Adventitial inversion technique without the aid of biologic glue or Teflon buttress for acute type A aortic dissection

Objective: This study was performed to evaluate the clinical usefulness of the adventitial inversion technique in acute type A aortic dissection, with special attention to the impact of this procedure on the postoperative status of false lumen evaluated by computed tomographic scan. Methods: From March 2001 to November 2004, 18 consecutive patients underwent emergent surgery for acute type A aortic dissection. Supracoronary graft replacement was performed in all the patients (ascending aorta/hemiarch replacement: 13/18 = 72%, total arch replacement: 5/18 = 28%). The adventitial inversion technique was used for both the proximal and the distal stump constructions of the dissected aortic wall without the aid of Teflon felt or biologic glue. Aortic regurgitation was treated with resuspension of the aortic commissures. Results: There were two hospital deaths and the overall hospital mortality rate was 11.1%. The mean postoperative blood loss was 635 ± 214 ml and no reexploration was required in any of the patients. Postoperative computed tomography showed closure of the false lumen in aortic root, aortic arch, and proximal descending thoracic aorta in all of the surviving patients. Postoperative echocardiography demonstrated no aortic regurgitation in any of the patients. Two patients died late postoperatively from unrelated causes to aortic dissection. The remaining 14 patients are doing well without a second-stage operation for aortic root or distal aortic lesions during the follow-up period of 7–51 months (mean: 28 ± 14 months). Conclusions: The adventitial inversion technique provides an excellent immediate hemostasis and facilitates thrombotic closure of the proximal and the distal false lumen in the treatment for acute type A aortic dissection

<症例>4回の開心術による癒着のため冠動脈走行が判別不能であった大動脈弁輪部膿瘍に対するトランスロケーション法における冠動脈再建の新方法

A new approach to the problem of recurrent infection of an aortic valve prosthesis in a patient with an inaccessible coronary arterial system is presented. The coronary arteries were reconstructed by anastomosing a looped ringed-PTFE graft to the left and right coronary ostia within the aorta, and the graft was withdrawn from the aorta just above th e ostia. Then the top of the looped graft was anastmosed to the aorta above a translocated aortic prosthesis. This procedure is most likely to be useful in the treatment of recurrent aortic prosthetic valv e endocarditis which has dense pericardial adhesion secondary to multiple cardiac operations. Aortic prosthetic valve endocarditis frequently is associated with a paravalvular ring abscess which may destroy the normal annulus. In these cases, translocating the aortic valve to the ascending aorta, and placing saphenous vein bypass grafts to the right and th e left anterior descending coronary arter y may be required. However, the coronary arteries may not be accesible following multipie operations. The following case illustrates a new solution to the problem how to translocated the aortic valve and reconstruct the coronary arteries in a patient with an infected aortic root and inaccessible coronary arteries.4回の関心術による癒着のため冠動脈の走行が判別不能であった大動脈弁輪部膿瘍を伴なった感染性心内膜炎症例に対し, 冠動脈再建に新しい方法を用いたトランスロケーション法を行った. 8 mmφ のリング付き PTFE 人工血管の両端を大動脈の内腔で左右冠動脈孔に縫着し, その直ぐ末梢側で一旦大動脈外にグラフトを出しそのループの頂点部を転位縫着した人工弁の末梢側で大動脈(弁付き人工血管の場合は人工血管)と側側に吻合する方法を行った. 術後経過は順調で, 狭心症, 不整脈は発生していない

<原著>心筋保護におけるグルタチオンペルオキシダーゼの重要性 : ラット心を用いて

Selenium (Se) is an integral component of glutathione poeroxidase (GSHPx), and the serum selenium concentration is age-depend. We speculated that myocardial GSHPx had relation to reperfusion injury in open heart operations, especially in infants in whom GSHPx activity is low. This study correlated GSHPx activity with the serum and myocardial selenium concentrations in Wistar rats, which were divided into three groups, infants, Se-deficient rats, and control rats. Serum GSHPx activity in infant and Se-deficient rats (22. 7± 3. 5 U/g protein, 24. 6 ± 22. 2 U/g protein) was lower than that in controls (179 ± 12. 0 U/g protein). The serum selenium concentration in infant and Se-deficient rats (3. 81 ± 0. 81 μg/g protein, 2. 06 ± 1. 69 μg/g protein) was also lower than that in controls (7. 32 ± 2. 96 μg/g protein). The myocardial GSHPx activity was significantly lower in infants and Se-deficient rats (4. 76 ± 1. 05 × 10_-1 U/mg protein, 3. 38 ± 0. 32 × 10_-1 U/mg protein) than that in controls (8. 03 ± 0. 57 × 10_-1 U/mg protein). However, the myocardial selenium concentra tion in infants (1. 42 ± 0. 24 × 10_-1μg/mg protein) was significantly higher than that in the other groups (0. 31 ± 0. 06 × 10_-1 μg/mg protein, 0. 28 ± 0. 04 × 10_-1 μg/mg protein). Next, in Se-deficient and control rats, isolated hearts were perfused for aerobically with Krebs-Henseleit solution in the Langendorff mode for 15 minutes, followed by 60 minutes of global ischemia at 4°C and then reperfused for 30 minutes in a working mode. The hemodynamic parameters were measured. The aortic pressure, LV max dp/dt, aortic flow, cardiac output and stroke volume were significantly lower in the Se-deficient rats than those of the control rats. Immediately following these measurements, the hearts were frozend in liquid nitrogen, and the myocardial lipid peroxide (TBARS) concentration was assayed and found to be significantly higher in the Se-deficient rats. The lower myocardial GSHPx activity may play a important role in vulnerability to reperfusion injury in infants as in Se-deficient rats.必須微量元素セレン(Se)は, フリーラジカルスカベンシャーの一つであるグルタチオンベルオキシダーゼ(GSHPx)の主要な構成成分である. 血清 Se 濃度は年齢により変化し新生児期, 乳児期は低い. このことが乳児期の関心術における再灌流障害に関与しているのではないかと推論した. ウィスター系ラットを乳児期ラット(乳児群), Se 欠乏食ラット(Se群), 対照成熟ラット(対照群)の3群に分けた乳児群, Se 群の血清 GSHPx 活性は, 対照群と比べ有意に低値を示した(順番に22. 7 ± 3. 5, 24. 6 ± 22. 2, 179. 0 ± 12. 0 U/g protein). 乳児群, Se 群の血清 S e濃度も同様に対照群と比べ有意に低値を示した(3. 81±0. 81, 2. 06 ± 1. 69, 7. 32 ± 2. 96 μg/g protein)・乳児群, Se 群の心筋 GSHPx 活性は対照群と比べ有意に低値を示した(4. 76 ± 1. 05 × 10_-1, 3. 38 ± 0. 32 × 10_-1, 8. 03 ± 0. 57× 10_-1 U/mg protein). しかし乳児群の心筋 Se 濃度は Se 群, 対照群と比べ有意に高値を示した(1. 42 ± 0. 24 × 10_-1, 0. 31 ± 0. 06 × 10_-1, 0. 28 ± 0. 04 × 10_-1 μg/mg protein). これとは別に Se 欠乏食ラットと対照成熟ラットの摘出心を用いて Neely JR らの working heart model により, 4°C 60分間の心停止後の心機能パラメーターを測定した. 大動脈圧, 左室 max dp/dt, 大動脈流量, 心拍出量, 一回拍出量は S e群で有意に低値を示した. また心筋内過酸化脂質(TBARS)濃度は, Se 群で有意に高値を示した. このことから, 心筋内 GSHPx 活性の低下は心筋の再灌流障害と非常に関連が深いことが示唆された