[Composite valve graft replacement in patients with type A aortic dissection--a modified cabrol procedure]

Composite valve graft replacement of the ascending aorta and aortic valve is indicated for a variety of conditions affecting the aortic root. However, a major drawback in this operation is bleeding from the proximal suture line and coronary anastomosis especially in patient with friable root tissue involved by aortic dissection. We describe here a modified technique to take advantage of the aortic button and cabrol techniques to reattach the coronary artery ostia. We have experienced seven patients with the aortic root replacements for type A dissection using the described technique over the past two years. In view of our favorable experience, we recommend this technique especially for patient with acute dissection involving nondilated aortic annulus, in addition to the patients with Marfan syndrome or annulo-aortic ectasia.

Retrohepatic cavoatrial shunt with a ringed polytetrafluoroethylene graft for the Budd-Chiari syndrome. A case report

This report describes a patient with Budd-Chiari syndrome who was operated on successfully by means of shunt formation with polytetrafluoroethylene graft between the inferior vena cava (IVC) and right atrium. The patient is a sixty-two-year-old woman suffering from persistent edema of the lower limbs for four years. The examination disclosed complete obstruction of the IVC at the level of the diaphragm with a patent right inferior hepatic vein. Following the operation, edema of the limbs disappeared, hypersplenism improved, and the serum ammonium concentration decreased to the normal range. In conclusion, a retrohepatic cavoatrial shunt is feasible and useful in treating a patient with the Budd-Chiari syndrome who has patent major hepatic veins.

Acute type A aortic dissection following intramural hematoma of the aorta. A case report

A seventy-three-year-old woman had symptoms of aortic dissection. Initial computed tomographic (CT) scan and angiography showed an extensive intramural hematoma (IMH) of the aortic segment from the ascending aorta to the bulk of the descending aorta without intimal tear or false lumen. Two weeks later the patient's symptoms recurred. A repeat CT demonstrated a classic type A aortic dissection with a false lumen and an intimal defect. The patient underwent a successful hemiarch repair with use of selective cerebral perfusion under profound hypothermic circulatory arrest. This case suggests extensive IMH as an important underlying pathology of the aortic dissection.

[Cerebral cytochrome oxidase monitoring by near infrared spectroscopy during selective cerebral perfusion]

To evaluate selective cerebral perfusion (SCP) for brain protection, the redox state of cytochrome oxidase (Cyt. aa3) in brain tissue were studied in 27 patients with thoracic aortic repair. The redox state of Cyt. aa3 was monitored by near infrared spectroscopy (NIRS) (OM-110, Shimazu). There were no significant changes in the Cyt. aa3 redox state in 13 (Group I), the oxidation state of Cyt. aa3 decreased then recovered to control levels in 12 (Group II), and the oxidation state decreased but did not recover in 2 patients (Group III). Postoperative cerebral damage was observed in 5 patients; blindness occurred in one patient in Group I (8.3%), 2 patients developed hemiplegia in Group II (15.4%), and the 2 patients in Group III failed to reawaken (100%). The incidence of cerebral damage was significantly higher in Group III than in Groups I and II (p < 0.05). We conclude that monitoring the redox state of Cyt. aa3 using NIRS is useful in predicting postoperative cerebral damage. However, it is necessary to increase the number of measurement sites since NIRS can reflect the state in only a small area of the brain.

[Ventricular septal perforation due to coronary artery spasm--a case report]

A 70-year-old female was referred due to chest pain and cardiogenic shock. Echocardiogram showed ventricular septal perforation (VSP) with large left to right shunt. ECG indicated ischemia on the left anterior descending region. Instantaneous coronary angiogram was done under the support of IABP. Neither obstructive nor stenotic lesions were found in the coronary arteries. Coronary artery spasm was a likely cause of VSP. The patient underwent emergency surgery within 12 hours from the onset. The VSP, 2 cm in diameter, was located on the postero-apical portion of the ventricular septum. The defect was closed by endocardial patch method using an equine pericardium. Postoperative course was uneventful, and the patient was transferred 3 weeks after the operation.

[Clinical experience with the gelatin-resorcine-formol biological glue in acute type A aortic dissection]

From May 1995 through June 1996, the gelatin-resorcine-formol (GRF) biological glue was used for tissue reinforcement in 20 patients operated on for acute type A aortic dissections at our institution. The results in these patients (Group I) were compared to those in 37 patients operated on between 1992 and 1994 with conventional techniques (Group II). There were no significant differences between the two groups concerning demographic data. Operative procedures in Group I consist of replacement of the ascending aorta with or without proximal arch (n = 10), total arch replacement (n = 7), and aortic root reconstruction (n = 2), whereas those in Group II were 22, 12, and 3, respectively. Cardiopulmonary bypass time was significantly shorter in Group I than Group II (164 +/- 39 vs 265 +/- 122, p < 0.05). Average blood loss in first 24 hours after operation was 688 +/- 601 ml in Group I and 1481 +/- 1505 ml in Group II (p < 0.05). Consequently operative mortality was significantly (p < 0.05) reduced from 40.5% (Group II) to 15.0% (Group I). In conclusion, the use of GRF glue reduces perioperative bleeding and improves results of operation for acute aortic dissections.

[Abdominal aortic aneurysm and annuloaortic ectasia in siblings with Marfan syndrome]

A combination of annuloaortic ectasia (AAE) and abdominal aortic aneurysm (AAA) appeared in siblings with Marfan syndrome is presented. The patients were a 53-year-old female and her younger brother. The brother died of arrhythmia twenty years before while waiting for surgical repair of AAE. His AAA and Marfan syndrome were ascertained at autopsy. The female patient received surgical repair for AAA and AAE subsequently. Pathologic study of the resected aneurysm revealed cystic medial necrosis. A combination of AAE and AAA developed in two members of a family with Marfan syndrome is extremely rare.

[Successful emergency coronary artery bypass grafting in a patient with systemic lupus erythematosus under hemodialysis therapy]

A 38-year-old woman, who had been suffering from systemic lupus erythematosus (SLE) and receiving steroid therapy for the past 25 years, underwent a successful emergency coronary artery bypass grafting for unstable angina. She had also been treated with a 10-year period of hemodialysis therapy for chronic renal failure. Her coronary angiography revealed the heavily calcified ectatic right coronary artery with a thrombus formation in its proximal portion associated with severe stenosis in the proximal left coronary artery. The left internal thoracic artery was anastomosed to #7 and the saphenous vein to #3, respectively. Postoperative coronary angiography performed one month later revealed both grafts to be patent with no stenosis. Ischemic heart disease (IHD) is one of the major complication limiting the prognosis of the patient with SLE. We discuss the point related to cause of IHD and the surgical management.

Pontine venous congestion caused by dural carotid-cavernous fistula: report of two cases

This is a report of two patients in whom a pontine venous congestion occurred with a dural carotid-cavernous fistula (CCF), an extremely rare complication. This is the first such report. We underscore the importance of early diagnosis and treatment of dural CCFs.

Extracorporeal venous bypass: a beneficial device in operation for superior vena caval syndrome

Life-threatening complications can occur unexpectedly during general anesthesia in operations for acute progressive superior vena caval syndrome. We describe a temporary extracorporeal axillofemoral venous bypass procedure to reduce the high venous pressure in the upper part of the body before induction of general anesthesia. The bypass supports the operation for superior vena caval syndrome without life-threatening accidents. No serious complications related to the procedure have been observed.

A new experimental model for simultaneous evaluation of aortic and pulmonary allograft performance in a composite graft

A model was developed in pigs for simultaneous evaluation of aortic and pulmonary allograft performance in a composite graft. The composite graft consisted of vascular prosthesis and aortic and pulmonary allografts. Following antibiotic preservation, it was anastomosed to the recipient's thoracic descending aorta by an extrapleural approach without using cardiopulmonary bypass. Aortic blood flow was completely diverted into the composite graft. All 12 recipient pigs recovered well, 4 of which were assigned for the initial study to design the suitable experimental schedule. Calcification readily occurred in the aortic allografts and aneurysmal dilatation without calcification developed in the pulmonary allografts. These morphological findings were consistent with those of previous reports. This model has several benefits. First, aortic and pulmonary allograft conduits can be implanted and evaluated simultaneously under the same conditions by making a composite graft. Second, the magnitude of the operation is minimum, and postoperative circulatory and respiratory management is uncomplicated. Third, wound infection rarely occurs, because the skin incision is made on the back. These preliminary studies suggest that this model will allow future study concerning aortic and pulmonary allograft conduits under different conditions.

[A case of acute thrombosed aortic dissection (Stanford type A) in association with a true aortic arch aneurysm]

We have experienced a rare case of Stanford type A thrombosed aortic dissection in association with true aortic arch aneurysm. A 73-year-old male with asymptomatic true aortic arch aneurysm had sudden onset of severe back pain. A through examination clarified that he had Stanford type A aortic dissection coexisting with true aneurysm. In operation, we found a tear on intima of the proxymal-part of the true aneurysm. Pathologically, dissection confined to the ascending aorta did not involve the true aneurysm. The replacement of ascending aorta and aortic arch was successfully accomplished. The combination of true aortic arch aneurysm and Stanford type A aortic dissection is rare bibliographically.

[Subacute effusive-constrictive pericarditis accompanied with miliary tuberculosis: a case report]

With the advent and the introduction of effective antimicrobial therapy, the mortality for tuberculosis pericarditis decreased in number dramatically. The problems, however, remains in several severe cases. We have experienced a rare case of 74 year old male with subacute effusive-constrictive pericarditis accompanied with miliary tuberculosis. The patient revealed improvement immediately after early an emergent pericardiectomy. However cardiac failure recurred thereafter because of fibrous epicarditis of tuberculous inflammation. Management of subacute effusive-constrictive pericarditis as this has many problems including surgical intervention such as operative timing and indication and/or role of corticosteroids together with antituberculotic drugs.

Successful application of hypothermia combined with intra-aortic balloon pump support to low-cardiac-output state after open heart surgery

The authors report a successful application of hypothermia, along with intra-aortic balloon pump (IABP) support, to postcardiotomy ventricular failure. Surface-cooling hypothermia was applied in 8 patients after open heart surgery. The original cardiac procedure consisted of 3 aortocoronary bypass graftings (ACBGs), 2 aortic valve replacements (AVRs), 1 repair for left ventricular (LV) rupture after mitral valve replacement (MVR), 1 MVR + ACBG, and 1 MVR + AVR + tricuspid valve annuloplasty (TAP). Their ages ranged from fifty-two to sixty-eight years with a mean of sixty-one years. Hemodynamic criteria for induction of hypothermia included cardiac index (CI) less than 2.0 L/min/m2 with left atrial pressure greater than 18 mmHg despite the use of IABP and maximum pharmacologic support. Blood temperature was maintained at around 33 degrees C. By six hours after induction of hypothermia the tissue oxygen consumption decreased significantly with no hemodynamic deterioration as compared with that before cooling. The duration of hypothermia ranged from thirty-six to one hundred fifty-nine hours with a mean of seventy-eight hours. All 8 patients finally discontinued IABP support with a mean driving time of one hundred thirty-two hours. Five of them were ultimately discharged from the hospital and returned to their previous life-style. The authors believe that, from the perspective of monetary and personal resources, the use of hypothermia with IABP support could be a therapeutic option for patients with postcardiotomy ventricular failure.

[Coronary arterial bypass grafting for angina pectoris suspected with aortitis syndrome: a case report]

We report herein the case of a 56-year-old man with angina pectoris suspected to be accompanied with aortitis syndrome who underwent coronary artery bypass grafting (CABG). His cerebral blood flow consisted of only that of the right vertebralartery, and the marked collaterals of the bronchial artery anastomosing to the coronary artery. CABG was performed under combined with electrical fibrillation and systemic deep hypothermia, for fear of a bad influence on the cerebral tissue by the influx of high potassium cardioplegic solution. The postoperative course was uneventful and the coronary angiography revealed that the all graft were patent.

[Open heart surgery in patients with chronic dialysis]

From January, 1986 to May, 1995, twelve patients with dialysis (11 hemodialysis; HD, and one continuous ambulatory peritoneal dialysis; CAPD) received open heart surgery. They consist of 10 males and two females aged between 35 and 66 with a mean of 58.8. The duration of dialysis was 6.8 years in a mean (the shortest for 2 months and the longest for 16 years). They classified into an equal number of four in NYHA class II, III and IV. Two of them had isolated coronary artery bypass grafting, four had aortic valve replacement (AVR) and two had mitral valve replacement (MVR). Others were each one of AVR and MVR, AVR plus MVR with tricuspid annuloplasty (TAP), AVR plus TAP, and removal of left atrial myxoma. All patients except for one of CAPD were dialysed daily 2 or 3 days before operation. Three patients were managed postoperatively with HD, one with PD, six with continuous hemodiafiltration, and two with continuous hemofiltration. The operative mortality was 25% (3/12). The causes of death were left ventricular rupture, bronchospasm, and respiratory failure. All patients who died were in class in III and IV. For the improvement of the results we emphasize the necessity of early operation that should be scheduled in class II period.

[Surgical results of valve replacement with the Björk-Shiley tilting disc valves]

We evaluated the Björk-Shiley tilting-disc (BS) valve replacement up to the longest duration for about 12 years. The study was started in November 1982 and ended in September 1991. There were total number of 206 with 117 males and 89 females aged between 18 and 71 with a mean of 51.6. Eighty three patients had isolated aortic valve replacement (AVR), 92 had isolated mitral valve replacement (MVR), and 31 had AVR plus MVR. One hundred and fourteen spherical-disc valves were replaced in the aortic, 112 spherical and 11 monostrut in the mitral position. The mean duration of follow up was 6.5 years for a total of 1330.6 patient years (PY). Forty-one patients (3.8%/PY) died later, and 14 out of 41 died of valve-related complications. Actuarial survival rates for all, AVR, MVR and DVR at 10 years after operation were 71.2%, 73.5%, 73.9% and 55.4%, respectively. The linearized rates of thromboembolism (TE), thrombosed valve (TV), anticoagulant-related hemorrhage (ACH), prosthetic valve endocarditis (PVE), hemolysis (H), and reoperation (RO) were 1.2%/PY, 0.2%/PY, 0.7%/PY, 0.2%/PY, 0.1%/PY, and 0.2%/PY, respectively. The rates of freedom from TE, TV, ACH, PVE, H, and RO and 10 years after operation were 83.5%, 98.5%, 94.0%, 98.4%, 99.0% and 95.6%, respectively. The major causes of postoperative mortality and morbidity were TE, TV, and ACH. One hundred and fifty-six out of 161 patients showed an improvement in NYHA functional class post operatively. The surgical results of valve replacement with the BS valve was excellent and acceptable one. Intensive management with a special reference of anticoagulant therapy is necessary for a long-term management of the patients with mechanical valve replacement.

[Surgical results of valve replacement with porcine bioprostheses]

We evaluated the 80 cases of porcine valve replacement, accomplished between April 1975 and December 1980. There were 48 males and 32 females aged between 16 and 60 years old with a mean of 37.4 +/- 11.4. Ten patients underwent aortic valve replacement (AVR), 63 mitral valve (MVR), and 7 AVR plus MVR. Twenty-seven Hancock valves (H) were implanted in aortic (3) and mitral (24) position and 61 Carpentier-Edwards valves (CE) were used in aortic (14), mitral (46), and tricuspid (1) position. The mean duration of follow-up was 9.3 years (0.2-19.2 years) and cumulative follow-up was 747.2 patient years (py). The late mortality was 3.3%/py (25 patients). Actuarial survival rates for all patients at 10 and 15 years were 67%, and 49% respectively. The linearized rates (LR) of structural valve deterioration (SVD) was 7.0%/py. The freedom from SVD for all patients at 10, and 15 years were 47.1%, and 12.4% respectively. There were no differences of free rates of SVD between H and CE. between valve sites implated, and among age at operation. The incidence of occurrence of SVD was gradually increased 6 years after operation. The LR of thromboembolism (TE), anticoagulant-related hemorrhage (ACH), prosthetic valve endocarditis (PVE), nonfunctional valve dysfunction (NVD), and reoperation (RO) were 0.7%/py, 0.1%/py, 0.3%/py, 0.1%/py and 7.4%/py, respectively. The freedom from TE, ACH, PVE, NVD, and RO for all patients at 15 years were 91.3%, 98.1%, 95.6%, 80%, and 6.5%, respectively. The surgical results of glutaraldehyde-preserved porcine bioprostheses was excellent during the first 5 years after operation. A high incidence of SVD has been occurred thereafter. According the indication for valve replacement with bioprotheses is now strictly limited for elderly, child bearing female case, contraindition for therapy of anticoagulants, and some social condition.

Massive endobronchial hemorrhage after pulmonary embolectomy

Massive endobronchial hemorrhage is a lethal complication in pulmonary embolectomy. We report a case of massive endobronchial hemorrhage occurring after successful restoration of pulmonary blood flow using cardiopulmonary bypass in a patient with pulmonary embolism. Two possible causative factors of this complication are described.

[Management of patients with closing aortic dissection]

Acute aortic dissection is a catastrophic event requiring immediate diagnosis and definitive treatment, while the clinical characteristics of closing aortic dissection are not well known. From Jan. 1991 through Dec. 1994 a total of 24 patients with closing aortic dissection (CAD) was managed at our institution. There were 19 men and 5 women, ranging in age from 49 to 74 years with a mean of 65 years. All patients presented with a sudden onset of severe chest and back pain. Twenty patients had a history of hypertension with a wide mediastinal silhouette on chest X-ray. The diagnosis of CAD was established by contrast computed tomographic (CT) scans in all patients with no evidence of patent false lumen. The descending thoracic aorta was involved in 17 patients and the ascending in 5. Conservative medical management was initially attempted for all. Seven patients (Stanford type A/B: 2/5) ultimately required surgical intervention, and 2 patients died. The follow-up was 100% complete with a mean term of 14.6 months. The overall survival rate was 74% at 3 years after the initial presentation. Based on our clinical experience, all patients with CAD need careful antihypertensive therapy and frequent follow-up studies to assess the aorta.

[Ventricular septal defect with severe pulmonary hypertension: the role of open biopsy in determination of operative indication: a case report]

A 51-year-old man having ventricular septal defect with severe pulmonary hypertension is reported. Operative indication that is denied was finally decided by open lung biopsy. He had pulmonary arterial pressure of 120/42 (70) mmHg. The ratio of pulmonary to systemic systolic pressure was 0.91, the ratio Of pulmonary to systemic flow was 1.26, the ratio of pulmonary to systemic vascular resistance was 0.34, and pulmonary vascular resistance was 14.2 unit x m2. For the reason of difficulty, in determination of operative indication through hemodynamic study, he received open lung biopsy. Histological assessment from biopsy specimen revealed severe occlusive pulmonary vascular disease exhibiting grade IV on the Heath Edwards classification. Open lung biopsy occasionally be selected in case with difficult determination of operative indication in severe pulmonary hypertension is a useful tool.

Echocardiographic diagnosis of partial anomalous pulmonary venous connection from right upper lobe to the coronary sinus

A 36-year-old woman was admitted because of an enlarged right heart. Echocardiographic examination revealed an abnormal vessel connecting to the dilated coronary sinus. The abnormal vessel traveled in the direction from the right axillary to the left epigastric region. Partial anomalous pulmonary venous connection (PAPVC) from the right upper lobe to the coronary sinus was initially considered as a possible diagnosis by echocardiography. At surgery, diagnosis of an isolated PAPVC of the right upper pulmonary vein to the coronary sinus was confirmed.

Acute aortic dissection in a patient with osteogenesis imperfecta

A case of osteogenesis imperfecta complicated with acute type A aortic dissection is presented. Emergency graft replacement of the ascending aorta was performed successfully despite the anticipated difficulties with tissue friability. Therefore, such an operation is suggested to be worthy of consideration and feasible in patients with osteogenesis imperfecta.