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We report successful aortic arch replacement using continuous retrograde cerebral perfusion (CRCP) for the three cases of ruptured distal aortic arch aneurysm (DAAA) into the left lung. All of them, who had preoperative episodes of hemosputum and hemoptysis, were diagnosed rupture of DAAA into the lung with computed tomography, magnetic resonance image, aortography or transesophageal echo. Following urgent graft replacement of the aortic arch or repair of the rupture on the suture line in the previous arch vessel reconstruction was carried out safely through median sternotomy approach. The left upper lobe of lung adherent tightly to the DAAA wall was not dissected to prevent the lung from bleeding, air leakage and infection. All of them, who awoke smoothly after CRCP, did not developed any pulmonary complications and survived uneventually. We concluded that median approach and not tearing lung from DAAA wall might be key-points for successful operation in cases of ruptured DAAA into lung and that CRCP is an safe and useful method to protect brain in such cases.

We report a rare case of coronary artery perforation by a guide wire for percutaneous transluminal coronary angioplasty (PTCA) complicating with postinfarction cardiac rupture (oozing type). The patient had acute myocardial infarction on the extensive anterior wall and developed cardiac rupture followed by serious cardiac tamponade during the emergency PTCA several hours after tissue plasminogen activator (t-PA) given intravenously. The meandering left anterior descending artery (LAD) was found injured by a PTCA guide wire apart from a small oozing-type cardiac rupture near the apex. We repaired urgently the perforated LAD as well as the ruptured left ventricle. It is thus suggested that coronary artery perforation by a PTCA guide wire may occur on meandering coronary arteries and develop a serious hemorrhagic complication, particularly after thrombolytic therapy.

In relation to the aortic arch operation, atherosclerotic lesions in this area was investigated in autopsy specimen. Fifty specimens of the aorta with severe atherosclerotic lesions were chosen from 182 autopsies of patients older than 70 years at Tenri Hospital. The aortic arch and the adjacent aorta were divided into 9 segments (three portions around orifices of the arch tributaries [1-3], the ascending aorta proximal to the branchiocephalic artery [4], the descending aorta distal to the left subclavian artery [5], and 4 portions of the aortic arch which consisted with proximal anterior [6], distal anterior [7], proximal posterior [8], and distal posterior wall [9]) as shown in the figure. The degree of atherosclerosis was scored by Gore-Tejada atherosclerosis index (ASCI). The ASCI of the arch (12.7) was significantly higher than the ascending aorta (5.3). (p0.05). Among 9 segments of the aortic arch, the ASCIs of the anterior wall of the distal arch (25.1), the aorta distal to the left subclavian artery (17.3), the arch around the orifice of the brachiocephalic artery (17.1) were significantly higher. The ulcerative plaques were predominantly found at the anterior wall of the distal arch (36%). On the other hand, the calcified plaques were predominantly found around the orifice of the brachiocephalic artery (26%). Ten specimens demonstrated significant stenosis at the orifice of the left subclavian artery. From this autopsy study, the degree of atherosclerotic lesion was predominant at the anterior wall of the distal aortic arch and at around the orifice of the brachiocephalic artery.(ABSTRACT TRUNCATED AT 250 WORDS)

Deep hypothermic circulatory arrest (DHCA) was introduced as an adjunct for operations involving aortic arch lesions in 1970's and has since been widely used. Profound hypothermia protects the brain and other vital organs by reducing metabolic rate. We initiated the use of continuous retrograde cerebral perfusion (CRCP) via the superior vena cava during DHCA in 1987. We studied 15 patients who required DHCA and CRCP during repair or replacement of the aortic arch. CRCP times ranged from 11 to 78 (mean +/- S.D.; 37.3 +/- 21) minutes, and minimal nasopharyngeal temperatures ranged from 13.7 to 25 (17.7 +/- 2.6) degrees C. Two patients died one month postoperatively due to preoperative disease. Three patients, who were in shock preoperatively due to cardiac tamponade, developed acute renal failure postoperatively. The remaining patients were weaned from the respirator by the 2nd postoperative day. No patient had CRCP-related complications. During CRCP, the partial pressure of oxygen (PO2), saturation of oxygen (SO2), and oxygen content significantly decreased (p0.001), and the partial pressure of carbon dioxide (PCO2) and CO2 content significantly increased (p0.001) between retrogradely perfused blood and blood draining from the arch vessels. These results most probably reflected that the aerobic metabolism of the brain was maintained by CRCP while the central nervous system was maintained in a hypothermic state, with oxygen and substrate availability, wash-out of metabolites, and buffering capacity and oncotic pressure of the blood maintained. This technique offers the potentials of sufficient metabolic support to the brain during DHCA and prolonged safe time limits of DHCA.

A 64-year-old man underwent CABG. 18000 unit of bovine lung heparin was used during operation for extracorporeal circulation and small amount of heparin was injected until the 5th postoperative day to keep intravenous line patent. His postoperative course was uneventful until the 10th postoperative day when marked ecchymosis developed on his eyelid. Laboratory data showed marked thrombocytopenia (1.3 x 10(4)/microliters) and disseminated intravascular coagulation. The diagnosis of heparin-induced thrombocytopenia (HIT) was confirmed by platelet aggregation test with heparin. Gabexate mesilate and platelet-concentrates were administered and platelet count returned to normal within a week. HIT usually occurs during administration of heparin. In this case, it occurred 5 days after we stopped heparin. Delayed onset of HIT might be related to delayed metabolism of heparin due to postoperative fluid shift.

We followed up thirty-three patients, to whom the superior vena cava-pulmonary artery anastomosis (Glenn procedure) was undergone between April 1966 and March 1988. There were eighteen patients with single ventricle and nine with tricuspid atresia, two with pulmonary atresia with intact ventricular septum and four with other complex anomalies. Seven patients (21%), including six with single ventricle, died 0.3 to 14.9 years after operation. Regurgitation of common atrioventricular valve was the cause of death in three patients. Serum hemoglobin level fell down from 19.3 +/- 2.2 g/dl preoperatively to 15.3 +/- 1.9 g/dl after operation but increased gradually to the preoperative level about ten years later. The actuarial survival rate at ten years is 80%. Reoperation was performed in 9 patients and reoperation free rate at 10 years is 78%. This analysis suggests that Glenn procedure is still good palliative operation for ten years, although some patients will be necessitated the second operation in future.