僧帽弁手術における視野展開

SJM提供 DVD 柴田先生 1年ほど前に入手したもの。当時はあまり思わなかったが、今見るとすごく勉強になった。 何度も経時的に勉強することが大切だ。 僧帽弁手術では、視野展開が全て。 SIVCの剥離は十分行う。特にSVCは右房付け根からPAを十分超える位置まで剥離する。心膜はSVC付け根から無名静脈まで切開。 エステックは一旦、助手側に押し込んでから、上に引き上げる。

The Operating Surgeon Is an Independent Predictor of Chest Tube Drainage Following Cardiac Surgery

The Operating Surgeon Is an Independent Predictor of Chest Tube Drainage Following Cardiac Surgery Journal of cardiothoracic and vascular anesthesia J Cardiothorac Vasc Anesth. 2014 Jan 16. pii: S1053-0770(13)00517-X. doi: 10.1053/j.jvca.2013.09.010. http://www.sciencedirect.com/science/article/pii/S105307701300517X In this single centre retrospective review, the authors in a multivariable analysis determined the surgeon was a predictor of blood loss after cardiac surgery. Despite much research, bleeding and blood use remains an issue after cardiac surgery. Each surgeon should examine their own techniques to minimise bleeding risk. IMA use and CPB time were other factors that were significant. この場合のチェストチューブは心嚢・縦隔ドレーンのこと。術後の出血量は個々の術者による。これが成績に大きく影響する。1000以上出血したら4倍術死リスクが増加する。耳の痛い話だ。

Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality.

Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality. Ann Thorac Surg. 2014 Jan;97(1):87-94. http://www.sciencedirect.com/science/article/pii/S0003497513016299 http://www.annalsthoracicsurgery.org/article/S0003-4975%2813%2901629-9/abstract Gaetano Paone, Donald S. Likosky, Robert Brewer, Patricia F. Theurer,Gail F. Bell, Chad M. Cogan, Richard L. Prager, Membership of the Michigan Society of Thoracic and Cardiovascular Surgeons The effect of blood transfusion (Tx; 1-2 units only) on mortality after isolated CABG was evaluated in nearly 17,000 pts in Michigan. Operative mortality was 0.5% for no Tx and 1.3% for Tx (p<0.0001). Nine other adverse postoperative outcomes were significantly increased in pts receiving Tx. Aggressive attempts at reducing even small Tx amounts may result in substantial outcomes improvement. 大規模1万7千人！3単位以上は除外。1、2単位の輸血群の成績が悪い。輸血自体が悪いのだろうか？それとも輸血を必要とする状態が悪いのだろうか？例えば出血洗浄自家血の投与は予後を改善するのだろうか？一度、検討してみよう。

Radial artery grafting in women improves 15-year survival

J Thorac Cardiovasc Surg. 2013 Dec;146(6):1467-73. doi: 10.1016/j.jtcvs.2012.10.004. Epub 2012 Nov 2. http://www.ncbi.nlm.nih.gov/pubmed/?term=23122697 This study by Dimitrova et al included 1339 patients who underwent CABG of which 332 patients received a LIMA with a radial artery and 1007 a LIMA with a SVG. In a propensity-matched cohort of 283 pairs, Kaplan-Meier survival in the radial artery versus SVG group at one year (99% vs. 97%), 5 years (93% vs. 87%), 10 years (80% vs. 72%) and 15 years (70% vs. 58%) favoured those receiving a radial artery (P=0.018). In a propensity-score adjusted multivariate analysis of the entire cohort, the use of a radial artery remained an independent predictor of long-term mortality: hazard ratio 0.64, 95% CI 0.44-0.90; P=0.017). 女性ではRAが良い。生存率で差がでている！すごい。今まで差がでなかったのはなんでだろう。性差がポイントなのかな？

The differences and similarities between intramural hematoma of the descending aorta and acute type B dissection

J Vasc Surg. 2013 Dec;58(6):1498-504. doi: 10.1016/j.jvs.2013.05.099. Epub 2013 Sep 21. http://www.ncbi.nlm.nih.gov/pubmed/?term=the+differences+and+similarities+between+intramural+hematoma+of+the+descending IRAD investigators Aortic intramural hematoma type B (IMHB) VS type B aortic dissection (ABAD) IMHB was considered when a crescentic thickening of the aortic wall was identified on the first or second imaging study in the absence of any entry tear, double lumen, and/or intimal flap There was no difference in in-hospital mortality between the two groups. Periaortic hematoma was observed more often in patients with IMHB and was identified as a risk factor for rupture. Patients with ABAD had significantly more dilation of the descending aorta during follow up and more often had extension into the abdominal aorta than those with IMHB. IMHB may have a more indolent clinical course than ABAD. IMHって定義が難しい。日本で言えば、どちらもB型解離。割れ方（下行で三日月形か、同心円型か）の違い。同心円型のほうが予後がいいという話。

Permanent Pacemaker Implantation Following Transcatheter Aortic Valve Implantation: Impact on Late Clinical Outcomes and Left Ventricular Function. Circulation. 2013 Dec 26. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/24370552 1556 patients undergoing transcatheter aortic valve implantation (TAVI) with self expandable valves (SEV) and balloon expandable valves (BEV), evaluating the effect of permanent pacemaker implantation (PPI) on outcomes at two years. 15.4% of the patients required PPI. （SEV (25,5%) >>> BEV (7,1%)) There was no difference in the primary outcome of the study, which was defined as a composite of all-cause mortality and hospitalization due to heart failure at last follow-up. Interestingly, there was a lower rate of unexpected death in patients with PPI. TAVI後のペースメーカーの話。AVRではほとんどないのにね。けどPM入れようがどうしようが、予後には関係ないとのこと。ほんとかな？？

Calcific Aortic Stenosis : A Disease of the Valve and the Myocardium

Calcific Aortic Stenosis : A Disease of the Valve and the Myocardium J Am Coll Cardiol. 2012 Nov 6;60(19):1854-63. doi: 10.1016/j.jacc.2012.02.093. Epub 2012 Oct 10. http://www.sciencedirect.com/science/article/pii/S0735109712041502 冠状動脈口に隣接する弁尖において冠動脈乱流が起こるためせん断応力は最も高い。従って、無冠尖がせん断応力がより低く、最も頻繁にASに関与している。 驚くべきことに、ASにおいて左心室肥大、症状の程度は狭窄度との関連は低い。人によってぜんぜん違う。