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A 56-year-old male was admitted for sudden chest pain followed by loss of consciousness and paraplegia. The electrocardiogram (ECG) revealed ST-elevation in leads II, III, and aVF and ST-depression in leads V3 to V6. The ultrasonic cardiography (UCG) demonstrated an intimal flap in the ascending aorta, grade III aortic regurgitation (AR), and akinesis of the posterior wall of the left ventricle. Transesophageal echocardiography directly showed dissection of the left main coronary artery. Emergency coronary artery bypass grafting (CABG) to the left anterior descending artery (LAD), obtuse marginal artery (OM) and posterolateral artery (PL) was performed using the saphenous vein. In addition, valve-sparing aortic root remodeling was performed in conjunction with replacement of the ascending aorta. The left coronary orifice was repaired and reattached to the prosthetic graft. The patient was weaned from cardiopulmonary bypass without catecholamine support. He was discharged from the hospital on foot after rehabilitation of the paraplegia. AR remains mild by UCG 3 years after surgery.

A 42-year-old male was diagnosed as having a traumatic rupture of the ascending aorta 24 hours after traffic accident. On admission, the patient was in a state of shock, but he was successfully treated by emergency surgery. Traumatic rupture of the ascending aorta is a serious condition and the mortality may be very high. Although physicians rarely encounter patients with this condition, it is relatively common among autopsy cases with multiple trauma. Urgent diagnosis and treatment are mandatory.

A 51-year-old man, with a history of corticosteroid pulse therapy 3 weeks previously, developed infective endocarditis of the mitral valve due to methicillin resistant Staphylococcus aureus, and underwent mitral valve replacement. Since the second postoperative day, clinical course was seriously complicated because of recurrent abdominal pain corresponding with commencement of oral intake, unremitting spike fever, and renal and hepatic dysfunction. Various examinations except angiography failed to demonstrate the etiology. Two months later, the patient developed panperitonitis due to perforation of ischemic ulcer of the cecum and underwent ileo-cecal resection. After this operation, he convalesced very quickly. Ischemia is one of the main causes of abdominal complication following cardiac surgery. Angiography should be positively considered in cases like the present one.

Few minutes of suspended malignant ventricular arrhythmia may be permitted for the patient with left ventricular assist system (LVAS). However, longer and continuous ventricular arrhythmia, especially ventricular fibrillation (Vf), may induce the low output of LVAS, which leads circulatory collapse immediately. Our presenting case is a female dilated cardiomyopathy patient who has been supported with LVAS. Four months after the LVAS installation, her electrocardiogram has changed to Vf without any symptoms. Her ventricular function has never recovered, even ventricular tachycardia. She has been a candidate of heart transplantation for more than 19 months with this rare hemodynamic condition (LVAS+Vf), like the Fontan circulation. Her performance status is limited due to deceasing of the LVAS flow, which caused by the change of her position: 2.5-2.9 l/min (lie down) to 2.0 l/min (rise). Her peak VO2/W is 6.9 ml/min/kg measured by the cardio-pulmonary exercise test. However, she has developed her general status by doing rehabilitation program and is able to walk for more than 100-150 meters.

A 52-year-old male with a 13 years history of hemodialysis developed unstable angina. Preoperative examination revealed critical stenoses in 3 coronary arteries and extensive calcification in the ascending aorta. During urgent coronary artery bypass surgery, epiaortic ultrasonography demonstrated a large and markedly mobile atheroma in the ascending aorta. Therefore, he underwent resection of this atheroma using cardiopulmonary bypass and circulatory arrest. His postoperative course was fine. This aggressive strategy for a diseased aorta can be a viable option in selected cases. Epiaortic ultrasonography appeared to be indispensable during surgery for patients like a present one.

We report a ruptured case of acute aortic syndrome and a successful treatment with transcatheter placed stent-graft. A 67-year-old man underwent a stent-graft implantation for the patient with ruptured acute aortic syndrome. The patient admitted in our institute for a diagnosis of ruptured acute aortic dissection. We planned to operate a graft replacement for distal arch aorta. But he was complicated with right-side monoplesia before the operation. Then we performed a stent-graft implantation in order to avoid the usage of extra-corporeal circulation. The implantation of the stent-graft was successful and shrinkage of the hematoma around the ruptured aorta was documented on the computed tomography of 7 post-operative day.

A 68-year-old woman without angina developed acute antero-septal myocardial infarction. Coronary angiogram revealed saccular coronary artery aneurysm at the origin of the diagonal branch and relatively mild coronary artery stenosis. Emboli from the coronary aneurysm was strongly suggested. We placed coronary bypass grafts onto left anterior descending, diagonal and obtuse marginal branches, and excluded the coronary aneurysm by ligating both its inflow and outflow. The postoperative course was uneventful. There are several treatments of choice for patients with coronary aneurysm. We believe that surgery is mandatory and that exclusion of the coronary aneurysm should be considered in every possible case.

Previous clinical results of left ventricular assist system (LVAS) therapy for cardiogenic shock due to acute myocardial infarction (AMI) are still unacceptable. Japanese LVAS was designed for left atrial inflow cannulation. However, to obtain higher initial LVAS flow and more decompression of left ventricular (LV) cavity and to avoid thromboembolic event, LV inflow cannulation is a preferable procedure. Therefore, LV inflow cannula for Japanese LVAS (Toyobo) was developed. We treated three AMI cases with Toyobo-LVAS using the new LV inflow cannula. All patients were in cardiogenic shock status since broad antero-septal AMI and treated with percutaneous cardio-pulmonary support before the LVAS installation. The LVAS was effective for recovery from cardiogenic shock status and multiple organ failure. Two patients died because of serious LVAS associated complications such as bleeding (case 1, 8 days) and cerebral thromboembolism (case 2, 45 days). One of them was assisted for 202 days and underwent second operation. Sixty days after removal of LVAS, the patient died due to sepsis. The technique of LV inflow cannulation is improved through our experiences. However, our result suggests that renovation of the regimen for anti-coagulation and anti-septic therapy are necessary.

Cardio-pulmonary bypass (CPB) leads the activation of neutrophil, which may cause reperfusion organ dysfunction. Utility of using the leukocyte depletion arterial filter to pretend postoperative complications has been reported. The other side, the risk of the leukocyte depletion filter occlusion with high-pressures of CPB arterial line (high-pressure occlusion) has been noted. We used the leukocyte deletion filter (LG-6, Pall), and experienced two cases of high-pressure occlusion in 421 CPB surgery with LG-6 (0.48%). No high-pressure occlusion was occurred with 1,508 patients used the standard arterial line filter in it period (0%, p = 0.007). In the both cases of high-pressure occlusion, monitored arterial line pressure increased to over 340 mmHg within 10 minutes after CPB installation. The filters were changed to standard type, then no more filter trouble was occurred. In the second case, we inspected the occluded LG-6. Light microscopic survey showed eosin stained small spherical cells (HE) and negative for fibrin (PTAH). Electromicroscopy revealed that spherical cells (1-2 microns) adherated to structure of the filter. No fibrin was detected with Gel electrophoresis. Because of the pathologic analysis, the cells, which might cause the filter occlusion, were platelet. In addition, no fibrin exist suggests that the coagulation system did not relate to the high-pressure occlusion. In conclusion, we experienced two high-pressure occlusion cases of the leukocyte depletion arterial filter with CPB surgery (0.48%); the filter occlusion may be caused by the initial thrombus formation by platelet.

The effect of milrinone in the 16 postoperative shock patients of cardiovascular surgery was studied. The preoperative hemodynamic status were 12 of cardiogenic shock, 2 cases of chronic heart failure and 2 cases of unstable angina pectoris. The operative procedure were 8 cases of coronary artery bypass grafting, 4 cases of valvular surgery, 2 cases of closure of ventricular septal perforation, 2 cases of Bentall operation and 1 case of ascending aortic replacement. The postoperative hemodynamic status were 15 cases of cardiogenic shock, 10 cases of hemorrhagic shock and 1 case of septic shock. Continuous intravenous infusion of 0.5 microgram/kg/min without initial bolus loading was administered immediately after the entrance of the intensive care unit. Significant increase in the maximum blood pressure 3 hours after the infusion were observed (84 +/- 17 mmHg vs 94 +/- 12, p = 0.033). The maximum blood pressure was increased gradually until 24 hours after the infusion. Significant increase in the peripheral body temperature 3 hours after the infusion were observed (32.5 +/- 2.0 degrees C vs 35.9 +/- 1.1 degrees C, p = 0.001). The difference between the peripheral temperature and the central body temperature diminished until 24 hours after the infusion. No significant change in the central venous pressure, pulmonary arterial pressure, pulmonary and cardiac index wedge pressure were observed. No significant change in the platelet number was observed until 3 days after the infusion. Twenty patients (75%) were discharged. Four hospital deaths included 1 cardiac and 3 septic cause were seen. These data suggest that the administration of milrinone for the shock patients after cardiac surgery showed safe and that the continuous intravenous infusion of 0.5 microgram/kg/min without bolus loading showed effective for the recovery of the peripheral circulation.

Three successful surgical cases of acute pulmonary embolism with severe cardiopulmonary impairment were reported. Currently, thrombolysis is widely accepted as the front-line treatment for most patients with pulmonary embolism. However, treatment failure is high and can lead to death in the most severe cases. If these patients have severe cardiopulmonary impairment, pulmonary embolectomy should be done immediately.

Bretschneider cardioplegic solution is used widely in Europe. The aim of this study is to investigate the efficacy of Bretschneider cardioplegic solution for open heart surgery of congenital heart disease in comparison with blood cardioplegia. From June 1995 to July 1997, we treated 32 congenital heart disease patients using Bretschneider cardioplegic solution and 20 patients using blood cardioplegia. Hospital mortality, water balance during operation, percentage of arrhythmia, and intubation time were not significant in both group. Also CPK and CPK-MB were not significant in both group. Bretschneider cardioplegic solution had preserved the heart as same as blood cardioplegia. This is a very convenient method so that we can use only one time infusion.

We report a case of rare anomaly of quadricuspid aortic valve associated aortic regurgitation and severe mitral regurgitation due to infective endocarditis. A 50-year-old man was admitted to our hospital for fever and dyspnea. The transesophageal echocardiography showed severe aortic regurgitation due to four equal aortic cusps and severe mitral regurgitation due to infective endocarditis. At the operation, aortic valve and mitral valve were replaced with 23 mm and 29 mm SJM valves. His postoperative course was uneventful.

We have treated 10 patients of left ventricular free wall rupture (LVFWR) resulting from acute myocardial infarction (AMI) in our intensive care unit (ICU) from Oct. 1984 to Dec. 1993. Nine of 10 patients underwent surgical repair, however, one patient was treated with pericardocentetesis in ICU and fibrin-glue was infused into the pericardial space (fibrin-glue therapy:FG therapy). The survival rate of surgical repair was only 33% (3/9), especially that was only 17% (1/6) when cardiopulmonary bypass (CPB) was required. One patient (49-year-old, male) suffered from cardiogenic shock following AMI in the posterior wall was performed coronary angioplasty (PTCA) in emergency and IABP support was required. Fourth day after PTCA, a sudden hemodynamical collapse had occurred on this patient due to cardiac tamponade. This patient was treated with pericardiocentetesis in ICU and FG therapy was performed, because all surgical teams were occupied in their operations. After FG therapy hemodynamical stability was obtained, the patient was survived and discharged at 2 months after LVFWR. In conclusion, the surgical result of LVFWR is still not good, especially when CPB was utilized. FG therapy was successful in one patient, suggesting FG therapy can be an alternative therapy for LVFWR when surgical team is not available.