Preoperative Cardiac Function Research Articles

93 Does Intervention of Severe Valve Lesions always Improve Cardiac Function?

<h3>Introduction</h3> Severe valve lesions can result in cardiac decompensation. This study investigated the effects of surgical valvular intervention upon cardiac function assessed as peak cardiac power output (CPO_max) generation during exercise. We hypothesised that (i) cardiac function improves after valvular intervention, and (ii) those with subnormal pre-operative cardiac reserve indicative of cardiac decompensation would gain less physical and cardiac functional benefits than those with preserved pre-operative cardiac function. <h3>Methods</h3> We compared the cardiopulmonary exercise performance and non-invasive haemodynamics of 46 consecutive patients with severe valvular disease before and after valvular intervention with reference to 101 healthy male and 139 female controls without cardiovascular disease. Cardiac and physical functional reserves were measured with standard respiratory gas analyses and CO₂ rebreathing to measure peak cardiac output and quantify peak cardiac power output (CPO_max) non-invasively during treadmill exercise. Data are given as mean±SD and statistical significance accepted at <i>P &lt; 0</i>.05. <h3>Results</h3> The patient cohort showed no overall benefit from valvular intervention (pre-operative CPO_max 3.48 ± 1.27W, post-operative CPO_max 3.60 ± 0.96W, P = 0.42, <i>n = 4</i>6). However, this comprised opposing effects upon two subgroups distinguished by a pre-operative CPO_max below (LoW subgroup) or within (HiW subgroup) the normal range defined by the control population. Thus, in the LoW subgroup CPO_max<i>increased</i> with valvular intervention from 2.63 ± 0.67 to 3.42 ± 0.98W (P = 0.000014; <i>n = 2</i>6), NYHA class improved (from 2.29 ± 0.75 to 1.65 ± 0.75, P = 0.0004), peak oxygen consumption (VO_2max) increased (from 1.38 ± 0.55 to 1.56 ± 0.59 l.min^-1, P = 0.002), and peak flow- and cardiac pressure-generating capacities increased. In contrast, in the HiW subgroup, CPO_max<i>decreased</i> from 4.58 ± 0.96 to 3.84 ± 0.92W following intervention (P = 0.00026; <i>n = 2</i>0). NYHA classification remained unchanged, VO_2max decreased (from 2.29 ± 0.72 to 1.97 ± 0.75 l.min^-1, P = 0.005) and peak cardiac flow- and pressure-generating capacities significantly decreased (all P &lt; 0.05) after valve intervention. <h3>Conclusions</h3> This is the first investigation of the effects of surgical intervention upon non-invasively measured CPO_max during exercise in patients with severe valvular disease. It unexpectedly demonstrates that valvular interventions performed in routine clinical practice do not consistently improve cardiac function. Patients with subnormal pre-operative cardiac functional reserve benefited from intervention, with significantly improved cardiac and physical fitness. Patients with normal pre-operative cardiac functional reserve generally showed decreased cardiac and physical fitness.

Early and Long-Term Outcomes in Japanese Patients Aged 80 Years or Older Undergoing Conventional Aortic Valve Replacement.

In this study, we investigated the early and long-term results of conventional aortic valve replacement (AVR) in very old patients. Seventy-five patients with aortic stenosis underwent conventional AVR for patients aged 80 years.We examined early death and major adverse cardiovascular and cerebrovascular event (MACCE). The operative mortality was 0% for isolated AVR and 19.2% for concomitant surgery. The postoperative survival rate and MACCE free-rate were no significant differences between the isolated AVR and the concomitant surgery. Univariate analysis confirmed that cardiac dysfunction, severe chronic kidney disease (CKD), hemodialysis, + coronary artery bypass grafting, and norepinephrine use were risk factor of early death. Univariate analysis confirmed that severe CKD, BNP &gt;1000 pg/ml, aortic cross clamping time (ACCT) &gt;180 min, and non-use carperitide and multivariate analysis confirmed that ACCT &gt;180 min, and non-use carperitide were risk factor of MACCE. This study showed that the results of conventional AVR in very old patients were not satisfactory. However, the results obtained with isolated AVR were favorable with no operative deaths. The present study demonstrated that preoperative cardiac function, preoperative renal function, and operative factors have an important impact on early mortality and MACCE.

Two contrasting outcomes of weight loss surgery: Positive impact on the heart, negative impact on the liver

Bariatric surgery results in significant weight loss in severely obese patients and is associated with beneficial as well as unintended negative consequences. Here we highlight the divergent impact of rapid weight loss in two individuals who underwent bariatric surgery. The first patient is a 58-year-old severely obese [body mass index (BMI) of 48.8 kg/m 2 ] Caucasian woman with metabolic syndrome and impaired left ventricular systolic function [preoperative left ventricular ejection fraction (LVEF) 29%]. After undergoing gastric banding, the LVEF improved to 65% at 24 months. This, along with a marked reversal of obesity-related comorbidities following surgery highlight the beneficial impacts that have popularized bariatric surgery. The second patient is a 27-year-old extremely obese (BMI = 81.0 kg/m 2 ) Hispanic man without metabolic syndrome and with normal preoperative cardiac and end organ function. One year after undergoing Roux-en-Y gastric bypass, his BMI had decreased to 28 kg/m 2 . The initial weight loss was rapid and paralleled by a loss of lean mass, muscle wasting and the development of cachexia with progressive liver failure and a diagnosis of crytopgenic hepatic cirrhosis. Herein we discuss the cases in detail and provide insight into the divergent impact of rapid weight loss on metabolic homeostasis, the heart, and end organ function. We hope this will aid with the preoperative risk/benefit assessment of severely obese patients being considered for weight loss surgery.

Myocardial protection by interferon-γ late preconditioning during cardiopulmonary bypass-associated myocardial ischemia-reperfusion in pigs

The impact of interferon-γ (IFN-γ) late preconditioning on myocardial ischemia-reperfusion injury during cardiopulmonary bypass (CPB) and the underlying mechanism were investigated. Using a porcine model of myocardial ischemia-reperfusion injury during CPB with a 60-min aorta cross-clamp, 20pigs (15±0.5kg) were treated randomly with either a 1-ml (20,000IU/kg) IFN-γ injection (IFN-γ group; n=10) or saline solution (control group; n=10) 24h prior to CPB. Heart rate, blood pressure, left ventricular end-systolic pressure (LVESP), left ventricular end-diastolic pressure (LVEDP), creatine kinase isoenzyme-MB (CK-MB), and cardiac troponin I (cTnI) were measured before CPB, before aortic clamping, and at post-reperfusion intervals of 10, 30, 60 and 120min. Heat shock protein 70 (HSP70), Mn-superoxide dismutase (Mn-SOD) and inducible nitric oxide synthase (iNOS) were measured by immunohistochemical staining in pre-CPB myocardial tissues. Myocardial cell apoptosis TUNEL measurement was assessed in samples obtained 60min following reperfusion. Both groups exhibited no statistical differences in age, weight, gender and preoperative cardiac function, and worsened left ventricular function, and hemodynamic index reductions, and significant cTnI and CK-MB leakage was observed 10 and 30min after reperfusion. At 10, 30 and 60min following reperfusion, ventricular function and leakage of the IFN-γ group were significantly improved, and expression of HSP70, iNOS and Mn-SOD increased and myocardial cell apoptosis decreased. IFN-γ late preconditioning exhibited preventative effects on myocardial tissues in pigs during CPB surgery, likely due to increased HSP70, Mn-SOD and iNOS expression.

Complex Ebstein's Malformation: Defining Preoperative Cardiac Anatomy and Function

Ebstein's malformation is a congenital malformation of the tricuspid valve and right ventricle, with a highly variable morphology, and clinical presentation, accounting for less than 1% of all congenital heart diseases, and about 40% of congenital malformations of the tricuspid valve. Systematic review of English language literature regarding the morphogenesis and progress of imaging techniques, especially echocardiography and cardiac magnetic resonance imaging, in the preoperative planning of Ebstein's malformation, using the MEDLINE database with the PubMed Entre interface. Technological developments of the recent years, with 3D echocardiographic and cardiac magnetic resonance imaging evolution, have resulted in better understanding of the malformed tricuspid valve and right ventricle in vivo anatomy. Through a better understanding of Ebstein's malformation, there is a continuous trend of surgical techniques favoring tricuspid valve sparing procedures, with a constant decrease in early and late postoperative mortality. Although imaging methods to investigate Ebstein's malformation have continuously evolved, standardization of assessment protocols by 3D echocardiographic imaging, speckle tracking imaging, and cardiac magnetic resonance imaging is required.

618 Benefit of Prenatal Diagnosis of Complex Congenital Heart Defects on Neonatal Morbidity

Background and AimsAs survival rates in neonatal cardiac surgery improve over time, morbidity becomes more important in complex congenital heart disease (cCHD). We investigated whether prenatal diagnosis of cCHD affects...

The Role of Myocardial Viability Assessed by Perfusion/F-18 FDG Imaging in Children With Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery

Although surgical treatments evolved, the short-term postoperative mortality is still high in children with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), and long-term survivors may suffer from restrained functional recovery. Therefore, an optimal means in predicting postoperative reversal is demanded. In this study, we assess the utility of myocardial perfusion/F-18 fluorodeoxyglucose (FDG) imaging in the evaluation of myocardial viability and postsurgery functional recovery in children with ALCAPA. A retrospective study was performed in 7 children with diagnosed ALCAPA who underwent myocardial perfusion/F-18 FDG imaging preoperatively. Global viability index was used to evaluate myocardial viability and was compared with the preoperative deviations of left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter (LVEDD) from age-matched healthy children and with the postoperative durations of intensive care. Children with more viable myocardium had less severe clinical symptoms. The viability index was correlated well with the preoperative deviations of LVEF (r = -0.98, P = 0.001) and LVEDD (r = 0.87, P = 0.02) and postoperative durations of intensive care hospitalization (r = 0.77, P = 0.04) and mechanical ventilation (r = 0.83, P = 0.02). LVEF and LVEDD reached normal range within 5 months in viable children, whereas incomplete reversal was observed in partial- and nonviable children. In children with ALCAPA, myocardial viability evaluated by perfusion/F-18 FDG imaging is related to the preoperative clinical manifestations and cardiac function. Additionally, it may predict functional recovery after surgical repair.

Surgical Correction and Prognostic Factors for Ascending Aortic Lesions Involving Coronary Arteries

The prognostic factors following aortic root reconstruction were studied in 19 patients including 13 with annuloaortic ectasia (AAE) and 6 without AAE (non-AAE). The preoperative diagnosis of six non-AAE patients was a dissecting aneurysm in five of the patients and supravalvular aortic stenosis associated with stenosis of the right coronary ostia in one patients. In the AAE group, the Bentall's method was initially selected in 11 patients and the Cabrol's method in the remaining 2 patients. In the non-AAE group, ascending aortic replacement was performed in 4 patients, patch plasty of the ascending aorta in 1 patient, and entry closure in the other patient. In this group, aorto-coronary bypass grafting using a saphenous vein graft was performed in 4 patients, ostioplasty of the right coronary artery (RCA) in 1, and the Bentall's method in 1. During the postoperative acute phase, one AAE patient died of acute myocardial infarction 3 days after surgery; the remaining 18 patients survived. In the follow-up study, 3 patients died of cardiac events which included two cardiac failures and one arrhythmia. The preoperative left ventricular diameter in the end-diastolic phase (LVDd) of 2 AAE patients who died of cardiac failure was 80 mm or larger and the left ventricular function remained unchanged after surgery. One non-AAE patient who underwent RCA ostioplasty suddenly died of arrhythmia. Postanastomotic leakage around the left coronary ostia associated with the patent Cabrol's trick occurred in 1 AAE patient and mitral valve regurgitation occurred in the other non-AAE patient. Reoperation using Cabrol's procedure and mitral valve replacement were performed for these 2 patients, respectively. Preoperative low cardiac function and large LVDd may influence the late results in AAE patients, therefore, earlier operations should be recommended.

Myocardial Infarction in the 31st Week of Pregnancy - Case Report

The occurrence of acute myocardial infarction (AMI) during pregnancy is rare. The authors describe the case of MI in a 31-week pregnant woman and the importance of a multidisciplinary team for its approach. Thirty-one week pregnant woman with history of smoking, alcoholism and hypertension was admitted after an episode of syncope. On admission she was conscious and asymptomatic, although hypotensive. The electrocardiogram showed marked ST-segment elevation in D1, aVL, V1-V6. The cardiac enzymes were positive. The transthoracic echocardiogram showed reduction in septal and left ventricular contractility and an ejection fraction of 30%. Angiography revealed proximal occlusion of the left anterior descending artery. After a non-successful balloon angioplasty, a metallic stent was placed. The patient started therapy with beta-blockers, aspirin and clopidogrel. As for the delivery, we chose to perform a cesarean section four weeks after MI. Clopidogrel was suspended seven days before delivery. The preoperative cardiac function was improved by infusion of levosimendan started the day before. Cesarean section occurred under epidural block. The intraoperative period showed no complications, except for mild hypotension easily corrected with phenylephrine. The Apgar score for the newborn was 9/10. This is one of the few cases of myocardial infarction and angioplasty reported during pregnancy. The authors discuss the decisions taken by the multidisciplinary team consisting of anesthesiologists, obstetricians, neonatologists and cardiologists, particularly with regard to dual antiplatelet therapy, the type of delivery and anesthesia.

Bleeding Complications and Blood Product Utilization With Left Ventricular Assist Device Implantation

Bleeding complications are a major source of morbidity and reoperation after left ventricular assist device (LVAD) implantation, yet remain poorly characterized in patients receiving LVADs. We assessed bleeding complications in an institutional cohort of LVAD patients. We reviewed patients who received continuous-flow (CF) LVADs at our institution (October 2004 to May 2009). Intraoperative and postoperative transfusion requirements (packed red blood cells, fresh frozen plasma, and platelets), chest tube output, and reoperation for bleeding complications were assessed. Univariate and multivariable Cox proportional hazard analysis assessed the impact of intraoperative bleeding on mortality. A subset of our patient population underwent delayed sternal closure as opposed to primary closure and an analysis of reoperation for bleeding was undertaken stratifying patients by approach to closure. Eighty-six CF LVADs were implanted over our study period. Patients had poor preoperative cardiac function and high preoperative risk indices. Patients receiving LVADs had high intraoperative (11.6 ± 7.5 units) and postoperative (15.6 [±12.6] units in the first week) blood product requirements, as well as significant chest tube output (5,880 [±4,480] milliliters in the first week). On multivariable analysis, intraoperative packed red blood cell transfusions were a significant predictor of mortality. Eleven (28%) patients undergoing primary sternal closure required reoperation for bleeding, while delayed sternal closure patients generally had resolution of bleeding prior to sternal closure. The incidence of gastrointestinal bleeding was 28% at one year. On multivariable analysis, intraoperative packed red blood cell transfusions were a significant predictor of 30-day and one-year mortality, while chest tube output during the first postoperative 48 hours predicted 30-day but not one-year mortality.

Long-term results of the maze procedure on left ventricular function for persistent atrial fibrillation associated with mitral valve disease

Although the maze procedure is often performed as a surgical treatment for atrial fibrillation (AF) combined with mitral valve surgery, the long-term efficacy of the maze procedure concerning cardiac function has not been determined. The aim of this study was to assess long-term results of the maze procedure for left ventricular function in patients with persistent AF associated with mitral valve disease. We analyzed 38 patients who underwent the maze procedure for persistent AF and mitral valve surgery. The cardiothoracic ratio on chest X-ray and the left atrial dimension, left ventricular end-diastolic dimension, left ventricular end-systolic dimension and left ventricular ejection fraction on transthoracic echocardiography were evaluated before and 6 years after the maze procedure. Twenty-two patients maintained sinus rhythm (SR group) and 16 patients had recurrence of permanent AF (AF group) after the maze procedure. Preoperative cardiac function and the methods of mitral surgery were similar between the two groups. At the latest follow-up, left ventricular function tended to be better in the SR group than in the AF group. Cardiovascular events occurred more often in the AF group during follow-up (50 vs. 18%, p < 0.05). This retrospective study revealed that maintaining the sinus rhythm after the maze procedure for patients who underwent mitral valve surgery might be important for preserving better long-term left ventricular function and result in fewer cardiovascular events.

Portopulmonary hypertension as an indication for combined heart, lung, and liver or lung and liver transplantation: Literature review and case presentation

End-stage liver disease with severe portopulmonary hypertension (PPHTN), which is refractory to vasodilator therapies, is a contraindication for isolated liver transplantation (LT) because of the high mortality rate. Combined heart, lung, and liver transplantation (CHLLT) and combined lung and liver transplantation (CLLT) can be lifesaving options for these patients; however, these procedures have rarely been performed. A 52-year-old man had end-stage liver disease due to hepatitis C and PPHTN; the latter showed a suboptimal response to pulmonary vasodilator therapy with continuous intravenous treprostinil sodium and oral sildenafil citrate and was considered a contraindication to isolated LT. His preoperative left ventricular function was normal, and he had mild to moderate right ventricular dysfunction. He underwent CLLT, which consisted of sequential double-lung transplantation under cardiopulmonary bypass followed by standard LT under venovenous bypass. Re-exploration of the chest cavity was necessary because of bleeding, and respiratory failure developed; however, the patient recovered, was discharged home on day 26, and remained well 1 year after CLLT with the standard immunosuppressants (similar to those used for heart and lung transplantation). For PPHTN, combined thoracic organ and liver transplantation has been reported in only 10 patients. Six of these patients, including our case, underwent CLLT, whereas 4 patients underwent CHLLT. Notably, 2 of the 6 CLLT patients expired within 24 hours of transplantation because of acute right heart failure. CHLLT should be considered for patients with refractory PPHTN. The assessment of preoperative cardiac function is a vital part of the decision to include heart transplantation in CLLT.

Profiling fetal cardiac function in twin–twin transfusion syndrome

Cardiomyopathy in the recipient twin is a marker of severity in twin-twin transfusion syndrome (TTTS), making it a potentially valuable tool for staging the disease. This study aimed to provide a quantitative description of cardiac function in the recipient twin. Consecutive monochorionic pregnancies complicated with TTTS and treated by percutaneous laser coagulation underwent fetal echocardiography before surgery. An unsupervised classification analysis was conducted to identify groups of twins with similar cardiac profiles. The predictive value of the recipient twin's preoperative cardiac function based on these profiles was assessed, using perinatal death of at least one twin as the main outcome. The cardiac function profiles that we identified were compared with the current Quintero staging. A total of 107 pregnancies were included, with six of these lost to follow-up; 63/107 complete cases were available for multivariate description of the recipient's cardiac function. Three different preoperative cardiac profiles were identified with increasing right and left myocardial performance index, decreasing right and left shortening fraction, and increasing ductus venosus pulsatility index. Although the three groups represented progressive stages of the syndrome-related cardiomyopathy, no correlation was found with pregnancy outcome. Of Quintero Stage 1 cases, 55% showed significant alterations of cardiac function in the recipient twin. Progressive cardiomyopathy can be assessed quantitatively in the recipient twin and does not influence pregnancy outcome when fetoscopic laser coagulation is the first-line treatment. Compared with the current staging, cardiac profiling allows discrimination of cases with significant myocardial dysfunction.

Preoperative haemodynamic parameters and the immediate outcome after open repair of ruptured abdominal aortic aneurysms

The aim of this study was to evaluate the impact of preoperative cardiac function and haemodynamic parameters on the immediate outcome after repair of ruptured abdominal aortic aneurysm (RAAA). This is a retrospective review of 68 consecutive patients who underwent emergency repair of RAAA. Baseline pulmonary artery pressure, cardiac index, oxygen saturation and pulse rate were measured and recorded immediately after insertion of a pulmonary artery thermodilution catheter and before anaesthesia induction. The in-hospital mortality rate was 39.7%. The area under the receiver operating characteristic (ROC) curve of cardiac index was 0.74 (95% CI 0.61-0.86), of stroke volume index was 0.78 (95% CI 0.67-0.89) and for oxygen delivery 0.72 (95% CI 0.60-0.84) for prediction of in-hospital death. The best cut-off values of cardiac index was 2.7 l/min/m(2) (18.8% vs. 58.3%, OR 6.07, 95% CI 2.00-18.37), of stroke volume index was 27 ml/m(2) (23.1% vs. 62.1%, OR 5.46, 95% CI 1.90-15.70) and of oxygen delivery was 370 ml/min/m(2) (17.9% vs. 56.4%, OR 5.05, 95% CI 1.87-18.91). Multivariate analysis showed that patient's age (P=0.01, OR 1.23, 95% CI 1.05-1.44), stroke volume index (P=0.018, OR 0.89, 95% CI 0.81-0.98), and shock (P=0.007, OR 14.20, 95% CI 2.09-96.67) were independent predictors of in-hospital death. This study suggests that impaired cardiac function and suboptimal oxyhaemodynamic parameters are important determinants of death after repair of RAAA.

Analysis in primary clinic outcomes of minimal extracorporeal circulation in the coronary artery bypass grafting

To analysis comparatively the primary clinic outcomes between minimal extracorporeal circulation (MECC) and conventional extracorporeal circulation (cECC). Forty cases accepted coronary artery bypass grafting from August to October at 2006 were divided into MECC group and cECC group at random, 20 cases for each group. Record and analysis of the general information, clinic data perioperatively, and complications postoperatively for each group were performed. There were no deference between groups in gender, anamnesis and preoperative cardiac function, while age (P < 0.05), standard EuroSCORE and logistic EuroSCORE were much more higher in MECC group than in cECC group (P < 0.01). Similarly, there were no deference in operative time, bypass time, ischemic time and graft number between two groups. Contrasted with cECC group, the values of cTNI were lower in MECC group at 2 h, 6 h and 12 h post-ECC (P < 0.01), oxygen index were higher post-operatively and there was a statistic deference at 12 h post-ECC (P < 0.05). The valves of ALT and TBIL in cECC group were higher abnormally at early post-ECC, and significant higher than in MECC group at 2 h, 6 h post-ECC of ALT (P < 0.05), and at termination, 2 h post-ECC of TBIL (P < 0.05). The values of activated partial thromboplastin time were almost at physiological status in MECC group, but were significantly prolonged in cECC group at early post-ECC, and were statistically longer than in MECC group at 2 h, 6 h, 12 h post-ECC (P < 0.05). The concentration of free hemoglobin in cECC group were higher than in MECC group peri-operative, and there was a statistic deference at 2 h post-ECC (P < 0.05). There were no deference between the two group in Cr, PLT and WBC. Compared with cECC, MECC carries more biocompatibility, more safe and credible. MECC system can alleviate the organ injury postoperatively and decrease the incidence of complications, especially in high-risk patients.

A novel survival model of cardioplegic arrest and cardiopulmonary bypass in rats: a methodology paper

BackgroundGiven the growing population of cardiac surgery patients with impaired preoperative cardiac function and rapidly expanding surgical techniques, continued efforts to improve myocardial protection strategies are warranted. Prior research is mostly limited to either large animal models or ex vivo preparations. We developed a new in vivo survival model that combines administration of antegrade cardioplegia with endoaortic crossclamping during cardiopulmonary bypass (CPB) in the rat.MethodsSprague-Dawley rats were cannulated for CPB (n = 10). With ultrasound guidance, a 3.5 mm balloon angioplasty catheter was positioned via the right common carotid artery with its tip proximal to the aortic valve. To initiate cardioplegic arrest, the balloon was inflated and cardioplegia solution injected. After 30 min of cardioplegic arrest, the balloon was deflated, ventilation resumed, and rats were weaned from CPB and recovered. To rule out any evidence of cerebral ischemia due to right carotid artery ligation, animals were neurologically tested on postoperative day 14, and their brains histologically assessed.ResultsThirty minutes of cardioplegic arrest was successfully established in all animals. Functional assessment revealed no neurologic deficits, and histology demonstrated no gross neuronal damage.ConclusionThis novel small animal CPB model with cardioplegic arrest allows for both the study of myocardial ischemia-reperfusion injury as well as new cardioprotective strategies. Major advantages of this model include its overall feasibility and cost effectiveness. In future experiments long-term echocardiographic outcomes as well as enzymatic, genetic, and histologic characterization of myocardial injury can be assessed. In the field of myocardial protection, rodent models will be an important avenue of research.

Surgical treatment of myocardial bridging: report of 31 cases

Myocardial bridging (MB) is usually considered a benign condition but may result in myocardial ischemia, myocardial infarction (MI), exercise-induced tachycardia, atrioventricular conduction block or even sudden cardiac death. This retrospective study summarizes our operative methods and outcomes for treatment of 31 cases of MB. From January 1997 to December 2006, 31 consecutive patients (24 men and 7 women; aged 35 - 67 years; mean 52.3 years) with MB underwent surgical treatment. Thirteen patients had MB only and 18 patients had MB associated with other heart diseases. In preoperative cardiac function grading, 5 patients were in NYHA class I and 18 in NYHA class II and 8 in NYHA class III. Among them, 15 underwent myotomy and 16 underwent coronary artery bypass grafting (CABG). All patients survived and recovered uneventfully. Neither hospital or late death nor major complications occurred. Postoperative exercise testing in all patients failed to reveal any persistent ischemia. Follow-up time was 3 - 115 months (mean 31 months). Follow-up angiographic studies in 21 patients (68%) demonstrated restoration of coronary blood flow and myocardial perfusion without significant residual compression of the artery. All patients were symptom-free and currently in NYHA class I - II. The patients who are refractory to medication should actively undergo the surgical procedures such as myotomy and CABG. Myotomy should be advocated as the first choice because of its safety and satisfactory results.

Successful living related liver transplantation in a case with biliary atresia associated with corrected transposition of the great arteries

Little is known about the safety of LRLTx in children with end stage liver disease associated with congenital cardiac anomalies. We report the successful LRLTx in a case with extrahepatic biliary atresia associated with cTGA, VSD, and PS. Preoperative cardiac function was evaluated by cardiac echogram and cardiac catheterization. The recipient's cardiac function was preserved (EF; 54%); however, because of the left to right shunt disease, oxygen saturation was 91%. At operation, carbon dioxide insufflation into the abdominal cavity was attempted to prevent sudden air embolism. Hemodynamic variables were stabilized during partial clamping of the inferior vena cava, and at reperfusion of the portal vein. However, a sudden decrease in blood oxygenation was observed during hepatico-jejunostomy, which was easily normalized by graft mobilization. Post-operatively, neither heart failure nor cerebral infarction because of air embolism was observed. In conclusion, together with preserved cardiac function and carbon dioxide insufflation, LRLTx was successful. Further studies are required to establish the algorithm for the strategy of treating both congenital cardiac anomalies and liver failure.

Surgical Repair for Atrial Septal Defect Associated With Myotonic Dystrophy

Myotonic dystrophy is a well-known hazard of anesthesia for various kinds of surgery. A 47-year-old male who had an increased CTG repeat of approximately 700 copies in the 3'-untranslated region of the myotonic dystrophy protein kinase gene underwent closure of an atrial septal defect under normothermic beating heart. A strong correlation between reduced left ventricular ejection fraction and stroke volume, and the number of CTG repeats, has been reported. Because this correlation is not completely understood, even if the preoperative cardiac function is normal, it is important to check the number of CTG repeats and the patients who have a large number of them should be carefully treated.

Does Preoperative Ejection Fraction Predict Operative Mortality With Left Ventricular Restoration?

Ischemic cardiomyopathy and aneurysmal disease have been treated surgically with coronary artery bypass grafting in the past. The Dor technique for left ventricular restoration has demonstrated improved outcomes in patients with ischemic, akinetic ventricles. Our hypothesis was that even marked reduction in preoperative cardiac function (ejection fraction < .25) would not correlate with worse outcomes since the ventricle would be reshaped to improve function. A retrospective analysis was performed on all patients who had undergone ventricular restoration with the Dor procedure from January 1996 through September 2005. Patients with a preoperative ejection fraction (EF) < .25 and those with a EF > or = .25 were compared. All Society of Thoracic Surgeons database characteristics, mortality, length of stay (LOS), and need for intraaortic balloon pump (IABP) were analyzed. The study included 89 patients (69 men, 20 women), 28 of whom had preoperative EFs < .25 (mean, .183 +/- .035; range, .08 to .25) and 61 had an EF > or = .25 (mean, .334 +/- .074; mean, .25 to .45). Overall operative mortality was 3.4% (3/89), with no statistically significant difference between the two groups (3.6% versus 3.3%). LOS was 7.4 +/- 3.6 days versus 8.9 +/- 15.6 days (p = NS), and need for IABP was 39.2% versus 8.1% (p < 0.05). Overall 5-year survival was 82%. Five-year survival in the EF < .25 cohort was 69.6% versus 88.3% in the EF > or = .25 cohort (p = 0.066). Ventricular restoration with the Dor technique is a safe procedure. Marked reduction in ejection fraction is not a contraindication to left ventricular restoration; however, increased usage of IABP should be anticipated.