < 0.001 and OR: 0.65, 95% CI: 0.45-0.94, p < 0.022, respectively), in particular. FIB-4I may serve as a diagnostic indicator of the presence or absence of CAD in hypertensive patients undergoing CCTA.

Association Between Major Adverse Cardiovascular Events and the Gensini Score or Coronary Artery Calcification Score in Hypertensive Patients Who Have Undergone Coronary Computed Tomography Angiography

Background

From the Fukuoka University Coronary Computed Tomography Angiography (FU-CCTA) registry, we present major adverse cardiovascular events (MACEs) in hypertensive patients who have undergone CCTA, and the association between MACEs and the Gensini score of coronary arteries or the coronary artery calcification (CAC) score.

Methods

Of the patients who underwent CCTA for coronary artery disease (CAD) screening at Fukuoka University Hospital, 318 hypertensive patients who had at least one cardiovascular risk factor or suspected CAD were enrolled. The patients were divided into two groups: MACEs and non-MACEs groups. The severity of atherosclerosis of coronary arteries was assessed by the Gensini score. The CAC score was also defined by computed tomography (CT) images at the time of CCTA. A primary endpoint was MACEs (all-cause death, ischemic stroke, acute myocardial infarction, coronary revascularization). The patients were followed for up to 5 years.

Results

The patients were 68 ± 10 years, and 50% were males. The percentages of smoking, dyslipidemia, diabetes, and chronic kidney disease were 39%, 70%, 26% and 37%, respectively. The %males, %smoking, CAC score and Gensini score in the MACEs group were significantly higher than those in the non-MACEs group. On the other hand, the differences in age, dyslipidemia, diabetes, or chronic kidney disease between the groups were not seen. A multivariate analysis was performed regarding the presence or absence of MACE by logistic regression analysis of the CAC score or Gensini score in addition to conventional risk factors as independent variables. A Cox regression analysis revealed significant relationships for both the CAC score (P = 0.043) and the Gensini score (P = 0.008).

Conclusions

The CAC score and the Gensini score could predict MACEs in hypertensive patients who have undergone CCTA.

Association between major adverse cardiovascular events and pentraxin-3 in patients who have undergone coronary computed tomography angiography: from the FU-CCTA registry

Chronic vasculitis is considered to be associated with future cardiovascular events. Here, we present major cardiovascular events (MACEs) in patients who underwent coronary computed tomography angiography (CCTA) for screening for coronary artery disease (CAD), and the association between MACEs and the inflammation marker pentraxin (PTX)-3 or highly sensitive C-reactive protein (hsCRP). The patients who underwent CCTA for the purpose of screening for CAD at Fukuoka University Hospital (FU-CCTA registry), 456 patients with suspected CAD or at least one cardiovascular risk factor were followed for up to 5 years. The levels of PTX-3 and hsCRP in blood were measured at the time of CCTA, and the patients were divided into two groups according to the presence (MACEs group) or absence (non-MACEs group) of MACEs. There were no differences in PTX-3 or hsCRP between the MACEs (-) and MACEs ( +) groups in all patients. A multivariate analysis related to the presence or absence of MACEs by logistic regression analysis of inflammation factors (PTX-3 and hsCRP) in addition to conventional risk factors as independent variables was performed. PTX-3 was a predictor of MACEs in males, whereas smoking, but not PTX-3, was a predictor of MACEs in females. PTX-3 could be a predictor of MACEs in males, but not females.

Association Between Major Adverse Cardiovascular Events and the Ratio of Subcutaneous Fat Area to Visceral Fat Area in Patients Who Have Undergone Multidetector Row Computed Tomography

Background: Obesity is a critical cardiovascular risk factor that has been defined in terms of body mass index (BMI), abdominal circumference (AC), and fat area. In this study, we examined which markers of obesity are most closely associated with major adverse cardiovascular events (MACE).

Methods and Results: This prospective cohort study enrolled 529 consecutive patients who initially underwent coronary computed tomography angiography for screening of coronary atherosclerosis at Fukuoka University Hospital (FU-CCTA Registry) and either were clinically suspected of having coronary artery disease (CAD) or had at least 1 cardiovascular risk factor with a follow-up of up to 5 years. Measurements of subcutaneous fat area (SFA), visceral fat area (VFA), and AC were quantified using multidetector row computed tomography. The primary endpoint was MACE. SFA and the SFA to VFA ratio (SFA/VFA) were significantly lower in the MACE than non-MACE group. SFA, AC, BMI, and SFA/VFA were each independently associated with MACE. Receiver operating characteristic curve analysis revealed a greater area under the curve for SFA/VFA than for the other parameters. The cut-off level of SFA/VFA with the greatest sensitivity and specificity for the diagnosis of MACE was 1.45 (sensitivity 0.849, specificity 0.472).

Conclusions: Our results suggest that SFA/VFA may be a marker for evaluating the presence of MACE.

Association between high-density lipoprotein cholesterol levels and major adverse cardiovascular events in patients who underwent coronary computed tomography angiography: FU-CCTA registry

It is unclear whether higher levels of serum high-density lipoprotein cholesterol (HDL-C) prevent major adverse cardiovascular events (MACE). We prospectively evaluated 501 patients who had undergone coronary computed tomography angiography at Fukuoka University Hospital and either were clinically suspected of having coronary artery disease (CAD) or had at least one cardiovascular risk factor with a follow-up of up to 5 years. The primary endpoint was MACE (cardiovascular death, ischemic stroke, acute myocardial infarction and coronary revascularization). The patients were divided into tertiles according to the HDL-C level: 47 mg/dl ≥ HDL-C level [n = 167, lower HDL-C level (L-HDL)], 58 mg/dl ≥ HDL-C level ≥ 48 mg/dl [n = 167, middle HDL-C level (M-HDL)] and HDL-C level ≥ 59 mg/dl [n = 167, higher HDL-C level (H-HDL)] groups. There were significant differences in %CAD among the L-HDL, M-HDL and H-HDL groups. Unexpectedly, there was no difference in %MACE between M-HDL and H-HDL, although %MACE in M-HDL was significantly lower than that in L-HDL (p < 0.05). By a multivariate logistic regression analysis, MACE in H-HDL-C was independently associated with diabetes mellitus (DM) (p = 0.03). A Kaplan-Meier curve according to the HDL subgroup indicated that M-HDL, not H-HDL, enjoyed the greatest freedom from MACE among the 3 groups (log-rank test p = 0.047). Finally, the results of a Cox regression model indicated that L-HDL and H-HDL had significantly higher risk of MACE than M-HDL. In conclusions, patients with middle HDL-C levels, not higher HDL-C levels, showed the greatest freedom from MACE. Patients with higher HDL-C levels need to be strictly managed for DM to prevent MACE.

Sequential variation of super periodic structures emerged in Bi-layered perovskite pillar-matrix epitaxial nanocomposite films with spinel ferrites

The phase stability of Aurivillius bismuth-layer structured Bi5Ti3FeO15 (BTFO15) has been investigated in an epitaxial pillar-matrix nanocomposite system with spinel ferrites.

Association Between the Level of Low-Density Lipoprotein Cholesterol and Coronary Atherosclerosis in Patients Who Have Undergone Coronary Computed Tomography Angiography

Background

Although the Japan Atherosclerosis Society Guidelines 2017 recommend lower levels of low-density lipoprotein cholesterol (LDL-C, < 70 mg/dL or ≤ 100 mg/dL) to prevent secondary cardiovascular events, we cannot conclude that a low level of LDL-C prevents primary cardiovascular events in patients with suspected coronary artery disease (CAD).

Methods

We registered 1,016 patients who were clinically suspected to have CAD and who underwent coronary computed tomography angiography (CCTA) for screening of coronary atherosclerosis. We excluded 350 patients who were receiving anti-lipidemic therapies and finally analyzed 666 patients. The patients were divided into three groups according to the LDL-C level: < 70 mg/dL (n = 25, Low LDL-C), 70 - 99 mg/dL (n = 141, Middle LDL-C), and ≥ 100 mg/dL (n = 500, High LDL-C). A ≥ 50% coronary stenosis was initially diagnosed as CAD, and the number of significantly stenosed coronary vessels (VD), Gensini score and coronary artery calcification (CAC) score were quantified.

Results

There were no significant differences in age, high-density lipoprotein cholesterol, rates of hypertension, hemoglobin A1c, blood sugar or systolic blood pressure among the Low, Middle and High LDL-C groups. On the other hand, there were significant differences in rates of males, smoking, dyslipidemia and diabetes, diastolic blood pressure and triglyceride among the groups. The prevalence of CAD values in the Low, Middle and High LDL-C groups were similar, at 52%, 47%, and 46%, respectively. In addition, there were no significant differences in the number of VD, Gensini score or CAC score among the Low LDL-C, Middle LDL-C and High LDL-C groups.

Conclusions

We showed that the level of LDL-C was not associated with the presence or severity of CAD, which indicates that we need to screen by CCTA to prevent primary coronary events even if patients without anti-lipidemic therapies show low levels of LDL-C.

Extended unroofing procedure for creation of a new ostium for anomalous left coronary artery

A modified procedure to create an alternative ostium for the left coronary artery was successfully carried out in a patient having anomalous origin of the left coronary artery from the right coronary sinus of the aorta. The proximal portion of the artery had an intramural course. The newly constructed orifice was widely patent and functioning well 44 months later, without episodes of myocardial ischemia or aortic regurgitation.

Continuous systemic perfusion improves outcome in one stage repair of obstructed aortic arch and associated cardiac malformation

OBJECTIVE

To determine whether continuous systemic perfusion is of effective use when establishing primary repair of the aortic obstruction and associated cardiac malformations.

METHODS

Since 1991, 56 infants have undergone reconstruction of interrupted (in 28) or coarctated (in 28) aorta, concomitantly with closure of ventricular septal defects in 37, and repair of other malformations in the remaining 19. Of these, total circulatory arrest (30+/-11 min) was employed in 23. In another 21 patients, perfusion was maintained for the carotid arteries with the descending aorta cross-clamped (31+/-15 min). The bodily organs were perfused throughout the operative procedures by placing dual aortic cannulae in the remaining 12 patients.

RESULTS

The postoperative courses were less eventful in the non-circulatory arrest group than other groups of patients undergoing total or partial circulatory arrest, although these groups were operated in different time periods, and consequently, a general progress might be one reason for improvements in the surgical outcomes. All patients undergoing no circulatory arrest survived the primary repair, could have the sternum primarily closed, and had no episodes of cerebral bleeding. Prolonged tracheal intubation was needed just in one patient of this group. The amount of urine output during cardiopulmonary bypass was significantly greater in the non-circulatory arrest group than in the others. The maximal concentrations of urinary beta-microglobulin, serous creatinine, creatine phosphokinase, and glutamic oxaloacetic transaminase were lower in this setting.

CONCLUSIONS

Continuous systemic perfusion was considered less invasive when concomitantly repairing the obstructed aorta and intracardiac malformations.

Double inlet right ventricle versus other types of double or common inlet ventricle: its clinical characteristics with reference to the Fontan procedure

OBJECTIVE

To determine the clinical features in patients with double inlet right ventricle (DIRV) and separate atrioventricular (AV) valves in terms of the Fontan procedure.

METHODS

Surgical procedures were carried out in 31 patients with this rare malformation. Their clinical characteristics were compared with similar features in 45 patients with double inlet left ventricle (DILV), 93 with common inlet right ventricle (CIRV), and 20 with common inlet left ventricle (CILV).

RESULTS

Pulmonary atresia with the right and the left pulmonary arteries being confluent was seen in 58% of patients with DIRV, and pulmonary atresia with non-confluent pulmonary arteries in 15% (P=0.0001). The incidence of these findings was significantly higher when compared with DILV (P=0.0001). Reflecting these morphologic features, constructions of systemic-to-pulmonary shunts and extensive plasty to the pulmonary arteries were more frequently needed in patients with DIRV than in the others (P=0.04, 0.0001). The AV valves have become moderately or severely regurgitant in three with DIRV (10%). The Fontan procedure has thus been employed in 21 with DIRV (64%), this incidence being significantly higher than that seen in the CIRV (37%) group (P=0.01). Survival rate of 95% at 10 years in this group was as excellent as that in the DILV group, and obviously better than that in either CIRV or CILV (P=0.002).

CONCLUSIONS

Although multiple palliative procedures might be frequently needed to maintain pulmonary perfusion, the Fontan circulation can be justifiably established in patients with DIRV, and regurgitation across the AV valves was not very common.

Repair of double outlet right ventricle with doubly-committed ventricular septal defect

OBJECTIVE

To investigate our surgical results of intraventricular rerouting in patients having double outlet right ventricle with doubly-committed ventricular septal defect.

METHODS

We undertook repair in 8 patients with this particular feature. Of these, 2 patients had pulmonary stenosis, and another had interruption of the aortic arch. The subarterial defect was unequivocally related to both the aortic and the-pulmonary orifices in all, albeit slightly deviated towards the aortic orifice in one, and towards the pulmonary orifice in another. Intraventricular rerouting was carried out via incisions to the right atrium and the pulmonary trunk. To ensure reconstruction of an unobstructed pulmonary pathway, a limited right ventriculotomy was made in 5.

RESULTS

All patients survived the procedure, and are currently doing well, with follow-up of 25 to 194 months, with a mean of 117+/-68 months. Catheterization carried out 16+/-6 months after repair demonstrated excellent ventricular parameters. Mean pulmonary arterial pressure was 16+/-7 mmHg, being higher than 20 mmHg in 2 patients. No significant obstruction was found between the right ventricle and the pulmonary arteries. A pressure gradient across the left ventricular outflow tract became significant in one patient in whom a small outlet septum was present, and a heart-shaped baffle had been used for intraventricular rerouting. Reoperation was eventually needed in this patient for treatment of the obstruction, which proved to be progressive.

CONCLUSION

Precise recognition of the morphologic features is of paramount importance when choosing the optimal options for biventricular repair in patients with double outlet right ventricle and doubly-committed interventricular communication.

[Reconstruction of the right ventricular outflow tract in patients undergoing the Ross procedure]

Since 1992, 46 patients have undergone the Ross procedure. Of these, a pulmonary homograft was used for reconstruction of the RVOT in 16, and a tailored heterologous or autologous pericardial roll tube in 9. In the remaining 21, the autologous tissues were used as a posterior wall of the channel, placing another patch (bearing a monocusp in 14) anteriorly. All the patients survived the procedure. Reoperation has been needed thus far in one for infection of the prosthetic patch placed at the right ventricular outflow tract, and catheter intervention in 2 for mild obstruction across the channel. On the basis of postoperative catheterization, presence or absence of a valvar structure across the right ventricular outflow tract did not affect ejection fraction of the right ventricle and right atrial pressure. In contrast, right ventricular end diastolic volume was smaller, as well as diastolic pulmonary arterial pressure was higher, when a competent trifoliate valve was provided at the right ventricular outflow tract. An incision to the ventricular septum for subaortic stenosis, coronary arterial obstruction preoperatively present, and age at operation younger than 2 years old, were unfavourable factors affecting right ventricular performance. We conclude that, in the majority of our patients, right ventricular performance was unlikely impaired even without a competent pulmonary valve. Use of a homograft, however, could be preferred in a selected group of patients with deleterious circumstances on the postoperative circulation.

Congenital diverticulum of the left ventricle

We present a case of a congenital left ventricular diverticulum of fibrous type that was surgically repaired. Considering the potential risks such as rupture, systemic thromboembolism, and arrhythmia, an early surgical intervention should be employed for this rare abnormality even in a child without clinical symptoms.

Staged unifocalization and anatomic repair in a patient with right isomerism

Anatomic biventricular repair was successfully achieved subsequent to bilateral unifocalizations of the pulmonary blood supply using heterologous pericardial rolls in a patient with isomeric right appendages and major aortopulmonary collateral arteries.

Renewal of the Fontan circulation with concomitant surgical intervention for atrial arrhythmia

BACKGROUND

Atrial arrhythmia remains one of the major complications in the longer term after the Fontan procedure.

METHODS

Conversion to total cavopulmonary connection was carried out concomitantly with surgical intervention for atrial arrhythmia in 4 patients undergoing the Fontan procedure by atriopulmonary connection and having continual atrial fibrillation or flutter in the longer term after the initial procedure.

RESULTS

The surgical intervention restored sinus rhythm. Transient atrial fibrillation occasionally occurred after the reoperation in 1 patient in whom duration of preoperative arrhythmic period had been 6 years, and defibrillation was needed twice. In the other 3 patients, no episodes of paroxysmal arrhythmia have been noted. Subsequent to renewal of the Fontan circulation, cardiac index increased, with systemic venous pressure decreasing. All 4 patients are currently doing well with their functional status of New York Heart Association functional class I.

CONCLUSIONS

Combination of conversion to total cavopulmonary connection and concomitant surgical intervention for atrial arrhythmia is effective, when used appropriately and in a timely manner in patients with atrial arrhythmia in the longer term after the initial Fontan procedure by atriopulmonary connection.

Anatomic biventricular repair by intraatrial and intraventricular re-routing in patients with left isomerism

OBJECTIVE

To determine the efficacy of anatomic biventricular repair by a combination of intraatrial and intraventricular re-routing in patients with isomerism of the left atrial appendages.

METHODS

Anatomic biventricular repair by means of combined intraratrial and intraventricular re-routing was achieved in 5 of the 63 patients with left isomerism in whom we attempted a definitive surgical procedure. The inferior caval vein was interrupted in 3. The Mustard procedure was chosen for intraatrial redirection of blood in 4, and the Senning procedure in the other. Intraventricular re-routing was carried out via a right ventriculotomy in all patients, using an external conduit to reconstruct the morphologically right ventricular outflow tract.

RESULTS

One patient died one month after the procedure because of low cardiac output and bronchial bleeding. Obstruction across the superior caval venous channel occurred after the Senning procedure in this particular patient, related to the interrupted inferior caval vein draining via the azygous vein. The other 4 patients are currently doing well. Postoperative catheterization showed excellent cardiac performance, with no obstruction across the venous channels or the ventricular outflow tracts in these 4. No episode of significant arrhythmia has been noted, all patients having a regular atrial rhythm, although the P wave vector was unusual in each patient. Reoperation has been needed thus far in one patient, 128 months after the initial repair, because of obstruction of the external conduit.

CONCLUSION

With precise recognition of the morphologic features, a combination of intraatrial and intraventricular re-routing can successfully be established in patients with isomeric left atrial appendages, with functional results in the intermediate term being reasonable.

Replacement of the tricuspid valve in children with congenital cardiac malformations

BACKGROUND AND AIM OF THE STUDY

When replacing the regurgitant tricuspid valve in children, the decision to use either a bioprosthesis or a mechanical valve remains controversial.

METHODS

The atrioventricular valve for the pulmonary circulation was replaced in 11 young patients aged between 8 months and 13 years. Complications of congenital cardiac malformation were present in seven patients, and Ebstein's anomaly in three; tricuspid valvular regurgitation was an isolated lesion in one patient. A bioprosthesis was implanted on seven occasions, and a bileaflet mechanical valve on eight, including re-replacement of the valve in four patients.

RESULTS

One patient died two years after implantation due to respiratory problems. Tricuspid stenosis due to valve calcification occurred in four bioprostheses at between four and nine years after initial replacement (57%). In three of these cases the native valve leaflets had not been removed. Thrombosis occurred in one patient with a mechanical valve; rereplacement was successful. Anticoagulant-related hemorrhage occurred in another patient. Among patients receiving a mechanical valve, 83% of valves were dysfunction-free after five and ten years.

CONCLUSION

When replacing an atrioventricular valve for the pulmonary circulation in children, we prefer to use a low-profile mechanical valve, especially when extensive repair of intracardiac malformation has been carried out, but ventricular function is good. In children with poor cardiac performance, a bioprosthesis is preferred, with total resection of the native valve leaflets.

A staged Fontan approach in patients initially unsuitable for the primary Fontan procedure

OBJECTIVE

To determine the efficacy of the Glenn procedure in terms of establishing the Fontan procedure.

METHODS

Surgical results were investigated in 248 patients undergoing either the total or partial right heart bypass. Of these, the conventional and the bidirectional Glenn procedures were employed in 27 and 58 patients, respectively.

RESULTS

Conversion to the Fontan circulation was attempted in 32 of 58 patients initially considered unsuitable for the Fontan circulation and undergoing the bidirectional Glenn procedure, with 2 operative deaths. Of the 27 undergoing the conventional Glenn procedure, 13 have undergone conversion with 2 deaths. Actuarial survival rate after the staged Fontan approach did not statistically differ from that after the primary Fontan procedure. Catheterization in 130 patients with the established Fontan circulation showed no significant differences in ejection fraction, end diastolic volume, and end diastolic pressure of the systemic ventricle, as well as in Cardiac Index, between the group of patients treated with the primary Fontan procedure and the group treated with the staged Fontan procedure. When achieving the bidirectional Glenn procedure, the size of the additional channel from the ventricles to the pulmonary arteries was correlated with the postoperative change in pulmonary arterial size, but such additional forward flow produced insufficient ventricular offloading in 9 of 16 patients with significant atrioventricular valvar regurgitation.

CONCLUSION

The staged Fontan strategy has an advantage in patients with complicated circumstances. Whether the primary or the staged Fontan procedure was used, however, did not affect the Fontan circulation itself when once the Fontan circulation was established. The additional forward flow in the bidirectional Glenn physiology, if employed, should be appropriately adjusted, considering both the advantages and the disadvantages of the option.

Result of surgical treatments in patients with coronary-arterial obstructive disease after Kawasaki disease

OBJECTIVE

To determine the efficacy of coronary artery bypass grafting (CABG) in young patients with coronary-arterial obstructive disease subsequent to Kawasaki disease.

METHODS

CABG was employed in 100 patients. Age at operation ranged from 1 to 23 years at a mean of 10+/-5 years. The number of bypass grafts placed was 1-5/patient (a mean of 1.7+/-0.8). The left internal-thoracic artery (ITA) was used as a graft in 99 patients; the right internal thoracic artery in 39, the gastroepiploic artery in nine and the saphenous vein in 21.

RESULTS

All patients survived the procedures. In the follow-up of 6.7+/-4.5 years, two patients died, one because of a traffic accident and the other due to sudden death. Considerable myocardial ischemia recurred postoperatively in 15, because of either obstruction of the bypass grafts or progression of other coronary-arterial obstructions. Of these, symptoms spontaneously regressed without interventional procedures in four, reoperation was indicated in four and catheter intervention was efficiently carried out in the remaining seven. Another two patients had episodes of critical ventricular arrhythmia; one of them with severe left ventricular dysfunction subsequently underwent cardiac transplantation. The patency rates of the arterial grafts were 94, 82 and 78% at 1, 5 and 10 years, respectively, and this was higher than that of the venous grafts (82, 63 and 36%, respectively). Strenuous exercise is currently prohibited in 15 patients, while the remaining 83 patients are doing well with no obvious restriction in their daily lives.

CONCLUSION

Collaborating with catheter interventions, CABG using the arterial grafts can provide attractive results in patients with obstructive coronary arteries associated with Kawasaki disease.

Total cavopulmonary connection in children with body weight less than 10 kg

OBJECTIVE

To evaluate the results after total cavopulmonary connection (TCPC) in small children, our clinical experience was retrospectively reviewed.

METHODS

Of 164 patients undergoing TCPC, the body weight at operation was less than 10 kg (8.8+/-1.1 kg) in 54, including 21 with visceral heterotaxy. The superior caval vein (SVC) was anastomosed to the pulmonary arteries in a bidirectional fashion. To construct a channel draining the inferior caval vein (IVC), an extended polytetrafluoroethylene (ePTFE) tube was placed intraatrially (in 15 patients) or outside the heart (in 13), its diameter being 14 mm in two patients, 16 mm in 12, and 18 mm or greater in 14. A heterologous pericardial baffle was used for intraatrial rerouting in 12 patients. A pedicled autologous pericardial roll was tailored as an extracardiac conduit in 11 patients, and the pulmonary trunk was directly anastomosed to IVC orifice in three.

RESULTS

Seven patients, including five with right isomerism, died in the intermediate term because of infection of the ePTFE tube in two, respiratory problems in three, atrioventricular valvar regurgitation in one, and pulmonary venous obstruction in one. Postoperative catheterization showed; SVC pressure, 11+/-2 mmHg without a pressure gradient between SVC and IVC; systemic ventricular end diastolic pressure, 5+/-2 mmHg; end diastolic volume, 122+/-54% of the anticipated normal value; ejection fraction, 0. 56+/-0.11; and cardiac index, 2.9+/-0.7 l/min per m(2). With the follow-up of 1-116 (35+/-31) months, the IVC channel has not become obstructive in all, except for one, in whom a pedicled pericardial roll was severely obstructed because of its tortuous extracardiac course crossing in front of the vertebrae. Postoperative growth was generally stable, although body weights and heights were smaller in the majority of patients when compared with the anticipated standards for Japanese children.

CONCLUSION

TCPC can be justifiably established in small children. The use of autologous tissues seemed preferable for constructing the IVC channel unless anatomic orientation was unsuitable.

[An experience with the Ross operation utilizing cryopreserved pulmonary homografts procured by and stored in our homograft valve bank]

Eight patients, 4 males and 4 females ranging in age from 10 to 54 years (mean 27 +/- 13 years) underwent the Ross operation using a cryopreserved pulmonary homograft harvested by and cryopreserved in our institutional "Tissue Bank". Seven patients had a congenital bicuspid aortic valve and 3 patients had had healed infective endocarditis of the aortic valve. Four young female patients wanted to have a baby after operation. The Ross procedure was carried out utilizing aortic root replacement techniques in all patients. All patients survived and are currently in NYHA class 1, but 2 cardiac events occurred in 2 patients during the mean follow-up term of 29 +/- 19 months. The one was the anastomic stenosis between the homograft and distal pulmonary artery treated by balloon dilatation and the other was ventricular tachycardia eventually managed by the insertion of an ICD. Pulmonary autograft valve regurgitation is present in 3 patients, but it is not progressive up to the present time. Pulmonary homograft valves function well in all patients. The Ross operation for adolescents and young adults should become more popular along with more easy availability of homograft valves based upon the establishment of the "Homograft Valve Bank" system in Japan.

Replacement of the morphologically tricuspid valve in children with discordant atrioventricular connections

BACKGROUND AND AIM OF THE STUDY

Our clinical experience was reviewed to determine the efficacy of replacement of the atrioventricular (AV) valve for the systemic circulation in children with discordant AV connections undergoing functional biventricular repair.

METHODS

Nine children underwent replacement of the morphologically tricuspid valve at the age of 10 months to 15 years. Ventriculoarterial connections were discordant in five children, and double outlet right ventricle with pulmonary stenosis or atresia in four. In all children the prosthesis chosen was a mechanical valve; valve sizes ranged from 19 mm to 31 mm.

RESULTS

One patient died of ventricular failure immediately after surgery. Two patients underwent reoperation for re-replacement at eight and 68 months after the initial replacement because of non-structural dysfunction. Complete AV block occurred after intracardiac maneuvers in the non-survivor. Transient AV dissociation was noted in another patient. General conditions improved greatly after surgery in all survivors. In the morphologically right ventricle placed for the systemic circulation the end-diastolic volume fell from 327 +/- 182% (range: 109-621%) to 169 +/- 97% (range: 85-352%) of the anticipated normal value (p = 0.03), while pressure fell from 13 +/- 4 (range: 7-19) mmHg to 8 +/- 3 (range: 2-12) mmHg (p = 0.005). The ejection fraction was only marginally reduced (47 +/- 13% (range: 26-62%) preoperatively versus 34 +/- 11% (range: 20-54%) postoperatively; p = 0.13).

CONCLUSIONS

In children with discordant atrioventricular connections and severe regurgitation across the morphologically tricuspid valve, the valve can be efficiently replaced for the systemic circulation.

Redirection of hepatic venous drainage after total cavopulmonary shunt in left isomerism

BACKGROUND

Conversion from total cavopulmonary shunt (TCPS) to the Fontan circulation can improve cyanosis in patients with potential risks of development of pulmonary arteriovenous fistula (PAVF).

METHODS

Inclusion of the hepatic veins in the pulmonary circulation was employed using an intra-atrial tube graft in 5 patients with left isomerism previously undergoing TCPS. Prior to the conversion, abnormal communication was identified between the azygos vein and either the hepatic or the portal vein in all. PAVF was seen in 3.

RESULTS

All patients survived the procedure. Postoperative catheterization showed 13 +/- 2 mm Hg of superior caval venous pressure, and 2.3 +/- 0.4 L/min/m2 of cardiac index. Pulmonary arteriovenous fistula progressed markedly in the right lung even after the conversion in 2 patients, in whom the hepatic veins had been exclusively diverted to the left lung. Arterial oxygen saturation became below 65%, with exercise capacity reduced, in these 2 patients. The other patients remain asymptomatic.

CONCLUSIONS

Total cavopulmonary shunt can be efficiently converted to the Fontan circulation by appropriately redirecting hepatic venous drainage to perfuse both lungs in a balanced fashion.

Re-replacement of the atrioventricular valve for the systemic circulation in children

BACKGROUND AND AIM OF THE STUDY

The study aim was to determine whether re-replacement of the systemic atrioventricular (AV) valve can be achieved efficiently in children.

METHODS

The systemic AV valve was re-replaced in 10 children. Initial replacement was needed for regurgitation in nine cases and congenital mitral stenosis in one case at a mean age of 3.7 +/- 3.1 years (range: 0.7-10.2 years). The initial prosthesis chosen was a mechanical valve in all cases; prosthesis size ranged from 16 mm to 27 mm. Reoperation was indicated at a mean age of 9.7 +/- 3.6 years (range: 3.5-14.8 years) because of non-structural dysfunction in five cases, prosthetic valve endocarditis in two, thrombosed valve in two, and progressive obstruction of the left ventricular outflow tract in one case. Fibrous tissues were extensively resected to enlarge the valvular orifice. A translocation maneuver was employed in five cases.

RESULTS

Re-replacement using a bileaflet mechanical valve was successful, with no operative or late deaths. Up-sizing was feasible in six cases with the initial valve < or = 25 mm, the alternative prosthesis being 2-8 mm (mean 4.5 mm) larger than the initial one. Consecutive echocardiography demonstrated improved peak flow velocity across the AV valve (from 2.3 +/- 0.6 to 1.6 +/- 0.3 m/s). Catheterization showed improved mean pulmonary arterial pressure (from 32 +/- 13 to 21 +/- 3 mmHg). No change was seen in cardiac index (3.4 +/- 0.6 and 3.5 +/- 0.6 l/min/m2) or systemic ventricular ejection fraction (55 +/- 14% and 49 +/- 23%).

CONCLUSIONS

Re-replacement of the systemic AV valve can be achieved efficiently, even in children, with up-sizing feasible by appropriate surgical maneuvers.

Gene transfection of beta 2-adrenergic receptor into the normal rat heart enhances cardiac response to beta-adrenergic agonist

BACKGROUND

Beta-adrenergic receptor system has a major role in cardiac contraction. If the receptor can be increased by gene transfection by means of intracoronary infusion of beta 2-adrenergic receptor to the hearts in which the receptor is down-regulated, this maneuver may improve the cardiac function and may be applied as one therapeutic approach during cardiopulmonary bypass or percutaneous cardiopulmonary support.

METHODS AND RESULTS

The beta 2-adrenergic receptor complementary DNA was transfected in vivo to the normal rat heart by intracoronary infusion by means of a hemagglutinating virus of Japan liposome method, and the transfected heart was transplanted into the abdomen of another rat. Four days after transfection, the sarcolemma of the cardiomyocytes was well labeled by immunohistochemical labeling. Expression of beta-adrenergic receptor in the heart was approximately 4 times greater than that in control hearts (134 +/- 42 vs 33 +/- 4 fmol/mg protein) according to a ligand binding assay. The cardiac response of the transfected heart to isoproterenol was shown to be enhanced in a Langendorff perfusion system: after isoproterenol, developed pressure and maximal derivative of the left ventricle were greater than in the control heart (200 +/- 12 vs 174 +/- 6 mm Hg and 4110 +/- 130 vs 3491 +/- 255 mm Hg/sec), and the minimal derivative of the left ventricle was markedly smaller (-3040 +/- 267 vs -2528 +/- 131 mm Hg/sec).

CONCLUSIONS

These results indicate that expression of beta 2-adrenergic receptor was approximately 4 times greater than in normal rat hearts by gene transfection using a hemagglutinating virus of Japan liposome method, and the transfected hearts demonstrated marked enhancements in cardiac response to beta-agonist, suggesting that transfer of this gene by intracoronary infusion has potential as a novel approach to enhance cardiac function.

Ventricular outflow tracts after Kawashima intraventricular rerouting for double outlet right ventricle with subpulmonary ventricular septal defect

OBJECTIVE

To determine whether or not the ventricular outflow tracts can be efficiently constructed in patients with double outlet right ventricle with subpulmonary ventricular septal defect by the Kawashima intraventricular rerouting in which the morphologically right ventricular outlet is divided into two, one for the systemic and the other for the pulmonary circulations.

METHODS

The intraventricular rerouting procedure was carried out in nine patients with this particular malformation. Age at repair ranged from 35 days to 3 years old. The distance between the attachments of the tricuspid and the pulmonary valves was 10 mm or greater in all except one patient in whom the measured value was 3 mm. Resecting subaortic musculature appropriately, a tailored patch, either oval-shaped (in seven) or heart-shaped (in two), was placed to construct an unobstructed channel for the left ventricular outflow tract with its diameter greater than that of the anticipated normal aortic orifice at the time of repair. For an unobstructed channel to the pulmonary arteries, enlargement of the right ventricular outflow tract was carried out using a patch in six.

RESULTS

All patients survived the operative procedure. On postoperative catheterization, mean pulmonary arterial pressure was 15 +/- 8 mmHg, and cardiac index was calculated as 3.3 +/- 0.6 l/min per m2. It proved that the constructed left ventricular outflow tract can become larger in the longer term. Pressure gradient across the left ventricular outflow tract was greater than 20 mmHg in two patients in the intermediate term. One of these two underwent reoperation for the obstruction 10 years after the initial repair. It was suspected that use of a heart-shaped internal conduit, which seems to result from inadequate conal resection, was one of the possible causes of such obstruction in the longer term. Pressure gradient of 47 mmHg was seen across the right ventricular outflow tract in one patient, although this patient has undergone no reoperation. Enlargement of the right ventricular outflow tract could minimize postoperative obstruction for the pulmonary pathway.

CONCLUSIONS

The intraventricular rerouting remains one of the attractive surgical options for repair in this particular setting, in terms of successful construction of the ventricular outflow tracts.

New indicator for the Fontan operation: diameters of the pulmonary veins in patients with univentricular heart

BACKGROUND

Operative survival after the Fontan procedure is good; however, there are some patients with disappointing results, especially those with atrial isomerism.

OBJECTIVES

We tested whether the diameter of the pulmonary veins, which is reported as a useful indicator of pulmonary blood flow, predicts operative results after the Fontan operation.

PATIENTS AND METHODS

We evaluated 30 consecutive patients undergoing either the bidirectional Glenn anastomosis (BDG) or the Fontan operation. Age at operation ranged from 3 to 81 months (mean 30). Diagnosis was right or left isomeric heart in 15 patients, double-outlet right ventricle in 4 and various other malformations in 11. BDG was performed in 16 patients and the Fontan operation in 14 patients. The diameters of the pulmonary veins were measured proximal to the entrance into the atrium in the late phase of a pulmonary arteriogram. The pulmonary vein (PV) index (in mm2/m2) was calculated from the sum of the cross-sectional areas of these veins divided by the body surface area.

RESULTS

Of the patients undergoing BDG (+/- ancillary procedures), 12 had successful results and 4 had unsuccessful results. The PV index for hemodynamically successful patients was 361 +/- 153 and 275 +/- 60 mm2/m2 (mean +/- SD) for unsuccessful patients (p = 0.30). Of the patients who underwent the Fontan operation, 13 had successful and 1 had unsuccessful results. The PV index for successful patients was > 285 mm2/m2 and 137 mm2/m2 for the nonsuccessful patients. The new pulmonary vascular resistance (PVR) calculated by using the PV index (mean pressure difference between the pulmonary artery and the atrium/PV index) for BDG patients with successful or unsuccessful results was 2.0 +/- 0.5 or 3.5 +/- 0.2 mmHg/mm2 per m2, respectively (p < 0.01). The new PVR for Fontan patients with successful results was < 2.0 mmHg/mm2 per m2, while that for the patient with an unsuccessful result was 4.4. The new PVR completely separated patients into successful and unsuccessful groups, while conventionally calculated PVR did not (p = 0.63).

CONCLUSIONS

PV index appears to be a useful morphological indicator of pulmonary blood flow and "new" PVR may improve the decision-making strategy for patients presenting with univentricular heart, especially those associated with isomeric heart.

Gene transfection of hepatocyte growth factor attenuates reperfusion injury in the heart

BACKGROUND

Hepatocyte growth factor (HGF), a ligand for the c-Met receptor tyrosine kinase, plays a role as organotrophic factor for regeneration of various organs. HGF has an angiogenic activity and exhibits a potent antiapoptotic activity in several types of cells. Although HGF and the c-Met/HGF receptor are expressed in the heart, the role of HGF in the heart has remained unknown.

METHODS

After we analyzed changes in expression of endogenous HGF and c-Met mRNA levels in the rat left ventricle after myocardial infarction, the human HGF gene in hemagglutinating virus of Japan (HVJ)-liposome was transfected into the normal whole rat heart. Three days after transfection, the heart was subjected to global warm ischemia and subsequent reperfusion, followed by assessment of its cardiac functions.

RESULTS

Both HGF and c-Met/HGF receptor mRNAs were expressed in adult rat heart, and c-Met/HGF receptor mRNA was upregulated in response to myocardial infarction. HGF-transfected heart showed significant increase of human HGF protein level in the heart. Cardiac functions in terms of the left ventricular developed pressure, maximum dp/dt, and pressure rate product in hearts with HGF gene transfection were significantly superior to those in control hearts. In addition, leakage of creatine phosphokinase in the coronary artery effluent in hearts with HGF gene transfection was significantly lower than that in control hearts.

CONCLUSIONS

These data indicated that both HGF and c-Met/HGF receptor mRNAs were upregulated in response to myocardial ischemic injury, and that HGF is likely to have a cytoprotective effect on cardiac tissue, presumably through the c-Met/HGF receptor.

Use of expanded polytetrafluoroethylene sutures as artificial tendinous cords in children with congenital mitral regurgitation

OBJECTIVE

To determine the efficacy in the intermediate term of artificial cords inserted in children with congenital mitral regurgitation.

METHODS

We reconstructed the tendinous cords using expanded polytetrafluoroethylene (ePTFE) sutures in 11 children with severe mitral regurgitation. In these patients, the aortic (anterior) leaflet of the mitral valve had been markedly prolapsed, the tendinous cords being partially lacking in seven, and elongated in the remaining four. In addition, one of the papillary muscles was hypoplastic in five and absent in three. The number of artificial cords constructed varied from two to six. Conventional annuloplasty was performed in all to plicate the dilated annular attachment of the valve. Ventricular septal defect was present in four patients, and other associated malformations in another two. Age at operation ranged from 9 months to 9 years old, with a mean of 4.5 years.

RESULTS

All patients survived the operation. No reoperation has been needed thus far. No complications were encountered related to the use of the prosthetic materials or anticoagulation. As judged by echocardiography, regurgitation became trivial or slight immediately after the repair. In two patients, however, regurgitation recurred within 1 year of the operation. Coaptation between the leaflets was maintained by a compensatory growth at the site of attachment of the artificial cords. Catheterization demonstrated significant improvements in the end-diastolic volume of the left ventricle.

CONCLUSION

Expanded polytetrafluoroethylene sutures can be used as artificial cords when attempting to repair the malformed mitral valve in children, providing excellent results in the short- and the intermediate-term after the surgical procedure.

In vivo transfer of a beta 2-adrenergic receptor gene into the pressure-overloaded rat heart enhances cardiac response to beta-adrenergic agonist

BACKGROUND

In the failing heart, the density and affinity of beta-adrenergic receptors in the myocardium both tend to decrease as the severity of cardiac dysfunction increases. If this suppression of beta-adrenergic receptors could be prevented or reversed, this could serve as a fundamental form of treatment for the failing heart. We report here a possible new therapeutic approach for the failing heart involving the transfer of the beta 2-adrenergic receptor (B2AR) gene.

METHODS AND RESULTS

The B2AR cDNA was transfected in vivo to the concentric hypertrophied rat heart by intracoronary infusion with a hemagglutinating virus of Japan liposome method, and the transfected heart was transplanted into the abdomen of another rat. Four days after transfection, the sarcolemma of the cardiomyocytes was well labeled by immunohistochemical labeling. An overexpression of BAR of approximately 5 times in the heart (140 +/- 35 versus 24 +/- 3 fmol/mg protein for the transfected versus control hearts) was demonstrated by a ligand binding assay. The cardiac response of the transfected heart to isoproterenol was shown to be enhanced in a Langendorff perfusion system: After isoproterenol, developed pressure and maximal derivative of the left ventricle were greater than in the control heart (260 +/- 20 versus 230 +/- 10 mm Hg and 5500 +/- 300 versus 4500 +/- 300 mm Hg/s), and the minimal derivative of the left ventricle was remarkably smaller (-4500 +/- 300 versus -3300 +/- 200 mm Hg/s).

CONCLUSIONS

These results indicate that in vivo transfection of the gene for B2AR enhances the cardiac response to isoproterenol in the pressure-overloaded rat heart (in which the disease causes a decrease in receptor density), suggesting that transfer of this gene by intracoronary infusion during cardiac arrest has potential as a novel therapeutic approach for failing hearts.

[A successful biventricular repair in an adult case with "common ventricle" and isomeric atrial appendages previously undergoing the conventional Glenn procedure]

We describe herein a successful biventricular repair in a 21-year-old male who had severe hypoplasia of isomeric right appendages. He had previously undergone the conventional Glenn procedure at the age of one and a half years. Although he had grown uneventfully until adolescence, cyanosis as well as fatigue than gradually became worse. When referred to us for further treatment, we deemed a Fontan type procedure to be contraindicated, because of the hypoplastic nature of the right pulmonary artery, and the presence of abundant collateral arteries supplying the right lung. In terms of ventricular morphology, however, because both apical components were present, separated by the hypoplastic septum, biventricular repair seemed feasible. Initially, the Glenn anastomosis was taken down, and systemic-to-pulmonary shunts were constructed via a median sternotomy to both the right and left pulmonary arteries. This was followed by surgical division of the developed collaterals to the right lung via the right thoracotomy. Definitive biventricular repair was then carried out by reconstructing the pulmonary arteries and right ventricular outflow tact, separating and rerouting within the ventricles using a EPTFE patch, and achieving redirection of blood within the atriums using bovine pericardium. Such staged surgical approaches, although extensive, can provide useful options when seeking definitive repair in grown-up patients with complicated malformations.

Establishment of total cavopulmonary connection without use of cardiopulmonary bypass

OBJECTIVE

To minimize deleterious postoperative influences of cardiopulmonary bypass on the pulmonary circulation immediately after the Fontan type procedure, total cavopulmonary connection was achieved without use of cardiopulmonary bypass.

METHODS

Since April 1996, 15 patients including five patients with visceral heterotaxy, in whom no intracardiac procedure was needed, have undergone this operative maneuver. Age at operation ranged from 1.2 to 44.6 years. Construction of a systemic to pulmonary shunt had been previously employed in seven patients, banding of the pulmonary trunk in two patients, and the Norwood procedure in one patient. The superior caval vein was initially anastomosed to the pulmonary arteries in bidirectional fashion under temporary bypass from the superior caval vein to the atrium. The channel for draining the inferior caval vein was subsequently constructed with the aid of temporary bypass from the inferior caval vein to the atrium, using a Goretex tube in ten patients, using a pedicled autologous pericardial roll in four patients, and directly anastomosing the pulmonary trunk to the orifice of the inferior caval vein in one patient. In patients with visceral heterotaxy and an independent hepatic venous drainage, redirection of the blood flow via the caval vein as well as the hepatic vein could be successfully achieved by placing dual temporary bypasses into these veins.

RESULTS

Postoperative courses were excellent in all patients. Superior caval venous pressure was 11 +/- 2 mmHg at 12 h after the operation. No blood transfusion was needed in nine patients(60%).

CONCLUSION

This alternative operative procedure is undoubtedly attractive when establishing the Fontan circulation in patients undergoing no intracardiac maneuvers.

Compression of the pulmonary veins by the descending aorta in patients corrected surgically by the Fontan procedure

We describe 4 patients in whom the pulmonary veins were compressed between the descending aorta and the atrial part of the heart in consequence of an abnormal distribution of the pulmonary blood flow after the Fontan procedure.

Diameters of the pulmonary arteries and veins as an indicator of bilateral and unilateral pulmonary blood flow in patients with congenital heart disease

OBJECTIVES

This study was done to clarify which diameter, that of the pulmonary arteries (PAs) or that of the pulmonary veins (PVs), more precisely reflects pulmonary blood flow (PBF) bilaterally and unilaterally.

METHODS

To evaluate bilateral PBF, we studied 15 consecutive patients with Kawasaki disease as normal patients and 30 patients with tetralogy of Fallot who received cardiac catheterization. To evaluate unilateral PBF, 20 patients with various congenital heart diseases undergoing cineangiography and lung perfusion scintigraphy were studied. The diameter of PA was measured immediately proximal to the origin of the first lobar branches bilaterally, and right PA area, left PA area, PA area (mm2), and PA index (mm2/m2) were calculated. The diameter of PV was also measured distal to the junction with the left atrium. Right PV area, left PV area, PV area (mm2), and PV index (mm2/m2) were calculated from these diameters. Pulmonary blood flow (PBF) was obtained by the Fick method during catheterization. To evaluate unilateral PBF, PBF was divided into right and left PBF according to the right/left perfusion ratio measured by lung perfusion scintigraphy.

RESULTS

Evaluation of bilateral PBF was as follows: in normal patients, PA and PV areas were correlated with body surface area (r = 0.88, p = 0.0001 and r = 0.93, p = 0.0001); PA index and PV index ranged from 248 to 436 (mean = 343) mm2/m2 and from 346 to 595 (mean = 466) mm2/m2, respectively, and were constant irrespective of body surface area; PA and PV areas were correlated with PBF in normal patients, as well as in patients with tetralogy of Fallot. There was a better correlation between PV area and PBF than between PA area and PBF in normal patients, as well as a significantly better correlation in patients with tetralogy of Fallot. Evaluation of unilateral PBF was as follows: right PV area was correlated with right PBF (p = 0.0002), while right PA area was not; left PV area and left PA area were correlated with left PBF; right/left PV area ratio was correlated with the right/left perfusion ratio with better agreement than right/left PA area ratio.

CONCLUSION

Our data suggest that the size of PVs in patients with congenital heart disease may be more useful than the size of PAs to indicate bilateral and unilateral PBF than the size of PAs. Differences in PV area of each lung may be a suitable indicator of discrepancy in blood flow to each lung.

Morphologic analysis of common atrioventricular valves in patients with right atrial isomerism

The objective of the study was to examine the relation between the morphology of the common atrioventricular valve and regurgitation of the valve in patients with right atrial isomerism. We examined seven consecutive patients with documented right atrial isomerism who subsequently underwent postmortem examination during a 10-year period. The degree of regurgitation and the diameters of the common valve were evaluated via cineangiography, and the site of regurgitation was evaluated by echocardiography. The morphology of the common atrioventricular valve was assessed further at autopsy. Cineangiography revealed valve diameters ranging from 14.8 to 27.8 mm (mean 20.9 mm). Valvar regurgitation was revealed within 2 months of birth in all patients. Regurgitation abruptly worsened in three patients after placement of a Blalock-Taussig shunt or a central shunt and postintubation. Autopsies revealed that the common atrioventricular valve consisted of four leaflets in five patients, and three leaflets in two. The anterior leaflets were large and protruding in all patients, and the lateral leaflets were thickened in six. All patients had a mass consisting of the left lateral leaflets and chordae with direct attachment of the chordae to the ventricular muscle (the right lateral leaflet was attached to the ventricular muscle and immobile in one patient). The lateral leaflets clung to the ventricular wall and exhibited poor movement in six patients. Leaflets with poor mobility corresponded to the regurgitant valvar site as assessed by echocardiography in six patients; and the regurgitation in three patients with acute deterioration occurred at the valvar side with poor mobility. It is concluded that the common atrioventricular valve in patients with right atrial isomerism has morphologic characteristics that may be associated with valvar regurgitation and malignant potential for abrupt deterioration after replacement of systemic-pulmonary shunting.

Surgical atrial septostomy without cardiopulmonary bypass

Surgical atrial septostomy using a special atriotomy knife without cardiopulmonary bypass in patients with obstruction of the left-sided atrioventricular valve and complex cardiac anomalies is described. This procedure is effective, safe, and economical for patients in the acute stage after intracardiac repair, and available for patients with a closed fossa ovalis.

Optimal degree of pulmonary artery banding--adequate circumference ratio to calculated size from normal pulmonary valve dimensions

These findings suggest that PA banding may be suitable in children with congenital heart disease and excessive pulmonary flow, and that best results are obtained when the band circumference is < 90% of the standard pulmonary valve-ring circumference, as calculated from an equation derived from normal pulmonary valve dimensions. This guideline applies equally well to small infants weighing < 3 kg and to larger patients.

Spontaneous aortic thrombosis in a neonate with multiple thrombi in the main branches of the abdominal aorta

Spontaneous aortic thrombosis in the neonate is a rare entity with a high mortality rate. The present patient, who was diagnosed after showing haematuria and cyanosis, underwent aortic thrombectomy with a Fogarty catheter through a left thoracotomy, but died of sepsis, disseminated intravascular coagulation and multiple organ failure. Autopsy revealed multiple residual thrombi in the main branches of the abdominal aorta and necrosis of the abdominal organs despite a patent thoracoabdominal aorta. In patients with no blood flow in the main branches of the abdominal aorta on preoperative examination, removal of thrombi, including those in the main branches of the abdominal aorta, might be performed in a single, early and aggressive procedure.

Open heart operation in a young child with spherocytosis

Open heart operations on patients with hereditary spherocytosis have been reported rarely. Young children who have not yet undergone splenectomy have a high risk of intraoperative hemolysis because of the heart-lung machine and secondary renal failure. We report the case of a 15-month-old child with spherocytosis who underwent an open heart operation without serious complications as a result of careful and appropriate perioperative management.

[Growth of the hypoplastic aortic arch after arch repair for coarctation and interruption of the aorta]

Surgical treatment for a hypoplastic aortic arch associated with coarctation or interruption of the aorta is controversial. We evaluate the changes of diameter of proximal transverse aortic arch after surgery in 28 patients. Proximal transverse aortic arch in all patients was preoperatively 3.5 +/- 0.9 mm (2.5 to 7 mm), and 54 +/- 12% (36 to 84%) to the normal aortic valve dimension (n-AVD: 16.6 X BSA0.6). While postoperative proximal transverse aortic arch was 6.5 +/- 1.8 mm, and 76 +/- 12% to the n-AVD, and significantly grew more than the preoperative arch dimension (p = 0.0001). In 18 patients having two times cardiac catheterization postoperatively, proximal transverse aortic arch was 6.5 +/- 1.6 mm, and 75 +/- 13% to n-AVD on the 1st postoperative examination. On the 2nd examination, the arch was 9.9 +/- 1.9 mm, and 88 +/- 12% to n-AVD, and significantly grew with increasing years (p < or = 0.0003). We concluded that the proximal transverse aortic arch, which was more than 36% to n-AVD in diameter, if not dilated surgically, grew with increasing years after aortic arch repair.

[Subaortic stenosis in coarctation or interruption of the aorta--changes of left ventricular outflow tract dimension after aortic arch repair and pulmonary artery banding]

Left ventricular outflow tract (LVOT) dimension was measured in seven patients with coarctation (CoA) or interruption (IAA) of the aorta before and after aortic arch repair and pulmonary artery banding. The age of patients ranged 3 to 69 (mean 16) days, the weight 3.0 to 3.9 (mean 3.4) kg. Associated cardiac anomalies were VSD in 6, MA and DORV in 1. In five patients compared by ultrasound, preoperative LVOT dimension ranged from 3.5 to 5.0 (mean 4.4) mm with the ratio to the normal aortic valve dimension (n-AVD; 16.6 x BSA0.6) from 54 to 82 (mean 69)%. Postoperative dimension increased 5.0 to 7.4 (mean 5.7) mm and the ratio to the n-AVD increased 65 to 89 (mean 80)%. In three patients compared by LV graphy, preoperative LVOT dimension ranged from 4.0 to 4.5 (4.2) mm and the ratio ranged from 61 to 72 (68)%. Postoperative dimension increased from 4.5 to 6.7 (5.3) mm, and 74 to 80 (78)% to n-AVD after operation. Postoperative pressure gradients between LV and ascending aorta in each patient were 1 to 9 (mean 6) mmHg. In any patients, LVOT obstruction did not advance after aortic arch repair and pulmonary artery banding.

[Usefulness of expandable metallic stent to bronchial stenosis caused by an advanced lung cancer--a case report]

We used Expandable Metallic Stent (EMS) to bilateral bronchial stenosis due to invasion of lung cancer. A 75-year-old man was admitted to our hospital because of dyspnea and a fainting fit on October 19, 1991. He had been suffered from squamous cell carcinoma of right lung with bilateral bronchial invasion (T4N2M0), which has no indication for surgery. As the stenosis of bilateral main bronchus and the respiratory distress progressed, we applied EMS to the patient and inserted it into the left main bronchus on December 19, 1991. The procedure promptly relieved the respiratory distress and improved his quality of life. Bronchial endoscopy, performed on the 20th postoperative day, revealed the left bronchus patency. Thus, EMS applied to the bronchial stenosis caused by advanced lung cancer may be a choice of palliative therapy and can improve the quality of patient's life.