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Forty octogenarians (OCTO) undergoing a variety of cardiac and thoracic aortic surgeries using cardiopulmonary bypass (CPB) between 1994 and 2002 were retrospectively studied. The results were compared with those of high-risk younger patients aged less than 60 years (YOUNG) (n=89). All patients had an expected operative mortality of EuroSCORE 5 and over. The EuroSCORE score was 9.9+/-3.3 (range, 5-18) in the OCTO group and 6.8+/-2.3 (range, 5-16) in the YOUNG patients (p<0.0001). There were 4 (10%) and 10 (11%) hospital deaths, respectively (p>0.99). Major postoperative complications occurred in 50% of the OCTO and 36% of the YOUNG patients (p=0.17). There were 10 and 7 late deaths, respectively. Actuarial survival including hospital death was significantly lower in the OCTO group than in the YOUNG (p=0.033). Actuarial survival was significantly higher in female octogenarians than in male (p=0.046). The overall 3-year survival rate was 88+/-8% and 64+/-11%, respectively. Multivariate analysis showed that predictors of late death were male gender (p=0.0005) and a high EuroSCORE (p=0.0010). Cardiac and thoracic aortic surgery using CPB can be performed in octogenarians with an acceptable hospital mortality rate and gratifying medium-term survival results.

A retrospective analysis was performed to determine the early outcome of cardiac and thoracic aortic surgery in patients over 80 years old. Between 1994 and 2000, 41 octogenarians (mean age, 82.6 +/- 2.5 years) underwent coronary artery bypass grafting (25), valve surgery (8), thoracic aortic aneurysm repair (7), or combined valve and bypass surgery (1). Overall hospital mortality was 9.8%. Mortality rates for specific procedures were 12% for coronary bypass, 0% for valve surgery, and 14% for thoracic aortic aneurysm repair. Major postoperative complications affected 27% of patients and included severe low cardiac output, respiratory failure, and acute renal failure, with a low incidence of perioperative stroke (2.4%). Cardiac and thoracic aortic operations can be performed with acceptable mortality and morbidity when appropriately applied in selected octogenarians.

Risk stratification according to the EuroSCORE additive model of 803 consecutive patients undergoing heart and thoracic aorta surgery using cardiopulmonary bypass from August 1994 to December 2000 was performed. The population was divided into 5 clinically relevant risk categories: 0-2% risk, 3-5% risk, 6-8% risk, 9-11% risk, and 12+% risk. Observed and predicted mortalities were compared within 3 groups of patients divided by year of operation (early: August 1994 to September 1996, n=260; middle: October 1996 to September 1998, n=259; late: October 1998 to December 2000, n=284). Overall hospital mortality was 4.5%; predicted mortality was 5.3% in the early, 5.1% in the middle, and 5.4% in the late period; observed mortality was 6.5%, 3.9%, and 3.2%, respectively (p=0.0024 in early vs late). In the early period, observed mortality was lower than predicted mortality in the 0-2% and 3-5% risk categories, but higher in the other categories. Moreover, observed mortality increased markedly with the increase in predicted mortality. In the late period, observed mortality was lower than predicted mortality in all 5 risk categories. The EuroSCORE is clinically relevant index for constructing a risk stratification scoring system for Japanese cardiovascular patients as well and shows that the quality of surgical care has improved gradually over the years.

Objective: Our purpose was to compare the performance of risk stratification model between Parsonnet and European System for Cardiac Operative Risk Evaluation (EuroSCORE) in our patient database., Methods: From August 1994 to December 2000, 803 consecutive patients have undergone heart and thoracic aorta surgery using cardiopulmonary bypass and scored according to Parsonnet and EuroSCORE algorithm. The population was divided into five clinically relevant risk categories. We compared correlation of predicted mortality and observed mortality between these two models. Score validity was assessed by calculating the area under the receiver operating characteristic (ROC) curve., Results: Overall hospital mortality was 4.5%. In Parsonnet model, predicted mortality was 2.4% for 0-4% risk, 6.7% for 5-9% risk, 12% for 10-14% risk, 17% for 15-19% risk, 25% for 20% plus risk, and 10.4% for overall patients. Observed mortality was 2.4, 0.4, 5.9, 8.7, 11, and 4.5%, respectively. The thoracic aorta and valve cohort indicated poor correlation between predicted and observed mortality compared to coronary cohort. In the EuroSCORE model, predicted mortality was 1.4% for 0-2% risk, 4.0% for 3-5% risk, 6.7% for 6-8% risk, 9.7% for 9-11% risk, 13% for 12% plus risk, and 5.3% for overall patients. Actual mortality was 0, 1.5, 6.8, 11, 21, and 4.5%, respectively. Each of the thoracic aorta, valve, and coronary cohort indicated good correlation between predicted and observed mortality. Areas under the ROC curves were 0.72 in Parsonnet and 0.82 in EuroSCORE., Conclusions: The EuroSCORE additive model yielded good predictive value for hospital mortality of Japanese patients undergoing not only cardiac but also thoracic aortic surgery.

Objective: Correlations and risk factors remain to be unclarified for post-heart-surgery posttransfusion graft-versus-host disease, mediastinitis, and late cardiac tamponade caused by deteriorated host-defense mechanisms due to cardiopulmonary bypass both with and without steroid usage., Methods: We sent questionnaires to 298 Japanese cardiovascular institutions asking for institution profiles, including infection control, steroid use in cardiopulmonary bypass, and prevalence of mediastinitis, late cardiac tamponade, and posttransfusion graft-versus-host disease during 1994. The overall prevalence of posttransfusion graft-versus-host disease since the start of service (from establishment of institution to date) was also requested., Results: The number of pump cases at the 119 institutions responding (40%) were 91.6 +/- 67.9 cases/institution (total = 10,904). The prevalence of mediastinitis was 1.2 +/- 1.8 and that of late cardiac tamponade 1.0 +/- 1.8%. Posttransfusion graft-versus-host disease occurred in 1 of 10,904 patients (0.01%) during 1994 at an institution where steroids and nonirradiated blood were used in surgery. The simple institutional mean prevalence of posttransfusion graft-versus-host disease since establishing institutions was 0.08 +/- 0.13%. Of the 119 institutions surveyed, 86 used steroids in all pump cases (72%); 11 institutions used steroids in a limited number of cases (9%). The institutional mean of methylprednisolone-converted steroid dose was 21.5 +/- 16.4 mg/kg (n = 119). In multivariate regression analysis, operation time (p = 0.005) for mediastinitis, steroid usage (all, limited, or no cases) (p = 0.01) and % aneurysm (p = 0.05) for late cardiac tamponade, and steroid dosage (p = 0.002) for posttransfusion graft-versus-host disease were identified as significant risk factors., Conclusion: Our results suggest that massive steroid administration for cardiopulmonary bypass may increase the risk of posttransfusion graft-versus-host disease and late cardiac tamponade, but not mediastinitis.

Objective: Amrinone, a selective phosphodiesterase III inhibitor, is reported to have a potent inotropic effect on the left ventricle, but the effects of this drug on right ventricular contractility in the clinical setting are unknown. The concept of ventricular/arterial coupling was applied to investigate the effects of amrinone on right ventricular contractility and afterload with transesophageal echocardiography., Methods and Results: The study was performed in the intensive care unit with 11 patients who had undergone cardiac operations. Right ventricular cross-sectional area was measured with transesophageal echocardiography equipped with a capability of automated border detection as a surrogate for right ventricular volume. Multiple pressure-area loops were obtained by reducing preload to measure end-systolic elastance and effective arterial elastance. External work and pressure-volume area were also measured to calculate the efficiency of energy transfer from pressure-volume area to external work. Nitroprusside (0.3 to 0.5 microg x kg(-1) x min(-1)) and amrinone (1 mg x kg(-1) intravenously followed by 10 microg x kg(-1) x min(-1)) were administered. With nitroprusside infusion, end-systolic elastance and effective arterial elastance remained unchanged (end-systolic elastance, 4.73 +/- 2.18 mm Hg/cm2 to 4.65 +/- 2.09 mm Hg/cm2; effective arterial elastance, 8.05 +/- 3.84 mm Hg/cm2 to 7.70 +/- 3.64 mm Hg/cm2). In contrast, amrinone reduced afterload (effective arterial elastance, 8.82 +/- 3.99 mm Hg/cm2 to 7.05 +/- 4.01 mm Hg/cm2, p = 0.004) and enhanced contractility (end-systolic elastance, 4.47 +/- 1.79 mm Hg/cm2 to 6.56 +/- 2.22 mm Hg/cm2, p = 0.007). Consequently, amrinone decreased the ventricular/arterial coupling ratio (effective arterial elastance/end-systolic elastance, 2.40 +/- 1.45 to 1.16 +/- 0.63, p = 0.009) and improved the efficiency of energy transfer (external work/pressure-volume area, 0.44 +/- 0.15 to 0.54 +/- 0.15, p = 0.013)., Conclusions: Right ventricular pressure-area relations obtained with transesophageal echocardiography could successfully separate the simultaneous change in right ventricular systolic mechanics and afterload caused by amrinone. Amrinone caused enhancement of right ventricular contractility and afterload reduction.

During cardiac surgery abrupt hypotension sometimes occurs by the atrium being pulled, though the hypotensive mechanism is not known. The effects of mechanical stretching of the right atrium on haemodynamics and renal sympathetic nerve activity in the anesthetized rabbit was investigated. During stretching of the right atrial appendage with a metal weight (right atrial stretch), both mean arterial pressure (mAP) and renal sympathetic nerve activity significantly decreased. Bilateral vagotomy significantly reduced the change in mean arterial pressure with right atrial stretch (P < 0.01), and significantly increased renal sympathetic nerve activity (P < 0.01). The duration of the decreases of mean arterial pressure with right atrial stretch was significantly shortened after vagotomy. Decreases of blood flow of the descending aorta with right atrial stretch were observed and not affected by vagotomy. These results suggest that hypotension with mechanical stimulation of the right atrium is not only due to the decrease in cardiac output but also to sympathetic inhibition through the vagus via cardiac baroreflex.

Background: Preoperative autologous blood donation is one of the most effective methods to avoid homologous blood transfusion in cardiac operations. However, there have been few reports about the safety and efficacy of autologous blood donation in children., Methods: Since 1986, we have instituted a blood conservation program including preoperative autologous blood donations in children. Eighty children as young as 3 years old (mean +/- SD, 8.6 +/- 3.9 years) and weighing as little as 12.3 kg (29.2 +/- 14.5 kg) were enrolled in the program, and 735 +/- 388 mL of blood was donated during an average of 3.1 +/- 1.5 phlebotomies before the operations., Results: Two episodes of mild vasovagal reaction were observed in 2 patients as a complication of the phlebotomy. Seventy-six percent of the collected blood was stored by cryopreservation; the remaining 24% was preserved by liquid storage. Seventy-eight of these patients (97.5%) underwent operations using cardiopulmonary bypass. Seventy-five patients (94%) were operated on successfully without the need for a homologous blood transfusion. As for the other 5 patients, 2 received only platelet concentrate., Conclusion: Preoperative autologous blood donation is a safe and effective method to avoid homologous blood transfusion in pediatric cardiac operations.

Progress in infant open-heart surgery last 10 years was reviewed mainly based on the surgical experiences in Fukuoka Children's Hospital. Recent advances and present problems in patient's care, cardiopulmonary bypass methods and cardioplegia were discussed. Low surgical mortality of 4.8% in 245 infant open-heart repairs between 1988 and 1990 in Fukuoka is highly suggestive of early primary repair for most of congenital heart diseases.

Five patients developed coronary artery spasm during open heart surgery in our institute between 1984 and 1988. One patient was undergoing coronary artery bypass grafting and the other four valvular surgery or surgery for congenital heart disease. In one of the patients undergoing non-coronary surgery, the preoperative induction of right coronary artery spasm by ergonovine had been documented angiographically while the remaining three patients did not possess organic or functional coronary disease. All five patients exhibited a sudden onset of hemodynamic collapse with ventricular tachyarrhythmias or ST elevation during the early period of reperfusion, the time to onset being 89.2 +/- 84.8 minutes after unclamping of the aorta. In addition, contraction of the right ventricular free wall was severely impaired. Although one patient died due to left ventricular rupture caused by direct cardiac massage, the early mortality thus being 20 per cent, the other four were successfully treated with the intravenous administration of nitroglycerin and diltiazem. Three patients required the assistance of intraaortic balloon pumping for severe cardiac failure. Thus, during open heart surgery, coronary artery spasm can occur even in patients without organic coronary lesions and the possible mechanisms of this condition are discussed herein.

Recently, it has been recognized in Japan that informed consent is indispensable to make decisions for medical treatment, although it had been already confirmed in western countries for several decades of years. However, there may be some differences in the content of informed consent between Japan and western countries. We discussed the problems of informed consent in Japan concerning the choice of prosthetic valve, mechanical prosthesis or bioprosthesis, in patients to be undergone valve replacement. We conclude that informed consent should be the humane relationship between therapists and a patient.

Hemoconcentration for the establishment of no-donor blood transfusion in open heart surgery was assessed in regard to both the saving of protein and platelets and the exclusion of free hemoglobin. Two different types of hemoconcentrator were compared: the ultrafilter (group I, 6 patients) and the Cell Saver (group II, 6 patients). The total serum protein level, expressed as the percent recovery of the preoperative value, after hemoconcentration was significantly higher in group I (group I versus group II: total serum protein, 118% versus 87% [p less than 0.05]; fibrinogen, 77% versus 50% [p less than 0.01]; immunoglobulin, 83% versus 60% [p less than 0.01]). The platelets also seemed to be well preserved after hemoconcentration in group I. Although the exclusion of free hemoglobin from plasma was inferior in group I compared with group II, the postoperative plasma free hemoglobin level did not increase in group I. We conclude that use of the Cell Saver in nontransfusion cardiopulmonary bypass might cause a severe depletion of various proteins and that the ultrafilter is both safer and more useful if employed routinely.