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

Objectives: Treatment of cardiac failure due to non-ischemic cardiomyopathy by left ventriculoplasty using partial left ventriculectomy (Batista operation) or septal anterior ventricular exclusion was evaluated., Methods: Left ventriculoplasty was performed in 70 patients (59 men and 11 women with a mean age of 51 years) from December 1996 to June 2000. Preoperative New York Heart Association (NYHA) functional class was IV in 43 patients including 29 receiving inotropic support, and class III in 27 patients. Nineteen patients required emergency surgery because of on-going shock and 51 patients were operated electively. Combined cardiac procedures were mitral valve reconstruction in 62 patients (45 replacements, 17 repairs), tricuspid annuloplasty in 37, and aortic valve replacement in 4. The initial 24 patients underwent typical Batista operation regardless of myocardial viability. The other 46 patients underwent selective ventriculoplasty to excise or exclude the weakest part according to the findings of the intraoperative echo-guided volume reduction test., Results: The intraaortic balloon pump was used in 12 patients and the left ventricular assist device in 2 patients. Three (5.9%) of the 51 patients who underwent elective operation and 12 (63.2%) of the 19 patients with emergency operation died in the hospital, giving an overall hospital mortality of 21.4% (15/70). Hospital mortality was reduced from 33.3% (8/24) in the initial 24 patients to 15.2% (7/46) in the recent 46 patients with the volume reduction test. Mean ejection fraction increased from 22.2 +/- 6.7% to 29.6 +/- 6.0%. Diastolic dimension decreased from 81.1 +/- 9.5 to 69.8 +/- 19.2 mm. End-diastolic and systolic volume indices decreased from 199.0 +/- 47.9 to 124.1 +/- 34.9 ml/m2 and from 154.0 +/- 41.2 to 89.3 +/- 31.7 ml/m2, respectively, at one postoperative month in the 55 hospital survivors. The mean pulmonary capillary wedge pressure decreased from 25.6 +/- 7.8 to 13.6 +/- 4.5 mmHg. Serum brain natriuretic peptide decreased from 999 +/- 647 preoperatively to 547 +/- 362 pg/ml one month after the operation. Thirteen patients (18.6%) died in the late period mainly due to heart failure. Among the 42 survivors, 37 patients returned to NYHA functional class I-II, and cardiac events were rare after one postoperative year. Actuarial survivals at 3 years in elective and emergency operations were 71.9% and 33.3%, respectively., Conclusions: Left ventriculoplasty is acceptably safe for elective operation and clinical improvement can be obtained by proper surgical procedures and careful postoperative medical treatment.

Objectives: To evaluate the efficacy of off pump coronary artery bypass grafting (CABG), results in the initial consecutive 200 patients were reviewed., Methods: Between October 1996 and December 1999, 200 patients underwent CABG without cardiopulmonary bypass. There were 146 men and 54 women aged from 27 to 89 years (mean 68 years). Single, double, triple and left main disease were noted in 94, 55, 33 and 18 patients, respectively, with a mean ejection fraction of 51%. Preoperative complications were previous stroke in 34 patients, chronic renal failure in 22 patients, previous CABG in 18 patients, and aortoiliac aneurysm or occlusive disease in 14 patients. Fifty-five patients (28%) were 75 years or older. Surgical approach was made through a midsternal incision including lower half small sternotomy in 105 patients, left anterior small thoracotomy in 92 and small epigastric incision (gastroepiploic-right coronary anastomosis) in 3. Mean number of distal anastomoses was 1.3 (range 1-4). Anastomosis was performed in 189 left anterior descending, 13 diagonal, 27 circumflex and 41 right coronary arteries. The conduits were 174 internal thoracic, 10 internal thoracic-inferior epigastric composite, 22 right gastroepiploic and 5 radial arteries, and 50 saphenous vein grafts. Four patients underwent combined off pump CABG and transmyocardial laser revascularization, and 36 patients underwent hybrid (off pump CABG and angioplasty) revascularization., Results: Four patients (2.0%) died in the hospital due to intestinal necrosis in 2 patients, postoperative aortic dissection in one, and multiorgan failure with stroke in one. No serious ventricular tachyarrhythmia or use of intraaortic balloon pump occurred. Perioperative myocardial infarction was noted in one patient. Stroke occurred in 4 patients (2.0%) but 3 patients recovered in a short period. Three-year survival and cardiac event free rate were 90.3% and 81.1% by the Kaplan-Meier method. Postoperative angiographic study showed excellent patent graft in 92% of grafts (192/209), stenosed (> or = 50%) graft in 5% (10/209) and occlusion in 3% (7/209)., Conclusions: Off pump CABG can be performed safely and effectively in both high risk and low risk patients with coronary artery disease. Refinement of surgical technique and equipment will make this procedure more useful.

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

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

Among the patients with idiopathic cardiomyopathy, those with dilated cardiomyopathy were surgically treated. Initial 18 patients were treated with partial left ventriculectomy(PLV) and thereafter PLV in 26 patients, septal exclusion technique (EVCPP) in 5 patients, or solo-valvular surgery in 12 patients were applied according to the findings of the intraoperative cardiac echogram. The postoperative morbidity and mortality decreased after the selection of the operative procedures. Conclusively, left ventriculoplasty with PLV or EVCPP is a hope for the patients with dilated cardiomyopathy.

Endoventricular circular patch plasty (Dor operation) was used to treat end-stage dilated ischemic cardiomyopathy in 13 patients from January to December, 1997. There were 10 men and three women aged from 57 to 78 years (mean 63 years). Single, double, triple and left main trunk coronary disease was present in one, two, eight and two patients, respectively. Mean ejection fraction was 22% (6-30%) and signs of congestive heart failure were clear in all patients [New York Heart Association (NYHA) class III in eight patients and class IV in five patients]. Angina pectoris was present in five patients. Six patients had associated significant mitral regurgitation. Coronary artery bypass grafting (mean 3.2 grafts) was used in 11 patients and mitral valve reconstruction was performed in 6 patients (4: replacement and 2: repair) combined with akinetic area exclusion by the Dor technique. All patients were successfully weaned from cardiopulmonary bypass without mechanical support and no perioperative death occurred. Three patients died in hospital at 1-2 postoperative months due to pneumonia, stroke and heart failure, respectively. Two patients died during the late period due to stroke and sudden death. Among the eight survivors, six patients were in NYHA class I-II and two patients in class III. Ejection fraction increased from 22% to 36%, end-diastolic and systolic volume indices decreased from 168 +/- 58 to 123 +/- 39 ml/m2 and from 131 +/- 60 to 81 +/- 33 ml/m2, respectively. Pulmonary capillary wedge pressure decreased from 19 +/- 10 to 14 +/- 5 mmHg. The Dor procedure is an effective surgical alternative for patients with end-stage ischemic cardiomyopathy who are considered to be candidates for cardiac transplantation.

The Batista operation is intended to improve cardiac function by reducing the diameter of the left ventricle by excising of a sizable amount of the left ventricular free wall. Candidates for this operation are patients awaiting cardiac transplantation due to end-stage dilated cardiomyopathy and those unsuitable for transplantation because of age, physical or economical reasons. We performed this operation in 10 patients between December 1996 and October 1997. The baseline indication is left ventricular diastolic dimension > or = 70 mm and New York Heart Association (NYHA) class III or IV. There were eight men and two women aged from 16 to 60 years (mean 46 years). All had non-ischemic cardiomyopathy including seven idiopathic and one each of hypertrophic, arrhythmogenic right ventricular and valvular (sarcoidosis) cardiomyopathy. Eight patients were in NYHA class IV and six needed inotropic drip therapy prior to the operation. Nine patients had significant mitral regurgitation and six had tricuspid insufficiency concomitantly. Eight patients underwent mitral valve replacement and one was treated with mitral valve plasty. Six patients also had tricuspid plasty combined with partial left ventriculectomy. Eight patients survived. Mean value of left ventricular end-diastolic diameter was reduced from 77.8 mm to 59.8 mm, left ventricular end-diastolic volume index was reduced from 189.3 to 99.2 ml/m2, ejection fraction was increased from 19.0% to 33.8% and NYHA class improved from 3.8 to 1.8. Six months later, left ventricular dilatation was not noticed in four patients examined. The Batista operation offers real hope for patients with end-stage dilated cardiomyopathy, but we still have much to learn.

A 53-year-old man with dilated cardiomyopathy underwent left ventriculoplasty (Batista procedure), a new surgical procedure, which reduces ventricular volume to improve left ventricular function. Left ventricular ejection fraction increased from 19.7% to 43.7%. Unfortunately, he died of pneumonia 12 days after surgery. This is the first such procedure in a human in Japan.

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

With increased use of catheter intervention, candidates for coronary artery bypass grafting (CABG) have become more severely diseased. In the past 4 years with normothermic cardiopulmonary bypass technique, operative mortality was 1.5% (0.7% for elective and 5.6% for emergency) in 690 primary CABGs. The internal thoracic artery graft was used in 94% of the patients and the patency rate was 98%. The gastroepiploic artery was used in 565 patients since 1986 with 2.3% operative mortality and the patency rate was 96% in early and 92% in mid-term angiography. The inferior epigastric artery was used in 48 patients with 2% operative mortality and 90% patency rate. The radial artery was used in 105 patients with 0.9% operative mortality and patency rate was 88% at 1 postoperative year. Surgical result and angiographic patency of the graft are acceptably good while candidates of CABG have become more severely diseased. With use of arterial conduits, better long term outcome can be expected.

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

We experienced reoperative coronary revascularization through a left thoracotomy in 12 patients between June 1992 and June 1994. All patients underwent grafting to the left coronary system except one, who underwent bypass procedure to the atrioventricular branch of the right coronary artery in addition to grafting to the left anterior descending artery, using the pedicled left internal thoracic artery, the gastroepiploic artery as a free graft, or a reversed saphenous vein graft. In one patient, revascularization was accomplished during temporary occlusion of the coronary artery without cardiopulmonary bypass. On the other hand, in 11 patients, cardiopulmonary bypass was used. Coronary bypass procedure was employed under the ventricular fibrillation with hypothermia in those but one, who underwent revascularization under the beating heart with cardiopulmonary support. All patients were hemodynamically stable in postoperative stage, and artificial ventilation time was not prolonged, with a mean time of 15.7 hours. Postoperative morbidity included reexploration for hemorrhage in one patient, convulsion in one, worsening of hemianopsia in one, ventricular arrhythmia in one, and wound complication in one, however, there were no hospital deaths. All patients underwent repeat coronary angiography, which revealed that all grafts were widely patient except one, which had inadequate flow due to diffuse narrowing. Based on these clinical results, we conclude that a left thoracotomy is a useful approach for reoperative coronary bypass procedures to reduce the surgical risk associated with a sternal reentry in properly selected patients.

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

Coronary artery bypass grafting was performed on a 31-year-old female for treatment of active aortitis syndrome with unstable angina. Preoperative coronary angiography revealed ostial stenosis of coronary arteries. The ascending aorta was intensely inflamed. In the proximal anastomosis, the ascending aorta was sutured with an autogenous pericardial patch and anastomosed with the saphenous vein (SV) to be jointed to left anterior descending (LAD). At the same time, gastroepiploic artery (GEA) was connected to LAD by taking into account a degenerative change in remote stage. Right coronary artery was anastomosed with right internal thoracic artery (RITA). The postoperative course was satisfactory. On graft angiography SV and RITA were adequately patent, but GEA was unsatisfactorily patent because of its competition with SV for patency. This surgical procedure seemed to be an option to be indicated for a patient with unstable angina at an active inflammatory stage.

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

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

Coronary artery reoperation has been performed in 51 patients (4%) including 5 second reoperations among 1,245 CABGs during past 9 years. There were 40 males and 11 females with a mean age of 58 year old ranging from 19 to 75 year old. Extent of coronary artery disease were; single vessel disease in 2 patients, double vessel disease in 18 patients, triple vessel disease in 22 patients and left main disease in 9 patients. Preoperative ejection fraction ranged from 0.24 to 0.69 (mean 0.48) and 21 patients (41%) showed unstable angina. Interval between primary CABG and reoperation ranged from 1 month to 20 years with a mean of 6 years. There were two groups which had early reoperation at the mean of 6 months (14 patients) and late reoperation at the mean of 9 years (37 patients) after primary CABG. Causes of reoperation varied from graft failure (29 patients), progression of native CAD (2 patients), both of them (19 patients), and incomplete revascularization (1 patient). There were 32 patients who had patent old graft at the time of reoperation. Re-entry approaches used were midsternal in 41 patients and left thoracotomy in 10 patients. The ITA, GEA, IEA and SV grafts were used in 30, 38, 5 and 28 patients, respectively. There were 4 patients who underwent CABG without cardiopulmonary bypass. The mean number of bypass was 2.1 and the mean duration of aortic crossclamp and cardiopulmonary bypass were 63 minutes and 114 minutes, respectively. As a result, there were 4 early and 1 late death. Postoperative angiography revealed that patency rate of ITA, GEA, IEA and SV grafts were 100% (22/22), 97% (30/31), 75% (3/4) and 87% (20/23), respectively. In conclusion, risk of coronary artery reoperation is still high and use of arterial graft is important to obtain high patency rate and low reoperation rate.

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

Mortality, morbidity, and 3-year survival rates were evaluated in patients aged over 75 years undergoing initial revascularization by percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). The groups of 74 patients undergoing PTCA and 27 undergoing CABG had similar clinical characteristics including age, sex, emergency operation, prior myocardial infarction, and ejection fraction. The PTCA group contained significantly more patients with single vessel disease (44% vs 8%, p < 0.01) while the CABG group had more three-vessel or left main trunk disease (30% vs 70%, p < 0.01). The patients in the PTCA group demonstrated more prior cerebral vascular events, renal insufficiency, and abdominal aortic aneurysms. Angiographic revascularization was achieved in 112 of 130 lesions (86%) and in 63 of the 74 (84%) patients in the PTCA group. Hospital mortality for the PTCA group was 5.4% (two cardiac deaths and two non-cardiac deaths), but 0% for the CABG group. Myocardial infarction occurred in 1.3% and 3.7%, respectively (p = NS). Three-year survival, excluding hospital deaths, was 90% for patients with PTCA and 96% for those with CABG (p = NS). All these deaths were of non-cardiac origin. Both PTCA and CABG are safe and effective for selected patients over the age of 75 years.

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

A 74 year old female with lung cancer had undergone coronary artery bypass graft surgery (CABGS) and survived for 9 months after subsequent chemotherapy. She had been suffering from severe chest pain since 2 years before that time, and deteriorated intractably. At the same time, lung cancer was suggested radiologically, and revealed as small cell lung cancer by bronchial biopsy. Coronary angiogram study was done to verify the coronary artery disease and severe triple artery disease was shown. CABGS was done to relieve her condition to start chemotherapy. Post-operative course was fine and CODE therapy [cisplatin, oncovin (vincristine), doxorubicin (adriamycin), etoposide] was done subsequently to CABGS. Cancer focus and swollen lymph node were vanished in radiographic examination. She had discharged and spent at home for a while. However, multiple metastatic lesions emerged later, and deceased finally 9 mouths after CABGS. We conclude, CABGS done for her was a reasonable therapy to relief her condition and was successful to carry out chemotherapy.

A 75-year-old female who had underwent coronary artery bypass grafting (CABG) reoperation 2 years before was readmitted because of unstable angina. Two arterial grafts and one saphenous vein graft (SVG) were all occluded one and half year after the primary operation. The second operation was approached via the repeated sternotomy. LAD and RCA were revascularized with a Y-shaped SVG which had only one inflow. Coronary angiogram revealed stenosis of LMT and RCA and occlusion of the inflow of the Y-shaped SVG. We performed the 3rd CABG via the left thoracotomy without cardiopulmonary bypass for revascularization of the LAD area. A new SVG was anastomosed from the descending aorta to the old SVG just proximal to the anastomotic site with LAD. Local coronary occlusion time was 7 min without any hemodynamic or electrocardiographic deteriorations. The operation was successfully performed in 3 hr 55 min. The patient recovered well uneventfully. Postoperative angiogram showed that the new SVG was adequately patent and she was discharged without angina. We conclude that CABG without cardiopulmonary bypass via the left thoracotomy is an useful alternative to decrease mortality and morbidity for reoperative myocardial reveascularization.

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

We report a case in conjunction with MRSA sepsis, who needed re-mitral valve replacement (re-MVR) and re-tricuspid valve imposition (re-TVI), and who was successfully treated with a number of antibiotics in conjunction with hyperthermal extracorporeal circulation. Initially, we performed MVR and tricuspid valve superimposition on a 62-year-old woman lationing under the MRSA sepsis condition to control against heart failure. However, she developed a fever following the first operation, and MRSA was detected from her blood cultivation. She thus underwent treatment employing many kinds of antibiotics. A thickened C.E. valve at the tricuspid valve cardiac echogram suggested PVE, we performed a second operation of re-MVR and re-TVI about a year after the first operation. We used a tangl of antibiotics during the operation, adding Vancomycin into the extracorporeal circulation, and utilized hyperthermal extracorporeal circulation. This patient's postoperative course was uneventful, with no recurrence arising at 23 months after the second operation.

While annual attrition and high break-down rate of saphenous vein graft (SVG) used for CABG has widely noted in Western countries, no sizable studies have yet available in Japan. We studied 142 SVGs of 77 pts, which we divided into two groups; 80 SVGs of 44 pts in mid-term period (5 to 8 years after surgery) and 62 SVGs of 33 pts in long-term period (9 to 17 years after surgery). The patency rate of SVGs was 69% in mid-term and 77% in long-term. Whereas these patency rates at each periods were superior to those reported from USA and European countries, a quarter of SVGs in mid-term period and a half in long-term period had significant stenotic changes (over 50%). Of patent SVGs, diseased SVGs reached 36% in mid-term period and 73% in long-term period. In conclusion, although the patency rate of SVGs in Japanese patients was higher than that of the Western countries, vein graft disease apparently occurred in a large proportion of patent SVGs.

A case report of serial repeat myocardial revascularization under the beating heart. A 56-year-old, hypertensive and hyperlipidemic male suffered from unstable angina who had undergone primary CABG with saphenous veins 10 years ago. The vein graft to the left anterior descending coronary artery (LAD) was solely patent but had a severely stenotic lesion. The stenotic LAD vein graft fed all coronary circulation. The second operation was approached through the sternal reentry but E-PTFE sheat for pericardial closure at the primary operation tightly adhered to an anterior aspect of the heart with abscess formation. So only gastroepiploic artery (GEA) could be anastomosed to the right coronary artery (RCA) under the beating heart without cardiopulmonary pump (CPB). While the postoperative angiogram showed GEA graft was patent, unstable angina recurred. Then the third operation was performed 2 weeks later through the left thoracotomy under the beating heart with CPB. A new saphenous vein was anastomosed from the descending aorta to LAD. He recovered well without any major complications. Postoperative angiogram showed two new grafts widely patent and he discharged with freedom from angina.

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

Aortic calcification was evaluated preoperatively by computed tomography (CT) in 136 of 275 candidates for coronary artery bypass surgery (age range, 30-80) years (mean 60.2 years), including 110 men and 26 women), from April 1989 to March 1991. Calcification in the mid-ascending aortic wall was detected in 20 (14.7%) cases, calcification in all regions of the aorta was more common in patients older than 60 years (22.5%, n = 71), than younger (6.2%, n = 65) (p less than 0.01). Atherosclerosis of the ascending aorta was identified intraoperatively in 25 (18.3%) cases. Practically, the specificity of CT findings was excellent (98.3%), but the sensitivity was less satisfactory (72.0%) due to the presence of atherosclerosis without calcification. In cases of arteriosclerosis of the ascending aorta, great care was taken to prevent embolism secondary to a dislodged atheromatous plaque. The "aortic no-touch technique", with in situ internal thoracic artery and right gastroepiploic artery anastomosis under ventricular fibrillation, was performed in 6 cases, a single aortic cross-clamp was applied in 19 cases, and conventional methods were employed when the ascending aorta was normal or the "no-touch" or "single-clamp" procedure could not be used (control, 111 cases). No neurologic complications occurred in the "no-touch" group, while 2 cerebral infarctions occurred in the single-clamp group (10.5%) and the control group (1.8%) respectively. These differences between groups was not significant. Patients with a calcified ascending aorta are at higher risk for neurologic complications of coronary bypass. The risk can be decreased by minimizing surgical trauma to the ascending aorta by the use of "no-touch" techniques.

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

Between June 1983 and July 1989, 25 consecutive chronic dialysis patients with medically refractory angina pectoris underwent revascularization, either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) (21 males and 4 females, mean age of 57 +/- 10 years, and mean duration of dialysis of 3.7 +/- 5.0 years). Patients with single-vessel disease and/or mildly calcified lesions received PTCA (n = 15), while those with multi-vessel disease and/or severely calcified lesions received CABG (n = 10). As controls for PTCA-treated dialysis patients, 208 non-dialysis patients who received initial PTCA in 1988 were used. The mean number of diseased vessels was 2.7 +/- 0.7 for CABG group, and 1.5 +/- 0.8 for PTCA group (p < 0.01). In both groups, 80% of patients were successfully revascularized. In CABG group, however, 7 of 10 patients had major complications including 2 hospital deaths, while no complications occurred in the PTCA group. During the follow-up period after CABG (35 +/- 30 months), recurrent angina developed in one patient, who was successfully treated with PTCA. In the PTCA group, angiographic success was initially obtained in 16 of 21 lesions (76%), which was significantly lower than that in the control group (92%, p < 0.05). Follow-up angiography revealed restenosis in 6 of 16 lesions with successful PTCA (38%), similar to that observed in the control group (32%, p = ns). A second PTCA was successful in 5 of 6 patients with restenosis, however, 4/5 patients developed recurrent angina. Three of 4 patients with a second episode of restenosis underwent a third PTCA, and angina recurred in 2.(ABSTRACT TRUNCATED AT 250 WORDS)

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

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

Several methods of dialysis have been employed to maintain the perioperative water-electrolyte balance caused by the disorders with chronic renal failure. We have experienced 13 cases of coronary artery bypass surgery with chronic renal failure, and employed hemodialysis (HD) in 5 cases, hemodialysis with extracorporeal ultrafiltration method (HD + ECUM) in 5 cases, continuous ambulatory peritoneal dialysis (CAPD) in 3 cases for perioperative management. The perioperative changes of the circulatory blood volume and the fluid-balance, were assumed by positive reaction with varied over 60 mmHg in systolic blood pressure or demanded over double dose of catecholamines in each observed terms until the next day of the patients extubated. The cases with HD or HD + ECUM have changed the blood pressure more frequently (HD cases = 21%, HD + ECUM cases = 19%) than the cases with CAPD (CAPD cases = 3%). We conclude that the each methods are available to manage perioperative dialysis to undergo coronary artery bypass grafting should be employed with some techniques, CAPD will be the most favorable method to maintain the fluid balance stably for patients with severe compromised cardiac function.

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

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

The pharmacological responses of internal thoracic artery (ITA), gastroepiploic artery (GEA) and saphenous vein (SV) obtained from patients receiving coronary artery bypass grafting (CABG) were assessed by isometric contraction records. The concentration-response curves for ergonovine and serotonin showed the leftward shift in SV compared with ITA and GEA. The 50% effective dose values of SV for ergonovine and serotonin were significantly less than those of ITA and GEA. The concentration-response curves for phenylephrine were similar among three kinds of grafts. There were no significant differences in the 50% effective dose values for phenylephrine among them. The effect of 0.4% papaverine chloride on the free graft flow was assessed in 15 patients receiving CABG with mean body surface area of 1.62 +/- 0.12 M2. The free flow of ITA graft was 71 +/- 32 ml/min before intraluminal papaverine injection, and that increased to 112 +/- 41 ml/min after injection. The free flow of GEA graft was 82 +/- 39 ml/min before injection, and that also increased to 128 +/- 40 ml/min after injection. The patency rates at the mean 2.2 months after grafting were 98% in ITA, 93% in GEA, and 88% in SV. In conclusion, both GEA graft and ITA graft can be expected as an excellent conduit in myocardial revascularization.

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

For 10 adult cases of Ebstein's anomaly, tricuspid valve supraannular imposition (TVSI) without excision of native tricuspid valve were performed and its late results (6 mo. to 11.5 y, mean 6.8 years) were investigated. All cases showed the severe low output syndrome after the surgery. But the postoperative recovery of the cardiac function was smooth and there was no early death nor A-V block. Both the A-V conduction and the RV subvalvular structures were preserved in TVSI and it contributed to the postoperative good contractility of RV. In two cases, the serious postoperative ventricular tachycardia or ventricular fibrillation were experienced, one case required open cardiac massage and 6 hours long assist circulation in the other. In late stage, one patient died 9 years after the TVSI from the failure of the bioprosthetic mitral valve which had been implanted simultaneously, and the other 9 survivors returned to the class I of NYHA classification. LVDd and DS obtained by echocardiography showed significant enlargement; 29 +/- 4.5 mm and 19 +/- 4.1 mm before operation to 42 +/- 3.1 mm and 29 +/- 5.8 mm in late stage respectively. EF showed the tendency of slight decrease from the preoperative supernormal value to the normal range. RVD showed significant decrease after the surgery (58 +/- 4.2 mm to 37 +/- 4.1 mm). Bioprosthetic valve failure in tricuspid position was not experienced. PAC or PVC were seen quite often and 8 of 9 cases received medication for arrhythmia even in late stage.(ABSTRACT TRUNCATED AT 250 WORDS)

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

Three patients with systemic disease requiring steroids, in whom coronary artery bypass grafting (CABG) was performed, are reported in this paper, Anesthetic problems and operative managements for such patients are also discussed. Patient 1, 57-year-old male with thrombocytosis underwent emergency double CABG using saphenous vein and the Bioflow graft. He discharged with freedom from angina. Patient 2, 59-year-old male with polymyositis who had been receiving steroid for 10 years underwent quadruple CABG using bilateral internal thoracic arteries with sequential technique and the Bioflow graft, but he died of multiple organ failure on 16 days after operation. Postmortem examination revealed that coronary artery sclerosis progressed more severely than we had expected from angiography. All the graft anastomosed were completely patent. Histological examination showed that the saphenous vein was fragile. The pathological changes might be due to steroid administration. On the other hand, arterial grafts were completely normal. Patient 3, 37-year-old male with idiopathic thrombocytopenic purpura who had been on steroids underwent combined triple CABG using internal thoracic artery, gastroepiploic artery and the Bioflow graft and splenectomy. He discharged with freedom from angina and tendency to bleed. Postoperative angiography showed both arterial grafts were well patent and left ventricular wall motion vastly improved. From our experience, a careful consideration of the bypass conduit is a major problem in such patients requiring steroids.

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

This study was designed to examine the response of coronary artery bypass conduit to serotonin, phenylephrine, and ergonovine as provocation agents of vasoconstriction. Saphenous veins (SV) and internal mammary arteries (IMA) were obtained during coronary artery bypass grafting (CABG), and their contractile properties were measured using isometric contraction recording apparatus. Both SV and IMA showed sigmoid contraction curves indicating dose dependence to ergonovine, serotonin, and phenylephrine. The concentration-response relations for phenylephrine showed a similar curve in both SV and IMA, however, those for ergonovine and serotonin showed a leftward shift in SV compared with IMA. Half maximum effective dose for ergonovine and serotonin were less in SV than IMA. From these results, it was suggested that "perioperative spasm" during CABG might occur not only in coronary arteries but also in the graft conduit itself. Graft spasm might be a possible mechanism for occlusion of the bypass graft. In conclusion, greater hyperreactivity of SV compared with IMA in response to ergonovine and serotonin was suggested, so it is concluded that, from this point of view, IMA is more suitable for use in CABG.

Seventy patients underwent sequential coronary artery bypass grafting with saphenous vein during 28 months period. Seventy eight sequential grafts comprising 165 distal anastomoses were performed. Early death was 2.9%. Postoperative angiographic evaluation within 6 months showed 86% patency of the 65 sequential grafts and 89% patency of the 136 distal anastomoses. The patency of anastomosis to left anterior descending artery (LAD), diagonal branch (Dx), obtuse marginal branch (OM), posterior lateral branch (PL), and posterior descending branch (PD) was 87% (13/15), 92% (36/39), 91% (40/44), 81% (26/32) and 100% (6/6), respectively. The patency of Dx-LAD, Dx-OM and OM-PL was 86% (12/14), 94% (15/16) and 76% (13/17), respectively. There was no significant difference in the patency rate according to the site of anastomosis and the inner diameter of the coronary artery. The patency of side to side anastomoses was 92% (65/71) which was not significantly different from that of the end to side anastomoses; 86% (56/65). These results showed sequential aorto-coronary vein grafting means to be effective for the complete coronary artery revascularization .

A study was conducted on 118 Hancock (HX) porcine valves, 251 Carpentier-Edwards (CE) porcine valves, and the biological valves in children used in the mitral position. Twenty-three HX valves, twenty-seven CE valves, and all valves except one operative death in children were diagnosed as primary tissue failure (PTF). Freedom from PTF for HX valves was 70.1 +/- 6.0% at ten years and for CE valves was 45.7 +/- 17.0% at ten years, although for children it was calculated 0% at eight years (significantly poor results compared with adults). No relation was found between the degree of calcified cusps and the duration of PTF valves used. The ruptures and calcifications of the cusps were most commonly observed in commissure. The peeled off commissures were characteristic in CE valves. Three adults and two children died without reoperation caused by calcified stenotic valves. Since the risk of reoperation was higher in NYHA functional class four, we recommend earlier elective reoperation.

From March 1986 to October 1989, 91 patients underwent CABG using the right gastroepiploic artery (GEA) at Osaka Medical College and Mitsui Memorial Hospital. Including 14 females, the mean age was 57.9 years old ranged from 34 to 73 years old. Triple vessel disease and left main disease occupied over 90% of the patients. There were 5 emergency operations and 6 reoperations. Associated serious diseases were; renal failure with hemodialysis in 2 pts., familial hyperlipidemia in 5 pts., severe atherosclerotic ascending aorta in 8 pts., arteriosclerosis obliterance in 3 pts., and each one of abdominal aortic aneurysm and idiopathic thrombocytopenic purpura. The internal thoracic artery (ITA) graft was concomitantly utilized in 96% of the patients. Single ITA in 60 pts., double ITA in 23 pts. and sequential ITA in 5 patients. Saphenous vein graft was used in 58 patients and remaining 33 patients were operated without leg wound. The mean number of distal anastomoses was 3.3 ranged from 1 to 5, and the mean number of arterial grafts was 2.5 ranged from 1 to 4. The mean aortic cross clamp time and cardiopulmonary bypass time was 62.8 minutes and 113.6 minutes, respectively. Sites of GEA anastomosis were; 4 anterior descending, 3 diagonal, 11 circumflex and 73 right coronary arteries. There were 86 in situ grafts mostly for the right coronary arteries, and remaining 5 GEAs were used as a free graft to bypass the left coronary arteries. On the contrary, ITA was used to bypass the left coronary artery system preferentially. There was 3 combined procedures; splenectomy, abdominal aorta replacement, and ascending aorta to bifemoral artery bypass in each one patients. Three patients including one emergency case died within 30 days after surgery. Two were cardiac and one was renal failure. Other 2 patients died of stroke at late period. New Q wave infarction was noted in 2 patients. Relief of angina was obtained in 98% of survivors. The patency rate of the GEA graft was 97% in 61 grafts restudied within 6 postoperative months, which was identical with that of the ITA graft, that is 97% of 76 grafts. In conclusion, the GEA has several advantages as a coronary artery bypass graft such as similarity in size to the coronary artery, rare arteriosclerosis, feasibility of in situ graft, and no gastric complication. Its flow capacity is studying now and favourable results are being obtained. The final problem, its long term patency, will be resolved in future. GEA is a promising conduit for the coronary bypass surgery.