Reoperative surgery in calves with a total artificial heart

Two surgical techniques have been developed in our laboratory to deal with identifiable problems in long-term artificial heart experiments. A right thoracotomy is used to deal with problems such as extensive bleeding, which occur in the immediate postoperative stage of the experiment, while a left thoracotomy is used in cases in Which the original implantation is preceded by more than one week, since extensive adhesions complicate the right thoracotomy at that stage. Pulmonary problems have been eliminated as a primary cause of difficulties after reoperation, but infection remains a serious problem.

The Appearance of Cytokines and Adhesion Molecules in Saphenous Vein Valves in Chronic Venous Insufficiency

Objective:

To evaluate the difference between competent valves and incompetent valves with regards to the development of expression of cytokines and adhesion molecules in primary varicose veins.

Methods:

Specimens were obtained from 13 patients with primary varicose veins during surgery. Valves were classified according to the angioscopic findings: 8 competent and 17 incompetent valves; type I (7 valves with elongated cusps) and type II (10 valves with expansion of commissures). The mRNA levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), tumour necrosis factor-α (TNF-α), transforming growth factor-β (TGF-β), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and endothelial leucocyte adhesion molecule-1 (ELAM-1) were measured by polymerase chain reaction (PCR) amplification of cDNA reverse-transcribed from RNAs.

Results:

In all cases there were few appearances of IL-6, IL-8 and TNF-α at the valve cusps. TGF-β and VCAM-1 levels were highly elevated in the cusps of incompetent valves compared with competent valves ( p<0.05). At the venous wall IL-6 and IL-8 occurred more frequently in incompetent valves than in competent valves ( p<0.05).

Conclusion:

This study suggests that inflammatory cytokines and adhesions molecules, especially TGF-β, IL-6, IL-8 and VCAM-1, may be related to the occurrence of valve insufficiency.

[Coronary sinus atrial septal defect diagnosed by cyanosis after operation of ventricular septal defect]

We have experienced a case of coronary sinus atrial septal defect (ASD) with ventricular septal defect (VSD). Cardiac catheterization revealed a step-up of oxygen saturation in right ventricle, L-R shunt 70.3%, R-L shunt 6.9% and pulmonary hypertension (PH). Since diagnosis of coronary sinus ASD was difficult, the operation was performed under diagnosis of VSD. Although the operation was success, cyanosis appeared after the operation. Contrast echocardiography using subcostal 4 chamber view showed coronary sinus ASD with a large Thebesian valve and the right-to-left shunt of the ASD. The Thebesian valve seemed to lead the venous return flow to the left atrium. Coronary sinus ASD was closed using a Xenomedica patch.

[Eleven cases of surgery for Marfan syndrome]

The surgical outcomes in 11 patients with a Marfan syndrome (mean [+/- SD] age, 32 +/- 16: range 0.5 to 60) were evaluated. Echocardiography demonstrated annuloaortic ectasia (AAE) in nine patients, mitral regurgitation (5 months baby: valve replaced) and abdominal aortic aneurysm in one each. Among 9 AAE, root were replaced in 8 patients and aortic valve was preserved only one patient. Our early-time result is encouraging in our valve-sparing operation.

Results of 256 consecutive abdominal aortic aneurysm repairs using extraperitoneal approach

Two hundred and fifty-six consecutive abdominal aortic aneurysms were repaired using three approaches for extraperitoneal exposure of the aorta and iliac vessels from February 1990 through September 1998. The perioperative mortality rate was 3.1% in 228 elective repairs and 14.3% in 28 ruptured cases. The initial 23 cases were repaired using Sicard's method. The duration of endotracheal intubation was 1.0+/-2.8 h, alimentation initiation was 2.7+/-1.6 days, and narcotic requirements were 1.2+/-1.1 times. Following these initial cases, we employed Williams' method for 192 abdominal aneurysms, however; repeated incisional pain and three cases of deforming bulge led us to avoid dividing muscles. In the last 13 cases, our approach was performed without muscle dividing. The narcotic requirements decreased to 0.3+/-0.7 times. As for postoperative complications, the larger skin incision approach had no shower embolism. However, the shorter skin incision had four cases of shower embolisms, one lymphorrhea and one vascular trauma by the aortic clamp. The extraperitoneal approach offers certain physiologic advantages with minimal disturbance of gastrointestinal and respiratory function. We believe that this method is useful for rapid approach to the proximal aorta in case of emergency. Postoperative wound complications could be prevented via an oblique incision without muscle dividing.

Bland white Garland syndrome with type A aortic dissection

We report the case of a 72-year-old patient with a left main coronary artery originating from the pulmonary trunk with type A aortic dissection. He is the oldest patient among those reported in the literature, operated due to acute type A aortic dissection and has survived 4 year after the operation without surgery on the coronary artery.

[A case of tracheo-bronchial stenosis after extended end-to-end aortic arch anastomosis for interrupted aortic arch treated with suspension of the ascending artery and pulmonary artery]

A 9-day-old boy had pulmonary artery banding and extended end-to-end aortic arch anastomosis for ventricular septal defect (VSD) and type A interrupted aortic arch. Severe dyspnea gradually developed. At 3 months of age, intracardiac repair of VSD was performed. Weaning from the ventilator was difficult. Endoscopic examination and chest CT revealed stenosis of the right and left main bronchi and compression of tracheal bifurcation and the right and left main bronchi by the ascending aorta and pulmonary artery. Suspension of the ascending aorta and pulmonary artery was performed 15 days after VSD closure. Nine days after this procedure, the patient was weaned from respirator. Postoperative course was uneventful. Bronchial stenosis may be caused from extended end-to-end aortic arch anastomosis.

Prevention of paraplegia in transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms

OBJECTIVE

To evaluate the efficacy of a temporary balloon occlusion test for the prevention of paraplegia following transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms.

SUBJECTS AND METHODS

Two occlusion balloons were inserted via the brachial and femoral arteries and positioned in the proximal and distal neck of the descending thoracic aortic aneurysms using fluoroscopy. After temporary occlusion of the thoracic aorta by inflation of both the proximal and distal balloons, the evoked spinal potential was measured for 15 mins. A maximum amplitude during temporary balloon occlusion test decreasing by more than 20% of the pre-balloon occlusion level was considered to be significant, enough to not perform transluminally placed endoluminal prosthetic grafts, but instead an open repair. The test was applied in 12 cases (9 males and 3 females, 50-86 years old). All aneurysms were located between the Th6 and Th12 with a maximum diameter of 40-70 mm, and average of 56 mm.

RESULTS

The changes in maximum amplitude of evoked spinal potential remained within 20% of the value before balloon occlusion in 11 cases. Transluminally placed endoluminal prosthetic grafts were performed in these 11 cases and no instance of paraplegia or other complication relating to the test was observed. Deployment of stent-grafts was successful in 10 cases (91%).

CONCLUSION

It is suggested that the preoperative measurement of evoked spinal potential during temporary balloon occlusion is clinically useful for the assessment of the risk to paraplegia occurring in transluminally placed endoluminal prosthetic grafts.

[Effect of low dose aprotinin on reduction of blood loss after extracorpreal circulation]

Aprotinin administration during open heart surgery has been reported to reduce blood loss after extracorporeal circulation (ECC). We administered aprotinin to 12 patients undergoing CABG or prosthetic valve replacement. We examined the blood loss, the coagulation, and the fibrinolytic system in comparison with that in non-aprotinin group of 12 patients. In the aprotinin group, 1,000,000 units of aprotinin was infused intravenously before initiation of ECC and mixed with priming volume of ECC. After ECC, 250,000 units/hr was continuously infused until 1 hour after operation. The aprotinin group showed a significantly enhanced level of alpha 2 plasmin inhibitor and a significantly reduced level of plasmin-alpha 2 plasmin inhibitor complex and D-dimer. Post operative blood loss was not different between two groups. Operation time and closure time after heparinneutralization was shorter and postoperative blood use was lower in the aprotinin group. In conclusion, The administration of low dosed of aprotinin suppresses the fibrinolytic system resulting in the reduction of operation and closure time.

Intravascular Imaging Methods for Venous Disorders

The purposes are to assess the problems associated with intravascular imaging methods such as angioscopy and intravascular ultrasound (IVUS) and to evaluate their efficacy through the results of our observations. A total of 54 limbs in 53 patients, 50 patients with chronic venous insufficiency and 3 patients with deep vein thrombosis, were diagnosed and operated on using angioscopy (Olympus OES, order made type) and IVUS (Endosonics, model 82700). The imaging catheters were inserted through a branch of the long saphenous vein and the valves and the intraluminal views were observed. By angioscopy, intraluminal views were clearly observed in 98% of all lesions. However, observation became more difficult in iliac veins compared to in femoral and in long saphenous veins (p < 0.01). Venous wall and thrombus were detected more by IVUS than by angioscopy (p < 0.01), but only 21 valves (24%) were visualized by IVUS among the 88 valves observed by angioscopy. The intravascular imaging method of angioscopy is more suitable for observing valves and intraluminal views compared with IVUS, whereas IVUS is more suitable for observing the cross-sectional venous wall.

Graft-wall endoleak 18 months after successful endoluminal AAA repair

PURPOSE

To describe a case of graft-wall endoleak 18 months after successful endoluminal repair of an abdominal aortic aneurysm (AAA).

METHODS AND RESULTS

A 71-year-old man with infrarenal AAA was successfully treated with an endoluminal aortomonoiliac graft and femorofemoral crossover bypass with surgical ligation of the right external iliac artery. The stent-graft was made from 2 Gianturco Z-stents and a tapered thin-walled (0.1-mm) Dacron graft. Eighteen months after endografting, the patient complained of a pulsatile abdominal mass. Angiography and computed tomography showed graft-wall endoleak. Aneurysmectomy was performed, and the aneurysm was successfully replaced with a Y-shaped knitted Dacron graft. A hole in the graft wall was found 3 cm from the proximal edge of the stent-graft.

CONCLUSIONS

This case suggests that the use of thin-walled graft material in endografts may not be sufficiently durable.

Cerebral blood flow and oxygen metabolism during cardiopulmonary bypass with moderate hypothermic selective cerebral perfusion

Cerebral blood flow was measured using transcranial doppler during cardiopulmonary bypass in nine patients with selective cerebral perfusion for surgery of arch aorta (group S). For comparison, 11 adult open heart patients (group C) were also measured. The authors' selective cerebral perfusion at 28 degrees C resulted in moderate hypothermia and antegrade perfusion using independent pumps for three branches. Total flow in the three branches was 500 ml/min. A Labodop DP-100 doppler ultrasound velocimeter was used to measure middle cerebral arterial blood flow velocity. Hemoglobin concentration and oxygen saturation were also measured in arterial and jugular venous blood. The arteriovenous oxygen content difference (Ca-vO2) was calculated and multiplied by the middle cerebral arterial blood flow velocity value, which resulted in the cerebral metabolic rate for oxygen (CMRO2). The cerebral perfusion pressure of group S was lower than in group C, and the arterial carbon-dioxide tension (PaCO2) of group S was higher than in group C during cardiopulmonary bypass. Middle cerebral arterial blood flow velocity values of both groups remained constant before, during and after cardiopulmonary bypass. The CMRO2 decreased during cardiopulmonary bypass and showed no difference between the two groups. The changes in PaCO2 might be significant factors in the increase in cerebral blood flow during selective cerebral perfusion. This study supports the conclusion that, compared with our routine open heart surgery procedures, our selective cerebral perfusion procedures had the same cerebral blood flow and oxygen metabolism during cardiopulmonary bypass.

[Partial median sternotomy for pediatric cardiac surgery]

In order to minimize scarring and thereby improve the postoperative cosmetic appearance of pediatric cardiac surgery patients, we perform partial median sternotomy incisions. A short midline skin incision, from 1 to 2 cm below the articular notch of the second rib to the xiphoid process, is made. The sternum was divided from the xiphoid process to the articular notch of the second rib. The thymus is mobilized and the pericardium incised longitudinally. The aorta and superior and inferior vena cava are mobilized to facilitate direct cannulation. Cardiopulmonary bypass is instituted in the usual fashion. Twenty-four pediatric patients underwent repair of cardiac anomalies through a partial median sternotomy incision at our institution between June 1997 and September 1998. The average age of the patients was 4 years and 4 months (range, 4 days to 12 years) and the average weight was 16.0 kg (range, 3.2 to 40.5 kg). Cases included 13 VSD (ventricular septal defect) [including one DCRV (double chambered right ventricle) and one PS (pulmonary stenosis)], 9 ASD (atrial septal defect), one ECD (endocardial cushion defect), and one DORV (double outlet right ventricle) with mitral atresia. All patients were extubated within 3 hours after surgery and the average length of the ICU stay was within 24 hours (except for one 4-day-old baby who died of LOS (low cardiac output syndrome) on the 16th postoperative day). There were no wound infections or hospital mortalities. In our experience, this approach is safe, provides good exposure, and provides excellent cosmetic results.

[Partial median sternotomy for pediatric cardiac surgery]

In order to minimize scar appearance and thereby improve postoperative cosmetic appearance for pediatric cardiac surgery patients, we performed partial median sternotomy incisions. A short midline incision, from 1 to 2 cm below the articular notch of the 2nd rib to the xiphoid process, was made. The sternum was divided from the xiphoid process to the articular notch of the 2nd rib. The thymus was mobilized and the pericardium incised longitudinally. The aorta and superior and inferior vena cava were mobilized to facilitate direct cannulations. Cardiopulmonary bypass was instituted in the usual fashion. From June to December 1997, 14 patients between the ages of 4 days and 12 years have undergone cardiac repair using this technique. Cases included 7 VSD (including 4 pulmonary hypertension and 1 DCRV), 5 ASD, 1 ECD and and 1 DORV with mitral atresia. All patients were extubated within 3 hours after surgery, and there were no wound infections or hospital mortalities (except one 4 day old baby who died by LOS on the 16th postoperative day). In our experience, this approach is safe and provides good exposure with excellent cosmetic results.

Evaluation of hemolysis in a pulsatile assist device for centrifugal pump

To evaluate the blood trauma caused by a new device for producing a pulsatile flow of the centrifugal pump, the pulsatile assist device for the centrifugal pump (PAD-CP) that we have developed, a hemolysis study was performed in vitro and in animal experimentation. For the in vitro testing, 2 identical sets of hemolysis test circuits were prepared with 2,400 ml of bovine blood. The 2 circuits were pumped simultaneously. Plasma total hemoglobin levels were less than 40 mg/dl after 3 h, under a pump flow of 2 L/min. Hemolysis increased to a severe level after 4 h of 4 L/min pump flow. The cause of this hemolysis was thought to be a vibration of the circuit because of incomplete compression of the polyurethane tube in the PAD-CP. Five adult sheep (average body weight, 47 kg) were used for in vivo evaluation of hemolysis. Hemolysis was less than 30 mg/dl of plasma hemoglobin after 4 h of open chest extracorporeal circulation with 3.0-3.6 L/min of flow rate using the PAD-CP. Other hematologic changes after PAD-CP driving were within normal limits. We conclude that the PAD-CP has proven to have possible clinical applications.

[A case of congenital tricuspid regurgitation associated with atrial septal defect and peripheral pulmonary stenosis]

This report describes a 5-year-old girl with congenital tricuspid regurgitation associated with an atrial septal defect and peripheral pulmonary stenosis. The girl was diagnosed with the heart murmur at birth and recently developed the cardiomegaly. Cardiac echocardiography and catheterization showed severe tricuspid regurgitation, an atrial septal defect of the secundum type and peripheral pulmonary stenosis. In the operative findings, the tricuspid annulus was dilated to 33 mm in diameter, and leaflets were attached normally to the antomic annulus. There was a large cleft of the anterior leaflet of the tricuspid valve. Suture of the cleft and annuloplasty of the tricuspid valve, suture closure of the atrial septal defect and patch dilatation of peripheral pulmonary stenosis were successfully performed. Including this case, 19 other cases with congenital tricuspid regurgitation undergoing surgery were reported to date.

[A case of malignant lung fibrous histiocytoma]

Malignant fibrous histiocytoma (MFH) is the most common soft tissue sarcoma in adults. However primary MFH of the lung is very rare and only a few cases have been reported in the literature. A 79-year-old man complained of coughing and was treated at our hospital. The chest X-ray and CT scan showed a mass shadow in left lung. He underwent partial resection of the left upper lobe (S 5). No other abnormal lesions were detected in the abdomen or extremities, and the tumor was diagnosed as malignant fibrous histiocytoma (MFH) of the lung. He has been well for 18 months since the operation.

[A case of left ventricular myxoma]

Left ventricular myxoma is very rare, and only 37 cases have been reported at present time. We here report a case of surgical extirpation of a left ventricular myxoma arising from the septal wall of the left ventricule. A 74-year-old woman was examined by transesophageal echocardiography because of palpitation. It revealed a small mass in the left ventricular cavity. This mass was then diagnosed and confirmed as a myxoma by echocardiogram, CT and MRI. MRI imaging showed the intensity of the myxoma to be higher than that of the myocardium. The myxoma was removed by transaortic approach using extracorponeal circulation. The grayly gelatinous mass was 11 x 12 x 12 mm and weighed 0.6 g. It was diagnosed as a myxoma pathohistologically. The patient recovered uneventfully and was discharged four weeks after the operation.

[Total cavopulmonary connection using a knitted dacron prosthesis impregnated with gelatin (GELSEAL) as an intracardiac conduit]

It is important to find a suitable vascular prosthesis as an intracardiac conduit for a total cavopulmonary connection because of the need for long-term patency. A 7-year-old girl with a double outlet of right ventricle, hypoplastic left ventricle, pulmonary atresia and single atrium with azygos connection underwent a total cavopulmonary connection using a knitted dacron prosthesis impregnated with gelatin (GELSEAL) as an intracardiac conduit. Her postoperative course was uneventful. GELSEAL is soft, easy to hand and effective at preventing blood loss. The conduit is also expected to have long-term patency because of good healing with thin and uniform pseudointimal formation. However, long-term patency especially in the right side of the heart is still unknown. She should be followed with close anticoagulant therapy and careful observation.

[A case of ruptured thoracoabdominal aortic aneurysm complicated with high aortic occlusion]

We report a rare case of 76-year-old man who developed ruptured thoracoabdominal aortic aneurysm complicated with abdominal high aortic occlusion. His left limb was amputated due to Buerger's disease. CT showed that the aneurysm extended from the descending thoracic aorta to the upper part of the abdominal aorta and its had a maximum width of 68 x 83 mm. Angiogram revealed the aortic occlusion at the level of the left renal pelvis. We performed emergency operation, which was aneurysmectomy and replacement with artificial vascular graft, under femoro-femoral and subrenal aortic extracorporeal bypass. Because of the severe calcification at the subrenal aorta and the weak pulsation of the left renal artery, the bypass was placed from the aortic graft to the right lower limb and the left renal artery was reconstructed. Abdominal aortic occlusion might increase his hypertension and might cause aneurysmal change on the proximal aortic wall.

Postoperative alteration in the size of Dacron vascular prostheses implanted in the infrarenal abdominal aorta

The degree and significance of postoperative alteration in the size of Dacron grafts in the infrarenal abdominal aorta was assessed by computed tomography. We studied a total of 41 knitted Dacron fabric grafts, comprising 28 Gelseal triaxial grafts and 13 Hemashield Microvel grafts, and 29 woven Dacron fabric (Veri-Soft Woven) grafts which were used to replace the infrarenal abdominal aneurysms. These three types of Dacron fabric dilated immediately after replacement to 1.4-1.5 times the manufactured size, but did not dilate further after the surgery.

In vitro evaluation of a pulsatile assist device for a centrifugal pump using a new principle

To induce a pulsatile flow in a centrifugal pump, we developed a new device (pulsatile assist device for centrifugal pump: PADCP) using a new concept. This device consists of a flexible polyurethane tube with an air chamber which is connected to the arterial side of the centrifugal pump circuit directly. A mock circulation system was used for evaluation of this PADCP. Thirty to 40 mm Hg of pulse pressure was obtained under 3-6 L/min of flow rate. By increasing the driving pressure of the PADCP from 200 to 600 mm Hg in a mock system, 4-48 mm Hg of pulse pressure was gained accompanied by a decrease in pump flow and increased left atrial pressure. The decreased pump flow and increased left atrial pressure were recovered easily by increasing the flow rate of the centrifugal pump. Pressures at the proximal site of the PADCP were less than 500 mm Hg. The PADCP was useful to induce a pulsatile flow in a centrifugal pump.

[A case of adult Wilms' tumor with vena caval involvement]

The patient was a 35-year-old female with the chief complaint of macrohematuria. Computerized tomographic (CT) scan, ultrasonography and magnetic resonance imaging (MRI) revealed the presence of a large and inhomogeneous mass in the left kidney, and a tumor thrombus growing in the inferior vena cava. Angiography also showed a hypervascular tumor in the left kidney. The chest X-ray and CT scan demonstrated multiple metastatic lesions in the bilateral lungs. Radical nephrectomy and thrombectomy was performed under the diagnosis of left renal tumor with its invasion of inferior vena cava. Pathological findings revealed that this tumor was nephroblastoma, and its type was clear cell sarcoma of the kidney (CCSK). The patient received chemotherapy according to National Wilms' Tumor Study (NWTS) IV chemotherapeutic drug regimen. In general, CCSK is known to have poor prognosis. However, doxorubicin has been reported to have a relatively good antitumor effect for CCSK. However, in this case, the evaluation after the first course of chemotherapy was progressive disease, because some new lesions appeared, although most old pulmonary metastatic lesions were reduced.

[A case of left ventricular outflow tract obstruction after repair of ostium primum defect]

We report a 3-year-old girl with left ventricular outflow tract obstruction after repair of ostium primum defect. The girl had closure of an ostium primum defect performed at the age of 1 year. Two years later, she developed left ventricular hypertrophy with systolic ejection murmur. Echocardiography showed discrete stenosis of the left ventricular outflow tract. Cardiac catheterization showed a peak systolic gradient of 63 mmHg across the left ventricular outflow tract. At the reoperation, the fibrous tissue was excised and myectomy was done. After the operation the peak systolic gradient across the left ventricular outflow tract disappeared. Since there is a possibility of occurrence of the left ventricular outflow tract obstruction after repair of atrioventricular septal defect, long term follow up is mandatory.

[A case of left atrial myxoma with ventricular septal defect and patent foramen ovale]

A 51-year-old female was referred to our institute because of chest oppressive feeling. Echocardiography and magnetic resonance imaging revealed a left atrial tumor with ventricular septal defect. At operation patent foramen ovale was recognized. After excision of the tumor including intraatrial septum, which defect was repaired using a Teflon patch, and the ventricular septal defect was closed directly.

[External valvuloplasty under preoperative angioscopic control]

Intraoperative angioscopy was applied to evaluate the venous valvular incompetence and perform external valvuloplasty in case of venous reflux. Sixty-seven limbs, 43 cases of primary varicose veins were examined using intraoperative angioscopy and the angioscopic findings of the incompetent venous valves were classified into three types as follows: valves with elongated and atrophic cusps 43 (50%)--type I, values with expanded and depressed commissures 36 (42%)--type II, and valves with perforated cusps or other changes 7 (8%)--type III, according to the angioscopie findings, external valvuloplasty was done in 31 subterminal valves of the long saphenous veins and 7 highest valves of the superficial femoral vein. Our external valvuloplasty consisted of two techniques. The first was the total plication technique for valvular annulus by a running suture of prolene and the second was by the venocuff sleeve of the autogenetic femorofascial band. The degree of plication was decided by angioscopic observation. Postoperative observation periods were from 2 to 28 months. There was no recurrence of varicose veins or prominent venous reflux. The application of intraoperative angioscopy is therefore useful for the choosing appropriate surgical procedures and for the evaluation of venous valvuloplasty.

[Left main coronary artery stenosis following aortic valve replacement using a solid coronary perfusion catheter: report of two cases]

We experienced two cases of iatrogenic left main coronary artery stenosis (IOCS) following double (aortic and mitral) valve replacement (DVR). The solid coronary perfusion catheter may attribute IOCS, with grave consequence. There have been no IOCS since the time we exchanged a solid catheter for a soft one. One case, she was successfully treated percutaneous transluminal coronary angioplasty (PTCA), because she developed angina pectoris about 5 years after PTCA. But she developed angina pectoris again and angiographically left main coronary was severe stenotic. So she was undergone aorto coronary bypass grafting (CABG) to the left anterior descending. The other case, he developed angina pectoris about 3 months after DVR. He was treated with PTCA. Angiographically left mine coronary artery stenosis reduced 50% from 90%. Generally the treatment of IOCS is CABG, but we performed PTCA for 2 patients. Because we thought it was very hazardous for us to perform them open heart surgery. When it is very hazardous to perform patients open heart surgery, they need to be performed PTCA.

[A successful removal of the left ventricular lipoma]

We reported a rare case of left ventricular lipoma, which arose nearby the papillary muscle in the left ventricular wall. It was disclosed by echocardiography and nearly diagnosed by computed tomography and magnetic resonance images. We successfully removed the tumor. It measured 3.8 x 1.5 x 1.3 cm and 3.6 g. Microscopically, it was not encapsulated and consisted of mature adipose tissue. But, it did not invaded the cardiac muscles. In conclusion, the tumor detected lipoma. Postoperative course is uneventful, and the patient has been followed by serial echocardiography.

[Two cases of atrial septal defect with absence of right superior vena cava and persistent left superior vena cava]

Two women (16-year-old, 54-year-old) of atrial septal defect with absence of right superior vena cava and persistent left superior vena cava were successfully operated on. Electrocardiographic findings show coronary sinus rhythm and atrial fibrillation. When we closed atrial septal defect cannulated to persistent left superior vena cava via the coronary sinus directly, sick sinus syndrome was not appeared postoperatively.

[A case of straddling tricuspid valve associated with VSD]

A case of straddling tricuspid valve associated with VSD was presented, who was diagnosed as VSD with pulmonary hypertension but not diagnosed as straddling in preoperative state. Two-dimensional echocardiography did not demonstrate a small right ventricle and overriding of tricuspid valve to the ventricular septum. Operative findings were as follows; the VSD was common A-V canal type and anomalous chordae of septal leaflet of tricuspid valve crossed through the VSD and attached to the contralateral side of the ventricular septum. We tried to preserve the anomalous chordae to prevent tricuspid regurgitation, so that we carried out patch closure of VSD. To avoid injury conduction system stitches were placed from upper margin of the VSD, and to keep away tricuspid regurgitation we plicated a depression of septal leaflet which caused by anomalous chordae in VSD patch closure. In postoperative state, A-V block did not arise and tricuspid regurgitation was shown a little as well as preoperative state.

[Two cases of congenital cardiac anomaly associated with esophageal atresia]

Two cases of congenital cardiac anomaly associated with esophageal atresia and tracheo-esophageal fistula were presented. One case was HLHS, and the other was TAPVR. Esophageal procedures were performed earlier than cardiac procedures in both cases. Primary anastomosis for esophageal atresia just after birth in the latter case. Corrective procedures for cardiac anomalies were performed at 36 days and 35 days after birth, respectively. The HLHS case died perioperatively and the TAPVR case survived the operation and is alive one year postoperatively.

[Two operated cases of mitral stenosis (MS) associated with left atrial ball thrombus]

Mitral stenosis associated with left atrial ball thrombus is rare. Removal of left atrial ball thrombus and mitral valve replacement was performed in two patients successfully. The rate of thromboembolism was high in patient who has left atrial ball thrombus. Also, sudden death was reported in these cases due to incarceration of ball thrombus in the mitral orifice (hole-in-one thrombus). We concluded that we should operate the MS associated with left atrial ball thrombus as soon as possible.

[A case of ruptured aneurysm of Valsalva sinus into right atrium with peculiar findings on aortography]

A 24-year-old man with ruptured aneurysm of sinus of Valsalva into the right atrium originating from the noncoronary sinus is presented. On aortography through the ascending aorta the right atrium in systolic phase and the right ventricle in diastolic phase were opacified. We considered ruptured aneurysm like a streamer (wind sock) entered into the right ventricle in diastolic phase and into the right atrium in systolic phase. Post-aneurysmectomy course was uneventful, and radiographic examination revealed complete repair of the aneurysm.

[A case report of perforated aneurysm of mitral valve with aortic regurgitation]

The patient was a 71-year-old male who complained of palpitation and tachycardia. The echocardiogram showed a bulging of the anterior mitral valve leaflet toward the left atrium that persisted throughout cardiac cycle. The cine angiogram showed deformity of the anterior mitral valve leaflet with severe mitral regurgitation and mild aortic regurgitation. At operation, a perforated aneurysm was recognized at the anterior mitral valve leaflet without thrombus and vegetation. The size of aneurysm was 40 x 25 x 25 mm. The patient underwent MVR + AVR, and the postoperative course was uneventful. Pathological examination of the anterior mitral valve leaflet revealed scar-like fibrosis and old inflammatory change. It was judged a true aneurysm of mitral valve, because the structure of endocardium was kept.

[Recurrent surgery for pulmonary venous obstruction after total correction of TAPVC (IIb)]

A 15-months-old boy underwent the intra-cardiac repair with a glutaraldehyde-preserved equine pericardium for total anomalous pulmonary venous connection (Darling's type IIb). Because of rapidly progressive dyspnea, tachycardia and respiratory acidosis, he required emergent reoperation at 234 postoperative days. The pseudointima was thickened heavily and detached from glutaraldehyde-preserved equine pericardium. New channel was created with a piece of EPTFE sheet to prevent obstruction of pulmonary venous flow. However, about four months after second surgery, cough and tachycardia progressed again remarkably. Intra-atrial channel was obstructed between EPTFE sheet and the partition from pulmonary venous orifice to the atrial septal defect in the third operation. The intra-atrial channel was enlarged by cut-back method using EPTFE sheet again. His postoperative hemodynamics were satisfactory

[Senile alteration of hemodynamics in surgery of abdominal aneurysm]

Hemodynamic measurements were performed before, during and after surgery of aneurysmal patients. Fifty non-ruptured infrarenal aneurysmal patients undergoing elective aortic reconstructions were studied. Patients who had no evidence of heart disease were divided into two groups by age. The older group consisted of 22 patients older than 70 years of age, and the younger group consisted of 28 patients younger than 70 years. The results may be summarized as follows: (1) Hemodynamics before surgery (volume loaded test): For 500 ml albumin infusion within 30 minutes, cardiac indices of the older group kept below 4.0 l/min/m2, whereas in the younger group there was an increase from 3.66 to 4.42 l/min/m2. (2) Hemodynamics during surgery: Peripheral resistance increased by cross-clamping of the aorta, and decreased after removal of the aorta, and decreased after removal of the cross clamp in both groups. Cardiac indices dropped during cross-clamping of the aorta. The older group dropped more noticeably compared with the younger group, for instance, at one minute after cross-clamping, the older group was 2.04 +/- 0.56, and the younger group was 2.44 +/- 0.56 l/min/m2. Mean pulmonary wedge pressure increased gradually during surgery in both groups. (3) Hemodynamics after surgery: The older group kept lower cardiac indices compared with the younger group, but not so noticeably. These results indicated that older patients have low cardiac function for preload and afterload change. We will be confronted by an increasing number of older patients in the near future. Hemodynamic managements of aortic reconstructions in the elderly might become important.

A case of right atrial thrombosis associated with isolated right ventricular hypoplasia

A rare case of right atrial thrombosis was observed in a 49-year-old woman. She had cyanotic ostium secundum atrial septal defect without pulmonary hypertension. By postoperative cardiac catheterization, she was diagnosed as having isolated right ventricular hypoplasia.

[A case of foreign body granuloma after aortic valve replacement]

A patient who developed a foreign body granuloma three years after aortic valve replacement was surgically treated. Oxidized cellulose was suspected of its cause.

[Disseminated intravascular coagulation (DIC) after artificial valve replacement: especially tricuspid regurgitation]

To investigate disseminated intravascular coagulation (DIC) after valve replacement, we studied DIC score in 80 patients with combined cardiac valvular disease. Thirty-three patients with (TR group) and 47 patients without (control group) tricuspid regurgitation were compared. 1) TR group, that included patients with severe cases, showed a significantly longer operative time and greater bleeding volume (p less than 0.01). 2) The DIC score was significantly higher in TR group. Administration of gabexate mesilate to patients with DIC improved their platelet counts. These results indicate that patients with combined cardiac valvular disease with tricuspid regurgitation have a hemorrhagic tendency and are subject to DIC. Administration of gabexate mesilate is useful for DIC.

[A case report of mycotic false aortic aneurysm associated with aortic regurgitation]

The patient was 63-year-old man, who underwent patch closure of VSP 37 days after onset. LVAD was required for weaning from CPB. Mediastinitis occurred after LVAD was removed. The mediastinum was irrigated using diluted antibiotics through the retrosternal drain. He discharged on 79th day postoperatively. False aortic aneurysm and marked AR was pointed out by cineangiography and enhanced CT scan two years after operation. AVR was performed through right thoracotomy, because false aortic aneurysm invaded the sternum. The aneurysmal wall was repaired with patch. Postoperatively, peritoneal dialysis was performed for two days. Flail chest made difficult weaning from the respirator. He died 11 days postoperatively due to respiratory failure. There remains the possibility that mediastinitis resulted in false aortic aneurysm and AR. It was esseutial to remove the foreign materials placed on the aorta for eradication of infection.

[Cardiac surgery of tetralogy of Fallot associated with DiGeorge syndrome: a case report]

A case of 7-year-old boy with tetralogy of Fallot associated with DiGeorge syndrome was reported. He had been diagnosed as cardio-facial syndrome with hypoparathyroidism because of hypocalcemia, convulsion, cardiac defect and the characteristic face. But immunologic study showed hypofunction of cellular immunity and cardiac catheterization and angiogram revealed the Tetralogy of Fallot. So we diagnosed as DiGeorge syndrome and performed operation. The thymus was not found and we close the ventricular defect with patch and reconstructed right ventricular outflow tract with transannular patch. We often measured serum ionized calcium level and corrected with calcium gluconate intravenously. Peritoneal dialysis was done due to oliguria and much inotropic support was necessary.

[A case of right aortic arch associated with subclavian steal syndrome]

A 20-year-old female of right aortic arch associated with subclavian steal syndrome is reported. She was admitted to our hospital for numbness of the left arm, headache and dysphagia. Division of the ligamentum arteriosum and left common carotid-left subclavian artery anastomosis were successfully performed.

[A case report of aneurysm of the sinus of Valsalva due to infectious endocarditis with ASR]

A case (56 year-old, female) of the aneurysm of sinus of Valsalva due to infectious endocarditis with aortic stenosis and regurgitation was described. The patient was successfully operated upon by patch closure of the orifice of the aneurysm and aortic valve replacement with Medtronic Hall 23A. Post operative course was uneventful and discharged from the hospital at 37 post operative days in good condition.

[Pulmonary artery aneurysm-like associated with pulmonary stenosis]

A 55-year old man had complained shortness of breathing and an abnormal shadow at left hilus region had been pointed out on the chest X-ray film. Right heart catheterization and right ventriculography revealed pulmonary valve stenosis with pulmonary artery aneurysm-like. Utilizing cardiopulmonary bypass, aneurysmorrhaphy and valvotomy was performed. Postoperative course was good and he was discharged on the 29th postoperative day. It is considered that mild post-stenotic dilatation of pulmonary trunk due to pulmonary valvular stenosis might develop into the aneurysmal change because of some congenital structural deficiency in the pulmonary arterial wall.