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It is obvious that there are many controversies regarding to the treatment of aortic dissection. In this report, we discuss following points such as 1) classification, 2) thrombosed type dissection, and 3) simultaneous graft replacement of ascending and aortic arch with the reconstruction of cervical branches. From the patho-morphological status, dissection will be classified into two types, localized and extended types. From the anatomical and surgical points of view, it will be also classified as 1) ascending-arch, 2) descending-thoracoabdominal, and 3) abdominal. With the combination of these two, dissection will be classified more clearly. The thrombosed type will be incorporated into localized type. We have experienced 76 cases of this dissection, and clinical features and outcome by medical treatment only are presented. The simultaneous reconstruction of ascending aorta and aortic arch for the dissection at ascending-arch type was undertaken in total of 35 patients. The surgical results as well as follow up data are presented and the benefit of this extended procedure is presented as well.

On the bases of the initial and follow-up results of patients who underwent percutaneous transluminal coronary angioplasty (PTCA) and percutaneous transvenous mitral commissurotomy (PTMC), the proper applications of these interventional therapies were discussed. The efficacy of PTMC on valvotomy was comparable to open mitral commissurotomy and the procedural safety was noticed. Our results supported the use of PTMC for patients with plicable mitral valve. Despite the good and acceptable results of elective PTCA, low initial success rate and high incidence of major cardiac events including mortality was noted in the group of urgent PTCA for patients with multivessel lesions. The urgent use of PTCA for refractory unstable angina should be restricted to selected patients without high-risk multivessel lesions.

In order to elucidate the changes of the gastrointestinal hormones (GIH), glucose and/or lipid were administered orally in 54 pancreatectomized patients, 22 gastrectomized patients and 28 healthy volunteers before and after the surgery. Peripheral plasma levels of cholecystokinin (CCK), neurotensin (NT), gastric inhibitory polypeptide (GIP) and pancreatic polypeptide (PP) were measured for 180 min by radioimmunoassay specific for each CIH. Hyperresponses of CCK, NT and GIP were observed before surgery in patients with tumor of the pancreatic head. The lack of bile in the alimentary tract was confirmed as one of causative factors for the hyperresponse of NT. No significant change was observed in response of CCK, NT, CIP and PP after caudal pancreatectomy. The responses of CCK and GIP were normalized after pancreatoduodenectomy (PD) or total pancreatectomy (TP). The response of PP was decreased after PD or TP. Such change of GIP was not noted after gastrectomy. These changes of GIH after pancreatectomies were considered to be caused by surgical removal of the structures in which these GIH mainly located.

Thirteen patients with successful or unsuccessful delayed sternal closure (DSC) after open heart surgery were reviewed. The indications of DSC were cardiac dilatation in 12 patients and intractable bleeding in one. Patients were divided into two groups as follows: Group A of 7 patients with mediastinum being sealed by prosthetic material, and Group B of 6 patients with primary skin closure by mobilized skin-flap. Postoperative complications and prognosis were compared between these two groups. There were 6 long term survivors. In group A, there were 4 deaths, 2 from low output syndrome (LOS) and 2 from sepsis due to mediastinitis. In group B, 2 died of LOS and 1 died of multiple organ failure, while no patients developed mediastinitis. In patients with unsuccessful DSC, mainly due to poor hemodynamics, there found no tendencies of decrease in CVP and LAP levels and no reduction in the amount of catecholamine dosage prior to attempted DSC. In conclusion, 1) mediastinal isolation with primary skin closure seemed more effective for preventing mediastinitis than coverage with prosthetic materials, 2) DSC was possible when there were hemodynamic improvements with decrease in CVP and LAP levels, and reduction in catecholamine dosage, and 3) plastic surgical technique was useful for primary skin closure.

We encountered one case of carotid body tumor. The patient was a 63-year-old man. The tumor was 5 cm X 6 cm in size, and it was strongly adhered to the carotid artery. Therefore, the tumor was removed with combined resection of the adherent lesion of the carotid artery. During the operation, we used a temporary external bypass method to prevent brain damage. The resected part of the carotid artery was reconstructed with saphenous vein graft. Angiogram one year after operation showed good patency of the graft. In Japanese literature, this is the second report of carotid body tumor removed by temporary bypass and the first report of use of a external bypass tube.

A clinicopathologic study of 14 cases of thyroid carcinoma with tracheal infiltration and 70 control cases of thyroid carcinoma without tracheal infiltration was performed. The cases with tracheal infiltration were classified into well differentiated carcinoma in 5 cases, poorly differentiated carcinoma in 6, undifferentiated in 2, and squamous cell carcinoma in one, thus showing a higher frequency (54.5%) of poorly differentiated carcinoma than that (11.4%) in the control cases. A comparative study of biological behavior between well differentiated and poorly differentiated carcinomas revealed that the latter was more aggressive, and the lymphnode metastatic rate of which was higher. The prognosis of poorly differentiated carcinoma was poorer than that of well differentiated carcinoma. Selective en bloc resection of the tumor including the larynx and trachea was followed by the improved prognosis of advanced thyroid carcinoma with tracheal infiltration.

One hundred and eighty-two patients had been followed for 1 year or longer after aorto-coronary bypass grafting ( ACBG ). Four of them died in this follow-up period, one due to cardiac failure, 8 years postoperatively (p.o.), two due to malignant tumor and one due to an accident. About three quarters of patients improved p.o. into NYHA functional classification I, though no patients was in NYHA I preoperatively. More than 90% of patients with successful complete revascularization in left coronary artery and with a patent left anterior descending artery (LAD), improved into NYHA I. Four patients had reoperation due to the occluded graft to LAD in 4 months to 9 years p.o.. There was neither operative death nor late death 6 months to 4 years after reoperation. Patients with successful revascularization in left coronary artery had significant improvement in left ventricular function, but with unsuccessful one had less improvement. The patients with a history of myocardial infarction in successful revascularization in left coronary artery showed remarkable improvement of ejection fraction at rest and in elevation in LVEDP at exercise. These results show myocardial infarction causes irreversible functional and morphological damage and it could not be full recovered even after ACBG .

We studied cardiac rhythm in 167 patients with mitral stenosis following open mitral commissurotomy in the last 7 years. After surgery 76 patients (72%) out of 106 patients who presented atrial fibrillation before surgery were reverted back to sinus rhythm by D-C cardioversion. Forty-three patients (41%) maintained sinus rhythm at the time of discharge from hospital, and 30 patients (28%) maintained it for 2.5 years (average) after surgery. The actuarial maintenance rate of sinus rhythm was 50 + 11% 7 years after surgery in these 43 patients. Ninety-three% of the 30 patients who reverted to and maintained sinus rhythm improved to class I (New York Heart Association criteria), whereas 47% of the 78 patients who retained atrial fibrillation remained in class II or III after surgery. In 30 patients who reverted back to sinus rhythm and maintained it late postoperatively, the preoperative duration of atrial fibrillation was up to 5 years, and 35% of the patients had had atrial fibrillation for more than 1 year. Also, in 40% of these 30 patients, the preoperative cardiothoracic ratio was more than 60%. Therefore, in the patients who reverted to atrial fibrillation immediately after surgery, secondary D-C cardioversion should be performed under stable hemodynamic conditions 10 to 14 days after surgery, even if their preoperative duration of atrial fibrillation was more than 1 year or their preoperative cardiothoracic ratio was more than 60%.

Some recently developed problems in cardiac surgery for acquired heart diseases, in our department, have been discussed in this paper. Ischemic heart disease (IHD): Indication for aortocoronary bypass grafting (ACBG) has been extended for the patients with poor left ventricular function. The number of the patients, who are found to have IHD before general surgery have been increased. Surgical treatments for these patients, five with malignant tumor, and two with aneurysm of the descending aorta, were performed 16 days to 4 months after ACBG without any operative death. In three patients with lesions of carotid arteries, blood flow of the carotid arteries was monitored with doppler echography, which was found useful for this purpose, during extracorporeal circulation. One hundred and four patients, over 40 years old, for valvular surgery, had coronary angiography at the cardiac catheterization between 1982-1983. Nine patients (8%) had significant IHD. They had ACBG and valvular surgery simultaneously. Valvular heart disease (VHD): Long-term results following aortic valve replacement have showed that 6 deaths were of cardiac origin. Five of them were with poor preoperative left ventricular function (ejection fraction: 0.35 or less, left ventricular endsystolic volume index: 200 ml/m2 or more) which might be indices for indication of surgical treatment for aortic regurgitation.

There were 14 patients with a mean age of 65 years (ranged from 47 to 77) who had severe coronary artery disease associated with cancer of other organs. Stomach cancer was in 8 patients, breast cancer in 2, lung cancer in 2, rectum cancer in 1, and esophagus cancer in 1. They were treated with sequence of coronary artery revascularization and surgery for cancer; 9 patients in a two-staged fashion and 5 recent patients in a simultaneous one. In the series of simultaneous procedure, A-C bypass was combined with left ventricular aneurysmectomy in one patient and closure of ASD in another. There was no cardiac complication in both series, but one death from the complication of surgery for cancer in the staged series. Three patients in the staged series could not help being postponed the surgery for cancer by slow recovery from A-C bypass. In conclusion, coronary artery revascularization should anticipate surgery for cancer and simultaneous combined procedures should be chosen when possible.

Among 23 patients with thyroid carcinoma infiltrating to the trachea, total 7 laryngectomy and 16 tracheal resection were carried out, associated with thyroidectomy and neck dissection. The infiltrating mode and degree to the trachea in these patients were classified into 2 types according to the anatomical characteristics: Types of cartilage and membranous portions. Moreover, the former was further subclassified into 3 divisions. The subtype I of cartilage portion: Infiltration to the adventitia of trachea. Histologically, there were 3 well differentiated carcinoma, 3 poorly differentiated carcinoma and one medullary carcinoma. The prognosis was favorable comparing to other types. All 7 patients are alive. The subtype II or III of cartilage portion: Infiltration to the cartilage or annular ligament of trachea. Poorly differentiated carcinoma were noted in 6 of 7 patients. Five are alive and 2 died. The membranous type: Infiltration to the membranous portion of trachea. Esophageal invasion was noted in 7 patients. Undifferentiated carcinomas and squamous cell carcinoma took over a half of the patients. Two are alive and 7 died. The prognosis was the worst.

Left ventricular function and coronary sinus blood flow at rest and during exercise were evaluated in 27 patients after aortocoronary bypass surgery and in 13 normal subjects (G-C). Twenty patients (G-1) had successfully revascularized left anterior descending artery (LAD). In 7 patients (G-2), the revascularization for LAD was not complete. There was no difference among 3 groups in stroke work index (SWI), left ventricular end-diastolic pressure (LVEDP) and coronary sinus blood flow (CSF) at rest. SWI during exercise in G-2 (44.7 +/- 14.7 g. M/beat/m2) was significantly lower than that in G-1 and G-C (67.9 +/- 15.0, 77.2 +/- 17.0 g.M/beat/m2) (p less than 0.02, p less than 0.002). LVEDP during exercise in G-2 (32 +/- 6 mmHg) was significantly higher than that in G-1, G-C (17 +/- 7, 13 +/- 3 mmHg) (p less than 0.001, p less than 0.001). CSF during exercise in G-2 (160 +/- 64 ml/min) was significantly lower than that in G-1, G-C (357 +/- 79, 290 +/- 113 ml/min) (p less than 0.001, p less than 0.002). These data indicated that left ventricular function during exercise and coronary sinus blood flow reserve for exercise in patient with completely revascularized LAD was significantly better than that in patients with incompletely revascularized LAD.

Left ventricular function and coronary sinus blood flow were evaluated in 7 patients with severe left ventricular dysfunction at rest before and after aortocoronary bypass surgery, and during exercise after surgery. Same evaluations were performed in 8 normal subject (G-C). Cardiac index (CI) at rest (2.09 +/- 0.55 l/min/m2) significantly increased after operation (2.94 +/- 0.59 l/min/m2) (p less than 0.02). There was no difference between CI during exercise after operation (5.94 +/- 1.51 l/min/m2) and that in G-C. Left ventricular end-diastolic pressure (LVEDP) at rest before operation (16 +/- 8 mmHg) was significantly higher than that in G-C (p less than 0.05). This difference disappeared after operation. LVEDP during exercise after operation (25 +/- 10 mmHg) was significantly higher than that in G-C (p less than 0.01). Coronary sinus blood flow (CSF) at rest (73 +/- 15 ml/min) significantly increased after operation (123 +/- 44 ml/min) (p less than 0.02). There was no difference between CSF during exercise after operation (282 +/- 99 ml/min) and that in G-C. These data indicated that the aortocoronary bypass surgery was effective on left ventricular function and coronary sinus blood flow in patients with severe left ventricular dysfunction.

This study was consisted of 69 patients undergoing aortic valve replacement for chronic aortic regurgitation (AR) and 29 patients, for aortic stenosis (AS) between 1978 and 1985. There was no operative death. There were 7 late cardiac deaths in AR patients, with preoperative left ventricular end-systolic volume index (LVESVI) greater than 200 ml/m2. None of the 55 patients with an LVESVI less than 200 m/m2 died of cardiac-causes. In AR patients with preoperative LVESVI greater than 200 ml/m2, despite the postoperative reduction of the wall stress, the ejection fraction failed to return to normal, indicating that irreversible myocardial dysfunction was responsible in these patients. There were two cardiac-related deaths in 29 AS patients, who had preoperative LVESVI greater than 100 ml/m2. In postoperative AS patients with LVESVI greater than 100 ml/m2, postoperative contractile function of the left ventricle was poor. In conclusion, minimal preoperative left ventricular function for satisfactory late results and reversal of functional results may be at a lower level was LVESVI 200 ml/m2 in AR patients and 100 ml/m2 in AS patients.

In tetralogy of Fallot (TF) a new method of repair has been utilized since 1978. The method is transpulmonary and trans-atrial repair without or with minimal right ventriculotomy. Out of consecutive 81 patients, 79 patients underwent repair with this method with one operative death (operative mortality 1.3%). Postoperative hemodynamic evaluation revealed the better results in cardiac index, right ventricular endodiastolic volume and right ventricular ejection fraction. Also, pulmonary regurgitation has been reduced significantly compared to the conventional method with right ventriculotomy. The main criteria for total repair in TF is size of the pulmonary artery, and PA area Index (PA area/Normal R-PA area) over 0.20 is our minimal criteria to obtain postoperative right ventricular peak pressure ratio below 0.8. In double outlet right ventricle (DORV), operative mortality in last 5 years has improved to 19% (21 cases) from 68% of previous series. Six Taussig-Bing anomalies have undergone primary repair with 2 deaths. Various methods have been utilized including Kawashima 's method in 1 (0, op-death), Rastelli's method in 1(1), Hightower 's method in 1(0), and recently 2 patients had repair with Rastelli's operation with creating AP window to avoid subaortic obstruction. Also, Jatene operation (arterial switch) has been successfully performed in 8 month-old patient.

As part of various defects in congenital heart disease, valvular lesions are frequently encountered and remain as one of the difficult subjects. Recent advances in the management of valvular lesions and late results of repair and replacement were reported. In congenital aortic stenosis, most of patients have obtained satisfactory results with valvotomy, but some required reoperation with valve replacement even during childhood. In supracristed VSD associated with aortic regurgitation, late recurrence of regurgitation was found in some, but 70% of the patients showed free of diastolic murmur after 10 years. In tetralogy of Fallot, definitive repair of pulmonary valve was performed in last 5 years with composite patch with patient's own pericardium to reduce postoperative pulmonary regurgitation. Recently, pericardium is treated with glutaraldehyde on the operating table to prevent late shrinkage. As external conduit, homograft aorta, which had been utilized previously, showed good late results comparable to xenograft in terms of free from reoperation. Xenograft has been frequently utilized without significant late obstruction so far. In atrioventricular canal, endocardial cushion prosthesis technique has been utilized satisfactory with recent modification of the wings made by glutaraldehyde treated patient's own pericardium as well as in tetralogy.

A clinicopathologic study of 48 patients of sarcoma was performed. This malignant neoplasm principally of middle and late adults occurred most often in the body surface (58%). Forty-six patients were treated by surgery with wide or marginal or palliative resection. In two only biopsy was done. Adjuvant chemotherapy was added in 27 patients. Histological grading of surgical specimens was Stage I in 9, II in 16, III in 18 and IV in 5. The evaluation of prognosis showed that wide resection with lymph node dissection was most excellent procedure as the operative methods. Regarding histological grading, significant difference between Stage I + II and III + IV could be detected in the survival rates (p less than 0.05). The adjuvant chemotherapy used did not affect the prognosis.

We evaluated the long-term (18 years) results of 356 patients undergoing valve replacement with Björk-Shiley valve prosthesis (aortic, 212; mitral 120; double valve, 24) between 1970 and 1988. Actuarial survival rates were 90% (18 years) for AVR, 80% 'years) for MVR and 90% (8 years) for DVR. Actuarial rates of thromboembolism were 99% (18 years) for AVR, 98% (8 years) for MVR and 94% (8 years) for DVR. Actuarial rates of freedom from events (including valve failure, thromboembolism, reoperation and prosthetic valve endocarditis) were 82% (18 years) for AVR, 95% (8 years) and 94% (8 years) for DVR. There were no differences in these results among spherical disc, convexo-concave disc and monostrut valve. In conclusion, this study demonstrated that Björk-Shiley valve showed a low incidence of postoperative events. These results endorse our choice of the Björk-Shiley.