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Intraoperative perfusion contrast echocardiography (PCE) is a new method to evaluate regional myocardial perfusion using Albunx (air encapsulated albumin microspheres-Molecular Biosystems, Inc.) and has been employed by direct individual injection into human saphenous vein coronary bypass grafts. Because this is not an appropriate technique for assessing left internal thoracic artery (LITA) graft, we tested the hypothesis that PCE can be performed with a single aortic root injection and, thereby, provide regional perfusion data for LITA and native coronary flow. CABG (LITA to the left anterior descending artery (LAD) was performed in adult swine. PCE was performed in each of the following conditions: 1) LITA occluded, LAD 100% flow; 2) LITA 100% flow, LAD occluded; 3) LITA 50% flow, LAD occluded; and 4) LITA and LAD occluded. Time-intensity curves were constructed to assess the time to initial appearance of myocardial enhancement (TIA), peak contrast intensity (PI), and area under the enhancement curve (AUC). In 12/14 cases, (85.7%), adequate enhancement was achieved. LITA perfusion, when compared to perfusion through the native LAD, showed delayed appearance (TIA 0.4 +/- 0.1 vs 1.9 +/- 0.2 secs), reduced PI (43 +/- 3 vs 28 +/- 3 AU) and reduced AUC (247 +/- 115 +/- 19 AU) (p < 0.01) when LITA flow was reduced 50%, TIA was prolonged (1.7 +/- 0.2 vs 2.4 +/- 0.2 secs) and AUC was reduced (152 +/- 18 vs 88 +/- 20 AU) (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Scimitar syndrome is relatively uncommon syndrome. A 14-year-old female referred to our hospital for abnormal shadow of chest fluoroscopic examination. She had no symptom except cough due to bronchial asthma. Chest X-ray film showed Scimitar sign. Cardiac catheterization revealed 30% left to right shunt without atrial septal defect. Pulmonary angiography showed anomalous pulmonary vein was drained to inferior vena cava and left atrium. Surgical correction was attempted monitoring the pulmonary arterial pressure. Anomalous pulmonary vein and systemic arteries were ligated and divided at the level of diaphragm. Postoperative course was smooth. We have found 4 similar operated cases previously reported in the world.

We reported a rare case of subtotal esophagectomy for esophageal basaloid carcinoma after mitral valve replacement. Up to present, only this case had been printed in Japan. A 51-year-old male who had been performed MVR for mitral stenosis at the 44 complained of dysphagia. On esophageal X-ray and esophagoscopic findings showed round, irregular, and stenotic lesion (type-3) in the middle thoracic esophagus. We performed subtotal esophagectomy, esophagogastrostomy through the posterior mediastinal pathway and lymph node dissection (R2). Despite normal cardiac function before operation, the patient followed lung edema and perioperative measurement of Extra Vascular Lung Water Index (EVLWI) was stable within high level. On microscopic inspection, we revealed lots of basophilic basal cells mainly occupied submucosal layer coexisted with pseudoglandular formation and poorly differentiated squamous cell carcinoma. And the tumor cells strongly invaded into the lymph ducts and blood vessels. We need more detailed exploration for more cases about factors causing poor prognosis.

We encountered a case of simultaneous association of an intraepithelial esophageal carcinoma and an intramucosal gastric carcinoma with radical operation. Up to present, only four cases including this report had been printed in Japan. A 67-year-old with chronic cholecystitis was pointed out the esophageal lesion (O-IIa) in the Im area by FGS after it had demonstrated the gastric lesion (early I) at the posterior wall of the prepyrolus. We performed subtotal esophagectomy, total gastrectomy, pyroloplasty with esophagoileostomy through the retrosternal tunnel and lymph nodes dissection (R2). On gross inspection, there was no obvious lesion in the esophagus. Microscopic examination revealed no invasion of cancerous cells to lymph nodes, lymph ducts, and vessels. The patient followed post operative respiratory disorders which not lung edema but atelectasis caused because perioperative measurement of Extra Vascular Lung Water Index (EVLWI) was stable within normal values.

We studied the prediction of postoperative complications in patients whose predicted postoperative FEV1.0% and/or %VC were below fifty. Preoperative exercise tests were performed in 88 cases mainly old patients of age or with impaired pulmonary function; 57 were lobectomies, 10 were bilobectomies and 21 were pneumonectomies. Predicted postoperative FEV1.0% and/or %VC were below fifty in 29 cases consisting of 12 lobectomies, one bilobectomy and 16 pneumonectomies. Among these 29 patients, thirteen suffered postoperative complications (A group) and sixteen did not (B group). All five cases of operative death (death within 30 days after operation) were included in the A group. The prediction of postoperative complications in cases of which pred. postope, FEV1.0% and %VC were fifty or over (C group) was also studied. The results were as follows; (1) The percentage of complications among A and B groups was higher than that among C group but no statistical difference could be found. (2) In the A group, the number of pred. postope. FEV1.0% and/or %VC had little correlation to complications. (3) Statistical differences between A and B group were found in submax VO2 (p < 0.05), VO2/VE at AT (p < 0.001) and VCO2/VE at submaximal exercise (p < 0.001). (4) Cardiac output ratio of maximal exercise to rest had marked correlation to complications (p < 0.001) in C group but had no correlation in the A and B groups. (5) The three items of A and B groups, submax VO2 < 500 ml/min/m2, VO2/VE at AT < 40 ml/l and submax VCO2/VE < 25 ml/l, showed high correlation to operative death (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

In 29 cases undergoing lung resection, effects of the surgery on left ventricular function were investigated indirectly with a Nuclear Stethoscope. Various parameters were measured following an exercise load before and after surgery. There were significant decreases in post-operative resting levels of stroke volume (SV) (p < 0.001), end-diastolic volume (EDV) (p < 0.001), ejection fraction (EF) (p < 0.05) and ejection rate (ER) (p < 0.001) and significant increase in heart rate (HR) (p < 0.001) when compared to pre-operative resting levels. Neither filling rate (FR) nor cardiac output (CO) showed significant difference. At maximum exercise load, there were significant decreases in post-operative EDV (p < 0.005), SV (p < 0.005), ER (p < 0.001) and FR (p < 0.005), but no significant differences were detected in HR and EF; consequently, there was a significant decrease in CO (p < 0.005). Ratio of the levels at maximum load to those at resting of each parameter did not show significant difference between before and after operation with regard to any parameters except CO and FR which showed significant decrease (p < 0.005 and p < 0.001, respectively). Effects of the surgery on left ventricular function were studied according to amount of lung resection. In 13 cases where more than two lobes were resected, similar significant differences to those mentioned above were found in all parameters except EF. In cases where a single lobe was resected, only ER and FR showed similar tendency to that described above. Effects of the surgery on left ventricular function were also studied according to age of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

By reviewing the outcome, we studied the propriety of our principles for the treatment of type A acute aortic dissection in 45 patients, encountered during the 10-year period between 1981 and 1990. We conducted a comparative study of patients with a thrombosed false lumen (type T) and a patent false lumen (type P) to examine the effect of an acutely thrombosed false lumen on the prognosis of this disease. For the 25 patients treated in the first 6 years (1981-1986), operation was performed as soon as exact diagnosis was made, regardless of the presence of complications and the type or severity of the disease. Early death occurred in 9/20 operated cases and in 4/5 unoperated cases, so 13/25 patients died for a 52.0% mortality rate. For the 20 patients who received treatment in the latter period (1987-1990), we gave priority to conservative treatment for type T cases that were free from complications, and adopted a treatment method attaching greater importance to the resection of intimal tears. As a results, early deaths were observed in only 4 type P patients (20.0%) who underwent operation, a significant better result (p < 0.05). For patients in whom we were able to excise the intimal tear (30.0%, early mortality rate), the results were better than in those in whom the intimal tear were left alone (53.8%). The results were particularly good in type T patients (25.0% of them underwent intimal tear resection and 71.4% underwent no operation for the intimal tear).(ABSTRACT TRUNCATED AT 250 WORDS)

A 16-year-old girl with medically refractory idiopathic ventricular tachycardia (VT) with ventricular fibrillation (VF) underwent cryoablations of the VT origin and received implantable cardioverter defibrillator (ICD). Intraoperative epicardial and endocardial mapping demonstrated the earliest activation site of VT in the infundibular septum of right ventricle. Cryoablations were applied through a pulmonary arteriotomy under mild hypothermic cardiopulmonary bypass with the heart beating. Because of the episodes of VF. ICD implantation was followed. Her postoperative course was uneventful and she remains free from VT and VF.

The purpose of this study is to evaluate the effect of newly developed balloon pumping system with synchronized blood flow assist for acute left ventricular failure. In 21 mongrel dogs with left heart failure following left coronary artery ligation, counterpulsatile flow assisted IABP (CFA-IABP) was instituted changing the flow rate from 5% to 70% of the aortic flow at control. The following results were obtained. 1) CFA-IABP significantly increased aortic, carotid, and coronary sinus flows as well increased aortic pressure and endocardial viability ratio, and also reduced left atrial pressure, LVEDP and myocardial oxygen uptake at the low flow assist of about 20% of aortic flow at control. 2) In high flow assist of more than the 50%, the effect of CFA-IABP was present but limited. 3) There was no change of hemodynamics and cardiac function at the timing of CFA method during the diastolic phase. 4) There was no statistically significant difference between CFA and constitute (non-pulsatile) flow assist, but CFA tended to much improve hemodynamics and cardiac function.

Malignant fibrous histiocytoma (MFH) has been rarely reported as a primary tumor of the heart. We present a case of a primary intracardiac MFH and review the 28 previous reports of this rare cardiac tumor. A 48-year-old woman underwent an operation for congestive heart failure (CHF) due to a left atrial tumor. A large multinodular tumor attached to the posterior wall of the left atrium and extended into the mitral annulus and the posterior leaflet of the mitral valve. The tumor was resected incompletely and mitral valve replacement was performed. Pathological diagnosis was MFH. The patient did well in the postoperative period, but she again presented with symptoms of CHF four months later. Chest CT and two-dimensional echocardiogram demonstrated a recurrent tumor of the left atrium. Since the tumor grew rapidly despite chemotherapy, a reoperation was performed to remove it. Nevertheless, as the tumor was found to have extended into the pericardial cavity and posterior mediastinum, only partial resection was possible. After a protracted operation, the heart failed to sustain the circulation and the patient died. The prognosis of intracardiac MFH was poor in spite of surgery, radiation and/or chemotherapy. However, repeated surgical treatments can relieve symptoms of CHF and may prolong the life of patients.

In surgical treatment for lung cancer, increase of right ventricular afterload associated with decrease of pulmonary vascular bed after lung resection is serious problem in acute phase. Intensive care is necessary for the patients having major surgery, especially in aged. Until now, we have studied on pre and post operative extravascular lung water (EVLW) in addition to measurement of conventional hemodynamic changes on right ventricular afterload. And then, we have discussed when we should start to care intensively for degradation of compensatory hyperdynamic change. According to percent exchanges (delta %) between pre and post operative measurement, we established following criterion 1) delta %HR greater than 150% 2) delta SVI less than 60% 3) delta % PARI greater than 200% 4) observed postoperative EVLW greater than predicted postoperative EVLW. Furthermore, we investigated the correlation with these criterion and RVEF in 14 patients using a rapid computerized thermodilution method on right cardiac function in acute phase. We found that 1) changes of RVEF seem to depend on endsystolic volume 2) RVEF decreased just after operation and then slowly increased until 48 hours 3) PARI elevated to 194 +/- 117% in average at 6 to 24 hours showing significant inversed linear correlation to changes of RVEF (R = -0.54). The patients having prolonged elevation of PARI showed degradation of cardiac output and RVEF. RVSWI showed compensative acceleration gradually with increased right ventricular afterload.(ABSTRACT TRUNCATED AT 250 WORDS)

For the purpose of simplification of prediction of postoperative lung function, we studied to predict lung function by analizing the frontal and lateral view of chest plain roentgenogram and investigate the correlation to respiratory complication on 111 patients with lung cancer. According to TNM classification of lung cancer, prediction was performed as follows. Predicted postoperative lung function = [(42-number of resected subsegments)/(42-number of occupied subsegments)] x preoperative VC or FEV1.0. In this formula, 42 was the number of functioning subsegments of whole lung (right: 22, left: 20), and then preoperative occupied subsegments was ordered by T factor, where T1 lesion in lung field was prescribed as 1 subsegment and T2 was more than 2 subsegments respectively in plain chest roentgenogram. And also, on the patients having hilar lesions, it was required to calculate the number of subsegments in atelectasis, peripheral obstructive pneumonia and/or partial emphysematous change due to intrabronchial lesions. There was uniformly positive correlations in VC (R = 0.7949) and FEV1.0 (R = 0.8235) of the patients studied respectively. The patients having pneumonectomy showed tendency of over estimation, on the other hand, the patients having resection of a few segments showed under estimation. To predict the postoperative respiratory condition, we calculated the predicted post-operative %VC and %FEV1.0 for predicted preoperative normal VC and FEV1.0. Above the al, we tried to investigate the correlation with predicted postoperative %VC, %FEV1.0 and postoperative respiratory complications.(ABSTRACT TRUNCATED AT 250 WORDS)

The relation between submaximal oxygen consumption (MVO2) before and after lung resection was studied, and the possibility to predict postoperative MVO2 was investigated. Thirty four patients (19 lobectomies, 9 bi-lobectomies, 6 pneumonectomies) performed exercise tests one week before operation and at the time when they were able to resume work daily after operation (in two to eleven months). Predicted postoperative MVO2 was calculated from preoperative MVO2 as follows: 0.8 x resection rate x age index x preoperative MVO2 + 183. In this formula the resection rate means [the number of total lung segments--the number of non-working segments]. The age index is 1.5 for patients under 50 years, 1.0 for those between 50 to 69, and 0.8 for those over 70. This predicted MVO2 had strong correlation with actual postoperative MVO2 (r = 0.94, t = 13.4, y = 1.08x - 83) in twenty five patients. Correlation was low in the remaining nine patients, however. The nine had old myocard infarction, postoperative cerebral infarction, marked wet lung, anticancerous chemotherapy within ten days or marked reduced exercise capacity (below 3 METS at maximal exercise). From these results, we concluded it is possible to predict the postoperative MVO2 using preoperative MVO2 except in cases which have some exercise limiting factors or whose exercise capacity is very small.

In surgical treatment for lung cancer, large amount of intrabronchial sputum and secretion was occasionally encountered in patients, especially underwent bronchoplastic surgery. It has been discussed as causes which was affected from transection of pulmonary branches of vagal nerve and bronchial arteries. So we have measured pre- and postoperative hemodynamics and extravascular lung water (EVLW) at the bedside, as to investigate the correlation with formyl sputum and increase of right ventricular afterload which was presumed by lung resection and bronchoplasty. Respiratory complication was classified by the incidence of forced bronchial toilet in acute phase. Seven patients were investigated. Three of seven showed white sputum which was difficult to excrete. EVLW was 9.91 +/- 2.12 ml/kg in average before operation and then showed a tendency to increase within 102 +/- 29% of percent exchange (delta %) between pre- and postoperation. As to comparison of delta % of EVLW in acute period, the patients underwent bronchoplastic surgery showed a tendency to increase rather than the patients underwent lobectomy. According to former studies, we found the uniform correlation R = 0.7075 between observed EVLW and predicted postoperative EVLW estimated by prediction of residual functioning lung volume before operation. And also, the patients showing postoperative EVLW more than predicted EVLW before operation had a tendency to increase amount of sputum. Furthermore, concerning hemodynamic changes, pulmonary arterial resistance index (PARI) elevated to 196 +/- 165% (83-515%) in average associated with increased right ventricular stroke work index (RVSWI) as a result of compensatory changes for increased right cardiac afterload.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of the level of high-energy phosphates in the myocardium before, during and after ischemia was performed in 19 consecutive patients who underwent cardiac operation. The following results were obtained. 1) The levels of total nucleotides (ATP, ADP, AMP, CP) determined before, during and after aortic cross clamp were 14.94 +/- 4.12, 5.59 +/- 2.16 and 3.58 +/- 1.14 micrograms/mg. protein in the right atrial appendage. Those in the left ventricular myocardium were 18.22 +/- 4.90, 6.99 +/- 1.52 and 4.35 +/- 1.06 micrograms/mg. protein. The latter levels were higher than the former. 2) Rapidly decreasing after aortic cross clamp, the nucleotides dropped to 37-38% of preischemic level during aortic cross clamp and to 23% of preischemic level 30 minutes after reperfusion. At the termination of extracorporeal circulation, when circulatory dynamics stabilized, the nucleotides were only recovered to 50-53% of preischemic level. 3) Negative correlation was observed between the length of aortic cross clamp time and the content of nucleotides in the atrial muscle. (p less than 0.05) 4) Fluctuations in the nucleotide level indicated that the current method of myocardial protection using GIK solution produced unsatisfactory recover from ischemic damage and reperfusion injury.

Among various methods to treat ventricular tachyarrhythmia (VT) in the presence of acute myocardial infraction, the surgical approach is a somewhat unsatisfactory method in case of preoperative acute hemodynamic deterioration. The transatrial approach with the "topical" application of Lugol solution on left ventricular (LV) endocardium, without left ventriculotomy, i.e. a transatrial chemical ablation method; has been reported in our department as suggestive to being efficacious. The objective of the present study is to investigate the occurrence of left bundle branch block (LBBB) and the like, as well as to examine the impact on heart function, particularly LV function, by employing the just-above mentioned approach. 15 mongrel dogs were being experimented on. Through a left transatrial approach toward LV endocardium and the application of Lugol solution, with pulmonary artery flow being as constant; we measured pre- and post-operative left atrial (LA) pressure, LV pressure, aortic pressure, LV functional shortening, and stroke volume. In addition, the same protocol was also employed in another group, with the application of physiologic normal saline solution, instead. A comparative study was made between the two groups. In the Lugol solution group, postoperative LA pressure and LVEDP showed a tendency toward exhibiting higher values, when compared to preoperative readings. However, no significant difference was observed in this setting. Furthermore, in comparison with postoperative readings in the saline group, the mean LA pressure in the Lugol solution group exhibited a tendency toward somewhat higher values. Nonetheless, no significant difference was observed in LV functional shortening between the two groups; though it is known a LBB pattern could be noticed on ECG in the Lugol solution group.(ABSTRACT TRUNCATED AT 250 WORDS)

Recently, coronary artery bypass grafting operations for patients with total proximal multi-vessel coronary obstructions are increased. In these cases, antegrade cardioplegia through the aortic root has been applied as usual. But it seems to be difficult to deliver cardioplegic solution to myocardium uniformly beyond coronary stenosis. Retrograde coronary sinus cardioplegia in the presence of proximal coronary artery obstruction could maintain improved cardioplegic delivery and satisfactory myocardial protection. Because of the limitation of antegrade cardioplegia, retrograde cardioplegic technique has, once again, been cited as a reasonable alternative to antegrade cardioplegia. But on the other hand, retrograde cardioplegia includes the potential for relatively inadequate preservation of right ventricle based on the venous drainage communication to the coronary sinus. The object of the present work is mainly to evaluate the efficacy of retrograde coronary sinus cardioplegic technique for right ventricle by electrophysiological method. Thirty-six adult mongrel dogs divided three groups. Sixteen animals (Group I) received GIK cardioplegia through the coronary sinus, thirteen animals (Group II) received GIK added diltiazem cardioplegia through the same way, and seven animals (Group III) received GIK cardioplegia through aortic root. No large temperature gradients of myocardium between right and left ventricle in each group and also temperature gradients of right ventricle between three groups have been observed. The time duration from starting of injection of cardioplegia to disappear the electrical activity in right and left ventricle were 11.4 +/- 8.2, 3.4 +/- 1.2 minutes in group I, 2.9 +/- 1.5, 2.2 +/- 1.4 minutes in group II, and 0.9 +/- 0.4, 0.9 +/- 0.2 minutes in group III. The time duration from starting of injection of cardioplegia to reappear the electrical activity in right and left ventricle were 6.4 +/- 8.7, 13.4 +/- 7.9 minutes in group I, 20.0 +/- 3.5, 21.3 +/- 1.6 minutes in group II and 18.0 +/- 5.5, 18.7 +/- 4.5 minutes in group III. Unipolar peak-to-peak amplitude (UPPA) analysis reveals the condition of myocardial preservation during ischemic arrest and we compared preischemic UPPA with post-ischemic UPPA. In group I, UPPA declined of 44.1 +/- 29.3% in right ventricle and 72.7 +/- 27.6% in left ventricle, in group II, 78.7 +/- 28.7%, 81.9 +/- 23.6%, in group III, 71.4 +/- 18.7%, 76.7 +/- 9.89%. Analysis of ultrastructural changes in the myocardium are shown that injury was most manifest in the right ventricle of group I, but in group II, ultrastructure of right ventricle maintained nearly normal condition.(ABSTRACT TRUNCATED AT 400 WORDS)

A 64-year-old male was admitted to our hospital suffering from dysphagia and dyspnea. The chest X-ray films and chest CT films revealed huge tumor in his upper-anterior mediastinum. The filling defect at lower rim of the left brachiocephalic vein on venography indicated malignant potential of the tumor. There was no abnormal value in blood and urine examinations except CA 19-9 which was 31.8 U/ml. The tumor was resected with bilateral pleura, pericardium and left brachiocephalic vein. Macroscopically the specimen accompanied with a lot of bleeding spots was soft and yellow and has no capsule. The size of tumor was 15 X 13 X 8 cm and its weight was 865 gm. No tumor recurrence was found until present time: two years after surgical therapy followed by adjuvant radiation therapy (60 Gray). Though histological findings of anterior part of the tumor were consisted of "Zellballen" cells and bleedings, the posterior part had cell atypia and invasion into vessels. These cells were slightly positive on Keratin stain and on NSE stain. Typical findings of paraganglioma were also indicated by electron microscopy: those findings were more chief cells, fewer sustentacular cells, abundant mitochondria and few dense-cored granules which are thought to secrete hormonal substances. Judging from these clinical and pathological results, this tumor was diagnosed nonfunctional aortico-pulmonary paraganglioma. Mediastinal paraganglioma is a very rare tumor. There is no report of malignant aortico-pulmonary paraganglioma in Japan after Glenner and Grimelys' study concerning extra-adrenal paraganglion system.

Left ventricular free wall rupture (LVFWR) complicating myocardial infarction is still a lethal complication. Although there have been reports of successful repair of LVFWR, most of them were of subacute type in which main symptom was cardiac tamponade and the surgical repair was undertaken several hours after the onset of rupture. Between March, 1984 and June, 1987. We treated 12 cases of LVFWR surgically, thoracotomy and open drainage in 2 cases, thoracotomy and direct closure of rupture in 8 cases, median sternotomy and patch closure of rupture in 2 cases. We used cardiopulmonary bypass (CPB) only in 3 cases, because most of the cases except two developed electromechanical dissociation abruptly, requiring an emergency thoracotomy and there was no time for establishing CPB. In the cases of electromechanical dissociation, cardiopulmonary resuscitation and an emergency thoracotomy were performed simultaneously. There were three early survivors (greater than 30 days) by emergency thoracotomy and direct closure of rupture and one survivor (double rupture case) by patch closure on CPB. We believe that acute type of LVFWR in which initial symptom is electromechanical dissociation without any preceding symptoms can be rescued by emergency thoracotomy and direct closure of rupture with no aid of CPB if rupture is a small tear of anterior or lateral left ventricle. For this purpose, prompt diagnosis is mandatory and this is possible by two dimensional echocardiogram even during cardiopulmonary resuscitation.

We studied the healing processes of operative cardiac wound around the patch on 8 patients (5 males, 3 females), who survived 6 to 147 days postoperatively for postinfarction ventricular septal perforation. The perforation was repaired either with a Dacron patch or with a Teflon-backed glutaraldehyde-preserved equine pericardium (Xenomedica). The patients with the Xenomedica patch had no perioperative bleeding or residual shunting across the patch. However, our long-term observations show that the patch is not covered with neoendocardium after 5 months and thus may pose a greater risk for thrombus formation, embolisms or infections; For instances, one case with mural thrombus formation and two cases of infection around the patch were observed. Therefore, while the Xenomedica patch may provide advantages in the immediate postoperative period, long term results indicate that this patch is inferior to the Dacron patch. We have also observed that the progress of healing was different on the patch between the right and left surface. Neoendocardium was observed on the 30th postoperative day on the right sided surface of the Darcron patch, while only pseudoneointima (mostly fibrinous membrane) with a few endothelial cells were found on the left side. The healing of infarcted myocardium was slower in these patients with patch than in patients with myocardial infarction without operation. Even after 62nd postoperative day, scarring was still incomplete, only granulation tissue was observed. Certainly, the operative trauma including the effect of extracorporeal circulation and postoperative low output syndrome may contribute to this finding. Suture insufficiency occurred in 4 cases, which may be associated with the delayed wound healing.(ABSTRACT TRUNCATED AT 250 WORDS)

A 22 year-old man was brought to our hospital about twenty-three minutes following a high-speed motorbicycle accident in which he had blunt chest trauma. He was in severe respiratory distress with marked dyspnea and restless with extensive subcutaneous emphysema involving anterior chest wall, cervical and bilateral inguinal regions. A chest X-ray revealed bilateral pneumothorax involving mediastinal emphysema and also fracture of right submandibular and clavicula. In spite of orotracheal intubation and insertion of bilateral chest tube, continuous air leak and pneumothorax did not improve. Bronchoscopy revealed the disruption of mucosa of the right main bronchus at the bifurcation. Emergency right thoracotomy was performed and there was the complete disruption of the right main bronchus. Anastomosis of the right main bronchus with circumferential resection was undertaken on May 30, 1987 about two hours after trauma. About three months after reconstruction, bronchoscopic examination revealed stomal stenosis with deformation of tracheobronchial cartilage and granulation. The stenosis showed severe irregularity by deformed cartilage and thickened scar, so widening by Nd-YAG laser vaporization was inadequate in effect. Seven months after first reconstruction, we performed re-reconstructive operation, right upper sleeve lobectomy with partial resection of carcina and right wall of trachea for scar with severe deformation of cartilage. Following the operation, the patient suffered from sepsis with pneumonitis accompanied by lung edema. This complication was treated successfully. We considered that acute pneumonitis was caused by reventilation with increase of perfusion after tracheobronchial reconstruction. Consequently, we thought it important to treat such patients with long term IPPB postoperatively with adequate medication for respiratory system.

A patient who had received balloon atrioseptotomy and B-T shunt operation previously experienced recurrent episodes of supraventricular tachycardia, and was refractory to medical treatment since the age to 3. At 9 years, the patient underwent intraoperative electrophysiological mapping which confirmed the earliest breakthrough at the crux of posterior septal region. Rastelli's operation and division of posterior septal Kent was simultaneously performed successfully. Post operative ECG was normalized with abolition of delta wave, and PSVT was gone. We concluded that the division of Kent bundle should be simultaneously performed with operative reconstruction in patients with congenital heart disease and WPW syndrome on postoperative care for SVT.

A 13-year-old boy with partial anomalous pulmonary venous connection (PAPVC) having an intact atrial septum (IAS) is reported. He had open heart surgery 3 years ago at another hospital, but the cardiac septum was intact and PDA was ligated. After his discharge, cardiomegaly and increased right pulmonary vasculature were seen in chest roentgenograms. Our cardiac catheterization data and pulmonary angiograms showed that he had a PAPVC with IAS. Surgical correction was accomplished by utilizing a polytetrafluoroethylene graft with external ring support and interposing it between the right upper pulmonary vein and the left atrium during thoracotomy without the need for extracorporeal circulation. The postoperative course was uneventful and he was discharged on the 14th postoperative day. At 3 months postoperatively, radionuclide studies demonstrated no evidence of pulmonary congestion or graft obstruction. To our knowledge, this is the first clinical report of prosthetic replacement of the pulmonary venous pathway with graft patency demonstrated postoperatively.