A comparative study in patients with Omnicarbon and Björk-Shiley heart valve replacement

To compare the Omnicarbon heart valve and the Björk-Shiley spherical valve, operative results, hemodynamic parameters and late results were examined after mitral valve replacement. There were no early deaths, and 6 late deaths in the Omnicarbon valve (2.9% per patient-year). The actuarial survival rate at 6 years was 82.1 +/- 4.8% and freedom from valve-related complications was 86.4 +/- 2.2%. Pressure gradients and effective mitral valve areas at rest calculated by Gorlin's formula were satisfactory in both valve. Cardiac index (l/min/m2) was slightly changed according to the pacer-induced tachycardia, but there was a significant decrease in 160 bpm in the Omnicarbon valve (2.01 vs 2.39, p < 0.05). Peak pressure gradients and pressure half time by Doppler echocardiography, revealed the same trends as those of the Björk-Shiley valve during tachycardiac exercise, though regurgitant flow was detected in 7 patients in 160 bpm in the Omnicarbon valve, while in 2 in the Björk-Shiley valve (28% vs 10%, p = ns). Phonocardiographic study demonstrated that aortic closure to mitral opening click (AC-OpC) interval and Q wave of the electrocardiogram to mitral closing click (Q-CC) interval, which were related to the mitral valve gradients, fell within the normal range in both valves. However, the Björk-Shiley valve compared favorable to the Omnicarbon valve in the AC-OpC interval (70.9 msec vs 76.8 msec, p < 0.05). Hemolysis was of no clinical importance in the intact function of the Omnicarbon valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Six years' experience with the Omnicarbon valve prosthesis

Between January 1985 and March 1990, isolated Omnicarbon valve replacement operations were performed on 90 patients aged 25-72 years. There were 53 aortic valve replacements (AVR) and 37 mitral valve replacements (MVR). The cumulative follow-up was 320 patient-years, with a mean(s.d.) follow-up of 3.7(1.4) years. There were three operative and hospital deaths (3.3%) resulting from retrograde aortic dissection during cardiopulmonary bypass, postoperative renal failure and postoperative mediastinitis. Seven patients died during the late postoperative period, four from valve-related causes. Two of these patients died from prosthetic valve endocarditis, and the others died from thromboembolism and valve thrombosis. The mean(s.d.) actuarial survival rate at 6 years was 86.2(4.3)% (98.8(0.8)% for AVR, 82.1(4.8)% for MVR). The mean(s.d.) actuarial survival rate of freedom from all valve-related mortality at 6 years was 93.5(2.6)% (100% for AVR, 88.1(2.9)% for MVR). There were two thromboembolic events (one mesenteric artery thrombosis and one valve thrombosis). The standardized incidence of thromboembolism was 0.63% per patient-year. Prosthetic valve endocarditis occurred in three patients (0.94% per patient-year). One patient (0.31% per patient-year) was found to have a paravalvular leak resulting from aortitis syndrome. The mean(s.d.) actuarial rate of freedom from all valve-related complications at 6 years was 89.2(2.0)% (98.6(1.0)% for AVR, 86.4(2.2)% for MVR). There were no instances of anticoagulant-related haemorrhage, valve-related haemolysis, or structural failure. Results of a follow-up period of 6 years indicated that good clinical results and a low incidence of valve-related complications can be demonstrated with the Omnicarbon valve.

Reoperations on prosthetic heart valves: an analysis of outcome

To evaluate risks and complications of reoperations on prosthetic heart valves, we reviewed data on 70 patients who underwent reoperations because of prosthetic valve malfunction. Overall hospital mortality was 13% (9/70 patients). The common cause of death was low cardiac output syndrome following surgery (4 patients). Respiratory failure and mediastinal infection accounted for 2 deaths each, and neurological complication for 1 death. However, hospital mortality was different according to the risk factors; reoperations for prosthetic valve endocarditis (18%, p < 0.05), advanced New York Heart Association (NYHA) class (50%, p < 0.001), and emergency operation (33%, p < 0.005) were the significant risk factors. In contrast, advanced age, female sex, type of prosthesis, valve position, and diagnosis (leak, structural deterioration, or valve thrombosis) did not appear to be significant risk factors. There were 7 late deaths (4 valve-related, 2 cardiac, and 1 noncardiac). Inasmuch as emergency operation, advanced NYHA class, and prosthetic valve endocarditis affected hospital mortality, these factors contributed to late death. Actuarial survival rate and freedom from valve-related mortality at 10 years were 75.8 +/- 2.8% and 87.2 +/- 2.3%, respectively. There were 8 valve-related complications, and freedom from valve-related complications at 10 years was 73.5 +/- 3.5%. As judged by these data, hospital mortality and late survival can be improved if hemodynamic conditions leading to myocardial damage can be prevented.

[Three-dimensional CT images of the lung--preliminary study using inflated lung specimens]

Three-dimensional CT images of six inflated lung specimens (4 lung cancer, 1 bronchiectasis, 1 hamartoma) were reconstructed from contiguous serial sections to study some probable problems in the clinical application of the technique. Optimal thickness and space of sections were evaluated, and contiguous 1.5-mm serial sections were found to provide a clear 3-D image with high fidelity. It was difficult to set a proper threshold to create clear images because a wide CT window is inconsistent with low noise. The images of tubular and linear structures such as from bronchi and vessels demonstrated higher resolution when reconstructed from scanning in the more perpendicular cross-sectional direction to their axis. Although 3-D images obtained here were not as clear as expected, technological advances such as helical CT or MRI may provide 3-D images with sufficient resolution to be applied clinically.

Candida prosthetic valve endocarditis. An autopsy review

Fungal endocarditis after cardiac surgery has been noticed increasingly in the past decade. We report a case of Candida parapsilosis endocarditis after mitral valve replacement in a patient with no predisposing factors. In this report we mainly examined the pathological findings in this patient with post-mortem examination.

Permanent cardiac pacing after cardiac operations

From January 1980 through December 1990, implantation of a permanent pacemaker was performed in 34 patients following open heart surgery. The patients were divided into two groups according to the clinical indications for implantation of permanent pacemakers. Group 1 (9 patients) had surgical atrioventricular block, and Group 2 (25 patients) had sick sinus syndrome. Tricuspid valve surgery was involved in 67% of Group 1 and 64% of Group 2. Adams-Stokes syncopal attack was the prime indication for permanent pacing in 100% of Group 1 and in 72% of Group 2. There were 2 operative deaths in Group 1, and no deaths in Group 2 (22% in Group 1 vs. 0% in Group 2, p < 0.005). Causes of the deaths were not related to the pacemaker implantation but to congestive heart failure following surgery. Among 32 survivors, there were 2 late deaths in Group 1, and 4 deaths in Group 2 (25% in Group 1 vs. 16% in Group 2, p < 0.05). The overall actuarial survival rate at 10 years was 82.1 +/- 2.8%. However, the actuarial survival rate of patients in Group 1 is 70.2 +/- 4.1%, which is statistically less than 85.4 +/- 2.2% in Group 2 (p < 0.01). As judged by these results, patients in Group 1 should be followed on a regular out-patient basis even if they are asymptomatic and there is no evidence of pacemaker failure.

Spontaneous and time-related degeneration of Carpentier-Edwards bioprosthesis in mitral position

To assess the spontaneous and time-related degeneration of the Carpentier-Edwards (C-E) bioprosthesis at 13 years after implantation, the cases of 48 patients who had undergone mitral valve replacement with C-E bioprosthesis are examined. The time-related clinical findings were started from a new rumbling murmur at an average of 5.9 years. The time-related change of transmitral flow was assessed by pressure half time and peak pressure gradient on pulsed Doppler cardiography, and pressure gradient and effective mitral valve area on cardiac catheterization. These values were expressed as an identical linearized curve: pressure half time Y = 13.3 X +41.9, peak pressure gradient Y = 1.47 X +1.25, pressure gradient Y = 1.90 X -3.79, mitral valve area Y = -0.87 X +1.39. From the combined evidence presented by these results, the initial structural deterioration of C-E bioprosthesis is stenotic change of the cusp, not tear or laceration, and correlates well in length of implantation, as evidenced by a linear curve. We are encouraged that the lack of catastrophic prosthetic valve failure, as has been associated with the pericardial valve, affords the opportunity for an elective safe reoperation.

[Autotransplantation as optimal technique for recurrent malignant myxoma of left ventricle]

Application of autotransplantation for left ventricular recurrent malignant tumor which was considered to be originating from the posterior leaflet of mitral valve was presented. A patient was 29 year-old-female and underwent the resection of tumor. The tumor was resected en bloc with the mitral valve, and its histology was myxoma. But she was required reoperation two times because of the recurrence of the tumor unfortunately. The tumor was ultimately diagnosed as the myxofibrosarcoma with chondroid differentiation. At the time of the third surgery, the heart transplantation was thought to be only treatment for radicality. While sounding American counterparts on the possibility of the heart transplantation, her condition took a sudden turn for the worse. An autotransplantation technique was applied for the resection of the tumor emergently. As a result, it was impossible to completely resect the tumor because of severe invasion to the left ventricle, and the patient died suddenly on the 75th day after the operation due to fetal arrhythmia. Through this case, heart transplantation should be considered for such a case, but autotransplantation technique allowed to be a life-prolonging in this case. We believe that this technique which will be obtained the excellent operative field could be used for repair of complex cardiac anomalies and rupture of left ventricle and so on.

[Surgical treatment of cardiac cachexia with mitral valve disease: the effect of preoperative IVH and left atrial plication on postoperative respiratory condition]

Twenty-four patients with cardiac cachexia associated with mitral valve disease were evaluated from the point of postoperative respiratory management. Our previous study suggested that preoperative intravenous hyperalimentation (IVH) had just a effect on postoperative respiratory management, but another study suggested that left atrial plication (LAP) for giant left atrium might improve the postoperative respiratory function. Therefore, four groups could be identified: (1) IVH group (17 patients), (2) No-IVH group (7 patients), (3) LAP group (6 patients), (4) No-LAP group (18 patients). The hospital mortality was 18% in IVH group and was not related to the postoperative respiratory distress. On the contrary, the mortality in No-IVH group was 57%, related to the postoperative respiratory distress. The mortality of LAP group was 67%, and was related to the respiratory distress except one patient. In No-LAP group which had undertaken preoperative IVH, the mortality was 17%. As a result, preoperative IVH therapy may consider to be a favorite procedure in order to get the good postoperative respiratory condition, but LAP itself would be suspicious for this purpose.

Competitive flow from a fully patent coronary artery does not limit acute mammary graft flow

The shriveled, stenotic mammary graft sometimes observed after internal mammary artery (IMA) to coronary artery bypass grafting has been attributed to competitive flow from the insufficiently stenosed native coronary vessel. To study further the effects of native coronary artery competing flow on IMA graft flow, 10 dogs (mean weight, 23.5 +/- 3.69 kg) underwent coronary artery bypass grafting using the pedicled left IMA anastomosed to a normal, fully patent proximal circumflex (CFX) coronary artery. The procedure was performed through a left thoracotomy, off pump, using a brief local occlusion to perform the anastomosis. Native in situ IMA flow, CFX flow distal to the anastomosis, and IMA graft flow were measured using calibrated electromagnetic flow probes. When the CFX proximal to the anastomosis was occluded transiently, IMA flow increased to supply 100% of the previously measured distal CFX flow (60.2 +/- 7.9 mL/min). When both the IMA graft and CFX proximal to the anastomosis were patent, total distal perfusion was maintained (58.9 +/- 7.8 mL/min) and relative IMA graft flow (26.5 +/- 3.3 mL/min) was proportional to the relative diameter of the IMA graft to the native coronary artery (r = 0.96). The mean flow in the IMA in situ on the chest wall before its division was 23.8 +/- 8.1 mL/min. These results suggest that, at least acutely in a canine model, IMA graft flow is maintained above in situ levels even when grafted to a completely patent coronary artery and that acute competitive flow probably does not cause mammary artery shriveling.

[Pseudoaneurysm of the left ventricle following mitral valve replacement]

This report describes a false aneurysm of atrioventricular groove in the patients who underwent the reoperation of the mitral valve replacement (MVR). Patient 1 underwent reMVR with a SJM prosthesis because of the malfunction of the previous prosthetic valve. A large hematoma was observed in the posterior atrioventricular groove with bleeding at weaning from cardiopulmonary bypass. Ventricular rupture was repaired under the cardioplegic arrest successfully from the epicardial surface with a woven Dacron felt. The postoperative left ventriculogram revealed the false ventricular aneurysm along the atrioventricular groove. Patient 2 underwent reMVR with Carpentier-Edwards prosthesis because of the malfunction of the previous Carpentier-Edwards prosthesis. Cardiopulmonary bypass was discontinued uneventfully, and there were no clinical symptoms suspicious of the formation of the false left ventricular aneurysm. The left ventriculogram at the discharge showed the false left ventricular aneurysm along the atrioventricular groove. Although both patients are in good condition without significant complications, we should involve in the postoperative care of the patients on a regular outpatient basis.

[Comparative study of anticoagulant management after coronary artery bypass surgery--warfarin versus dipyridamole]

A prospective randomized study was performed in 137 coronary artery bypass surgery cases to determine if the administration of antiplatelet drugs would improve the patency of coronary artery bypass grafts. The warfarin group received warfarin and thrombotest was controlled to 20% or so. The dipyridamole group received both 300 mg of dipyridamole and 250 mg of aspirin orally each day. These two groups were compared for study in grafts patency. Results were analyzed by chi-square. In the warfarin group, 66 patients had three ITA-LAD grafts and 115 saphenous vein grafts (including 4 sequential grafts). In the dipyridamole group, 71 patients underwent 38 ITA grafts and 167 saphenous vein grafts (including 56 sequential grafts). Eighty-eight of the 107 grafts (82%) were patent in the warfarin group, and 190 of 205 grafts (95%) were patent in the dipyridamole group (p less than 0.01). Of the two ITA grafts in the warfarin group, no graft was occluded, a patency of 100%. In the dipyridamole group, 35 of 38 ITA grafts (92%) were patent. In the warfarin group, 86 of 105 saphenous vein grafts (82%) were patent. In the dipyridamole group, 155 of 167 saphenous vein grafts (95%) were patent (p less than 0.01). In the study of grafted coronary vessel, the patency of left anterior descending coronary artery, diagonal branch and right coronary artery was not significant between two groups. In the dipyridamole group, the patency of left circumflex coronary artery was 93%, and that of the warfarin group was 50% (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[A case report of Candida prosthetic endocarditis: an autopsy review]

Most of the increasing numbers of cases of Candida endocarditis have developed after cardiac surgery. We report a case of Candida parapsilosis endocarditis after mitral valve replacement in a patient with no predisposing factors. In this report we mainly examined the pathological findings in this patient with postmortem examination. A woman, age 55, underwent valve replacement with a Björk-Shiley prosthesis for mitral stenosis. The spike fever occurred on the 22nd postoperative day and Candida parapsilosis was cultured from the blood. On the 76th day, a conscious disturbance with the right side hemiplegia was experienced. A CT scan revealed massive hemorrhagic infarction. Despite the intensive care the patient died of cerebral damage. Pathologic findings showed that the vegetation in the major orifice of the Björk-Shiley valve was composed of both necrotic debris and tissue, with Candida organisms being scattered throughout the interstices. Additionally there were also multiple myocardial abscesses with necrotic tissue.

[Percutaneous transluminal coronary angioplasty in patients with previous coronary artery bypass grafting]

Percutaneous transluminal coronary angioplasty (PTCA) has been used to treat patients with previous coronary artery bypass grafting (CABG). Seven patients with previous CABG underwent coronary artery or vein graft angioplasty following a recurrence of symptoms. Fifteen lesions were attempted in 7 patients. The primary angiographic success rate was 100%. The primary angiographic success rate was defined as reduction of a stenosis by at least 20% of the vessel diameter, leaving a stenosis of less than 60%. There were no complications following PTCA such as death or myocardial infarction. No patients were referred for urgent surgery. Three patients have undergone another PTCA after 3 months and remain well. All patients at follow-up continue to have improved symptoms. Our experience suggests that the patients with recurrence of coronary artery or bypass stenosis following CABG may be suitable for PTCA.

[Operative results with total composite replacement of the aortic valve and ascending aorta]

From December 1980 to December 1990, ten patients, 9 male and 1 female, ranging in age from 21 to 68 years, were operated on for aortic valve insufficiency associated with an aneurysm of the ascending aorta. The surgical treatment in all cases consisted of total replacement of the ascending aorta with Bentall's procedure (n = 4), or Cabrol's procedure (n = 6). In 5 patients an uncomplicated annulo-aortic ectasia existed. Three of them had annulo-aortic ectasia with an aortic dissection. One had aortitis syndrome, and one had syphilitic aortitis. The operative mortality for the entire group was 0% (0 death). Hospital survivors revealed satisfactory clinical improvement in NYHA class (mean value: 3.2 to 1.0). Late complications developed in 2 of the 10 patients. They had a picture of pseudoaneurysm formation at the anastomoses between the graft and the right coronary 46 months and 15 months, respectively, after the initial operation. Despite the reoperation, one died of hepatic failure 30 days after the operation, and the other died of postoperative bleeding at the anastomosis sites. We, furthermore, considered the difference in aortic cross clamp time and cardiopulmonary bypass time between Bentall's procedure and Cabrol's procedure. Aortic cross clamp time and cardiopulmonary bypass time were significantly shorter in Cabrol's procedure than in Bentall's procedure, if a probability value less than 0.20 was considered to be of statistical significance. We were able to conclude that the treatment of aortic valve regurgitation associated with an aneurysm of the ascending aorta by insertion of a composite graft is a reliable method with low operative mortality and excellent long term results, especially in Cabrol's procedure.

Percutaneous transradial approach for coronary angiography

A percutaneous radial artery approach for coronary angiography was performed in 40 patients using a 5-F catheter. The patients, in whom the femoral artery approach was difficult or contraindicated because of advanced arteriosclerosis, were selected on the basis of easily palpable radial and ulnar arteries and a normal Allen test. In 1 patient the catheter could not be advanced to the brachial artery, and subsequently this patient underwent the brachial approach. In all 39 patients, selective left coronary angiography was accomplished using a left Judkins catheter, and the right coronary artery and the saphenous vein graft were entered successfully using a right Judkins or Amplatz catheter. All patients had excellent quality of images of coronaries and vein grafts. In 5 patients (13%), the pulse remained acutely diminished, but there were no evidences or complaints of pain. Bleeding at the puncture site occurred in 1 patient (3%), and 5 patients (13%) had subcutaneous bleeding around the puncture site. Pseudoaneurysm, nerve injury and arteriovenous fistula were not detected at the time of discharge.

[A case of "postoperative erythroderma" following coronary artery bypass grafting operation]

So-called "Postoperative Erythroderma" was experienced in a 68 year-old man who received CABG for unstable angina. After a seemingly uneventful recovery, he revealed high grade fever on 13th post operative day (POD), rashes over the whole body on 15th POD and pancytopenia on 20th POD. He died of sepsis, multiple organ failure and DIC on 21st POD. Blood transfusion (concentrated red cell: 3 units) was done on operation. In this case, the rate of premature and atypical lymphocytes increased, and the ratio of OKT4 (helper)/OKT8 (suppressor) decreased. These findings of the examination suggested that there was a possibility of cell-mediated immunological depression. We considered this to be acute GVHD after blood transfusion.

[Left ventricular-right atrial shunt due to infective endocarditis--report of a case]

Acquired left ventricular-right atrial shunt is a very rare cardiac disease. Infective endocarditis, cardiac operative procedures, and thoracic trauma were reported as origins. We report a case of a patient with left ventricular-right atrial shunt due to infective endocarditis. A 53-year-old male who had aortic regurgitation due to infective endocarditis developed suddenly severe congestive heart failure. Two-dimensional and pulsed doppler echocardiography demonstrated left ventricular-right atrial shunt. Emergency operation was done. The fistula was found through the atrioventricular membranous septum. The position from the left view was just below the commissure between the right coronary cusp and non coronary cusp and the opening position from the right view was just above the septal leaflet of tricuspid valve. Aortic valve replacement and direct closure of fistula were done and patient's recovery was uneventful. Case reports of left ventricular-right atrial shunt due to infective endocarditis have been rarely seen, most of which were followed by poor prognosis. Surgical intervention in acute phase is recommended.

[Surgical repair of Scimitar syndrome with azygos connection by extracardiac conduit between right pulmonary vein and left atrium]

We present a surgical case of 41-year-old woman with Scimitar syndrome. Preoperative catheterization showed azygos connection and L-R shunt ratio of 45% without intracardiac malformations. To our knowledge, this combination has not been previously reported. At operation the right single pulmonary vein was found and drained into the inferior vena cava below the diaphragm. Because of counter clockwise rotation of the heart the distance of the scimitar vein and the left atrium was too long for direct anastomosis, a polytetrafluoroethylene tube (10 mm in diameter) was utilized for an extracardiac conduit using cardiopulmonary bypass. Postoperative course was uneventful. We conclude that this technique is effective for this syndrome with a large amount of L-R shunt and a sufficient patency is expected.

[Active bronchial tuberculosis--a clinical study on 36 cases]

A total of 36 patients (16 male and 20 female) with tracheobronchial tuberculosis were admitted during the last nine years and were evaluated for their clinical features. The chief complaint in three quarters of the patients was intractable cough, in particular, in those with tracheal tuberculosis. One of three patients who suffered from wheezing was prescribed steroid, being diagnosed as having bronchial asthma instead of tuberculosis. Plain chest X-rays of two patients revealed no abnormality. Pleural effusion was observed in three patients, and miliary tuberculosis in two patients. Bronchial biopsy was carried out in 23 patients, however, in only 11 patients a histopathological diagnosis of tracheobronchial tuberculosis could be made. In contrast, in all 36 patients smear and/or culture for tubercle bacilli were positive. Therefore, bronchial biopsy was considered not to be essential in making a definite diagnosis of bronchial tuberculosis, although it did not exacerbate the lesion to lead to endobronchial stenosis. Only seven out of 36 patients were in the habit of smoking but three of the four had already broken the habit at least one year before being diagnosed as having the disease. The remaining four patients were still smoking but less than 10 cigarettes a day, with one exceptional patient who was smoking 30 cigarettes on average a day. It has been well known that there is a sexual difference in the incidence of bronchial tuberculosis, namely among females with relatively low population of smokers, the incidence is high. Another probable reason for the higher female incidence is assumed to be due to the structural susceptibility of the bronchus with smaller diameter lumen.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical experience of autotransfusion of shed mediastinal blood using a new chest drainage unit]

The autotransfusion system (ATS) of shed mediastinal blood is expected as one of the techniques for non-blood open heart surgery. The ATS which has been used previously for this purpose required such items as cardiotomy reservoir, vacuum bottle, infusion pump and was complicated to manipulate. This time we have used a new chest drainage unit, Sentinel Seal Autotransfusion System (Sherwood Medical Co.), and report our clinical experience. This unit consists of two component parts. One is a blood collection bag which is later used for reinfusion of shed blood. The other part is a regular chest drainage unit with the water seal which protects pleural cavity from atmosphere. We used this system for 24 cases of open heart surgery and studied about the hematological and biochemical changes after reinfusing the shed blood postoperatively. There were no complications and side effects related to the reinfusion. The unit we have used is simple to handle and is useful when returning shed blood. We believe that this unit is quite safe for clinical use and that it will become a new strong support for non-blood open heart surgery.

[A case report of surgical treatment of prosthetic valve endocarditis in tricuspid position]

A case of right sided prosthetic valve endocarditis in tricuspid position was presented. This 38-year-old male underwent tricuspid valve replacement (TVR) with SJM (31 mm) prosthetic valve because of tricuspid valve endocarditis caused by staphylococcus epidermidis five years ago. At the beginning of this year, 1989, he was admitted with complain of high fever and bloody sputa. Doppler color imaging showed prosthetic valve was stenotic whose pressure gradient was 16 mmHg in peak pressure gradient, but vegetation was not identified. Following with gastrectomy perhaps due to AGML, re-TVR was done with Carpentier-Edwards vale (31 mm). He was discharged without any problems. It seems important to determine the timing of re-operation before leading any complications.

[A case report of the reinforcing technique with collared prosthesis for the prosthetic valve endocarditis in mitral position]

A 58-year-old female was admitted to our hospital because of the prosthetic valve endocarditis in mitral position. In the past, this patient was undertaken double valve replacement in mitral and aortic position. Nevertheless, postoperative course was not in stable condition, showing persistent sign of the infection. The appearance of mitral regurgitant murmur and regurgitant signal by colour Doppler cardiography could make sure of the diagnosis for prosthetic valve endocarditis (PVE) in mitral position. The operation for PVE in mitral prosthesis was undertaken as follows. As there was extensive annular infection around the mitral valve, the new mitral prosthesis (Duromedics valve) with the Gore-tex flange, so called collared prosthesis, was revised. The collared prosthesis was implanted in the mitral annulus by using the suture ring of the Duromedics valve as well as possible, furthermore, the Gore-tex flange were sutured in the left atrial wall 2 cm above the mitral ring. Postoperatively, the infection sign and congestive heart failure were completely subsided. This patient has been in very healthy condition these days and restored to the daily life.

[Experimental evaluation for tricuspid annular constriction with the model of tricuspid annular dilatation]

We have obtained the good result about tricuspid annular constriction (TAC) for secondary tricuspid insufficiency. The purpose of this study is to investigate the effectiveness of TAC for the experimental model of tricuspid annular dilatation. First of all, tricuspid annular dilatation was made surgically in 8 mongrel dogs by placing 8 incisions to tricuspid annulus except septal cusp under the condition of heart-lung preparation. On clinical evaluation, septal annulus was kept to be intact in many cases compared with the two other areas. This experimental model of tricuspid annular dilatation was considered to be substituted to the clinical model of tricuspid annular dilatation. TAC suture was surrounded circumferentially around the dilated tricuspid annulus. And then, TAC suture was pulled out from the right atrial wall, and the circumferential length of tricuspid annulus was completely accommodated by pulling the TAC suture. The hemodynamic status was observed by right atrial pressure (V wave and mean) and right ventricular end-diastolic pressure (RVEDP). After heart resuscitation and gradual increase of preload, right atrial pressure was significantly elevated especially right atrial pressure (V wave) compared with control values. When 2 cm of circumferential length of tricuspid annulus on an average was constricted by shortening of TAC suture, right atrial pressure was significantly decreased, and then RVEDP tended to decrease. It was shown that TAC was an effective operative technique for the secondary tricuspid annular dilatation and tricuspid insufficiency from the standpoint of experimental aspect as well as clinical results.

[A study of tricuspid-tailoring annular constriction in autopsy cases--cases which appear to embody limitation of tricuspid-tailoring annular constriction]

We our department have performed tricuspid-tailoring annular constriction (T-TAC) as salvage operation for secondary tricuspid regurgitation (TR) with gratifying results. Of those cases undergoing MVR and T-TAC for mitral valve regurgitation (MR) and secondary TR with an associated severe cardiac cachexia, 2 autopsy cases in which an associated severe cardiac cachexia, 2 autopsy cases in which residual tricuspid regurgitation culminated in patient's death long after operation were investigated. In Case 1, the patient was discharged asymptomatic 2 months after operation, but later developed severe left heart failure and marked tricuspid regurgitation as precipitated by upper respiratory tract infection and died from exacerbation of LOS before undergoing a scheduled reoperation. T-TAC was found successful on autopsy. In Case 2, the patient died of long-persisting left heart failure and severe residual tricuspid regurgitation after following a similar postoperative course to that in Case 1. On autopsy stitches made through the tricuspid anterior leaflet, septum and posterior leaflet were found untied and loosened and the tricuspid annulus diameter increased. In severe valvular heart disease, even if T-TAC has proven successful, aggravation of cardiac failure may lead to the development of TR. Because of the fragility of myocardial tissue due to severe myocardial damage in such compromised patients, sophisticated operative techniques need to be devised. Cases illustrative of a limited long-term success of T-TAC used alone are presented.

[A case of constrictive pericarditis due to traumatic pericardial hematoma]

Although the cause varies widely, we recently experienced a case of constrictive pericarditis of which cause seemed to be traumatic as described below. The patient was a 62-year-old man having a history of epigastric trauma about 20 years ago. Since then, palpitation appeared and he was recently hospitalized in our department for the purpose of receiving an operation under the diagnosis of constrictive pericarditis. At operation, a hematoma was found in the pericardial region, which was considered to have been caused by trauma in the past. Less reports have so far been available concerning trauma-induced constrictive pericarditis and this case thus seemed to be of rarity as well.

[Application of a large occlusion balloon catheter to re-do open heart surgery]

A very rare case having re-do open heart surgery four times during two years was reported. The case was 30 year-old-male complicated with aortitis syndrome and underwent mitral valve replacement because of infective endocarditis. But the prosthetic valve repeated detachment over and over again after first MVR in spite of complete treatment of steroid for aortitis syndrome. When fourth re-operation, it was easily expected that median sternotomy, cannulation and clamping would be difficult because of tough adhesion. So large occlusion balloon catheter was used to clamp the ascending aorta and operative field was exposed by left thoracotomy under femoro-femoral bypass. We could accomplish the operative procedure safely under "instrument free" operative field. Large occlusion balloon catheter is very useful for aortic clamping in case of not only reoperation but calcified aorta and so on.

[Operative indication for aortic valvuloplasty by rasping procedure from the point of histopathologic evaluation]

Rasping procedure is proposed by the author as one of the methods of aortic valvuloplasty and defined as shaving the surface of rheumato-degenerative aortic valve by using the electric rasp. Materials were the removed rheumato-degenerative aortic valves as specimen, and classified into 3 groups. The first group (type I) was valve lesion limited to valve free edge, second (type II) was mild thickening entirely, third (type III) was severe thickening with calcified degeneration. Rasping procedure was performed for the thickened portion of the valve specimen by the electric rasp. Morphologic examinations after rasping procedure were evaluated by histopathologic study. Histopathologically, there was hyaline degenerative connective tissue in superficial layer above the collagen fiber's layer in rheumato-degenerative thickened valve in type I. This hyaline degenerative connective tissue was considered to be fragile and pathologic in the tissue structure. Rasping procedure could remove this connective tissue layer. Type II, there was the similar finding to the type I from the free edge to the mid portion of the cusp. So, Rasping procedure was effective for type I and type II valve degeneration. On the contrary, the calcified lesion (type III), rasping procedure was not effective in valve coaptation and the pathological findings showed the fragmentation in the calcified layer. In the pathological comparison with the slicing procedure for type II by the surgical knife, there was a crack and cleft in the collagen fiber's layer in the case of slicing procedure. It can be concluded the results of histopathological study of the rasping procedure proved to be superior to the conventional aortic valvuloplasty (slicing method).

[The determinant factors for open heart surgery with non-blood transfusion--analysis by quantitative theory class II]

The serious complications in the field of cardiovascular surgery are the blood transfusion related problems such as post transfusion hepatitis, AIDS, GVHD and immunosuppressed conditions. These problems have not been settled so far. In our department, open heart surgery with non-blood transfusion is the final goal and extracorporeal circulation with non-blood priming has been indicated under normal conditions. However depending on the cases, blood transfusion is definitely required. Under such circumstances, we analyzed the determinant factors as to whether open heart surgery with non-blood transfusion may be indicated or not, according to the formula based on the quantitative theory (class II). Extracorporeal circulation with non-blood priming were indicated on 124 patients in our department, and they were divided into two groups; blood transfusion group (group I): 64 patients, and non-blood transfusion group (group II): 60 patients. These two groups were compared for study in terms of age, preoperative weight, the body surface area, preoperative Ht value, calculated Ht value at the start of extracorporeal circulation, the aortic cross-clamping time, the total extracorporeal circulation time and total bleeding amount. The following are described in the order of importance. 1) Calculated Ht value: more than 30%. 2) The amount of blood loss after ECC is removed: less than 500 ml. 3) Preoperative body weight: more than 50 kg. 4) Preoperative Ht value: more than 40%. 5) The total ECC time: less than 90 min. In addition, prospective factors which should be considered preoperatively are determined in the following orders. 1) Calculated Ht value. 2) Preoperative Ht value. 3) Preoperative body weight.(ABSTRACT TRUNCATED AT 250 WORDS)

[A comment on optimal shaped prosthesis for tricuspid valve using an experimental model]

The prosthesis for mitral valve has been in use instead of the prosthesis for tricuspid valve, since the latter prosthesis has not at present been available. In view of the shape of tricuspid valve, which is essentially flat in form, it is not good for replacing with the prosthesis for mitral valve which has an almost circular shape because of the difficulties in suturing, and many criticisms on this substitution have been raised. In order to obtain more suitable prosthesis as exactly benefits TVR, we have developed at first an instrument indicating the change of cardiac function occurring in the course of fixing the annulus of tricuspid valve that would undergo the difference in shape from circular to flat, using experimental models throughout, which has eventually led to the exploration of the possible exact shape of a prosthesis of the annulus for tricuspid valve. Our series of experiments proved as conclusion that the annulus of tricuspid valve is more advantageous when fixed with an ellipse of a flattened rate 1.6 compared with any circular ones tested. In view of the left ventricular stroke work, it is apparent that a prosthesis for mitral valve which is circular in shape should not be applied. We emphasize that a prosthesis for tricuspid valve which is ellipse in shape with desired flattened rate of 1.6 should be developed for our future applications.

[Time-related degeneration of Carpentier-Edwards bioprosthesis in mitral position]

Carpentier-Edwards bioprostheses have been shown to provide a low incidence of valve-related complications, especially thromboembolism, but the durability has caused the serious concern. This report suggests that Carpentier-Edwards prostheses have been gradually degenerative, and stenotic degeneration and the year after operation are well correlative. In Osaka National Hospital, Carpentier-Edwards prostheses were implanted in 89 patients in mitral position from 1973 to 1981. Of all the patients, 50 patients were undertaken to single valve replacement in mitral position and could be followed up in our department. For a total of 50 patients, materials are 30 patients who could be detected by clinical findings, pulsed Doppler echocardiography, cardiac catheterization and soft X-ray evaluation in explanted prostheses at reoperation. Follow-up duration was ranged 4.2 to 12.1 years with a mean duration of 7.94 years. The age ranged from 32 to 71 years of age. The initial diagnosis of the time-related degeneration was the appearance of newly acoustic rumbiling murmur. Furthermore, regurgitant murmur, arrythmia (atrial fibrillation) and cardiac enlargement were followed in addition to rumbling murmur. The assess of the transmitral flow such as pressure half time and peak pressure gradient by pulsed Doppler echocardiography was the easy way to evaluated the time-related degeneration. Time-related stenotic change by pulsed Doppler was expressed as a linearized curve. At 6 years and below valve function seemed not to be impaired but stenotic dominant degeneration with the cusp tear was prominent beyond 7 years. Cardiac catheterization data could make sure of the pulsed Doppler findings by assessing mitral valve gradient and mitral valve area.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary artery stenosis following aortic valve replacement--a case report]

A case with severe left main trunk (LMT) stenosis nine months after aortic valve replacement was presented. The patient, 57-year-old female, underwent aortic valve replacement with a tilting disk valve (Omnicarbon 21 A). Her postoperative course was uneventful, but angina pectoris developed after nine months. Coronary angiography was performed and revealed 99% LMT stenosis. Operation was performed with OTCA to LMT and with a saphenous vein graft to left anterior descending artery. Coronary artery stenosis following aortic valve replacement may be dangerous and it must be treated as soon as the diagnosis is established.

Extensive spinal necrosis with spinal leptomeningeal dissemination of cerebral astrocytoma. Case report

A 58-year-old male with malignant astrocytoma in the right parietal lobe developed ascending spinal dysfunction 15 months after subtotal resection of the primary lesion. He was treated by postoperative radiation and combined chemotherapy. Autopsy revealed extensive spinal necrosis affecting the level below the lower cervical region. Microscopic examination demonstrated diffuse leptomeningeal metastasis of glioma cells to the whole spine. There was no previous report in the literature of massive myelomalacia attributable to leptomeningeal dissemination an astrocytic supratentorial tumour. Clinical and neuropathological findings suggested that disturbance of venous drainage of the spinal cord might be responsible for myelomalacia in this case.

[Expanding the surgical indication to the cases with high risk valve diseases]

Four hundred and fifty eight cases of valve surgery were performed at this institution over the past 7 years, during which the surgical indication has been gradually expanded to cases of three types. The first type is serious disease complicated by cardiac cachexia; in these cases, in addition to the aggressive use of IABP, we also use the intrapulmonary artery balloon pumping (IPBP) technique we developed. IVH therapy for two months before surgery has been especially effective and given good results to cases with low liver function and low respiratory function. The second type consists of cases necessitating special surgical technique, for example, cases with very narrow valvular annuli and cases complicated by acute endocarditis. Good results have been obtained in the former with a new technique that we developed, called "Coupling Valve Grafting", and in the latter with a technique of "Collared Prosthesis". The third type is elderly patients aged 70 years or more. In particular, the greatest problem now seems to lie in low liver function of which ICG (15 min) is higher than 40% and total serum bilirubin is over 3 mg/dl; in these cases, progression to MOF is frequent and the patient's life is saved in only 40% of cases.