Kanji Kawachi

A partial lower inverted J sternotomy and an extended transseptal incision provide excellent exposure for minimally invasive mitral valve surgery. However, the extended trasnsseptal incision causes dividing the sinus node artery, which may result in conduction system disturbance and need for permanent pacemaker implantation. Therefore, there is a challenge in the patient who requires concomitant ablation for atrial fibrillation because of possible conduction system disturbance caused by extended transseptal incision. We describe a new strategy for combined ablation of atrial fibrillation with minimally invasive cardiac surgery by a transseptal approach to the mitral valve through a partial lower sternotomy incision. Cryoablation was performed using a T-shaped cryoprobe with a lesion set of pulmonary vein isolation and ablation of the left and right isthmus in performing mitral annuloplasty, tricuspid annuloplasty, and atrial septal defect closure through a limited sternotomy incision. This technique might minimize possible conduction system disturbance and provide good surgical result for the patients who undergo mitral valve surgery and ablation of atrial fibrillation.

During the perioperative period for off-pump coronary artery bypass surgery (OPCAB) and on-pump coronary artery bypass surgery (on-pump CABG), the volume of extra cellular fluid (ECF) was measured. The subjects were elective adult coronary artery bypass surgery cases, consisting of 13 OPCAB cases and 7 on-pump CABG cases. The ECF volume was measured the day before surgery, immediately after surgery, and 2, 4, 6, 8, 12, 24 and 48 hours after surgery, with a bioimpedance analyzer (XITRON 4000 C). ECF volume variation was defined as the difference from the preoperative value divided by body weight, and was expressed in %BW. At the same time, respiratory-index and leukocyte count were measured. The maximum postoperative ECF volume was 3.13 +/- 2.6 %BW in the OPCAB group and 5.36 +/- 2.0 %BW in the on-pump CABG group, that is, significantly higher in the on-pump CABG group. The ECF volume started to increase in the on-pump CABG group immediately after surgery (4.38 +/- 1.8 %BW in the on-pump CABG group and 2.07 +/- 2.4 %BW in the OPCAB group), reaching its peak 6 hours after surgery in the on-pump CABG group and 4 hours after surgery in the OPCAB group. Thereafter, the volume gradually decreased, and 48 hours after surgery the volume decreased in the OPCAB group to 0.064 +/- 1.5 %BW, or to about the same value as the preoperative value, whereas in the on-pump CABG group the volume remained high: 1.9 +/- 2.9 % BW. There was no significant difference between the 2 groups in the change in respiratory-index. The leukocyte count remained significantly higher in the on-pump CABG group. The ECF volume was measured by the bioimpedance measuring method. This is a useful method of measuring the volume non-invasively and continuously. In the OPCAB group, the increase in postoperative ECF volume was less, and recovery to the preoperative level was faster than in the on-pump CABG group.

Extracellular fluid (ECF) was assessed before and after the cardiac surgery using cardiopulmonary bypass (CPB), by means of a bioimpedance spectrum analyzer to see volumes of the fluid based on changes of the impedance to various frequencies. Difference between the levels before and after the operation was divided by body weight to study about a % BW. Simultaneously its relation to the lung compliance [tidal volume/(peak inspiratory pressure-end expiratory pressure)] was studied. Mean age of the 18 patients was 59.1 +/- 19 years old. ECF was assessed before to 24 hours after the operation continuously and once more after 48 hours. Mean CPB time was 165 +/- 52 minutes, and aortic cross clamp time was 121 +/- 4 minutes. A remarkable increase of ECF was noted immediately after the operation, which further increased gradually till arriving at the peak 4 hours after the operation (4.52 +/- 1.8% BW). Then it gradually decreased to 0.641 +/- 2.7% BW 48 hours later. Lung compliance measured at the same time showed the lowest level 6 hours after the operation. It was known that the bioimpedance spectrum analysis is a simple and non-invasive method, which enables to monitor the vital stable before and after the operation.

We report a rare case of lung cancer associated with the right aortic arch. A 72-year-old male was admitted to our hospital for surgical treatment of squamous cell carcinoma arising from left B3. The patient had a right aortic arch with the type of mirror-image branching. He underwent a left upper lobectomy and lymph node dissection. We easily resected the lymph nodes in the left side of the upper mediastinum without rotating aortic arch because the aortic arch was positioned on the other side.

A 78-year-old woman was admitted to our hospital after computed tomography (CT) had revealed in her the presence of a giant ascending aorta-arch aneurysm. This aneurysm was about 8 cm in diameter and associated with DeBakey type II dissection. Aortography showed the same condition as the CT view with the entry on the ascending aorta. The ascending aortaarch was replaced with a Hemashield 24 mm, by using deep-hypothermic selective cerebral perfusion and the open distal method. There were no complications during her peripostoperative state and no evidence of leakage and remnant dissection on CT and aortography. This is a rare case in which thoracic aortic aneurysm coexisted with dissection. In this case of severe atherosclerosis, deep-hypothermic selective cerebral perfusion and the open distal method provided effective treatment.

An emergency coronary artery bypass graft (CABG) was given to a 66 year-old patient due to acute myocardial infarction (AMI). Circulating blood volume (BV) was measured to study in the perioperative period. Three coronary artery bypasses were made under cardiopulmonary bypass, being managed by ultrafiltration when the pump-oxygenator was in action and by peritoneal dialysis in the early postoperative period. Preoperative BV reduced immediately after the operation. It showed an increasing trend 4 hours after the operation, but after that BV reduced from that before the operation while water balance was kept positive. Cardiac output after the operation was higher than before. It suggested that in this patient using hemodialysis BV levels turned to be lower compared with that before the operation, as excessive water leaked out of the blood vessel, although water balance was kept positive due to improved cardiac functions after the operation.

A 70-year-old woman underwent three coronary artery bypass grafting using the left internal thoracic artery and saphenous vein grafts. She had high fever in the 3rd month after surgery. Computed tomography and angiogram revealed a pseudoan eurysm of ascending aorta (Fig. 1) . Reoperation with repair with femoral artery autograft for pseudoaneurysm was performed (Fig. 2) . Two year-postoperative CT revealed no pseudoaneurysm of the ascending aorta (Fig. 1).

To investigate that blood transfusion under cardiopulmonary bypass is a possible inducer for inflammation, a retrospective study was made with 20 adult patients who underwent coronary artery bypass grafting. The subjects were divided into two groups; transfusion group (group T) including 9 patients who received blood transfusion during cardiopulmonary bypass and the control group (group C) including 11 patients who did not undergo perioperative transfusion. Respiratory index as an indicator of respiratory functions was determined before and immediately after cardiopulmonary bypass, at the end of surgery and 4 hours thereafter. Cardiac index and arterial pressure were determined as the indicator of cardiac function. Moreover, interleukin 6 and 8 (IL-6 and IL-8), inflammatory cytokines were measured and compared between the two groups. The mean amount of blood transfusion was 2.1 units per individual of group T. The minimum value of hematocrit during cardiopulmonary bypass was significantly lower in group T (15.8 +/- 1.8%) than group C (19.1 +/- 1.4%), but the difference became not significant after cardiopulmonary bypass. There were no significant differences either in aortic pressure or cardiac index between two groups. The respiratory index at the end of surgery was higher in group T but the difference was not significant. Meanwhile IL-8 level at the end of cardiopulmonary bypass was significantly higher in group T (67.9 +/- 36 pg/ml) than group C (35.1 +/- 21 pg/ml). However, there was no difference in IL-6 level between the two. These results suggested that inflammation might be aggravated by an increase of IL-8 induced by blood transfusion.

The purpose of this study was to investigate the influence of coronary artery bypass grafting on the degree of stenosis of the native coronary artery. retrospective data analysis. University hospital. consecutive patients undergoing coronary artery bypass grafting (n=52). Bypasses using internal thoracic artery grafts (n=26) and saphenous vein grafts (n=37) to incompletely occluded coronary arteries were studied. coronary artery bypass grafting using internal thoracic artery or saphenous vein grafts. stenosis of the native coronary artery on angiography. Three recipient coronary arteries bypassed with internal thoracic artery grafts (12%) and 14 recipient coronary arteries bypassed with saphenous vein grafts (38%) showed progression of narrowing (p=0.024). Two recipient coronary arteries bypassed with internal thoracic artery grafts (8%) and 13 recipient coronary arteries bypassed with saphenous vein grafts (35%) showed total occlusion (p=0.016). Hypertension, hyperlipidemia, diabetes mellitus, and smoking history did not correlate with progression of stenosis of the native coronary arteries. Graft flow measured during surgery in the saphenous vein grafts was not significantly different between the group that exhibited progression of the native stenosis and the group that did not. Coronary artery bypass grafting with saphenous vein grafts may result in progression of stenosis of the recipient coronary artery. This is less likely after coronary artery bypass grafting with internal thoracic artery grafts. This difference may be due to the ability of the pedicled internal thoracic artery graft to regulate flow. Thus competitive flow in the native coronary artery is minimized. This has significant clinical implications.