An Analysis of Cardiopulmonary Hemodynamics During Hemorrhagic Shock in Dogs

Utilizing the standard Wiggers' method, hemorrhagic shock was induced in ten anesthetized dogs by bleeding to a mean arterial pressure (MAP) of 50 mmHg for 2 hr and then to 30 mmHg for 1 hr, followed by reinfusion of the shed blood. The experimental protocol was designed to evaluate the effect of hemorrhagic shock on sequential pulmonary hemodynamic changes in relation to those of cardiac and systemic circulation. All selected cardiopulmonary hemodynamic parameters were recorded throughout the experiment on a multi-channel poly-oscillograph monitor. Total pulmonary resistance (TPuR) started rising early in hemorrhagic shock and was found to rise to a level that was 10-fold greater than pulmonary arteriolar resistance (PAR). This meant that, 90% of TPuR came from the venous side of the pulmonary vascular bed. Persistently raised TPuR even after reinfusion was linked to early death of the experimental animals. Myocardial contractility (max dp/dt mmHg/sec) which is one of the indices for cardiac performance was found to be severely depressed at terminal stage (p<0.001). Both total pulmonary and peripheral resistances were found to have an inverse relationship to ventricular performance which was measured by left ventricular stroke work (LVSW) and right ventricular stroke work (RVSW). There is a high suspicion that reinfusion or resuscitation following prolonged hypovolemic shock may aggrevate the hemorrhagic shock effects by facilitating the distribution of accumulated blood-borne toxic substances to various target organs and that, this has been linked with the early and sustained pulmonary hemodynamic disturbance found in these experiments

One-stage hybrid procedure for aberrant right subclavian artery and thoracic aneurysm

A 60-year-old man without any symptoms was referred to our department because computed tomography revealed an aberrant right subclavian artery (ARSA) and a saccular aortic aneurysm arising opposite to the ARSA. We performed the following procedures through a median sternotomy: total arch replacement, insertion of a frozen elephant trunk to exclude the aneurysm and ARSA, placement of a vascular plug under transesophageal ultrasonography to occlude the dilated ARSA, and right axillary artery bypass. Postoperative computed tomography showed complete occlusion of the ARSA and exclusion of the aneurysm. This procedure should be considered an alternative strategy for treatment of patients with an ARSA

Experimental Evaluation of Bretschneider's Solution for Myocardial Preservation in Cardiac Transplantation

Myocardial preservation by Bretschneider's solution (BR solution, Group I) with an intracellular like electrolyte and histidine buffer action was compared with EC-Bi solution (Group II) which has an extracellular like electrolyte and bicarbonate buffer action in the mongrel dogs. The PH and PCO2 of the effluent from the coronary sinus were maintained during myocardial ischemia for 3 hr but the lactate rose gradually in group I. The oxygen and lactate up-take ratio of the myocardium after re-perfusion was satisfactory and LV max dp/dt was also maintained at a high level in group I. Morphologically, myelin figure and mitochondrial deformation were more found in group II on electron microscopy. A donor heart preserved for 3 hr in cold BR solution was transplanted in the left thoracic cavity in four mongrel dogs by the technique of the heterotopic cardiac transplantation. Resuscitation of cardiac pulsation was smooth and maintenance of the systemic circulation after transplantation was possible in every case. From these findings, it might be concluded that myocardial preservation using cold BR solution was useful for cardiac transplantation

Efficacy of the Pulse Pressure Generator during Cardiopulmonary Bypass Training Using the Extracorporeal Circulation Simulator

Objective: Cardiopulmonary bypass during cardiac surgery is an essential procedure, and the perfusionist needs to have sufficient education and training. Simulation training is suitable in such cases. We have developed a simulation system for cardiopulmonary bypass training (extracorporeal circulation simulator [ECCSIM]) and reported its efficacy. ECCSIM had no pulse pressure generator, so some perfusionists have mentioned that the operational feeling during training differs from that in real clinical cases. In this study, we have developed a new pulse pressure generator and examined the efficacy of this system during cardiopulmonary bypass training using ECCSIM. Materials and Methods: Results were observed as wave patterns during simulation of extracorporeal circulation with and without pulse pressure flow. Operational feeling during training of extracorporeal circulation was compared using a questionnaire survey, based on the Japanese version of the NASA Task Load Index (NASA-TLX), a subjective index, completed by seven perfusionists. Results: With the addition of pulse pressure flow, fluctuation of arterial flow at low speed with the centrifugal pump increased, and operation of extracorporeal circulation became unstable. The questionnaire survey, including ‘Operational feeling of centrifugal pump’, ‘Feeling of afterload’, and ‘Display of pressure monitor’, showed results similar to that of the clinical situation using pulse pressure flow. The difficulty of simulator operation in extracorporeal circulation was significantly greater in the group with pulse pressure flow. Mental/physical load examined with NASA-TLX increased with pulse pressure flow. Conclusion: Using a new pulse pressure generator with ECCSIM was effective in extracorporeal circulation training

Effect of Immunomodulatory Artificial Blood Exchange (IABX) on Guinea Pig-to-Rat Heart Xenografts

The aim of this study was to assess the effectiveness of pregraft immunomodulatory artificial blood exchange (IABX) in a guinea pig-to-rat xeno discordant heart transplantation, using an artificial blood (FC43 emulsion: The Green Cross, Japan) in exchange for a large volume of whole blood to remove humoral immune factors en bloc from the recipient rat. In the rats treated with IABX, rhythmic beating of the grafted heart was maintained for 2 hr, whereas the untreated heart beat lasted for only 15.2 ± 5.2 min (n=6). In the graft hearts treated with IABX, no pathologic changes such as multiple coronary thromboses due to hyperacute rejection (HAR) were observed. Humoral immune factors (natural-IgM titer, ACH50 and CH50 complement activities, platelet count, prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen serum concentration), which are thought to contribute to HAR, decreased significantly following the IABX treatment.　　 We conclude that IABX is an efficient method for prolonging the survival time of guinea pig heart xenografts by inhibiting thrombus formation in the xeno-graft heart. It was confirmed that IABX could remove recipient humoral immune factors en bloc.This study was supported by The Green Cross Co.,Ltd

Management of Neonatal Ovarian Cyst

Objective: There is no guideline for the treatment of neonatal ovarian cysts. The present study analyzed our clinical management of such cysts, as well as the results of treatment. Methods: The present study involved 16 patients with neonatal ovarian cysts who had been diagnosed and treated between January 2002 and December 2016. We classified the cysts into two groups based on ultrasonographic images: (1) simple cysts (SCs)—thin-walled, round, or anechoic; (2) complex cysts (CCs), containing fluid-debris level, solid masses, or intracystic septa. We analyzed the clinical characteristics and results in the two groups. Results: Ten of the patients had SCs and six had CCs. Fourteen were diagnosed during the prenatal stages. Of the 10 patients with SCs, eight were managed using observation only, and the cysts spontaneously resolved in all such cases. Six patients had CCs, including one with an SC that had developed into a CC. Eight of the patients underwent surgical treatment, and the surgical methods did not differ in terms of operation time or complication rate. None of the oophorectomy specimens contained any normal ovarian tissue. Conclusion: We operated on all CCs and on SCs more than 40 mm in diameter, while patients with SCs less than 40 mm in diameter were managed using observation only, as were those in whom differential diagnosis was not possible. We must emphasize that percutaneous aspirations are safe, and we recommend transumbilical incisions, because they preserve both esthetics and ovarian function

Long-term Antibiotics and Simple TEVAR for Treatment of Infectious Thoracic Aortic Aneurysm

Purpose: The principle treatment of infectious aortic aneurysm is to remove the infected aneurysm and replace it with Rifampicin-soaked prosthesis by omentopecxy. This study aimed to clarify the efficacy of long-term antibiotics and subsequent thoracic endovascular aneurysm repair (TEVAR) for infectious thoracic aortic aneurysm. Methods: Between July 2011 and December 2015, 213 TEVARs were performed at Hiroshima University Hospital. Six patients (2.8%) had infectious aneurysm and received long-term antibiotic therapy and secondary TEVAR. L ong-term antibiotic therapy and subsequent TEVAR is paradoxical. This study aimed to clarify the timing of TEVAR for infectious thoracic aortic aneurysm. Results: All patients presented with fever and back pain, and had positive blood cultures; five patients had significant co-morbidities. Bacteraemia was caused by Methicillin Sensitive Staphylococcus Aureus (MSSA) (2), Streptococcus sanguinis (1), Methicillin Resistant Staphylococcus Aureus (MRSA) (1), Chryseobacterium meningosepticum (1), and Enterococcus faecalis (1). B lood examination at admission revealed a WBC count ranging from 10,470 to 16,170/μl and CRP ranging from 7.9 to 16.4 mg/dl. Long-term antibiotic therapy was continued until WBC and CRP were within the normal range. TEVAR was performed emergently in 3 cases and electively in 3 cases. The time from admission to TEVAR ranged from 7 to 26 days. One stent-graft was deployed in all 6 cases. All patients survived and were followed for an average of 48 months; they were free from re-infection. Conclusion: Long-term antibiotics and simple TEVAR may be a feasible treatment for infectious thoracic aortic aneurysms

Clinical Analysis of 110 Postoperative Deaths of the Patients with Permanent Implantable Pacemaker

During 14 years follow up of 754 patients received permanent cardiac pacemaker (PM) implantation, 110 cases have died. In this paper, the cause of death of them was clinically analyzed. The death to senility was most frequent, in 31 cases out of 110 deaths (28.2%), and then heart failure in 19 cases (17.3%), cerebrovascular disease in 16 cases (14.5%), sudden death in 14 cases (12.7%), malignancy in 7 cases (6.4%), acute myocardial infarction in 7 cases (6.4%), severe infectious disease in 4 cases (3.6%), unknown etiology in 4 cases (3.6%), renal failure and Disseminated Intravascular Coagulation Syndrome (DIC) in 2 cases (1.8%), respectively, suicide in one case (0.9%). Cause of death by underlying disease was rather characteristic. Senility was frequent in the patients with atrioventricular (A-V) block (38.5%), while cerebrovascular disease was highly observed in the patients with Sick Sinus Syndrome (SSS) (28.1%), and heart failure was highly observed in the patients with atrial fibrillation (46.2%). Senility was seen in 44.8% of the patients with coronary arteriosclerosis, cardiac death in 85. 7% of the patients with cardiomyopathy, and in 100.0% of the cases with valvular disease. The above mentioned fact suggests that cardiovascular check up is most important in postoperative follow up of the patients with PM. In old cases, senility and infection were major cause of death, so guidance concerning to dietary life and periodical health examination against wasting disease is important especially in this group. And, active care for heart failure is also more important in the patients with cardiomyopathy and valvular disease

Trans-vertebral Regional Cooling for Spinal Cord Protection during Thoracoabdominal Aortic Surgery : An Experimental Study

We developed a simple cooling method for spinal cord protection against ischemic injury during aortic surgery. The neuroprotective effects of our method were investigated using an animal study. Selective spinal hypothermia was produced by means of originally-designed cooling pads placed over the lower thoracic and lumbar vertebral column. Spinal cord ischemia was induced by cross-clamping the thoracic aorta for 60 min in beagle dogs. The neuroprotective effects were evaluated by a multi-modal study. The motor-evoked potentials of the spinal cord resulting from transcranial electric stimulation (MEPs) were recorded during both the ischemic and reperfusion periods. Hindlimb motor function was graded with the Tarlov score, and a histologic examination of the spinal cord injury was performed, at 24 hours after ischemia in animals undergoing hypothermia (hypothermia group: n = 7) or a sham (control group: n = 7). The spinal cord temperatures at the lower thoracic (T10) and lumbar (L3) levels decreased by -9.1°C per hour and -8.1°C per hour, respectively. The amplitude of the MEPs decreased during ischemia in both groups of animals, and significantly recovered during the early phase of aortic reperfusion in the hypothermia group. The Tarlov scores in the hypothermia and control groups were 3.3 ± 1.0 and 1.1 ± 1.5 (mean ± SD, p = 0.015), respectively. Histopathologic study revealed that ischemic injury of the lumbar cord was reduced in the animals undergoing hypothermia. Trans-vertebral regional cooling reduced ischemic spinal cord injury in a canine study. The current method is potentially feasible for clinical use, especially in view of its technical simplicity and few procedure-related complications

Findings of Transesophageal Echocardiographic Images in Placing the Coronary Sinus Perfusion Catheter

In retrograde cardioplegia (RCP), some difficulty is occasionally encountered when inserting a catheter into the coronary sinus (CS). Although the usefulness of transesophageal echocardiography (TEE) for guiding the cannulation procedures has been previously reported by other authors, we have obtained additional findings by TEE monitoring of eleven patients during placement of the CS catheter. The diameter of the CS ranged from 5.5 to 10.7 mm, indicating that it was large enough for the CS catheter to be inserted and that the resistance at insertion was not due to narrow CS. The precise time for inserting the catheter, for which myocardial protection is delayed, ranged from 8 to 376 seconds, with an average of 98 seconds. Dislodgement of the catheter was found in two cases. In case of difficult cannulation, the catheter tip was found to be pushing the right atrial wall adjacent to the CS orifice or alternatively it entered the middle cardiac vein which had a common atrial orifice with the CS in this particular case. We found that the knowing the following technical problems helps appropriate monitoring: the catheter tip becomes unclear when it is not perpendicular to the ultrasonic beam, when surgeon's fingers are placed behind the heart, or when the blood is entirely exsanguinated. Finally we present the possibility of employing images of overflow out of CS during RCP infusion, detected by TEE, as an index of efficient perfusion at the interventricular septum