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Pulmonary thromboendarterectomy was performed on a patient with chronic pulmonary thromboembolism showing thrombophilia. The patient was a 56-year-old female with the above condition complicated by congenital protein C deficiency. She was admitted to our hospital with severe dyspnea accompanied by right ventricular failure. A pulmonary arteriogram showed occlusion and stenosis from lobar to segmental arteries. Cardiac catheterization showed marked pulmonary hypertension. A lung perfusion scintigram revealed multiple defects in the right and left lungs. After the insertion of an inferior vena cava filter, she was operated on. Following a median sternotomy, thromboendarterectomy of the bilateral pulmonary arteries was performed using deep hypothermia and intermittent circulatory arrest. Circulatory arrest was employed in three periods totaling up to 36 minutes. After surgery, she had improvements in pulmonary hypertension and pulmonary vascular resistance. She maintained improved lung functions, and remained in the New York Heart Association functional class I for more than two years and eight months after surgery.

A 54-year-old man with congenital bicuspid aortic valve underwent simultaneous valve repair for aortic and mitral regurgitation. Surgical technique consisted of plication of redundant aortic valve repair and mitral annuloplasty with chordal replacement. One-year follow-up transthoracic echocardiography showed no valve regurgitation. Valve repair for both bicuspid aortic valve and mitral valve regurgitation should be the first option in this subset of patients.

Cardiac surgery in a patient with myelodysplastic syndrome (MDS) increases the risk of bleeding and infection. Here we report a case of a 70-year-old man with MDS who underwent successful replacement of the aortic root with the valve-sparing technique and proximal arch for aneurysmal dilatation from the aortic root to ascending aorta with moderate aortic valve regurgitation. Perioperatively, a transfusion of red blood cells and an infusion of a grannulocyte colony-stimulating factor were required for his serious erythrocytopenia and leukocytopenia. Bleeding tendency was so severe that re-exploration to control postoperative surgical bleeding was performed and a large amount of blood cells were transfused. There was no infection on the postoperative course. Perioperative management for cardiac surgery in patients with MDS must be carefully programmed by a co-operative team consisting of cardiovascular surgeons and hematologists.

A 31-year-old man with severe aortic regurgitation due to a defective bicuspid valve underwent surgery using modified Ross procedure. The right ventricular outflow tract (RVOT) was reconstructed with a 25 mm stentless xenograft valve sutured with a rolled equine pericardium. Oozy bleeding from the RVOT was controlled with an autologous pericardial patch and fibrin glue. Postoperative echocardiography showed no aortic regurgitation. No blood transfusion was required.

Objective: The potential benefits of adynamic cardiomyoplasty remain unclear. We determined whether unstimulated skeletal muscle wrap alone prevents or attenuates progressive left ventricular dilation in a canine model of congestive heart failure produced by repeated intracoronary infusions of doxorubicin., Subjects and Methods: 14 dogs were randomized in to 2 groups, 1 undergoing cardiomyoplasty (CMP group) and 1 that did not (CONT group). Intracoronary doxorubicin was administered weekly for 5 weeks to induce heart failure. Hemodynamic data was obtained before infusion and 5 weeks afterward. Echocardiography was done weekly., Results: Significant left ventricular dilation was observed in the CONT group--left ventricular end-diastolic diameter increased from 28.9 +/- 2.7 to 38.5 +/- 3.3 mm (p < 0.05). Significant left ventricular dilation was also observed in the CMP group--left ventricular end-diastolic diameter increased from 28.9 +/- 3.3 to 38.0 +/- 4.2 mm (p < 0.05). Dilation was slower in the CMP group than in the CONT group, however. Ejection fraction decreased from 58.0 +/- 13.8 to 29.9 +/- 13.7% in the CONT group, but was preserved from 56.0 +/- 8.8 to 51.9 +/- 10.3% in the CMP group., Conclusions: Adynamic cardiomyoplasty reduces ventricular dilation associated with heart failure without exacerbating left ventricular dysfunction.

We investigated the levels of oxygenation in the extended cerebral regions, including the middle cerebral artery region, using optical topography in two patients who underwent total arch replacement assisted by selective cerebral perfusion. During the cooling phase, the oxyhemoglobin levels were almost homogenous. During selective cerebral perfusion, when 18 French and 16 French cannulae were used for the innominate and the left common carotid artery respectively, the oxyhemoglobin levels in the left hemisphere were consistently greater than those in the right. After the 16 French cannula was replaced with a 14 French in the left common carotid artery, then no difference between the hemispheres was found. During the rewarming phase, the increase in the oxyhemoglobin levels in the parietal region was consistently more delayed than that in the temporal region, in both patients. Optical topography might be useful for more precise monitoring of the cerebral circulatory status during an aortic arch operation.

Objectives: Aortic regurgitation associated with Behçet's disease is rare, and prosthetic valve detachment after aortic valve replacement is one of the most serious complications reported. We have investigated the surgical results of valved conduit operation in 8 patients., Methods: Between 1987 and April 1999, 8 patients underwent surgery. There were 7 males and 1 female, and their ages ranged from 33 to 60 years (mean, 48 +/- 10 years). The valved conduit procedure was a modified Bentall operation., Results: One patient died of arrhythmia during the hospital stay. The follow-up period in the other 7 patients ranged from 1 to 138 months after surgery (mean, 74 months). None of these 7 patients died during the follow-up period. Valve detachment needing redo-operation occurred in 1 patient, and he underwent a valved conduit operation again., Conclusions: Valved conduit reconstruction is indicated in patients with aortic regurgitation caused by Behçet's disease, in whom prevention of valve detachment is difficult even by current valve fixation methods.

Objective: Three-channeled aortic dissection with 2 adjacent false lumens present is rare., Methods: The 31 patients whose dissections we treated surgically accounted for 7.3% of the 426 patients with aortic dissection treated surgically between 1978 and May 1999. The 17 men and 14 women ranged in age from 24 to 77 years (mean: 45 +/- 12 years). Marfan syndrome was present in 18. Pain was observed at different times in 20. computed tomography scanning and magnetic resonance image proved useful in preoperative diagnosis. The morphology of the 1st and 2nd false lumens was Stanford type A + B in 13, type B + B in 15, type A + A in 2, and localized abdominal dissection in 1., Results: Descending aortic replacement was done in 18 patients, thoracoabdominal aortic replacement in 7, ascending aortic replacement in 3, and others in 3. Five patients died in hospital and later during follow-up for 1-181 months (mean, 57 +/- 55 months)., Conclusions: Pain recurring in patients with aortic dissection should alert the physician to the possibility of 3-channeled dissection and the necessity of surgery. The incidence of such dissection is high in patients with Marfan syndrome.

Laser ablation under bronchoscopic guidance was conducted on 2 patients with severe tracheal stenosis. Case 1 was a 57-year-old man admitted to our emergency unit because asphyxia. Bronchoscopy showed the lumen occluded at the bifurcation by tracheal cancer. Case 2 was a 62-year-old woman who underwent tracheostomy elsewhere for respiratory failure caused by a brain contusion and was treated for 3 months. After transfer to our emergency unit, bronchoscopy showed severe tracheal stenosis. Tracheoplasty conducted under bronchoscopy used a noncontact Nd:YAG laser at an output of 10-40 W and irradiation time of 1 second per shot. Total irradiation energy was 1700-1900 J. Percutaneous cardiopulmonary support was used during the laser procedure due to asphyxia. All procedures were completed satisfactorily and clinical symptoms improved dramatically in both cases. Laser tracheoplasty under bronchoscopic guidance treated severe stenosis safely and completely. Percutaneous cardiopulmonary support was very useful in preventing severe respiratory failure or asphyxia during this procedure.

Objective: Takayasu's arteritis is an inflammatory vascular disease of unknown etiology that affects the aorta and its main branches, requiring surgical intervention due to occlusive lesions. We studied early and late surgical results., Methods: Between 1979 and December 1998, 46 patients--1 man and 45 women aged 15 to 72 years (mean: 46 +/- 13 years)--with occlusive lesions caused by Takayasu's arteritis underwent surgery. Preoperative steroids were administered to 22 patients having inflammation. Diagnosis indicating surgery included obstructive cervical vessel disease in 13 patients, obstructive coronary artery disease in 19, aortic coarctation in 15, and abdominal branch stenosis in 3. Surgical procedures involved bypass grafting in 31 (cervical vessel bypass in 13, ascending-abdominal aortic bypass in 4, axillary artery-abdominal aortic bypass in 10, descending-abdominal aortic bypass in 1, abdominal branch bypass in 3), coronary artery bypass grafting in 10, and coronary ostial endarterectomy in 9., Results: Four (8.7%) died during hospitalization. Follow-up ranged from 1 to 240 months (mean: 117 months). Eight suffered late deaths and 6 patients died of cardiovascular problems. The total actuarial survival rate was 76.2% at 5 years and 70.5% at 10 years., Conclusions: Steroid therapy before and after surgery appears to affect the overall prognosis positively in patients with Takayasu's arteritis.

Pulmonary thromboendarterectomy was performed on two patients with chronic pulmonary thromboembolism showing thrombotic tendency. Patient 1 was a 25-year-old male with the disease complicated by congenital antithrombin III deficiency. Patient 2 was a 21-year-old male with the disease complicated by antiphospholipid syndrome. Both patients were admitted to the center upon showing dyspnea. Lung perfusion scintigraphy revealed multiple defects in the right and left lungs. Pulmonary arteriography showed occlusion and stenosis from lobar to segmental arteries. Cardiac catheterization showed marked pulmonary hypertension. Pulmonary angioscopy confirmed the presence of organized thrombi while an intravascular ultrasound revealed a thickening of the pulmonary arterial walls in both lungs. After the insertion of an inferior vena cava filter in each patient, surgery was performed. Following a median sternotomy, a cardiopulmonary bypass was utilized to induce deep hypothermia at a pharyngeal temperature of 16 degrees C, after which a thromboendarterectomy of the bilateral pulmonary arteries was performed under intermittent circulatory arrest. A large amount of organized thrombi was extracted from these arteries. After surgery, both patients showed good postoperative outcome with improved blood flow in both lungs, reduced pulmonary arterial pressure and increased cardiac output.

Congenital bicuspid aortic valve is a relatively rare malformation. It is reported that the presence of this anomaly predisposes the patient to the development of dissecting aortic aneurysms. Between 1981 and October 1997, 7 patients with aortic dissection associated with congenital bicuspid aortic valve underwent surgical treatment at our institution. The patients consisted of six males and one female. The age of the patients ranged from 54 to 74 years (mean 61 years). The classification of dissecting aortic aneurysms was DeBakey type I dissection in 4 patients, type II dissection in 2 patients and type IIIb dissection in 1 patient. These 7 patients constituted 2.0% (7/356) of all cases of surgical operation for dissecting thoracic aneurysm. Aortic valve dysfunction was noted in 5 patients, 4 of whom had previously undergone aortic valve replacement. We performed graft replacement of the ascending aorta in 4 patients, graft replacement of the ascending aorta and aortic arch in 2 patients, and graft replacement of the descending aorta in 1 patient. There were no hospital deaths in any of the 7 patients. Pathological examination of surgical specimens of the aortic wall showed cystic medial necrosis in 2 patients and mucoid degeneration in 4 patients. In addition to complication by valve dysfunction, patients with congenital bicuspid aortic valve are at risk for the development of aortic dissection.

We surgically treated a 35-year-old male with acute 3-channeled aortic dissection in Marfan syndrome. He had acute type A aortic dissection, and underwent Bentall's type operation, simultaneous graft replacement of the ascending aorta and total aortic arch. Pain recurred 5 years and 9 months after the first operation. CT scan showed two adjacent false lumens in the descending aorta. The morphology of the first and second dissections was Stanford type A + B. The second dissection was acute. In the second false lumen, a re-entry formation was observed in the abdominal aorta. Because severe pain was persistent, we immediately replaced the descending aorta using a femoro-femoral partial cardiopulmonary bypass. The patient was doing well and was discharged. When pain recurs in a Marfan patient with an aortic dissection, a 3-channeled aortic dissection should be suspected, and we recommend emergency surgery.

The safety limit of retrograde cerebral perfusion (RCP) in aortic arch reconstruction was evaluated in comparison with long (> or = 60 min: group A = 28 cases) and short (< 60 min: group B = 88 cases) RCP time (RCPT). RCPT was 60-94 min in group A and 24-59 min in group B. Hospital mortality was 7.1% and 6.8% in group A and B, respectively. There was no case who was died due to cerebral insufficiency. Postoperative neurological complication was observed 3 in group A and 3 in group B. There was no significance between 2 groups. There were no significant differences in the time to awake, ICU stay, electroencephalogram, and cognitive functions between 2 groups. Based on these results, the safety limit of RCP is over than 60 min and, maybe, about 90 min. We monitored the increase of deoxygenated hemoglobin (HbR) during RCP using a near infrared spectroscopy (n = 55). Since HbR increased gradually during RCP, HbR reflects oxygen metabolism non-invasively in the brain. HbR can be one of useful indexes of the brain protection during RCP.

Two cases of acute type A aortic dissection after replacement of descending thoracic aorta for type B dissection were reported. One case involved a 75-year-old male who had hypertension. The second case involved a 33-year-old female with a familial history of thoracic aneurysms. Both patients underwent simultaneous graft replacement of the ascending aorta and total aortic arch using selective perfusion to the brain. Both patients survived the operations, and the postoperative courses were satisfactory. Acute type A dissection after replacement of descending thoracic aorta for type B dissection is rare, and careful and long-term follow-up is needed for the patients.

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

The patient was a 48-year-old man who was brought to our hospital complaining of chest pain, paresthesia of the lower extremities, and pain in the lumbar region. At first, acute myocardial infarction was diagnosed, but transthoracic echocardiogram revealed an intimal flap in the ascending aorta. The presence of an intimal tear below the left subclavian artery was confirmed by intraoperative transesophageal echocardiogram, and a diagnosis of myocardial infarction accompanying type IIIb aortic dissection with retrograde extension to the ascending aorta was made. Coronary artery bypass grafting to segment #2 using a section of saphenous vein and total aortic arch replacement with "elephant trunk" technique, which concurrently served as a means of amputated stump plasty, was performed. The cerebral circulation was preserved by retrograde cerebral circulation. The post operative progress was good, and thrombo-occlusion of the false lumens of the proximal descending aorta was verified. Type IIIb aortic dissection complicated with myocardial infarction is rare, but examination with both transthoracic and transesophageal echocardiograms were useful for the morphological diagnosis and for determining the surgical technique for the dissection.

In relation to the aortic arch operation, atherosclerotic lesions in this area was investigated in autopsy specimen. Fifty specimens of the aorta with severe atherosclerotic lesions were chosen from 182 autopsies of patients older than 70 years at Tenri Hospital. The aortic arch and the adjacent aorta were divided into 9 segments (three portions around orifices of the arch tributaries [1-3], the ascending aorta proximal to the branchiocephalic artery [4], the descending aorta distal to the left subclavian artery [5], and 4 portions of the aortic arch which consisted with proximal anterior [6], distal anterior [7], proximal posterior [8], and distal posterior wall [9]) as shown in the figure. The degree of atherosclerosis was scored by Gore-Tejada atherosclerosis index (ASCI). The ASCI of the arch (12.7) was significantly higher than the ascending aorta (5.3). (p > 0.05). Among 9 segments of the aortic arch, the ASCIs of the anterior wall of the distal arch (25.1), the aorta distal to the left subclavian artery (17.3), the arch around the orifice of the brachiocephalic artery (17.1) were significantly higher. The ulcerative plaques were predominantly found at the anterior wall of the distal arch (36%). On the other hand, the calcified plaques were predominantly found around the orifice of the brachiocephalic artery (26%). Ten specimens demonstrated significant stenosis at the orifice of the left subclavian artery. From this autopsy study, the degree of atherosclerotic lesion was predominant at the anterior wall of the distal aortic arch and at around the orifice of the brachiocephalic artery.(ABSTRACT TRUNCATED AT 250 WORDS)

An 11-year-old boy with tetralogy of Fallot had undergone palliative right ventricular outflow tract reconstruction twice previously. After the second palliative surgery recurrent mediastinitis persisted. At the age of 5 years and 11 months, he underwent closure of VSD and reconstruction of the right ventricular outflow tract with an equine pericardial patch after removal of the infected prosthetic material. The postoperative course was uneventful, however, severe pulmonary stenosis developed 6 years later. The stenosis was caused by the severely deformed and calcified equine pericardial patch used for intracardiac repair. The reason for severe calcification seemed to be the accentuated calcium metabolism in children, hemodynamic stress and persistent infection.

An urgent pulmonary embolectomy on a patient under intraoperative angioscopy for the treatment of massive pulmonary embolism was performed and successfully saved the patient. The case was a 19-year-old man who had been bedridden over along period of time. He developed pulmonary embolism immediately after the initiation of walking rehabilitation. Although anticoagulation therapy was immediately carried out, hemodynamics deteriorated, and as a result, it became necessary to treat this patient with the urgent surgical procedure. Under extracorporeal circulation with the clamping of the aorta, the pulmonary artery was opened. Following embolectomy for the left pulmonary artery, the right pulmonary artery, where the presence of clots had not been confirmed with the naked eye, was inspected using an flexible fiberoptic choledochoscope 4.9 mm in diameter. Consequently, amount of clots were removed using forceps or an aspirating tube. The patient recovered from hypoxemia after surgery. The use of intraoperative angioscopy in the pulmonary artery proved to be very useful to examine the presence of emboli up to tertiary branches of pulmonary artery.

Deep hypothermic circulatory arrest (DHCA) was introduced as an adjunct for operations involving aortic arch lesions in 1970's and has since been widely used. Profound hypothermia protects the brain and other vital organs by reducing metabolic rate. We initiated the use of continuous retrograde cerebral perfusion (CRCP) via the superior vena cava during DHCA in 1987. We studied 15 patients who required DHCA and CRCP during repair or replacement of the aortic arch. CRCP times ranged from 11 to 78 (mean +/- S.D.; 37.3 +/- 21) minutes, and minimal nasopharyngeal temperatures ranged from 13.7 to 25 (17.7 +/- 2.6) degrees C. Two patients died one month postoperatively due to preoperative disease. Three patients, who were in shock preoperatively due to cardiac tamponade, developed acute renal failure postoperatively. The remaining patients were weaned from the respirator by the 2nd postoperative day. No patient had CRCP-related complications. During CRCP, the partial pressure of oxygen (PO2), saturation of oxygen (SO2), and oxygen content significantly decreased (p < 0.001), and the partial pressure of carbon dioxide (PCO2) and CO2 content significantly increased (p < 0.001) between retrogradely perfused blood and blood draining from the arch vessels. These results most probably reflected that the aerobic metabolism of the brain was maintained by CRCP while the central nervous system was maintained in a hypothermic state, with oxygen and substrate availability, wash-out of metabolites, and buffering capacity and oncotic pressure of the blood maintained. This technique offers the potentials of sufficient metabolic support to the brain during DHCA and prolonged safe time limits of DHCA.

A 64-year-old man underwent CABG. 18000 unit of bovine lung heparin was used during operation for extracorporeal circulation and small amount of heparin was injected until the 5th postoperative day to keep intravenous line patent. His postoperative course was uneventful until the 10th postoperative day when marked ecchymosis developed on his eyelid. Laboratory data showed marked thrombocytopenia (1.3 x 10(4)/microliters) and disseminated intravascular coagulation. The diagnosis of heparin-induced thrombocytopenia (HIT) was confirmed by platelet aggregation test with heparin. Gabexate mesilate and platelet-concentrates were administered and platelet count returned to normal within a week. HIT usually occurs during administration of heparin. In this case, it occurred 5 days after we stopped heparin. Delayed onset of HIT might be related to delayed metabolism of heparin due to postoperative fluid shift.

We followed up thirty-three patients, to whom the superior vena cava-pulmonary artery anastomosis (Glenn procedure) was undergone between April 1966 and March 1988. There were eighteen patients with single ventricle and nine with tricuspid atresia, two with pulmonary atresia with intact ventricular septum and four with other complex anomalies. Seven patients (21%), including six with single ventricle, died 0.3 to 14.9 years after operation. Regurgitation of common atrioventricular valve was the cause of death in three patients. Serum hemoglobin level fell down from 19.3 +/- 2.2 g/dl preoperatively to 15.3 +/- 1.9 g/dl after operation but increased gradually to the preoperative level about ten years later. The actuarial survival rate at ten years is 80%. Reoperation was performed in 9 patients and reoperation free rate at 10 years is 78%. This analysis suggests that Glenn procedure is still good palliative operation for ten years, although some patients will be necessitated the second operation in future.