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Treatment of cardiac failure due to non-ischemic cardiomyopathy by left ventriculoplasty using partial left ventriculectomy (Batista operation) or septal anterior ventricular exclusion was evaluated.Left ventriculoplasty was performed in 70 patients (59 men and 11 women with a mean age of 51 years) from December 1996 to June 2000. Preoperative New York Heart Association (NYHA) functional class was IV in 43 patients including 29 receiving inotropic support, and class III in 27 patients. Nineteen patients required emergency surgery because of on-going shock and 51 patients were operated electively. Combined cardiac procedures were mitral valve reconstruction in 62 patients (45 replacements, 17 repairs), tricuspid annuloplasty in 37, and aortic valve replacement in 4. The initial 24 patients underwent typical Batista operation regardless of myocardial viability. The other 46 patients underwent selective ventriculoplasty to excise or exclude the weakest part according to the findings of the intraoperative echo-guided volume reduction test.The intraaortic balloon pump was used in 12 patients and the left ventricular assist device in 2 patients. Three (5.9%) of the 51 patients who underwent elective operation and 12 (63.2%) of the 19 patients with emergency operation died in the hospital, giving an overall hospital mortality of 21.4% (15/70). Hospital mortality was reduced from 33.3% (8/24) in the initial 24 patients to 15.2% (7/46) in the recent 46 patients with the volume reduction test. Mean ejection fraction increased from 22.2 +/- 6.7% to 29.6 +/- 6.0%. Diastolic dimension decreased from 81.1 +/- 9.5 to 69.8 +/- 19.2 mm. End-diastolic and systolic volume indices decreased from 199.0 +/- 47.9 to 124.1 +/- 34.9 ml/m2 and from 154.0 +/- 41.2 to 89.3 +/- 31.7 ml/m2, respectively, at one postoperative month in the 55 hospital survivors. The mean pulmonary capillary wedge pressure decreased from 25.6 +/- 7.8 to 13.6 +/- 4.5 mmHg. Serum brain natriuretic peptide decreased from 999 +/- 647 preoperatively to 547 +/- 362 pg/ml one month after the operation. Thirteen patients (18.6%) died in the late period mainly due to heart failure. Among the 42 survivors, 37 patients returned to NYHA functional class I-II, and cardiac events were rare after one postoperative year. Actuarial survivals at 3 years in elective and emergency operations were 71.9% and 33.3%, respectively.Left ventriculoplasty is acceptably safe for elective operation and clinical improvement can be obtained by proper surgical procedures and careful postoperative medical treatment.

To evaluate the efficacy of off pump coronary artery bypass grafting (CABG), results in the initial consecutive 200 patients were reviewed.Between October 1996 and December 1999, 200 patients underwent CABG without cardiopulmonary bypass. There were 146 men and 54 women aged from 27 to 89 years (mean 68 years). Single, double, triple and left main disease were noted in 94, 55, 33 and 18 patients, respectively, with a mean ejection fraction of 51%. Preoperative complications were previous stroke in 34 patients, chronic renal failure in 22 patients, previous CABG in 18 patients, and aortoiliac aneurysm or occlusive disease in 14 patients. Fifty-five patients (28%) were 75 years or older. Surgical approach was made through a midsternal incision including lower half small sternotomy in 105 patients, left anterior small thoracotomy in 92 and small epigastric incision (gastroepiploic-right coronary anastomosis) in 3. Mean number of distal anastomoses was 1.3 (range 1-4). Anastomosis was performed in 189 left anterior descending, 13 diagonal, 27 circumflex and 41 right coronary arteries. The conduits were 174 internal thoracic, 10 internal thoracic-inferior epigastric composite, 22 right gastroepiploic and 5 radial arteries, and 50 saphenous vein grafts. Four patients underwent combined off pump CABG and transmyocardial laser revascularization, and 36 patients underwent hybrid (off pump CABG and angioplasty) revascularization.Four patients (2.0%) died in the hospital due to intestinal necrosis in 2 patients, postoperative aortic dissection in one, and multiorgan failure with stroke in one. No serious ventricular tachyarrhythmia or use of intraaortic balloon pump occurred. Perioperative myocardial infarction was noted in one patient. Stroke occurred in 4 patients (2.0%) but 3 patients recovered in a short period. Three-year survival and cardiac event free rate were 90.3% and 81.1% by the Kaplan-Meier method. Postoperative angiographic study showed excellent patent graft in 92% of grafts (192/209), stenosed (or = 50%) graft in 5% (10/209) and occlusion in 3% (7/209).Off pump CABG can be performed safely and effectively in both high risk and low risk patients with coronary artery disease. Refinement of surgical technique and equipment will make this procedure more useful.

Between January 1997 and November 1999, 31 patients underwent combined valve and coronary artery bypass grafting (CABG) surgery in our institute. There was no hospital death and clinical symptom improved in all patients after surgery. Mean follow-up was 16.3 months. The actuarial survival rate was 96.8% at 1 year. There were 4 late deaths (CHF in 3, arrhythmia in 1). Tepid blood cardioplegia was effective for those operations. Operation of CABG combined with valve surgery or LV surgery could be safely performed. We therefore considered that complete correction of the lesion with not only CABG but also combined valve surgery or LV surgery was the procedures of choice in patients with complicated lesions.

Among the patients with idiopathic cardiomyopathy, those with dilated cardiomyopathy were surgically treated. Initial 18 patients were treated with partial left ventriculectomy(PLV) and thereafter PLV in 26 patients, septal exclusion technique (EVCPP) in 5 patients, or solo-valvular surgery in 12 patients were applied according to the findings of the intraoperative cardiac echogram. The postoperative morbidity and mortality decreased after the selection of the operative procedures. Conclusively, left ventriculoplasty with PLV or EVCPP is a hope for the patients with dilated cardiomyopathy.

The purpose of the study is to assess the clinical and hemodynamic performance of aortic valve replacement (AVR) with the Freestyle bioprosthesis.Twenty-one patients received AVR with a Freestyle aortic root bio-prosthesis between May 1998 and October 1999. Eighteen patients underwent AVR with subcoronary method and three patients with aortic root (full root) method. Patients were evaluated postoperatively at discharge by clinical examination and color Doppler echocardiography.There was one death due to multi-organ failure. No patients experienced valve deterioration, paravalvular leak, unacceptable hemodynamic performance, nor thromboembolic event. Excellent function is demonstrated by very low gradient (mean gradient 7.2 +/- 4.7 mmHg) through aortic valve and no significant aortic regurgitation (none: 11, trivial/mild: 10). All patients had been in New York Heart Association Functional Class III and IV preoperatively, and after surgery, 17 patients were in Class I, and 3 were in Class II.The Freestyle bioprosthesis has good clinical and hemodynamic performance without Coumadin. Further follow-up is required to evaluated valve durability.

A 38-year-old man underwent the Batista operation to treat end-stage dilated cardiomyopathy. There was no associated mitral regurgitation, so only partial left ventriculectomy was performed. The patient recovered successfully. His New York Heart Association (NYHA) class improved from IV to I, ejection fraction increased from 8% to 37% and left ventricular diastolic dimension decreased from 89 to 68 mm. Cardiac output and stroke volume increased from 3.8 to 6.7 l/min and from 52 to 85 ml/min, respectively. This case shows the isolated positive effect of partial left ventriculectomy without mitral valve reconstruction.

The Batista operation was performed in 30 patients (25 men and 5 women, mean age 47 years) to treat cardiac failure due to non-ischemic cardiomyopathy, mostly idiopathic dilated cardiomyopathy, from December 1996 to June 1998. Preoperative New York Heart Association (NYHA) class was IV in 21 patients including 17 receiving inotropic support, and class III in 9 patients. Seven patients required emergency surgery because of on-going shock and 23 patients were operated electively. Combined cardiac procedures were; mitral valve reconstruction in 26 patients (19 replacements, 7 repairs), tricuspid annuloplasty in 15, aortic valve replacement in 3 and one each of maze and coronary artery bypass grafting. All patients successfully weaned from cardiopulmonary bypass. Intraaortic balloon pump was used in 6 patients but no left ventricular assist device was used. Two of 23 patients (8.7%) who underwent elective operation died during hospitalization and 3 patients (13.0%) died in the late period. Six of 7 patients (85.7%) with emergency operation died in the hospital and only one survived. Sixteen of 19 survivors returned to NYHA class I-II, and 3 were in class III. Mean ejection fraction increased from 18 +/- 6% to 31 +/- 5%. Diastolic dimension decreased from 79 +/- 8 to 60 +/- 8 mm. End-diastolic and systolic volume indices decreased from 203 +/- 43 to 103 +/- 25 ml/m2 and from 164 +/- 39 to 70 +/- 25 ml/m2, respectively, at the second postoperative week. Six patients had ventriculography at one year after the operation, and no redilation was noted. Increased thickness of left ventricular wall was observed postoperatively. The Batista operation can be performed with relatively low risk and clinical improvement was obvious in elective operation, wheras risk is very high in emergency cases. Therefore, proper guidelines for patient selection and choice of procedure are critically important to achieve a successful outcome in the Batista operation.

Endoventricular circular patch plasty (Dor operation) was used to treat end-stage dilated ischemic cardiomyopathy in 13 patients from January to December, 1997. There were 10 men and three women aged from 57 to 78 years (mean 63 years). Single, double, triple and left main trunk coronary disease was present in one, two, eight and two patients, respectively. Mean ejection fraction was 22% (6-30%) and signs of congestive heart failure were clear in all patients [New York Heart Association (NYHA) class III in eight patients and class IV in five patients]. Angina pectoris was present in five patients. Six patients had associated significant mitral regurgitation. Coronary artery bypass grafting (mean 3.2 grafts) was used in 11 patients and mitral valve reconstruction was performed in 6 patients (4: replacement and 2: repair) combined with akinetic area exclusion by the Dor technique. All patients were successfully weaned from cardiopulmonary bypass without mechanical support and no perioperative death occurred. Three patients died in hospital at 1-2 postoperative months due to pneumonia, stroke and heart failure, respectively. Two patients died during the late period due to stroke and sudden death. Among the eight survivors, six patients were in NYHA class I-II and two patients in class III. Ejection fraction increased from 22% to 36%, end-diastolic and systolic volume indices decreased from 168 +/- 58 to 123 +/- 39 ml/m2 and from 131 +/- 60 to 81 +/- 33 ml/m2, respectively. Pulmonary capillary wedge pressure decreased from 19 +/- 10 to 14 +/- 5 mmHg. The Dor procedure is an effective surgical alternative for patients with end-stage ischemic cardiomyopathy who are considered to be candidates for cardiac transplantation.

The Batista operation is intended to improve cardiac function by reducing the diameter of the left ventricle by excising of a sizable amount of the left ventricular free wall. Candidates for this operation are patients awaiting cardiac transplantation due to end-stage dilated cardiomyopathy and those unsuitable for transplantation because of age, physical or economical reasons. We performed this operation in 10 patients between December 1996 and October 1997. The baseline indication is left ventricular diastolic dimensionor = 70 mm and New York Heart Association (NYHA) class III or IV. There were eight men and two women aged from 16 to 60 years (mean 46 years). All had non-ischemic cardiomyopathy including seven idiopathic and one each of hypertrophic, arrhythmogenic right ventricular and valvular (sarcoidosis) cardiomyopathy. Eight patients were in NYHA class IV and six needed inotropic drip therapy prior to the operation. Nine patients had significant mitral regurgitation and six had tricuspid insufficiency concomitantly. Eight patients underwent mitral valve replacement and one was treated with mitral valve plasty. Six patients also had tricuspid plasty combined with partial left ventriculectomy. Eight patients survived. Mean value of left ventricular end-diastolic diameter was reduced from 77.8 mm to 59.8 mm, left ventricular end-diastolic volume index was reduced from 189.3 to 99.2 ml/m2, ejection fraction was increased from 19.0% to 33.8% and NYHA class improved from 3.8 to 1.8. Six months later, left ventricular dilatation was not noticed in four patients examined. The Batista operation offers real hope for patients with end-stage dilated cardiomyopathy, but we still have much to learn.

A 53-year-old man with dilated cardiomyopathy underwent left ventriculoplasty (Batista procedure), a new surgical procedure, which reduces ventricular volume to improve left ventricular function. Left ventricular ejection fraction increased from 19.7% to 43.7%. Unfortunately, he died of pneumonia 12 days after surgery. This is the first such procedure in a human in Japan.

To treat end-stage dilated cardiomyopathy, we have performed volume reduction left ventriculoplasty (as introduced by Randas Batista in Brazil) in four patients since December 1996. All patients had end-stage idiopathic cardiomyopathy. Mitral valve replacement was also performed in three patients. In all four patients, improvement of left ventricular function was noted. One patient died of respiratory failure on the 12th postoperative day. The other three patients recovered successfully from the operation (i.e., they were discharged from hospital with the functional status in New York Heart Association Class I or II). We conclude that the Batista operation provides a real hope for patients with end-stage dilated cardiomyopathy.

In redo coronary artery bypass grafting a left anterior thoracotomy can be used, if necessary, to avoid a dangerous repeat median sternotomy. In 2 patients with a well-functioning left internal mammary artery graft to a left anterior descending artery attached to the sternum, a radial artery was used with the left subclavian artery as the blood source. This technique can be used successfully in selected cases when a left thoracotomy is advisable and an arterial graft is preferred to a saphenous vein.

We describe a case of coronary stenting in which accidental detachment of the Palmaz-Schatz stent induced thrombotic occlusion of the coronary artery. This case suggests that careful consideration of the risk involving coronary occlusion is mandatory on deciding the therapeutic strategy of the cases in which the unexpanded coronary stent cannot be retrieved following successful deployment.

The authors describe a case with an internal mammary artery (IMA) graft that demonstrated prolonged, but reversible, luminal narrowing persistingtwenty-four hours following percutaneous transluminal angioplasty. Luminal narrowing disappeared spontaneously, however, at the time of follow-up angiography one week after the angioplasty. Since haziness at the dilation site had been shown on preprocedural angiogram, suggestive of intraluminal thrombus, this phenomenon may be attributed to either prolonged vasospasm or distal embolization of the IMA graft.

With increased use of catheter intervention, candidates for coronary artery bypass grafting (CABG) have become more severely diseased. In the past 4 years with normothermic cardiopulmonary bypass technique, operative mortality was 1.5% (0.7% for elective and 5.6% for emergency) in 690 primary CABGs. The internal thoracic artery graft was used in 94% of the patients and the patency rate was 98%. The gastroepiploic artery was used in 565 patients since 1986 with 2.3% operative mortality and the patency rate was 96% in early and 92% in mid-term angiography. The inferior epigastric artery was used in 48 patients with 2% operative mortality and 90% patency rate. The radial artery was used in 105 patients with 0.9% operative mortality and patency rate was 88% at 1 postoperative year. Surgical result and angiographic patency of the graft are acceptably good while candidates of CABG have become more severely diseased. With use of arterial conduits, better long term outcome can be expected.

To identify predictors of arterial graft patency, we followed up 30 internal thoracic arterial grafts and 23 right gastroepiploic arterial grafts in situ with patency documented during postoperative angiography. After 24 months of follow-up on average, repeat angiography detected that one internal thoracic artery and two gastroepiploic arteries were anatomically occluded and that the other three gastroepiploic arteries were nonfunctioning. The logistic regression model identified a relationship between graft patency and competitive flow, which was detected as stenosis in the recipient coronary arteries (coefficients, p0.05; model, Hosmer-Lemeshow chi2 statistic 3.59, p = 0.89). The linear regression model demonstrated that changes in graft luminal diameter correlated with competitive flow (p0.01), smoking history (p0.05), and type of arterial grafts (p0.001) (R2 = 0.40, adjusted R2 = 0.36). The findings suggest a temporal relationship between competitive flow and prognosis of arterial graft.

In 10 years' experience with the right gastroepiploic artery graft for myocardial revascularization, excellent clinical and angiographic mid-term results have been reported. From our experience in 518 patients who underwent CABG with a gastroepiploic artery graft since 1986, early and late mortality rates were 2.3% and 1.0%, respectively. Early and mid-term (2 to 5 years) angiographic patency rates were 96% and 92%, respectively, in the in situ gastroepiploic artery grafts. The gastroepiploic artery is the second best arterial conduit next to the internal thoracic artery at present, and is most useful at reoperation or for patients with atherosclerotic ascending aorta. With proper basic knowledge and surgical technique, the gastroepiploic artery can be used without increasing surgical mortality and morbidity, and good long-term patency can be expected.

From January 1992 through December 1993, 31 patients underwent myocardial revascularization with the inferior epigastric artery (IEA) graft. There were one emergency case and four coronary reoperation cases. IEA grafts were taken down through the left side paramedian incision and dilated with papaverine hydrochloride solution. The distal anastomoses were made to left anterior descending (3 cases), diagonal (14 cases), obtuse marginal (9 cases), postero-lateral (I case) and right coronary artery (4 cases). The proximal anastomoses were made to the aorta (22 cases), the hood of a new vein graft (4 cases) and the hood of an old vein graft (4 cases). When IEA was not long enough to reach the ascending aorta, it was anastomosed to the internal thoracic artery (2 cases) or the gastroepiploic artery (1 case) graft. There was one hospital death, and early patency rate (within one month) was 90% (19/21). The postoperative angiography performed at 1.3 years or 2 years showed excellent IEA graft patency. These results suggested that the IEA is suitable as a coronary artery bypass graft. Further long-term patency must be evaluated.

We experienced reoperative coronary revascularization through a left thoracotomy in 12 patients between June 1992 and June 1994. All patients underwent grafting to the left coronary system except one, who underwent bypass procedure to the atrioventricular branch of the right coronary artery in addition to grafting to the left anterior descending artery, using the pedicled left internal thoracic artery, the gastroepiploic artery as a free graft, or a reversed saphenous vein graft. In one patient, revascularization was accomplished during temporary occlusion of the coronary artery without cardiopulmonary bypass. On the other hand, in 11 patients, cardiopulmonary bypass was used. Coronary bypass procedure was employed under the ventricular fibrillation with hypothermia in those but one, who underwent revascularization under the beating heart with cardiopulmonary support. All patients were hemodynamically stable in postoperative stage, and artificial ventilation time was not prolonged, with a mean time of 15.7 hours. Postoperative morbidity included reexploration for hemorrhage in one patient, convulsion in one, worsening of hemianopsia in one, ventricular arrhythmia in one, and wound complication in one, however, there were no hospital deaths. All patients underwent repeat coronary angiography, which revealed that all grafts were widely patient except one, which had inadequate flow due to diffuse narrowing. Based on these clinical results, we conclude that a left thoracotomy is a useful approach for reoperative coronary bypass procedures to reduce the surgical risk associated with a sternal reentry in properly selected patients.

We report a case of successful reoperation of coronary revascularization without cardiopulmonary bypass. The patient was a 62-year-old man, who had undergone coronary artery bypass grafting (CABG) to the LAD and CX with two saphenous vein grafts (SVG) for the left main lesion 12 years before. He required reoperation for unstable angina due to progressive ischemic heart disease and the diseased SVG. Preoperative coronary angiogram revealed total occlusion of major 3 branches and the diseased SVG to the LAD. The reoperation was performed without cardiopulmonary bypass through the repeated median sternotomy for revascularization of the LAD and RCA. The left internal thoracic artery and the gastroepiploic artery were anastomosed to the LAD and RCA under the beating heart without any hemodynamic or electrocardiographic deteriorations. The operation was uneventfully finished in 3 hr 40 min. without the use of blood products. Postoperative angiogram showed both new grafts were widely patent, and he was discharged 14 days after the operation without angina. We also performed 4 other cases of reoperative CABG without cardiopulmonary bypass, and conclude that this technique is a safe and effective alternative in a carefully selected group of patients for reoperative CABG to reduce several technical problems related to coronary reoperation.

Coronary artery bypass grafting (CABG) was performed using saphenous vein grafts anastomosed in reversed Y-shaped in two patients because of the atherosclerotic ascending aorta. Postoperative course was uneventful, however, the common part of reversed Y-shaped grafts was occluded in both patients within two years after operations. The arms of reversed Y-shaped grafts were patent, and played a role of major collateral between LAD and RCA. They were treated successfully with reoperation in one patient and PTCA in another.

We report a case of 50-year-old male underwent reoperative coronary artery bypass grafting (CABG) through the left thoracotomy. He had undergone primary CABG with a saphenous vein graft to the left anterior descending coronary artery (LAD) to revascularize the left main trunk lesion a year ago, which was occluded, and recurred angina. The second operation was performed through the left thoracotomy under the the hypothermic cardiopulmonary bypass. The left internal thoracic artery was anastomosed to LAD, and a new saphenous vein was anastomosed to the descending aorta proximally, and to the left circumflex artery distally, under a hypothermic circulatory arrest (9 minutes and 8 minutes for each anastomosis). He recovered well without any major complications, and postoperative angiogram showed two new grafts patent.

Mortality, morbidity, and 3-year survival rates were evaluated in patients aged over 75 years undergoing initial revascularization by percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). The groups of 74 patients undergoing PTCA and 27 undergoing CABG had similar clinical characteristics including age, sex, emergency operation, prior myocardial infarction, and ejection fraction. The PTCA group contained significantly more patients with single vessel disease (44% vs 8%, p0.01) while the CABG group had more three-vessel or left main trunk disease (30% vs 70%, p0.01). The patients in the PTCA group demonstrated more prior cerebral vascular events, renal insufficiency, and abdominal aortic aneurysms. Angiographic revascularization was achieved in 112 of 130 lesions (86%) and in 63 of the 74 (84%) patients in the PTCA group. Hospital mortality for the PTCA group was 5.4% (two cardiac deaths and two non-cardiac deaths), but 0% for the CABG group. Myocardial infarction occurred in 1.3% and 3.7%, respectively (p = NS). Three-year survival, excluding hospital deaths, was 90% for patients with PTCA and 96% for those with CABG (p = NS). All these deaths were of non-cardiac origin. Both PTCA and CABG are safe and effective for selected patients over the age of 75 years.

Isolated stenosis of the left main coronary artery was surgically enlarged by patch angioplasty using a distal flap of the left internal mammary artery. The remaining proximal mammary artery pedicle was anastomosed to the anterior descending coronary artery as an in situ graft for security. The patient's recovery was uneventful, and postoperative angiography at 2 weeks showed good patency of both the left main trunk and the internal mammary artery graft.

59 cases of late cardiac tamponade following open heart surgery were studied. The incidence was 2.1%. Postoperative prolonged heart failure, anticoagulants, and blood in the pericardium left undrained may play a role in its pathogenesis. Echocardiography was the sure method of diagnosis. Insertion of a drainage tube into the pericardium through the subxiphoid approach was effective with minimal invasion and a treatment of choice.

While annual attrition and high break-down rate of saphenous vein graft (SVG) used for CABG has widely noted in Western countries, no sizable studies have yet available in Japan. We studied 142 SVGs of 77 pts, which we divided into two groups; 80 SVGs of 44 pts in mid-term period (5 to 8 years after surgery) and 62 SVGs of 33 pts in long-term period (9 to 17 years after surgery). The patency rate of SVGs was 69% in mid-term and 77% in long-term. Whereas these patency rates at each periods were superior to those reported from USA and European countries, a quarter of SVGs in mid-term period and a half in long-term period had significant stenotic changes (over 50%). Of patent SVGs, diseased SVGs reached 36% in mid-term period and 73% in long-term period. In conclusion, although the patency rate of SVGs in Japanese patients was higher than that of the Western countries, vein graft disease apparently occurred in a large proportion of patent SVGs.

A case report of serial repeat myocardial revascularization under the beating heart. A 56-year-old, hypertensive and hyperlipidemic male suffered from unstable angina who had undergone primary CABG with saphenous veins 10 years ago. The vein graft to the left anterior descending coronary artery (LAD) was solely patent but had a severely stenotic lesion. The stenotic LAD vein graft fed all coronary circulation. The second operation was approached through the sternal reentry but E-PTFE sheat for pericardial closure at the primary operation tightly adhered to an anterior aspect of the heart with abscess formation. So only gastroepiploic artery (GEA) could be anastomosed to the right coronary artery (RCA) under the beating heart without cardiopulmonary pump (CPB). While the postoperative angiogram showed GEA graft was patent, unstable angina recurred. Then the third operation was performed 2 weeks later through the left thoracotomy under the beating heart with CPB. A new saphenous vein was anastomosed from the descending aorta to LAD. He recovered well without any major complications. Postoperative angiogram showed two new grafts widely patent and he discharged with freedom from angina.

Hemodynamic situation immediately after cardiopulmonary bypass was studied in cases of CABG using bilateral ITAs and right GEA. Though cardiac output was kept greater than 4.0 l/min, the blood pressure soon after weaning from cardiopulmonary bypass was low in patients who necessitated further circulatory assist, intraaortic balloon pumping (IABP) and/or additional surgical bypass procedure. In cases of CABG using arterial grafts and no vein graft, the perfusion pressure is most important to stabilize the hemodynamic status because low pressure may provoke peripheral vasoconstriction resulting in spastic reaction of the ITA and GEA. These arterial grafts seemed to keep the characteristics as the peripheral artery. Some papers pointed out less flow capacity of arterial grafts compared with that of saphenous vein graft, but CABG with arterial grafts alone was safe clinically if care is taken for keeping the perfusion pressure as high as preoperatively.

From March 1986 to September 1991, the right gastroepiploic artery has been used for coronary artery bypass grafting in 200 patients (171 male and 29 female patients, mean age 58 years, range 6 to 80 years. They were followed up from 6 to 70 months with a mean of 27 months. There were 16 reoperations and 176 patients had triple vessel or left main disease. The gastroepiploic artery (182 in situ and 18 free grafts) was anastomosed to 11 anterior descending, 3 diagonal, 26 circumflex, and 160 right coronary arteries. The internal thoracic artery was concomitantly used in 192 patients. The mean number of distal anastomoses was 2.3 with arterial grafts and 3.3 including additional saphenous vein grafts. Postoperative angiography was performed in 152 patients within 6 months after the operation (mean 2 months) and after the operation second angiograms were done sequentially 1 to 5 years (mean 2 years) after the operation in 40 patients. There were 6 early and 4 late deaths. A new Q wave was noted in 4 patients. Duration of the operation and postoperative complications did not increase with the use of the gastroepiploic artery. Relief of angina was noted in 186 patients. Gastroepiploic artery graft patency was 95% (144/152) in the early postoperative period and 95% (38/40) in the late postoperative period. Percutaneous transluminal coronary angioplasty was done successfully through the in situ gastroepiploic artery graft for anastomotic stenosis in four cases. In stress myocardial scintiscans, performed sequentially preoperatively and in the immediate, 1-year, and 2-year postoperative periods in 11 patients, washout rate of the gastroepiploic artery-grafted area improved from 35% +/- 10% to 45% +/- 15% (p0.05) and was maintained to 43% +/- 6% and 48% +/- 9% at respective periods. In conclusion, the gastroepiploic artery is a suitable conduit for coronary artery bypass grafting in terms of low surgical risk, high patency rate, and excellent patient outcome.

The present study was designed to investigate physiological and pharmacological responses of the arterial graft flow measured by the directly implanted ultrasonic pulsed Doppler miniprobe after coronary artery bypass grafting (CABG).Our original 5-MHz, 5-mm-diameter, Doppler mini-flow probe catheter, which has four silicone brims in front to facilitate its fixation onto the graft without direct suture, was attached onto internal thoracic artery (ITA) and gastroepiploic artery (GEA) grafts during CABG in 10 patients. Approximately 2 weeks postoperatively, when the patient's condition was quite stable without medication, changes of flow velocity in those grafts induced by catecholamine, exercise, taking meals, and coronary vasodilating drugs were measured. Dobutamine significantly increased both ITA and GEA graft flow velocity (p0.01), whereas dopamine had no distinct positive effect. Upon the patient taking meals, the GEA graft showed an 83% increase of the flow velocity (p0.05), whereas the ITA graft showed no significant change. Walking exercise for 6 minutes increased both grafts' flow velocity up to two times that of control values (p0.01). Oral intake of coronary vasodilating drugs showed no significant effect. After the investigation was completed, the probe was removed easily at bedside without difficulty.Using this implantable Doppler miniprobe, postoperative function in the individual coronary bypass graft under various conditions was effectively investigated.

Aortic calcification was evaluated preoperatively by computed tomography (CT) in 136 of 275 candidates for coronary artery bypass surgery (age range, 30-80) years (mean 60.2 years), including 110 men and 26 women), from April 1989 to March 1991. Calcification in the mid-ascending aortic wall was detected in 20 (14.7%) cases, calcification in all regions of the aorta was more common in patients older than 60 years (22.5%, n = 71), than younger (6.2%, n = 65) (p less than 0.01). Atherosclerosis of the ascending aorta was identified intraoperatively in 25 (18.3%) cases. Practically, the specificity of CT findings was excellent (98.3%), but the sensitivity was less satisfactory (72.0%) due to the presence of atherosclerosis without calcification. In cases of arteriosclerosis of the ascending aorta, great care was taken to prevent embolism secondary to a dislodged atheromatous plaque. The "aortic no-touch technique", with in situ internal thoracic artery and right gastroepiploic artery anastomosis under ventricular fibrillation, was performed in 6 cases, a single aortic cross-clamp was applied in 19 cases, and conventional methods were employed when the ascending aorta was normal or the "no-touch" or "single-clamp" procedure could not be used (control, 111 cases). No neurologic complications occurred in the "no-touch" group, while 2 cerebral infarctions occurred in the single-clamp group (10.5%) and the control group (1.8%) respectively. These differences between groups was not significant. Patients with a calcified ascending aorta are at higher risk for neurologic complications of coronary bypass. The risk can be decreased by minimizing surgical trauma to the ascending aorta by the use of "no-touch" techniques.

We performed coronary artery bypass grafting (CABG) in a 80-year-old male with calcified ascending aorta and severe varicose veins utilizing the bilateral internal thoracic arteries and the right gastroepiploic artery under fibrillatory arrest without aortic cross-clamp (aortic no-touch technique). After triple coronary artery bypass grafting was completed, heart failure occurred. Additional Bioflow graft to the circumflex artery restored good cardiac function. The aortic no-touch technique is a useful method for CABG in patients with severe calcified ascending aorta. This experience suggests that the Bioflow graft is a helpful conduit at an urgent situation in CABG.

Between June 1983 and July 1989, 25 consecutive chronic dialysis patients with medically refractory angina pectoris underwent revascularization, either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) (21 males and 4 females, mean age of 57 +/- 10 years, and mean duration of dialysis of 3.7 +/- 5.0 years). Patients with single-vessel disease and/or mildly calcified lesions received PTCA (n = 15), while those with multi-vessel disease and/or severely calcified lesions received CABG (n = 10). As controls for PTCA-treated dialysis patients, 208 non-dialysis patients who received initial PTCA in 1988 were used. The mean number of diseased vessels was 2.7 +/- 0.7 for CABG group, and 1.5 +/- 0.8 for PTCA group (p0.01). In both groups, 80% of patients were successfully revascularized. In CABG group, however, 7 of 10 patients had major complications including 2 hospital deaths, while no complications occurred in the PTCA group. During the follow-up period after CABG (35 +/- 30 months), recurrent angina developed in one patient, who was successfully treated with PTCA. In the PTCA group, angiographic success was initially obtained in 16 of 21 lesions (76%), which was significantly lower than that in the control group (92%, p0.05). Follow-up angiography revealed restenosis in 6 of 16 lesions with successful PTCA (38%), similar to that observed in the control group (32%, p = ns). A second PTCA was successful in 5 of 6 patients with restenosis, however, 4/5 patients developed recurrent angina. Three of 4 patients with a second episode of restenosis underwent a third PTCA, and angina recurred in 2.(ABSTRACT TRUNCATED AT 250 WORDS)

A 62-year-old man with both coronary artery disease and leg ischemia was successfully treated with a combined revascularization procedure. Coronary artery bypass grafting (CABG) was carried out using in situ left internal thoracic artery and right gastroepiploic artery grafts, and bilateral femoropopliteal bypass grafting were performed reversed saphenous vein grafts simultaneously. The patient recovered well and experienced neither angina nor intermittent claudication.

The pharmacological responses of internal thoracic artery (ITA), gastroepiploic artery (GEA) and saphenous vein (SV) obtained from patients receiving coronary artery bypass grafting (CABG) were assessed by isometric contraction records. The concentration-response curves for ergonovine and serotonin showed the leftward shift in SV compared with ITA and GEA. The 50% effective dose values of SV for ergonovine and serotonin were significantly less than those of ITA and GEA. The concentration-response curves for phenylephrine were similar among three kinds of grafts. There were no significant differences in the 50% effective dose values for phenylephrine among them. The effect of 0.4% papaverine chloride on the free graft flow was assessed in 15 patients receiving CABG with mean body surface area of 1.62 +/- 0.12 M2. The free flow of ITA graft was 71 +/- 32 ml/min before intraluminal papaverine injection, and that increased to 112 +/- 41 ml/min after injection. The free flow of GEA graft was 82 +/- 39 ml/min before injection, and that also increased to 128 +/- 40 ml/min after injection. The patency rates at the mean 2.2 months after grafting were 98% in ITA, 93% in GEA, and 88% in SV. In conclusion, both GEA graft and ITA graft can be expected as an excellent conduit in myocardial revascularization.

We report two cases simultaneously operated on CABG using rt. GEA and cholecystectomy for silent gallstone detected by routine preoperative examinations. We prefer that two different procedures are performed simultaneously even if gallstone is asymptomatic, for about 50% of silent gallstone is said to become symptomatic within further five years in the literature and the pedicle of rt. GEA may be troublesome during cholecystectomy.

Bovine internal thoracic artery grafts (Bioflow) were successfully utilized in two patients for emergency coronary artery bypass grafting (CABG). One patient was an 80-year-old man with severe varicose veins and a calcified ascending aorta. Heart failure occurred after triple CABG with bilateral internal thoracic and gastroepiploic arteries. The addition of a Bioflow graft to the circumflex artery restored good cardiac function. The second case was a 54-year-old man whose patent old saphenous vein graft was accidentally injured at reoperation. Emergency use of the Bioflow to bypass the right coronary artery in combination with the right gastroepiploic artery graft to the anterior descending artery resulted in an excellent outcome. The two Bioflow grafts were patent at the 20th and 10th postoperative days, respectively. These cases strongly suggest the efficacy of Bioflow during emergency situations in CABG.

For 10 adult cases of Ebstein's anomaly, tricuspid valve supraannular imposition (TVSI) without excision of native tricuspid valve were performed and its late results (6 mo. to 11.5 y, mean 6.8 years) were investigated. All cases showed the severe low output syndrome after the surgery. But the postoperative recovery of the cardiac function was smooth and there was no early death nor A-V block. Both the A-V conduction and the RV subvalvular structures were preserved in TVSI and it contributed to the postoperative good contractility of RV. In two cases, the serious postoperative ventricular tachycardia or ventricular fibrillation were experienced, one case required open cardiac massage and 6 hours long assist circulation in the other. In late stage, one patient died 9 years after the TVSI from the failure of the bioprosthetic mitral valve which had been implanted simultaneously, and the other 9 survivors returned to the class I of NYHA classification. LVDd and DS obtained by echocardiography showed significant enlargement; 29 +/- 4.5 mm and 19 +/- 4.1 mm before operation to 42 +/- 3.1 mm and 29 +/- 5.8 mm in late stage respectively. EF showed the tendency of slight decrease from the preoperative supernormal value to the normal range. RVD showed significant decrease after the surgery (58 +/- 4.2 mm to 37 +/- 4.1 mm). Bioprosthetic valve failure in tricuspid position was not experienced. PAC or PVC were seen quite often and 8 of 9 cases received medication for arrhythmia even in late stage.(ABSTRACT TRUNCATED AT 250 WORDS)

The long term (10 to 15 years) results of coronary artery bypass grafting (CABG) were studied in 20 patients. The duration of follow-up was ranged from 130 to 170 months with mean 146.4 months. Ten out of 20 patients underwent coronary angiography (CAG), which disclosed that the late patency of saphenous vein (SV) grafts was 68.8% (11/16), but 54.5% (6/11) of patent SV grafts showed atherosclerotic changes such as irregularity and localized narrowing. On the other hand, internal thoracic artery (ITA) grafts were all patent without any atherosclerotic luminal changes. We recognized that ITA grafts were superior to SV grafts from an angiographic standpoint of view in the long term in Japan.

This study was designed to examine the response of coronary artery bypass conduit to serotonin, phenylephrine, and ergonovine as provocation agents of vasoconstriction. Saphenous veins (SV) and internal mammary arteries (IMA) were obtained during coronary artery bypass grafting (CABG), and their contractile properties were measured using isometric contraction recording apparatus. Both SV and IMA showed sigmoid contraction curves indicating dose dependence to ergonovine, serotonin, and phenylephrine. The concentration-response relations for phenylephrine showed a similar curve in both SV and IMA, however, those for ergonovine and serotonin showed a leftward shift in SV compared with IMA. Half maximum effective dose for ergonovine and serotonin were less in SV than IMA. From these results, it was suggested that "perioperative spasm" during CABG might occur not only in coronary arteries but also in the graft conduit itself. Graft spasm might be a possible mechanism for occlusion of the bypass graft. In conclusion, greater hyperreactivity of SV compared with IMA in response to ergonovine and serotonin was suggested, so it is concluded that, from this point of view, IMA is more suitable for use in CABG.

Seventy patients underwent sequential coronary artery bypass grafting with saphenous vein during 28 months period. Seventy eight sequential grafts comprising 165 distal anastomoses were performed. Early death was 2.9%. Postoperative angiographic evaluation within 6 months showed 86% patency of the 65 sequential grafts and 89% patency of the 136 distal anastomoses. The patency of anastomosis to left anterior descending artery (LAD), diagonal branch (Dx), obtuse marginal branch (OM), posterior lateral branch (PL), and posterior descending branch (PD) was 87% (13/15), 92% (36/39), 91% (40/44), 81% (26/32) and 100% (6/6), respectively. The patency of Dx-LAD, Dx-OM and OM-PL was 86% (12/14), 94% (15/16) and 76% (13/17), respectively. There was no significant difference in the patency rate according to the site of anastomosis and the inner diameter of the coronary artery. The patency of side to side anastomoses was 92% (65/71) which was not significantly different from that of the end to side anastomoses; 86% (56/65). These results showed sequential aorto-coronary vein grafting means to be effective for the complete coronary artery revascularization .

From March 1986 to October 1989, 91 patients underwent CABG using the right gastroepiploic artery (GEA) at Osaka Medical College and Mitsui Memorial Hospital. Including 14 females, the mean age was 57.9 years old ranged from 34 to 73 years old. Triple vessel disease and left main disease occupied over 90% of the patients. There were 5 emergency operations and 6 reoperations. Associated serious diseases were; renal failure with hemodialysis in 2 pts., familial hyperlipidemia in 5 pts., severe atherosclerotic ascending aorta in 8 pts., arteriosclerosis obliterance in 3 pts., and each one of abdominal aortic aneurysm and idiopathic thrombocytopenic purpura. The internal thoracic artery (ITA) graft was concomitantly utilized in 96% of the patients. Single ITA in 60 pts., double ITA in 23 pts. and sequential ITA in 5 patients. Saphenous vein graft was used in 58 patients and remaining 33 patients were operated without leg wound. The mean number of distal anastomoses was 3.3 ranged from 1 to 5, and the mean number of arterial grafts was 2.5 ranged from 1 to 4. The mean aortic cross clamp time and cardiopulmonary bypass time was 62.8 minutes and 113.6 minutes, respectively. Sites of GEA anastomosis were; 4 anterior descending, 3 diagonal, 11 circumflex and 73 right coronary arteries. There were 86 in situ grafts mostly for the right coronary arteries, and remaining 5 GEAs were used as a free graft to bypass the left coronary arteries. On the contrary, ITA was used to bypass the left coronary artery system preferentially. There was 3 combined procedures; splenectomy, abdominal aorta replacement, and ascending aorta to bifemoral artery bypass in each one patients. Three patients including one emergency case died within 30 days after surgery. Two were cardiac and one was renal failure. Other 2 patients died of stroke at late period. New Q wave infarction was noted in 2 patients. Relief of angina was obtained in 98% of survivors. The patency rate of the GEA graft was 97% in 61 grafts restudied within 6 postoperative months, which was identical with that of the ITA graft, that is 97% of 76 grafts. In conclusion, the GEA has several advantages as a coronary artery bypass graft such as similarity in size to the coronary artery, rare arteriosclerosis, feasibility of in situ graft, and no gastric complication. Its flow capacity is studying now and favourable results are being obtained. The final problem, its long term patency, will be resolved in future. GEA is a promising conduit for the coronary bypass surgery.

Free arterial graft of the internal mammary artery (IMA) and the gastroepiploic artery (GEA) has been utilized for coronary artery bypass grafting in 10 patients during 44 months period. There were 6 males and 4 females and age ranged 42 to 73 year old with the mean of 60.8 year old. Eight IMA and 2 GEA were used as a free graft. Sites of distal anastomosis of the free graft were 3 at anterior descending arteries, 3 at diagonal branches and 4 at circumflex arteries. Sites of proximal anastomosis of those grafts were ascending aorta in one, concomitantly utilized saphenous vein graft in 5 and in situ IMA graft in 4 patients. Mean number of grafts was 2.9 (2-5) and mean aortic cross clamp time was 56.2 minutes (16-90 minutes). There was neither operative death, nor perioperative myocardial infarction and intra-aortic balloon pumping was not required. Postoperative angiography was made in 9 patients within 3 postoperative months. Eight (89%) free arterial grafts were patent. Relief of angina was obtained in all patients. We concluded that the complete revascularization with only arterial graft can be achieved more widely by utilizing the free arterial graft with an acceptable patency.

A total of ten patients have undergone sequential bypass grafting of the internal mammary artery (IMA) to the coronary arteries at Osaka Medical College. Operative procedures included left IMA bypass to the left anterior descending (LAD) artery and its major diagonal branch in six patients; to the obtuse marginal branch and diagonal branch in three patients; and to the first and the second diagonal branches in one patient. The right internal mammary artery was concomitantly utilized in 4 patients and saphenous vein graft was also utilized in 6 patients. Postoperative angiographic studies were performed in nine patients within 6 months after operation and in all 18 sites of IMA anastomoses, the IMA sequential grafts were patent. Since sequential IMA-coronary bypass technique means the increase of arterial graft, we believe that this technique should be used for multivessel coronary revascularization especially in younger patients.