Biomedical subjects
Publications and source records attributed to S Sasaguri.
A simple approach for exposing a difficult mitral valve within a small left atrium is described herein through the report of case. Mobilization of the superior vena cava with direct venous cannulation and extended dissection of the interatrial groove provide excellent mitral valve exposure, even in patients with a small left atrium.
The changes in myosin light chain I (MLC I) following aortocoronary bypass were studied in 31 patients and the curves of these changes were classified into three different patterns. A peak level of 14.7 +/- 1.54 ng/ml was seen in seven patients on postoperative day (POD) 2 which decreased suddenly to less than twice the normal value by POD 7 (group 1). Another 19 patients showed a peak level of 20.7 +/- 16.5 ng/ml on POD 5, which decreased slowly and was still high even by POD 7 (group 2). The remaining five patients developed only a slight increase in the MLC I level after the operation, with a peak value of 5.5 +/- 0.8 ng/ml (group 3). Creatine kinase myocardial band and glutamic oxaloacetic transaminase also remained low in this group. No correlation existed between the peak value of MLC I and the aortic cross-clamping time, or between the peak value of MLC I and the cardiopulmonary bypass time. Furthermore, the difference in cardiac output before and after the operation did not significantly differ among the three groups. These findings indicate that the measurement of MLC I is useful for diagnosing perioperative myocardial damage and may also be useful in the study of myocardial protection.
A 30-year-old man was admitted to the hospital because of type A aortic dissection associated with annuloaortic ectasia (AAE). A magnetic resonance image (MRI), computed tomography of the aorta demonstrated aortic enlargement with dissection, but revealed no evidence of dissection of the aortic arch. A transesophageal echocardiography demonstrated dissection of the aortic arch. A graft replacement of the total aortic root were performed using hypothermic circulatory arrest with retrograde cerebral perfusion and open distal anastomosis. We reconstructed coronary ostiums with carrel patch, and discontinued the operation without major bleeding. No neurological deficit was found postoperatively.
Pericardial cyst and diverticulum are commonly found in areas of cardiophrenic angles. In this article, we reported on two operated cases (54-year-old female, 43-year-old male) with pericardial diverticula in upper mediastinum. On their chest CT films, well circumscribed cystic lesions were seen in the right (case 1) and left (case 2) upper mediastinum. Based on findings of imaging modalities such as CT, MRI and transesophageal ultrasonography, the lesions were suspected of benign cystic tumors such as bronchogenic cyst, lymphatic cyst, esophageal cyst and pericardial cyst. However, definite diagnoses were made by thoracotomy. Even though the cystic lesion is recognized in the upper mediastinum, pericardial diverticulum should be considered as its diagnosis as well as bronchogenic cyst, lymphatic cyst, esophageal cyst.
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Since April 1989, we have been using autologous blood donation in order to avoid homologous blood transfusion as much as possible. To determine the factors which influence the necessity for homologous blood transfusion as well as autologous blood donation. Of them 77.6% (group 1) required autologous blood only, but others needed homologous blood transfusion as well as autologous blood. Using an invert analysis, preoperative factors that showed significant differences were age, body weight, number of autologous blood donations, amount of donated autologous blood, preoperative Hb and Ht. Among operative factors, aortic cross clamping time, cardiopulmonary bypass time, amount of concentrated blood from CPB circuit, amount of transfused autologous blood and amount of drainage demonstrated significant differences between groups. Univariately significant factors were studied by multivariate discriminant analysis. Total amount of drainage proved to be the best contributor of non-homologous blood transfusion surgery, followed by preoperative Hb, body weight, amount of concentrated blood from CPB circuit and amount of donated autologous blood in order of contribution Understanding these factors, homologous blood transfusion requirement may be greatly reduced. This is thought to be the largest series of autologous blood donation in Japan.
Since 1984, 1410 patients underwent coronary bypass grafting at Juntendo University Hospital. At the primary operation 797 patients had internal thoracic artery (ITA) graft and 613 patients received only saphenous vein graft (SVG). Reoperation was done in one pt. in ITA group and 10 pts. in SVG group. There were 2 deaths (reoperative mortality 18%). Percutaneous Transluminal Coronary Angioplasty to stenotic SVG was applied to 71 lesions in CABG patients. The primary success rate was 81.7% and restenosis rate was 38.9%. Urgent reoperation was performed on 3 pts. who had PTCA to diseased LAD or stenotic SVG to LAD. Reoperation is technically demanding and is associated with high mortality. Balloon angioplasty may provide a suitable alternative. But high restenosis rate (especially acute stenosis) remains a significant problem, particularly in the pts. with diseased LAD or stenotic vein graft to LAD. Reoperation is another option to relieve the ischemic symptoms in pts. with diseased LAD or stenotic vein graft to LAD.
The effects of pulsatile and nonpulsatile cardiopulmonary bypass using a roller pump on levels of vasoactive hormones and hematologic changes were studied in 32 patients subjected to elective primary coronary artery bypass graft surgery. Seventeen patients had nonpulsatile perfusion (nonpulsatile group) and 15 patients had pulsatile perfusion (pulsatile group) during the period of cardiac arrest. Vasoactive hormones (plasma renin, angiotensin II, aldosterone, epinephrine, and norepinephrine) were measured in these patients. In order to clarify hematologic changes, plasma free hemoglobin, number of platelets, platelet factor 4, and beta-thromboglobulin were measured. There were no significant differences between the pulsatile and nonpulsatile groups with regard to vasoactive hormones and damage of platelets. In the pulsatile group, however, the rise of plasma free hemoglobin levels was significantly higher than that in the nonpulsatile group during and after cardiopulmonary bypass. We did not see the benefit of pulsatile perfusion using a roller pump on vasoactive hormones. Evidence of increased hemolysis with pulsatile flow was demonstrated in our cases.
A total of 806 primary coronary artery bypass graft operations were performed between January 1984 and December 1989. Excluding eight hospital deaths (1.0%) and three patients lost in follow-up, a total of 795 patients were contracted, with a follow-up rate of 99.6%. The mean follow-up period was 53.6 months, the longest being 92 months. Of the patients 42 died in late follow-up. Malignant neoplasm was the major cause of death (n = 17, 40% of total late deaths), which far exceeded the number of cardiac deaths (n = 6, 14%). The actuarial survival, excluding the initial hospital deaths, was 95% at 5 years and 91% at 7 years by the Kaplan-Meier method. By multivariate logistic analysis, four clinical variables were identified as significant in influencing the late survival, in the following order: (1) presence or absence of diabetes mellitus (P = 0.00008); (2) age > or = 65 years or < 65 years (P = 0.002); (3) left ventricular function with ejection fraction < 45% or > or = 45% (P = 0.014); and (4) use or non-use of left internal mammary arteries to bypass the left anterior descending artery (P = 0.016). Sex (male versus female), severity of anginal symptoms (mild versus severe) and number of diseased vessels (single and double versus triple vessel and left main trunk disease) did not significantly influence the late survival of the patients.
The arterial conduits such as internal thoracic artery (ITA) and right gastroepiploic artery (GEA) are widely used in coronary artery bypass surgery because of their resistance to atherosclerosis. In this study, immunophenotypes of smooth muscle cells (SMCs) in intima and media of ITA, GEA and saphenous vein (SV) were studied using monoclonal antibodies specific to cytoskeletal proteins; actin (A), vimentin (V) and desmin (V). In addition, the ultrastructures of endothelium of these vessels were examined. The most SMCs in intima and media of ITA and GEA were found positive for (A) and (V) but negative for (D). In contrast, the majority of SMCs both in intima and media of SV were found positive for (A), (V) and (D). The ultrastructure of endothelium of ITA and GEA showed the deeper penetration of cytoplasmic process than SV, which might anchor the endothelium. We suggest the morphological difference of endothelium and phenotypic diversity of SMCs between arterial and venous grafts may account for the different susceptibility to atherosclerotic changes in coronary bypass grafting.
Occluded saphenous vein aorto-coronary bypass grafts were investigated using two types of monoclonal antibodies, specific to either the muscle actin (HHF 35) or the macrophage (HAM 56). The early post operative occlusions of saphenous vein grafts were associated with the deposition of mural thrombi with little intimal proliferation. The late occlusions of saphenous vein grafts were associated with intimal fibrous proliferation without mural thrombus formation. Proliferated smooth muscle cells were a major constituent of intimal fibrous proliferation in both early and late occluded grafts. Macrophages were not detected in both groups. The proliferation of smooth muscle cells in the intima may play a role in the development of late occlusion, rather than the organizational process of accumulated mural thrombi.
Isolated coronary ostial stenosis (OS) is a rare disease of unknown etiology. Five cases of OS were observed amongst 700 elective coronary bypass patients, and were compared with 111 cases of atherosclerotic left main trunk disease (LMTD) to clarify clinical characteristics. Mean age for LMTD patients was 61.2 years, while, it was 43.0 years for OS patients. 4 patients out of the 5 cases (80%) in the OS group were female, but there were only 10 females (9%) in the LMTD group. 60% of the OS group presented unstable angina without any episodes of myocardial infarction. 69.4% of the LMTD group presented stable angina, and 42% had a previous myocardial infarction. Left ventricular function was well preserved in the OS group compared to the LMTD group. Aorto-coronary bypass grafting was the only surgical method of our choice in both groups. The average number of grafts were 2.2 for the OS group, and 2.4 for LMTD group. Operative mortality was 0% for the OS group and 0.9% for the LMTD group. Clinical and angiographic profiles of ostial stenosis suggest that this group may represent a distinct entity, different from the more common atherosclerotic left main trunk stenosis. Coronary bypass grafting can provide good operative prognosis in ostial stenosis as well as in left main trunk stenosis.
To determine the priority of the surgical treatment of coexistent aortic and coronary disease (CAD), we reviewed 19 cases of aortic aneurysm combined with severe coronary lesions who underwent operation from Jan, 1984 to Aug, 1989. There were 15 cases of abdominal and 4 cases of thoracic aneurysm. All patients had graft replacement for the aneurysm and 12 patients had elective aortocoronary bypass surgery (CABG), one had percutaneous transluminal coronary angioplasty and 6 received medical treatment for CAD. In 6 cases, CABG preceded abdominal aneurysm operation. In 3 cases of ascending thoracic aneurysm, simultaneous coronary and aortic operation were performed. There were no early and late operative death. In an attempt to reduce perioperative myocardial infarction which is one of the most frequent complications of aneurysmal operation, we performed routine coronary angiogram before operation. In 104 patients considered for elective aortic and peripheral vascular disease, coronary angiogram were performed. The incidence of coexistent coronary artery disease in peripheral vascular and aortic disease were 46.1%. The incidence of multiple vessel CAD in patients with aortic and peripheral disease were high. Our surgical strategy for coexistent aortic, peripheral vascular and coronary disease is basically staged operation and simultaneous operation are performed only in ascending and proximal arch aneurysm.
To evaluate the operative risk of coronary diseased patients who had severe left ventricular dysfunction, we retrospectively reviewed the cases of 798 patients who had received A-C bypass surgery at Juntendo University between Jan. 1984 and Dec. 1989. The patients with severe left ventricular dysfunction (Ejection Fraction less than 30%) (Group-A, n = 9) were compared with the patients with moderately impaired left ventricular function (E.F. 30%-40%) (Group-B, n = 28) and normal left ventricular function (E.F. greater than or equal to 50%) (Group C, n = 34). The mean E.F. were 21.56 +/- 3.72% in Group-A, 34.28 +/- 3.17% in Group-B, 64.19 +/- 12.02% in Group-C. There were no differences between the 3 groups with regard to Cardiac Index, LVEDP, number of diseased vessels, number of grafts, aortic cross clamp time and cardio-pulmonary bypass time. The percentages of patient who needed catecholamines support in postoperatively were 77.8% in Group-A, 46.4% in Group-B and 61.8% in Group-C. There were no operative and hospital deaths in each of the 3 Groups, whereas 2 patients of Group-A died later of noncardiac disease. We propose that patients with severe left ventricular dysfunction (15 less than or equal to EF, less than 30%) benefit from CABG surgery with low risk, and that each left ventricular E.F., Cardiac Index or LVEDP alone were less significant predictors of operative results as measured by preoperative left ventricular function.
A case of post-sternotomy mediastinitis due to methicillin-resistant Staphylococcus aureus after aortocoronary bypass procedure was treated with debridement, open clean packing, and delayed wound closure by the technique of pectoral muscle flap mobilization. The cosmetic and functional results were excellent. This technique seems to be a very effective method of treatment for the serious complication of deep sternal infection with mediastinitis after cardiac operation.
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Accelerated coronary arteriosclerosis is one of the major complications affecting long-term survival in cardiac transplantation. In this study, we sought to clarify the cellular components in cardiac and vessel allograft arteriosclerotic lesions using monoclonal antibodies specific to either the muscle actin (HHF 35) or the macrophage (RAM 11). Four kinds of allogeneic transplantations were performed in the rabbits: 1) cardiac heterotopic transplantations, low cholesterol-fed (n = 6), 2) cardiac heterotopic transplantations, 1% cholesterol-fed (n = 6), 3) vessel transplantations, low cholesterol-fed (n = 6), 4) vessel transplantations, 1% cholesterol-fed (n = 6). All recipients were immunosuppressed with cyclosporine. The donor hearts and the arterial grafts were excised 5 weeks after transplantation and submitted to immunocytochemical analysis. The intimal lesions in both groups 1 and 3 were composed of infiltrating mononuclear cells and HHF 35 positive smooth muscle cells. The more thickened intima in both groups 2 and 4 were occupied with smooth muscle cells and foam cells, which were derived from macrophages. These data suggest that the proliferation of smooth muscle cells might be a major factor contributing to graft arteriosclerosis, and that long term exposure to hypercholesterolemia could induce the accumulation of smooth muscle cells or macrophage derived foam cells.
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