Application of Ultra Short Acting Beta Blockade (Esmolol) in Pediatric Open Heart Surgery: A Trial in Total Anomalous Pulmonary Venous Return

A bstract Background : In the repair of total anomalous pulmonary venous return (TAPVR) under cardiopulmonary bypass, esmolol, ultra short acting beta blocker, was applied to obtain low heart rate and weak ventricular contraction under mild hypothermic cardiopulmonary bypass. Methods : Five infants aged from 14 to 158 days with an average of 70 days, underwent a primary or palliative repair of TAPVR. The type of anomalous return was supracardiac type (2), infracardiac (2), and intracardiac (1). A primary repair was done in three for isolated TAPVR with bypass time of 65 to 76 minutes, and a palliative repair for two with complex anomalies with bypass time of 64 and 87 minutes. Results : There was one operative death from cerebral bleeding in an infant with complex TAPVR who underwent simultaneous pulmonary banding. Conclusion : This strategy seems to be applicable in pediatric cardiac surgery when aortic cross-clamping is better to be avoided and the surgery is mainly limited to the atrial level.     

Experimental comparison of albumin-sealed and gelatin-sealed knitted Dacron conduits. Porosity control, handling, sealant resorption, and healing.

Two high-porosity knitted Dacron vascular grafts sealed with aldehyde cross-linked gelatin or albumin were compared with respect to the following characteristics. Porosity control by the absorbable sealant was assessed with a water porosity meter at 120 mm Hg pressure. Ease of suturing was determined by an objective needle penetration test. Sealant resorption was assessed histologically in a subcutaneous immature rat model as well as in circulatory implants. Gross and microscopic healing characteristics were compared in circulatory implants in the thoracic aorta of sheep with use of a composite conduit in every animal, which allowed direct comparison of the two graft materials and minimized differences in healing between individual animals. Both grafts demonstrated excellent porosity control and better handling characteristics than woven Dacron. Sealant resorption was generally rapid, although residual albumin sealant was often seen adjacent to anastomoses. Residual sealant appeared to result in focally poor healing with focal loss of adhesion of surrounding tissue to graft. We conclude that details of sealant preparation and application can importantly influence the performance of presealed knitted Dacron grafts and should be carefully evaluated in the laboratory before clinical implantation is begun.     

Age-related Epstein-Barr Virus-associated Lymphoproliferative Disorder Masquerading as Systemic Lupus Erythematosus

Age-related Epstein-Barr virus (EBV)-positive B-cell lymphoproliferative disorder (LPD) occurs in elderly patients without immunodeficiency. An 81-year-old woman without any known immunodeficiency was examined for fever, rash, arthritis, thrombocytopenia, pleural and pericardial effusions, lymphadenopathy, and positive autoantibodies, which satisfied the classification criteria for systemic lupus erythematosus (SLE). However, a lymph node biopsy revealed EBV-LPD, and she was diagnosed with age-related EBV-LPD. In young individuals, EBV infection is a major differential diagnosis of SLE, but to our knowledge, this is the first reported case of age-related EBV-LPD mimicking SLE. We should therefore consider EBV-related disorders in the differential diagnosis of SLE even in elderly individuals.     

Analysis of the elephant trunk method in patients with extensive thoracic aortic aneurysm.

We assessed the appropriate length of an elephant trunk prosthesis based on our experience with 9 patients experiencing extensive thoracic aneurysms. There were 3 patients with a true aneurysm, 5 patients with a dissecting aortic aneurysm, and 1 patient with a true plus dissecting aortic aneurysm. The subjects were 4 men and 5 women and, at the time of operation, were from 38 to 74 years old. The second-stage operations were performed on 6 patients from 9 days to 6 months after the first-stage operation. In the first-stage operation, one patient died of pneumonia during the hospital stay and another died of multi-organ infarction after 15 months. In the second-stage operation, two patients died of brain hemorrhage in the chronic stage after the operation. The length of the elephant trunk prosthesis was 3 cm in the three early patients, and in one of them the elephant trunk could not be utilized due to its insufficient length. In the next three patients, the length was extended to 5 cm, but one of patient experienced an expansion of the aneurysm in the descending aorta due to a graft of insufficient length which could not decompress the aneurysmal wall. Therefore, in the last three patients, the length was further extended to 10 cm, and the second-stage operation was performed uneventfully on the 64th, 9th and 45th day, respectively after the first-stage operation within a continuous hospital stay. Neither expansion of the aneurysm nor thromboembolism was found during the waiting period for any of the second-stage operations. Accordingly, we recommend using a 10 cm elephant trunk prosthesis.     

Clinical analysis of the patients with delayed sternal closure following open heart surgery

Thirteen patients with successful or unsuccessful delayed sternal closure (DSC) after open heart surgery were reviewed. The indications of DSC were cardiac dilatation in 12 patients and intractable bleeding in one. Patients were divided into two groups as follows: Group A of 7 patients with mediastinum being sealed by prosthetic material, and Group B of 6 patients with primary skin closure by mobilized skin-flap. Postoperative complications and prognosis were compared between these two groups. There were 6 long term survivors. In group A, there were 4 deaths, 2 from low output syndrome (LOS) and 2 from sepsis due to mediastinitis. In group B, 2 died of LOS and 1 died of multiple organ failure, while no patients developed mediastinitis. In patients with unsuccessful DSC, mainly due to poor hemodynamics, there found no tendencies of decrease in CVP and LAP levels and no reduction in the amount of catecholamine dosage prior to attempted DSC. In conclusion, 1) mediastinal isolation with primary skin closure seemed more effective for preventing mediastinitis than coverage with prosthetic materials, 2) DSC was possible when there were hemodynamic improvements with decrease in CVP and LAP levels, and reduction in catecholamine dosage, and 3) plastic surgical technique was useful for primary skin closure.     

Concomitant surgical procedures for coronary artery disease and intraperitoneal double cancers: Report of a case

Concomitant surgical procedures for coronary artery disease and double cancers are reported. A 61-year-old man with severe triple-vessel coronary disease was found to have early gastric cancer and advanced rectal cancer. We successfully performed a concomitant coronary artery bypass graft using an extracorporeal ultrafiltration membrane and curative surgery for both cancers. Concomitant surgery thus appears to be a benefical and safe approach for the treatment of critical coronary artery disease and intraperitoneal double cancers in carefully selected patients.     

Role of nitric oxide in a temperature dependent regulation of systemic vascular resistance in cardiopulmonary bypass.

OBJECTIVES: Nitric oxide is the most potent vasodilator among inflammation-mediated vasoactive substances. Tepid cardiopulmonary bypass has been known to maintain low vascular resistance and nitric oxide may also be involved. There has been no previous clinical study elucidating a role of nitric oxide in a temperature dependent regulation of systemic vascular resistance in cardiopulmonary bypass. METHODS: Thirty-one patients who underwent valvular surgery were randomly divided into two comparable groups; consisting of the hypothermic cardiopulmonary bypass (28 degrees C:14 patients) and the tepid cardiopulmonary bypass group (34 degrees C:17 patients). The serum levels of nitric oxide (NO(2)(-)+NO(3)(-)), prostaglandin E(2), bradykinin, 6-keto PGF1alpha, thromboxane B(2), endothelin-1, systemic vascular resistance index were measured before, 0, 12 and 24 h after cardiopulmonary bypass. RESULTS: The pattern of change in systemic vascular resistance index and nitric oxide during and after cardiopulmonary bypass were significantly different between the two groups (P=0.0008, P=0.02). The tepid group showed significantly lower levels of systemic vascular resistance index after cardiopulmonary bypass than the hypothermic group (0 h: 2278+/-735 vs. 4387+/-1289, 12 h: 1827+/-817 vs. 2817+/-1146 and 24 h: 1690+/-548 vs. 2761+/-641 dyne s cm(-5) m(2), P=0.0001, P=0.03, P=0. 0006). The nitric oxide levels were significantly higher at 0, 12 and 24 h after cardiopulmonary bypass in the tepid group than those in the hypothermic group (84.7+/-33.3 vs. 46.3+/-18.1, 69.8+/-31.1 vs. 40.1+/-17.5 and 80.1+/-38.5 vs. 39.1+/-15.6 micromol/l, P=0.008, P=0.03, P=0.01). The prostaglandin E(2) levels in the tepid group was significantly higher just after cardiopulmonary bypass than that in the hypothermic group (37.3+/-20.0 vs. 15.8+/-8.6 pg/ml, P=0.02). The bradykinin level in the hypothermic group was significantly higher just after cardiopulmonary bypass than that in the tepid group (2.40+/-0.32 vs. 1.85+/-0.21 log(10) (pg/ml), P=0.005). Only nitric oxide showed a significant negative correlation with the systemic vascular resistance index both during and after cardiopulmonary bypass (r=-0.60, P<0.0001) as compared with prostaglandin E(2) and bradykinin. CONCLUSIONS: These findings demonstrated that serum nitric oxide levels in tepid cardiopulmonary bypass were significantly higher than those in hypothermic cardiopulmonary bypass. Nitric oxide correlated with systemic vascular resistance. Thus, nitric oxide may play a pivotal role in a temperature dependent regulation of systemic vascular resistance in cardiopulmonary bypass.     

Myocardial protective effect of deep hypothermic cardiac arrest without aortic cross clamp in neonatal hearts: Comparison with cardioplegic arrest in a rabbit model

Summary Using an isolated perfusion model of neonatal rabbit hearts aged 3 to 6 days, cardioplegic arrest (CPA) using crystalloid cold cardioplegia with aortic cross clamp (AXC: 60min,n = 15) and continuous deep hypothermic perfusion (DHP) at 15°C without AXC (n = 15) were compared. The hearts were divided into two subgroups: intact hearts (n = 18) and with preceding 40min warm ischemia (stressed hearts,n = 22). In the intact hearts, there were no significant differences between the CPA and DHP groups in left ventricular function, myocardial water content, and myocardial mitochondrial score after reperfusion. In the stressed hearts, recovery of cardiac output and left ventricular work was significantly higher in the DHP group than in the CPA group. The postreperfusion myocardial mitochondrial score was significantly better in the DHP group than in the CPA group. These results suggest that non-AXC DHP may be advantageous in the setting of stressed hearts with preceding ischemic injury where conventional CPA cannot provide adequate myocardial protection.