[A case report of surgical treatment of dissecting aneurysm of the thoracic aorta (DeBakey IIIb) with chronic renal failure]

The patient has been receiving hemodialysis (H.D.) for chronic renal failure due to polycystic kidney since last February. He suddenly had back pain and short of breath February 8, 1988. He was pointed out to have hypertension and cardiomegaly on chest roentgenogram. He was transferred to our hospital, and suspected dissecting aneurysm. Magnetic resonance imaging was useful for the diagnosis of the dissecting aneurysm and may have a potential advantage in following up the residual false lumen. The patient underwent graft inclusion technique for dissecting aneurysm of the thoracic aorta of type IIIb with an aid of partial femoro-femoral bypass. The water and electrolytes balances were controlled by GI therapy and hemoconcentrator during operation. Since serum potassium level was gradually increasing up to 7.8 mEq/l inducing arrhythmias with coronary arterial spasm postoperatively, H.D. was instituted. The induction of H.D. was easily performed with satisfactory results. Heparin was not used while blood coagulation profiles tended to be low in early postoperative period. He returned to his work this August.

[Implications of preoperative angiography and coronary artery bypass grafting for patients with combined coronary artery and great vessels diseases]

Preoperative coronary angiography showed that the significant coronary artery disease (CAD) was present in 47% of patients with thoracic aortic aneurysm (TAA), abdominal aortic aneurysm (AAA), or aortoiliac occlusive disease (A.I). Fifty-seven patients underwent the both coronary artery and great vessel diseases on the simultaneous or sequential stage. As CAD, 13 patients had one vessel disease (VD), 18 had two-VD, 26 had three-VD and 4 of them had left main trunk lesions. As great vessel diseases, 23 patients had A-I, 20 had AAA, 8 had TAA, 5 had TAA+AAA, and 1 had TAA+A-I. There were 4 early deaths (7%) in 57 patients, and 4 (3%) in total 120 coronary and great vessel's operative procedures. The 5-year survival rates were 57.4 +/- 15.5% for TAA, 87.1 +/- 8.5% for AAA and 63.9 +/- 11.1% for A-I, which were not significantly different from those of patients without CAD, respectively except for TAA. The present data suggest that preoperative coronary angiography and CABG in the selected patients may have the beneficial effects on survival and quality of life.

Wada-Cutter heart valve: overall experience at the Sapporo Medical College

We performed cardiac valve replacement using the Wada-Cutter valve in 124 patients during the 9 years between 1966 and 1974: aortic valve replacement in 48, mitral valve replacement in 56, tricuspid valve replacement in 9, and multiple valve replacement in 11. Sixteen patients died within 30 days after operation, and 34 died in the late postoperative period, with a cumulative mortality rate of 40.3%. Postoperative complications included valve thrombosis in 9 patients, thromboembolism in 4, and mechanical valve failure in 5. The Wada-Cutter valve, first described at the Annual Meeting of The Society of Thoracic Surgeons on January 27, 1967, in a discussion on the paper by Cooley and colleagues on mitral valve replacement with a discoid valve, attracted attention for its unique design. Four of the Wada-Cutter valves were incorporated in Liotia's total artificial heart, which was implanted clinically for the first time in Cooley's second-stage heart transplantation. It may not only claim to be the origin of today's most popular tilting-disc heart valves but also has some original concepts with regard to bileaflet and tricuspid tilting-disc heart valves. However, at that time, cardiac valve replacement with this prosthesis resulted in a high incidence of thrombosis without systemic anticoagulation and in mechanical valve failure due to hinge wear of the Teflon occluder. For these reasons, its clinical use was discontinued in 1974. If Pyrolite carbon had been adopted in construction of the valve when it first became available, the valve design could have been useful even today.

[Long-term results of cardiac valve replacement: a 10- to 25-year retrospective study]

A total of 149 patients who underwent cardiac valve replacement between January, 1964 and June, 1979 in our institution have been survived more than 10 years postoperatively. The prosthetic valves primary employed in this series were both mechanical valve such as Starr-Edwards, Smeloff-Cutter, Wada-Cutter, Lillehei-Kaster valves and biological valve such as Hancock valve. Of these, 69 patients (46%) implanted with Starr-Edwards or Wada-Cutter valve were not anticoagulated postoperatively, and 52 (53%) underwent reoperation mainly for valve-related complications or aggravated other valve lesions during the follow-up period. One hundred and thirteen patients were confirmed to be alive at the end of June, 1989, with the follow-up period of 10 to 25 years. Of these, 98 patients (87%) are in the NYHA I or II at the present time. Other twenty-two patients were dead and fourteen were lost to follow-up over 10 years after operation. Although cardiac valve replacement may improve the longevity and the quality of life, available prosthetic valves were not ideal both in material and design. The increased risk of thrombogenesis of mechanical valve and the limited durability of biological valve necessitated re-replacement in the long-term period. Therefore, in addition to selection of the appropriate valve prosthesis, and optimal prevention of valve-related complications, early diagnosis and treatment of these complications are important to improve the long-term results of cardiac valve replacement.

[Evaluation of left ventricular function in the patients with aortic regurgitation following aortic valve replacement by radionuclide cardiography]

Twenty patients undergoing AVR were subjected to this study and divided into the early and the late groups. 6 healthy adults were dealt as the control group. The EF, PER, 1/3 EF, TPE were compared among these three groups both at rest and during exercise. The detailed responses to the exercise were measured by %delta between at rest and during exercise. Furthermore, the LV function in the filling period were examined by the 1/3 FF and RFR at rest. This study suggests that although the left ventricular function and contractile reserve to the exercise remained insufficient in the early postoperative phase, nearly complete recovery of the reserve could be obtained in the later phase, while the left ventricular function in the rapid filling period was significantly decreased in both early and late postoperative phase.

[Successful right pneumonectomy in pulmonary aspergilloma]

Right extrapleural pneumonectomy was performed on a 50-year-old male with aspergilloma suffering from severe hemoptysis. The post operative course was uneventful and he was discharged on the 30th day following operation. Aspergilloma is a potentially life threatening disease with large hemoptysis. So surgery is the only choice for treatment. We discussed the preoperative and postoperative problems including selection of the operative techniques for pulmonary aspergilloma.

[Total graft replacement of the thoracoabdominal aorta with reconstruction of visceral branches, intercostal and lumbar arteries in expanding chronic dissecting aneurysms of the thoracoabdominal aorta]

Four patients with expanding chronic dissecting thoracoabdominal aneurysm underwent total replacement of the thoracoabdominal aorta with reconstruction of all visceral branches, intercostal and lumbar arteries with the aid of femoro-femoral bypass. During aortic cross-clamping, selective celiac and both renal arteries perfusion was performed to prevent the organ ischemia. Somatosensory evoked potentials monitoring or spinal cord evoked potentials monitoring was also performed to detect the spinal cord ischemia. Surgical technique employed in this series was direct anastomosis of onlay patch graft to the normal true lumen from which visceral branches and intercostal and lumbar arteries arise. The celiac artery and left renal artery arise from the false lumen in some cases were reconstructed with graft interposition or direct anastomosis to an opening made in the onlay patch graft. All patients survived the operation, and are leading normal life late in the postoperative period except one who developed partial paraplegia. Total graft replacement of the thoracoabdominal aorta may be a valid technique for the treatment of expanding aneurysms of the dissecting thoracoabdominal aorta.

[Quantitative analysis of myocardial revascularization on left ventricular diastolic function]

To evaluate the effects of myocardial revascularization on left ventricular diastolic function, we studied three groups of subjects. Group I consisted of 10 patients without any previous myocardial infarction. Group II consisted of 10 patients with previous myocardial infarction. The control group consisted of 8 normal subjects, all with no evidence of cardiac disease as determined by cardiac catheterization. Left ventricular diastolic function was assessed by maximum negative dp/dt, constant T, diastolic compliance and 1/3 fractional filling before and after surgical revascularization. (1) Constant T, maximum negative dp/dt and diastolic compliance: There was no significant difference among groups I, II and the control group preoperatively, and the variables were not improved postoperatively. (2) 1/3 fractional filling: 1/3 fractional fillings in groups I and II were significantly lower (p less than 0.05, p less than 0.01) than the control group preoperatively, and it was significantly improved in group I, but unchanged in group II postoperatively. In conclusion, myocardial revascularization improves left ventricular diastolic function in the patients without previous myocardial infarction. The effects of myocardial revascularization, however, in the patients with prior myocardial infarction do not bring about an enhancement of left ventricular diastolic function.

[Surgical management of acquired tricuspid valve disease--the effects and comparison of tricuspid annuloplasty (De Vega) and tricuspid valve replacement]

A total of 92 patients with tricuspid valvular disease (TR) had surgical repair of DeVega's annuloplasty in 80 patients (87%) and of valve replacement in 12 patients (13%) from January, 1978, to March, 1988. All of those patients were diagnosed by cardiac catheterization and angiogram, clinical findings and in recent cases, pulsed and color Doppler echocardiography were applied. Eighty-nine of 92 patients (97%) were in NYHA class III or IV before operation. There were 7 early death (8.5%) with DeVega procedure and one death (8.3%) in TVR and late deaths were noted in 3 patients (3.6%) (DeVega's procedure) and one (8.3%) in TVR. Two patients after DeVega procedure at 5 and 6 years were required re-operation of TVR because of recurrent mitral valvular disease. Seventy-seven of 80 survivors were in NYHA class I or II postoperatively. Twenty-seven randomized selected patients after DeVega's annuloplasty were investigated by pulsed and color Doppler echocardiography, 17 of them (63%) had no regurgitation and the remaining 10 patient had mild to moderate regurgitation. This study suggests that DeVega's annuloplasty has a simple and reliable procedure in patients with functional TR and results in excellent hemodynamic and functional effects postoperatively.

A case of a right coronary artery to left ventricle fistula observed over twenty years

Since the natural history of a coronary artery to left ventricle fistula is not well known, a case of such a fistula in 36-year-old female patient, followed for 20 years is presented. Two-dimensional echocardiography performed as a follow-up examination revealed enlargement of the right coronary artery and the right Valsalva sinus. Two-dimensional color flow mapping showed the jet flow to the apex from the base of the left ventricle only during the diastolic phase. An aortogram confirmed that enlargement of both the right coronary artery and the right Valsalva sinus had occurred during the 20 years. The shunt flow ratio was about 50%. The Symbas procedure, closing of the coronary artery fistula by arteriotomy directly over the site of the fistula, was performed with the aid of extracorporeal circulation. Our findings indicate that enlargement of the shunted coronary artery and its Valsalva sinus can occur gradually where there is a relatively large shunt flow. Therefore, early surgical treatment is recommended in cases like this one.

[Clinical evaluation of low cardiac output syndrome following adult open heart surgery]

Between April, 1984 and December, 1988, 450 adult patients underwent open heart surgery for the valvular heart disease (VHD) and ischemic heart disease (IHD) in our institution. As the postoperative complication, LOS was observed in 33 patients with VHD (14.2%), and in 27 patients with IHD (12.4%) with no significant difference between the two groups. Treatment for LOS employed in this series consisted of pharmacological therapy in 11 patients, IABP in 42, IABP+veno-arterial bypass (VAB) in 5, right heart bypass (RHB)+IABP in 1 and left ventricular assist device (LVAD)+IABP in 1. All patients who were treated by the pharmacological therapy were alive and were discharged. Eighty-one % of the patients who were assisted with IABP were able to weaned off IABP, and 57% of the patients were alive and were discharged. All patients who were assisted with IABP+VAB died of LOS within 3 days after the operation. One patients who was assisted with RHB+IABP for pulmonary hypertension after emergency re-MVR and the other patient with LVAD+IABP for LOS after emergency CABG were able to be weaned off the assisted circulation and were discharged from the hospital. The salvage rate of patients with IHD by mechanical assisted circulation was generally higher than that of patients with VHD. Because of the limitation of IABP or VAB effect on the hemodynamic, LVAD directly assisted cardiac function would be indicated for severe LOS following open heart surgery without delay.

Double exposure speckle technique for imaging system analysis and use in rod lens arrays

New double exposure speckle techniques for imaging system analysis are developed and their feasibility is experimentally examined. Using a single convex lens as the test lens, the MTF of the lens is obtained from the measured visibility of Young's fringes which have been produced by Fourier transforming a double exposure specklegram recorded through the test lens. By using conventional optical filtering techniques the spatial variations in the imaging quality are visualized for GRIN rod lens arrays.

Surgical treatment of aneurysms of the transverse aortic arch

Over the past four years, 21 patients have been operated for aneurysms of the thoracic aorta requiring aortic arch reconstruction. The causes of the aneurysms were dissecting aneurysms of the aorta (type A) in 16 patients and atherosclerosis in 5 patients. To prevent cerebral ischemia during operation, selective cerebral perfusion (SCP) (600 ml/min at 25 degrees C) was employed in 11 patients and hypothermic circulatory arrest (HCA) at 15 degrees C in 10 patients. There were three early deaths (14.3%) in the series. There were no serious neurologic complications in either group. The present data suggests that both selective cerebral perfusion SCP and HCA are useful methods for cerebral protection during resection of aortic arch aneurysms, although the latter method has the limitation of restricted cerebral arrest time.

[Comparative analysis of mechanical and biological prosthetic valves after isolated valve replacement--cooperative study on total 1281 patients]

A total of 1281 patients (594 aortic and 687 mitral) received 734 mechanical valves (320 Björk-Shiley, 283 SJM and 131 Omniscience) and 547 biological (259 ionescu-Shiley, 227 Hancock, and 61 Carpentier-Edwards) were analyzed for postoperative valve dysfunction and thromboembolism. The actuarial survival rates (free from late cardiac deaths and valve-related deaths) were 88.6% (11 years) for mechanical mitral and 86.0% (11 years) for biological mitral valves, and 91.7% (16 years) and 88.5% (12 years), for mechanical and biological aortic valves, respectively. There were no significant differences among these groups. Actuarial rates of freedom from valve-related events were 88.7% (11 years) and 51.7%, for mechanical and biological mitral valves, respectively. There was significant difference between the two types of valves in over 7 years after surgery. In contrast, there were no significant differences between mechanical and biological aortic valves. Actuarial rates of freedom from valve dysfunction were 97.6% (11 years) for mechanical and 56.5% (12 years) for biological mitral valves. The net 12 year results showed no significant differences between the two types of mitral prosthetic valves, but a significantly increased rate of valve dysfunction in the biological mitral valves compared with the mechanical in over 6 years of the study. Concerning AVR, there were no significant differences in the incidence of valve dysfunction between mechanical and biological aortic valves. Actuarial rates of freedom thromboembolism were 92.3% (11 years) and 93.8% (11 years) for mechanical and biological mitral valves, respectively. There were no significant differences between the two types of mitral prosthetic valves.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diltiazem blood cardioplegia in patients of severe valvular heart disease]

This study was undertaken to analyze the effect of diltiazem blood cardioplegia (D-BCP) in patients of valvular heart disease with severe left ventricular dysfunction (EF = 56.3%, FS = 26.0%, CI = 2.241/min/m3), they were satisfied with NYHA functional class 3 and 4, also cardiothoracic ratio over 65%. By negative choronotropic action of D, the heart rates in D added group tend to be less than those of D free group 4 to 16 hours postoperatively, although that may diminish the incidence of ventricular arrhythmia postoperatively. D-BCP improved better functional recovery (mPAWP-LVSWI relation) during the early postoperative period than those seen in preoperatively. The pulmonary vascular resistance index of D added group showed significantly lower levels than those in the preoperative period, 0 to 16 hours after surgery. Consequently, D-BCP might be safe and provide superior protection for severe valvular heart disease.

[Clinical study on surgical treatment of aortic arch aneurysm using selective cerebral perfusion or hypothermic circulatory arrest]

To improve the surgical results of aneurysms of the transverse aortic arch, it is essential to select the optimal support technique to protect the cerebral ischemia during the aortic arch occlusion. In the four year period between 1983 and 1987, 21 consecutive patients had surgical correction of aneurysms of the transverse aortic arch at our institution. The causes of aneurysms were dissection (type A) in 16 patients and arteriosclerosis in 5 patients. Seven patients had emergency operation for frank or impending rupture. Two method for cerebral protection were employed during the period of arch exclusion. In Group I, 11 patients underwent selective cerebral perfusion both to innominate and left common carotid arteries via one roller pump at a rate of 600 ml/min (25 degrees C). The average cerebral perfusion time was 70.4 +/- 20.5 minutes. In Group II, 10 patients underwent deep hypothermia (15 degrees C to 20 degrees C) and total circulatory arrest to allow repair of the transverse aortic arch. The concomitant AVR was performed in two patients and CABG in one patient. The average cerebral arrest time was 35.2 +/- 3.4 minutes. Two out of 10 patients had additional cerebral perfusion because cerebral ischemic time exceeded over 45 minutes. There were three early deaths (14.3%) in this series. The causes of early death were bleeding in two patients and renal failure in one patient. There were no cerebral complications in both groups. The duration of extracorporeal bypass necessary for cooling and rewarming phase in Group II was longer than that in Group I.(ABSTRACT TRUNCATED AT 250 WORDS)

[The effects of aorto-coronary bypass grafting on left ventricular diastolic function in patients with left ventricular dysfunction]

To determine the effects of aorto-coronary bypass grafting on left ventricular diastolic function in patients with low ejection fraction (EF less than or equal to 0.40), 17 patients were studied. They were divided into two groups, Group I: 8 patients without previous myocardial infarction, Group II: 9 patients with previous myocardial infarction. Left ventricular diastolic function was assessed by maximum negative dp/dt, constant T, diastolic compliance and 1/3 functional filling. In conclusions, when ejection fraction is depressed (EF less than or equal to 0.40), myocardial revascularization improves left ventricular diastolic function in patients without previous myocardial infarction, but not with previous myocardial infarction.

High-performance liquid chromatographic determination of 6-amidino-2-naphthyl [4-(4,5-dihydro-1H-imidazol-2-yl) amino]benzoate dimethanesulphonate and its metabolites in biological fluids

6-Amidino-2-naphthyl [4-(4,5-dihydro-1H-imidazol-2-yl) amino]benzoate dimethanesulphonate has been developed for the therapy of pancreatitis. A reversed-phase high-performance liquid chromatographic assay of the levels of this drug and its metabolites in biological fluids was investigated. Fluorescence detection with post-column alkaline degradation was used for the determination of the intact drug and the amidinonaphthol moiety metabolite, and ultraviolet detection at 254 nm was used to determine the levels of the benzoic acid moiety metabolite. Satisfactory recoveries and variabilities of the intact drug and its metabolites from biological fluids were obtained. The detection limits for the intact drug and amidinonaphthol were 0.5 ng/ml at a signal-to-noise ratio of 12 in plasma and 10 ng/ml at a signal-to-noise ratio of 32 in urine and homogenized faeces, and those of benzoic acid were 5 ng/ml at a signal-to-noise ratio of 3 in plasma and 50 ng/ml at a signal-to-noise ratio of 7 in urine and homogenized faeces.

Modified Fontan operation for complex cardiac anomalies--postoperative hemodynamics, cardiac function and clinical status

The purpose of this paper is to compare and define the postoperative hemodynamics, cardiac function and clinical status after the modified Fontan operation in patients with complex cardiac anomalies. Thirteen consecutive patients (6 with double-outlet right ventricle [DORV] [SLL : 4, SDL : 2], 5 with single ventricle [SV] [A-III : 3, B-III : 1, C-III : 1] and 2 with tricuspid atresia [TA] [Ib : 1, IIb : 1]) underwent the modified Fontan operation. These 13 patients ranging in age from 7 to 42 years of age (mean 18) were catheterized at 7 to 46 months (mean 8 months) postoperatively. Pressure tracings at rest demonstrated a dominant "a" wave in both the right atrium and the pulmonary artery suggesting a marked right atrial contraction after this operation. Left ventricular filling pressure was significantly decreased after the modified Fontan operation in DORV and SV. The ejection fraction and left ventricular end-diastolic volume index were unchanged or slightly increased after the modified Fontan operation. Cardiac index in 6 patients with DORV was significantly increased from rest to exercise by +48% (p less than 0.05) with a significant increase in the stroke volume (p less than 0.05) and with a slight increase in heart rate, but this index in 5 patients with SV and in 2 patients with TA was not significantly increased from rest to exercise. In the postoperative clinical status, 11 of 13 patients were in NYHA class I and 2 in class II at follow-up periods ranging from 4 to 75 months (mean 48 months). These results suggest that the modified Fontan operation can be of value and can provide excellent exercise tolerance for patients with complex cardiac lesions.

Surgical repair and long-term results in ruptured sinus of Valsalva aneurysm

Thirty-one patients with a ruptured sinus of Valsalva aneurysm (SVA) were operated on between January, 1961, and December, 1987. Twenty-five patients (81%) were in New York Heart Association (NYHA) Functional Class III or IV. Coexistent cardiac anomalies included a ventricular septal defect (VSD) in 16 patients (52%) and aortic valve regurgitation in 12 patients (39%). The ruptured SVA originated from the right coronary sinus in 29 patients (94%) and the noncoronary sinus in 2 patients (6%), and drained into the right ventricle in 30 patients (97%). In 6 patients treated recently, we used patches to repair the ruptured SVA and VSD through a double approach, thereby avoiding a ventriculotomy. This method resulted in no recurrent rupture or residual VSD postoperatively. There was one operative death (3%) and 4 late deaths (13%). Of the 26 surviving patients, 22 (85%) were in NYHA Class I at follow-up ranging from 6 months to 26.7 years (mean, 11.1 years). Actuarial survival at 25 years is 85.6 +/- 7.4% (mean +/- standard deviation). Repair of ruptured SVA with a patch through a double approach provides an excellent operative procedure and offers a long-term outcome.

Aneurysm of the celiac artery

A 50-year-old male with asymptomatic aneurysm of the celiac artery is described and the diagnosis and surgical treatment as well as problems and considerations involved in surgical management are discussed in conjunction with a review of the literature.