In total aortic arch replacement (TARCH) using hypothermic circulatory arrest (HCA) and selective cerebral perfusion (SCP), postoperative cerebral complications, including metabolic abnormalities, are by no means rare. Furthermore, there is a lack of international guidelines for the optimal perfusion temperature and flow for SCP. Starting in 2008, TARCH was performed using tepid HCA at 32 °C. In the present study, 27 patients (group C) who underwent TARCH with deep hypothermia at the lowest rectal temperatures of 20-25 °C were retrospectively reviewed and compared with 23 patients (group W) who underwent TARCH with 32 °C tepid hypothermia. Preoperative patient characteristics and intraoperative and postoperative parameters were compared. Preoperative patient characteristics did not differ significantly between the two groups. Circulatory arrest time, cardiopulmonary bypass time, operating time, amount of blood transfused and postoperative neurological complications were significantly reduced in group W compared with group C. Our procedure of TARCH using tepid hypothermia at 32 °C was safe, and it significantly reduced all parameters of extracorporeal circulation time. However, this study has several limitations. To indicate the safety and usefulness of tepid HCA for TARCH, a further multifaceted study should be performed with a greater number of patients.
This study evaluated the effects of lidocaine-magnesium blood cardioplegia on left ventricular function compared with potassium blood cardioplegia. Crystalloid cardioplegia which contains lidocaine has been reported but blood cardioplegia is rare. Thirteen dogs received 60 min of global ischemia under hypothermic cardioplumonary bypass (30 degrees C). Potassium blood cardioplegia was administered every 20 min in group A (n=6), and lidocaine-magnesium blood cardioplegia in group B (n=7). We compared the ratio of Emax obtained during IVC occlusion at pre- and post-global ischemia (%Emax) and LVSW (%LVSV). Cardiac function was evaluated prior to CPB and 60 min after reperfusion. There was no difference in time required for cardiac arrest between the two groups (group A: 78+/-3 s, group B: 89+/-9 s). Percentage maximal elastance was significantly better in group B (group A: 63+/-3%, group B: 76+/-4%, P<0.05). Percentage tissue water content of the myocardium after CPB was significantly lower in group B (group A: 82.3+/-4%, group B: 75.5+/-2%, P<0.05). Lidocaine-magnesium blood cardioplegia was equivalent to potassium blood cardioplegia in systolic left ventricular function and reduced myocardial edema in canine heart.
Off-pump coronary artery bypass graft (CABG) surgery has become a widely used modality and has received recognized as a minimally invasive surgery with few complications. However, for patients with severely impaired pulmonary function, further considerations have to be given to reduce the complications associated with general anesthesia. We have accumulated experience in awake off-pump surgery combined with high thoracic epidural anesthesia. In this report we describe the use of alternative subxiphoid approach in patients with severe pulmonary dysfunction. A catheter for high thoracic epidural anesthesia was inserted one day before surgery. After obtaining an adequate level of anesthesia, a small subxiphoid incision was made and the pericardium was opened to expose the left anterior descending branch. The conduit for bypass, gastroepiploic artery was accessed through a minilaparotomy, and separated under the same surgical field and anatomozed under beating heart. This procedure was performed in three patients. Patency was confirmed by postoperative angiography in all three cases. All patients were discharged after an uneventful postoperative course. Awake subxiphoid approach has the advantages that both thoracotomy and sternotomy can be avoided thus permitting surgery with extremely low invasiveness. This method is recommended for patients with severe pulmonary dysfunction.
Fasudil is a very effective Rho kinase inhibitor that deinhibits myosin light chain phosphatase and powerfully relieves vasospasm in situ in radial arteries.
Open-heart surgery is a relatively high-risk procedure when performed in patients with Child-Pugh class C cirrhosis. Even though they can tolerate cardiac surgery with cardiopulmonary bypass (CPB), most of them suffer major postoperative complications and prolonged hospital stay. The present report describes a case of a patient with Child-Pugh class C cirrhosis who developed severe heart failure secondary to aortic valve stenosis. The patient underwent successful aortic valve replacement with the use of dilutional ultrafiltration during CPB to reduce adverse effects of CPB. He recovered smoothly after the operation without major postoperative complications. Thus, the use of dilutional ultrafiltration (DUF) during CPB appears to produce beneficial effects for improving outcomes in patients with decompensated cirrhosis who require open-heart surgery.
Objectives The technique used to harvest the radial artery was modified, with improved results. Skeletonized radial artery conduits prepared with phosphodiesterase-III inhibitor were compared with pedicled conduits by angiography. Methods Isolated coronary artery bypass graft surgery that used the radial artery for conduits was performed on 83 consecutive occasions from March 2003 to February 2004. The mean age of the patients was 68 ± 7 years; 65% were male. The radial arteries were harvested randomly for skeletonized (group SPD and group SPa) or pedicled (group PPD). A phosphodiesterase-III inhibitor, olprinone hydrochloride, was used as an antispastic agent during harvesting of the radial artery for both in groups SPD and PPD. Papaverine was used in group SPa. Postoperative angiograms were performed within 1 month. Diameters of the radial artery were scaled at proximal, mid, and distal sections and averaged. Optical stenosis was measured as a percent stenosis value. Results There were no significant differences among groups SPD, SPa, and PPD in morbidity or mortality rates. Graft patency rates were 97.4% in group SPD, 98.6% in group SPa, and 95.4% in group PPD (P = 0.67). Diameters of the radial artery conduits were significantly wider in group SPD compared with group PPD (P < 0.001). Spasm and stenosis were less frequent in group PPD (P < 0.05). Conclusions Skeletonized radial artery grafting prepared with a phosphodiesterase-III inhibitor indicated favorable results in angiographic studies.
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