The guidewire technique for transseptal puncture.
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Catheter Ablation↗
Biomedical subjects
Tadayuki Shimakura
Publications and source records attributed to Tadayuki Shimakura.
Autologous blood donation before elective off-pump coronary artery bypass grafting.
PURPOSE: Preoperative autologous blood donation reduces exposure to homologous blood transfusions in cardiac surgery. The purpose of this study was to ascertain the volume of predonated autologous blood needed to avoid homologous blood transfusion in scheduled off-pump coronary artery bypass grafting (off-pump CABG). METHODS: Fifty-six patients underwent scheduled off-pump CABG between January 1999 and December 2000. These patients all donated either 400 ml (group 1, n = 33) or 800 ml (group 2, n = 23) of autologous blood before operation. These patients donated at a rate of 400 ml per week. All patients were given an equal volume of saline solution at the time of autologous donation. RESULTS: There were no significant differences in the mean age, mean body weight, mean preoperative hematocrit values, mean graft number, or mean volume of intraoperative blood loss between groups 1 and 2. There was a significant difference in the mean postoperative day-7 hematocrit value (33.6% +/- 1.3% vs 39.3% +/- 1.3%, P << 0.05). The rates of avoiding homologous blood transfusion were 63.6% in group 1 and 100% in group 2 ( P << 0.05). CONCLUSIONS: Autologous blood transfusion is effective for reducing the homologous blood requirement. We believe that an 800-ml predonation is sufficient to avoid homologous blood transfusion in scheduled off-pump CABG; furthermore, patients with cardiovascular disease, including severe coronary artery disease, should be administered saline along with the blood donation.
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Cerebral perfusion during off-pump coronary artery bypass grafting.
PURPOSE: It is still unclear whether cerebral perfusion is affected during off-pump coronary bypass grafting (OPCABG). We investigated the predictive value of the neurobiochemical markers of brain damage and cerebral perfusion in relation to early neuropsychological outcome after OPCABG. METHODS: We performed OPCABG in ten patients (mean age, 63.4 +/- 5.5 years). A 5.5 F oximetric catheter was placed in the jugular bulb to continuously measure jugular oxygen saturation (SjO(2)) during OPCABG. We also examined the activity of daily living (ADL) index and performed the Mini-Mental State Examination (MMSE) to assess neuropsychological state preoperatively and 7 days postoperatively. Venous serum levels of neuron-specific enolase (NSE) and brain-specific creatine kinase (CK-BB) were measured preoperatively and 24 h after skin closure. RESULTS: The mean arterial blood pressure and the SjO(2) during anastomosis of the left circumflex coronary artery (Cx) were significantly lower than that of the left anterior descending coronary artery (LAD) (P < 0.001). None of the patients died. There was no transient or permanent neurologic deficit. Cognitive decline was evident in two patients with a low SjO(2) and a high postoperative NSE level. The postoperative CK-BB value was normal in all patients. CONCLUSIONS: Monitoring intraoperative continuous cerebral oxygen desaturation and postoperative NSE levels could be useful for predicting early neuropsychological outcome after OPCABG.
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Immediate and 3-month follow-up outcome after cutting balloon angioplasty for bifurcation lesions.
Balloon angioplasty of a bifurcation lesion is associated with lower rates of success and higher rates of complications than such treatment of lesions of most other morphologies. To date, the best device or procedure for bifurcation lesions has not been determined. The aim of this study was to compare the immediate and 3-month follow-up outcome of cutting balloon angioplasty (CBA) versus conventional balloon angioplasty (PTCA) for the treatment of bifurcation lesions. We treated 87 consecutive bifurcation lesions with CBA (n = 50) or PTCA (n = 37). Paired angiograms were analyzed by quantitative angiography, and angiographic follow-up was achieved for 93% of the lesions. The procedural success was 92% in the CBA group and 76% in the PTCA group (P < 0.05). Major in-hospital complications occurred in two lesions in the CBA group and six in the PTCA group (P = 0.05). The incidence of bail-out stenting in the CBA group was lower than in the conventional PTCA (8% vs 24%, P < 0.05). At the 3-month follow-up, the restenosis rate was 40% in the CBA group versus 67% in the PTCA group (P < 0.05). Clinical events during follow-up did not differ between the two groups. In conclusion, in comparison with PTCA, procedural success was greater and the restenosis rate lower with CBA. The results of this study support the use of the cutting balloon as optimal treatment for bifurcation lesions.
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Aortic root replacements in reoperations.
We evaluated 4 patients who had undergone previous cardiac surgery underwent reoperation involving aortic root replacement. Subjects were a 55-year-old man who had undergone separate valve graft replacement for a dissecting aneurysm (DeBakey type I) 3.25 years earlier; a 51-year-old woman who had undergone separate valve graft replacement for a dissecting aneurysm (DeBakey type I) 6 years earlier; a 66-year-old woman who had undergone aortic valve replacement and single coronary artery bypass grafting for severe aortic regurgitation, angina pectoris, and aortitis syndrome 11 years earlier; a 47-year-old man who had undergone mitral valve replacement and 3-coronary artery bypass grafting for severe mitral regurgitation and angina pectoris 4 years earlier. Development of a surgical technique, coupled with myocardial protection, and pharmacological treatment at reoperation yielded excellent early surgical results. To reduce the incidence of reoperation and ensure satisfactory long-term results, we recommend radical management for the individual case be selected at initial operation and entire resections be conducted for aneurysmal degeneration or dissected segments.
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Surgical case of aortic root and thoracic aortic aneurysm after the Wheat procedure.
A 52 year-old man underwent aortic valve replacement and ascending aortic replacement (Wheat procedure) for acute dissection (Stanford type A) and aortic regurgitation (grade 3/4). At that time, the aortic root was slightly dilated at about 45 mm and the descending aorta was within a normal range at about 35 mm. Forty months after the initial operation, a follow-up chest enhanced computed tomography showed an aortic root aneurysm about 60 mm in diameter, a thoracic aortic aneurysm about 70 mm in diameter and chronic aortic dissection. First we performed the Bentall procedure, innominate artery and left common carotid artery replacement by 12 mm, and 10 mm Hemashield grafts during selective cerebral perfusion. After 10 weeks, we carried out aortic arch, descending aorta and left subclavian artery replacement. The postoperative course was uneventful and postoperative examination demonstrated a good surgical result. Histological findings of the aortic aneurysm wall showed cystic medial necrosis, but Marfan's syndrome was excluded clinically. We could diagnose aortic root aneurysm by regular follow-up chest enhanced computed tomography (CT) and echocardiography. Therefore, cases with slight dilation of the aortic root in the Wheat procedure should undergo regular follow-up evaluation by chest enhanced CT and echocardiography.
Aortic Dissection↗
Minimally invasive direct redo coronary artery bypass grafting.
Redo coronary artery bypass grafting due to graft failure and the progression of new lesions has been increasing in frequency recently. We are often forced to revascularize only the left anterior descending artery (LAD) in very elderly patients with a high risk to median sternotomy. We performed reoperative minimally invasive direct coronary artery bypass grafting (MIDCABG) in seven patients. The target sites were as follows: LAD, 7; first diagonal branch, 1; and the graft material was the left internal thoracic artery (LITA), 7; and saphenous vein graft (SVG), 1. Complete revascularization was accomplished in all patients, by including hybrid therapy in three patients and axillo-coronary bypass grafting with SVGs in two patients. Postoperative angiography showed all patent grafts and all patients were discharged. During a mean follow-up period of 2.4 years (range: 0.5 to 3.5 years), all were free from cardiac events, except for one patient who had recurrent angina due to failure of a previously patent graft 3 years after redo MIDCAB. These results suggest that MIDCABG via left antero-lateral thoracotomy is an effective and safe technique in redo cases, as well as an alternative procedure for hybrid revascularization that combines minimally invasive revascularization of LAD with additional catheter interventional therapy.
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A technique for infusion of cardioplegic solution in coronary artery bypass with aortic regurgitation.
BACKGROUND: Complications such as heart failure due to insufficient cardioplegia may develop in on-pump coronary artery bypass (CAB) with mild-to-moderate aortic regurgitation (AR). A technique for administration of cardioplegic solution was carried out to avoid such complications. METHODS AND RESULTS: Cardiopulmonary bypass was established. After aortic cross-clamping, cardioplegic solution was administered from aortic root. Because complete cardiac arrest was not rapidly achieved, the aortic root was incised. Three cusps of the aortic valve were sutured. The aorta was closed; cardioplegic solution was administered from the aortic root. Then, cardiac arrest was rapidly achieved. After distal anastomosis of quadruple bypass was completed, the suture of the cusps was removed. There was no exacerbation of AR due to this method compared to the preoperative state. CONCLUSION: When off-pump coronary artery bypass is impossible and retrograde cardioplegia cannot be performed for a certain reason, this method may be set to one of the choices.
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