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Giant aneurysms are the most serious issue of patients with Kawasaki disease (KD). To clarify risk factors for these giant aneurysms, we conducted a matched case-control study. Among the patients reported in nationwide surveys, 117 patients with giant aneurysms had an unequivocal new diagnosis and presented at the treatment center within 9 d of illness. We obtained clinical information on admission of about 69 patients (case) from the treatment centers. One control was selected for each case, an age- and sex-matched patient without coronary involvement, reported from the same treatment center at about the same time as the case, and we obtained the same clinical information about controls. Fourteen variables were analysed with a conditional logistic regression model: body temperature, hematocrit, hemoglobin, numbers of leukocyte and platelets, concentrations of serum albumin, globulin, total cholesterol, sodium, potassium and chloride, erythrocyte sedimentation rate, C-reactive protein and alanine aminotransferase activity. After adjustment for age, duration of illness before admission and use of intravenous gamma globulin therapy, C-reactive protein [odds ratio (OR)=1.142, 95% confidence interval (CI) 1.054-1.237], alanine aminotransferase activity (OR=1.008, 95% CI 1.002-1.014), serum sodium concentration (OR=0.877, 95% CI 0.770-0.999) and serum potassium concentration (OR=0.319, 95% CI 0.124-0.822) were significantly related to the risk for giant aneurysms. Further analyses with these four explanatory variables revealed that C-reactive protein (OR=1.159, 95% CI 1.022-1.315) and serum potassium concentration (OR=0.222, 95% CI 0.052-0.948) met the significant level. Thus, the values for serum C-reactive protein and potassium are independent risk factors for the development of the giant aneurysms of Kawasaki disease.

In the latest survey of Kawasaki disease in Japan, questionnaires on maximal leukocyte counts of the patients were included to clarify whether leukocyte counts could be of value for the diagnosis and prediction of outcome. A questionnaire form and diagnostic guidelines for Kawasaki disease were sent to all pediatric departments of hospitals withor = 100 beds throughout Japan, and information including maximal leukocyte counts was obtained on patients with Kawasaki disease diagnosed during the 2-y period from January 1993 to December 1994. Of the 11,458 patients diagnosed during the 2-y period, maximal leukocyte counts were reported in 11,062 patients (96.5%). The mean value and the distribution of maximal leukocyte counts were lower in the age group under 1 y. The mean values and the distribution of leukocyte counts were lowest in suspected cases among three diagnostic categories: typical cases of Kawasaki disease, atypical cases, and suspected cases. The mean values of maximal leukocyte counts of the patients with cardiac sequelae were significantly higher than those without cardiac sequelae in each age group. The proportion of patients with cardiac sequelae increased with leukocyte counts in each age group. The Receiver/Response Operating Characteristic (ROC) curve for maximal leukocyte counts in Kawasaki disease revealed that the accuracy of maximal leukocyte counts for prediction of cardiac sequelae was highest in the age group6 months, and the most accurate cut-off point was 16 x 10(9)/l. The strongest association between higher leukocyte counts (or = 16 x 10(9)/l) and cardiac sequelae was observed in the age group6 M. A large-scale analysis of leukocyte counts in patients with Kawasaki disease revealed age-dependent relationship between maximal leukocyte counts, diagnostic categories and outcome. Maximal leukocyte counts may be helpful for the prediction of outcome with the consideration of age.

The aim of this study was to evaluate the late results of left ventricular (LV) aneurysm repair.From July 1968 to 1999, 86 consecutive patients (74 male, 12 female, mean age 56.0 +/- 9.3) underwent LV aneurysm repair at our institute. The surgical methods were as follows; linear repair in 71 patients, endoaneurysmorrhaphy in 5, endoventricular circular plasty in 4, Jatene method in 1 and plication of aneurysm in 5. Thirty-nine patients underwent concomitant myocardial revascularization. Major arrhythmias occurred in 38 patients. The results were retrospectively reviewed and follow-up was achieved in 95.3%.There were 6 operative deaths and 4 hospital deaths. Actuarial survival rate including the 10 deaths was 72.7% at 5 years and 46.3% at 10 years. In patients with coronary artery bypass grafting (CABG), survival rate was 82.2% at 5 years and 56.3% at 10 years, and was significantly higher than that in those without revascularization (p = 0.01). In patients without arrhythmias, survival rate was 79.2% at 5 years and 55.0% at 10 years, and was significantly higher than that in patients with arrhythmias.The patients were not homologous and the techniques were not the same; however, in spite of these study limitations, patients who underwent revascularization, and were without major arrhythmias preoperatively, had better long-term survival.

A review of past and current operative procedures for the treatment of aneurysms of the distal aortic arch is presented in conjunction with a series of 43 patients. In this study, distal aortic arch aneurysm refers to an aneurysm involving at least the origin of the left subclavian artery, but not extending beyond the left common carotid artery. We excluded dissection aneurysm and extended aneurysm to the descending thoracic aorta from this study.Between January, 1985, and March, 2000, 43 consecutive patients (37 males, 6 females; mean age 67.5 years) underwent repair of aneurysms of the distal aortic arch. The approach to the aneurysm was through a left thoracotomy in 4 patients and a median sternotomy in 39 patients, including an additional left thoracotomy continued to a median sternotomy in 2 patients. The supportive methods during surgery were left heart bypass using a centrifugal pump in 4 patients (LHB group), cardiopulmonary bypass with selective cerebral perfusion in 11 patients (SCP group), and cardiopulmonary bypass with continuous retrograde cerebral perfusion in 28 patients (RCP group). In the RCP group, the "aortic no-touch technique" was applied in 21 patients. The operative methods were patch closure in 4 patients, graft replacement of the distal arch using the inclusion technique in 14 patients, and total arch replacement using the exclusion technique in 25 patients.There were 5 hospital deaths: 1 patient in the LHB group, intractable bleeding; 1 patient in the SCP group, rupture of the distal anastomosis; 3 patients in the RCP group, stroke, rupture of the dissection arising from the distal anastomosis, and perioperative myocardial infarction. Stroke occurred in 1 patient (25%) with LHB, 3 patients (27.2%) with SCP, and 1 patient (3.6%) with RCP. Among the postoperative survivors, a new onset of left recurrent nerve palsy occurred in 2 patients (66.7%) with LHB, 1 patient (10%) with SCP, and in 1 patient (4%) with RCP. No neurological injury or left recurrent nerve palsy occurred in the patients who underwent the "aortic no-touch technique".Total arch replacement with the graft exclusion technique under profound hypothermic circulatory arrest using RCP through the median sternotomy is a promising surgical treatment for atherosclerotic distal aortic arch aneurysm. The "aortic no-touch technique" further improved the surgical results of the distal aortic arch aneurysm.

Although some surgeons prefer to use artificial valve rings for tricuspid valve annuloplasty, we have mainly performed De Vega's tricuspid annuloplasty for functional tricuspid regurgitation, because it is a simple and effective technique for reducing tricuspid regurgitation due to annular dilatation. We evaluated long-term results of the De Vega's tricuspid annuloplasty up to 19 postoperative years.Between January 1980 and June 1999, 408 patients underwent De Vega's tricuspid annuloplasty. Long-term results after De Vega's tricuspid annuloplasty were analyzed.There were 14 (3.4%) early deaths within 30 postoperative days. There were 63 (15.4%) late deaths during the follow-up period. The actuarial survival rate at 15 years after operation was 74.0%, the 15-year freedom from re-operation was 91.6%, and the 15-year freedom from all events was 58.7%, respectively.These results suggest that De Vega's tricuspid annuloplasty was an effective and reliable procedure of choice for secondary tricuspid regurgitation with annular dilatation.

From March 1996 to May 2000, 41 patients [age 39-78 (mean 63.5 +/- 8.8) years, 90.2% male] underwent all arterial multiple coronary artery bypass grafting (CABG) using bilateral internal thoracic (BiITA) and radial (RA) arterial conduits. The reason for using RA was that the right gastroepiploic artery (RGEA) was small or occluded on preoperative angiography, a history of upper abdominal surgery or disease, or the right coronary arterial lesion was proximal and mild. The BiITA were used as in situ grafts and the proximal anastomosis of RA was to the ascending aorta in all cases. All patients underwent conventional elective CABG with median sternotomy using cardiopulmonary bypass. The mean number of anastomoses was 3.3 +/- 0.5 branches and complete revascularization rate was 80.5%. Postoperative follow-up averaged 20 months and the longest was 50 months. There was no early death, and overall graft patency 2-3 weeks after surgery was 96.2% (LITA 94.0%, RITA 97.6%, RA 97.6%). Four-year actuarial survival rate was 96.4 +/- 3.5% (1 patient: 9 months, no cardiac death), and cardiac event-free rate after surgery was 89.7 +/- 4.9% [4 patients: percutaneous transluminal coronary angioplasty (PTCA)]. However, once patients were discharged from hospital, cardiac event-free rate was 100%. These excellent results suggest that all arterial graft CABG was satisfactory, and RA can be used as a third suitable arterial bypass conduit, if RGEA cannot be used or is unsuitable for use.

Dissecting aneurysm of the ventricular septum as a complication after myocardial infarction (MI) is very rare. The patient was a 70-year-old women who was diagnosed with acute inferior MI. Three months after MI, catheterization showed a left ventricular aneurysm of the inferior wall, and left-to-right ventricular shunt flow was detected in the aneurysm. Echocardiography showed that the inferior left ventricular free wall was aneurysmal and dissected from the septal wall. Nine months after MI, chronic heart failure was uncontrollable by medication. At surgery, a tear (5 mm long) in the dissecting aneurysm of the ventricular septum was found and closed directly using 2 felt patches, and aneurysmectomy was performed using felt strips. The postoperative course was uneventful and she has been free from any complication for over 1 year.

Combined therapy of stent graft implantation and open surgery is an alternative method for aortic aneurysm. Seven patients with aortic aneurysm [annulo aortic ectasia (AAE) + Marfan syndrome (4), AAE + arch aneurysm + s/o Behçet disease (1), acute dissected aneurysm (type A) (1), thoracic aortic true aneurysm (1)] were successfully treated by means of elephant trunk method using a stent graft during total arch replacement. There was no complication related to the stent graft during the perioperative period. Postoperative computed tomographic scans were performed 1 and 6 months later. There was no endleak and no migration, and the aortic diameter around the stent graft was not changed in six patients. However, one patient showed thrombus around the stent graft, because of endleak 2 months after the operation. Such patients should therefore have careful long-term follow-up.

This study was proposed to define early and long-term results of coronary artery bypass grafting (CABG) in dialysis-dependent renal failure (RF) patients, and preoperative patient characteristics. This study included 105 patients (87 males and 18 females; mean age 60.0 +/- 9.0 years, range 39-79) with RF on maintenance dialysis (hemodialysis 100, peritoneal dialysis 5) who underwent isolated CABG between August 1985 and April 2000. Postoperative follow-up was completed in 100% and averaged 3.1 years. There were 22 emergency and 2 re-CABG cases. Previous myocardial infarction (MI) was found in 55 patients (52%), and unstable angina was noted in 53 patients (50%). Diabetes mellitus was the cause of RF in 50 patients (48%; 24 patients required insulin). There was 1 case of single vessel disease, 31 cases of double vessel disease, 54 cases of triple vessel disease, and 19 cases of left main disease. Preoperative left ventriculography was performed in 92 patients (88%). Left ventricular ejection fraction (LVEF) was 48.3 +/- 15.8% (range 11-74%) and was 40% or less in 25 patients (27%). The mean number of distal anastomoses was 2.5 (range 1-5). Three patients received only vein grafts, but all were cases of emergency CABG. The remaining 102 patients (97%) received at least 1 arterial conduit. Among them, 64 patients received only arterial conduits, and 72 patients received 2 or more distal anastomoses with arterial conduits. Five patients (4.8%) died within 30 days after CABG (2 cardiac deaths and 3 noncardiac deaths), and 8 patients (7.6%) died beyond 30 days after CABG before discharge (all noncardiac deaths). The cause of 2 cardiac deaths was abrupt circulatory collapse during or after hemodialysis in patients with severe left ventricular dysfunction (LVEF; 11% and 28%) in the early postoperative period. The causes of 8 noncardiac deaths included infection in 4 and rupture of aortic aneurysm, stroke, sleep apnea syndrome, and mesenteric infarction. During the follow-up period, there were 29 late deaths (8 cardiac, 13 noncardiac, and 8 sudden death), 6 MIs, 13 percutaneous transluminal coronary angioplasty, and 1 re-CABG. The 5-year actuarial survival rate was 59.8%, the cardiac death-free rate was 83.0%, and the cardiac event-free rate was 62.4%. Although CABG in patients on hemodialysis is associated with high early and long-term mortality in terms of both cardiac and noncardiac deaths in proportion to the severity of the preoperative condition, long-term survival was still better than that of general dialysis patients. Meticulous perioperative management may be the key factor in the improvement of early results.

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.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.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 (p0.01) 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% (p0.05), 1 sec percentage of forced expiratory volume of 98.8 +/- 2.3%/71.8 +/- 2.8% (p0.05) and peak expiratory flow rate of 91.7 +/- 4.2%/89.4 +/- 4.5%.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.

In Japan, the number of chronic hemodialysis (HD) patients is increasing, and there are 7,000 cases with a more than 20 year history of HD. At our institute, we have experienced 135 cases of open heart surgery in patients on HD, including 92 isolated CABG cases and 43 other open heart surgery cases. However, open heart surgery for patients with a more than 20 year history on HD is rare. Open heart surgery on HD patients is rather difficult, since perioperative management can be complicated and special care must be taken for prophylaxis of infection, fluid and electrolyte management and anticoagulation therapy. Many complications have been published in HD patients. At our institute, 3 cases of open heart surgery in patients with more than a 20 year history of HD have been performed. These included triple CABG, double CABG + AVR and double CABG in a post-kidney transplantation patient. They were discharged uneventfully with angiographically patent grafts. It is concluded that for CABG in patients on HD, aggressive use of arterial conduits for revascularization is recommended. For patients with a transplanted kidney, careful management against dysfunction and rejection is necessary.

Recently, Bentall procedure is commonly performed for annuloaortic ectasia with aortic regurgitation or dissecting aneurysm. And the operative results are improving. In this study, we evaluated results of the St. Jude Medical (SJM) and Carbomedics (CM) valves which were used in this procedure. From 1979 to 1994, 87 SJM valves and 22 CM valves were implanted in the aortic position of Bentall procedure. Total follow-up was 528.6 years in the SJM group and 56.5 years in the CM group. According to the Kaplan-Meier actuarial method and the Cox-Mantel statistical analysis, actuarial survival, thromboembolism free rate, reoperation free rate, event free rate were not different between the SJM and CM groups. These results suggest that, current selection of the SJM and CM valves would be acceptable in Bentall procedure.

This study was undertaken to assess optimum anticoagulation control after bileaflet mechanical valve replacement by using the international normalized ratio of prothrombin time (PT-INR). From January to December 1995, 261 patients (pts) underwent mechanical valve replacement in the aortic (n = 95), mitral (n = 126), aortomitral (n = 39) or isolated tricuspid (n = 1) valve position in 8 medical centers in Tokyo, Japan. The St. Jude Medical valves were implanted in 184 pts and the Carbomedics valves in 77. There were 17 valve-related events as follows: 11 thromboembolic events (3.62%/pt-yr) including 10 transient ischemic attacks. 5 non-fatal bleeding events (1.65%/pt-yr), 2 reoperations (0.66%/pt-yr). At 18 postoperative months, free rates from all deaths (actuarial survival) thromboembolism, reoperation and all valve-related events were 95.3%, 95.7%, 98.7% and 88.9%, respectively. Under anticoagulant therapy, thrombin-antithrombin III complex and D-dimmer remained in high levels at 1 month after operation, and both values decreased to the control level at 6 months. In patients with thromboembolic events, PT-INR tended to be less than 2.0. The patients with bleeding events showed some increase of PT-INP or received anti-platelet agents. The 5 to 95 percentile of PT-INR at 6 months was 1.2 to 3.0 in the patients without valve-related events. These results suggested that optimum range of PT-INR might be between 1.2 and 3.0 after bileaflet mechanical valve replacement in patients without high risk of thromboembolism and between 2.0 and 3.0 in patients with the high risk.

Many reports indicated that terminal warm blood cardioplegia (TWBC) was useful for reduction of the reperfusion injury in cardiac operations. We introduced Bretschneider-HTK solution (B-HTK) from April 1992, and combined use of the TWBC and the B-HTK was performed from May 1996. The purpose of this study was to evaluate clinical efficacy of the TWBC in combination with B-HTK for myocardial protection. In patient with valve operations from May 1995 to May 1997, clinical results were compared between the B-HTK with TWBC group (34 patients) and the B-HTK alone group (37 patients). Between two groups, there was no significant difference in patient characteristics, preoperative NYHA class, cardiopulmonary bypass time, aortic cross clamp time, minimum rectal temperature, rewarming and circulatory support time, incidence of IABP and blood concentration of max CPK, max GOT. Furthermore, the cardiac index in 1 postoperative day showed some trend to be higher in the combined TWBC group than that in the B-HTK alone group. But there was no significant difference between two groups in the LV shortening fraction at 14 postoperative day. Incidence of DC defibrillation was significantly lower in the combined TWBC group than that in the B-HTK alone group. These results suggested that combination of the TWBC might be useful for reduction of the reperfusion injury following myocardial protection with B-HTK solution.

Between August 1987 and November 1998, 137 patients underwent emergency CABG within 24 hours from the notification of cardiologist. Among them, 37 patients (27%) (34 men, 3 women) with a mean age of 59.9 (range, 39-76) underwent multiple CABG with exclusive use of arterial conduits. Preoperative diagnosis was acute myocardial infarction in 20 patients and unstable angina in 17 patients. Twenty-nine patients (78%) had either triple vessel or left main disease. There were 3 redo CABG and 3 patients were on hemodialysis. Postoperative follow-up averaged 44 months. Twenty-nine patients (78%) were under IABP support preoperatively. The mean number of anastomoses was 2.65 (range, 2-5). One patient (2.7%) died of persistent heart failure 54 days postoperatively. The patency was confirmed angiographically in 33 patients 3-4 weeks after surgery. Overall patency was 90.6% (LITA: 93.0%, RGEA: 76.2%, RITA, radial: 100%). There were no late deaths or redo CABG, and 2 patients sustained myocardial infarction and 3 patients underwent PTCA during follow-up. Five-year actuarial survival rate was 97.1% and cardiac event-free rate was 75.7%. These excellent early and long-term results suggest that complete arterial grafting for emergency CABG should be considered as a primary treatment in patients who have multivessel or left main disease, and no ongoing profound cardiogenic shock or rapid deterioration.

The 60-year-old women who complicated by multiple sclerosis was referred to our hospital under diagnosis of mitral valve stenosis and tricuspid valve regurgitation. The mitral valve replacement and the tricuspid valve annuloplasty were performed under cardiopulmonary bypass. In the state of multiple sclerosis, even an operation by general anesthesia could become a cause of abrupt change, but by appropriate management during and after surgery, the post operative course was uneventful without any complications, and the patient discharged on the 35th post operative day.

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 (p0.05). The degree of MR was reduced from 3.5 to 1.2 (p0.05), and left ventricular end-diastolic pressure decreased from 18 +/- 7 to 13 +/- 8 mmHg (p0.05). 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.

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.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).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.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.

Three patients underwent pedicle transposition of the greater omentum for sternal osteomyelitis and mediastinitis after cardiac operation. These patients were previously operated on with coronary artery bypass grafting, aortic valve replacement and redo Fontan operation in each. This procedure was carried out on 4, 6, 8, and 14th postoperative day. The complications cured within about one month after the procedure in all cases. It is suggested that this maneuver is effective for obtaining healing osteomyelitis and mediastinitis following cardiac operation.

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.

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 gradient50 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.

Based on the STS/AATS guidelines of 1996, we compared the long-term results after mitral (Re-MVR) and/or tricuspid valve re-replacement (Re-TVR) in a total 324 patients (Re-MVT 299.Re-MVT+TVR 19, and Re-TVR 6 patients) with those after initial valve replacement in 763 patients (MVR 741, MVR+TVR 6 and TVR 16 patients). The actuarial survival (AS), reoperation-free (RF), thromboembolism-free (TF), and freedom from all valve-related events (EF) rates at the 15th postoperative year were 69.3%, 82.4% 86.6%, and 48.9% after Re-MVR and 87.2%, 92.2%, 83.9%, and 61.4% after initial MVR, respectively. The only significant difference between the two MVR groups occurred in the RF proportion. Similarly, the incidence of valve-related events after Re-MVR+TVR or Re-TVR was the same as that after the initial operation for the respective valve lesions. These long-term results suggest that valve re-replacement for mitral and/or tricuspid valve lesions should be encouraged to the same extent as the initial operation.

The Novacor left ventricular assist device has been widely applied as a bridge to heart transplantation. The patient, a 29-year-old, male had severe left ventricular failure due to dilated cardiomyopathy. The heart failure had progressively worsened and showed severely reduced wall motion of the left ventricle with fraction shortening of 0.03. His cardiac catheterization data with 7 r of dopamine infusion was as follows; RA(12), RV46/9EDP(12), PA(w)(31), cardiac Index 1.73 l/min/cm2. Novacor implantation was performed on March 11th, 1996. After the implantation the patient was extubated on day 3 and recovered rapidly. No complications, such as bleeding or thromboembolic episodes were seen. The patient was flown to the USA for cardiac transplantation on 24th, September, 1996. During the 11-hour flight from Narita to Los Angeles, he experienced no adverse effects. The patient underwent a successful cardiac transplant at UCLA Medical Center. His post-operative course was uneventful. We believe that either chronic circulatory support or the bridge to transplant using Novacor LVAS will be a significant breakthrough for the treatment of Japanese patients with severely deteriorated cardiomyopathy.

In triple valvular surgery, AVR+MVR+TVR or TVP, there are some problems around operation, because patients impaired cardiac function after a long history of the disease and some of them are reoperation cases. The sixty-five patients operated from May in 1980 to June in 1993 were examined. They were divided into two groups, group P and group R, depending upon procedure of tricuspid position. Group P consisted of 51 patients and group R of 14 patients. There were 22 (34%) reoperations. In group P, organic changes in tricuspid valve were mild, however in group R, there were commissural fusion in 8 patients, destruction of leaflet due to infectious endocarditis in one patient, and marked tricuspid annular dilatation in five patients. There was one early death in group R, no early death in group P. Actuarial survival rate at the 10th postoperative year was good as 81.6% in group P and 85.7% in group R. There were no significant differences in operative mortality and actuarial survival between group P and R.

We successfully performed DVR with aortic annular reconstruction by Nick's procedure for a case of active infective endocarditis (IE) with perianular abscess. The patient was 26-year-old woman, who suffered from acute AR and MR due to active IE. At operation, a bicuspid aortic valve was noted with scattered vegetations. The periannular abscess extended from the aortic annulus to the anterior mitral leaflet on which there was a leaflet aneurysm. The complete debridement of infected lesions resulted in the defect of aortic annulus at the area of the aorto-mitral fibrous continuity. We reconstructed the aortic annulus by the equine pericardial patch and performed DVR, followed by the reconstruction of the aortic root by Nicks's procedure. After the operation the antibiotics had been administrated to the patient until CRP became completely negative. The patient was discharged from our hospital at 59 POD with no evidence of recurrence of IE. In such cases, we acknowledge the importance of as much complete debridement of infected lesions as possible and regard Nicks's procedure useful as one of the options for reconstruction of aortic root after debridement.

The mechanism of obstruction of the left ventricular outflow tract (LVOT) in hypertrophic obstructive cardiomyopathy (HOCM) is mainly due to dynamic systolic anterior motion (SAM) of the mitral valve. We report a case of HOCM with mitral regurgitation (MR) associated with complicated abnormalities of the mitral apparatus which contributed to a high pressure gradient through the LVOT. A small, 53-year-old woman was admitted for chest pain and palpitation. Examinations revealed asymmetric septal hypertrophy of the left ventricle, MR, SAM of the mitral valve and a high pressure gradient (108 mmHg) through the LVOT. Operative findings revealed an abnormally hypertrophied interventricular septum, an extensively thickened and enlarged anterior mitral leaflet (AML), malposition of the origin of the anterior papillary muscle arising closer to the aortic annulus than normal, and its direct insertion into the AML without any distinguishable chordae tendineae. The hypertrophied septum and the large and protruding AML appeared to obstruct the LVOT, resulting in a loss of subaortic clearance that was recovered after mitral valve replacement and myectomy. Pathology of the papillary muscle was characteristic of HOCM, showing disorganization and disarray of myocardial fibers, bizarre-shaped nuclei, and intercellular fibrosis, while those of the mitral leaflets negated both rheumatic changes and endocarditis.

From 1993 to 1997, nine Japanese heart transplant candidates were accepted by the University of California at Los Angeles (UCLA) Medical Center, because no donor heart was available in Japan from a brain-dead patient. In all nine heart transplant patients described in this investigation, the preoperative diagnosis was dilated cardiomyopathy. One patient underwent implantation with a Novacor left ventricular assist device (Baxter Japan, Tokyo, Japan) as a bridge to heart transplant. All patients survived surgery and for a long-term period. The actuarial 1-year and 3-year survival curves of these patients were both 100%. The postoperative functional status was New York Heart Association Class 1 in all patients (100%). Immunosuppressive triple drug therapy (azathioprine, steroids, and cyclosporine) was given in seven patients; in two patients, cyclosporine was withdrawn and replaced by FK506 due to refractory rejection. The incidence of acute rejection per patient of more than grade 3 according to the International Society for Heart and Lung Transplantation was 6% within 3 months and 4.5% in 3-6 months; there was no rejection episode more than 6 months after transplantation. Post-transplant coronary artery disease was seen in two patients. However, no disease progression was seen after diltiazem therapy. These results may encourage heart transplantation in Japan.

To evaluate cerebral oxygen desaturation during retrograde cerebral perfusion with total circulatory arrest (RCP), we measured cerebral oxygen extraction (O2 Ext), and arterio-venous oxygen differences (AV DO2) during and after RCP and compared the results with usual cardiopulmonary bypass (CPB) using continuous jugular blood saturation (SjO2) monitoring. In the RCP group, 7 patients underwent aortic arch replacement with RCP and in the CPB group, 4 patients underwent valvular surgery with CPB. A 5.5 Fr oximetric catheter was placed in the jugular bulb and cerebral venous and radial arterial blood were sampled. Oxygen partial pressure and saturation were measured at six intervals from cerebral venous and radial arterial blood. Measurements were taken at the following phases: phase I: before ECC was established, phase II: immediately after ECC started; phase III: at hypothermia (18 degrees C in the RCP group and 28 degrees C in the CPB group), phase IV: during rewarming (30 degrees C), phase V: after rewarming (36 degrees C), phase IV: immediately after weaning from ECC. All 11 patients survived without neurological complications. The minimum SjO2 of continuous monitoring during rewarming in the RCP group was significantly lower than in the CPB group. AVDO2 in the RCP group was also significantly higher than in the CPB group during rewarming. O2 Ext in the RCP group was significantly higher than in the CPB group during and after rewarming. Differences in glucose utilization during and after rewarming were also detected. Moreover, to determine factors that influence SjO2 during and after rewarming, we evaluated correlations with arterial PaCO2, arterial pH, and rewarming duration. There were significant (p0.05) correlations between SjO2 and PaCO2 in phase IV and phase V, between SjO2 and pH, and between SjO2 and rewarming duration. In conclusion, continuous SjO2 measurements reflected cerebral oxygen desaturation during and after rewarming in RCP. In RCP, significantly greater desaturation during and after rewarming was detected than in CPB. Therefore we suggest that relatively slow rewarming, higher PaCO2, and more acidic pH strategies were advantageous for preventing desaturation during and after rewarming in RCP.

Surgical treatments for aortic valve disease in the presence of a small aortic annulus need appropriate indications for operative procedures and precise selection of valve prostheses. The objective of this study was to compare long term results after aortic annular enlargement with those after operation using a small valve prosthesis.Since 1980, 45 patients with small aortic annulus underwent operation at our institution. There were six men and 39 women, and their ages ranged from 16 to 69 with a mean of 45.6 years. Of these patients, 28 underwent aortic annular enlargements (Nicks' procedure in 13, Manouguian's in 12 and apico-aortic bypass in three patients) and 17 patients received standard aortic valve replacement with a small valve prosthesis (19 mm Standard St. Jude Medical). Mean follow up was 8.6 years in the enlargement group and 4.9 years in the standard group.Early mortality was 3.6% (1/28) in the enlargement group and 5.9% (1/17) in the standard group (NS). The 10-year actuarial survival including all deaths was 85.7% in the enlargement group and 62.7% in the standard group (p0.10). The rate of freedom from reoperation at 10 years was 90.7% in the enlargement group and 93.8% in the standard group (NS). The 10-year freedom from all valve-related events was 81.0% in the enlargement group and 58.8% in the standard group (p0.05).The above results suggest that long term mortality and morbidity after aortic annular enlargement might be superior to those after standard AVR with a small valve prosthesis.

Records from 99 patients who received the Delrin-disk model (Group D) of the Björk-Shiley (BS) prosthesis between December, 1971 and November, 1974 were reviewed and compared to those from 248 patients who received the Spherical-disk model BS between January, 1975 and June, 1981 (Group S). Complete follow-up was obtained in 98.8% of the patients. The follow-up was over 1302.3 patient-years (mean 13.2 years per patient) in Group D and 2967.5 patient-years (mean 12.0 years per patient) in Group S. Early mortality was not significantly different (Group D: 18.2%, Group S: 10.5%). Of 15 late deaths in Group D, 12 (60%) were valve related and of 58 late deaths in Group S, 34 (58.6%) were valve related. The survival proportion based on Kaplan-Meier analysis, and which included early deaths, was equivalent in both groups (Group D: 65.7% at 21 years, Group S: 64.8% at 18 years). The freedom from reoperation was 74.3% at 21 years for Group D and 95% at 18 years for Group S (p0.005). The incidence of prosthetic valve dysfunction in Group D was significantly higher than that in Group S during 15 years after insertion of the valve. The freedoms from thromboembolism and valve-related events were not significant in both groups. Gross examination of the explanted Delrin disk found wear indentations and excessive clearance between the disk and the prosthetic ring. Therefore, disk wear was the primary cause of prosthetic valve dysfunction for the Delrin model. These results suggest that patients with the Delrin-disk model of the Björk-Shiley prosthesis should receive close follow-up for structural integrity of the valve. Further, reoperation might be needed due to significant valve dysfunction in this group of patients.

From July 1989 to March 1995, 83 patients (79 men, 4 women, mean age 58.3 years, range 35 to 76 years) underwent coronary artery bypass grafting with the both internal thoracic arteries (ITAs) and the right gastroepiploic artery (RGEA). Postoperative follow-up ranged from one to 69 months with a mean of 31 months. Seventy-eight patients (94%) had either triple vessel disease or left main disease. A total of 264 distal anastomoses with arterial grafts were constructed; 90 with the left ITA, 73 with the right ITA, 90 with the RGEA and 1 with the inferior epigastric artery (IEA). An additional saphenous vein graft was constructed in 13 patients including 4 sequential bypass grafting. The mean number of distal anastomoses was 3.4. Postoperative angiography was performed in 80 patients (96%) 3 to 4 weeks after the operation. There were no operative deaths or hospital deaths. No patients developed perioperative myocardial infarction. Graft patency in arterial grafts was 96% (242/253), 95% (80/84) in the left ITA, 100% (82/82) in the right ITA and IEA (1/1), and 93% (80/86) in the RGEA. Graft patency in vein grafts was 99% (84/85) and overall patency rate was 96% (326/338). Four patients (5%) died during follow-up period but all were non-cardiac deaths. Six postoperative percutaneous transluminal coronary angioplasties (PTCA) (7%) and two reoperations (re-CABG) (2%) were required, but no patients developed myocardial infarction (MI). The 5-year actuarial survival rate and cardiac event (cardiac death, MI, PTCA, and re-CABG) free rate was 90.1% and 86.6% respectively. In conclusion, the clinical outcome of the coronary artery bypass grafting with the both ITAs and RGEA was satisfactory in terms of low operative risk, high patency rate, and excellent long-term results.

The objective of this article is to describe the epidemiologic pictures of Kawasaki disease(KD) in Japan during the 2-year period of 1993 and 1994 based on the data obtained by the thirteenth nationwide epidemiologic survey of KD which was conducted by the Japan Kawasaki Disease Research Committee.A survey form and diagnostic criteria of KD were sent to all hospital pediatric departments (2,640) throughout Japan with 100 or more beds. The patients to be reported in this surveys were all the incident KD cases who satisfied the diagnostic criteria.(1) A total of 1,730 (65.5%) hospitals responded, reporting 11,458(5,389 in 1993 and 6,069 in 1994; 6,729 males and 4,729 females; male/female ratio = 1.42) with an incidence rate of 95.1 per 100,000 children of age5 years. (2) The monthly number of patients was higher in winter and summer, although the monthly difference was not marked. (3) Age specific incidence rates showed a uni-modal peak at one year of age. (4) The proportion of patients with family history of KD in sibling was 1%. (5) The proportion of recurrent patients was 3%. (6) The proportion of patients with cardiac sequelae in one month after disease onset was 13%. (7) Number of fatal patients reported was 9, which conforms to 0.08% of total patients.

From March 1993 to February 1993, 36 patients with chronic renal failure underwent cardiac surgery with intraoperative hemodialysis (HD). We examined and compared the medium term results of those patients cased upon the time periods of operation and types of heart disease. With respect to the time periods of operation, the 1st term (n = 12) was between March 1985 and February 1989, and the 2nd term (n = 24) was between March 1989 and February 1993. Concerning types of disease, Group A was comprised of 24 patients with ischemic heart disease, and Group B was comprised of 12 patients with valvular or congenital heart disease. Only one early death was observed in the 1st term (8.3%: LOS). As for late death, 5 cases were observed in the 1st term (45.3%), and 2 cases were observed in the 2nd term (8.3%). The actuarial survival rate (post 3 years) was 72.7% in the 1st term and 91.3% in the 2nd term. In each case, the survival rate of the 2nd term was significantly better than the that of the 1st term (p0.025). When compared cased upon the types of disease, the actuarial survival rate (post 6 years) was 84.6% in Group A, and 45.5% in Group B, respectively. This difference was statistically significant (p0.05). Causes of late death were cerebral hemorrhage in 5 cases, sudden and unknown in one and DIC in the remaining one patient. There were many postoperative complications in this series in addition to the above stated fatal ones. The majority of them, however, were successfully treated, if early diagnosis of them was obtained. During the perioperative period through the long-term period, incidents of fatal hemorrhage among patients on chronic dialysis were reduced by 1) strict management of hypertension; 2) HD without use of Heparin; and 3) with respect to patients who required Warfarin after valve replacement, through the careful anti-coagulant therapy which maintained the thrombo-test (TT) value at precise levels.

A 24-year-old woman with manifestations of Turner's syndrome was referred for detail examinations and treatment of right subclavian tumor on chest X-ray. She was short and obese (147 cm tall and weigh 65 kg). And she had hypertension at upper extremities (160/100 mmHg). Chest enhanced CT revealed right subclavian arterial aneurysm and coarctation of aorta. Aortography showed interrupted descending thoracic aorta with short atretic segment followed by distal descending aorta, aneurysmal collateral artery from right subclavian artery to abdominal aorta and other small collateral arteries. Left lateral thoracotomy was thought to have a high risk for bleeding in the short and obese patient with ample collateral arteries. Therefore, extra anatomical bypass grafting from ascending aorta to abdominal aorta was performed through median sternotomy and laparotomy. After operation recovery was uneventful without residual hypertension. In this report, we discuss about the operation of adult coarctation of aorta and usefulness of extraanatomical bypass grafting.

A 69-year-old woman with combined valvular heart disease (mitral regurgitation and aortic regurgitation), ascending aortic aneurysm, and atrial fibrillation underwent double valve replacement (DVR) and, ascending aortic wall plication. The postoperative thrombo-test level was around 20%. The ST elevation on ECG (II, III, aVFm, V4 approximately V6) with chest pain were recognized on the 13 th postoperative day. She was diagnosed as having acute myocardial infarction, and percutaneous transluminal coronary recanalization was performed immediately. The coronary angiogram showed occlusion at the left anterior descending branch (#8). This lesion could be recanalized by 6,000 U plasminogen pro activator (pro-UK) administration. The cineangiogram on the 35th postoperative day, revealed complete recanalization of this occlusion. Several cases of acute myocardial infarction associated with valvular heart diseases has been reported previously in Japan. However, there has been no report, except for this case, demonstrating occlusion in the coronary artery after prosthetic replacement and successful PTCR. So, this case is the first report on that point.

Between 1977 and June 1996, 183 patients underwent operation for infective endocarditis (IE) at our institution. Long-term mortality and morbidity were analyzed according to the STS/AATS guidelines (1988). Operative mortality including hospital deaths was 4.9% in all patients. Actuarial survival (including all deaths) at 10 postoperative years was 79.6% after AVR (n = 91), 87.9% after MVR (n = 40) and 90.0% after DVR (n = 46). There was no significant difference among 3 groups. Reoperation free and freedom from all valve-related mortality and morbidity at 10 years were 94.0% and 70.4% after AVR, 90.9% and 83.7% after MVR and 93.4% and 79.7% after DVR, respectively. And the differences among 3 groups were not significant in both freedom proportions. Overall results in this series of patients were acceptable. However, several patients with active IE and extensive perivalvular abscess were not saved even if translocation method and/or other advanced surgical procedures were applied. Introduction of aortic valve homografts might be a key factor for successful treatment for patients with extensive IE lesion.

A new supportive method of centrifugal left heart bypass with oxygenation was performed in 25 patients and compared with standard left heart bypass in 45 patients. Femoro-femoral bypass was selected in another 6 patients because of the presence of a left atrial adhesion. Intraoperative complications related to standard left heart bypass, hypoxia, hypothermia, and ventricular fibrillation, were eliminated by using this method. This supportive method maintained good hemodynamics and improved the surgical result of extended thoracoabdominal aortic replacement. Hospital deaths decreased from 6.7% to 3.2%.

St. Jude Medical Hemodynamic plus bileaflet valve prosthesis (HP) was employed in 7 cases undergoing aortic valve replacement since December 1993. Echocardiographic evaluation of left ventricular dimension and transvalvular pressure gradient was performed in 5 cases with 19 HP before and after operation. Each data was compared with those of 21 cases having undergone aortic valve replacement with 19 mm Standard model (19 SD). There was no significant postoperative change in left ventricular end-diastolic dimension (50 +/- 4 mm to 44 +/- 8 mm; p = NS) and left ventricular end-systolic dimension (34 +/- 4 mm to 34 +/- 9 mm; p = NS) in 19 HP cases. However, left ventricular end-diastolic dimension (51 +/- 11 mm to 41 +/- 8 mm; p0.05) and left ventricular end-systolic dimension (35 +/- 12 mm to 28 +/- 9 mm; p0.05) decreased in 19 SD cases. Transvalvular systolic peak pressure gradient was reduced significantly in both groups (19 HP: 94 +/- 38 mmHg to 43 +/- 19 mmHg; p0.05, 19 SD: 73 +/- 49 mmHg to 33 +/- 14 mmHg; p0.05). Poor reduction of left ventricular volume and high residual systolic pressure gradient in patients with 19 HP might be due to relatively high incidence of stenotic lesion in original aortic valve disease. In some cases with these critical aortic stenosis, radical annular enlargement procedure would provide more fundamental release of left ventricular outflow tract stenosis rather than one size increase of effective orifice area by employing HPs. Structural examination demonstrated that 19 HP had the same outer diameter of sewing flange with identical orifice ring as 21 SD (24 mm) did, and 17 HP had that of 19 SD (22 mm). Therefore, precise attention is needed for application of SJM-19 HP in patients with small aortic annuli.

From June 1970 to Aug. 1995. We were experienced 2,235 coronary surgical patients at the Heart Institute of Japan. Among them, the ischemic cardiomyopathy (ICM) was defined as the elective, isolated CABG with the EF of less than 20%. Among the 1,640 cases of elective, isolated CABG, the cases with the EF of less than 20% were 29, 1.8% of the total. The hospital mortality was 2 cases (6.9%). The late mortality was 2 cases. The graft patency rate was 96.6%. An actuarial survival rates at 1 year, 3 years and 5 years were 93%, 93 and 87%. Operative mortality and 5-year survival rate of CABG for ICM are acceptable, and appear comparable to that achieved in similar patients after transplantation.

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.

Between January, 1985, and December, 1993, 20 patients (18 males, 2 females; median age 65 years) underwent repair of aneurysms of the distal arch. fourteen patients had sacciform aneurysms and 6 patients had fusiform aneurysms. The approaching methods to the aneurysms were left thoracotomy in 3 patients and median sternotomy in 17 patients, including the so-called "door open method" in 2 patients. The supportive methods during surgery were left heart bypass using a centrifugal pump in 3 patients cardiopulmonary bypass with selective cerebral perfusion in 11 patients, and cardiopulmonary bypass with retrograde cerebral perfusion in 6 patients. The operative methods were patch closure in 4 patients, graft replacement using the inclusion technique in 13 patients, and total arch replacement using the exclusion technique in 3 patients. One patient who underwent left heart bypass died intraoperatively from intractable bleeding, one who had undergone selective cerebral perfusion died postoperatively of rupture of the distal anastomosis and two patients, who were supported with retrograde cerebral perfusion, died postoperatively because of perioperative myocardial infarction or rupture of the dissection arising from the aneurysm. There were three cases with cerebral complications postoperatively. These three patients were supported with selective cerebral perfusion. Graft exclusion technique using a prosthetic graft with three branches under the retrograde cerebral perfusion shortened cardiopulmonary bypass time and heart and brain ischemic time, so that this technique might reduce cerebral complications and should be a promising surgical treatment for the distal arch aneurysm.

Increases in pancreatic enzyme levels after cardiovascular surgery were studied, and their clinical characteristics evaluated. The subjects were 128 patients who had undergone cardiovascular surgery (65 patients after valve replacement, 32 after coronary bypass surgery and 31 after aortic artificial graft replacement). The pancreatic enzyme (serum amylase and lypase) levels were monitored serially before and after operation, and amylase fractions were measured at their peaks. The relationships of the peak lypase level with underlying cardiac diseases, background factors, factors related to surgery, factors related to the extracorporeal circulation, presence or absence of symptoms, and treatments were examined. The amylase level exhibited biphasic changes consisting of a peak in which salivary glands amylase (S type) was dominant and a peak in which pancreatic amylase (P type) was dominant. The second peak coincided with the peak lypase and occurred mostly 3 to 10 days after operation. The peak lypase level exceeded the normal range in 78% of all the patients. It exceeded 564 U/l, 4 times the normal value in 28% of the patients, many of whom were symptomatic. So, we recommended that these cases should be treated as "postoperative pancreatitis". A high peak lypase level showed a significant correlation with the history of gallbladder and pancreatic diseases and diabetes mellitus among the background factors and emergency operation and the use of IABP among the surgery-related factors.(ABSTRACT TRUNCATED AT 250 WORDS)

From March 1973 to December 1994, 8 patients (2 males and 6 females) aged 34.4 +/- 7.8 years, underwent composite graft replacement (CGR) for aortitis syndrome combined with annuloaortic ectasia (AAE) in our institute. Five patients showed active aortitis syndrome and steroid therapy was administrated to 2 of them. The mean value of the C-reactive protein (CRP) was 1.6 +/- 1.8 before the operation. The maximum diameter of the ascending aorta was 67.1 +/- 10.3 mm (range 53 to 85 mm). Stenosis and/or ectasia of the neck vessels were recognized in 5 cases, as well as the coronary artery in 2 cases. Isolated CGR was performed in 6 cases, and combined with single CABG to LAD in 1 case and with total arch replacement in 1 case. The enlarged ascending aorta was replaced with main graft using the exclusion method and interposed grafts for coronary arteries were sutured with pledgetted mattress sutures all around the coronary ostia. In patients with stenosis of neck vessels, oxygen saturation of the jugular vein was monitored during extracorporeal circulation for surveillance of cerebral ischemia. There was 1 early death due to pulmonary failure. Seven cases survived without any complications during 4-132 months (mean 83.4 months) of the follow-up period. After the operation, 3 cases required steroid therapy during 4-50 months. We concluded that preoperative control of active inflammation, selection of operative procedures, timing for the operation, and the long-term precise management of the intractable disease were essential for successful treatment of aortitis syndrome with AAE.

A 62-year-old woman was admitted with malfunction of the Hancock valve in mitral position. She had been suffering from gastroduodenal ulcer for about ten years. She couldn't take warfarin after 5 years later of the initial operation due to recurrent gastrointestinal bleeding. Judging from her age and renal dysfunction, we preferred mechanical valve to avoid the risks for the reoperation. After confirming the healed ulcer with administering omeprazole, we performed prosthetic valve replacement with SJM 29 M successfully. Postoperative course was uneventful and recurrence of the ulcer was not observed.

Thirteen patients with severe aortic stenosis and left ventricular dysfunction (ejection fraction0.50, Group A) received echocardiographic evaluation before, and early and late after isolated aortic valve replacement. The results were compared with those of 11 aortic stenosis patients without left ventricular dysfunction (Group B). Using two-dimensional echocardiography, left ventricular diastolic internal diameter (LVIDd), left ventricular systolic internal diameter (LVIDs), left ventricular wall thickness (interventricular septum + posterior wall: LVWT), left ventricular fractional shortening (FS), left ventricular mass index (LVMI) and left ventricular end-systolic wall stress (ESWS) were assessed before (Pre), at one month (Early) and 4-7.6 (mean 5.5 +/- 1.0) years (Late) after operation. In the early postoperative period in Group A, significant decrease was observed in LVIDd (5.4 +/- 0.8 to 4.5 +/- 1.0 cm, p = 0.010), LVWT (3.3 +/- 0.7 to 2.9 +/- 0.7 cm, p = 0.027) and LVMI (336 +/- 149 to 222 +/- 112 g/M2, p = 0.013). From the early to late postoperative period FS showed significant improvement in both groups (0.23 +/- 0.12 to 0.32 +/- 0.12 in Group A, p = 0.025 and 0.27 +/- 0.07 to 0.36 +/- 0.07, p = 0.014). However, changes of other parameters were not significant and LVMI in Group A remained twice as high as the normal value. It is concluded from the above results, that LV contraction in aortic stenosis patients with preoperative left ventricular dysfunction improved during the late postoperative period. Although LVMI in the early postoperative period significantly decreased as compared with the preoperative value, it showed no further improvement and remained at an abnormally high level. Therefore, early surgical treatment of severe aortic stenosis before appearance of LV dysfunction should be recommended for postoperative recovery from LV hypertrophy.