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Background: As the life expectancy of cancer-bearing patients has increased, more patients with bone metastasis are receiving long-term treatment with bone-modifying agents (BMAs; e.g., zoledronate and denosumab), which are a risk factor for developing atypical femoral fracture (AFF). In this study, we surveyed the risk of iatrogenic AFF using a clinical database on treatment of bone metastasis in the past 10 years., Methods: From April 2011 through October 2019, 721 patients with bone metastasis (436 men, 285 women; mean age, 65.7 ± 12.4 years) were registered under the bone metastasis consultation system, which has been run by orthopaedic surgeons since 2011, at a university hospital in Japan. We retrospectively reviewed the database to identify patients who had received BMAs for treatment of bone metastasis, and we investigated the incidence of critical skeletal-related events (including AFF) which required surgical interventions by orthopaedic surgeons., Results: BMAs were administered to 529 patients (73.4%). Orthopaedic surgery for the treatment of skeletal-related events was performed in 36 patients (5.0%): femur, 13 (1.8%); others, 23 (3.2%). Eight AFFs in 5 patients (breast cancer, n  = 4; prostate cancer, n  = 1), who all had prior exposure to zoledronate or denosumab before onset of AFF, were treated with internal fixation using intramedullary nailing. In 192 patients with no BMA exposure, critical (surgically treated) AFF was not detected. In summary, the incidence of critical AFF was 0.9% among 529 patients who received BMAs for treatment of bone metastasis, and the incidence was 6.6% when limited to breast cancer patients (4 of 61)., Conclusion: In treatment of bone metastasis using BMAs, especially for breast cancer patients, attention should be paid to the risk of developing AFFs. Routine radiographic screening for AFF might be necessary in patients with prolonged BMA use for bone metastasis, even if asymptomatic. This report alerts all physicians and surgeons involved in the management of cancer patients, especially those with bone metastasis, regarding the risk of AFF following BMA use., (© 2020 The Author(s).)

Background: Rotationplasty is one treatment option for femoral bone sarcomas in skeletally immature patients. This procedure can also be used to save failed limb salvage procedures such as infected prostheses and failed bone grafts in adults. Rotationplasty is only rarely indicated, and the surgical complications and risk factors for failure of the procedure that might influence the treatment or patient choices have not been well described., Methods: We retrospectively reviewed 19 patients who underwent rotationplasty focusing on surgical indications, surgical procedures such as the type of rotationplasty, and whether vessels were sacrificed and reconstructed with vascular anastomosis or preserved. Risk factors for failure of rotationplasty were categorized into either early or late postoperative complications., Results: Thirteen of 19 rotationplasties were done for patients diagnosed with primary sarcoma, 3 patients for unplanned excisions of sarcomas, and 3 patients for infection. Two of 19 patients did not have sufficient circulation resulting in amputation. Six of 19 patients underwent vascular anastomoses, and all of these anastomoses were successful. Three patients had multiple operations for infection before rotationplasty, and one patient's treatment failed so an amputation was required. As late complications, one patient had delayed bone union and one had postoperative infection that healed after removal of plate fixation. Two patients had malrotation of the tibia that resolved with revision surgery. One patient had a skin ulcer that healed with conservative treatment. One patient who had an unplanned excision had a hemipelvectomy for non-union 11 months after rotationplasty., Conclusions: Rotationplasty was successfully accomplished in 16 of the 19 patients (84 %) with sarcomas, unplanned excision of sarcomas or infection. Vascular anastomosis did not increase the risk of rotationplasty failure in our series. Patients appeared to have a higher risk of failure of rotationplasty after multiple operations, possibly because of inflammation around the vessels. The surgeon should be aware of the higher potential risk and consider vascular anastomosis for these patients.

Background: Pasteurized bone (PB) is recycled bone. The pasteurization has a tumor cell-killing effect wit retention of initial strength. However, few reports have been published on its long-term course; thus, in this study, we evaluated the long-term course of use of PB and examined appropriate reconstruction methods., Patients and Methods: We reviewed 27 cases in which reconstructive surgery using PB was performed between 1990 and 2002. Of these, we excluded 12 fatal cases and 1 case in which follow-up was discontinued. Therefore, our final analysis consisted of 14 cases with an average follow-up period of 165 months. The reconstruction methods used were: osteoarticular graft in 6 cases, composite graft with prosthesis in 3 cases, intercalary graft in 1 case, and reconstruction using PB from the pelvis in 4 cases., Results: The PB survived in 7 of the 14 cases. Five and 10-year survival of the PB was 78.6 and 47.6%, respectively. Three of the 6 osteoarticular cases failed because of late-onset absorption or infection of the PB. For patients with composite graft or intercalary graft, long-term survival was achieved when small amounts of PB were used. For patients with pelvic grafts, long-term survival was achieved in a case of P1 pelvis, but large PB grafts on small bone-junction surfaces were not successful in the long term. On the basis of these results, we were able to achieve successful long-term results with small PB grafts on large bone-junction surfaces., Conclusions: To prevent bone absorption and achieve long-term survival of PB, it is important to use a small PB graft and create a large surface area of contact with normal bone. These factors are advantageous to PB survival and to gaining limb function.

A 24-year-old woman with atopic dermatitis was admitted to our hospital with fever. Echocardiography showed a huge vegetation attached to the posterior mitral commissure without mitral valve dysfunction. Blood culture identified methicillin-sensitive Staphylococcus aureus. The serum level of antiphospholipid antibody was elevated. A splenic infarction occurred on the second hospital day. Surgery to resect the residual mobile vegetation was performed uneventfully on the 6th hospital day. The postoperative course was uneventful, and the patient was discharged after 4 weeks of antibiotic therapy. Preservation of the mitral valve is rare in the face of virulent Staphylococcus infection and the presence of a huge mobile vegetation. These findings were apparently related to the high serum level of infection-related antiphospholipid antibody and atopic dermatitis.

Background: In the present study we analyzed the in vivo performance of the 19-mm St. Jude Medical Hemodynamic Plus aortic prosthesis (19HP), evaluated the midterm performance of 19HP in the aortic position, and compared the implantability and hemodynamic characteristics of this valve with those of the 21-mm standard St. Jude Medical valve (21SD) in adult patients with aortic stenosis and a narrowed aortic annulus., Methods: From February 1994 to December 1999, 60 patients who underwent isolated aortic valve replacement with either the 19HP (n = 31) or the 21SD (n = 29) were studied. Comparison between the two models included analysis of early and late mortality and morbidity. Pre- and postoperative echocardiography was performed in all patients to evaluate and compare the hemodynamic performance of both prosthetic valves. The postoperative serum lactic dehydrogenase activity was measured in both groups of patients as an indicator of hemolysis., Results: The mean body surface area was 1.46 +/- 0.16 m2 in the 19HP group and 1.49 +/- 0.13 m2 in the 21SD group (p = 0.1577). Other than female dominance in the 19HP group, there was no statistically significant difference between the two groups in terms of preoperative variables (age, preoperative pressure gradients, and New York Heart Association functional class). The average postoperative peak pressure gradient was 23.3 +/- 10.5 mm Hg in the 19HP group and 27.9 +/- 9.9 mm Hg in the 21SD group (p = 0.0666). There was no hospital death in either group. Six-year follow-up was completed in both groups of patients. Late death occurred in 1 patient in the 19HP group (1.09% per patient-year). Actuarial survival at 6 years was 92.3% +/- 7.4% in the 19HP group, and 100% in the 21SD group (p = 0.33). The linearized complication rate was 1.09% per patient-year and 1.02% per patient-year for thromboembolism, and 1.09% per patient-year and 1.02% per patient-year for anticoagulant-related hemorrhage in the 19HP group and the 21SD group, respectively. Freedom from all complications at 6 years did not show any significant difference between the two groups (p = 0.54). Although left ventricular mass indices decreased significantly after aortic valve replacement in both groups (19HP group, p = 0.0002; 21SD group, p = 0.0006), there were no significant differences in the two indices between the groups after aortic valve replacement (p = 0.999). There was no significant difference in the lactic dehydrogenase level between the two groups (p = 0.4915)., Conclusions: In vivo hemodynamic performance of the 19HP valve as well as the early and intermediate clinical outcome up to 6 years was satisfactory and corresponded closely to that of the 21SD valve in adult patients. The 19-mm Hemodynamic Plus model can be recommended in patients with a measured 19-mm annulus and this valve will minimize the need for the aortic annular enlargement procedure.

Coronary ostial stenosis between an interposition graft and coronary artery is rare and fatal. A 46-year-old woman who had reconstruction of both coronary arteries using interposition grafts for type A acute dissecting aneurysm presented with acute chest pain. Emergent coronary artery bypass grafting was done with saphenous vein grafts. Inappropriate use of gelatin-resorcinol-formaldehyde glue can be associated with ostial stenosis in the long term. Transesophageal echocardiography is useful to diagnose ostial stenosis of the coronary arteries.

A 28-year-old man was admitted because of dyspnea on effort. His tricuspid valve had been affected by granulocytic sarcoma and manifested tricuspid valve stenosis 8 years previously. After chemotherapy and radiation therapy, the tumor had disappeared and the tricuspid valve stenosis was relieved. Echocardiography showed that the posterior leaflet of the mitral valve was affected by the tumor, and Doppler ultrasonography revealed mild mitral valve stenosis. Biopsy of the anterior chest wall detected granulocytic sarcoma. Chemotherapy was started. The tumor size was reduced and the mitral valve stenosis became slight. Primary cardiac granulocytic sarcoma is very rare and stenosis of the atrioventricular valve by relapse of this tumor after complete remission is extremely unusual.

Cardiac hemangiomas in the left ventricle are extremely rare. A 34-year-old woman, without symptoms, with a diagnosis of cardiac tumor at the apex of the left ventricle was referred to us. The tumor was surgically resected, and the diagnosis was hemangioma. The Jatene technique, originally introduced for left ventricular aneurysmectomy was excellent for repair after resection of a cardiac tumor at the apex.

Objectives: Early recovery in patients after minimally invasive coronary artery bypass grafting with mini-sternotomy and cardiopulmonary bypass (MICS-CABG) was compared to standard CABG by assessing preoperative and postoperative (7 to 10 days after) respiratory function., Methods: Fifteen patients (Group M; mean age 62.1 years) underwent MICS-CABG with a mean of 2.3 distal anastomoses per patient. Ten patients (Group F; mean age 63.8 years) underwent standard CABG through full sternotomy with a mean of 2.4 distal anastomoses per patient., Results: Postoperative coronary angiography showed that the patency rate of the grafts was 97% in Group M and 96% in Group F. Intubation time and hospital stay were significantly shorter (p < 0.01) in Group M (6.2 +/- 2.4 hours, 16.3 +/- 3.1 days) than in Group F (10.8 +/- 2.9 hours, 22.8 +/- 2.5 days). Respiratory function measured as the percentage of postoperative to preoperative values (Group M/Group F; mean +/- standard error) were vital capacity of 95.8 +/- 3.1%/74.6 +/- 3.4% (p < 0.05), 1 sec percentage of forced expiratory volume of 98.8 +/- 2.3%/71.8 +/- 2.8% (p < 0.05) and peak expiratory flow rate of 91.7 +/- 4.2%/89.4 +/- 4.5%., Conclusions: Quick recovery of the respiratory function after MICS-CABG may be important in the early recovery and short hospital stay of MICS-CABG patients compared with standard CABG patients.

A method of heart retraction during coronary artery bypass operations is described. The technique improves exposure of the coronary arteries, especially of the circumflex and posterior descending coronary branches during grafting. In addition, it is simple, safe, and inexpensive. Furthermore, this technique can be applied for off-pump coronary artery bypass surgery.

Background: After open heart operations about 1% of patients still need temporary circulatory support for severe cardiac failure, and over half of those patients die during or after the support. This study assessed the efficacy of the current strategy of circulatory support., Methods: We assessed clinical outcome of 64 consecutive patients (1.5% of pump cases) who had temporary circulatory support associated with perioperative variables. The results were analyzed by logistic regression analysis., Results: The weaning and discharge rates were 50.0% and 26.7% with venoarterial bypass, 76.2% and 57.1% with biventricular bypass, 87.5% and 37.5% with isolated left ventricular bypass, and 60.0% and 40.0% with pulsatile left ventricular assistance, respectively. Logistic regression analysis identified presupport cardiogenic shock (odds ratio, 9.922) and support type (14.684) as factors significantly associated with nonweaning from the temporary support, and cardiogenic shock (28.268), support duration (2.948), and support type (14.184) as factors significantly associated with mortality during or after the circulatory support., Conclusions: The current strategy of temporary circulatory support improved clinical outcome of patients with severe cardiac failure. Early application of circulatory support before profound cardiogenic shock and proper selection of the support type might be key factors for successful circulatory support postoperatively after operation.

Background: Marfan syndrome patients frequently develop aneurysms or dissections involving multiple segments of the aorta, and occasionally require staged replacement of the entire aorta. This study reviews the surgical outcome of patients with Marfan syndrome who underwent extensive aortic reconstruction. Extensive reconstruction is defined as reconstruction of more than two segments of the ascending, arch, descending thoracic, or abdominal aorta., Methods: From March 1973 to December 1997, 101 patients with Marfan syndrome underwent aortic operation. Twenty-six patients (25.7%) had extensive aortic reconstruction. All 26 patients suffered from aortic dissection: 13 patients had Stanford type A and 13 had type B dissection. Twenty-three patients (88.4%) had annuloaortic ectasia and aortic regurgitation. Surgical procedures included composite valve graft replacement (n = 23, 88.4%), aortic arch reconstruction (n = 15, 57.7%), graft replacement of the descending thoracic aorta (n = 6, 23.1%), and graft replacement of the thoracoabdominal aorta (n = 16, 61.5%). Five patients (19.2%) had total thoracoabdominal aortic replacement, and three patients (11.5%) had replacement of the entire aorta. Twenty-one patients (80.8%) required multiple operations., Results: Follow-up was complete in all patients. The 30-day survival rate was 88.5%. None of the survivors had paraplegia or paraparesis. The overall long-term survival rate was 88.5 +/- 6% at 1 year, and 81.7 +/- 9% at 9 years., Conclusions: Aortic surgery prolongs survival in patients with Marfan syndrome, and currently there is a relatively low associated morbidity and mortality even for aggressive surgical treatment.

Background: Retrograde cerebral perfusion (RCP) has been widely adopted during aortic arch surgery under hypothermic circulatory arrest (HCA). However, the risks in terms of mortality and morbidity in aortic arch surgery using HCA with RCP have not yet been confirmed., Methods: The present study is a retrospective review of 249 patients who underwent aortic arch surgery at three Japanese cardiovascular centers where RCP is a routine adjunct. The median age was 65 years, and 38 patients were more than 75 years old. The pathology in the aortic arch was atherosclerotic aneurysm in 133 patients and dissection in 116. Seventy patients had surgery on an emergency basis. Surgery was performed through a median sternotomy in 182 patients and through a left thoracotomy in 67. Using HCA with RCP, graft replacement of the total aortic arch was performed in 109, the distal arch in 63, and the ascending aorta and hemi-arch in 66; 11 patients had patch repair., Results: The overall hospital mortality was 25/249 (10%), and 12/70 (17%) in emergent surgery. Stroke developed in 11 patients (4%). The median duration of RCP was 46 minutes (range, 5 to 95). Univariate analysis of risk factors revealed that an age of 75 years or more (p < 0.001), and urgency of surgery (p = 0.02) affected hospital mortality. Multivariate logistic analysis revealed that pump time (p = 0.0001), age (p = 0.0001) and RCP time (p = 0.05) are the most significant risk factors for mortality. The risk factors for mortality and neurological morbidity combined are pump time (p = 0.0001), age (p = 0.0002), and urgency of surgery (p = 0.07); RCP time is marginally significant (p = 0.15)., Conclusions: The dominant risk factors for mortality and morbidity are pump time, urgency of the surgery, and age. RCP is a simple and useful adjunct for aortic arch surgery with up to 80 minutes of HCA, although prolonged RCP is a risk factor for mortality and morbidity.

Background: Graft coronary arteriosclerosis is the major limiting factor for long-term survival after heart transplantation. In this study, we investigate the effect of multiglycosidorum tripterygii on graft coronary arteriosclerosis and platelet-derived growth factor A mRNA expression of transplanted hearts., Methods: Three groups of Lewis rats (n = 7/Group) underwent heterotopic heart transplantation from Wistar-King donors and were treated with cyclosporine A (10 mg/ kg/day) for 60 days (Group A) or with multiglycosidorum tripterygii (30 mg/kg/day) for 60 days (Group B) or with cyclosporine A for the first 30 days and followed by multiglycosidorum tripterygii for another 30 days (Group C). Histological evaluations of rejection and coronary arteriosclerosis, as well as Northern blot analysis on graft platelet-derived growth factor A mRNA expression were made 60 days after transplantation., Results: Morphometric results indicated no significant difference in rejection among three groups. However, the extent of graft coronary arteriosclerosis in Group B (1.12 +/- 0.21) and Group C (1.41 +/- 0.19) was significantly less than that seen in Group A (1.72 +/- 0.18) (p < 0.01 andp < 0.05, respectively). Furthermore, the incidence of diseased vessels was significantly less in Group B (29.5% +/- 7.8%) and Group C (42% +/- 9.1%) compared with Group A (69.1% +/- 11%) (p < 0.01 and p < 0.05, respectively). The expression of platelet-derived growth factor A mRNA of cardiac allograft was also significantly suppressed in Group B (25.4 +/- 6.2) and Group C (39.8 +/- 9.4), when compared with Group A (62.2 +/- 12.9) (p < 0.01 and p < 0.05, respectively)., Conclusion: Multiglycosidorum tripterygii is superior to cyclosporine in prevention and attenuation of graft coronary arteriosclerosis and this efficacy is probably associated with the depressed expression of graft platelet-derived growth factor A mRNA in the multiglycosidorum tripterygii-treated groups.

Dilated cardiomyopathy (DCM) is often accompanied by severe mitral regurgitation (MR) which deteriorates the clinical course. Mitral reconstruction for severe MR may improve the symptoms and prognosis. Five patients with DCM and one patient with dilated phase of hypertrophic cardiomyopathy underwent mitral reconstruction for severe MR (4 males, 2 females, mean age 50 +/- 17 years) from 1983 to 1995. Their New York Heart Association (NYHA) functional class and findings of echocardiography and cardiac catheterization were compared before and after surgery. Five patients underwent annuloplasty and one patient underwent mechanical valve replacement. There was no operative or in-hospital death. NYHA class improved from 3.2 to 1.8 (p < 0.05). The degree of MR was reduced from 3.5 to 1.2 (p < 0.05), and left ventricular end-diastolic pressure decreased from 18 +/- 7 to 13 +/- 8 mmHg (p < 0.05). Left ventricular fractional shortening, ejection fraction and cardiac index (2.4 +/- 0.4 to 2.7 +/- 1.1 l/min/m2) did not change significantly. Two patients died within one year due to exacerbation of congestive heart failure (2.5 month later) or sudden death (6 months later). Three patients died at 21 months, 5 and 8 years after the operation (renal insufficiency, heart failure, sudden death, respectively). Mitral reconstruction improved the symptoms in patients with DCM and severe MR in the short term. However, 5 of 6 patients died in the intermediate or long-term. Mitral reconstruction may be a therapeutic option for early outcome in patients with refractory congestive heart failure due to DCM and severe MR.

Background: Problems associated with heart transplantation, such as shortage of suitable organs and the side effects of immunosuppressive therapy, are especially serious for patients in the pediatric age group. Induction of donor-specific immunologic tolerance without immunosuppressive drugs would be ideal for clinical organ transplantation. In this study, we used a vascularized cardiac xenograft model to achieve donor-specific unresponsiveness without immunosuppression by manipulating the intrauterine immune response., Methods: Lewis rats and Golden Syrian hamsters were used as the recipients and donors, respectively. Donor bone marrow cells (15 x 10(6) in 0.05 mL) were injected into each fetus of pregnant Lewis rats on days 9 (n = 2) and 16 (n = 2) of gestation. Donor hearts were heterotopically transplanted into each surviving (n = 8, n = 5) fetus of the Lewis rats at 8 weeks of age. Donor hearts were also transplanted into untreated rats as controls (n = 8)., Results: The mean cardiac xenograft survival time was 2.5 +/- 0.5, 7.4 +/- 4.1, and 2.8 +/- 0.8 days in the control group, gestational day 9 group, and gestational day 16 group, respectively. Chromosomal analysis of the day 9 group showed Golden Syrian hamster chromosomes as well as Lewis rat chromosomes., Conclusions: Cardiac xenograft survival was significantly prolonged by intrauterine exposure to xenograft bone marrow cells on day 9 but not on day 16 of gestation. Cardiac xenograft survival and chromosomal analysis of the recipient bone marrow suggested that chimerism was achieved between Golden Syrian hamsters and Lewis rats. Cardiac xenotransplantation may be possible by induction of donor-specific tolerance in utero.

The efficacy of catheter intervention for adult congenital heart diseases was evaluated in 27 patients aged 20 to 52 years (mean age at catheterization 25 +/- 7 years) from 1986 to 1996. Four patients had pulmonary valve stenosis, four had aortic valve stenosis, three had coarctation of the aorta, 10 had pulmonary artery stenosis, four had cyanotic heart diseases and aorto-pulmonary collateral arteries, one had patent ductus arteriosus, and one had cyanotic heart disease and stenotic Blalock-Taussig shunt. Balloon dilation was successful in all patients with pulmonary valve stenosis, and follow-up evaluation (1-8 years) showed no restenosis in any patients. Balloon dilation was successful in all patients with aortic valve stenosis, and follow-up evaluation (0.5-5 years) showed transvalvular pressure gradient < 50 mmHg. Stenosis was relieved successfully in all patients with coarctation of the aorta, and follow-up evaluation showed no restenosis. Balloon dilation was successful in eight of 13 locations (62%) in patients with pulmonary artery stenosis. Coil embolization was successful in all patients with cyanotic heart diseases and aortopulmonary collateral arteries. In a patient with patent ductus arteriosus, two coils were placed in the ductus arteriosus but were retrieved because hemolysis was observed after the embolization. These data indicate that catheter intervention in young adults with congenital heart diseases is as effective as in children.

Background: The number of homograft donors is limited and the once-thawed homograft may be unsuitable for the recipient and obliged to be wasted. The purpose of this study was to investigate the possibility of recryopreserving and using the once-thawed homograft for another patient., Methods: Canine aortic valve leaflets were frozen to -80 degrees C by a programmed freezer, stored in liquid nitrogen, and thawed after 1 week. A subgroup of leaflets was left at 4 degrees C for 15 minutes, re-cryopreserved, and thawed after 1 week. Pathologic and flow cytometric evaluations were performed., Results: After thawing, by pathology, alignment of the fibers was acceptably maintained but the membrane and cytoplasm of the fibroblast were damaged. These findings were not significantly aggravated even after rethawing. By flow cytometry, fibroblast viability was 90.7%+/-1.7% immediately after thawing, 87.6%+/-1.0% after thawing for 15 minutes at 4 degrees C, 63.7%+/-2.7% during refreezing at 0 degrees C, and 39.4%+/-4.3% after rethawing., Conclusions: From the standpoint of fibroblast viability, it is not possible to recryopreserve the once-cryopreserved and thawed aortic valve homograft.

The treatment of aortic regurgitation (AR) caused by cardiovascular Behçet's disease was retrospectively analyzed in five patients with Behçet's disease complicated by moderate or severe AR (four men and one woman, with a mean age of 47 +/- 5.8 years; complete 1, incomplete 2, and suspected 2). The preoperative left ventricular end-diastolic diameter was larger than 60 mm (mean: 74 mm) in all patients, and the left ventricular fractional shortening was less than 0.28 in three patients. Aortic valve replacement (AVR) was performed in four patients, but perivalvular regurgitation developed in all patients after a mean of 5.4 +/- 1.2 months (range: 0.6-10 months) following surgery, causing the death of three patients. One patient (grade III) who did not undergo operation showed gradually increasing end-diastolic diameter, but he is still being followed up medically due to the poor outcome of surgery. Because of inflammation-induced tissue fragility, AVR was associated with postoperative perivalvular regurgitation and suture breakdown, resulting in an extremely poor outcome. Thus, AVR was considered best avoided even if Behçet's disease was complicated with moderate or severe AR.

This study was designed to assess whether the protective effect of ischemic preconditioning can be adapted for myocardium undergoing 6 h of no-flow ischemia. Twelve isolated rat hearts were either perfused with oxygen-bicarbonated Krebs-Henseleit buffer in the Langendorff mode for 35 min (n=6), or perfused in the same way for 20 min, following 5 min of global normothermic ischemia and 100 min of buffer-perfusion (n=6). The 12 hearts were then preserved for 6 h in HTK solution at 4 degrees C, followed by 30 min of reperfusion. Recovery of cardiac function, metabolic activity and intracellular free calcium concentration were compared between the two groups. After 6 h ischemia, the hearts that underwent preconditioning showed better recovery of left ventricular developed pressure (P<0.01), a lower end-diastolic pressure level (P<0.05), less creatine kinase leakage and a lower calcium concentration. There was no statistical difference in the recovery rate of coronary flow and leakage rate of LDH between the two groups. In conclusion, this experiment demonstrates that ischemic preconditioning improved myocardial functional recovery after 6 h of hypothermic ischemic preservation in the isolated rat heart. Preconditioning might be a potential mechanism for preserving the heart against long-term ischemia/reperfusion injury.

Background: Intractable congestive heart failure is known as a serious complication of acromegaly, but valvular heart disease rarely occurs in acromegalic patients. We experienced 5 surgical cases of valvular heart disease associated with acromegaly. We describe the features of those cases in this report., Methods: The patient characteristics and operative and pathologic findings were retrospectively studied., Results: There were 4 men and 1 women. Age at operation was 59 +/- 5.5 years. Cardiac lesions consisted of 1 case of aortic regurgitation associated with mitral regurgitation, 1 of aortic regurgitation, and 3 of mitral regurgitation. Operative procedures consisted of 1 double valve replacement (aortic and mitral valve replacement), 1 aortic valve replacement, and 3 mitral valve replacements. The causes of aortic valvular regurgitation were aortic valvular degeneration and aortic annular dilatation. The causes of mitral regurgitation were chordal rupture and mitral valvular degeneration. Histopathologic examination of the excised valves showed mucopolysaccharide deposits and myxomatous degeneration of the leaflets. The myocardium showed fibrosis of interstitial spaces and endocardium, and disarrangement of muscle fibers., Conclusions: We report 5 successful surgical cases of valvular heart disease associated with acromegaly. Earlier operation is recommended for such cases because of acromegalic cardiomyopathy.

Background: The purpose of this study was to compare the myocardial protective effect of histidine-tryptophan-potassium and glucose-insulin-potassium cardioplegic solutions in patients with a dilated heart (left ventricular diastolic diameter > 55 mm, left ventricular systolic diameter > 45 mm) associated with prolonged cross-clamp time (longer than 200 minutes)., Methods: We selected 20 patients with dilated hearts due to severe aortic regurgitation. Glucose-insulin-potassium cardioplegia was used in 11 patients and histidine-tryptophan-potassium cardioplegia was used in 9 patients., Results: After operation, the cardiac index was significantly increased in the histidine-tryptophan-potassium group (p < 0.05). Postoperative percent fractional shortening was 13.4% +/- 3.1% in the glucose-insulin-potassium group and 23.6% +/- 2.6% in the histidine-tryptophan-potassium group (p < 0.05). Creatine kinase levels were significantly lower in the histidine-tryptophan-potassium group than that in the glucose-insulin-potassium group (p < 0.05). The incidence of ventricular arrhythmia (higher than Lown's grade 2) was lower in the histidine-tryptophan-potassium group., Conclusions: These data support the superiority of the histidine-tryptophan-potassium method over the glucose-insulin-potassium method for protection of the dilated heart during prolonged ischemia in open heart operations.

The diagnostic value of transesophageal echocardiography was investigated in heart transplant recipients, i.e., four patients who received orthotopic heart transplantation and one patient who received total heart transplantation. Donor-recipient atrial anastomosis was identified in the four patients with orthotopic heart transplantation, but not in the patient with total heart transplantation. Transthoracic and transesophageal echocardiography detected no thrombus or spontaneous echo contrast in any of the patients. Color Doppler transesophageal echocardiography showed trivial mitral regurgitation in all patients. Total heart transplantation resulted in no protruding suture line and normal atrial cavity size. The patient with total heart transplantation showed some difference in the peak flow velocity of the right and left pulmonary veins (left superior pulmonary vein: 48 cm/sec; right superior pulmonary vein: 86 cm/sec), possibly due to stenosis at the suture line between the left atrium and right superior pulmonary vein, or compression of the right superior pulmonary vein by the anastomosis between the superior vena cava and right atrium. Transesophageal echocardiography was helpful for detecting thrombus in the left atrium and left atrial appendage after heart transplantation, and allowed evaluation of the flow pattern in the pulmonary veins and left atrial appendage as well as abnormal flow in the atrium. In conclusion, transesophageal echocardiography is useful in the follow-up of heart transplant recipients.

A 53-year-old man, who had undergone tricuspid valve replacement with Hancock valve and direct closure of a ventricular septal defect when aged 34 years, was admitted with signs of right heart failure. Two-dimensional echocardiography showed bioprosthetic tricuspid valve malfunction with right atrial thrombus. He was treated by tricuspid valve replacement using a Hancock II valve and removal of the right atrial thrombus with remarkable improvement. Transesophageal echocardiography was the most useful method for recognizing the presence of right atrial thrombus and assessing its actual or potential hemodynamic effects.

We describe a method to perform successful drainage of pericardial effusion by incising the diaphragm via the peritoneal cavity assisted by transesophageal echocardiography. This transdiaphragmatic approach is a remarkably simple and useful method for pericardial drainage when the conventional transsubxiphoid approach is difficult and dangerous because of intractable adhesions between the heart and the pericardium.

Background: The trend in coronary artery bypass grafting is for a gradual transition to the more extensive use of arterial grafts. This study was designed to investigate the effects of patient body size on complex arterial grafting in coronary artery bypass procedures., Methods: Four hundred forty-five patients who underwent coronary artery bypass grafting with two or more distal anastomoses using arterial grafts were divided into two groups according to body surface area: group A (n = 114), 1.60 m2 or less; and group B (n = 331), greater than 1.60 m2. Preoperative patient characteristics and early and long-term results were compared between the groups., Results: The prevalence of female sex (27% in group A versus 0.9% in group B; p < 0.0001) and age (62.7 +/- 8.1 years in group A versus 58.9 +/- 7.0 years in group B; p < 0.001) were significantly different. However, the prevalence of previous myocardial infarction and of left ventricular dysfunction and the extent of coronary artery disease were not significantly different. Three patients (2.6%) in group A and 3 patients (0.9%) in group B died within 30 days of operation (p = 0.18). The 1-month patency rate of arterial grafts was not significantly different (98.7% versus 96.7%; p = 0.16), but that of venous grafts was significantly lower in group A than in group B (88.9% versus 97.7%; p = 0.045). No significant difference was noted in the 3-year actuarial survival rate (93.8% versus 91.6%)., Conclusions: The extensive use of arterial grafts in patients with small body size was associated with excellent long-term results, with no significant increase in operative mortality or morbidity.

Background: The leading cause of death in chronic renal dialysis patients is cardiovascular disease. As the number of dialysis patients increases, we are encountering more patients with severe ischemic heart disease requiring coronary intervention., Methods: A retrospective analysis was performed of the short- and long-term clinical results in 23 coronary artery bypass grafting patients and 20 coronary angioplasty patients undergoing chronic renal dialysis., Results: Among coronary bypass grafting patients, there were no hospital deaths. The graft patency rate was 100% for arterial grafts. There were four late deaths and four cardiac events. In coronary angioplasty patients, the lesion success rate was 76%. There were no hospital deaths and three major complications. The restenosis rate was 70%. There were two late deaths and 14 cardiac events. The 5-year cardiac event-free rate was 70% in coronary bypass grafting patients, significantly better than 18% in coronary angioplasty patients (p < 0.001)., Conclusions: Coronary artery bypass grafting in chronic renal dialysis patients can be accomplished with a better short- and long-term outcome than coronary angioplasty, through an intensive perioperative dialysis program and extensive use of arterial grafts.

No heart transplants have been performed in Japan due to various obstacles since the only operation performed in 1968. Since 1981, a number of patients requiring heart transplants have been accepted by foreign transplantation centers in England, the U.S.A., and Germany. This report describes an investigation of the postoperative course of these Japanese heart transplant patients and discusses the problems regarding transplantation in Japan. Of the 21 transplant patients, the diagnosis was dilated cardiomyopathy in 17, restrictive cardiomyopathy in 1, hypertrophic cardiomyopathy in 2, and congenital muscle dystrophy in 1. All patients survived surgery but three died in the long-term period. The causes of death were acute rejection (after 3 months), chronic rejection (after 50 months) and infection (after 30 months). The actuarial survival curve of these patients was 95.0% for one-year survival and 86.4% for three-year survival. The postoperative functional class was NYHA classification I in all patients (100%). Ninety-three percent of patients returned to work. Immunosuppressive therapies included triple drug therapy in 14 patients (66.7%), double drug therapy in 4 (19.0%), ciclosporin alone in 2 (9.5%) and FK506 in 2 (5.0%). The incidence of acute rejection was 1.56 episodes per patient per year within 3 months and 2.9 episodes per patient per year within 1 year. The postoperative courses of Japanese patients who underwent heart transplantation at foreign transplantation centers were satisfactory. These results will encourage heart transplantation in Japan.

Stenting seems to be a definitive procedure after failed balloon coronary angioplasty. This report describes a case of redo coronary bypass grafting and concomitant resection of enlarging false aneurysm of a saphenous vein graft that developed secondary to stenting for recurrent stenosis after serial percutaneous transluminal coronary angioplasty. It warns us of a pitfall in catheter intervention in an aged saphenous vein graft.

Background: This study was undertaken to examine long-term results of coronary artery bypass grafting in elderly Japanese patients., Methods: Of 1,425 coronary artery bypass grafting patients over the last 13 years, 137 patients were 70 or more years old and 1,288 were less than 70 years old. Mean number of distal anastomoses was similar in both groups. Postoperative survival and event-free proportion were estimated by the Kaplan-Meier actuarial method and compared among the groups by Cox-Mantel statistical analysis., Results: Operative mortality and the incidence of late cardiac death after coronary artery bypass grafting were equivalent between the elderly and younger groups, although the rates of left main trunk disease, acute myocardial infarction, and emergency operation in the elderly group were significantly higher than those in the younger group. Coronary artery bypass grafting in elderly patients had a relatively high hospital mortality and more late noncardiac deaths, but the incidence of postoperative cardiac intervention in elderly patients was lower than that in younger patients., Conclusions: These results suggest that coronary artery bypass grafting for elderly patients is encouraged as well as is that for younger patients in a representative Japanese population.

Adult T cell leukemia-derived factor (ADF)/Thioredoxin (TRX), originally defined as an IL-2 receptor alpha-chain/p55 inducer, has many cytokine-like activities. We reported that the release of major basic protein (MBP) from mature eosinophils stimulated with cytochalasin B and C5a were augmented after preincubation with recombinant ADF/TRX. The addition of a TRX specific inhibitor, BE40644, suppressed the augmentation of MBP release from mature eosinophils. It is suggested that BE40644 is applicable in allergic diseases associated with eosinophils.

Circulatory support during operation for type A aortic dissection is controversial among many medical centers. In the last 21 years, 100 patients with type A aortic dissection underwent 102 operations including 2 reoperations, and 29 patients showed Marfan's syndrome. During operation, no cerebral perfusion technique was used through February 1985 (period I), antegrade cerebral perfusion was applied since March 1985 (period II), and retrograde cerebral perfusion was introduced in November 1990 (period III). Surgical results were compared among these subgroups. Operative mortality was 12.1% in 33 chronic and 57.1% in 7 acute patients in period I, 11.1% in 27 chronic and 54.5% in 11 acute patients in period II, and 6.7% in 15 chronic and 0% in 9 acute patients in period III (period II versus III; p = 0.04). Retrograde cerebral perfusion decreased permanent brain complications. The 5-year actuarial survival was 59.7% in period I and 63.2% in period II (not significant), and the 3-year survival of period III was 91.7%. Actuarial survival of period III was significantly higher than those of periods I and II (p < 0.05). Surgical repair of aortic arch with cerebral perfusion techniques reduced the residual aneurysms. These results show that surgical results of type A aortic dissection in this series improved with the introduction of retrograde cerebral perfusion and extended surgical procedures.

This study investigated the changes in treatment procedures for mitral stenosis (MS) and mitral regurgitation (MR) against the background of a decrease in the incidence of rheumatic valvular disease. The study included 3,955 patients with MS undergoing closed mitral commissurotomy (CMC), open mitral commissurotomy (OMC), mitral valve replacement (MVR), or percutaneous transvenous mitral commissurotomy (PTMC) between 1952 and 1991, and 478 patients with MR undergoing MVR or mitral valvuloplasty in the Heart Institute of Japan, Tokyo Women's Medical College. The number of patients with MS undergoing surgical or catheter interventions has decreased and is now about 80 per year, a half of that experienced in the 1960s. CMC and OMC have been replaced by PTMC since the 1990s. The most popular treatment procedure is now MVR. The number of patients with MR undergoing surgery has increased to about 30 per year. Eighty percent of operations for MR are MVR and the others are mitral valvoplasty. Survey of the etiology of MR shows decreased rheumatic disease and increased degenerative disease. The incidence of MR due to ischemic heart disease and hypertrophic obstructive cardiomyopathy has slightly increased.

Various support techniques for surgical treatment of type B aortic dissection have been used and recommended in many medical centers. In the last 21 years, 55 patients with type B aortic dissection underwent 65 operations including 10 reoperations, and 10 cases showed Marfan's syndrome. As circulatory support during operation, venoarterial bypass mainly was used until March 1987 (period I) and low-dose heparinized left heart bypass was applied since April 1987 (period II). Surgical results were compared among subgroups by the Kaplan-Meier actuarial method and Cox-Mantel statistical analysis. After the operation, early mortality was 27.3% in 33 patients in period I and 9.4% in 32 patients in period II (p = 0.06). The incidence of fatal hemorrhagic complications was decreased significantly by using the left heart bypass technique (p < 0.02). The 5-year actuarial survival of type B dissection was 60.6% in period I and 79.2% in period II (p = 0.07). These results suggest that surgical results of type B aortic dissection in this series might be improved with the introduction of left heart bypass and extended surgical procedures.

Leakage from the composite graft at the site of coronary anastomosis into the perigraftal space (pseudoaneurysm) is an important complication of Bentall's operation. The clinical value of transesophageal echocardiography (TEE) for detecting this graft failure was evaluated in 30 patients who underwent Bentall's operation or Piehler's modification. Three patients (10%) had perigraftal leakage (pseudoaneurysm). TEE demonstrated the leakage site which was not clearly showed by computed tomography (CT) scan and aortography. The detection rate of the anastomosed native coronary artery was 89% (left: 100%, right: 67%). Interposition graft by Pichler's modification method was detected in 96% (left: 100%, right: 92%) of cases by TEE, but only in 43% (left: 57%, right: 29%) by CT scan (left: p < 0.005, right: p < 0.0001). The detection rate of the right coronary artery, interposition graft to right coronary artery, and their color signals were lower than those of the left coronary artery. TEE has considerable diagnostic value in evaluating patients after Bentall's operation.

Since July 1978, 1,284 patients have received the St. Jude Medical prosthesis (425 aortic, 636 mitral, and 223 double aortic-mitral), and the results in these patients were reviewed according to guidelines of the Society of Thoracic Surgeons. Follow-up was complete in 98%. Of 80 late deaths, 29% were valve related. The actuarial survival rate, including operative deaths, at 12 years was 81.7% and 87.1%, respectively, for aortic and mitral valve replacement, and it was 82.6% at 11 years after double valve replacement. All patients were anticoagulated with warfarin to maintain the thrombotest value between 10% and 25%, which is equivalent to between 2.8 and 1.6 times the control according to the international normalized ratio of the prothrombin time. The linearized rate of complication for aortic, mitral, and double valve replacement, respectively (expressed as the percent per patient-year), was as follows: structural deterioration, 0; non-structural dysfunction, 0.16, 0.30, and 0.20; valve thrombosis, 0.05, 0.09, and 0; thromboembolism, 1.35, 1.63, and 0.79; anticoagulant-related hemorrhage, 0.10, 0.18, and 0.10; and prosthetic valve endocarditis, 0.21, 0.06, and 0.20. Reoperation was performed in 16 patients. The freedom from reoperation rate at 12 years was 99.5% and 98.0% for aortic and mitral valve replacement, respectively, and it was 99.1% at 11 years for double valve replacement. Thus, during the 12-year follow-up in patient who received the St. Jude Medical prosthesis, the valve performed satisfactorily and with an acceptable risk of late complication even though patients were anticoagulated using a lower dose of warfarin.

Pulmonary lobar transplantation is an option for pediatric lung transplantation, and it has the potential of extended applications. We compared the relationship between segmental blood flow and segmental vascular resistance of the pulmonary lobe with that of the transplanted single lung. Eight of 14 puppies received a left upper pulmonary lobe from double-weighed adult dogs, and the other six puppies received a left lung from puppies. All recipient dogs were treated with oral cyclosporine (15 mg/kg/day) and intramuscular prednisolone (1.0 mg/kg/day), after the operation. Pulmonary arterial and left atrial pressures and segmental flow of the lungs were measured at rest and while the inferior vena cava or right pulmonary artery was clamped, before and 1 hour and 2 weeks after lung transplantation. Vascular resistance of the lung segment was calculated at each hemodynamic state. Segmental resistance of the lung at rest significantly increased from pretransplantation to 1 hour after transplantation (pulmonary lobe group, 2211 +/- 42 to 2555 +/- 61 dyne.sec.cm-5; single lung group, 2126 +/- 56 to 2557 +/- 72 dyne.sec.cm-5) and recovered 2 weeks after transplantation in both groups. However, by means of partial clamp of the right pulmonary artery, segmental resistances of 1 hour after transplantation pulmonary lobe (2248 +/- 37 dyne.sec.cm-5), and single lung (2206 +/- 34 dyne.sec.cm-5) at the same segmental flow of the pretransplantation state (310 to 320 ml/min) were equivalent to those of the pretransplantation lungs. There was no significant difference in the segmental resistance at any segmental flow between the pulmonary lobe and single lung before and after lung transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of aneurysm of the descending thoracic aorta with dominant left vertebral artery and poor cross-collateral circulation is reported. We believe that in such a patient perfusion of the dominant left subclavian artery is a safe method to prevent vertebrobasilar ischemia during thoracic aortic aneurysm operation under normothermia.

A 15-year-old girl with pseudoxanthoma elasticum and associated severe coronary artery disease underwent double coronary artery bypass using left internal mammary artery and saphenous vein. Preoperatively the patient had life-threatening syncope and positive treadmill test results. The postoperative course was uneventful, and the patient has been doing well for 3 years. Pseudoxanthoma elasticum is a rare disease that can cause premature coronary arterial obstructive disease in children and adolescents.

During the past 15 years, we followed 21 patients with prosthetic heart valves who experienced a total of 24 pregnancies at mean age of 31.3 +/- 3.6 years. The course of these patients and their pregnancies were reviewed to evaluate the problems associated with prosthetic heart valves and anticoagulation. Among the 21 patients, the aortic valve (AV) had been replaced in 10 (12 pregnancies), the mitral valve (MV) in nine (10 pregnancies), AV + MV in one (one pregnancy), and the tricuspid valve (TV) in one (one pregnancy). The implanted prosthetic valves were mechanical type in 16 cases (Björk-Shiley 15, Starr-Edwards 1) and bioprosthetic type in six (Hancock 5, Ionescu-Shiley 1). With the exception of one case of intra-uterine fetal death probably related with warfarin therapy, all the patients with bioprosthetic valves underwent successful deliveries. Anticoagulant therapy was employed for 11 pregnancies; warfarin for 10 and subcutaneous heparin for one. No anticoagulant therapy was performed for 13 pregnancies. Ten of the 21 mothers had atrial fibrillation. Eighteen pregnancies (67%) culminated in uneventful deliveries for both mothers and infants. Three mothers (13%) died of thromboembolic complications; two of cerebrovascular accidents and one of acute heart failure caused by thrombus on the replaced valve. All of them had Björk-Shiley valves. Oral warfarin was administered in one of the three, heparin in one and no anticoagulant in the remaining one. Massive maternal bleeding occurred in two cases (8%). There were three cases (12%) of intra-uterine fetal death which were caused by intracranial hemorrhages.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardio-Behcet's disease is not often reported; only one case to our knowledge has described complete atrioventricular (AV) block, without pathologic details. We document, from direct observation during surgery and pathologic examination of associated lesions, a case whose conduction disturbance was possibly caused by direct extension of Behcet's disease itself into the conduction system.

The influence of inward bending of the stent posts on bioprosthetic valve function was assessed in a hydromechanical simulation of the left heart. A Carpentier-Edwards mitral xenograft (31 mm) and an aortic xenograft (27 mm) were used. Valve function was evaluated before and after the stent posts were bent inward 15 degrees by suture constriction of the tops of the three posts. To evaluate the effects of the stent-post deformity on valve performance, the mean transvalvular pressure drop during steady flow, the bioprosthetic valve orifice area, and the maximum valve opening and closing speeds during pulsatile flow were measured using an area meter. Steady-flow data showed identical transvalvular pressure drops, and no significant difference in valve performance was detected in the pulsatile-flow study under the two experimental conditions (i.e., normal valve and deformed valve). We conclude that a 15-degree inward bending of the stent posts does not appreciably affect valve function in vitro.

Stent creep, often associated with valve malfunction, is said to play an important role in the long-term performance of a porcine bioprosthesis. We have measured the angle of the stent post showing maximal inward bending (IBA) on 44 mitral porcine bioprostheses. All of them were explanted 1 to 12 years (mean explant time, 7.8 years) postoperatively at reoperation. Patients included 19 men and 25 women, ranging in age from 24 to 66 years (mean age, 47.2 years). Mean IBA was 12.7 +/- 4.2 [SD] degrees in 14 valves implanted for 7 years or less and 16.4 +/- 5.8 degrees in 30 valves implanted 8 years or longer (p less than 0.05). There was no significant difference in IBA among valves based on type (25 Hancock valves, 15.0 +/- 4.7 degrees; 10 Angell-Shiley valves, 16.2 +/- 8.6 degrees; and 9 Carpentier-Edwards valves, 14.4 +/- 3.7 degrees). There was a significant difference in IBA based on valve size (37 valves measuring 25-29 mm in diameter, 16.3 +/- 5.1 degrees; and 7 valves measuring 31 mm in diameter, 9.9 +/- 5.1 degrees; p less than 0.05). IBA showed a tendency to have a large value in a heart with a small left ventricular end-systolic volume. We conclude that (1) stent creep is not related to the materials or designs of the stent post, but tends to increase with passage of time in place; and (2) compression of the left ventricular wall is one of the main causes of stent-post bending.

A composite valve prosthesis was prepared by direct suture of the ring prosthesis, which was separated from an intraluminal ringed graft, with a St. Jude Medical aortic valve. A new translocation method using this composite valve prosthesis was performed on a patient with aortic periannular abscess, with favorable result.

Visualization of the conduction bundle is advantageous in the prevention of surgical trauma to the conduction system during open-heart surgery. Because vital staining using an iodine starch complex has been known to result in tissue damage, we have evaluated the effects of iodine gas on the specialized conduction system. The conduction bundle was stained, well enough to be identified, with iodine tincture, with Lugol's solution, and with iodine gas. However, all these agents except for iodine gas caused marked electrophysiological changes. Similar changes occurred with the use of ethanol and of 10% potassium iodine solution, which are the solvents of iodine tincture and Lugol's solution, respectively. Microscopic examination showed that iodine tincture, Lugol's solution, and their solvents caused marked histological changes in the conduction tissue. However, no significant changes in the conduction tissue were noted from iodine gas spraying. Therefore, tissue damage caused by iodine tincture and Lugol's solution was thought to be due not to a reaction to the iodine starch complex itself, but to their solvents. In a long-term experimental study of 10 dogs, we found that iodine gas caused no electrophysiological disturbances or damage of microscopic tissue. Of the agents we tested, only iodine gas is free from harmful effects and can be used clinically.

An epicardial approach has been developed and applied to 31 Kent bundles (23 parietal, 1 right anteroseptal, and 7 posteroseptal bundles) in 28 patients with Wolff-Parkinson-White syndrome. Our technique consists of dissection of the atrioventricular fat pad of the Kent bundle site using an ultrasonic aspirator and subsequent cryosurgical ablation. For the left parietal and posteroseptal pathways, the apex of the heart has to be retracted upward, but this maneuver was well tolerated in all patients. Moreover, even through a narrow operative field, the ultrasonic aspirator permitted deliberate dissection on the beating heart without injury to major coronary vessels or the atrial wall. In 89% of the patients, operation was performed without the use of heart-lung bypass. All patients were free from preexcitation. With this technique, all Kent bundles except that adjacent to the atrioventricular node can be ablated on the beating heart, usually without heart-lung bypass.

Continuous wave (CW) Doppler ultrasound has facilitated accurate estimates of pressure gradient (PG) across a stenotic valve. However, the severity of stenosis cannot be assessed using PG alone because it is dependent on actual flow across the valve. In this study, Doppler techniques were used to predict PG and aortic valve areas (AVA) in adults with aortic stenosis (AS). Fifty-four adult patients undergoing cardiac catheterization for suspected AS were prospectively evaluated. There were 28 men and 26 women, who ranged in age from 25 to 68 years with a mean of 56 years. These Doppler ultrasound studies were performed using a 2 MHz transducer and an Aloka SSD-730. With CW Doppler ultrasound, the highest velocities of the aortic jet were recorded from an apical approach. Left ventricular outflow flows were recorded about 1.0-1.5 cm below the aortic annulus using high PRF. Doppler waveforms were analyzed for the AT/ET (AT: acceleration time, ET: ejection time), and Doppler PG was calculated from the maximum velocity (V) of the aortic jet based on a modified Bernoulli equation (PG = 4V2), and aortic valve area was obtained using the continuity equation-(AVA = left ventricular outflow tract stroke volume divided by AS jet velocity integral). These data were compared with hemodynamic data obtained from cardiac catheterization. The following results were obtained: 1. In eight patients with substantial aortic regurgitation, whose maximum catheter PG were from 20 to 45 mmHg, the AT/ET was less than 0.30. The ratio of AT/ET correlated with the peak velocity of the aortic jet (r = 0.88) and the maximum PG (r = 0.87) obtained from cardiac catheterization. 2. In 46 patients with AS, the maximum PG by CW Doppler showed an excellent correlation with maximum catheterization PG (r = 0.97, SEE 6 mmHg), and the mean PG as calculated by the two techniques also disclosed a good correlation (r = 0.97, SEE 5.4 mmHg).(ABSTRACT TRUNCATED AT 400 WORDS)