[Problems on promotion for clinical heart transplantation in Japan. Construction of institutional back-up system].
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Ethics Committees↗
Biomedical subjects
Y Shimazaki
Publications and source records attributed to Y Shimazaki.
[Surgical approach to the nasal valve stenosis].
Nasal valve, originally defined by Mink (1903), has changed its concept and is now regarded as slit-like opening between the caudal end of the upper lateral cartilage and the septum. Contrary to Caucasians whose smallest area of the nose lies at the nasal valve, the narrowest part of Japanese nose situates at the area between the anterior portion of the inferior turbinate and the septum. Thus, we have fewer chance to experience patients with stenotic nasal valve. Six patients complaining nasal obstruction resulted from nasal valve stenosis, mainly due to dislocated or collapsed upper lateral cartilage, underwent surgery during the last 2 years and a half. Cases of septal deformity, even it it produced valve stenosis, were excluded in this study. Surgical intervention was directed toward reconstruction of normal anatomic relationships, usually by widening the nasal valve angle and preventing collapsibility. Three underwent open rhinoplasty with gull-wing columellar skin incision, whereas 3 others were operated on via transnostril approach. History of midfacial trauma caused us to choose open rhinoplasty for restoring the function and structure. Immediate postoperative result was excellent in the aspect of appearance and subjective data regardless of surgical approach. Open rhinoplasty provided a splendid long-term result without remarkable complications. On the other hand, 2 cases operated via transnostril approach complained recurrence of stuffy nose.
Adult↗
[The evaluation of interval period to prepare the left ventricle for Jatene operation for simple transposition of the great arteries].
Laboratory studies indicate that it can be as short as one week after a first-stage operation to prepare the left ventricle for a subsequent second-stage arterial switch (Jatene operation) for simple transposition of the great arteries (TGA). In order to ascertain it, we evaluated the left ventricular (LV) function immediately after the first-stage procedure and late postoperatively by echocardiography and catheterization. There were 6 cases with simple TGA. The age at palliation was 6.6 +/- 4.5 (mean +/- SD) months, and the interval between the first-stage and Jatene operation was 16 days-16 months (6.7 +/- 6.4 months). All patients survived after arterial switch. In 2 early infant cases, arterial switch operation was performed with ventilatory support due to cardiac and respiratory failures 16 and 21 days after the first-stage operation respectively. LV end-diastolic dimension increased by 1 week and showed no change after 1 week (n = 4). LV ejection fraction was depressed from 0.84 +/- 0.03 preoperatively to 0.61 +/- 0.08 at 1-4 days after the first-stage operation but improved to 0.83 +/- 0.06 by 7-9 days after that (n = 4). LV end-diastolic posterior wall thickness increased to more than 4 mm in 3 infant cases, more than 3 mm in 2 early infant cases by 7 days. The results of catheterization after the first-stage operation were as follows (n = 5); left ventricular right ventricular peak systolic pressure ratio increased from 0.53 +/- 0.16 to 0.94 +/- 0.04 (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Adaptation, Physiological↗
[Reconstruction of the pulmonary outflow tract without prosthetic conduit for correction of tetralogy of Fallot with pulmonary atresia].
We reconstructed right ventricular outflow tract without prosthetic conduit for 2 year 11 month and 59 day old Tetralogy of Fallot with pulmonary atresia patients. Left appendage anastomosed between pulmonary trunk and right ventricle was utilized as the posterior wall of the tract. Pericardial patch covered the tract the beneficial methods for patients with Tetralogy of Fallot with pulmonary atresia to avoid late postoperative deleterious complications of prosthetic conduit.
Cardiac Surgical Procedures↗
[Anatomic correction without extracardiac conduit for Taussig-Bing malformation (REV procedure)].
A 2-year-old boy with Taussig-Bing malformation with mild pulmonary stenosis underwent anatomical repair without extracardiac conduit (REV procedure). He had pulmonary arterial banding at 4 months of age, and REV procedure was performed at 2 years and 4 months of age. Under cardiopulmonary bypass, enlargement of ventricular septal defect were performed with an internal conduit. Pulmonary arterial trunk was divided and the proximal end was closed. Direct anastomosis of the posterior wall of the distal pulmonary arterial trunk to the right ventriculotomy was carried out without transection of aorta or translocation of pulmonary artery. Right ventricular outflow tract (RVOT) was reconstructed with a patch bearing a monocusp. The postoperative course was very smooth and postoperative cardiac catheterization revealed no stenosis in both left and right ventricular outlfow tract and good cardiac performance.
Aorta↗
[Response to exercise in patients after repair of tetralogy of Fallot].
Cardiac catheterization and submaximal exercise testing was performed in 38 patients after repair of tetralogy of Fallot (TF), and compared to 6 control patients who had functional murmurs. Cardiac index, heart rate, and stroke volume index were significantly lower in the TF group than in the control group. Right and left ventricular end-diastolic pressure increased significantly during exercise, which was not found in the control group. Total pulmonary vascular resistance (TPVR), which decreased significantly with exercise in the control group, did not change remarkably during exercise. TPVR was significantly higher in the TF group than in the control group both at rest and during exercise. Several factors were compared between patients with good cardiac index (> 5.0 l/min/m2; Group 1) and poor cardiac index (< 5.0 l/min/m2; Group 2) during exercise. Stroke volume index, right ventricular ejection fraction at rest were significantly higher in Group 1 than Group 2. TPVR, right and left ventricular end-diastolic and end-systolic volume index were significantly lower in Group 1 than in Group 2. There was no significant difference in heart rate, left ventricular ejection fraction, residual pulmonary stenosis, right to left ventricular systolic pressure ratio, and severity of pulmonary regurgitation between two groups. These findings indicate that abnormalities of exercise tolerance in patients after repair of TF were related to poor response of heart rate, pulmonary vascular resistance, and systolic and diastolic ventricular function.
Adolescent↗
[Aortic valve re-replacement with a SJM valve by aortic ring re-enlargement with Nick's method--report of a successful case].
An 11-year-old girl had undergone an aortic valve replacement for congenital aortic stenosis with #17 Björk-Shiley valve and aortic ring enlargement by Nick's method eight years later, the pressure gradient across the prosthetic valve increased up to 100 mmHg. Re-aortic valve replacement was successfully performed with #21 St. Jude Medical valve, when aortic valve ring increased to accommodate #21 SJM valve.
Aortic Valve↗
Intraventricular repair for Taussig-Bing anomaly.
Among 41 patients with Taussig-Bing anomaly who underwent intracardiac repair, 10 patients were treated by intraventricular rerouting repair. The ages at operation ranged form 1 month to 8 years (average 2 years 3 months). Primary repair was done in four (average age 2 years 7 months), and repair was done after pulmonary artery banding in six patients (average age 2 years 2 months). The relationship of the great arteries was side by side in nine patients and oblique in one. After extensive resection of the infundibular septum, a distance of 8 to 18 mm from the tricuspid ring or chordae to the pulmonary valve was obtained (24% to 71% of total circumference for the subaortic route). The subaortic route was created to obtain an internal diameter at least equal to that of the aortic route. Tricuspid chordal or papillary muscle reattachment was performed in two patients. There were no early or late deaths. Follow-up ranged from 1 year 4 months to 22 years 3 months (average 5 years 8 months), and reoperation was required in one patient for residual pulmonary stenosis. The intraoperative pressure gradient between the left ventricle and aorta was 0 to 24 mm Hg (average 10.3 mm Hg), and postoperative study showed the gradients to be less than 19 mm Hg (n = 8). The age at operation, left ventricular-aortic pressure gradient, and postoperative tricuspid regurgitation were not significantly affected by the presence of severe hypertrophy of the infundibular septum (n = 4). These results indicate that intraventricular rerouting may be feasible in most patients who have the Taussig-Bing anomaly with side-by-side or similar relationships of the great arteries, and the age and conal anatomic variations do not appear to be significant limiting factors.
Cardiac Catheterization↗
[Thinning of ventricular septum in tetralogy of Fallot].
Cross sectional echocardiography was used to evaluate the thickness of the ventricular septum in tetralogy of Fallot (TOF). Forty-six patients with TOF and 20 patients with pseudo-truncus arteriosus underwent echocardiography during a five-year period beginning in 1984. Thicknesses of the right ventricular anterior wall (RVAWT), trabecular septum (IVST) and left ventricular posterior wall (LVPWT) were measured in end diastole on parasternal short axis view at the level of the tips of papillary muscles. The ratios of IVST to RVAWT and IVST to LVPWT were assessed. The ratio of IVST to RVAWT was 1.09 +/- 0.15 in the group aged less than 7 years (less than 7 y.o.) and 0.94 +/- 0.15 in the group aged of 7 years or more (greater than = 7 y.o.). The ratios of IVST to LVPWT were 1.10 +/- 0.14 (less than 7 y.o.) and 0.90 +/- 0.15 (greater than = 7 y.o.), respectively. Both ratios were significantly different (p less than 0.01) in the two age groups, and relative thinning of the septum was demonstrated in the older patients. It is speculated that thinning of the interventricular septum is caused by the lower systolic wall stress of the ventricular septum compared with that of the free walls, which is produced under equal systolic pressure of the two ventricles. It is suggested that this thinning is one of the factors that reduces left ventricular function after repair of TOF.
Adolescent↗
Transaortic patch angioplasty for left coronary ostial stenosis in a patient with Takayasu's aortitis.
A 35-year-old woman who had left coronary ostial stenosis and aortic valve regurgitation due to Takayasu's aortitis underwent transaortic patch enlargement of the stenosed left coronary ostium in combination with aortic valve replacement. This technique may be suitable and recommendable as an alternative to aortocoronary bypass grafting or endarterectomy for coronary ostial stenosis in Takayasu's aortitis.
Adult↗
An appraisal of patch enlargement of the small aortic annulus in 33 patients undergoing aortic valve replacement.
To avoid the problem of valve prosthesis/patient mismatch in the late postoperative period, we have adopted patch enlargement of the small aortic annulus in 33 patients having undergone aortic valve replacement since 1975, when the aortic annulus could not accept a large enough prosthesis. The mean age was 40 years, including 2 children aged 4. The technique of patch enlargement utilized was Nicks' method wherein the incision does not extend onto the mitral leaflet. In 31 adult patients, the aortic annulus before enlargement ranged in diameter from 18 to 24 mm with an average of 20.8 mm. After enlargement, the diameter of the annulus was 25.0 mm on average. In 2 children, the mean diameter of the annulus was enlarged from 16.5 mm to 20.5 mm. There were 2 early deaths in the initial series and 2 late deaths. Patch enlargement of the small aortic annulus is a simple, safe, and effective adjunct permitting the insertion of a valve one or two sizes larger than that which could be accommodated by the native annulus.
Adolescent↗
[Left ventricular function in mitral regurgitation--relation to postoperative survival and left ventricular contractile state after mitral valve replacement].
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Adult↗
[Phrenic nerve palsy after open heart surgery--problems in post-operative respiratory management].
We clarified the problems in respiratory management in patients with phrenic nerve palsy (PNP) after open heart surgery. From December 1988 to March 1991, 248 adult patients underwent open heart surgery with topical myocardial cooling. In these patients PNP was diagnosed in 17 patients (6.9%). Age of these patients at operation ranged from 25 to 76 years with a mean age of 57 years. 9 patients were valvular heart disease (7 were reoperation), 7 were coronary artery disease, and one patient was aortic aneurysm. PNP was diagnosed by chest roentgenogram or percutaneous phrenic nerve stimulation test (PNST). Frequency of long-term intubation (> 14 days) was higher in complete PNP patients than incomplete PNP patients. 2 patients, who were observed effort dyspnea at the time of respiratory weaning, were extubated followed by respiratory and circulatory deterioration, and were reintubated. PNP were confirmed after reintubation by PNST. These patients died of pneumonia. Another 2 patients were observed effort dyspnea during respiratory weaning, and were doubted of PNP. PNP were confirmed by PNST before extubation. After hemodynamic stabilization and respiratory physiotherapy, these patients were extubated without any trouble. One patient, who required repeated intubation, was diagnosed PNP by PNST. This patient was extubated after confirmation of improvement of PNP by follow-up PNST. The incidence of PNP was higher in patients with previous open heart surgery than without previous operation. We supposed that the dissection around the heart might be one of major cause of postoperative PNP. So, in recent 4 cases of mitral reoperation, we attempted to reach mitral valve through atrial septum with minimum dissection.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Pulsed Doppler echocardiographic observation of left ventricular filling dynamics after aortic valve replacement in patients with chronic aortic regurgitation].
The 23 patients who underwent aortic valve replacement (AVR) for aortic regurgitation (AR) from 1977 to 1990 were studied with pulsed Doppler echocardiography. The patients were divided into two groups. The A group consisted of 5 patients whose end-systolic volume index (ESVI) were more than 200 ml/m2 and/or left ventricular ejection fraction (EF) were less than 0.35 before AVR. The B group consisted of 18 patients whose ESVI were less than 200 ml/m2 and EF were more than 0.35 before AVR. A Doppler volume sampler was placed at the center of mitral orifice to measure the transmitral inflow velocity after AVR (mean 28 months). Left ventricular filling dynamics were assessed by the peak velocity in the rapid filling phase (R), the peak velocity in the atrial contraction phase (A) and the ratio of A by R (A/R ratio) of mitral flow velocity pattern. The deceleration rate of early diastolic rapid inflow (DeR) determined as the slope a straight line drawn between the peak of early diastolic inflow and a point at half peak velocity on the fall side of the envelope. Result was as follows; 1) The DeR showed significant correlation with the EF (r = 0.56, p < 0.01). The DeR showed significant inverse correlation with the ESVI (r = -0.52, p < 0.05). 2) The R velocity (mean 43.9 +/- 7.9 cm/sec) in group A was significantly lower than in group B (mean 61.4 +/- 18.6 cm/sec), (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Preoperative and postoperative right ventricular function during exercise in patients with mitral stenosis.
To elucidate the effects of mitral valve surgery on right ventricular function in 11 patients with mitral stenosis, pre- and postoperative right ventricular function were quantified using gated equilibrium blood pool radionuclide ventriculography at rest and during exercise. The preoperative right ventricular ejection fraction was 39 +/- 4% at rest and 36 +/- 9% during exercise, which during exercise was lower than control values (51 +/- 5%) (p < 0.01). When the preoperative right ventricular ejection fraction was lower during exercise than at rest, postoperative right ventricular ejection fraction during exercise was lower than normal values (42 +/- 3% versus 51 +/- 5%) (p < 0.01). When the preoperative right ventricular ejection fraction did not decrease during exercise, the postoperative right ventricular ejection fraction was within normal limits during exercise (54 +/- 5%). In addition, postoperative right ventricular ejection fraction during exercise increased to normal values in patients whose preoperative right ventricular ejection fraction during exercise had been 40% or higher. Preoperative peak ejection rate was -1.81 +/- 0.19 EDV/sec at rest and -1.72 +/- 0.39 EDV/sec during exercise, which during exercise was lower than control values (-2.44 +/- 0.53 EDV/sec) (p < 0.01). Postoperatively, peak ejection rate during exercise (-2.50 +/- 0.37 EDV/sec) increased (p < 0.05) to normal levels. Preoperative peak filling rate was 1.61 +/- 0.47 EDV/sec at rest and 1.88 +/- 0.54 EDV/sec during exercise, which during exercise was lower than control values (2.58 +/- 0.62 EDV/sec) (p < 0.01). Postoperatively, peak filling rate during exercise (2.82 +/- 0.62 EDV/sec) increased (p < 0.05) to normal values in all patients. Preoperative changes in both right ventricular ejection fraction and peak ejection rate from rest to exercise inversely correlated with the preoperative pulmonary vascular resistance at rest (right ventricular ejection fraction, r = -0.79, p < 0.005; and peak ejection rate, r = -0.67, p < 0.05). In conclusion, right ventricular systolic function improved in about half of the patients with mitral stenosis, and diastolic function improved in all patients during exercise following surgery. When the preoperative pulmonary vascular resistance was elevated, the right ventricular systolic dysfunction persisted.
Adult↗
Assessment of regional and transmural myocardial perfusion by means of intraoperative myocardial contrast echocardiography during coronary artery bypass grafting.
By using intraoperative myocardial contrast echocardiography, we assessed regional myocardial perfusion and transmural blood flow distribution immediately after myocardial revascularization. A total of 62 revascularized myocardial areas were studied in 31 patients undergoing coronary artery bypass grafting. The revascularized areas were divided into three different areas: S area, supplied by significantly stenosed coronary arteries (43 areas); C area, supplied by coronary collateral situation associated with totally occluded coronary arteries (12 areas); MI area, preexisting transmural myocardial infarction (7 areas). Myocardial contrast echocardiography was obtained by direct injection of 2 ml of sonicated 5% human albumin into the saphenous vein grafts at rest and during atrial pacing. Each area was divided into two layers of endocardial and epicardial halves, and myocardial enhancement of peak intensity was measured for each half and endocardial/epicardial gray level ratio was calculated: (1) The peak intensity of myocardial enhancement in S area and C area was significantly higher than that in MI area at rest as well as during pacing after myocardial revascularization. There was no significant difference in the peak intensity between S area and C area both at rest and during pacing. In S area the peak intensity significantly increased during pacing (p < 0.01), whereas it did not change in C area and MI area. (2) S area demonstrated no significant change in endocardial/epicardial intensity ratio during pacing. In contrast, the ratio in C area significantly decreased during pacing. (3) In S area with preoperative percent increase of segmental wall thickening lower than 25%, there was a significant correlation (r = 0.84, p < 0.001) between the peak intensity of myocardial enhancement and the postoperative changes of percent increase of segmental wall thickening in the revascularized areas. Thus, immediately after myocardial revascularization, intraoperative myocardial contrast echocardiography could provide a quantitative assessment of regional myocardial perfusion as well as blood flow distribution in the areas with myocardial infarction and with coronary collateral situation and in the areas supplied by stenosed coronary arteries.
Cardiac Pacing, Artificial↗
Evaluation of right ventricular function by regional wall motion analysis in patients after correction of tetralogy of Fallot. Comparison of transventricular and nontransventricular repairs.
Right ventricular function was assessed by regional wall motion analysis and by global function in 62 patients after repair for tetralogy of Fallot. Its relation to surgical procedures, with special attention to right ventriculotomy, was investigated. Patients were classified as follows: group Ia (n = 17), transpulmonary-transatrial repair without right ventriculotomy; group Ib (n = 22), transpulmonary-transatrial repair with minimal right ventriculotomy and small transannular patch; and group II (n = 23), transventricular repair with or without transannular patch. For regional wall motion analysis, fractional area change was used for three anterior parts obtained from hemiaxis area analysis of the lateral right ventriculogram. Ejection fractions were used for global right ventricular function. Functional assessment was done both at rest and during isoproterenol infusion, which is a stress test to evaluate cardiac functional reserve. At rest, group Ia showed better right ventricular anterior wall motion as well as global ejection fraction than did group II. Group Ib showed a global ejection fraction comparable to group Ia, with better regional wall motion in the middle anterior part of the right ventricle despite the depressed upper and lower anterior parts of the right ventricle. Group II showed depressed wall motion of the middle anterior part and the resultant impaired global ejection fraction. During isoproterenol infusion, group Ia showed significant increase in fractional area change of all anterior parts and in global ejection fraction. Group Ib showed significant increases in fractional area change at the middle and lower parts and in global ejection fraction comparable with group Ia. Otherwise, group II showed no significant change in fractional area change, or in global ejection fraction, at the upper and middle parts. These results indicated that transpulmonary-transatrial repair for tetralogy of Fallot provided better postoperative global right ventricular function and its reserve, with less impaired regional wall motion, than did the transventricular repair.
Cardiac Catheterization↗
Global left ventricular performance and regional systolic function after suture annuloplasty for chronic mitral regurgitation.
BACKGROUND: In surgery for chronic mitral regurgitation, the mitral subvalvular apparatus, including annulus, may play an important role in preserving left ventricular (LV) performance. The suture annuloplasty for mitral regurgitation allows annular contraction of the mitral valve. The potential effects of suture annuloplasty on the postoperative LV performance have not been fully defined. METHODS AND RESULTS: Global and regional LV function in 12 patients with suture annuloplasty were compared with 12 patients with conventional mitral valve replacement (MVR). Cineangiography and echocardiography were obtained before and 10.8 months after surgery. End-diastolic volume index and end-systolic volume index decreased significantly in both groups after surgery (p < 0.01). Ejection fraction remained unchanged in the suture annuloplasty group, whereas it decreased significantly in the MVR group after surgery (p < 0.01). There was a significant inverse relation between ejection fraction and end-systolic wall stress in the two groups after surgery (suture annuloplasty group, r = -0.69, p = 0.01; MVR group, r = -0.60, p = 0.04). The intercept on the y axis was significantly (p < 0.005) higher in the suture annuloplasty group than in the MVR group. In the suture annuloplasty group, cross-sectional area ejection fraction at the mitral valve level and at the papillary muscle level by LV two-dimensional echocardiography remained unchanged after surgery. In the MVR group, they decreased significantly after surgery (p < 0.01). There was a significant correlation between the cross-sectional area ejection fraction and the global ejection fraction at both levels after surgery. Therefore, the improvement of the regional wall motion can be attributed to the improvement of the global LV performance after suture annuloplasty. CONCLUSIONS: These data suggest that suture annuloplasty can provide more desirable postoperative LV systolic performance than conventional MVR by preserving both the contraction of the mitral annulus and the mitral valvular-ventricular interaction.
Echocardiography↗