Surgical intervention for anomalous origin of the left coronary artery from the pulmonary artery: The Tokyo experience

AbstractBackground: Few studies after surgical repair of the anomalous origin of the left coronary artery have reported the importance of the mitral annuloplasty or the long-term results. Methods: Between January 1982 and March 2000, 29 patients with anomalous origin underwent surgical intervention at our institution (direct aortic reimplantation in 19 and Takeuchi procedure in 10). Age at the time of operation ranged from 2 months to 24 years (median, 29.3 months), and 9 patients were infants. Twenty-four patients had varying degrees of mitral incompetence. Simultaneous mitral annuloplasty at the anterolateral commissure was performed in all 24 patients with incompetence. Results: There were 2 hospital deaths among the infants, and no late deaths. Mean follow-up was 100 ± 57 months, and the actuarial survival was 93.1% at 10 years (70% confidence limits, 87-99). Cardiothoracic ratio at discharge was not decreasing significantly (P =.35); however, this value 5 years after the operation showed the significant decrease (P =.003) versus preoperative value. Preoperative mitral incompetence decreased in all but one of the operative survivors with mitral annuloplasty at the last follow-up. The left ventricular fractional shortening z-score was not normalized at discharge but was normalized in the late period. Conclusion: These data demonstrate that impaired left ventricular function normalized in the long term (even if it was below normal immediately after operation) after 2-coronary repair. We recommend that the simultaneous mitral annuloplasty should be performed at the time of operation for patients who have mitral incompetence with anomalous origin of the left coronary artery. (J Thorac Cardiovasc Surg 2001;121:792-7

Higher hematocrit improves cerebral outcome after deep hypothermic circulatory arrest

AbstractBackground: Various degrees of hemodilution are currently in clinical use during deep hypothermic circulatory arrest to counteract deleterious rheologic effects linked with brain injury by previous reports. Material and methods: Seventeen piglets were randomly assigned to three groups. Group I piglets (n = 7) received colloid and crystalloid prime (hematocrit < 10%), group II piglets (n = 5) received blood and crystalloid prime (hematocrit 20%), group III piglets (n = 5) received blood prime (hematocrit 30%). All groups underwent 60 minutes of deep hypothermic circulatory arrest at 15º C. with continuous magnetic resonance spectroscopy and near-infrared spectroscopy Neurologic recovery was evaluated for 4 days (neurologic deficit score 0, normal, to 500, brain death; overall performance category 1, normal, to 5, brain death). Neurohistologic score (0, normal, to 5+, necrosis) was assessed after the animals were euthanized on day 4. Results: Group I had significant loss of phosphocreatine and intracellular acidosis during early cooling (phosphocreatine in group I, 86.3% ± 26.8%; group II, 117.3% ± 8.6%; group III, 110.9% ± 2.68%; p = 0.0008; intracellular pH in group I, 6.95 ± 0.18; group II, 7.28 ± 0.04; group III, 7.49 ± 0.04; p = 0.0048). Final recovery was the same for all groups. Cytochrome aa3 was more reduced in group I during deep hypothermic circulatory arrest than in either of the other groups (group I, -43.6 ± 2.6; group II, -16.0 ± 5.2; group III, 1.3 ± 3.1; p < 0.0001). Neurologic deficit score was best preserved in group III (p < 0.05 group II vs group III) on the first postoperative day, although this difference diminished with time and all animals were neurologically normal after 4 days. Histologic assessment was worst among group I in neocortex area (group I, 1.33 ± 0.3; group II, 0.22 ± 0.1; group III, 0.40 ± 0.2, p < 0.05, group I vs group II; p = 0.0287, group I vs group III). Conclusion: Extreme hemodilution during cardiopulmonary bypass may cause inadequate oxygen delivery during early cooling. The higher hematocrit with a blood prime is associated with improved cerebral recovery after deep hypothermic circulatory arrest. (J Thorac Cardiovasc Surg 1996;112:1610-21

A novel sialyl lewis x analog attenuates cerebral injury after deep hypothermic circulatory arrest

AbstractBackground: The initial step in the inflammatory process, which can be initiated by cardiopulmonary bypass and by ischemia/reperfusion, is mediated by interactions between selectins on endothelial cells and on neutrophils. We studied the effects of selectin blockade using a novel Sialyl Lewis X analog (CY-1503) on recovery after deep hypothermic circulatory arrest in a piglet model. Methods: Twelve Yorkshire piglets were subjected to cardiopulmonary bypass, 30 minutes of cooling, 100 minutes of circulatory arrest at 15°C, and 40 minutes of rewarming. Five animals received a bolus of 60 mg/kg of CY-1503 and an infusion (3 mg/kg per hour) for 24 hours from reperfusion (group O), and 7 randomly selected control piglets received saline solution (group C). Body weight and total body water content were evaluated 3 hours and 24 hours after reperfusion by a bio-impedance technique. Neurologic recovery of animals was evaluated daily by neurologic deficit score (0 = normal, 500 = brain death) and overall performance categories (1 = normal, 5 = brain death). The brain was fixed in situ on the fourth postoperative day and examined by histologic score (0 = normal, 5+ = necrosis) in a blinded fashion. Results: Two of 7 animals in group C died. The neurologic deficit score was significantly lower in group O than in group C (postoperative day 1, P < .001; postoperative day 2, P = .02). The overall performance category was significantly lower in group O than in group C on postoperative day 2 (P = .01). Percentage total body water after cardiopulmonary bypass was significantly higher in group C than in group O (P = .03). Histologic score tended to be higher in group C than in group O, but this difference did not reach statistical significance (group O = 0.5 ± 0.7; group C = 1.3 ± 1.9). Conclusion: Blockade of selectin adhesion molecules by saturation with a Sialyl Lewisxanalog accelerates recovery after 100 minutes of deep hypothermic circulatory arrest in a piglet survival model. (J Thorac Cardiovasc Surg 1999; 117:1204-11

Long-Term Results of Cell-Free Biodegradable Scaffolds for In Situ Tissue-Engineering Vasculature: In a Canine Inferior Vena Cava Model

We have developed a new biodegradable scaffold that does not require any cell seeding to create an in-situ tissue-engineering vasculature (iTEV). Animal experiments were conducted to test its characteristics and long-term efficacy. An 8-mm tubular biodegradable scaffold, consisting of polyglycolide knitted fibers and an L-lactide and ε-caprolactone copolymer sponge with outer glycolide and ε-caprolactone copolymer monofilament reinforcement, was implanted into the inferior vena cava (IVC) of 13 canines. All the animals remained alive without any major complications until euthanasia. The utility of the iTEV was evaluated from 1 to 24 months postoperatively. The elastic modulus of the iTEV determined by an intravascular ultrasound imaging system was about 90% of the native IVC after 1 month. Angiography of the iTEV after 2 years showed a well-formed vasculature without marked stenosis or thrombosis with a mean pressure gradient of 0.51±0.19 mmHg. The length of the iTEV at 2 years had increased by 0.48±0.15 cm compared with the length of the original scaffold (2–3 cm). Histological examinations revealed a well-formed vessel-like vasculature without calcification. Biochemical analyses showed no significant differences in the hydroxyproline, elastin, and calcium contents compared with the native IVC. We concluded that the findings shown above provide direct evidence that the new scaffold can be useful for cell-free tissue-engineering of vasculature. The long-term results revealed that the iTEV was of good quality and had adapted its shape to the needs of the living body. Therefore, this scaffold would be applicable for pediatric cardiovascular surgery involving biocompatible materials

Long term follow up after surgery in congenitally corrected transposition of the great arteries with a right ventricle in the systemic circulation

Aim of the study: To investigate the long-term outcome of surgical treatment for congenitally corrected transposition of the great arteries (CCTGA), in patients with biventricular repair with the right ventricle as systemic ventricle.Methods: A total of 32 patients with CCTGA were operated between January 1972 and October 2008. These operations comprised 18 patients with a repair with a normal left ventricular outflow tract, 11 patients with a Rastelli repair of the left ventricle to the pulmonary artery and 3 patients with a cardiac transplantation.Results: Excluding the cardiac transplantation patients, mean age at operation was 16 years (sd 15 years, range 1 week - 49 years). Median follow-up was 12 years (sd 10 years, range 7 days - 32 years). Survival obtained from Kaplan-Meier analysis at 20 years after surgery was 63% (CI 53-73%). For the non-Rastelli group these data at 20 years were

MicroRNAs in vascular tissue engineering and post-ischemic neovascularization

Increasing numbers of paediatric patients with congenital heart defects are surviving to adulthood, albeit with continuing clinical needs. Hence, there is still scope for revolutionary new strategies to correct vascular anatomical defects. Adult patients are also surviving longer with the adverse consequences of ischemic vascular disease, especially after acute coronary syndromes brought on by plaque erosion and rupture. Vascular tissue engineering and therapeutic angiogenesis provide new hope for these patients. Both approaches have shown promise in laboratory studies, but have not yet been able to deliver clear evidence of clinical success. More research into biomaterials, molecular medicine and cell and molecular therapies is necessary. This review article focuses on the new opportunities offered by targeting microRNAs for the improved production and greater empowerment of vascular cells for use in vascular tissue engineering or for increasing blood perfusion of ischemic tissues by amplifying the resident microvascular network

心臓手術における抗PF4・ヘパリン複合体抗体に対する危険因子の検討

ヘパリン起因性血小板減少症(HIT)は,免疫機序で発生するヘパリンの重篤な合併症である.抗PF4・ヘパリン複合体抗体(HIT抗体)はHITの病因となるが,心臓外科領域において,その詳細は明らかではない.今回,カテーテル検査後3ヵ月以内に心臓手術を施行された計28例を対象とし,HIT・HIT抗体の発生率,HIT抗体のseroconversion・危険因子について検討した.HIT抗体は術前と術後にELISAを用いて測定した.全症例において臨床上明らかなHITは認めなかった.術前HIT抗体は28例中1例(4%)にみられ,28例中6例(21%)で術前HIT抗体陰性から術後陽性となった(seroconversion).術後HIT抗体陽性と陰性患者において術前検査結果と人工心肺時間などを比較検討した結果,総グロブリンのみが有意差を示した.術前総グロプリンは術後HIT抗体陽性群(2.89±0.33g/dl)において陰性群(2.42±0.50K/dl)より高値であった(p=0.030).また,術前総グロブリン値は術後HIT抗体陽性と関連性があった(p=0.048;オッズ比.12.09;95%信頼区間,1.02-144.06).Seroconversionの発生率は低く,術前総グロブリン高値は術後HIT抗体陽性の危険因子となる可能性があると考えられた.Heparin-induced thrombocytopenia (HIT) is a serious, immune system-mediated complication of heparin therapy. Antibody to the platelet factor 4/heparin complex is linked to the pathogenesis of HIT. However, there is insufficient information on anti-PF4/heparin antibody (HIT antibody) in cardiac surgery. In this study, we examined the occurrence of HIT and HIT antibody, seroconversion and the risk factors. We selected 28 patients who underwent cardiac procedure following catheterization within 3 months. An enzyme-linked immunosorbent assay (ELISA) for the antibody was measured using preoperative and postoperative serum samples. We could not identify patients with clinical HIT. The incidence of preoperative HIT antibody was 4%. Six of the 28 (21%) patients changed to positive postoperative assay from negative preoperative assay. Comparison of preoperative laboratory data and surgical details did not show significant differences between the patients with positive assays and those with negative assays on postoperative day 10, except total globulin. Preoperative total globulin of positive antibody assay was higher than that of negative antibody assay (2.89 ± 0.33 g/dl versus 2.42 ± 0.50 g/dl, p=0.030) and was related to positive postoperative antibody (p=0.048; odds ratio, 12.09; 95% confidence interval, 1.02-144.06). The rate of seroconversion was low, and elevated level of preoperative total globulin may be the risk factor for positive postoperative HIT antibody