髙味 良行

BACKGROUNDS:  One of the strategies to prevent stroke after coronary artery bypass grafting (CABG) may be the use of a device for proximal anastomosis without partial clamp of the ascending aorta. METHODS:  We retrospectively investigated early and late outcomes in consecutive 881 patients undergoing isolated CABG using Heartstring for proximal anastomosis from January 2008 to December 2022, to reveal the validity to use it. All patients underwent preoperative imaging workups to evaluate neurovascular atherosclerosis. RESULTS:  The mean age of the patients was 68.9 years, 20% were female and 13% had previous history of stroke. CABG was on-pump beating heart (52.2%) or off-pump (47.8%) with a mean number of distal anastomoses of 3.38 ± 0.93, using 1.62 ± 0.53 Heartstring devices under different aortic manipulations. In-hospital mortality was 2.0% and perioperative stroke rate was 0.9%, none of them died during hospital stay. During the follow-up period of 70 ± 47 months, the overall actuarial survival rates were 86 and 66%, and major adverse cardiac and cerebrovascular events (MACCEs)-free rates were 86 and 70% at 5 and 10 years, respectively. On multivariable analysis, risk factors for late death included male, previous history of stroke, postoperative sternomediastinitis, late new-onset stroke, and MACCEs, but did not include the perioperative stroke. CONCLUSION:  Low stroke rate, as low as 0.9%, after CABG using Heartstring for proximal anastomosis, although under a variety of aortic manipulations, may contribute to the improved long-term prognosis.

Abstract Background Although coronary artery bypass grafting (CABG) is performed via three different techniques, conventional, on-pump beating heart CABG (ONBHCAB), or off-pump CABG (OPCAB), data are limited to compare ONBHCAB with OPCAB. Methods We retrospectively investigated the postoperative cardiac biomarkers, creatine kinase-MB (CK-MB), and troponin I (cTnI), and early and late outcomes in 806 patients undergoing isolated ONBHCAB or OPCAB between February 2008 and September 2022. To eliminate the bias between different groups, propensity score matching was conducted to validate the findings. Results After matching, the number of each study group totaled 270 patients. In both complete and matched cohorts, early outcomes, including morbidities and mortalities, were similar. However, cTnI and CK-MB levels were significantly higher after ONBHCAB than after OPCAB with median peak cTnI of 9.85 versus 4.60 ng/mL and median peak CK-MB of 48.45 versus 17.10 ng/mL in the matched cohort, which were quite low, below the threshold for values defining perioperative myocardial infarction. At follow-up of 73 ± 45 months, the overall actuarial survival rates were similar between the ONBHCAB and OPCAB patients (86 vs. 87% at 5 years and 64 vs. 68% at 10 years, respectively, in the matched cohort). Conclusion ONBHCAB may be a comparable alternative to OPCAB with similar early and late outcomes, despite higher elevation of postoperative cardiac biomarkers. ONBHCAB provides more efficient hemodynamic support, providing a better surgical visual field, than OPCAB while reducing the risk of incomplete revascularization.

OBJECTIVES: Patients with cardiovascular disease are vulnerable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection. Although SARS-CoV2 vaccination may be effective, its impact on surgical patients is not well studied. We investigated the effects of cardiovascular surgery, especially under cardiopulmonary bypass (CPB), on the antibody titres after SARS-CoV2 vaccination. METHODS: A prospective observational study was designed for patients undergoing surgery between July and November 2021. The immunoglobulin G against the receptor-binding domain was measured and antibody preserved rate (APR) was calculated from perioperative titres comparison. RESULTS: Enrolled 63 study patients were divided into 39 undergoing surgery with CPB (Group CPB) and 24 without CPB (Group None). Preoperative vaccines were BNT162b2 (Pfizer/BioNTech) (n = 58, 92%) and mRNA-1273 (Moderna) (n = 5, 8%). While immunoglobulin G against the receptor-binding domain titres did not significantly decrease after surgery in Group None, they decreased significantly in Group CPB from 21.80 [11.15, 37.85] to 11.95 [6.80, 18.18] U/ml (P < 0.001) a day after surgery, 11.40 [7.85, 22.65] U/ml (P < 0.001) 14 days after surgery and 7.60 [4.80, 17.60] U/ml (P < 0.001) a month after surgery. The APRs a day after the surgery were significantly lower in Group CPB (0.46 [0.41, 0.60]) than in Group None (0.80 [0.68, 0.87]) (P < 0.001). CONCLUSIONS: The SARS-CoV2 antibody titres significantly decreased with lower APRs immediately after surgery under CPB. Based on our informative results, careful considerations of vaccination schedule might be required for surgery under CPB.

A 70-year-old patient who survived about 40 years after left pneumonectomy for tuberculosis visited emergency hospital, because of dyspnea. She received suitable medical therapy for atirial fibrillation and severe mitral regurgitation and hesitated heart surgery because of anxiety for surgical risk. The computed-tomography showed mediastinal shift to left and right lung compensatory expansion. Respiratory function test after treatment of heart failure showed only mild restrictive disorder. And the blood-gas examination in room air was 101 mmHg of Pao2 and 37 mmHg of Paco2. The mitral valve replacement was performed via median sternotomy and using normal cardiopulmonary bypass. And she fully recoverd without any respiratory complications. Mediastinal shift did not obstract the surgical view and establishment of cardiopulmonary bypass in this case. It seemed that the key of surgical successs is the preserved function of healthy residual lung.

We report wound management using a vacuum-assisted closure (VAC) system for the cannula sites of extracorporeal biventricular assist devices (BiVADs) for 295 days in a 23-year old Chinese female patient with fulminant giant cell myocarditis, who finally underwent heart transplantation. When the cannula sites appeared necrotic 3 months after BiVADs placement, she received negative pressure wound therapy prophylactically for four cannula sites, using a VAC system for 3 months, followed by no infections. Such prophylactic VAC therapy, using the skin barrier paste usually used for the ostomy pouching system to create a flatter surface and airtightness, may be useful to avoid cannula site infections, which is still a fatal complication causing sepsis, especially in patients with extracorporeal BiVADs.

BACKGROUND: Transit-time flow measurement (TTFM) is frequently used for intraoperative graft flow analysis during coronary artery bypass grafting (CABG). Although the TTFM results may be influenced by fractional flow reserve (FFR) of the target coronary artery as a determinant of coronary lesion-specific ischemia, the data has been limited. METHODS: We retrospectively investigated the relationships between the intraoperative TTFM parameters and preoperative FFR values of the target coronary arteries in 40 in-situ left internal thoracic artery (LITA) grafts to the left anterior descending artery (LAD), which were revealed to be patent on postoperative computed tomography angiography. RESULTS: The Spearman correlation coefficients of the TTFM parameters with FFR were as follows; maximum flow: -0.12 (p = 0.301), minimum flow (Qmin): -0.43 (p = 0.004), mean flow (Qm): -0.30 (p = 0.036), pulsatility index (PI): 0.37 (p = 0.012), diastolic filling (DF): -0.36 (p = 0.012), percent insufficiency (%Insuf): 0.45 (p = 0.002), and fast Fourier transform (FFT) ratio: -0.07 (p = 0.329). While Min and Qm showed significant negative correlation, PI and %Insuf showed significant positive correlation with FFR. CONCLUSIONS: Most TTFM parameters, including Qm, of the LITA graft to the LAD during CABG are strongly affected by preoperative FFR values. Since the FFT ratio is not influenced by FFR, FFT analysis of the TTFM may be recommend in the case of the in-situ LITA graft to the LAD with moderate stenosis with a higher FFR＞0.75.

BACKGROUND: Thoracic aortitis caused by Clostridium septicum is a rare infection with a strong association with malignancy and high mortality rate when left untreated. We report a case of surgical treatment for Stanford type A acute aortic dissection in a patient with C. septicum sepsis and thoracic aortitis. CASE PRESENTATION: A 63-year-old hypertensive man with rheumatoid arthritis presented with general malaise and diagnosed with C. septicum-infected aortitis with sepsis. On the 5th day of hospitalization, Stanford type A acute aortic dissection developed with severe aortic regurgitation. The patient underwent emergent surgical treatment successfully with excision of the infected ascending aorta and aortic root followed by replacement using a composite graft, followed by diagnosis of sigmoid colon cancer 7 months after aortic surgery. He was scheduled to undergo elective colon surgery. CONCLUSIONS: C. septicum aortitis can progress quickly, causing aneurysm or dissection. Therefore, in a patient with C. septicum aortitis, prompt surgical in situ graft replacement should be performed to debride the infected vascular lesions. Further investigations for gastrointestinal and hematological malignancies as a source of C. septicum should be also conducted.

OBJECTIVES: Postoperative acute kidney injury (AKI) is known as a risk factor for death after surgery for Stanford type A acute aortic dissection under hypothermic circulatory arrest. It may also adversely affect long-term survival. We searched for modifiable risk factors for postoperative AKI, focusing on lower body ischaemic time. METHODS: We reviewed 191 patients undergoing surgical repair for Stanford type A acute aortic dissection. The distal anastomosis depended on excluding the primary tear location, resulting in ascending/hemiarch (n = 119), partial arch (n = 18) and total arch replacement (n = 54). We defined an increase in the serum creatinine level to ≧2 times the baseline level as AKI. The incidence of AKI was investigated with multivariate analysis of its risk factors. RESULTS: Postoperative AKI was observed in 49 patients (26%), 31% of whom required renal replacement therapy. The overall hospital mortality rate was 8.5%. Postoperative AKI, preoperative shock and organ malperfusion were predictors of hospital death. Multivariate stepwise logistic regression analysis identified age, body mass index, preoperative chronic kidney disease and lower body ischaemic time as risk factors for postoperative AKI. CONCLUSIONS: Although surgical repair for Stanford type A acute aortic dissection showed favourable results, the incidence of postoperative AKI is still high, closely associated with hospital death. Lower body ischaemic time should be recognized specifically as a modifiable surgical risk factor for postoperative AKI.

腹部大動脈狭窄病変に対して、ステントグラフト脚を用いた血管内治療を2例経験したので文献的考察を加えて報告する。症例Iは79歳女性。下肢間歇性跛行と左足外側の有痛性潰瘍が認められ来院。CT検査にて腹部大動脈石灰化による高度狭窄と診断され、局所麻酔下にステントグラフト脚を留置した。術直後より症状軽快し歩行も可能となった。術後3ヵ月目には潰瘍の治癒も認めた。症例IIは74歳女性。62歳時に腹部大動脈閉塞病変に対するI型人工血管を用いた血行再建の手術歴がある。術後経過良好であったが、両下肢間歇性跛行が出現し来院。CT検査にてグラフト中枢側、末梢側吻合部の石灰化による高度狭窄を認めた。局所麻酔下にステントグラフト脚を留置し術直後より、症状の改善を認めた。(著者抄録)

<p>We report a rare case of retrograde Stanford type A aortic dissection after endovascular repair for complicated Stanford type B aortic dissection. A 45-year-old man presented with a sudden onset of back pain and was transferred to our hospital. Computed tomography demonstrated acute Stanford type B aortic dissection with lower limb ischemia. Emergency endovascular surgery was planned for repair of the Stanford type B aortic dissection. The patient suddenly developed recurrent chest pain 10 days after the initial procedure. Computed tomography revealed retrograde Stanford type A aortic dissection involving the ascending aorta and aortic arch. The patient underwent a successful emergency total aortic arch replacement.</p>

<p>Objectives: Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is technically demanding. We reviewed the surgical outcomes of consecutive patients who underwent PEA with aggressive use of pulmonary vasodilators, including epoprostenol sodium.</p><p>Methods: We retrospectively assessed perioperative clinical data of 122 patients with CTEPH who underwent PEA with hypothermic circulatory arrest between 2005 and 2013. Peri-operatively, all of the patients received pulmonary vasodilator therapy, including epoprostenol sodium and beraprost sodium.</p><p>Results: Patients were classified as having CTEPH type 1 (n=57), type 2 (n=32), and type 3 (n=33) disease according to the Jamison classification system. In-hospital mortality was 7.4% (n=9), caused by right heart failure (n=5), pulmonary hemorrhage (n=3), and pneumonia (n=1). The 113 patients who survived PEA showed significantly decreased mPAP (46±11 to 23±10 mmHg, P<0.01) and PVR (826±357 to 237±153 dyne·s^–1·cm^–5, P<0.01).</p><p>Conclusions: Aggressive pulmonary vasodilator treatment during surgical PEA results in favorable early outcomes. This treatment also leads to immediate and substantial improvement in pulmonary hemodynamics in patients with CTEPH.</p>

Background: Because increased age is a strong independent predictor of mortality and morbidity, surgery for octogenarians with Stanford type A aortic dissection (AAD) may be avoided. Methods and Results: From 2005 to 2015, 158 patients underwent surgical repair for AAD via a median sternotomy. We compared 24 (15.2%) octogenarians (83 +/- 3 years) with 134 (84.8%) patients aged &lt;= 79 years (62 +/- 13 years), based on retrospectively collected clinical data. Octogenarians were predominantly female (79.2% vs. 44.8%, P=0.0033). Ascending aortic replacement was more frequently performed in the octogenarians (95.8% vs. 65.7%, P=0.0015) and total arch replacement in the younger patients (4.2% vs. 26.9%, P=0.0165). There were 14 hospital deaths among the younger patients, none among the octogenarians (0% vs. 10.4%, P=0.1303), and major morbidity rates were comparable. There were 3 late deaths among the octogenarians and 9 deaths among the younger patients. The respective 1-, 3-, and 5-year survival rates were 94.4%, 81.5%, and 81.5% in the octogenarians and 86.9%, 85.6%, and 83.9% in the younger patients, with no significant differences. Conclusions: Surgical repair for AAD in octogenarians showed favorable results when compared with a younger patient cohort, with low hospital mortality rate and excellent late outcomes. Therefore, this technique should not be disregarded just because the patient is an octogenarian.

Limited data exist on clinical relevance of aortic valve stenosis (AVS) and mitral annular calcification (MAC), although with similar pathophysiologic basis. We sought to reveal the prevalence of MAC and its clinical features in the patients undergoing aortic valve replacement (AVR) for AVS. We reviewed 106 consecutive patients who underwent isolated AVR from 2004 to 2010. Before AVR, CT scans were performed to identify MAC, whose severity was graded on a scale of 0-4, with grade 0 denoting no MAC and grade 4 indicating severe MAC. Echocardiography was performed before AVR and at follow-up over 2 years after AVR. MAC was identified in 56 patients with grade 1 (30 %), 2 (39 %), 3 (18 %), and 4 (13 %), respectively. Patients with MAC presented older age (72 +/- 8 versus 66 +/- 11 years), higher rate of dialysis-dependent renal failure (43 versus 4 %), and less frequency of bicuspid aortic valve (9 versus 36 %), when compared to those without MAC. No significant differences were seen in short-and mid-term mortality after AVR between the groups. In patients with MAC, progression of neither mitral regurgitation nor stenosis was observed at follow-up of 53 +/- 23 months for 102 survivors, although the transmitral flow velocities were higher than in those without MAC. In conclusion, MAC represented 53 % of the patients undergoing isolated AVR for AVS, usually appeared in dialysis-dependent elder patients with tricuspid AVS. MAC does not affect adversely upon the survival, without progression of mitral valve disease, at least within 2 years after AVR.

Cardiac events associated with congenital coronary abnormalities are rare but potentially life-threatening in a young population. Most of these patients are not diagnosed before their initial cardiac event. Amongst such coronary artery anomalies, sudden death is frequently seen in an anomalous origination of a coronary artery from the opposite sinus. We herein present the case of a patient who presented with sudden cardiac arrest associated with an anomalous right coronary artery originating from the left sinus of Valsalva. Surgical treatment was selected because there was evidence of reversible ischemia based on the findings of a stress test.

In hemodialysis (HD)-dependent patients, secondary hyperparathyroidism induces cardiac hypertrophy. This study investigated whether parathyroid hormone (PTH) levels affect the degree of left ventricular (LV) mass regression in HD patients after aortic valve replacement (AVR) for aortic stenosis (AS). We retrospectively obtained preoperative and 2-year postoperative echocardiography and intact PTH measurements in 88 HD patients who underwent AVR, with bioprostheses (n = 35, 40 %) and mechanical valves (n = 53, 60 %) of effective orifice area &gt; 0.80 cm(2)/m(2), between January 1997 and December 2010. The LV mass decreased significantly from 308 +/- A 88 to 217 +/- A 68 g at follow-up of 28 +/- A 4 months after AVR (p &lt; 0.001). The LV mass regression at follow-up was inversely related to preoperative PTH values (R = 0.44, p = 0.001). The LV mass regression at follow-up was significantly smaller in the patients (n = 47) with PTH a parts per thousand yen100 pg/mL than in those (n = 41) with PTH &lt; 100 pg/mL throughout the study period (61 +/- A 75 versus 108 +/- A 49 g, p &lt; 0.0001). After adjusting for female sex, hypertension, and baseline LV mass, high PTH values were found to be independent predictor of less LV mass regression at 2-year follow-up (beta = 0.23, r (2) = 0.24, p = 0.02). In conclusion, the HD patients with high levels of PTH presented with less LV mass regression after AVR for AS without patient-prosthesis mismatch. Secondary hyperparathyroidism may impair regression of cardiac hypertrophy after AVR in HD patients with AS.

Background. Prosthetic valve selection in dialysis patients remains controversial because of the limited data available. This study aimed to clarify late clinical outcomes and discuss strategies for optimal valve selection in dialysis patients. Methods. We retrospectively analyzed the data obtained from 406 consecutive patients who underwent aortic valve replacement between 1995 and 2010. We compared valve-related outcomes among 89 dialysis and 317 nondialysis patients. We selected bioprostheses for all patients older than 65 to 70 years, irrespective of the renal function. Results. Dialysis was found to be a significant risk factor for bleeding events (hazard ratio, 3.98; 95% confidence interval, 2.51 to 6.30; p &lt; 0.001), however, no significant differences were observed according to the type of prosthesis. The overall survival was significantly worse in the dialysis patients (63% versus 85% at 5 years; p &lt; 0.001), and freedom from structural valve deterioration was also lower in the dialysis patients (82% versus 100% at 5 years; p &lt; 0.001). Among the dialysis patients, an advanced age (&gt;= 70 years; hazard ratio, 3.53; p = 0.011), diabetes mellitus (hazard ratio, 2.48; p = 0.041), and concomitant coronary artery bypass grafting (hazard ratio, 1.99; p = 0.071) were independent predictors for late death based on a multivariate analysis. Conclusions. Our valve selection criteria in dialysis patients, which are the same as the current practice guidelines for nondialysis patients, are acceptable. Bioprostheses can be considered in all dialysis patients with diabetes or coronary artery disease. (C) 2015 by The Society of Thoracic Surgeons

Objective: The aim of the study was to determine whether using the in situ internal thoracic artery (ITA) graft ipsilateral to the arteriovenous fistula adversely affects the outcomes after isolated coronary artery bypass grafting (CABG) in the dialysis-dependent patients to answer the concerns of a possible steal and consequent myocardial ischemia. Methods: We categorized 155 dialysis patients undergoing isolated CABG between January 1993 and December 2011 into 108 patients (70%, ipsilateral group) whose left anterior descending artery (LAD) was revascularized with the ITA ipsilateral to the arteriovenous fistula and 47 patients (contralateral group) whose LAD was grafted with the ITA opposite to the fistula, to compare their early and late outcomes. Results: While 94% of the ipsilateral group had left fistula, 55% of the contralateral group had left fistulas. The LAD was grafted with the left ITA in 94% of the ipsilateral group, whereas it was grafted with left (49%) or right (51%) ITAs in the contralateral group. There was no significant difference in hospital mortality between the groups (ipsilateral 10.2% vs contralateral 10.6%). After follow-up for 55 +/- 42 months, the overall survival (ipsilateral 58% vs contralateral 65% at 5 years) and cardiac event-free rates (ipsilateral 74% vs contralateral 68% at 5 years) were also similar between the groups by log-rank tests (P = .90 and P = .07). Conclusions: Revascularization of the LAD using the in situ ITA graft ipsilateral to the arteriovenous fistula increases neither the operative mortality nor the risks of late death and cardiac events after isolated CABG in dialysis patients.

Objectives: Intracoronary shunts have been developed for a bloodless field and preserved forward flow preventing ischemia during off-pump coronary artery bypass (OPCAB) surgery. However, reports directly measuring the forward flow through the shunt in clinical settings are lacking. Methods: Using a 7.5-MHz Doppler probe, we investigated the coronary flow through a 1.5-mm shunt inserted into the left anterior descending artery (LAD) for anastomosis with the internal thoracic artery during OPCAB in 30 consecutive patients. The following Doppler flow parameters were obtained before and after shunting: peak velocity, mean velocity, time-velocity integral, and flow. Results: No patients developed significant electrocardiographic changes and the peak value of postoperative myocardial band of creatine kinase was 17 +/- 16 IU/L. All Doppler flow parameters of the LAD decreased significantly after shunting; peal velocity: 71.3 +/- 34.6 cm/second to 54.5 +/- 25.3 cm/second (-24% +/- 27%), mean velocity: 33.3 +/- 18.3 cm/second to 26.3 +/- 14.0 cm./second (-21% +/- 23%), and time-velocity integral: 28.7 +/- 12.1 cm to 19.0 +/- 7.1 cm (-28% +/- 14%), and flow: 38.7 +/- 16.8 mL/minute to 25.0 +/- 9.5 mL/minute (-31% +/- 13%) (P &lt; .01). Conclusions: The LAD flow is preserved at least 50% through a 1.5-mm intracoronary shunt, although the flow pattern was attenuated, during OPCAB anastomosis. The Doppler evaluation of the coronary artery flow before and after shunting is useful to justify the protective use of the shunt on myocardial perfusion during OPCAB.

症例は60歳，男性．2型糖尿病，高度肥満（身長170 cm，体重160 kg，BMI 55）の既往があり，右冠動脈（RCA）の急性血栓閉塞による急性下壁心筋梗塞で入院した．同時に三枝病変を認め，内科的管理を行った後に冠動脈バイパス手術（CABG）が予定された．心不全，肺炎のため気管内挿管され人工呼吸管理となったが，肥満低換気症候群のため人工呼吸器離脱が困難となり，気管切開施行された．全身状態の改善が得られた，1年2カ月の入院治療後に手術施行となった．体重は107.5 kg，BMI 37.2まで改善を得ていた．呼吸器合併症を防ぐため周術期に気管切開管理は継続が必要と考えられたが，気管切開孔による胸骨正中切開創の汚染を回避することと，左前下行枝（LAD），対角枝（D1），後側壁（PL），後下行（PD）領域へのグラフトとしては左内胸動脈（LITA），右胃大網動脈（RGEA）で十分に到達可能なことより，Thoracoabdominal Spiral Incisionを選択した．術後疼痛による呼吸障害を予防するために術前に硬膜外麻酔を留置した．上半身30度程度の右半側臥位にて第4肋間開胸し，LITAを剥離した．腹部正中へ皮膚切開延長して開腹し，RGEAを採取した．LITAをFree GEAとのI CompositeにしてオフポンプにてLAD，D1，14 PL，4 PLと吻合した．無輸血にて手術終了し術後経過良好で縦隔炎合併なく独歩退院となった．本切開法にて確実な気管切開孔からの汚染回避，全長にわたり剥離されたLITAおよびGEAの使用，比較的少ない心脱転で，LAD，左回旋枝（LCx），RCA領域にかけて正中開胸に劣らない良好な視野を得ることができた．

Background. Markedly higher hospital and long-term mortality after coronary artery bypass grafting (CABG) have been reported in hemodialysis (HD)-dependent patients. We tried to identify the predictors for short-term and long-term outcomes after CABG, which have not been well studied. Methods. Between 1993 and 2010, 152 patients undergoing HD (117 men; HD duration of 8.7 +/- 8.0 years) underwent isolated CABG. Our strategies included use of a single internal thoracic artery (ITA) in patients with diabetes mellitus (DM), bilateral ITAs in patients without DM, and possible avoidance of cardiopulmonary bypass (CPB) after 2003. Results. Thirty-six percent of patients underwent conventional CABG: 20% had on-pump beating heart procedures and 44% had off-pump procedures, with 2.8 +/- 1.0 anastomoses. Hospital mortality was 10.6% with improvement to 6.8% after 2003. Predictors for hospital death were left ventricular ejection fraction (LVEF) less than 0.40 (p = 0.042), use of CPB (p = 0.046), and postoperative need for continuous hemofiltration (p = 0.037). After follow-up of 49 +/- 42 months, the overall survival rates were 76.9%, 60.0%, 43.9%, and 36.2% and the cardiac events- free rates were 77.0%, 70.1%, 55.9%, and 44.8% at 3, 5, 8, and 10 years, respectively, in the Kaplan-Meier model. A multivariate Cox proportional hazard model identified age older than 63 years (p = 0.014), DM (p = 0.036), and peripheral artery disease (PAD) (p = 0.044) as predictors for late death, and DM (p = 0.038) and LVEF less than 0.40 (p = 0.027) as predictors for late cardiac events. Conclusions. Although early outcomes have been improved by off-pump techniques, late outcomes are not satisfactory in patients who rely on HD and undergo CABG. To improve late outcomes we may need aggressive management of DM, PAD, and low LVEF in those patients.

Background: In patients with acute type A aortic dissection (AAD), localization of the primary entry tear to be excluded is of major importance for intervention. Hypothesis: There are reliable indirect computed tomography (CT) findings to predict the entry site. Methods: In 83 patients with type A AAD whose primary entry tears were identified surgically between 2003 and 2009, we retrospectively examined the diagnostic CT scans regarding pericardial effusion, the largest short-axial diameter of the aorta, widths of true and false lumens, and false lumen thrombosis at 6 levels of thoracic aorta from the aortic root to the descending aorta. Results: The primary entry sites identified intraoperatively were proximal ascending in 21 patients, middle ascending in 21, distal ascending in 21, arch in 17, and descending or unknown in 16. The multivariate logistic analysis revealed that pericardial effusion (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.23.4, P &lt; 0.001) and dilated ascending aorta (OR: 1.6, 95% CI: 1.12.4, P = 0.012) were the significant CT findings to predict the entry tear in the ascending aorta. It also revealed that the significant CT finding to predict the entry tear distal to the aortic arch was nonthrombosed false lumen in the descending aorta (OR: 1.2, 95% CI: 1.12.1, P = 0.048). Conclusions: We can predict the primary entry site by the preoperative CT findings in patients with type A AAD, considering pericardial effusion, aortic diameter, widths of true and false lumens, and false lumen thrombosis at different anatomic levels. Clin. Cardiol. 2012 DOI: 10.1002/clc.21991 The authors have no funding, financial relationships, or conflicts of interest to disclose.

Background: Advances in percutaneous coronary intervention (PCI) using drug-eluting stents (DES) have impacted clinical practice. However, the efficacy of DES for dialysis patients still remains controversial. This study compares the early and long-term clinical outcomes of coronary artery bypass grafting (CABG) and PCI with DES in dialysis patients. Methods: A retrospective review was performed in 125 dialysis patients treated between 2004 and 2007. Fifty-eight patients underwent CABG and 67 underwent PCI with DES. The overall death, cardiac death, and cardiac-related event rates were analyzed using the Kaplan-Meier method. For the risk-adjusted comparisons, multivariable logistic and Cox regression analyses were used. Results: The preoperative characteristics of the patients were similar except for the ejection fraction (p = 0.002) and the number of diseased vessels (p &lt; 0.001). The 30-day mortality was 0 in both groups. The overall survival rates at one, three, and five years were 84.2%, 64.7%, and 56.2% in CABG group and 88.2%, 75.5%, and 61.7% in DES group, respectively (p = 0.202). The rates of freedom from cardiac-related events at one, three, and five years were 76.6%, 68.1%, and 48.6%, and 63.0%, 31.4%, and 0% in CABG and DES groups (p &lt; 0.001), respectively, including seven (10%) late thromboses in the DES group. Although the risk-adjusted analysis showed no significant difference for overall and cardiac death rates, the rates of cardiac-related events and graft/stent failure were significantly higher in the DES group. Conclusions: CABG is superior for revascularization in dialysis patients compared with PCI using DES in terms of freedom from cardiac-related events. doi: 10.1111/j.1540-8191.2012.01444.x (J Card Surg 2012;27:281-287)

癒着による様々なリスクが伴う心臓大血管再手術に対する当院の戦略・術中損傷・合併症・治療成績について検証した．2003年1月から2008年12月までに再手術を施行した52名（男性36名，62±14歳，全成人手術患者の4.5%）を対象とした．先行手術から再手術までは10.1±9.3年であった．内訳は，感染症10例，弁手術後16例，冠動脈バイパス術後9例，Marfan症候群3例，大動脈手術後7例，先天性手術後4例，その他3例であった．前回と同一部位手術は34例（65%），開胸前大腿動静脈露出40例（77%），上行大動脈送血18例（35%），開胸前人工心肺19例（37%）であり，開胸前冷却を4例に，開存内胸動脈グラフトへの対処を6例に要した．手術時間9.6±2.5時間，人工心肺295±111分で，術中損傷を16例（31%）に認めた．47例（90%）に濃厚血小板輸血を要し，人工心肺再使用を8例（15%）に要した．主たる合併症は，出血14%，感染13%，脳梗塞4%，呼吸不全44%，血液浄化を要する腎不全10%であり，病院死亡は4例（7.7%）に認めた（感染再発，肝不全，肺出血，左室破裂）．平均観察期間24±18カ月において1年生存率86.7%，2年生存率83.1%であった．心臓大血管再手術での胸骨再切開によるリスクは高くないが，癒着に伴う術野展開不良が致命的損傷を来たす．さらに死亡・合併症を削減する戦略には改善の余地がある．