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ignal-averaged electrocardiography (SAECG) is a non-invasive technique to detect ventricular late potentials (LP), which are low-amplitude and highfrequency signals at the end of the QRS complex, from the body surface. 1 The presence of LP in an abnormal SAECG reflects slow and heterogeneous conduction in myocardium, which is predictive of ventricular arrhythmia and sudden cardiac death in patients with ischemic heart disease, 2-4 and successful coronary angioplasty of an occluded infarctrelated artery reduces the incidence of ventricular LP. [5][6][7][8] It has been reported that coronary artery bypass grafting (CABG) also reduced the incidence of LP perioperatively, 9,10 but that study focused on patients with abnormal SAECG before CABG. In the present study, we investigated changes in the parameters of SAECG after CABG, in a patient group that included those with normal preoperative SAECG, to determine the quantitative effect of CABG on SAECG and to identify the factors that are related to it. Methods PatientsPre-and postoperative SAECGs were recorded in consecutive 100 patients (78 men, 22 women; mean age, 66.5±7.7 years) undergoing an elective CABG who did not have a conduction disturbance on a standard ECG. Their coronary risk factors included smoking (n=63), diabetes (n=42), hyperlipidemia (n=50), hypertension (n=55), and obesity (n=11); 35 patients had a prior myocardial infarction (MI): 19 with an antero-lateral MI and 16 with a postero-inferior MI. Of the 100 CABG procedures, 78 had cardiopulmonary bypass (CPB) and 22 did not have CPB. Combined procedures included mitral valve replacement (n=4), mitral valve plasty (n=2), aortic valve replacement (n=4), and abdominal aneurysmectomy (n=3). Cardiac CatheterizationBased upon the preoperative cardiac catheterization results, the left ventricular ejection fraction (LVEF) and myocardial score, which reflects the degree of myocardial ischemia, were calculated for each patient. The myocardial scores were obtained by the method described by Brandt et al; 11 that is, the left ventricle is given 15 units, comprising 7 units for the antero-septal area, 3 units each for the obtuse marginal and inferior areas, and 2 units for the diagonal area. The myocardial value is the total number of units of the myocardium supplied by a particular artery distal to the stenosis or obstruction. Using the grade of stenosis and the myocardial value, each artery is given a myocardial score using the table described by Brandt et al. 11 The separate scores are summed to give the total myocardial score, which cannot exceed 15.Postoperative catheterization was performed a mean of 14±5 days after CABG, at which time all bypass grafts were examined from at least 3 different views. Complete revascularization was defined as all diseased arterial systems receiving patent grafts with stenosis of less than 50%. SAECG RecordingTime domain SAECGs were recorded with an HM-1000 electrocardiograph (Fukuda Denshi Co, Tokyo, Japan) a mean of 5±2 days before and a mean of 14±2 days after CABG. Signal ...

ostoperative constrictive pericarditis may not be as uncommon as we think. The incidence has been reported from 0.2% to 0.3% after open heart surgery 1-3 and should be suspected when the postoperative course deviates from expected. Although the actual cause is unknown, several factors after cardiac operations are suspected, including surgical trauma, hemopericardium, infection, postpericardiotomy inflammation, cold injury, and air desiccation. The onset has been reported from 2 weeks to 21 years after surgery 1,2 and we present an unusual case of a patient who developed symptoms of constrictive pericarditis 30 years after cardiac surgery. Case ReportA 54-year-old man was admitted for evaluation of exertional dyspnea and chest oppression. He had undergone closure of ASD via a median sternotomy 30 years previously and had not had any health problems since then. On admission, his blood pressure 94/66 mmHg and heart rate was 90 beats/min. The jugular vein was markedly distended and the liver was palpable below the right costal margin. Auscultation revealed no pathological sounds or arrhythmia. Laboratory data showed mild liver dysfunction (total billirubin of 1.9 mg/dl and lactate dehydrogenase of 567 IU/L). An electrocardiogram demonstrated normal sinus rhythm with inverted T waves in the precordal leads. The chest radiograph revealed mild cardiac enlargement with a cardiothoracic ratio of 0.6, right pleural effusion, calcification on the posterior and inferior parts of the cardiac silhouette, and 2 wires fixing the sternum. An echocardiography showed dilated right atrium (RA), ventricle (RV) and inferior vena cava (IVC), prominent diastolic flow reversals in the dilated hepatic vein (Fig 1), and an echolucent mass anterior to the main pulmonary artery (PA) and RV. On a computed tomography (CT) chest scan, the mass was revealed to be multiple cystic lesions compressing the PA and RV outflow (Fig 2). CT also showed right pleural effusion and a heavily calcified mass over the posterior and diaphragmatic sides of the heart. From the T2-weighted magnetic resonance imaging (MRI) scans, the cystic mass anterior to the PA seemed to contain blood, protein and viscous components (Fig 3). A gallium scintigram did not show accumulation of the agent around the heart. Cardiac catheterization revealed elevated end-diastolic pressures in the right atrium and both ventricles (22, 20, and 27 mmHg, respectively). The pressures were: RA 25/22 mmHg; RV 40/16 mmHg with an early diastolic dip; PA 41/23 mmHg; mean pulmonary wedge, 24 mmHg; and left ventricle, 119/14 mmHg. The thermodilution cardiac index was 2.8 L·min -1 ·m -2 .Circ J 2002; 66: 610 -612 (Received June 22, 2001; revised manuscript received July 18, 2001; accepted July 27, 2001 Constrictive Pericarditis Caused by Calcification and Organized Hematoma 30 Years After Cardiac SurgeryYoshiyuki Takami, MD; Hiroshi Ina, MD; Yukiaki Tanaka, MD*; Akihiro Terasawa, MD* A 54-year-old man, who had undergone atrial septal defect (ASD) closure 30 years previously, was admitted for exe...

ignal-averaged electrocardiography (SAECG) is a non-invasive technique to detect ventricular late potentials (LPs) from the body surface, characterized by low-amplitude and high-frequency signals at the end of the QRS complexes. 1 Their presence in an abnormal SAECG reflects slow and heterogeneous conduction in the myocardium, predicting increased risk of ventricular arrhythmia and sudden cardiac death in patients with ischemic heart disease. 2,3 Successful coronary angioplasty of an occluded infarct-related artery reduces the incidence of ventricular LPs. 4,5 Coronary artery bypass grafting (CABG) has also been reported to reduce the incidence of LPs perioperatively. [6][7][8][9][10] Although it has been reported that multiple CABG for multivessel disease markedly improves several parameters of SAECG, its beneficial effect on SAECG is variable. 9 We have reported that the improvements in SAECG were greater in CABG patients who underwent complete revascularization and in those without prior myocardial infarction. 10 We hypothesized that the presence of diabetes mellitus (DM) also affects the improvement in SAECG after CABG and in the present study, the perioperative SAECG changes in diabetic patients were compared with those in non-diabetic patients. Methods PatientsPre-and post-operative SAECGs were recorded in 100 consecutive elective CABG patients (78 men, 22 women; mean age, 66.5±7.9 years) without conduction disturbance in a standard ECG, who underwent complete revascularization with all patent grafts proved by postoperative angiography. Of the 100 patients, 43 had type 2 non-insulin-dependent DM being treated with insulin, oral medications, or diet. They underwent CABG either with cardiopulmonary bypass (n=78) or without (n=22). Cardiac CatheterizationBased upon the preoperative cardiac catheterization results, the left ventricular ejection fraction and myocardial score, which reflects the degree of myocardial ischemia, were calculated in each patient. The myocardial scores were obtained according to the method described by Brandt et al. 11 The left ventricle is divided into 15 units, comprising the 7 antero-septal units, 3 obtuse marginal and 3 inferior units, and the 2 diagonal units. A myocardial value is defined as the total number of units of myocardium supplied by that artery distal to the stenosis or obstruction. Using the grade of stenosis and the myocardial value, each artery is given a myocardial score according to the table described by Brandt et al. 11 The separate scores are summed to give the total myocardial score, which cannot exceed 15. Postoperative catheterization was performed a mean of 14±5 days after CABG and all bypass grafts were examined from at least 3 different views. Complete revascularization was defined as all diseased arterial systems having patent grafts Circ J 2004; 68: 334 -337 (Received July 23, 2003; revised manuscript received January 14, 2004; accepted January 22, 2004 Impact of Diabetes Mellitus on the Improvement in Signal-Averaged Electrocardiography After Coronar...

To support injured lungs, we have been applying bilevel positive airway pressure for adult patients undergoing surgery with cardiopulmonary bypass. Among 120 consecutive patients, 31 patients whose PaO2/FiO2 decreased to less than 180 after extubation assigned to the intermittent 15 min bilevel positive airway pressure (7.3+/-3.6 times per patient). Bilevel positive airway pressure improved oxygenation (PaO2/FiO2: 128+/-43 vs. 198+/-62, P=0.004) and allowed the patients with poor oxygenation after extubation to maintain PaO2/FiO2 levels similar to those of the patients without bilevel positive airway pressure. In conclusion, the bilevel positive airway pressure therapy after extubation was effective to improve lung oxygenation non-invasively in adult patients undergoing more invasive surgery with prolonged cardiopulmonary bypass.

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