[Emergency operation due to complications of cardiac catheterization]

From January 2001 to July 2005, 4,741 cardiac catheterizations were performed on adult patients at our institute. Five of them underwent emergency operation due to complications of cardiac catheterization. The causes of operations were acute coronary occlusion due to coronary arterial dissection in 3 patients and bleeding due to perforation of the coronary artery in 2. Intra-aortic balloon pumping was used preoperatively in 4 patients and percutaneous cardio-pulmonary support in 2. Coronary artery bypass grafting was performed on all patients. Perforation sites of the coronary arteries were closed. One patient died 4 months after surgery, due to neurological damage, but the other 4 patients recovered and have been doing well. As coronary artery disruption is one of the main complications of cardiac catheterization, it is necessary to recognize the risk of hemodynamic derangement and to give prompt and appropriate treatment.

[Two-stage repair of the transposition of great arteries with interruption/coarctation of the aorta]

We report on 10 patients who underwent two-stage repair of transposition of the great arteries (TGA) with interruption (IAA) or coarctation (CoA) of the aorta. First, an operation for aortic arch reconstruction was performed: Blalock-Park with pulmonary artery banding (PAB) for IAA (5 patients), subclavian flap with PAB for CoA (4 patients) and end-to-end anastomosis without PAB (1 patient). All survived the first operation and had no significant pressure gradient with good growth of the ascending aorta, except for the 1 case without PAB. Half of the 8 patients who underwent PAB developed migration of the PAB. The arterial switch operation (ASO) was performed 0.7-12.6 (5.6+/-4.7) months after the first surgery. One patient with an abnormal coronary artery tract was lost after ASO. Five developed pulmonary artery stenosis and 1 developed supra-aortic stenosis late after ASO. Two patients need reoperation, 1 for supra-aortic stenosis, and the other for reCoA. Two-stage repair for TGA with IAA/CoA is still a useful method with a good operative result. However, strict follow-up is necessary because of the high frequency of late morbidity.

[Mitral valve replacement 41 years after right pneumonectomy]

Mitral valve replacement was performed successfully on a 68-year-old patient who had undergone right pneumonectomy and thoracoplasty 41 years earlier. Preoperative pulmonary function tests revealed poor results; the forced vital capacity was 950 ml (28.0% of the predicted value) and the forced expiratory volume in 1 second was 750 ml (28.9% of the predicted value). Despite such poor pulmonary function, the patient tolerated the operation well and led uneventful course. Careful perioperative management to prevent pulmonary edema and aggressive postoperative pulmonary toilet to facilitate recovery of the pulmonary function seem important.

Bidirectional Glenn procedure improves the mechanical efficiency of a total cavopulmonary connection in high-risk fontan candidates

BACKGROUND

A total cavopulmonary connection (TCPC) is a widely performed surgical procedure for Fontan candidates. High-risk candidates who have undergone the bidirectional Glenn procedure (BDG) before TCPC have shown good results. The exact mechanism of this procedure, however, is still poorly understood. We hypothesized that a volume reduction with BDG improved ventricular contractility, thereby optimizing mechanical efficiency after TCPC.

METHODS AND RESULTS

We measured percent normal systemic ventricular end-diastolic volume (%N-EDV), contractility (end-systolic elastance; E(es)), afterload (effective arterial elastance; E(a)), and mechanical efficiency (ventriculoarterial coupling; E(a)/E(es)) on the basis of the cardiac catheterization data before and after TCPC. Eighteen patients who underwent staged TCPC after BDG (staged group) were compared with 29 patients who underwent primary TCPC (primary group). E(es) and E(a) were approximated as follows: E(es)=mean arterial pressure/minimal ventricular volume, and E(a)=maximal ventricular pressure/(maximal ventricular volume-minimal ventricular volume), and E(a)/E(es) was then calculated. The ventricular volume was normalized with the body surface area. A canine experimental model with conductance catheter was used to validate the accuracy of this approximation of E(es) and E(a). %N-EDV decreased after TCPC in both groups. In the staged group, a smaller ventricular volume resulted in better contractility (E(es)). Although afterload (E(a)) increased in both groups, the increment of E(a) was smaller in the staged group. These changes resulted in an improvement of E(a)/E(es) in the staged group, whereas E(a)/E(es) increased in the primary group.

CONCLUSIONS

The volume reduction of BDG preceding TCPC allows for any afterload mismatch to be corrected, thereby improving ventricular energetics after TCPC.

Surgical management of aortopulmonary window

OBJECTIVE

Aortopulmonary window is a rare congenital malformation involving a window-like communication between the ascending aorta and the pulmonary artery. Here, we present our experience regarding the surgical repair of an aortopulmonary window, and also assess the long-term outcome.

METHODS

Thirteen children with an aortopulmonary window associated with various congenital lesions underwent a repair of the defect. The age at operation ranged from 3 days to 1 year (median age, 19 days). The patient's weight ranged from 2.1 to 7.0 kg (mean weight, 3.6 kg). The associated lesions included an interrupted aortic arch (5 patients), a ventricular septal defect (2), an atrial septal defect (1), mitral valve regurgitation (1), and tricuspid atresia [Ic] with mitral valve regurgitation (1). The aortopulmonary window was repaired with a cardiopulmonary bypass in 11 patients, and 2 patients were ligated without a cardiopulmonary bypass.

RESULTS

One patient associated with tricuspid atresia died (mortality rate of 7.7%). There has been no late death during a mean follow-up of 7 years and 3 months.

CONCLUSIONS

The surgical results for an aortopulmonary window are encouraging, even if such patients are associated with major cardiac anomalies and an interrupted aortic arch. Most have shown a good long-term outcome.

[Surgical treatment of interrupted aortic arch with aorticopulmonary window]

From January, 1988, through September, 1993, 3 neonates underwent one-stage repair for interrupted aortic arch (IAA) with aorticopulmonary window (APW). Their mean weight was 3.0 kg (2.7-3.3 kg). IAA was Celloria-Patton classification type B in two patients and type A in the other. In all cases, APW was Mori's classification type II. Two patients took a sudden turn for worse during the stay of our hospital and underwent emergency operation. Surgical procedures were as follows; In the first patient, aortic arch reconstruction was performed with phi 8 mm Golaski graft, under extracorporeal circulation for only upper body under moderate hypothermia. After distal anastomosis, perfusion for lower body was restarted through the graft branch, then proximal anastomosis was done. In the other two patients, arch reconstruction was performed by end to side direct anastomosis under total circulatory arrest and deep hypothermia, and APW was divided during recirculation, rewarming period. In the first patient, graft was anastomosed to the defect of the ascending aorta. In the other two patients the defect of the aorta was directly closed. The defect of the pulmonary artery was closed directly in two patients and with autopericardium in the other. There was no operative deaths. Two cases who underwent emergency operation due to sudden turn for worse didn't become well soon. Thus, we concluded that surgical intervention should be done as soon as possible before patient became critically ill and one-stage repair should be recommended because of the difficulty of palliation such as PA banding in this disease.

Recurrent forearm thrombophlebitis after transvenous permanent pacemaker insertion

This report describes a 69-year-old Japanese woman with bilateral forearm thrombophlebitis that developed soon after transvenous permanent pacemaker insertion. Intravenous administration of urokinase and heparin rapidly resolved fever, painful forearm swelling and inflammatory findings. Digital subtraction venograms revealed a brachiocephalic vein thrombosis. A ten-month treatment with warfarin and ticlopidine resulted in the complete restoration of venous flow. Although thrombophlebitis associated with transvenous permanent pacemaker insertion has a relatively low incidence (0.3%), prompt diagnosis and treatment with anticoagulant and/or thrombolytic agents are important for the late clinical outcome in cases with deep venous thrombosis.

[Transvenous monitoring of left atrial and central venous pressure with a double-lumen catheter]

We developed a new method to monitor left atrial pressure in the patients undergoing open heart surgery. The advantages of our method are 1) freedom from complications relating its removal (eg. bleeding) because of its transvenous insertion, and 2) simultaneous monitoring of both right and left atrial pressures by a single catheter. We designed to place the second port of a two-lumen central venous catheter 5 or 7 cm proximal to the tip. The catheter is inserted into the right atrium before surgery and the tip is advanced in the left atrium through the foramen ovale intraoperatively. We used this catheter in 16 infants and children, and found that effective hemodynamic monitoring was obtained without any complications. We recommend this method for the postoperative management of open heart surgery in the pediatric patients.

Trans-septal left atrial catheterisation

A newly designed 4 FG double-lumen catheter with the second port located either 5 or 7 cm proximal to the tip was tested in five children undergoing open heart surgery. The catheter was inserted percutaneously and initially positioned in the superior vena cava, right atrium or inferior vena cava. During cardiopulmonary bypass, the tip of the catheter was repositioned manually in the left atrium across the interatrial septum. In all patients, left atrial pressure was monitored successfully while central venous pressure was monitored with the second port positioned in the superior vena cava. Removal of the catheter from the left atrium was easily performed and caused no problems.

New technique in the transfer of an anomalously originated left coronary artery to the aorta

A 21-month-old girl with an anomalous origin of the left coronary artery underwent a transfer of the left coronary artery to the aorta using a new technique of coronary prolongation. Because the anomalous left coronary artery arising from the left anterior aspect of the pulmonary trunk was too short to reach the aorta, a simple transfer of the left coronary artery to the aorta was deemed impossible. Therefore, a transfer was performed with the help of a coronary prolongation technique using the cuff of the pulmonary trunk and an aortic flap. The new route of the left coronary artery was established anterior to the pulmonary trunk. Postoperative angiography showed a patent left coronary artery without any narrowing or kinking, as well as an improved contractility of the left ventricle. Postoperative cardiac scintigraphy showed a decreased ischemic area. This technique is thus considered applicable when the orifice of the anomalous left coronary artery is too distant from the aorta for a direct anastomosis.

[Methicillin-resistant Staphylococcus aureus endocarditis following patch closure of ventricular septal defect]

Mediastinitis due to methicillin-resistant Staphylococcus aureus was found on the ninth postoperative day after patch closure of ventricular septal defect (VSD) in a six-month-old girl. Intravenous administration of vancomycin and debridement of the wound followed by irrigation with povidone iodine and vancomycin led to wound disinfection, but blood cultures continued positive. On the 22nd postoperative day, an echocardiographic examination revealed vegetations in the right ventricle. An emergency open heart operation was undergone. The largest vegetation was 1 x 2 cm in size, originating from the intracardiac patch used for closure of the VSD. The pulmonary and tricuspid valves were also involved. After removal of the infected tissues, including the two cusps of the pulmonary valve and a part of the tricuspid valve, the ventricular septal defect was closed again with a woven Dacron patch. The defect in the tricuspid valve was repaired. Postoperative examinations revealed severe pulmonary regurgitation and mild tricuspid regurgitation, but the cardiac function was good and neither vegetation nor leakage around the patch was recognized.

[Surgical treatment of total anomalous pulmonary venous connection under three months of age]

Nine infants under 3 months of age with total anomalous pulmonary venous connection underwent total correction between June, 1986 and September, 1988. The age at operation ranged from 4 days to 59 days, averaging 19 days, and the body weight ranged from 1,814 g to 4,105 g, with a mean of 3,050 g. The types of TAPVC were Darling Ia in 4, Ib in 1 and III in 4. All the patients were operated by the posterior approach under cardiopulmonary bypass with high flow (130-200 ml/kg/min) and mild hypothermia using modified GIK-cardioplegia, topical cooling and aortic cross clamping. Although the incision in the common pulmonary vein trunk was never extended into the pulmonary veins or vertical vein, the length of the mouth was at least 10 mm. In the postoperative management, care was taken to avoid overhydration and rapid volume infusion. Blood pressure was kept just enough to maintain urine output. Heart rate was kept over 170/min for early postoperative days with the use of isoproterenol or atrial pacing. There was no operative or late death. Postoperative course was uneventful in all cases except one with low output syndrome in which mechanical ventilation for 8 days was required. Postoperative catheterization and angiography revealed normal intracardiac pressure values and no pulmonary venous obstruction in all cases. Follow-up period ranged from 10 to 37 months, and there has been no patient with the signs of PVO.

[A successful case of localized aortic dissection associated with bicuspid aortic valve]

It is known that bicuspid aortic valve is a risk factor of aortic dissection in Europe and America, but there is no report of the case in Japan. A 47-year-old male teacher of senior high school had an abrupt onset of chest pain. Aortogram showed localized dissection of the ascending aorta and moderate degree of aortic regurgitation. Cold cardioplegic arrest with moderate systemic hypothermia was used under cardiopulmonary bypass. The aortic valve was bicuspid and localized transverse intimal dissection was also found above left-sided commissure. As both cusps were soft and not degenerative, mattress sutures were used to support the prolapsed cusps against the outer aortic wall. The ascending aorta was replaced with a prosthetic vascular graft. Postoperative clinical course was uneventful and he is doing well two years after the surgery. The bicuspid aortic valve and aortic dissection were also discussed.

[Early and late results of St. Jude Medical prosthesis in aortic and mitral portion]

January, 1980 to December, 1988, 118 patients underwent aortic (AVR) (45), mitral (MVR) (55), aortic and mitral (DVR) (21) valve replacement with a tilting disc valve prosthesis, the St. Jude Medical. Age ranged from 11 to 69 years (mean 49). There were seven death within thirty days after the surgery (AVR 1, MVR 5, DVR 1). Follow-up is complete and ranges from 1 month to 107 months (total 392, 4 patient-year (pt-yr), AVR 127.7 pt-yr, MVR 182.6 pt-yr, DVR 82.0 pt-yr). In the AVR group, three late deaths have occurred and actuarial survival at 8 years is 89 +/- 5%. Five patients have sustained thromboembolic episodes from linearized rate of 4.7%/patients-year, and the probability of remaining free of thromboembolism at 8 years is 83 +/- 7% in survivors longer than thirty days after the surgery. In the MVR group, one late death has occurred and actuarial survival at 8 years is 87 +/- 5%. Two patients have sustained thromboembolic episodes from linearized rate of 1.1%/patient-years, and the probability of remaining free of thromboembolism at 8 years is 86 +/- 1% in survivors longer than thirty days after the surgery. In the DVR group, four late deaths have occurred and actuarial survival at 8 years is 75 +/- 12%. Two patients have sustained thromboembolic episodes from linearized rate of 2.4%/patients-year, and the probability of remaining free of thromboembolism at 8 years is 85 +/- 5% in survivors longer than thirty days after the surgery. There is no significance of actuarial survival rate among three groups, but the rate of thromboembolism in AVR group is significantly higher than in other MVR and DVR groups in the first 20 months. Reoperation was carried out in one patient because of perivalvular leak. There have been no thromboses of the SJM valve and no mechanical valve failure. Because of this experience, The St. Jude Medical heart valve prosthesis is our prosthesis of choice for any patient undergoing valve replacement with a mechanical prosthesis.

[Surgical treatment of coarctation of the aorta and interrupted aortic arch]

From December, 1984, through April, 1987, ten infants with coarctation of the aorta and six with interrupted aortic arch underwent staged repair of aorta and other cardiac lesions. Simultaneous pulmonary artery banding was performed in six of 8 patients with ventricular septal defect (VSD) and in all of seven patients with complex cardiac lesions. With first operation, there were no operative deaths and two late deaths. Eight of 14 survivors underwent total correction of associated lesions at three to 17 months after initial operation. VSD was closed in five patients with one operative death. One patient required pulmonary artery debanding alone because of decrease of VSD size. The Damus-Kaye-Stansel operation was performed successfully in one patient with Taussig-Bing anomaly and the Jatene operation was done in one with transposition of the great arteries. Based on these results, we prefer staged repair with pulmonary artery banding for coarctation or interruption of the aorta associated with complex cardiac lesions.

Kay's mitral valve repair for mitral regurgitation due to ruptured chordae tendineae--clinical and hemodynamic observations

Kay's mitral valve repair was performed in six consecutive patients with symptomatic mitral regurgitation due to ruptured chordae tendineae of the posterior leaflet. All patients including one with mild residual murmur showed a marked decrease in the heart size and significant clinical improvement. Postoperative hemodynamic studies, performed in four patients, showed restoration of normal or near-normal dynamics. The medium-term follow-up, 15 to 30 months after the operation, revealed continuing asymptomatic states in all. The function of the repaired valves was significantly better than that of the Hancock mitral bioprostheses. The advantages of this procedure compared with mitral valve replacement for the same condition were stressed.

Coenzyme Q10: the prophylactic effect on low cardiac output following cardiac valve replacement

A randomized, prospective study of the effectiveness of preoperative administration of coenzyme Q10 on the prophylaxis of postoperative low cardiac output state was performed in 50 patients with acquired valvular diseases necessitating valve replacement. There were 25 patients in the treatment group and 25 in the control group. Patients in the treatment group received 30 to 60 mg of coenzyme Q10 orally for six days before operation. Preoperative clinical variables, operative procedures, total cardiopulmonary bypass time, and aortic cross-clamping time were similar for the two groups. Postoperatively, mild to severe low cardiac output state developed in 28 of 50 patients (56%) and necessitated the administration of considerable amounts of inotropic agent. The treatment group showed a significantly lower incidence of low cardiac output state during the recovery period than the control group (p less than 0.05). These results suggest that preoperative administration of coenzyme Q10 will increase the tolerance of human hearts to ischemia during aortic cross-clamping.

Predisposing factors of renal dysfunction following total correction of tetralogy of Fallot in the adult

A retrospective study of 21 adult patients with tetralogy of Fallot (TOF) was undertaken to determine the predisposing risk factors of renal dysfunction following total correction of the disease. Five of the 21 patients exhibited moderate-to-severe postoperative azotemia and an additional five exhibited mild azotemia. Significant risk factors for postoperative renal dysfunction found in routine preoperative examinations were as follows: arterial oxygen saturation of less than 90%, cardiothoracic ratio (CTR) of greater than 50%, mean electrical axis of the QRS complexes of greater than +120 degrees, S wave in Lead V6 of greater than 7 mm, R/S voltage ratio in Lead V6 of less than 2, and negative T wave in Lead V6. In addition, preoperative cardiac catheterization data showed that the patients exhibiting postoperative azotemia had more severe pulmonary stenosis, a smaller pulmonary-to-systemic flow ratio (Qp/Qs), and a larger left ventricular cavity than nonazotemic patients. The incidence of postoperative low cardiac output state (LOS) was significantly higher in the azotemic patients. These findings suggest that a combination of the severe form of TOF and a large left ventricle increase susceptibility to LOS and postoperative renal dysfunction. The cause and the clinical significance of the large left ventricular cavity in adults with TOF are discussed.

Detection of flail aortic valve in bacterial endocarditis with real-time two-dimensional echocardiography. A case report

This report describes a case with flail right and noncoronary cusps due to bacterial endocarditis, diagnosed with real-time two-dimensional echocardiography. Real-time two-dimensional phased array sector scanner demonstrated 2 cugdel-shaped lesions in the region of the left ventricular outflow tract through the aortic root, pendulating upward and downward floating along the blood stream. This study shows that the real-time two-dimensional echocardiography is a very useful noninvasive tool in the early diagnosis of flail aortic valve.