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We introduce our technique for the treatment of aneurysms arising in the descending thoracic aorta and the thoracoabdominal aorta. Thoracotomy is performed at a single site. The costal arch is transected to ensure an adequate field of vision. A lifting hook is used to open the proximal side of the aorta. The diaphragm is not totally transected to preserve respiratory function after surgery. In principle, partial extracorporeal circulation is performed using a percutaneous cardiopulmonary support system. The dose of heparin for systemic treatment is limited to 50 U/kg. The abdominal branches are perfused with the use of balloon catheters. Cardiac arrest is induced for about 10 seconds by intravenous administration of adenosine triphosphate to avoid aortic injury when the proximal aorta is clamped during partial extracorporeal circulation and to prevent massive bleeding when the elephant trunk is clamped. To prevent paraplegia, the Adamkiewics artery and 2 pairs of adjacent intercostal arteries identified by preoperative computed tomography are reconstructed, and cerebrospinal drainage and motor evoked potential monitoring are performed. more...

From January 1990 to December 1996, 71 patients aged 33 to 79 years (mean 60 +/- 11) underwent an emergency operation for type A acute aortic dissection. Fifty-three (74.6%) survived, and were followed 7 to 94 months (mean follow up 2.9 +/- 1.8 years) after the first operation. Five patients underwent reoperation for dilatation of the distal false lumen 7 to 52 months (mean period, 25 months) after primary repair. One patient underwent replacement of the arch and descending aorta, three patients underwent replacement of the descending aorta, and one patient underwent the stented graft implantation, resulting in closure of the entry site. Three patients underwent reoperation for severe aortic valve regurgitation 12 to 31 months (mean period, 24 months) after primary repair. Two patients underwent aortic valve replacement, and one patient underwent aortic root replacement. The actuarial freedom from reoperations was 81 +/- 6.9% at 3 years, and 73 +/- 9.9% at 5 years. more...

Long-term results in QOL of patients over 75 years old after emergent cardiovascular surgery were examined. From January 1991 to June 1996, 46 patients underwent cardiovascular surgery. 22 patients who had elective surgery (elective group) and 15 patients who had emergency surgery (emergency group) tolerated with the operation: Two-year survival rate after surgery was 80.7% in the elective group and 78% in the emergency group, and relative survival rate was 0.89 in the elective group and 0.86 in the emergency group. As regards to the ability to live independently, 89% of elective group and 75% of emergency group showed good improvement, and there was no significant difference between two groups. The rate of patients who did not feel anxiety for disease at all was 61.1% in the elective group and 41.7% in the emergency group. The relationship between the patient and his family was good in both groups. For physical condition, the emergency group was superior to the elective group with no significant difference. Although QOL was relatively good after emergency surgery, some items were inferior compared with elective surgery. To improve the long-term results, elective surgery is required to avoid emergency surgery. more...

From 1978 through 1995, surgical treatment for active infective endocarditis (native valve) was performed in 17 patients. The indication for operation at the active phase was progressive heart failure in 5 (A-group) and uncontrolled infection in 12 (B-group). Operative findings showed vegetations in all cases, perforations of the valve in 6, rupture of tendon in 2, and annular abscesses in 2. One patient in B-group died 14 days after the operation with postoperative mediastinitis and sepsis. There was no perioperative complications in A-group. In B-group before operations 8 patients (66.7%) has an embolic event before operations. The anatomic sites of embolization were the central nervous system (3 patients), viscera (2 patient) and peripheral arteries (3 patients). And after operation there were 2 mycotic aneurysms of the hepatic artery and the popliteal artery, and 1 pyogenic spondylitis. We conclude that the risk of embolization is high in patients undergoing surgery at active phase of infective endocarditis because of uncontrolled infection ; thus, such patients should be carefully monitored for emboli and mycotic aneurysms. more...

Anomalous origin of the left coronary artery from the pulmonary artery is a very rare congenital malformation. Re-coronary artery bypass grafting was performed in a 18-year-old man who had received coronary artery reconstruction with a homologous saphenous vein (from his mother) at 7-months old. After the first operation, clinical course was uneventful, but the patient became symptomatic because of effort angina at age 15. The electrocardiogram showed abnormal ST segments in Lead V2-5 and abnormal T waves in Lead V5-6. Coronary arteriography revealed that saphenous vein graft was occluded. The left internal thoracic artery (LITA) was anastomosed to the left anterior descending artery and a two coronary system was established. Postoperative angiography revealed that LITA was patent, and relief of angina was obtained. more...

Delayed sternal closure (DSC) was used for 4 patients undergoing various cardiac reoperations to control perioperative hemorrhage. DSC was performed 48-72 hours later. All patients left the hospital alive and in good condition. The only recognized complication was an abscess formation around the bleeding area, which was successfully treated with systemic antibiotics. The remaining 3 patients manifested no infections. In two of these patients, hemodynamic instability was continued because of right ventricular outflow tract obstruction by compression of the packs which were left over the bleeding area. The function of coagulation of the blood was recovered except prothrombin time (PT) at the time of definitive closure of the chest. Recovery of the function of coagulation was useful in deciding the timing of DSC than hemodynamic state. more...

Causes of some complications such as pyrexia, fluid accumulation and unusual scar formation around the graft in "Hemashield" implantation were examined both in vivo and in vitro. In an animal study, the grafts were implanted in the thoracic descending aorta of 9 dogs, and were explanted at 2 weeks after implantation. Macroscopic evaluation of the explants revealed that the graft had no infection, but fluid accumulation and a thick scar layer formation were noticed in the pleural cavity and around the graft. Microscopical observations demonstrated that the impregnated collagen was almost absorbed and numerous plasma cells, lymphocytes and macrophages had infiltrated in the interstices of the Dacron fibers, but neither fibroblasts nor capillary blood vessels. Numerous erythrocyte were also noticed in the graft wall. In vivo experiment of the extract from Hemashield, endotoxin and/or (1-3) beta-D-glucan were detected by the special quantitative methods; Toxicolor and Endospecy. These results indicated that the graft had some contaminants which contained a certain amount of endotoxin, (1-3) beta-D-glucan, resulting in non-infective inflammatory responses around the graft. more...

In clinical use, the Gelseal Triaxial graft have been shown to have several problems, such as pyrexia, pleural effusion and seroma formation around the graft. To investigate the cause of these complications, we examined mechanical and biological properties of the graft. The water permeability was found to be 0 ml at 120 mmHg in an in vitro study. Scanning electron microscopical observation revealed that gelatin in the graft wall was not uniform and easily detached from the luminal surface. The amount of impregnated gelatin in the graft was found to be 6.73 mg/cm2. In addition, this graft contained 297 and 73 pg endotoxin in extract/g of graft wt at 25 degrees C 72 hrs as assessed by Toxicolor and Endospecy pyrogen tests, respectively. The grafts were implanted in the descending aorta of 8 dogs for 2 weeks in an animal study. Three out of 8 animals died of graft occlusion. Both macroscopic and microscopic evaluations of the explants from 5 dogs showed that neither fibroblasts nor capillary blood vessels had infiltrated in some area of the graft wall. Serous fluid was found to be retained between the graft and the surrounding host tissue in three cases. These results indicated that the Gelseal graft was easy to implant due to zero porosity, but the coated gelatin was not clean and gelatin was easily detachable. Hence, the graft would be prone to some complications such as pyrexia, immune response, thromboembolism, seroma, and pleural effusion. One must be aware of the potential disadvantages of the Gelseal grafts before using it in patients. more...

Since October 1984 to December 1992, 47 aortic arch replacements were performed under selective cerebral perfusion (SCP). Patient age ranged from 19 to 81 years, with an average of 60.2 years. Thirty one patients were male and 16 female. Twenty patients were diagnosed with dissecting aneurysms, 27 true aneurysms. The operative mortality was 14 out of 47 (29.8%) over all. The mortality of dissecting aneurysm related acuity that is 5 of 9 (55.6%) for patients in acute phase, against none in chronic. The operative mortality of true aneurysms was 6 out of 11 (54.5%) for patients who had emergency operation, against 3 out of 16 (18.8%) scheduled, extensive surgery. Cerebral disorders developed on 8 patients out of 44 (18.2%, except 3 operative deaths). The mortality rate of cerebral disorder was 6 out of 8 (75.0%). Six patients with true aneurysm had cerebral infarctions after the surgery. Two patients had already cerebral disorders in advance the surgery. The cause of cerebral infarction was resumed by atherosclerotic materials. Our operative results indicate that cerebral disorder subsequently affects the mortality of aortic arch replacement. For the prevention of cerebral infarction, we modified the method of SCP. We start the SCP at the initiation of total cardiopulmonary bypass, routinely associated to an aortic clamp and cardiac arrest under myocardial protective procedure that is the use of perfusion cooling (30 degrees C, monitored at the esophagus), topical cooling and cold Saint Thomas solution infused in the coronary arteries. When aortic arch replacement is done, we need to make sure a good restarting of the heart and a good recovery of the systemic circulation.(ABSTRACT TRUNCATED AT 250 WORDS) more...

A 59-year-old man had developed gradual prominence of the aortic knob in a chest X-ray film after a blunt chest trauma. Two and a half years after trauma, an angiogram revealed the aberrant right subclavian artery and a saccular aneurysm at the thoracic descending aorta just distal to it. It was treated with patch closure of the entrance of the aneurysm under a temporary bypass. Pathological findings were tearing off of a medial layer of the aorta. Postoperative course of this case was excellent. It must be noticed that the traumatic thoracic aortic aneurysm had a high possibility of rupture even in the chronic stage. more...

A 21-year-old male with ruptured aneurysm of sinus of Valsalva caused by bacterial endocarditis is presented. The patient complained of palpitation and a attack of fever. Continuous murmur was heard with a thrill at the third intercostal space of the left sternal border. On plain chest x-ray film pulmonary congestion and increase in pulmonary flow were observed. Cardiac catheterization showed step up of oxygen contents at the level of right ventricle and left to right shunt of 36.5%. Aortography demonstrated the aneurysm of the sinus of Valsalva ruptured to right ventricle. The operation was performed by right ventricular approach. Aneurysmal sac was resected and its orifice was closed with mattress sutures. Bacteriological examination at the time of operation revealed Staphylococcus aureus. Postoperative course was uneventful. more...