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Endoventricular circular patch plasty (EVCPP; Dor's operation) for akinesis or dyskinesis in patients with ischemic heart disease may improve the cardiac function and prognosis. In this paper, the operative results are reviewed based on the reports in the literature and the author's experience. EVCPP was performed in patients with large dyskinesis and global akinesis. The akinetic left ventricular wall was excluded with an oval patch and the left ventricle was restored. In Dor's report, 49 patients with akinesis underwent EVCPP with a 10% mortality rate, and left ventricular function improved after surgery. The ejection fraction (EF) improved from 23% to 38% and end-diastolic volume index (EDVI) improved from 248 ml/m2 to 107 ml/m2. Recently, it was reported that the 8-year survival rate in 59 patients with akinesis was similar to that in 49 patients with large dyskinesis. In the author's experience there were 10 hospital deaths in 81 patients with akinesis, and 17 patients died in the late follow-up period, while 53 patients were in NYHA class I or II after surgery. The EF improved from 24% to 36% and the EDVI improved from 153 ml/m2 to 103 ml/m2. The EVCPP is effective in patients with ischemic cardiomyopathy to improve postoperative cardiac function and prognosis.

Between August 1981 and August 1992, operation for ventricular septal perforation (VSP) after acute myocardial infarction (AMI) was performed in 12 patients and the results were studied. During this period, medical treatment was attempted as a standard therapy for more than two weeks after AMI, followed by operation. However, only four patients received elective operation two weeks after the onset of AMI. Regarding the relationship between the preoperative circulatory status and timing of surgery, elective operative could not be performed in seven patients showing a pulmonary to systemic flow ratio (Qp/Qs) of more than 3.0, while four out of five patients with a ratio of less than 3.0 received operation more than two weeks after the onset of AMI. Two patients with severe right heart failure after the repair of VSP died on table without weaning from the pump. Ten operative survivors were weaned from the pump without any difficulty of hemostasis and intraaortic balloon pumping was removed after operation. However, three patients died of multiple organ failure which had been deteriorating before operation. Postoperative activity improved to New York Heart Association Functional Class I or II in six survivors for the late follow-up period. In the case of high Qp/Qs due to VSP, early operation is recommended to prevent multiple organ failure.

The effect of additional albumin in crystalloid cardioplegic solution (CS) was investigated for infant with open heart surgery. Patients were divided into two groups; CS containing with or without 1% albumin. CS without albumin was administered for Group-I in 13 patients and CS with albumin for Group-II in 14 patients. The blood samples were collected from radial artery and coronary sinus at 5, 15 and 30 minutes after reperfusion and blood gas analysis, hemoglobin, lactate, creatine kinase-MB (CK-MB) and malondialdehyde (MDA) were measured. In percentage of CK-MB secretion, no significant differences were seen between two groups. However, in oxygen consumption, lactate and MDA secretion, significant differences between the groups were noted at five minutes after reperfusion. In conclusion, additional albumin in CS solution, especially in infant cases was effective for myocardial preservation immediately after reperfusion.

We studied the effect of additional albumin in preservation solution on reperfusion after immersion of isolated rat hearts by measuring cardiac function, myocardial enzymes and calcium. Male Wistar rats weighing 300 gr to 450 gr were used. Isolated rat hearts were arrested by cardioplegic solution and washed out with preservation solution. Then, the hearts were immersed at 4 degrees C for six hours. The group was divided into four by the concentration of additional albumin in preservation solution which basically consisted of Euro-Collins solution. In control group, the cardiac function was immediately measured after the heart was isolated. Albumin was not added in group I (n = 16), 2% of albumin in group II (n = 18), 5% of albumin in group III (n = 17) and 7% of albumin in group IV (n = 18). There were no significant differences between groups II and III in cardiac function and myocardial enzymes. The levels of myocardial malondialdehyde (nmol/g dry weight) and calcium (mumol/g dry weight) at 15 minutes after reperfusion were 279.3 +/- 38.1, 5.9 +/- 5.3 in group I; 243.3 +/- 86.5, 4.1 +/- 2.0 in group II; 217.1 +/- 106.6, 4.1 +/- 1.3 in group III and 274.9 +/- 77.1, 4.9 +/- 1.2 in group IV, respectively. Although no statistical significances were seen among those results, those data might suggest the relationship between the recovery of cardiac output and myocardial ATP contents. Those results also suggested that additional albumin with optimal concentration might inhibit reperfusion injury.

We studied clinical and immunological changes of the post-transfusional syndrome like graft versus host disease (GVDH) in six patients after open heart surgery and in one patient after hepatectomy. In the patient with hepatocellular carcinoma, transcatheter arterial embolization had been previously done. All patients received homologous blood transfusion during and after surgery and erythroderma associated hyperthermia occurred approximately 10 days after operation. Patients receiving open heart surgery died on between postoperative 17th and 21st day. One patient with hepatectomy died on the 29th day after operation. Skin biopsies in all patients showed the findings of acute GVHD. The number of CD3+ and CD4+ T lymphocytes decreased at postoperative day 1, however, the number of CD3+ T lymphocyte increased in three patients after postoperative day 14. The postoperative value of interleukin-2 production was low in patients in whom the value was measured. The immunological status in host has not been clearly resolved. However, the postoperative changes of lymphocytes subsets were abnormal and IL-2 production in two patients showed low level. Therefore, it was considered that pre and postoperative measurement of cell-modiated immunity might predict the occurrence of the post-transfusional GVHD and might be one of useful examinations to prevent the disease.

Early morphological and functional changes in arterial graft were studied. Autologous free graft of dog femoral artery or vein was implanted in the arterial system and the changes of endothelial cell by scanning electron microscope and prostacyclin levels were observed. In arterial graft, endothelial cell detachment after the implantation was rarely observed except the site with mechanical damage around the anastomosis. The site of cell detachment regenerated by 21 days after the implantation. The prostacyclin level was 2.5 pg/mg in venous graft or 35.9 pg/mg in arterial graft. The level in venous graft decreased after the implantation and it increased according to the cell regeneration, while the level was stable in arterial graft. The prostacyclin level of internal thoracic artery or gastroepiploic artery in clinical use was 54.5 pg/mg or 50.1 pg/mg, respectively. However the level in saphenous vein (SV) was 17.3 pg/mg and there were significant differences between the levels of arterial grafts and one of SV. Conclusively the arterial graft was superior to venous graft in early morphological and functional changes after the implantation and the superiority in early period after graft implantation may be one of the factor to contribute good graft patency in long term period.

The change of cell-mediated immunity was studied in patients receiving open heart surgery with or without administration of recombinant erythropoietin (rEPO). Group I was not administered rEPO in 30 patients, and Group II was done intravenously with 200U/kg/day of rEPO for 6.4 +/- 2.4 days before operation and also for 7.2 +/- 3.6 days after operation in 20 patients. The ratio of reticulocyte increased in all patients receiving rEPO. In both groups the ratios of OKT3 and OKT4 positive T lymphocytes decreased significantly on postoperative day 1. However, the ratios in patients with rEPO increased more significantly than in those without rEPO. Lymphocyte blast formation which was indicated by PHA-SI (phytohemagglutinin stimulation index) increased after administration of rEPO. The postoperative PHA-SI in both groups showed similar changes. The level of interleukin-2 (IL-2) production increased after the administration similar to PHA-SI change. The level of it decreased on postoperative day 1 and increased on postoperative days 3 and 7. We administered 200U/kg/day of rEPO for 7 days in a patient with postoperative erythroderma after open heart surgery and the level of IL-2 production was found to also increase in patient according with recovery of symptom. In conclusion, our data suggested that the rEPO might effect on not only erythrocyte but also lymphocyte activation.

During 10 years between 1981 and 1990 surgical treatment was performed in 77 elderly patients (emergency 19) for cardiovascular disease at the 2nd Dept of Kurume Univ. Hospital. The 58 elective patients were studied. There were CABG in 29; valve replacement in 18; aneurysm operation in 11. The control patients were consisted of CABG in 60; valve replacement in 40; and aneurysm operation in 20 patients whose age were under 60 years. In the elderly group, operative mortality was 3 in 58 (5.2%) and there were no significant differences compared to that in the control patients. However, low output syndrome or respiratory complication was relatively prevented in the elderly patients and careful post operative management was required. The late results in the elderly patients NYHA or exercise tolerance was improved well. The 5 years actuarial survival rate was 93.3% in ischemic heart disease group, 87.7% in valvular heart disease group, and 90.0% in thoracic aneurysm group. No significant difference was seen compared to these results in control patients and no significant differences among these diseases.

During the last two years and six months, ten patients underwent operation for both coronary artery disease and non-cardiac surgery. There were six patients with vascular disease, three with gastric cancer and one with cholelithiasis. Six patients had simultaneous operation of both coronary artery bypass grafting (CABG) and non-cardiac surgery, and four underwent non-cardiac surgery mean of 105 days after CABG. The number of significant lesions of coronary artery in patients with simultaneous or two-staged operation was 2.2 +/- 0.8 or 2.8 +/- 0.5 per patient, respectively. The operative time in patients with simultaneous operation was 361 +/- 49 minutes. However, in patients with staged operation the time for cardiac surgery was 380 +/- 36 minutes and the time for non-cardiac operation was 388 +/- 83 minutes. There were no patients with complications after either cardiac or non-cardiac operation. In patients having surgical indications for both coronary artery and non-cardiac diseases, CABG should be performed prior to the non-cardiac surgery. In patients with normal cardiac function and sufficient operative time after CABG, concomitant operation seemed to be recommended. In case with advanced malignant disease or incompetent cardiac function, staged operation would be selected for good surgical result.

Valvuloplasty is first applied as the surgical treatment for congenital mitral regurgitation (MR). Follow up study after the operation around the valvuloplasty was performed in the patients with congenital MR. In the patient under 12 years old, there were isolated MR in 3; MR associated with VSD in 14; MR and ASD in 3; MR with PDA in 10; and MR with ECD in 36. Operative methods were suturing of mitral cleft in 27; mitral annuloplasty in 17; mitral valve a, advancement in 7; cusp plasty in 4; no treatment for the MR in 14. Early death was noted in 6 cases (9.0% of mortality) and late death was noted in 3 cases (mortality rate of 9.0%). Conclusions were as follows: Surgical treatment was required in the patients with MR more severe than Sellers' Grade-II. Single suturing was recommended for the suturing of mitral cleft because shortening of the valve occurred in a few degree and the residual regurgitation reduced. Mitral valve advancement by elongation of the valvular apex was useful for the impediment of the regurgitation caused by incompetence of mitral coaptation. Mitral annuloplasty increased the effect for the impediment of the regurgitation. Ultrasonic cardiogram was useful for the follow up after the operation of the mitral valvuloplasty.

We compared the case like acute GVHD (graft versus host disease) induced by blood transfusion with the cases after open heart surgery which received blood transfusion by the measurement of cell-mediated immunity. Furthermore, we investigated the etiology of GVHD in comparison with cases according to age. Seventy-three cases (under 60 years old: 55 cases, over 60 years old: 18 cases) underwent open heart surgery and the mean blood transfusion volume was 2368cc and the mean age was 52.8 years old. After open heart surgery the rate of peripheral OKT3+ and OKT4+ cells, lymphocyte transformation and IL-2 (interleukin 2 product) were significantly decreased at postoperative day (POD) 1 and recovered to preoperative value until POD 14. However, in the cases like GVHD the rate of OKT4+ cell was decreased in contrast with the change of OKT8+ cell, and lymphocyte transformation and IL-2 production did not recover to normal range postoperatively. In conclusion, in the cases like GVHD the postoperative charge of cell-immunity is similar to the acute GVHD induced after bone marrow transplantation and we must take care about the blood transfusion to the older patients after open heart surgery because there is a possibility that cell-mediated immunity may be more depressed in the elder patient pre and postoperatively.

Between 1981 and 1988, 52 patients with dissecting aneurysms were operated and four of them (7.7%) had right coronary dissections that were repaired by Bentall's method with or without right coronary bypass grafting (CABG). Three (8.5%) of 35 patients with thoracic aneurysms had coronary disease. Among them, two had one vessel disease (1VD) and one had 2VD; two underwent temporary axillofemoral bypass grafting (AFBG) without CABG and one underwent extracorporeal circulation with CABG. Eight (5.6%) of 142 patients with abdominal aneurysms had coronary disease. They consisted of three patients with 1VD, two with 2VD and three with 3VD; their ejection fraction rates were 0.46 to 0.75. Three of them underwent temporary AFBG and one first underwent CABG but later underwent abdominal aortic graft replacement. In conclusion, patients with good coronary distal run-off and a low ejection fraction rate (under 0.5) should initially undergo CABG, but for those with poor run-off, temporary AFBG is better to prevent cardiac afterload.