Eight-year experience of combined valve repair for mitral regurgitation and maze procedure

BACKGROUND AND AIMS OF THE STUDY: Although atrial fibrillation (AF) is often associated with severe mitral regurgitation (MR), a simultaneous maze procedure for AF associated with repair of MR remains controversial. In this study, mid-term results of combined mitral valve repair and the maze procedure were examined. METHODS: Between May 1992 and April 2001, 85 patients (61 males, 24 females) underwent valve repair for MR and the maze procedure. Mean age at surgery was 61.8+/-9.1 years; mean follow up was 4.7+/-2.3 years. Valve lesions were anterior in 26 patients (31%), posterior in 31 (36%), anterior + posterior in 23 (27%), and simple dilated annulus in five (6%). Chordal replacement with expanded PTFE sutures was performed in 40 patients (47%), and leaflet resection in 41 (48%). Ring annuloplasty was also applied in 61 patients (72%). Associated procedures were tricuspid valve annuloplasty in 33 (36%), coronary artery bypass grafting in four, atrial septal defect closure in two, aortic valve repair in one, and resection of abnormal septum in the left atrium in one. RESULTS: There was one hospital death (1%), and one late death (1%). Reopening the chest for bleeding was necessary in six cases (7%). One thromboembolic episode was detected during follow up (0.25%/patient-year). Reoperation for MR was performed in three patients (4%). Actuarial event-free survival rate was 90.0+/-6.4% at eight years. Sinus rhythm was regained in 68 patients (81%), and atrial A-wave was detected in 57 (68%) by pulsed Doppler study. Postoperative left ventricular diastolic and systolic dimensions were significantly (p = 0.001 and p = 0.017) smaller in patients who restored sinus rhythm than in those who did not (48.6+/-4.6 versus 54.6+/-4.7 mm, and 33.0+/-6.0 versus 38.1+/-6.9 mm). CONCLUSION: Combined mitral valve repair for MR and the maze procedure showed satisfactory midterm results. Postoperative sinus rhythm conversion by the maze procedure may reduce left ventricular size, and the incidence of thromboembolic episodes in mitral valve repair.     

Esophageal perforation associated with profound shock successfully managed with hemodynamic assistance using percutaneous cardiopulmonary support

A 51-year-old man was admitted to our hospital with complaints of severe chest pain, nausea, and vomiting. These symptoms had progressed rapidly and he was in shock. It was necessary to make a correct diagnosis as early as possible. However, the hemodynamic condition of the patient deteriorated rapidly before a definitive diagnosis could be established in spite of conventional therapies. Under hemodynamic assistance with percutaneous cardiopulmonary support (PCPS), a final diagnosis of esophageal perforation was made by esophagography. Our report illustrates a new application of PCPS for highly selected cases of noncardiogenic shock as a "bridge" until an accurate diagnosis is made and a specific treatment is applied.     

Perioperative multivessel coronary vasospasm as a cause of cardiogenic shock immediately after off-pump coronary artery bypass grafting surgery: a case report

Perioperative coronary vasospasm has been recognized as a possible cause of myocardial infarction or low output syndrome after open heart operations. A 57-year-old male suffered cardiogenic shock immediately after off-pump coronary artery bypass grafting surgery. Emergent angiography performed under intraaortic balloon pumping and percutaneous cardiopulmonary support revealed severe multivessel coronary vasospasm which was effectively treated with a high dose intracoronary administration of isosorbide dinitrate. Emergent angiography for patients with cardiogenic shock after open heart operation is feasible and effective for the diagnosis and treatment of perioperative coronary vasospasm.     

Clinical Experience of Percutaneous Cardiopulmonary Support

Abstract: Recently, percutaneous cardiopulmonary support (PCPS) combined with femoro-femoral bypass without reservoir has become valued because of its quick and easy application. We developed a fully preconnected compact integrated cardiopulmonary bypass (CPB) unit (priming volume of 250 ml) with a blind pore membrane oxygenator (Kuraray Menox) for PCPS. From 1990 to 1995, PCPS was performed in 49 patients of whom 26 were weaned from support. In most cases, we applied this CICU in patients with no active bleeding (22 patients); in patients with active bleeding (n = 13), we used Medtron-ic's heparin-bonded close chest support pack (CCSP). Of these, PCPS was performed uneventfully for 2 h (median) in 8 elective cases; all of these patients were weaned or were switched to a left ventricular assist system (LVAS). In 8 urgent cases, such as those with low cardiac output syndrome, PCPS was performed for 4 days (median), 1 was weaned, and 2 CICU were cases switched to other procedures. In 32 cases of shock, 5 CICU patients were weaned, and 3 of them survived. Eight patients including 5 CICU patients and 1 CCSP patient were switched to operation or LVAS, and 2 CICU patients remain alive. From these data, PCPS has been shown to support the patient's circulation in the acute phase and earn time to switch to operation or LVAS; the quick and easy set-up of the CICU can improve the clinical results. The use of the Medtronic device broadened the indication for PCPS. The CCSP enlarged the indication of PCPS but could not improve the results. To improve the results, a heparin-bonded surface is desired.     

Segmental autotransplantation of the pancreas after total pancreatectomy for advanced periampullary carcinoma —A case report—

A case is reported here in which segmental autotransplantation of the pancreas was performed after total pancreatectomy for advanced periampullary carcinoma in an attempt to preserve pancreatic endocrine function. The postoperative course was uneventful. The requirement of insulin decreased after the operation and the daily profile examination, done 5 months following surgery, showed a permissive fluctuation of blood sugar levels without insulin injection. Thus, segmental autotransplantation of the pancreas offers a method of preserving pancreatic endocrine function after total pancreatectomy for periampullary carcinoma in selected patients.     

Segmental autotransplantation of the pancreas after total pancreatectomy for advanced periampullary carcinoma--a case report

A case is reported here in which segmental autotransplantation of the pancreas was performed after total pancreatectomy for advanced periampullary carcinoma in an attempt to preserve pancreatic endocrine function. The postoperative course was uneventful. The requirement of insulin decreased after the operation and the daily profile examination, done 5 months following surgery, showed a permissive fluctuation of blood sugar levels without insulin injection. Thus, segmental autotransplantation of the pancreas offers a method of preserving pancreatic endocrine function after total pancreatectomy for periampullary carcinoma in selected patients.     

Mechanical circulatory support as a bridge to transplantation: current status of total artificial heart in 1989 and determinants of survival

Since April 1986, 40 total artificial hearts (TAH) were implanted as a bridge to transplantation in our institution. In an attempt to identify factors affecting survival of TAH recipients we reviewed our experience over 1000 days of mechanical support. There was no postoperative bleeding requiring surgery nor were there any clinical episodes of thromboembolic complications. Over a total functioning period greater than 3 years there were no mechanical failures in the driving system but one artificial ventricle had to be replaced because of mechanical dysfunction. Infections and multiple organ failure were the primary causes of morbidity and mortality during mechanical support. When the patients who underwent staged transplantation (no. 17) were compared with those who died during mechanical support (no. 23) there were no differences in TAH driving mode or hemodynamic variables between the groups. Although preoperative pulmonary, hepatic and renal functions were found to be similar between the groups, there were significant differences in the early evolution (3 days) of hepatic and renal functions following TAH implant (p less than 0.01). Urinary output was found to be the earliest variable discriminating recovery and survival (p less than 0.01). Finally, univariate analysis indicated age (less than 40 vs greater than 40 years) and modality of cardiac decompensation (acute vs chronic) as the most important factors affecting survival after TAH implantation. Since young patients (less than 40 years of age) with acute decompensation were successfully transplanted in 82% of cases while 100% of older patients with chronic decompensation died before or after transplantation, TAH should be advised in young patients with acute or chronic heart failure and in selected older candidates with recent, acute cardiac failure.     

Preoperative assessment of lymph node metastases in patients with gastric cancer: evaluation of the Maruyama computer program.

The probability of survival of patients with gastric cancer depends upon depth of wall penetration by the primary tumour and metastatic lymph node burden. Radical lymphadenectomy may lead to prolonged survival but with increased morbidity. A computer program from Maruyama, National Cancer Centre, Tokyo enables evaluation of individual survival time and infiltration of lymph nodes. This analysis was applied to a German population. Computer-aided predictions were determined retrospectively using the prognostic factors of sex, age, Borrmann classification, histology, depth of wall penetration, location and diameter of the tumour. Data were collected from 222 patients at the Technical University of Munich (median age 66 years, sex ratio (M:F) 2:1), who had been operated on (72 per cent total gastrectomy, 28 per cent subtotal gastrectomy) for gastric cancer. The predicted results were compared with the postoperative pathological findings. The prediction of node metastases was highly accurate (lymph nodes 13-16, 96 per cent; 7-12, 89 per cent; 1-6, 82 per cent). These computer predictions may provide perioperative information of therapeutic value.     

Left thoracoabdominal approach versus abdominal-transhiatal approach for gastric cancer of the cardia or subcardia: a randomised controlled trial

BACKGROUND: Because of the inaccessibility of mediastinal nodal metastases, the left thoracoabdominal approach (LTA) has often been used to treat gastric cancer of the cardia or subcardia. In a randomised phase III study, we aimed to compare LTA with the abdominal-transhiatal approach (TH) in the treatment of these tumours. METHODS: Between July, 1995, and December, 2003, 167 patients were enrolled from 27 Japanese hospitals and randomly assigned to TH (n=82) or LTA (n=85). The primary endpoint was overall survival, and secondary endpoints were disease-free survival, postoperative morbidity and hospital mortality, and postoperative symptoms and change of respiratory function. The projected sample size was 302. After the first interim analysis, the predicted probability of LTA having a significantly better overall survival than TH at the final analysis was only 3.65%, and the trial was closed immediately. Analysis was by intention to treat. This study is registered with , number NCT00149266. FINDINGS: 5-year overall survival was 52.3% (95% CI 40.4-64.1) in the TH group and 37.9% (26.1-49.6) in the LTA group. The hazard ratio of death for LTA compared with TH was 1.36 (0.89-2.08, p=0.92). Three patients died in hospital after LTA but none after TH. Morbidity was worse after LTA than after TH. INTERPRETATION: Because LTA does not improve survival after TH and leads to increased morbidity in patients with cancer of the cardia or subcardia, LTA cannot be justified to treat these tumours.     

Early gastric stump cancer following distal gastrectomy

Background—Gastric stump cancer(GSC) is usually diagnosed at an advanced stage, and consequently theprognosis is poor.
Aims—To investigate theclinicopathological characteristics of GSC at an early stage to assistin its identification, and thereby improve its prognosis.
Methods—Forty three patients withresected early GSC were compared with 156 patients with resectedprimary early cancer in the upper third of the stomach.
Results—Sixty five per cent (28/43)of the early GSC patients showed the elevated type endoscopically,although the frequency of the depressed type in GSC has tended toincrease in the past five years. This occurred in less than 26%(40/156) of the primary early cancers. Half of the early GSCs werelocated on the lesser curvature (47%), and revealed differentiatedadenocarcinoma (81%) histologically. The male:female ratio of earlyGSC cases was about 6:1, which was much higher than that in patientswith primary early cancer. The five year survival rates of patientswith early GSCs and early primary cancers were 84% and 95%,respectively. GSC had a favourable prognosis, if it was detected at anearly stage.
Conclusion—To detect early GSC, ourresults suggest that special attention should be given to elevated aswell as depressed lesions on the lesser curvature of the stomach,particularly in men, during endoscopic examinations.

Keywords:gastric stump cancer; early gastric cancer; prognosis; endoscopy