Constrictive pericarditis following hemopericardium due to ascending aortic dissection: A case report

A 79-year-old woman, who had had no history of trauma, tuberculosis, or collagen diseases, was referred for examination of general fatigue and shortness of breath on exertion. Physical examination revealed engorged neck veins, hepatomegaly, and ascites with abdominal distention. On chest x-ray the cardiac shadow was slightly enlarged and bilateral pleural effusion was present. An electrocardiogram showed low voltage of the QRS complex. Computed tomographic scans revealed two lumens in the remarkably dilated ascending aorta and the severely thickened pericardium. Cardiac catheterization showed elevated right atrial pressure and elevated right and left ventricular end-diastolic pressures, in addition to a pressure record of early diastolic dip and end-systolic plateau in the right ventricle. Aortography demonstrated aortic dissection localized to the ascending aorta. On the basis of these findings, the diagnosis of chronic ascending aortic dissection complicated with constrictive pericarditis was made. After subtotal pericardiectomy, graft replacement of the ascending aorta and proximal aortic arch was performed with successful results. Her postoperative recovery was uneventful. Histological studies of the pericardium showed fibrosis and marked infiltration of the inflammatory cells. No findings of specific pericarditis such as tuberculosis or collagen diseases were detected.

Flow balance between the left and right cardiac output of an eccentric roller type total artificial heart

We have made an eccentric roller type total artificial heart (ERTAH). The ERTAH is a positive-displacement device comparable to a DeBakey roller pump. Its left and right outputs are determined by the size of its blood chambers, and the ratio of its left and right output is almost constant. We focused on an interatrial shunt to achieve left-right balance. We have conducted numerical simulation, a mock test, and an acute animal experiment to analyze left-right heart balance during ERTAH operation. Numerical simulation was performed under conditions in which the flow of the left artificial heart was fixed at 6 L/min, the flow of the right artificial heart was varied from 4.8 to 6 L/min, and the interatrial resistance was also varied. The relationship between the interatrial shunt flow rate and the output of the left and right artificial hearts was balanced when the flow of the right artificial heart was at 5.45 L/min. In a mock test, 2 DeBakey roller pumps were connected to the left and right sides of a Donovan mock circulatory system, and an interatrial shunt was created between the inlet ports of the left and right roller pumps. The interatrial resistance of the mock system was varied from 7.7, to 4.3, and to 2.9 mm Hg x min/L when the inner diameter of the interatrial shunt was 6, 8, and 10 mm, respectively. As in the mock test, 2 roller pumps were used to bypass the right and left hearts of a goat weighing 60 kg. The flow rate of the left heart was almost constant (4.7 L/min). The flow of the right heart was approximately 4.1 L/min when the interatrial shunt flow rate was zero. A leading consideration was that the left to left shunt through the bronchial arteries in this goat was approximately 0.6 L/min. In developing the ERTAH, we considered that creating an interatrial shunt between the inlet ports of the ERTAH as well as making a difference between the chamber volumes might be effective in balancing the left-right sides of the artificial heart.

Protective effects of pretreatment with ginsenosides on cardiac and coronary vascular function after hypothermic rat heart preservation

Prevention of cardiac and vascular dysfunction with pretreatment has been accepted as an important factor in heart transplantation. Ginsenosides (GS) have been reported to have some beneficial effects on the cardiac and vascular system. We hypothesized that pretreatment with GS would result in an improvement of functional recovery after a 12 hour (hr) rat heart preservation. A Langendorff apparatus was applied to estimate the cardiac and vascular function in an isolated rat heart preparation. The hearts were preserved in University of Wisconsin solution at 0 degree C for 12 hr, after pretreatment with 0.9% sodium chloride or GS 100 mg/kg, respectively, in control (n = 9) and GS (n = 14) groups. After storage, the cardiac function, myocardial water content, and coronary vasodilatory response were evaluated. The GS group showed a significantly higher recovery percentage of cardiac function compared with the control group: aortic flow 81.4 +/- 21.4% versus 57.2 +/- 11.0% (p = 0.0052); coronary flow 81.4 +/- 14.5% versus 57.2 +/- 6.0% (p = 0.0001); +/- dp/dt max 72.5 +/- 16.1% and 66.0 +/- 16.1% versus 53.7 +/- 4.1% and 51.4 +/- 7.1% (p = 0.0027 and p = 0.0189) respectively. The GS group showed a lower increase in myocardial water content. With Langendorff perfusion, the endothelial and vascular smooth-muscle cell function were evaluated by an increasing percentage of coronary flow in response to acetylcholine chloride (0.3 x 10(-7) mol/liter) and nitroglycerin (0.5 x 10(-5) mol/liter). It was significantly higher in the GS group than that in the control group (19.2 +/- 8.8% and 28.0 +/- 14.1% versus 9.9 +/- 4.7% and 14.7 +/- 8.1%, p = 0.008 and p = 0.0187, respectively) at the first minute. These results suggest a protective effect on ventricular and coronary vascular function in the rats pretreated with Ginsenosides, indicating potential benefits for long-term heart preservation.

The use of gelatin-resorcin-formalin glue in acute aortic dissection type A

OBJECTIVES

The Gelatin-resorcin-formalin (GRF) glue is widely used in the surgical treatment of dissecting aneurysms. This paper is focused on our experience with the GRF glue in cases, operated for acute aortic dissection type A.

METHODS

Between September 1990 and December 1997, 164 patients were operated on for acute aortic dissection type A. In 148 patients GRF was used to reinforce the dissected layers proximal (n = 106) or distal (n = 144) of the grafted aortic segment. An intervention at the aortic valve was necessary in 93 instances. In 111 patients, an open distal anastomosis for replacement of the proximal aortic arch was performed. Thirty-seven additional patients underwent subtotal or total aortic arch replacement.

RESULTS

Early postoperative mortality was 26.2% (43/164 patients). Another 16 patients died late postoperatively. Actuarial survival rates are 69.9% at 1 year, 62.5% at 3 years, 59.4% at 5 years and 56.1% at 7 years, post-operatively. Twenty-two reoperations were performed in 20 patients (16.5%). Nine of these patients had developed complications in aortic segments that underwent reconstruction by use of GRF during the primary intervention. Aortic root redissection was found in 7/9 patients intraoperatively, whereas 1/9 patients presented with a rupture near the distal graft to aortic anastomosis.

CONCLUSIONS

The introduction of GRF glue has greatly facilitated the reconstruction of dissected aortic wall layers adjacent to the vascular graft. However, the use of the adhesive for aortic root reconstruction in acute aortic dissection type A may bear a significant risk of late postoperative proximal aortic redissection. Complications associated with the GRF glue are likely to be due to the toxic effects of the formalin component. Therefore, care should be taken that the amount of formalin administered to the glue components remains as low as possible.

Maternal thyroid function in multiple pregnancy: the variable thyrotropic activity of human chorionic gonadotropin

The present study was undertaken to evaluate thyroid function and thyrotropic action of hCG in multiple pregnancy. We examined serum samples from 9 multiple pregnant women (3 triplets and 6 twins) and 27 singleton pregnant women as control subjects. Serum hCG levels in multiple pregnancy were higher than those in singleton pregnancy in the second and third trimesters (P < 0.01). The mean free T3 and T4 concentrations in multiple pregnancy did not differ from those in singleton pregnancy in each trimester. Serum hCG levels showed a statistically significant positive correlation with free T3 and T4 levels in singleton pregnancy (P < 0.001). However, these correlations were not observed in multiple pregnancy. Thyroid stimulation activity (TSA) determined by cAMP accumulation in FRTL-5 cells in multiple pregnancy sera was significantly higher than that in singleton pregnancy in the first trimester (P < 0.05), but did not differ in the second and third trimesters. Moreover, TSA did not show any correlation with serum hCG levels in multiple pregnancy in contrast with the results in normal pregnancy. A bioactivity/immunoreactivity ratio of hCG in multiple pregnancy was lower than in singleton pregnancy in the second and third trimesters. The discrepancy between immunoreactivity and thyrotropic activity of hCG may be caused by the variable thyrotropic potency of heterogeneous hCG molecules in multiple pregnancy.

Assessment of a new silicone tri-leaflet valve seamlessly assembled with blood chamber for a low-cost ventricular assist device

We have developed a practical, low-cost ventricular assist device (VAD) comprising a newly designed blood chamber with a silicone lenticular sac and two silicone tri-leaflet valves (STV), made en bloc. This new VAD is seamless, can be made cost-effectively and assembled with the blood chamber and valve as one body. This novel design should reduce the incident of thrombus formation because of the absence of a junction at the connecting ring and because of the use of flexible silicone materials which have both antithrombogenecity and biocompatibility. In in vitro hemodynamics testing, a batch of 3 consecutively manufactured VADs with STVs underwent hydrodynamic functional testing. These showed less regurgitation, a lower value of water hammer phenomenon, and a slightly greater pressure gradient across the valves than a mechanical valve (MV) [Björk-Shiley monostrut valve]. The flow and pulsatile efficiency were adequate and similar to that of a VAD with MVs. In in vitro durability and hemolysis tests, a VAD with STV functioned well for 54 days and showed similar hemolytic profiles to a VAD with MVs. In an in vivo acute experiment using an adult sheep, our device was problem-free providing sufficient output as a left ventricular assist device (LVAD). Although it will be necessary to decrease the pressure gradient across this STV in the future, our device showed efficient performance as a practical land cost-effective VAD for short term use.

Eccentric roller type total artificial heart designed for implantation

In the process of developing a completely implantable total artificial heart system, we have made an eccentric roller type total artificial heart and evaluated it by means of a mock circulatory system and by an acute animal experiment. The actuator of the artificial heart consists of 2 cylindrical drum type rollers which squeeze 2 blood chambers. The blood chambers are made of silicone rubber and are torus in shape. There is no valve used in this artificial heart. The artificial heart appears to be a nearly circular cylinder, approximately 10 cm in length and 8 cm in diameter. In the Donovan mock test, the artificial heart worked at a roller speed of 100-125 rpm with flow rates of 2.5-3.0 L/min for the right side and 3.2-3.8 L/min for the left side, respectively. The electric power consumption was 19.0-24.7 W. Our artificial heart is characterized by an ejection of blood alternatively in the pulsatile mode without need for reversing the motor. In the ex vivo evaluation, circulation of an adult sheep was maintained with this artificial heart for 4 h.

Study of left ventricular bypass using Wankel type semipulsatile blood pump

The influence of the Wankel type semipulsatile left ventricular assistance on hemodynamics was investigated with a computer simulation and an animal experiment. A simulation circuit was constructed to express the circulatory system. A current source was added to create a semipulsatile blood pump. The left and right ventricles were replaced by variable compliances. Left heart failure was simulated by decreasing the amount of compliance change of the left ventricle. Under the condition of heart failure when semipulsatile assist flow increased, the mean aortic pressure (AoP), tension time index (TTI), and diastolic pressure time index (DPTI) increased, and the cardiac output, pulse pressure (PP), and pulsatility indicator (PI) decreased. In an animal experiment, a Wankel type blood pump was used in a calf. With the increase of the assist flow, AoP curves became less pulsatile, and PP and PI decreased in accordance, which was predicted by the numerical simulation.

Aortic valve replacement with a small mechanical valve prosthesis--a clinical and echocardiographic study of a St Jude Medical valve prosthesis

The use of small aortic valve prostheses raises concerns about harmful effects of residual obstruction to left ventricular outflow. The present study was undertaken to examine long-term clinical and echocardiographic results in 193 patients who underwent isolated aortic valve replacement (AVR) with a St Jude Medical (SJM) valve of 25 mm or smaller. The study subjects comprised 128 male and 65 female patients with a mean age of 54.1 years. The patients were divided into 2 groups according to the size of the valve prosthesis used for AVR. Small valves (19 or 21 mm) were implanted in 49 patients (group S) and large valves (23 or 25 mm) were used in 144 patients (group L). The group S patients were mainly female, older, and had smaller body surface areas. There were no significant differences in early and late mortality in group S as compared with group L. Furthermore, there was no difference in the incidence of valve-related or cardiac, non-valve-related death, including the incidence of sudden death, between the 2 groups, and they enjoy a similar level of daily routine activity regardless of the valve size used. Left ventricular (LV) function (ejection fraction, fractional shortening, LV mass index, LV end-systolic volume index, and LV end-diastolic volume index) measured by echocardiography improved significantly and returned to normal values after AVR in both groups. Moreover, no significant differences were observed in the postoperative variables of the LV function. These results suggest that 19-mm and 21-mm SJM valves can be safely used for AVR in the majority of Japanese patients.

An aortic balloon catheter incorporating a conduit for percutaneous cardiopulmonary support

Circulatory support using both intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) can improve general hemodynamics; however, sometimes brain damage occurs caused by hypoperfusion. Such cerebral hypoperfusion is likely to be caused by PCPS when applying the conventional femoral cannulation. We have developed a new IABP catheter which incorporates a conduit for PCPS with an outlet at the catheter tip, the goal of which is the improvement of cerebral perfusion. The hemodynamic characteristics of this new IABP catheter were compared with those of the conventional combination of IABP and PCPS. Studies were performed by mock test using a pulsatile artificial heart. A polyvinyl chloride tube acted as the aorta with 2 branches at the proximal and distal portions representing the upper and lower portions of the body. The IABP balloon was positioned between the 2 branches, and changes in flow at the 2 branches were examined at varying PCPS flow rates. Flow in the proximal branch using the new device was greater than it was using the conventional PCPS device. We conclude that cerebral perfusion could be improved with the use of this new special IABP catheter.

Development of a direct mechanical left ventricular assist device for left ventricular failure

We have developed a direct mechanical left ventricular assist device (DMLVAD) for severe left ventricular failure. The DMLVAD was attached to the left ventricle and compressed the heart by a pneumatic driving unit. In a mock circulation model with an extracted nonbeating heart, a cardiac output (CO) of 1.93 L/min was obtained at a driving pressure of 200 mm Hg. In a canine left ventricular failure model induced by injection of sodium hydroxide into the myocardium, the systolic arterial pressure, systolic left ventricular pressure, maximum LV dP/dt, peak flow, and CO increased by 21, 24, 58, 144, and 37%, respectively. The mean left atrial pressure also decreased by 15% when the DMLVAD was driven. These effects were most prominent when the mean left atrial pressure was over 15 mm Hg, and the driving pressure was over 100 mm Hg. Compression at late systole was more effective in obtaining greater CO. We suggest that the DMLVAD could be an optional circulatory assist device for patients with left ventricular failure awaiting heart transplantation.

Trial manufacture of eccentric roller type total artificial heart

Working toward a completely implantable total artificial heart, we have designed an eccentric roller type total artificial heart. The actuator of this artificial heart is a drum type eccentric roller that squeezes the blood chambers. The blood chambers are made of silicone rubber and are torus in shape. The shape of the artificial heart is an almost circular cylinder, and its length and diameter are 10 cm and 8 cm, respectively. The 2 main characteristics of this artificial heart are that it discharges blood in a pulsatile mode and that it requires no reversing of the motor. Because we have not completed the artificial heart yet, we have tested the eccentric roller mechanism on the prototype with an overflow type mock circulation with a 100 mm Hg afterload. The prototype worked at the roller speeds of 50, 100, and 150 rpm with flow rates of 1.7, 3.7, and 5.4 L/min, respectively. Next the prototype was connected to a Donovan type mock circulatory system and worked at roller speeds of 88-214 rpm with flow rates of 3.0-8.4 L/min against mean afterloads of 82-120 mm Hg.

[Heart valvular disease in patients 70 years old and older]

From June 1986 to December 1996, 69 patients older than 70 years old underwent AVR (29 cases), MVR (21 cases), MVP (5 cases), DVR (10 cases), aortic root replacement (3 cases), repair of PVL (1 case) in our hospital. There are five (7.2%) operative and hospital deaths. The survival rate was 88.4% at 10 year after surgery and three (4.7%) late deaths. The factors associated with early deaths were renal dysfunction and DVR. Our surgical results suggest that open heart surgery can be performed safely even elderly patients, in spite of their precarious physiologic homeostasis. Not the chronological age but the physiological age is important determinant for surgical indication. If quality of life (QOL) can be expected to be enhanced, we recommend an aggressive surgical approach.

[Combined superior-transseptal approach to left atrial myxoma]

A 60-year-old woman was referred to our hospital for treatment of an intracardiac tumor Echocardiography revealed a 47 x 30 mm tumor in the left atrium which had a short stalk attached to the atrial septum. At operation, a large left atrial myxoma was extirpated using a combine superior transseptal approach. Through this incision, exposure of the left atrial myxoma and it stalk was excellent and removal of the myxoma was easily performed with minimal minpulation. Postoperative arrhythmias related to the operative procedures were not observed. The patient recovered uneventfully. The operative technique and indications of the combined superior transseptal approach to the left atrium are discussed in this paper.

Cineradiographic evaluation of ATS open pivot bileaflet valves

BACKGROUND AND AIMS OF THE STUDY

Echocardiography and cineradiography are both valuable for the evaluation of prosthetic valve function, especially of mechanical valves. Although Doppler echocardiography data are available for the recently developed ATS valve, cineradiographic evaluation of leaflet movement of the valve has not been performed.

MATERIALS AND METHODS

Five patients received aortic and another five mitral valve replacement with the open pivot ATS bileaflet prosthetic valve. There were three men and seven women; mean patient age was 58.8 years. Cineradiographic and Doppler echocardiographic evaluations of the ATS valve were performed early after surgery in all 10 patients.

RESULTS

There were no early deaths after surgery or after discharge from the hospital. No valve-related complications were seen, and no clinical symptoms or signs of prosthetic malfunction were observed during the follow up period. Doppler-derived values of the ATS valve were comparable with those previously reported; however, cineradiography of the valve demonstrated that the mean angle enclosed by the two open leaflets was 37.6 degrees (range: 34 degrees to 44 degrees) in the aortic position and 29.7 degrees (range: 20 degrees to 35 degrees) in the mitral position. Mean leaflet mobility was 93.0 degrees (range: 86 degrees to 96 degrees) in the aortic position and 100.0 degrees (range: 92 degrees to 110 degrees) in the mitral position. Thus, the opening of the normally functioning ATS valves in vivo was less than that observed in vitro and reported by the manufacturer.

CONCLUSIONS

These results suggest that unevenly distributed blood flows with different velocities through the two side orifices and the central orifice may result in incomplete opening of the ATS leaflets, which respond with great sensitivity to localized blood flow. Our findings appear to be important to avoid the removal of a normally functioning ATS valve only because the leaflet opening appears to be 'restricted'.

Aortic root replacement for annuloaortic ectasia in Shprintzen-Goldberg syndrome: a case report

Annuloaortic ectasia due to Shprintzen-Goldberg syndrome (SGS) is reported. A 10-year-old boy was admitted to our hospital for evaluation of chest pain. On admission, he was diagnosed as SGS on the basis of his various anomalies. Two-dimensional echocardiography showed a bicuspid aortic valve and marked annular dilatation, Doppler flow studies revealed severe aortic regurgitation, and retrograde aortography showed severe aortic regurgitation with annular dilatation. Successful aortic root replacement was performed; subsequent histologic examination of the ascending aorta demonstrated cystic medial necrosis. In conclusion, SGS is a generalized connective tissue dysplasia, with clinical manifestations of cardiovascular lesions similar to those in Marfan syndrome. Aortic root replacement was successfully performed; however, recurrence of aortic aneurysms outside of the ascending aorta should be carefully observed. Surgical treatment for cardiovascular disorders may be necessary to save the life of patients with SGS.

Operation for type B aortic dissection using hypothermic selective cerebral perfusion

A 56-year-old man who had a huge type B dissecting aortic aneurysm extending from the distal arch to the thoracoabdominal aorta underwent replacement of the descending thoracic and thoracoabdominal aorta under hypothermic circulatory arrest with selective cerebral perfusion. The intercostal arteries at the T-8 to T-11 level were preserved with beveled distal anastomosis, and the celiac artery and the intercostal arteries at the T-5 and T-6 levels were reconstructed. The patient recovered uneventfully and is presently doing well 1 year after the operation.

Development of an intravascular pumping oxygenator using a new silicone membrane

A new intravascular pumping oxygenator (IVPO) was developed for intravascular gas exchange and circulatory assistance in critically ill patients with respiratory and circulatory failure. The IVPO utilizes new silicone hollow fibers (diameter, 1 mm; membrane width, 50 microns) and consists of two driving tubes for the oxygenation and pumping of circulating blood. The performance characteristics of the IVPO were studied using an experiment ex vivo model. With a mean hemoglobin concentration of 10.5 +/- 2.3 g/dl, total oxygen transfer was 5.6 +/- 1.5 ml/min at a blood flow of 200 ml/min and 6.3 +/- 2.2 ml/min at a blood flow of 250 ml/min. Total CO2 transfer was 3.8 +/- 1.4 ml/min at a blood flow of 200 ml/min and 4.2 +/- 1.6 ml/min at a blood flow of 250 ml/min. Blood flow increased to a maximum of 250 ml/min during IVPO pumping. This preliminary experiment demonstrated that the IVPO has the capacity to function both as circulatory assist pump and as an intravascular hollow fiber oxygenator.

In vitro evaluation of linear motor-driven total artificial heart

This paper deals with the in vitro evaluation of a newly developed linear motor-driven total artificial heart (linear TAH). The linear TAHs have been developed and evaluated in mock testing and acute animal experiments. The new linear TAH was made based on experience with acute animal experiments. The maximum static thrust of the new linear pulse motor is 146 N with exciting current of 1.69 A. The weight and the volume of this linear TAH are 1.9 kg and 560 ml, respectively. The linear TAH has a kinetic thrust of 85 to 43 N and provides the maximum flow rate of 6.8 L/min in mock circulatory testing.

Mock test characteristic of intraaortic balloon pump using linear motor

This article describes the composition of the intraaortic balloon pump (IABP) system, which uses a linear pulse motor, that is, the linear type of IABP, and the results of the mock test that was performed. The expansion time is 100-110 ms, and the contraction time is 85-95 ms at the balloon of the linear type IABP. This level is similar to that of the IABP system used in the market. When the speed of the mover is 0.3 m/s, the necessary thrust of the linear pulse motor to drive the balloon of the IABP is 200 N. The conversion efficiency from the bellows to the balloon is 5.6%, and the efficiency of the entire linear type IABP system is 0.6%. The volume of the entire system is 45 L, and the mass is 40 kg excluding the chassis. Therefore, there is an expectation that the IABP system can be miniaturized to about half of the conventional model.

Past, present, and future of total artificial heart development at research institute of replacement medicine, Hiroshima University School of Medicine

The history and recent progress in total artificial heart (TAH) development were reviewed and divided into three stages. The first stage was between 1966 and 1972, when a trial developing an artificial heart (AH) driver was begun using poppet valves. Fluid amplifiers and air operated valves were then employed as a controller. The second stage was between 1973 and 1983. Several models of pneumatic AH were manufactured and implanted into animals, and it was confirmed that animals could survive with their circulation supported by these mechanical hearts. The third stage was from 1984 to the present, and now a trial to construct a totally implantable type of AH is under way. On the basis of the experience of developing TAHs, the following points are discussed as future problems to be solved: first, the production of small yet powerful actuators; second, the establishment of safe and reliable controls and an energy supply method; third, the development of a durable blood chamber containing valves; and fourth, the acquisition of large research funds for TAH from governments and other granting agencies.

[Surgery for aortic valvular disease with congenital quadricuspid aortic valve]

A case of quadricuspid aortic valve is reported. A 69-year-old man was hospitalized with chest oppression at rest and abnormal electrocardiogram and diagnosed aortic regurgitation by echocardiography and aortic angiography. Aortic regurgitation was grade III according to Seller. Aortic valve replacement was performed successfully with a 21 mm St. Jude Medical valve. The aortic valve showed four cusps consisting of two equal larger cusps and two equal smaller cusps which was type C according to Hurwitz. Each valve was thickened and adhered, and fenestrations were found at each commissure. The right coronary ostium was small but not displaced. Twenty five cases in literature which were corrected surgically are also reviewed. Quadricuspid aortic valve is a rare anomaly but must be considered as a malformation which leads to severe valve failure in later life.

[Surgical treatment for active infective endocarditis]

Between April 1975 and December 1995, 33 patients with active infective endocarditis underwent surgical treatment at our hospital. The location of diseased valve was shown as ; 18 in aortic, 11 in mitral, and 4 in aortic and mitral position. Of these, 14 patients had an annular abscess or mycotic aneurysm. All patients achieved antibiotic therapy previously, and predominant indication for operation was congestive heart failure. All patients underwent valve replacement. The reconstructive procedures for 14 patients with paravalvular involvement were as follows ; direct closure : 5 cases, direct closure+tilted prosthesis technique : 5 cases, and another 4 cases were, patch closure of VSP resulting from a septal abscess, patch closure+translocation, translocation, and reconstruction of annulas with pericardial patch. There were five (15.2%) operative and hospital deaths and actuarial survival rate was 81% and 61% at 5 and 10 years after operation. Including one who died early after operation, there were 5 cases with postoperative paravalvular leakage and its main cause were persistent infection. In conclusion, it considered that the principles of treating active infective endocarditis is to decide the optimal timing for operation, debride the infected tissue, and close the defect completely.

[Acute aortic dissection complicated with acute myocardial infarction--a case report of successful operation for the case of DOA]

A 61-year-old woman who suddenly manifested chest and back pain was admitted after the diagnosis of acute type A dissection complicated with acute inferior myocardial infarction at another hospital. While being transported to our hospital by ambulance, her ECG repeatedly demonstrated ventricular fibrillation of cardiac arrest. She was in the state of dead on arrival (DOA) when arrived at our hospital. ECG demonstrated complete A-V block and cardiac arrest alternately. However, soon after right ventricular pacing was done, her blood pressure increased and she recovered consciousness. We therefore performed an emergency operation. We performed reconstruction of the ascending aorta and right coronary bypass grafting, since she had aortic dissection and conus brach avulsion. The postoperative course was uneventful.