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We present a case of acute pulmonary embolism (APE) after cesarean section. A cesarean section was performed on a 27-year old woman with normal course. However, one day after operation, she suddenly developed syncope and dyspnea. Soon after the symptom, she developed hypotension 60 mmHg. As a result of various examinations, her illness was diagnosed as APE with right ventricular dysfunction after cesarean section. She was consulted to our hospital for treatment. Soon after her arrival, we treated her for both APE and cardiogenic shock. The combined with antithrombotic therapy using heparin sodium, was successfully treated the patient from cardiogenic shock due to APE with right ventricular dysfunction after cesarean section.

Between January 1997 and November 1999, 31 patients underwent combined valve and coronary artery bypass grafting (CABG) surgery in our institute. There was no hospital death and clinical symptom improved in all patients after surgery. Mean follow-up was 16.3 months. The actuarial survival rate was 96.8% at 1 year. There were 4 late deaths (CHF in 3, arrhythmia in 1). Tepid blood cardioplegia was effective for those operations. Operation of CABG combined with valve surgery or LV surgery could be safely performed. We therefore considered that complete correction of the lesion with not only CABG but also combined valve surgery or LV surgery was the procedures of choice in patients with complicated lesions.

The purpose of the study is to assess the clinical and hemodynamic performance of aortic valve replacement (AVR) with the Freestyle bioprosthesis.Twenty-one patients received AVR with a Freestyle aortic root bio-prosthesis between May 1998 and October 1999. Eighteen patients underwent AVR with subcoronary method and three patients with aortic root (full root) method. Patients were evaluated postoperatively at discharge by clinical examination and color Doppler echocardiography.There was one death due to multi-organ failure. No patients experienced valve deterioration, paravalvular leak, unacceptable hemodynamic performance, nor thromboembolic event. Excellent function is demonstrated by very low gradient (mean gradient 7.2 +/- 4.7 mmHg) through aortic valve and no significant aortic regurgitation (none: 11, trivial/mild: 10). All patients had been in New York Heart Association Functional Class III and IV preoperatively, and after surgery, 17 patients were in Class I, and 3 were in Class II.The Freestyle bioprosthesis has good clinical and hemodynamic performance without Coumadin. Further follow-up is required to evaluated valve durability.

We experienced a case of familial cardiac myxoma observed in a mother and her daughter. A 58-year-old woman was addmited to our hospital because of repeated cerebral embolism. Echocardiography showed a left atrial myxoma to be considered as the cause of cerebral embolism. At the operation, 3 myxomas were found in the left atrium, and were removed successfully. No recurrence has been observed for 14 years after the operation. Three years after that, her 3rd child, 31-year-old-women, suffered from cerebral embolism and was also diagnosed as a left atrial myxoma. A friable myxoma was removed with the interatrial septum. She had no recurrence for 11 years after the operation. In patients with cardiac myxoma who have unusual biologic behavior, including familial myxoma, "complex" type myxoma must be suspected. We suggest that it is important to distinguish patients with "complex" type myxoma, because the recurrence rate is much higher in those than in patients with "sporadic" type myxoma.

From January 1992 through December 1993, 31 patients underwent myocardial revascularization with the inferior epigastric artery (IEA) graft. There were one emergency case and four coronary reoperation cases. IEA grafts were taken down through the left side paramedian incision and dilated with papaverine hydrochloride solution. The distal anastomoses were made to left anterior descending (3 cases), diagonal (14 cases), obtuse marginal (9 cases), postero-lateral (I case) and right coronary artery (4 cases). The proximal anastomoses were made to the aorta (22 cases), the hood of a new vein graft (4 cases) and the hood of an old vein graft (4 cases). When IEA was not long enough to reach the ascending aorta, it was anastomosed to the internal thoracic artery (2 cases) or the gastroepiploic artery (1 case) graft. There was one hospital death, and early patency rate (within one month) was 90% (19/21). The postoperative angiography performed at 1.3 years or 2 years showed excellent IEA graft patency. These results suggested that the IEA is suitable as a coronary artery bypass graft. Further long-term patency must be evaluated.

A 66-year-old woman was referred to our hospital because of cerebral infarction, myocardial infarction and renal infarction. Further examination indicated that she was suffering from mitral valve stenosis with a floating thrombus in the left atrium. She underwent emergency mitral valve replacement and thrombectomy. The thrombus was attached to the left atrium by only four thin and weak strings and removed easily. We think that the thrombus was the precursor of a free-floating ball thrombus without stalk.

Coronary artery bypass grafting in a 68-year-old woman with familial hypercholesterolemia and severe calcification of the ascending aorta was successfully performed. The left internal thoracic artery bypassed the left anterior descending artery, the right gastroepiploic artery bypassed the left circumflex artery and the saphenous vein graft bypassed the right coronary artery, the proximal anastomosis was based on segment 1 and the distal anastomosis was on segment 3 of the right coronary artery (coronary-coronary bypass). The operation was performed with aortic no touch technique which consisted of fibrillatory arrest without aortic cross-clamping, and femoral artery perfusion. The post operative angiogram revealed patency of all graft, and she discharged at 20th post operative day. Coronary-coronary bypass was took into consideration in a patient with severe calcification of the ascending aorta and without suitable in situ arterial graft.

We report a case of successful reoperation of coronary revascularization without cardiopulmonary bypass. The patient was a 62-year-old man, who had undergone coronary artery bypass grafting (CABG) to the LAD and CX with two saphenous vein grafts (SVG) for the left main lesion 12 years before. He required reoperation for unstable angina due to progressive ischemic heart disease and the diseased SVG. Preoperative coronary angiogram revealed total occlusion of major 3 branches and the diseased SVG to the LAD. The reoperation was performed without cardiopulmonary bypass through the repeated median sternotomy for revascularization of the LAD and RCA. The left internal thoracic artery and the gastroepiploic artery were anastomosed to the LAD and RCA under the beating heart without any hemodynamic or electrocardiographic deteriorations. The operation was uneventfully finished in 3 hr 40 min. without the use of blood products. Postoperative angiogram showed both new grafts were widely patent, and he was discharged 14 days after the operation without angina. We also performed 4 other cases of reoperative CABG without cardiopulmonary bypass, and conclude that this technique is a safe and effective alternative in a carefully selected group of patients for reoperative CABG to reduce several technical problems related to coronary reoperation.

Coronary artery bypass grafting (CABG) was performed using saphenous vein grafts anastomosed in reversed Y-shaped in two patients because of the atherosclerotic ascending aorta. Postoperative course was uneventful, however, the common part of reversed Y-shaped grafts was occluded in both patients within two years after operations. The arms of reversed Y-shaped grafts were patent, and played a role of major collateral between LAD and RCA. They were treated successfully with reoperation in one patient and PTCA in another.

We report a case of 50-year-old male underwent reoperative coronary artery bypass grafting (CABG) through the left thoracotomy. He had undergone primary CABG with a saphenous vein graft to the left anterior descending coronary artery (LAD) to revascularize the left main trunk lesion a year ago, which was occluded, and recurred angina. The second operation was performed through the left thoracotomy under the the hypothermic cardiopulmonary bypass. The left internal thoracic artery was anastomosed to LAD, and a new saphenous vein was anastomosed to the descending aorta proximally, and to the left circumflex artery distally, under a hypothermic circulatory arrest (9 minutes and 8 minutes for each anastomosis). He recovered well without any major complications, and postoperative angiogram showed two new grafts patent.

59 cases of late cardiac tamponade following open heart surgery were studied. The incidence was 2.1%. Postoperative prolonged heart failure, anticoagulants, and blood in the pericardium left undrained may play a role in its pathogenesis. Echocardiography was the sure method of diagnosis. Insertion of a drainage tube into the pericardium through the subxiphoid approach was effective with minimal invasion and a treatment of choice.

Hemodynamic situation immediately after cardiopulmonary bypass was studied in cases of CABG using bilateral ITAs and right GEA. Though cardiac output was kept greater than 4.0 l/min, the blood pressure soon after weaning from cardiopulmonary bypass was low in patients who necessitated further circulatory assist, intraaortic balloon pumping (IABP) and/or additional surgical bypass procedure. In cases of CABG using arterial grafts and no vein graft, the perfusion pressure is most important to stabilize the hemodynamic status because low pressure may provoke peripheral vasoconstriction resulting in spastic reaction of the ITA and GEA. These arterial grafts seemed to keep the characteristics as the peripheral artery. Some papers pointed out less flow capacity of arterial grafts compared with that of saphenous vein graft, but CABG with arterial grafts alone was safe clinically if care is taken for keeping the perfusion pressure as high as preoperatively.

We performed coronary artery bypass grafting (CABG) in a 80-year-old male with calcified ascending aorta and severe varicose veins utilizing the bilateral internal thoracic arteries and the right gastroepiploic artery under fibrillatory arrest without aortic cross-clamp (aortic no-touch technique). After triple coronary artery bypass grafting was completed, heart failure occurred. Additional Bioflow graft to the circumflex artery restored good cardiac function. The aortic no-touch technique is a useful method for CABG in patients with severe calcified ascending aorta. This experience suggests that the Bioflow graft is a helpful conduit at an urgent situation in CABG.

The cases of acute pulmonary thromboembolism after coronary artery bypass surgery have been rarely reported in Japan. We, however, experienced 2 cases of them and lost them against intensive therapy. In Mitsui Memorial Hospital, 6 cases of pulmonary thromboembolism had been diagnosed in 1990 (0.074% in admission patients), four of the cases had occurred following surgical procedures. Its manifestations are deceivingly nonspecific and are difficult to distinguish perioperative myocardial infarction, pericardial tamponade, and pneumothorax, especially in postoperative states. We would like to emphasize that acute pulmonary thromboembolism is getting important problems also in Japan.

A 62-year-old man with both coronary artery disease and leg ischemia was successfully treated with a combined revascularization procedure. Coronary artery bypass grafting (CABG) was carried out using in situ left internal thoracic artery and right gastroepiploic artery grafts, and bilateral femoropopliteal bypass grafting were performed reversed saphenous vein grafts simultaneously. The patient recovered well and experienced neither angina nor intermittent claudication.

A case of the elder PDA with aneurysm of the main pulmonary artery is reported. The patient was a 59-year-old female who had been suffering from severe heart failure. The PDA was closed directly from inside of the pulmonary artery using balloon catheter under usual cardiopulmonary bypass with limited circulatory arrest, and the aneurysm was repaired by aneurysmorrhaphy. The postoperative course was uneventful and she was discharged after 34 postoperative days. The pathological finding of the aneurysm of the main pulmonary artery is a cystic mucoid degeneration like a finding of Marfan syndrome. The etiology of the aneurysm of the main pulmonary artery seems to be extended Ao-PA shunt besides somewhat congenital change of the pulmonary artery.

The surgical treatment of the aortic regurgitation with aneurysm of ascending aorta has been considered by Wheat, Bentall and Cabrol as improved combined techniques. 24 cases of the aortic regurgitation with aneurysm of ascending aorta that had been operated in Mitsui Memorial Hospital from November 1975 to August 1990 were examined their late results with the classification of 3 types of operative techniques (aortic valve replacement alone, Bentall's procedure, and Cabrol's procedure). 5 cases of them with aortic valve replacement alone were elected by their aortic angiographic findings, were not significant differences in their late results in the other cases with Bentall's or Cabrol's procedures. So we considered that treatment of the ascending aortic aneurysm with aortic regurgitation would not be necessary to operate with the combined techniques, but their selection of the indication would be limited in the cases that were not widened in aortic ring diameter in their preoperative angiography, and not complicated the systemic diseases such as Marfan's syndrome.

We report two cases simultaneously operated on CABG using rt. GEA and cholecystectomy for silent gallstone detected by routine preoperative examinations. We prefer that two different procedures are performed simultaneously even if gallstone is asymptomatic, for about 50% of silent gallstone is said to become symptomatic within further five years in the literature and the pedicle of rt. GEA may be troublesome during cholecystectomy.

Coronary artery bypass grafting with combined arterial graft using the left internal mammary artery (IMA), right IMA, and the right gastroepiploic artery (GEA) was performed in 45 patients with saphenous vein graft (SVG) (29 patients) or without SVG (16 patients) from February 1989 to October 1989. The left IMA was used in all patients, the right IMA was used in 9 patients, and the GEA was used in 43 patients. Perioperative myocardial infarction was noted in two patients who had hospital deaths. Reopening the chest for postoperative bleeding was performed in two patients, and the cerebral accident was noted in one patient. Fourteen patients were operated on without the requirement for blood transfusion. Studied within 3 postoperative months, all arterial grafts were patent though the patency was 97.7% (43/44) in SVG. It is concluded that the combined arterial graft utilizing the IMAs and GEA can be used safely and effectively.

The long term (10 to 15 years) results of coronary artery bypass grafting (CABG) were studied in 20 patients. The duration of follow-up was ranged from 130 to 170 months with mean 146.4 months. Ten out of 20 patients underwent coronary angiography (CAG), which disclosed that the late patency of saphenous vein (SV) grafts was 68.8% (11/16), but 54.5% (6/11) of patent SV grafts showed atherosclerotic changes such as irregularity and localized narrowing. On the other hand, internal thoracic artery (ITA) grafts were all patent without any atherosclerotic luminal changes. We recognized that ITA grafts were superior to SV grafts from an angiographic standpoint of view in the long term in Japan.

A total of ten patients have undergone sequential bypass grafting of the internal mammary artery (IMA) to the coronary arteries at Osaka Medical College. Operative procedures included left IMA bypass to the left anterior descending (LAD) artery and its major diagonal branch in six patients; to the obtuse marginal branch and diagonal branch in three patients; and to the first and the second diagonal branches in one patient. The right internal mammary artery was concomitantly utilized in 4 patients and saphenous vein graft was also utilized in 6 patients. Postoperative angiographic studies were performed in nine patients within 6 months after operation and in all 18 sites of IMA anastomoses, the IMA sequential grafts were patent. Since sequential IMA-coronary bypass technique means the increase of arterial graft, we believe that this technique should be used for multivessel coronary revascularization especially in younger patients.

Since March 1986, coronary artery bypass grafting (CABG) by utilizing the right gastroepiploic artery (GEA) has been performed in 60 patients during 3 year period. There were 52 males and 8 females, and age ranged from 34 to 73 year old with the mean of 56.2 year old. Triple vessel disease and the left main disease involved 90% of the patients. There were two patients under hemodialysis for chronic renal failure, one patient with idiopathic thrombocytopenic purpura, one patient with aneurysm of the abdominal aorta, and two patients with arteriosclerosis obliterance, preoperatively. Five patients were second CABG. GEA was used as an in-situ graft in 57 patients and as a free graft in 3 patients and was anastomosed to 3 left anterior descending, 3 diagonal (all "free" graft), 5 circumflex, and 49 right coronary arteries. To bypass the other coronary arteries, the internal mammary artery graft (unilateral 38, bilateral 20, sequential 5) with or without saphenous vein graft was used. The mean number of distal anastomoses was 3.3 (1-5) and the mean number of arterial graft anastomoses was 2.4 (1-4) per patient with the mean aortic cross clamp time of 62.4 minutes (23-137 minutes) and the mean cardiopulmonary bypass time of 120.8 minutes (69-210 minutes). Splenectomy, Y graft replacement of the abdominal aorta, and ascending aorta-bifemoral bypass were concomitantly carried out in each one patient. Two patients (3.3%) died of renal and cardiac failure within 30 postoperative days. One patient (1.7%) died of stroke lately. New Q wave was noted in 2 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The in-situ left internal mammary artery (LIMA) was anastomosed to the circumflex coronary artery (Cx) in 20 patients. The right internal mammary artery, the saphenous vein and the right gastroepiploic artery were also utilized to bypass the other coronary arteries. Sequential LIMA grafting to the diagonal branch and CX was performed in 2 patients. The sites of LIMA anastomosis were 15 obtuse marginal branches and 5 posterior lateral branches. All LIMA-Cx anastomoses were performed with single 8-0 polypropylene continuous suture technique. Mean number of distal anastomosis was 3.1 ranged from 2 to 4. Mean aortic cross clamp time was 68.5 minutes ranged from 42 to 87 minutes, and mean cardiopulmonary bypass time was 116.6 minutes ranged from 73 to 167 minutes. One patient died of renal failure at 22nd postoperative day, and the other patients were alive with relief of angina. New Q wave was noted in 1 patient. Postoperative angiogram at mean 2.0 months showed 100% patency of LIMA in restudied 12 patients. We concluded that the in-situ LIMA grafting to Cx system can be done with acceptably low mortality and excellent patency rate, and its utilization is particularly desirable in younger patients.

The use of the internal mammary artery (IMA) in coronary artery bypass grafting (CABG) is recently common. The authors have been actively using the IMA in graft of the anterior descending artery (LAD). However, there are cases in which the onset of ventricular fibrillation or low cardiac output occurred around weaning from CPB or chest closure. We have experienced 8 such cases, 3 of which expired due to LOS or renal failure. When the IMA is to be used in CABG, one must be extremely cautious in next cases. 1. Cases of 3 VD with good EF. 2. Cases of OMI in RCA area or not to be expected complete revascularization in inferior wall. 3. Cases in the absence of collateral between R and L coronaries. In such cases, IABP should be carried out and anastomosed with an additional saphenous vein graft (SVG) at that coronary artery.