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A 50-year-old man with hemobilia after percutaneous transhepatic gallbladder drainage (PTGBD) for cholecystitis is presented. PTGBD had been performed for acute cholecystitis following aortic valve replacement. A combination of aspirin and warfarin as anticoagulant therapy had been administrated with the prothrombin time of approximate 40%. Six months later, the patient was again admitted to our hospital because of jaundice, high fever and digestive bleeding. PTGBD was again attempted under the diagnosis of acute cholecystitis. Endoscopic retrograde cholangiopancreatography revealed coagula which were excreted from the papilla of Vater, thus followed by a cholecystectomy accompanying with a choledochotomy. Three ulcers were observed in the cut surface of the resected gallbladder. Microscopic examinations of the gallbladder showed hemorrhage and inflammation. We reported out patient because hemobilia in the chronic phase after aortic valve replacement is rare.

Unlabelled: The aim of this study was to determine the effect of the continuous perfusion with St. Thomas' Hospital cardioplegic solution (ST solution) containing glucose, insulin and L-aspartate upon post-preservation recovery of cardiac function in the isolated rat heart., Methods: Hearts from Wistar male rats were perfused with Krebs-Henseleit bicarbonate buffer (KHBB) solution and cardiac function was measured using an isolated working heart preparation. Hearts were then preserved by continuous perfusion, (1) with ST solution or ST solution containing L-aspartate (20 mmol/L9 at 20 degrees C and 4 degrees C for 12 hours, (2) with ST solution containing L-aspartate at 4 degrees C for 24 hours, (3) with ST solution containing glucose (9 mmol/L) and insulin (10 U/L solution) or ST solution containing glucose, insulin and L-aspartate at 20 degrees C for 24 hours. This was followed by 15 minutes of Langendorff perfusion and 20 minutes of working perfusion with KHBB solution. During the working perfusion in the post-preservation period, cardiac function was remeasured., Results: (1) At 20 degrees C, percent recovery of cardiac output (%CO) was 57.7 +/- 3.8% and 79.9 +/- 1.4*% in the L-aspartate-free group and the L-aspartate-containing group, respectively (*p < 0.05). At 4 degrees C, %CO was 74.4 +/- 2.2% and 80.5 +/- 1.7% in the L-aspartate-free group and the L-aspartate-containing group, respectively (NS). (2) %CO in L-aspartate-containing group at 4 degrees C decreased to 46.8 +/- 2.4% when preservation time was extended to 24-hours from 12 hours. (3) On the other hands, the addition of L-aspartate to the ST solution containing glucose and insulin resulted in an additive protection and %CO was 76.0 +/- 1.1% even after 24 hour preservation at 20 degrees C., Conclusions: Our results indicate that L-aspartate as an additive to perfusion medium might be beneficial for myocardial preservation, and that at 20 degrees C, the addition of L-aspartate to the ST solution containing glucose and insulin could improve the post-preservation recovery after the 24-hour preservation.

Among patients who underwent reconstruction of the aortic root by Bentall-type procedure using a composite graft, we investigated patients who underwent reoperation for complications related to composite graft. We employed composite graft reconstruction of the aortic root in 155 patients for 16 years prior to December 1994. Annulo-aortic ectasia was observed in 112 patients, aortic dissection in 34, and aortitis without aneurysm formation in 9. The original Bentall procedure was performed in 36, the Cabrol method in 8, the interposition method in 26, and the Carrel patch method in 85 patients. Thirteen (8.4%) of these patients required reoperation for complications related to the composite graft. Three of 4 patients with graft infection early after surgery underwent reconstruction with composite graft, but died in the hospital. The remaining patient survived after combined treatment that included the graft washing with Iodine (Isozin) solution and omentopexy. Four patients developed pseudoaneurysm formation due to sutural insufficiency and 7 has prosthetic valve failure as late complications. Three of the 4 patients with pseudoaneurysm underwent reconstruction with a second composite graft by the interposition method, while one patient with aortitis required another reoperation. In the remaining one patient, the leak was directly close along with second aortic valve replacement. All prosthetic valves used in 7 patients with prosthetic valve failure were Ionescu-Shiley biological valves. Primary tissue failure was observed in 6 and prosthetic valve endocarditis in one patient. Second cardiac valve replacement using a mechanical valve was possible. All the patients who underwent late reoperation showed favorable results. Infection of the composite graft showed the poor prognosis, and prevention of infection is important. Sutural insufficiency at the anastomosed site can be prevented by appropriate surgical procedures such as reinforcing suture, but further countermeasures for sutural insufficiency were considered necessary for aortitis in conditions, such as Behcet's diseases.

One hundred twenty-eight valvular surgeries in patients over 70-year-old were reviewed (AVR:58, MVR:38, AVR and MVR: 11, mitral valvuloplasty (MVP): 11, AVR + MVP:11, mitral valvuloplasty (MVP): 11, AVR + MVP: 8, others: 2). Concomitant CABG was performed in 7, Maze in 6, TVR in 5 and Bentall in 3 cases. Early deaths occurred in 17 patients (13%). The early mortality was 5% in AVR, 21% MVR, 18% in AVR and MVR, 0% in MVP and 38% in AVR and MVP. Late death occurred in 16 patients. Forty-three percent of the late deaths were cardiac death. The actuarial survival at 10 years was around 50% in all groups. In the aortic position, a mechanical valve was implanted in 47 cases and a bioprosthetic valve was implanted in 33 cases. In the mitral position, the mechanical valve was implanted in 37 cases and the bioprosthetic valve was implanted in 12 cases. The event free rate after AVR at 10 years was 37% in patients with the mechanical valve (3 cerebral hemorrhage, 2 PVE, 1 thromboembolism and 1 sudden death) and 46% in patients with the bioprosthetic valve (2 PVE and 1 primary tissue failure). The event free rate after MVR at 10 years was 84% in patients with mechanical valves (1 perivalvular leak, 1 PVE and 1 sudden death) and 75% in patients with bioprosthetic valves (1 PVE and 1 sudden death). Between mechanical valve group and bioprosthesis group, no statistically significance was found in the event free curve after AVR nor MVR. There was no valve related event after MVP. Considering the better durability of bioprostheses in the aortic position than in the mitral position, the presence of atrial fibrillation and necessity of warfarin anticoagulation, we conclude that a choice of a bioprosthetic valve could be acceptable in the aortic position, but may not be recommended in the mitral position.

The results of direct pulmonary embolectomy in 20 cases of pulmonary embolism treated in our facility from 1982 to May, 1995 was analyzed. The ages of the patients ranged from 25 to 72 years (mean: 46 years). The male-to-female ratio was 12:8. The 20 cases were divided into three groups based on the type of pulmonary embolism: Group I (4 cases of acute massive pulmonary thrombo-embolism). Group II (12 cases of chronic pulmonary thrombo-embolism) and Group III (4 cases of tumor embolism). In Group I, 2 patients developed shock and 2 developed severe right heart failure. Emergency thrombectomy using cardiopulmonary bypass succeeded in saving the lives of 3 patients in this group. In Group II, the preoperative NYHA grade was II in 1 case, III in 9 cases, and IV in 2 cases. The preoperative systolic pressure of the pulmonary artery ranged from 24 to 90 mmHg (mean: 74 mmHg). Surgery through a thoracotomy was carried out on 7 cases (on the right side in 4 cases on the left in 3 cases). Of these 7 patients, 2 died of heart failure and respiratory failure because thromboendarterectomy was inadequate. In another 2 patients, symptoms improved enough to allow them to resume their previous lives. The other three patients showed no change in their symptoms after surgery, but they could be discharged. The remaining 5 patients in Group II underwent surgery through the median approach. Deep hypothermia with circulatory arrest was used in the latter 4 of these 5 patients during surgery. 3 patients died during the perioperative period because adequate thromboendarterectomy was not possible and because their preoperative condition was very poor. 2 patients who were able to be performed adequate thromboendarterectomy showed good postoperative courses. Of the 4 patients in Group III, one patient survived 11 months after surgery, but the other 3 died during the preoperative period because very little embolus could be removed. These results allow us to conclude that the lives of patients with acute pulmonary thromboembolism can be saved by early detection and prompt surgery, but that management of chronic pulmonary thromboembolism involves difficulties in selecting surgical cases and in performing thromboendarterectomy.

The surgical procedures were reviewed based on the types of hypertrophied obstructive cardiomyopathy in 20 patients. The patients were classified in three groups: (1) Asymmetric septal hypertrophy (ASH), (2) Atypical or diffuse concentric hypertrophy (DIF), (3) Mid ventricular obstructive hypertrophy (MID). Among 11 patients with ASH, the ventricular septal myotomy (My) or the myotomy-myectomy (Mye) were performed in 9 patients and MVR was performed in 2 patients. Among 6 patients with DIF, My or Mye were performed in 4 and MVR was performed in 2. All three patients with MID were treated with MVR. The intraventricular systolic pressure gradient greater than 40 mmHg was still existent postoperatively in one ASH patient on whom Mye was performed and in 3 DIF patients on whom My or Mye were performed. The four patients had III degree mitral regurgitation preoperatively and were successfully treated. The postoperative NYHA functional class became II or less in all patients. For ASH, the My was effective in 9 patients except one earlier patient. For DIF, further consideration of surgical procedure might be required. For MID, a MVR is recommended.

To determine the short- and medium-term results of coronary artery bypass grafting (CABG) in dialysis patients, we analyzed a group of 14 patients with chronic renal failure who underwent CABG between May 1990 and October 1994. Two patients had concomitant valve repair for mitral regurgitation. Hospital mortality was 14% (2 out of 14). These two patients died of ileus due to ischemic colitis and agranulocytosis respectively. There was one late death from stroke. The four significant postoperative complications (morbidity 29%) were composed of two sternal dehiscence, one cardiac tamponade because of bleeding, and one perioperative myocardial infarction. Graft patency rate was 97% (34 out of 35 in 13 patients) within one month. Actuarial survival was 86% at one 1 to 3 years, and 43% at 3 and a half years. This rate is not significantly different from all dialysis patients, but night be better than dialysis patients with coronary artery disease who had not undergone CABG in the previous reports. Left ventricular size is larger in patients who died or who had significant complications in hospital than in patients with uneventful postoperative course. Cardiac arrest time, cardiopulmonary bypass time, chest tube output, and the amount of transfusion might be also related to mortality and morbidity though statistically not significant.

Unlabelled: The aim of this study was to determine the effect of the continuous perfusion with Krebs-Henseleit bicarbonate buffer (KHBB) solution or St. Thomas' Hospital cardioplegic solution (ST solution) containing glucose and insulin upon the post-preservation recovery in the isolated rat heart., Methods: Hearts from male Wistar rats (n = 6/group) were subjected to working perfusion with KHBB solution for measurement of cardiac function. They were continuously perfused (1) with KHBB solution or ST solution for 12 hours at 20 degrees C, (2) with ST solution for 12 hours at 37 degrees C, 20 degrees C or 4 degrees C, (3) with ST solution or ST solution containing glucose (9 mmol/L) for 12 hours at 20 degrees C or 4 degrees C, and (4) with ST solution containing glucose (9 mmol/L) or ST solution containing glucose (9 mmol/L) and insulin (10 U/L solution) for 20 hours at 20 degrees C. This was followed by 15 min of Langendorff perfusion and 20 min of working perfusion with KHBB solution. During the second working perfusion after preservation, cardiac function was measured again., Results: (1) Percent recoveries of cardiac output (%CO) preserved with KHBB and ST solution were 44.9 +/- 4.0 and 57.7 +/- 3.8%, respectively (p < 0.05). (2) %CO after preservation with ST solution at 37, 20, 4 degrees C were 0*, 57.7 +/- 3.8 and 74.4 +/- 2.2*%, respectively (*p < 0.05 vs the 20 degrees C group). (3) At 20 degrees C, glucose addition to ST solution increased %CO to 76.5 +/- 2.4% from 57.7 +/- 3.8% in glucose-free ST solution group (p < 0.05). However, at 4 degrees C, glucose addition to ST solution was rather harmful and decreased %CO to 61.4 +/- 2.8% from 74.4 +/- 2.2 in glucose-free ST solution group (p < 0.05). (4) The addition of insulin to the glucose-containing ST solution resulted in a significant increase in %CO from 24.6 +/- 4.0% in the insulin-free solution to 69.2 +/- 2.0%., Conclusions: Our results indicate that 1) ST solution might be better than KHBB solution for a continuous perfusion medium of myocardial preservation, and 2) at 20 degrees C, the addition of glucose and insulin to the ST solution could be beneficial for the continuous infusion as a method of preservation, however, at 4 degrees C, these addition might be harmful, suggesting the temperature dependence in the utility of energy substrate.

The effects of Ebselen (DR-3305) upon cardiac function and CK leakage with or without ischemia reperfusion insults were investigated in this isolated working rat heart study. In order to evaluate the effects of Ebselen upon cardiac function, it was administrated to the isolated rat heart with Langendorff perfusion for 15 min at 100 cmH2O. Cardiac functions such as aortic and coronary flow, heart rate and aortic pressure, before and after Ebselen treatment, were measured and expressed as percent of the control value. The coronary resistance was significantly reduced in 100 nM, 500 nM and 1000 nM of Ebselen pretreatment with dose dependent manner. However pretreatment with 1000 nM of Ebselen significantly decreased cardiac output with significant increase of CK leakage. The myocardial protective effects of Ebselen in the cardioplegia or reperfusate were investigated under conditions of normothermic ischemia. After measuring preischemic cardiac functions, the St. Thomas' Hospital cardioplegic solution was infused for 3 min followed by 35 min of global ischemia at 37 degrees C. Hearts were then aerobically reperfused for 15 min in the Langendorff mode. Subsequently, cardiac function was measured and expressed as percent of the preischemic control value. Ebselen addition to the St. Thomas' cardioplegic solution did not possess any myocardial protective effects, although addition to reperfusate possess the protective abilities at a concentration of 10 nM. From these data, Ebselen, which was one of the free radical scavenger, had the myocardial protective effects if it was added to reperfusate at a concentration of 10 nM.

The aim of this study was to determine the temperature dependency of the optimal pressure in myocardial preservation by continuous perfusion with Krebs-Henseleit bicarbonate buffer (KHBB) solution. Hearts from Wistar male rats were perfused with KHBB solution and cardiac function (aortic flow) was measured using an isolated working rat heart preparation. In the preliminary experiment, hearts were then preserved using Langendorff perfusion with KHBB solution of 37, 20 or 4 degrees C for 2 hours at a perfusion pressure of 100 cmH2O. This was followed by 15 min of Langendorff perfusion (37 degrees C, 100 cmH2O) and 20 min working perfusion. The 37 degrees C group and 20 degrees C group exhibited better functional recoveries of aortic flow (%AF) in the post-preservation period compared to the 4 degrees C group. In the test experiment, hearts were preserved using Langendorff perfusion for 4 hours at 37 degrees C or for 8 hours at 20 degrees C at various perfusion pressures. At 37 degrees C, %AF after 4 hours of the preservation were 64.7 +/- 2.6, 69.0 +/- 3.2, 81.9 +/- 3.1, 94.7 +/- 3.3 and 63.5 +/- 4.0% (p < 0.05 vs the 100 cmH2O group) at the perfusion pressure of 100, 60, 20, 15 and 10 cmH2O, respectively. %AF after 8 hours of the preservation at 15 cmH2O was 56.3 +/- 2.5%. At 20 degrees C, %AF after 8 hours of the preservatin was 78.9 +/- 3.3, 81.9 +/- 2.3, 67.4 +/- 1.9 and 65.9 +/- 2.2% (p < 0.05 vs the 60 cmH2O group) at the perfusion pressure of 60, 30, 10 and 15 cmH2O, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Two infants with congenital aortic valve stenosis underwent successful aortic root replacement with pulmonary autograft. One of the patients was 9 months and weighted 4.2 kg, and the other was 10 weeks weighing 4.6 kg. The former had undergone balloon valvotomy with a resultant severe aortic regurgitation. Operative method was basically similar to that taught by Ross. In terms of the right ventricular outflow reconstruction, however, left atrial appendage was utilized as the posterior wall while equine pericardial monocusp patch formed the anterior wall in the former patient. In the latter, morphology of the left atrial appendage was not suitable for the same kind of reconstruction, and nonvalved equine pericardial tube was used. Both of the patients eventually gained satisfactory circulatory condition. Advantages of aortic root replacement with pulmonary autograft are good competence without residual stenosis, avoidance of anticoagulation, and the high potential of future growth. So this operation is especially indicated for neonates and infants with left ventricular outflow obstruction.

Follow-up has been achieved in 41 hospital survivals who received xenograft valved conduits in the pulmonary position. The interval after operation ranged 6 months to 13 years (average 5.2 +/- 3.7 years) (+/- standard deviation). There has been 8 late deaths, 3 of which were sudden. Of the 11 reoperations, 7 underwent graft replacement with no operative death. The actuarial reoperation free survival rate was 73% at 5 years, and 54% at 10 years. There was a significant correlation between the interval after operation (x years) and the pressure gradient across the conduits (y mmHg). (y = 20.7 + 9.7x, r = 0.74, p < 0.001). Balloon dilatation of the conduits was performed in 15 patients. The mean conduit gradient was significantly (p < 0.001) reduced from 85 +/- 29 to 54 +/- 22 mmHg. However, the effect was not satisfactory enough and 4 patients received graft replacement after the balloon dilatation. These results warrant the avoidance of xenograft valved conduits in the pulmonary position, the safety of the graft replacement, and the limitation of the balloon dilatation for the stenosed conduits.

Cardiac catheterization and submaximal exercise testing was performed in 38 patients after repair of tetralogy of Fallot (TF), and compared to 6 control patients who had functional murmurs. Cardiac index, heart rate, and stroke volume index were significantly lower in the TF group than in the control group. Right and left ventricular end-diastolic pressure increased significantly during exercise, which was not found in the control group. Total pulmonary vascular resistance (TPVR), which decreased significantly with exercise in the control group, did not change remarkably during exercise. TPVR was significantly higher in the TF group than in the control group both at rest and during exercise. Several factors were compared between patients with good cardiac index (> 5.0 l/min/m2; Group 1) and poor cardiac index (< 5.0 l/min/m2; Group 2) during exercise. Stroke volume index, right ventricular ejection fraction at rest were significantly higher in Group 1 than Group 2. TPVR, right and left ventricular end-diastolic and end-systolic volume index were significantly lower in Group 1 than in Group 2. There was no significant difference in heart rate, left ventricular ejection fraction, residual pulmonary stenosis, right to left ventricular systolic pressure ratio, and severity of pulmonary regurgitation between two groups. These findings indicate that abnormalities of exercise tolerance in patients after repair of TF were related to poor response of heart rate, pulmonary vascular resistance, and systolic and diastolic ventricular function.

An 11-year-old girl had undergone an aortic valve replacement for congenital aortic stenosis with #17 Björk-Shiley valve and aortic ring enlargement by Nick's method eight years later, the pressure gradient across the prosthetic valve increased up to 100 mmHg. Re-aortic valve replacement was successfully performed with #21 St. Jude Medical valve, when aortic valve ring increased to accommodate #21 SJM valve.

We experienced a case of constrictive pericarditis following replacement of the descending aorta. It has been pointed out that constrictive pericarditis can be developed following LV bypass using centrifugal pump due to the cardiotomy. But no actual case has reported so far. The case was a 61-year-old man for whom graft replacement of the descending aorta through left thoracotomy was performed. Fever and heart failure was elicited 3 weeks after the operation, and he was diagnosed as constrictive pericarditis by chest CT and echocardiography. The reoperation was performed 39 days after the graft replacement. Anterior wall of the both ventricle and postero-lateral wall of the left ventricle were strongly adhered to the pericardium. The adhesion was entirely dissected and the thickened pericardium was resected. The post-operative course was uneventful and the patient was discharged 42 days after the reoperation.

Results of surgical treatment of atherosclerotic aneurysm of the distal aortic arch, reported to date, are not satisfactory. We recently analyzed the surgical results in 119 patients with this condition who were treated at our department. There were 104 males and 15 females, ranging in age from 38 to 81 years (mean: 66 years). The arch was reconstructed by total replacement in 29 cases, partial replacement in 49 cases, patch reconstruction in 34 cases and extra-anatomic bypass in 7 cases. The lesion was approached by median sternotomy in 75 cases, median sternotomy+left thoracotomy in 9 cases and left thoracotomy in 35 cases. In cases where median sternotomy was used, selective cerebral perfusion was generally employed as an auxiliary procedure. After surgery, cerebral complications were observed in 19 cases (16.0%). In 15 of these 19 cases, postoperative cerebral damage was attributed to atheromatous emboli. Twenty-six patients (21.8%) died in the hospital. Major causes of death included respiratory insufficiency, multiple organ failure and low cardiac output syndrome. To improve surgical results for this type of aneurysm, the operative procedure needs to be modified so that these postoperative complications are prevented. Especially it is essential to prevent intraoperative embolisms of brain and coronary arteries, and a reconstruction by total arch replacement with median sternotomy has improved recent surgical results.

A 54-year-old male who had received an aortic valve replacement with SJM 23 about 3 years before suffered from an acute cardiac failure because of the valve detachment. From his clinical course, it was diagnosed that the aortic valve insufficiency was complicated by an aortitis. We operated on him by an aortic root replacement using a cryopreserved allograft which we prepared. A donor of the allograft was 35-year-old male, died of a subarachnoidal hemorrhage. We harvested his aortic root at an autopsy and dipped it into a nutrition medium with 10% dimethylsulfoxide. Within 10 hours from his death, we froze the tissue using a program freezer and stored it in a liquid nitrogen for 7 months. After thawing it in 37 degrees C water quickly, we rinsed the graft and used for the operation. The cell viability of the graft was confirmed by a tissue culture. Indication of the allograft valve to an aortitis case is still controversial. We think the allograft is recommendable to valve detachment case due to aortitis, because the softness of the graft decreases a compliance mismatch between the graft and the patient's annulus, which may prevent redetachment. Although we felt concern about redetachment of the conduit due to the weakness of the patient's aortic annulus, no complication regarding the allograft happened at all as yet.

We have applied recombinant human superoxide dismutase (RH-SOD) to prevent ischemia reperfusion injury in the patients who received open heart surgery. Twenty-four patients were divided into 2 groups; group A had no treatment as control and group B received bolus injection of RH-SOD (35,000 IU/kg) into cardiopulmonary bypass 5 minutes before reperfusion. Arterial and coronary sinus blood was collected to measure chemiluminescence (ChL) value, SOD activity, lactate and pyruvate level, and several parameters of myocardial oxygen metabolism after reperfusion. Arterio-venous difference of ChL value showed the tendency of less ChL generation of the heart in group B compared with those in group A. But no other parameters showed significant difference between the two groups. Our data suggested that this way of the administration of RH-SOD failed to improve the myocardial protection during open heart surgery. Further investigation, such as dose response study, might be required to determine whether RH-SOD possess beneficial effects or not in the clinical setting.

A female infant weighing 2.4 kg had respiratory distress at birth. She became dyspneic and hypercapnic and required intubation with assisted ventilation 11 days after birth. Because cardiac failure and respiratory failure did not improve, she underwent total correction at 26 days old, which consisted of VSD closure, right ventricular outflow tract reconstruction with valved porcine pericardial roll (VPR) and plication of both pulmonary arteries. She was weaned from the ventilator 11 days after operation and discharged at 12 weeks of age. One year later, reoperation was successfully performed for the replacement of the stenotic VPR with a transannular patch.

Between November, 1987 and May, 1990, definitive operation was performed in 7 infants for tetralogy of Fallot with absent pulmonary valve. Preoperative respiratory failure was serious in 5 patients and semi-emergency operation was done. Surgical procedure consisted of closure of ventricular septal defect, reconstruction of right ventricular outflow tract using heterograft valved pericardial roll and plication of aneurysmally dilated pulmonary artery with or without pulmonary artery suspension in 5 infants with severe respiratory distress and heart failure, operated on 26 days to 5 months of age. In the other two less symptomatic infants, operated on at 13 months of age, reconstruction of right ventricular outflow tract was performed by transannular bovine pericardial patch with monocusp. There were no operative death and six infants are doing well 6 months to 3 years postoperatively, but one patient died of prolonged respiratory infection and respiratory failure one year after operation. Postoperative pulmonary arteriogram revealed a 42 to 61 (mean 54) percent reduction in right and left pulmonary artery size in 3 patients who underwent extensive plication of pulmonary artery. We suggest that definitive plication with or without suspension of pulmonary artery, together with closure of ventricular septal defect and reconstruction of right ventricular outflow tract is supposed to eliminate air way obstruction.

A 27-year-old woman with Turner syndrome was admitted to NCVC for congestive heart failure. 2-D echocardiography and magnetic resonance imaging (MRI) disclosed annuloaortic ectasia with severe aortic regurgitation and coarctation of the aorta. One staged operation by a modified Bentall procedure and extra-anatomical bypass grafting from the ascending aorta to the infrarenal abdominal aorta was successfully performed. The postoperative course was uneventful. The pressure gradient between upper and lower extremities decreased as to be 30 mmHg compared with preoperative 60 mmHg.

The effects of potassium in reperfusion solution (RS) and the influence of sodium on this effect were studied. Experimental time course was as followed: 20 min working perfusion, 3 min cardioplegic infusion with St. Thomas Cardioplegic Solution followed by global ischemia for 33 or 35 min at 37.5 degrees C, 15 min early Langendorff reperfusion with several different potassium concentration modified with Krebs Henseleit Bicarbonate Buffer (KHBB) containing 145 mM and 110 mM sodium and 5 min late reperfusion with KHBB, followed by 20 min working perfusion. Potassium in RS possessed bell shaped dose response nature with optimal concentration of 10 mM in the condition of 145 mM sodium but 6 m in the condition of 110 mM in terms of percent recovery of aortic flow. Although higher potassium reperfusion produced less Creatine Kinase leakage.

A 31-year-old male with tetralogy of Fallot (TF) and total occlusion of the right coronary orifice complicated with infective endocarditis successfully underwent total repair of TF and coronary artery bypass graft (CABG). The patient had severely suffered from symptoms including breathlessness, palpitation (SVT) and chest pain. The coronary arteriography revealed occlusion of the right coronary orifice. The preoperative course was further complicated by endocarditis with vegetation of the aortic valve that did not respond to antibiotics. Concomitant surgical procedures consisting of TF repair, CABG to the right coronary artery with saphenous vein graft and vegetectomy of the aortic valve were carried out. The postoperative course was uneventful though he underwent cholecystectomy for symptomatic gall stones after TF repair. The patient is now in NYHA class II.

Ten patients underwent open heart surgery for mitral valve after PTMC because of post PTMC MS (n = 4) and MR (n = 6) out of 150 patients undergoing PTMC in our hospital between June 1987 and October 1991. Intraoperative findings of 4 patients with residual mitral stenosis included severe thickening, stiffening and calcification on anterior and posterior leaflets, commissures and subvalvular apparatus. Mitral valve repair was possible in 2 and mitral valve replacement (MVR) was necessary in the other 2. In all 6 cases who massive mitral regurgitation after PTMC, in repairable tears in the mitral leaflets necessitated MVR. Since in these cases changes in the leaflets were less severe than those of the commissures or subvalvular apparatus, surgical repair could have been possible if open mitral commissurotomy (OMC) was done primarily. Patients selection for PTMC versus OMC based on precise morphological evaluation of mitral valve would reduce occurrence of massive MR resulting in surgical replacement.

The purpose of the study is to investigate the effects of protease inhibitor (Nafamostat mesilate: NM) upon myocardial protection. Hearts were subjected to 20 min working control perfusion followed by 3 min cardioplegic infusion with the St. Thomas Cardioplegic Solution (ST) contained various concentrations of NM, and global ischemia for 33 min at 37 degrees C (Exp. 1) or 150 min at 20 degrees C (Exp. 2). Hearts were then converted to Langendorff reperfusion (the leakage of Creatine Kinase (CK) and Cathepsin B (Cat-B) ware measured) and 20 min working reperfusion. Various concentrations of NM added during Langendorff reperfusion (Exp. 3). During working perfusion cardiac functions (aortic flow (AoF), coronary flow (CoF), heart rate (HR), aortic pressure (AoP)) were measured, and expressed as the percent recovery of pre-ischemic control value. Post-ischemic recovery of AoF (%AoF) showed the bell-shaped dose-response curve, and the optimal dose was 3 microM (Exp. 1) and 10 microM (Exp. 2) respectively. There was a significant (p < 0.05) increase of %AoF in optimal dose compared with that in controls (64.2 +/- 1.2% vs 52.3 +/- 2.5% in Exp. 1, 68.9 +/- 3.1% vs 54.1 +/- 1.4% in Exp. 2). These increase of functional recovery reflected in the values for CK and Cat-B leakage. The addition of NM in ST reduced CK and Cat-B leakage significantly in the concentration of 5 microM (in Exp. 1) and 10 microM (in Exp. 2) respectively. But the addition of NM in reperfusate did not reduced CK leakage significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors reported the first case of acute spinal epidural hematoma (SEH) developed after open heart surgery. The patient was noticed that her legs felt weak and numb on the first postoperative day evening. On the next day morning, neurological examination revealed that flaccid paralysis of both legs and also loss of all sensory perception below the level of Th-6 spine bilaterally. The prolonged effect of anesthesia and painless onset made delayed recognition of the lesion. SEH (Th5-7) was diagnosed with MRI and decompressive surgery was immediately done, sixty hours after the beginning of cardiac operation. But in this case neurological deficits were not changed. We concluded that a routine diagnostic approach was very important procedure to find out this serious complication for all patients underwent open heart surgery in early period of its onset.

A 5-years old boy, whose thoracic situs was right isomerism, was diagnosed as transposition of great arteries, common atrioventricular canal (intermediate type), severe tricuspid valve regurgitation, pulmonary valve stenosis, bilateral superior vena cava and left sided inferior vena cava. The preoperative RVEDV was 95% and LVEDV 160%, and LV/RV pressure ratio was 0.54. Atrial rerouting using pericardial patch, replacement of tricuspid valve and pulmonary valvotomy were performed. Postoperative course was uneventful. This was a rare case of right isomerism who received biventricular repair.

The effects of several different osmolarity in reperfusion solution were studied. Experimental time course was as follows: 20 min working perfusion, 3 min cardioplegic infusion with St. Thomas Cardioplegic Solution (STS) followed by global ischemia for 33 min at 37.5 degrees C, 15 min early Langendorff reperfusion with different osmolarity by adding sucrose and 5 min late reperfusion with Krebs Henseleit bicarbonate buffer, followed by 20 min working perfusion. Percent recoveries of aortic flow showed that 290 mOsm/L in reperfusion solution possessed optimal protective properties with bell shaped dose response characteristics.

The effects of several sodium concentrations in reperfusion solution (RS) were studied. Experimental time course was as follows: 20 min working perfusion, 3 min cardioplegic infusion with St. Thomas Cardioplegic Solution followed by global ischemia for 33 min at 37.5 degrees C, 15 min early Langendorff reperfusion with various sodium concentrations modified with Krebs Henseleit Bicarbonate Buffer (KHBB) and 5 min late reperfusion with KHBB, followed by 20 min working perfusion. Percent recoveries of aortic flow and Creatine Kinase leakage showed that 110 mM sodium of RS possessed optimal protective properties with bell shaped dose response characteristics.

Six hundred forty-eight serial graded exercise tests were performed on 400 patients up to 10 years after coronary bypass graftings (CABG). The maximal attained exercise tolerance, over 10 METS, were observed in 60% of patients and the negative response to exercise test in 43% of patients. The positive response in various parameters were observed at the following rates: graft occlusion-30% vs graft patent-46% (p less than 0.01); incomplete revascularization-39% vs complete revascularization-22% (p less than 0.01); and less than or equal to 8 METS 4-45% vs greater than or equal to 10 METS-28% (p less than 0.01), respectively. However, no significant difference was observed among number of vessels diseased, number of graftings, and presence of old myocardial infarction. The maximal attained stage of exercise, over 10 METS, in various parameters were at the following rates: less than or equal to 59 years old-70% vs greater than or equal to 60 years old-44% (p less than 0.01); male-63% vs female-32% (p less than 0.01); and graft patent-63% vs graft occlusion-50% (p less than 0.05), respectively. The serial analysis of exercise test demonstrated that improved exercise tolerance appears to persist for at least 5 years after CABG. However, the patients in complete revascularization had a tendency to increase the rate of positive response. In conclusion, the completeness of revascularization as well as graft patency was the main factor limiting exercise tolerance, and correlates with the extent and the duration of improvement after CABG.

We have assessed the long-term prognosis about cardiac death of isolated coronary artery bypass surgery from 1972 to 1988 in 361 consecutive patients. The duration of follow-up were from 0.4 years to 14.6 (mean 5.7) years. Of the 361 study patients, the operative morality was 4.7% (17 patients) and 29 patients (8.0%) died during follow-up, 11 (3.0%) of which were from cardiac causes. Actuarial survival rate was 85.2% at 10 years after surgery. The 10 year-survival rate was similar for patients with single, double, triple vessel disease, and left main trunk disease (94.5%, 83.7%, 75.1% and 89.1%, respectively). For patients with and without old myocardial infarction, the 10 year-survival rate was significantly different (75.4% and 93.3%, respectively) (p less than 0.005). In order to detect which factors of preoperative cardiac function among cardiac index, LV end-diastolic pressure, LV end-diastolic volume index, LV end-systolic volume index, and LV ejection fraction influenced the long-term prognosis, multivariant regression analysis was performed. Only LV end-systolic volume index was a significant factor, and the discriminative point was 50 ml/m2. For patients with LV end-systolic volume index less than 50 ml/m2 and greater than or equal to 50 ml/m2, the 10 year-survival rate was significantly different (88.3% and 32.9%, respectively) (p less than 0.005). In conclusion, the most significant factor influencing longterm prognosis after coronary artery bypass surgery was left ventricular end-systolic volume, indicating the importance of preventing preoperative dilatation of left ventricle.

In 28 children with congenital cardiac lesions, open heart surgery was attempted without homologous blood transfusion using extreme hemodilution for cardiopulmonary bypass (CPB) and moderate to profound hypothermia. The entry criteria for this study were preoperative hemoglobin value above 10 g/dl and expected CPB time of less than 120 minutes. Acyanotic heart diseases such as ventricular or atrial septal defect were the main lesion, but some cases of tetralogy of Fallot and single ventricle were also included in this study. Intraoperative saving of autologous blood and autotransfusion using cell saver were carried out in a part of the subjects. Acceptable lowest values for hemoglobin was 4-5 g/dl and 40% for mixed venous oxygen saturation. As the results, 18 patients tolerated CPB without transfusion and eventually 16 patients were discharged without transfusion at all. The body weight for those without transfusion was 13.9 kg in average and the lowest was 6.8 kg. The significant factor affecting the needs for homologous blood transfusion was prolonged CPB time over 120 minutes. Although there was a tendency that the patients with body weight less than 15 kg received transfusion more frequently than those with body weight more than 15 kg, the body weight was not necessarily a limiting factor. Pre-CPB blood saving and intraoperative autotransfusion were the positive factors for successful non-transfusion open heart surgery.

Experimental time course was as follows: 20 min working perfusion, 3 min cardioplegic infusion with St Thomas Cardioplegic Solution followed by global ischemia for 35 min at 37.5 degrees C, 15 min first Langendorff reperfusion with reperfusion solution (RS) with various concentrations of Mg and 5 min second reperfusion with KHBB, followed by 20 min working. Cardiac functions were measured during pre and post working perfusion and CK leakage were measured during reperfusion. Percent recoveries of aortic flow at the Mg concentration of 0, 0.6, 1.2, 3.0, 6.0, 12 mM were 21 +/- 5, 22 +/- 3, 48 +/- 2, 37 +/- 4, 28 +/- 3, 15 +/- 3 (%) (mean +/- SEM), respectively. Our data indicated that 1.2 mM Mg of RS possessed protective properties with bell shaped dose response characteristics.

A 5-year-old boy with double inlet left ventricle and ventriculoarterial discordance (SDD type) underwent ventricular septation with arterial switch procedure. Previously he had received pulmonary arterial banding at 3 months-old. Preoperative cardiac catheterization revealed Qp/Qs 1.26, Pp/Ps 0.19 and LVEDV was 315% of normal (as left ventricle). Arterial switch with Lecompte modification was performed in order to separate ventricle with straight patch could be done. Post operative course was uneventful and patient was extubated 4 post operative day. These procedures had employed in this patient as follows; 1) systemic ventricle could be constructed with morphological left ventricle with mitral valve. 2) left ventricular outflow tract stenosis due to ventricular outlet foramen occasionally observed in conventional procedure such as intraventricular rerouting could be prevented, and 3) ventricular septation could be easy and simple with straight patch.

The effects of several calcium concentrations in reperfusion solution were studied. Experimental time course was as followed: 20 min working perfusion, 3 min cardioplegic infusion with St. Thomas cardioplegic solution (STS) followed by global ischemia for 30 min at 37.5 degrees C, 15 min early Langendorff reperfusion with reperfusion solution and 5 min late reperfusion with Krebs Henseleit bicarbonate buffer [( Calcium] = 2.5 mM), followed by 20 min working perfusion. Percent recoveries of aortic flow at the Ca concentration of 0, 0.1, 0.6, 1.2, 1.8, 2.5 mM were 0, 14 +/- 1, 43 +/- 4, 64 +/- 3, 55 +/- 2, 59 +/- 1 (%), respectively. Our data indicated that reperfusion solution with less than 1.2 mM calcium reduced the protective properties of STS.

A 53-year-old woman who had severe mitral regurgitation associated with moderate tricuspid regurgitation and mild aortic regurgitation underwent mitral valve replacement with a 27 mm Björk-Shiley mechanical valve, left atrial plication and tricuspid annuloplasty. She fell into low output syndrome on the first postoperative day because of persistent intractable ventricular arrhythmia and eventually required open cardiac massage. The left ventricular (LV) bypass using a centrifugal pump was initiated with cannulation to ascending aorta and left atrium. Echocardiography showed LV wall motion extremely poor with the prosthetic valve being in closed posture. For prevention from thrombus formation on the prosthetic valve and in the LV, a catheter was inserted into LV through RV to give heparin and monitor the LV pressure. As the result, activated clotting time of LV was higher (range from 280-388 sec) than that of systemic blood (range from 182-258 sec). Also, the change of LV pressure was monitored through this LV catheter. Under this monitor, IABP was smoothly applied in the presence of aortic regurgitation, and she was weaned from LV-bypass successfully after 157 hrs support. She was discharge on the 77th postoperative day without thromboembolic complication.

In eight hundred eighty three patients with prior coronary bypass grafting (CABG), cardiac symptoms were recurred in 179 patients in late follow-up period (mean 5 +/- 2.8 years). Of 179 patients, 43 patients had PTCA eventually. In these, 57 times of angioplasties were attempted. Twenty-one lesions in venous bypass grafts and 50 in native coronary arteries were performed, respectively. The initial success rate per bypass graft and per stenosis of native coronary artery were 68% and 74%, respectively. Five patients had elective CABG following failed PTCA. There were no emergency CABG procedures required after unsuccessful PTCA. Intracoronary thrombolysis (ICT) were performed in 13 patients. In these, 15 ICT attempts were made. Nine lesions in venous bypass grafts, 9 for native coronary arteries, and 3 for both were attempted. The primary success rate per occlusion was 67%. Twenty reoperation were done. There was one hospital death and one late death due to congestive heart failure 4 years after the reoperation. In conclusion, invasive treatments in patients with prior CABG can be performed with satisfactory safety and good results. Therefore, invasive treatment should be considered in the patients with CABG if cardiac symptoms are disabling and angiographically suitable lesions are present in the native coronary arteries or vein grafts.

Single ventricle (SV) seems to likely to develop congestive heart failure after Blalock-Taussig shunt (BT), particularly when the regurgitation of atrioventricular valve (AVVR) is combined. Analysis of the relation between operative result and intraoperative BT shunt flow is made in order to draw a safety limit or shunt flow in SV. Twenty-six patients (pts) with SV who underwent BT had shunt flow measurement at surgery, 20 pts showed right ventricular (RV) type of SV, 5 had left ventricular (LV) type, and 1 undivided type. The common atrioventricular valve was associated in 19 patients. The age at operation ranged from 6 days to 14 years of mean 3.2 years and the flow ranged from 6 to 146 of mean 49 ml/min/kg. Seven developed congestive heart failure at late follow-up with 4 late deaths. The average flow in this group (poor result) was 68 +/- 40 (mean +/- SD) ml/min/kg, and the remaining pts with favorable results (n = 16) had a mean flow of 41 +/- 22 ml/min/kg (p less than 0.05). In the group of LV type (n = 5), there was one late death caused from apparently excessive shunt flow (146 ml/min/kg). In the group of RV type without AVVR (n = 10), three pts of poor result had flow over 50 ml/min/kg. In those with AVVR (n = 8), pts with poor result were found with flow below 50 ml/min/kg.(ABSTRACT TRUNCATED AT 250 WORDS)

We have assessed the long-term results of heptagenerians after isolated coronary artery bypass surgery from 1979 to 1989 in 32 patients over 70 (mean 72) years old using actuarial techniques. In these patients, the long-term results could not be properly assessed because many other factors other than cardiac events influenced their survival. Accordingly, we compared our subjects with the general population matching the operative age and sex characteristics from life tables (= matched population). There was no operative mortality. The 5 year and 9 year survival rates were 93% and 31%. In the matched population, the 5 year and 9 year survival rates were 81% and 59%. The survival rate between the two groups was not significantly different. We concluded that the long-term results of coronary artery bypass surgery in patients over 70 years were similar to those of the matched population. Therefore, coronary artery bypass surgery should be offered to older patients for usual indications.

We evaluated the late results of coronary bypass grafting (CABG) in 85 patients. The patients were divided into two groups according to preoperative MI size estimated by the Selvester QRS score; 24 with MI size of larger than 20% of LV muscle (group A; average 28 +/- 11%), and 61 with MI size smaller than 20% (group B; average 10 +/- 9%). New York Heart Association classes of both groups following CABG improved significantly (from 2.8 +/- 0.7 to 1.3 +/- 0.4 in group A; p less than 0.01, from 2.5 +/- 0.6 to 1.2 +/- 0.5 in group B; p less than 0.01). There was higher incidence of serious ventricular arrhythmias in group A than in group B (83% vs. 21%, p less than 0.01). In Group A, LVEF and LVESVI did not improve following CABG (from 17 +/- 9 to 16 +/- 8 mmHg, from 39 +/- 15 to 40 +/- 15%, from 66 +/- 28 to 69 +/- 40 ml/M2), while in Group B, those improved significantly (from 13 +/- 6 to 11 +/- 5 mmHg; p less than 0.01, from 53 +/- 14 to 58 +/- 10%; p less than 0.01, from 39 +/- 23 to 32 +/- 14 ml/M2; p less than 0.05). The exercise-to-rest LVSWI ratios increased significantly following CABG in both groups (from 86 +/- 25 to 160 +/- 56% in group A; p less than 0.05, from 92 +/- 31 to 140 +/- 37% in group B; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of right ventricular (RV) volume overload by pulmonary regurgitation (PR) on left ventricular (LV) function was evaluated postoperatively in 23 patients with tetralogy of Fallot (TF). The age at operation was 3.1 +/- 1.7 (mean +/- SD) years. The age at postoperative study was 5.9 +/- 2.0 years. We determined RV end-diastolic volume (%RVEDV), RV ejection fraction (EF), %LVEDV, LV end-systolic volume (%LVESV), LVEF, and LV end-systolic stress (ESS)/%LVESV. Patients were divided into 2 groups on the basis of presence or absence of RV volume overload by PR as follows: The %RVEDV (175 +/- 23%) of group 1 (n = 10) was 150% greater than normal RVEDV. Group 2 (n = 13) had normal %RVEDV (108 +/- 23%). Preoperatively, there had been no differences in hemoglobin, %RVEDV, RVEF, %LVEDV, LVEF, and in the ratio of average cross-sectional area of the left and right pulmonary arteries to cross-sectional area of the normal right pulmonary artery between the 2 groups. Moreover, there were no differences in age at repair, or during postoperative study, nor in the postoperative ratio of RV to LV systolic pressure between the 2 groups. RVEF was significantly less in group 1 than in group 2 (0.53 +/- 0.05 vs 0.58 +/- 0.05, p less than 0.05). %LVEDV and %LVESV in group 1, 138 +/- 10% and 171 +/- 30% respectively, were significantly greater than those in group 2, 116 +/- 11% and 133 +/- 20% respectively (p less than 0.001 in %LVEDV and p less than 0.01 in %LVESV).(ABSTRACT TRUNCATED AT 250 WORDS)

Five adult patients (pts) with age 15-67 (mean 43) received mechanical circulatory support with centrifugal pump (Biomedicus, BP-80, Sarns centrifugal pump) for postcardiotomy profound shock. Three pts underwent left ventricular support (LVS) alone, and the other 2 required biventricular support (BVS). Duration of the LVS ranged from 33 to 240 hours (mean 126 hours) and the right ventricular support 92, 120 hrs. Pump flow rate was 1.1 to 2.5 (mean 1.9) L/min/m2. Sixteen pumps were used and the pump exchange was performed 9 times in five pts and an average perfusion time per pump was 57 hrs. Two of 3 pts with LVS alone survived and one died of multiorgan failure associated with right heart dysfunction. In two pts with BVS, one survived and the other died of persistent low cardiac output early after pump removal. As the complication during mechanical support, bleeding was seen in 3 pts and cerebral infarction in one. Although centrifugal pump has potential limitation in antithrombogenicity and durability, this device provides a simple and effective mechanical circulatory support.

The patient was a 5-year-old girl and had a history of recurrent pneumonia. Angiogram demonstrated that the aberrant arteries arising from descending aorta communicated with left pulmonary A10 where the multi-lobulated cystic lesion was seen by chest X-P. The right heart catheterization revealed the step-up of oxygen saturation in distal part of left pulmonary artery A10. Diagnosis was the intralobar pulmonary sequestration with the aberrant arteries communicating with pulmonary artery. The connection between aberrant arteries and pulmonary artery in this case might be caused by the chronic inflammation in the sequestrated lung. We found 4 case reports in which the communication between aberrant arteries and pulmonary artery was evident.

We reported a 65-year-old male with the history of both cerebral and myocardial infarctions. Simultaneous carotid endarterectomy and myocardial revascularization (coronary artery bypass grafting = CABG) were performed. Ascending aorta was severely calcified. CABG was performed without aortic cross clamp under systemic moderate hypothermia and elective ventricular fibrillation. The wean off from extracorporeal circulation was successful. The postoperative course was uneventful. We recommend the simultaneous revascularization for the carotid and coronary artery obstructive diseases. CABG under ventricular fibrillation without aortic cross clamp was useful and unhazardous in patients presenting calcified ascending aorta.

We evaluated right and left atrial (RA and LA) volumes after modified Fontan operation in 6 patients, in 1 with mitral atresia and 5 with single ventricle. The age at operation was 10.2 +/- 2.5 (mean +/- SD) years. The interval between operation and study was 4.1 +/- 4.8 months. RA and LA maximum volume indexes (VImax) (ml/m2) were measured by angiography. One patient died 72 days after operation due to low output syndrome. In survived patients (n = 5), postoperative pulmonary arterial wedge pressure was 6 +/- 3 mmHg, right atrial pressure 13 +/- 5 mmHg, and end-diastolic pressure in the systemic ventricle 6 +/- 3 mmHg, and one who died had 18 mmHg, 25 mmHg, and 9 mmHg in each parameter, respectively. LAVImax in the survivors (53 +/- 18 ml/m2) were in the range of normal or above normal value. The nonsurvivor had extremely small LAVImax (13 ml/m2). RAVImax in the alive patients (25 +/- 11 ml/m2) was smaller than normal (data was not available in a non-survived patient). These results may indicate that a normal LA volume appears to be as important factor for the prognosis after modified Fontan operations with intraatrial routing for complex lesions regardless of the postoperative RA volume.

Although selective cerebral perfusion (SCP) might be an useful supportive method for aortic arch surgery, its optimal perfusion criteria has not been established. We studied the relationship between the oxygen saturation of superior vena cava or internal jugular vein (SvO2) and the perfusion hemodynamics during deep hypothermic (DH) SCP in twenty patients (pts) (type A dissection; 10, arch aneurysm; 10). SCP was accomplished by perfusion to the brachiocephalic trunk (BCT) and the left common carotid artery (LCC) using separate pumps. Cardiopulmonary bypass and DHSCP time were 128-312 (222 +/- 43, mean +/- SD) minutes and 25-214 (122 +/- 49) minutes, respectively. The cerebral perfusion pressures (CPP) monitored at the bilateral temporal arteries were 20-60 (47 +/- 9) mmHg and cerebral perfusion flow (CPF) was 0.28-0.7 (0.43 +/- 0.10) L/min/m2. The cerebral perfusion score (CPS) defined as CPP X CPF was 7-39 (20 +/- 8). SvO2 ranged from 79 to 99 (94 +/- 7)%. Two operative deaths were encountered from unrelated causes to SCP in both cases. Cerebral infarction occurred in one patient possibly form prolonged low perfusion with low SvO2. When the safety range of SvO2 in DHSCP was defined as greater than 90%, essential criteria to keep this range was CPP greater than 40 mmHg. In 13 out of 15 pts with SvO2 greater than 90%, CPS were above 15. In conclusion, optimal perfusion criteria for DHSCP was defined as CPP greater than 40 mmHg and CPS(CPP X CPF) greater than 15 considering adequate cerebral oxygen consumption.

Ten patients with lung cancer and mediastinal tumor invading the mediastinal structures underwent replacement of superior vena cava (SVC) with ringed Gore-Tex to resect malignant tumors. In patients with lung cancer sleeve pneumonectomy (3 patients), sleeve lobectomy (1 patients) and tracheal resection (one patient) were performed simultaneously. By resection of the VCS system, invasive thymomas were able to be resected completely in 2 of 3 patients. In 2 patients with mediastinal tumors, one with metastatic testicular chorio carcinoma and one with malignant lymphoma of non-Hodgkin type, aggressive chemotherapy was followed by resection of the residual tumors including VCS. Except for one patient, there was no sign showing disturbance of the venous return in the VCS system in the 5 to 43 months' postoperative follow up period. We conclude that ringed Gore-Tex graft permits the extended operation for intrathoracic malignancies invading the mediastinal structures.