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Seventeen patients treated for infected grafts (11/17) or aneurysms (6/17) of the aorta between 1998 and 2003 were reviewed to evaluate our experience with aortic infection. The causative organisms were identified in 12 patients (71%), with 5 (29%) having methicillin-resistant Staphylococcus aureus. A periaortic abscess occurred in eight patients, and all of them were associated with infected grafts. Surgical treatment included cryopreserved allograft replacement in eight patients, prosthetic graft replacement in four patients, and drainage with or without omental wrapping in five patients. One patient was still hospitalized at the end of the study period. Five patients with infected grafts died after the operation during the initial hospitalization. No early mortality occurred in the aneurysm group. The early mortality rate was 31% for all patients, 50% for the graft group, and 63% for patients with a periaortie abscess. Another patient with an infected aneurysm died of arrhythmia after discharge from the initial hospitalization, Ten patients are still alive without evidence of reinfection. The early mortality rate for patients with infected aortic grafts is higher than that for those with infected aneurysms, especially when a periaortic abscess accompanies them. However, the late outcome is favorable, with no reinfection or late treatment-related deaths.

This study evaluates the effectiveness and potential complications of stent-grafting for the treatment of distal arch aneurysms using profound hypothermia and circulatory arrest with retrograde cerebral perfusion. Between December 1998 and December 2001, 9 consecutive patients with a distal arch aneurysm (6 men and 3 women, mean age 71 years) underwent surgical repair using a stent-graft. Profound hypothermic circulatory arrest and retrograde cerebral perfusion were performed in all patients. Endovascular leakage was screened postoperatively using three-dimensional computerized tomography. The mean follow-up period was 27.4 months. Thirty day mortality was 0%. One patient died 3 months after stent-grafting due to proximal leakage into her aneurysm. The mean postoperative extubation period was 2.1 days. No patients suffered cerebral infarction or paraplegia. Although preliminary outcomes using this technique were good, endovascular leakage is a concern. We suggest that, if major proximal leakage is recognized postoperatively, re-intervention should be performed as soon as possible. Endovascular stent-grafting appears to be a good alternative treatment for distal arch aneurysms, although longer follow-up is necessary to more comprehensively evaluate this procedure.

1240 The Journal of Thoracic and Cardiovascular Surgery • December 2001 O pen surgery with an endovascular stent graft is a novel therapeutic technique for aortic aneurysm that is especially useful for aneurysms of the distal arch. In this report we describe the clinical course and autopsy findings of 2 patients who had paraplegia after undergoing this procedure and died during the hospital stay.

Objective: We evaluated effects of type, size, and orientation of mechanical mitral valve prostheses on hemolysis.Methods: Subjects were 84 patients who had undergone mitral valve replacement. Lactate dehydrogenase was mainly used as a marker of hemolysis and was measured before surgery, 1 month after surgery, and in the late postoperative period.Results: Valves used included 16 Medtronic-Hall, 32 St. Jude Medical, and 36 CarboMedics valves. Medtronic-Hall valves caused less hemolysis than St. Jude Medical or CarboMedics valves in the late postoperative period. This resulted because hemolysis due to Medtronic-Hall valves was more severe 1 month after surgery than in the late postoperative period and because hemolysis due to St. Jude Medical or CarboMedics valves was more severe in the late postoperative period than 1 month after surgery. One reason for this finding is that cardiac output was greater in the late postoperative period than 1 month after surgery, making regurgitation through the pivots of bileaflet valves more severe. The orifice area and the orientation of prostheses did not affect hemolysis.Conclusion: St. Jude Medical or CarboMedics valves caused more severe hemolysis than Medtronic-Hall valves in the late postoperative period.

The Harmonic Scalpel (HS; Ethicon Endo-Surgery, Cincinnati, OH, USA) is an ultrasonic coagulator that generates less heat than electrocautery. We compared canine internal mammary arteries (IMAs) harvested using the HS or electrocautery and reviewed the early clinical outcome after thoracoscopic IMA takedown with the HS. Using HS and bipolar electrocautery (BE), 51 and 49 IMA branches, respectively, in six mongrel dogs were divided. The divided branches were subjected to a pressure tolerance test. The impact of coagulation on the main trunk was investigated microscopically. Thoracoscopic IMA harvesting with the HS was performed in 41 patients. Seven human IMA segments including 10 branches were examined microscopically. Postoperative angiography of 40 IMA grafts (97.6%) was performed. All the IMA branches withstood intraluminal pressures up to 250 mmHg. With BE, coagulation reached the adventitia of the main trunk in six segments (12.2%), but the HS caused no injury. Thoracoscopic IMA harvesting with excellent hemostasis was achieved using only the HS in all 41 patients. The main trunks of the human IMA segments were microscopically intact, and postoperative angiography demonstrated that the IMA grafts were intact. The HS appears to be a reliable coagulator for thoracoscopic IMA harvesting with minimal damage.

Background . The hemodynamic effects of carbon dioxide insufflation under single-lung ventilation were studied in 22 consecutive thoracoscopic harvests of the left internal mammary artery, which was used for minimally invasive coronary artery bypass grafting. Methods . An electrocardiograph, arterial catheter, Swan-Ganz catheter, and transesophageal echocardiograph were used to monitor seven hemodynamic variables. Baseline data were obtained during ventilation of both lungs and the measurements were repeated after the left lung was collapsed and at 5 and 30 minutes after hemithorax insufflation with low-flow (2 to 3 L/minute) carbon dioxide gas was begun. The intrapleural pressure was maintained at 8 to 10 mm Hg. Results . Thoracoscopic harvest of the internal mammary artery was completed in all cases with a mean insufflation time of 44 ± 12 minutes. There were no significant changes in the mean arterial pressure, heart rate, cardiac index, and left ventricular ejection fraction throughout the procedure, whereas the central venous pressure, mean pulmonary arterial pressure, and pulmonary capillary wedge pressure ( p Conclusions . Low-flow carbon dioxide insufflation into the left hemithorax with an intrapleural pressure of 8 to 10 mm Hg under selective right-lung ventilation does not compromise the human heart with normal to moderately depressed function and can be an efficacious adjunct in specific thoracoscopic procedures.

Background . Paravalvular leakage is one of the most serious complications of aortic valve replacement in patients with aortitis syndrome. The purpose of this study was to compare the effectiveness of the intravalvular implantation technique in preventing paravalvular leakage with that of the conventional technique. Methods . Since 1982, 14 patients with aortic regurgitation caused by aortitis syndrome have undergone aortic valve replacement at our institute. An intravalvular implantation technique was applied in 7 of the 14 patients. The technique consists of suturing a prosthetic valve to the aortic annulus and sandwiching the leaflets between exogenous felt pledgets and the inflamed aortic annulus. Results . Paravalvular leakage occurred in 3 of 7 patients in the conventionally treated group and in none of 7 in the intravalvular implantation group. Conclusions . The intravalvular implantation technique is effective in preventing paravalvular leakage in patients with aortitis syndrome.

Open-heart surgery has been performed since 1975 on 25 patients who are Jehovah's Witnesses by religion. The patients' ages ranged from 6–60 years, and their body weights from 18–51 kg. Surgical procedures included correction of congenital heart disease in 14 patients and valve repair or replacement in 11. Six procedures were reoperations. The lowest mean haematocrits, during perfusion and the postoperative period, were 22.7% (range 15.0–31.0%) and 27% (range 16.0–36.0%), respectively. Twenty-four patients survived and are alive and well. One patient died of low output failure before discharge. The blood return system reduced blood loss. Five of the patients who underwent cardiac surgery received recombinant erythropoietin before and after surgery, leading to higher postoperative haematocrits. In one patient, a haematocrit which fell to 16.9% after surgery was raised to 27% by administration of erythropoietin, without blood transfusion. In two recent cases, high doses of aprotinin were used during surgery, resulting in better haemostasis after cardiopulmonary bypass.

We report an unusual case of aortobronchial fistula late after transverse arch replacement caused by the remnant of a temporary bypass near the ascending aorta. In reconstructive surgery of the ascending aorta, antegrade perfusion is preferably performed through a side branch after completion of the distal anastomosis by some surgeons. This report suggests possible risk of a serious late complication unless the side branch is placed and tailored properly.

The approach to the heart for open heart surgery in patients with a tracheostoma requires careful consideration. The presence of a tracheostoma interferes with the standard sternotomy and increases the risk of mediastinitis. We have successfully performed coronary artery bypass grafting in two patients with a tracheostoma using the limited median sternotomy and describe the surgical procedure used in these patients.

Endovascular covered stents were successfully applied to temporarily halt hemoptysis and postpone surgical intervention in a 69-year-old man with a ruptured anastomotic false aneurysm of the distal aortic arch. Surgical graft implantation was performed successfully by the elephant trunk technique 14 days after the endovascular stent-grafting, at which time aspiration pneumonia had subsided.

Objective: The efficacy of acute normovolemic hemodilution (ANH) in avoiding homologous blood transfusion (HBT) during cardiovascular surgery remains controversial. Our objective was to evaluate the impact of ANH on blood transfusion requirements during open cardiovascular surgery using cardiopulmonary bypass (CPB). Methods: We retrospectively reviewed 243 patients who had undergone open cardiac or thoracic aortic surgery using CPB between September 2001 and July 2003 in our department. ANH was performed when the hematocrit was over 35% and the patient was hemodynamically stable. Risk factors were selected in accordance with the Japanese Adult Cardiovascular Surgery Database and analyzed to determine their effect on perioperative HBT requirement. Results: Of the 243 patients, 64 (26%) underwent preoperative autologous blood donation and 62 (26%) ANH. HBT was required in 62% of patients (150/243) overall, in 32% (20/62) of ANH patients, and in 76% (130/171) of non-ANH patients. Multivariate stepwise logistic regression analysis revealed that preoperative or pre-donation hemoglobin value (p

Objective: Retrograde cerebral perfusion (RCP) is used as an adjunctive method to hypothermic circulatory arrest to enhance cerebral protection in patients undergoing thoracic aortic surgery. It remains unclear whether RCP provides improved neurological and neuropsychological outcome. Methods: Forty-six patients undergoing thoracic aortic surgery using RCP, and 28 undergoing coronary artery bypass grafting (CABG; nZ28) with CPB, were enrolled in the study. Patients receiving RCP were subdivided into two groups, those with less than 60 min of RCP (S-RCP; nZ27) and with 60 min or more (L-RCP; nZ19). The patients’ neurocognitive state was assessed by the revised Wechsler Adult Intelligence Scale a few days before operation, at 2–3 weeks and 4–6 months after operation. Results: There were no stroke, seizure, and hospital mortality in either group. Significant decline between baseline and early scores were seen in three subtests (digit span, arithmetic, and picture completion) for S-RCP and four (digit span, arithmetic, picture completion, and picture arrangement) for L-RCP. Significant decline between baseline and late scores were seen in one subtest (arithmetic) for S-RCP, four (digit span, arithmetic, picture completion, and picture arrangement) for L-RCP, and one (object assembly) for CABG. The mean change of scores for one late test (digit symbol) was significantly lower in S-RCP than in CABG. The mean change of scores for three early tests (digit span, vocabulary, and picture arrangement) and four late tests (information, digit span, picture completion, and picture arrangement) were significantly lower in L-RCP than in CABG. Stepwise logistic regression analysis disclosed that, after considering the other variables, significant difference in test score changes were observed between CABG and L-RCP for two early tests (picture completion and digit symbol) as well as for three late tests (digit span, similarities, and picture completion). None of test score changes showed significant difference between CABG and S-RCP. Conclusions: The neurocognitive outcome in patients undergoing RCP less than 60 min were comparable with patients undergoing CABG without circulatory arrest. Prolonged RCP of 60 min or more in patients undergoing surgery of the thoracic aorta was associated with postoperative neurocognitive impairment.

Clinical Summary A 52-year-old man had undergone, in another hospital, a graft replacement of the ascending aorta and coronary bypass grafting (saphenous vein to the right coronary artery) for acute type A aortic dissection. Gelatin-resorcinol-formaldehyde tissue glue had been used in reinforcement of the dissected aorta in both ends. Nine months after that operation, the patient had dyspnea and mild fever. Computed tomographic (CT) scan showed pseudoaneurysm of the ascending aorta, and he was referred to us. Physical findings included a continuous murmur maximal at the second right intercostal space. Chest radiography showed mild cardiomegaly and enhancement of the right pulmonary vasculature. Transesophageal echocardiography and a new CT scan (Figure 1) revealed a pseudoaneurysm of the ascending aorta, with fistulization to the right pulmonary artery arising from the proximal anastomosis. Aortography confirmed complete occlusion of the vein graft as well as the presence of the aortopulmonary fistula. Right heart catheterization revealed right-sided pressure elevation. When the left ventricular pressure was 74/20 mm Hg, the right atrial pressure was 17 mm Hg, the right ventricular was 34/18 mm Hg, and the pulmonary arterial pressure was 35/16 mm Hg. An oxygen saturation step-up was observed in the pulmonary artery, with 59.8% in the main pulmonary artery and 91.8% in the right pulmonary artery. Because of the risks of repeated median sternotomy, we chose a right thoracotomy to approach the aortic root. We prepared a cryopreserved aortic valve allograft in case of infection. The right fourth intercostal space was opened, and sternal transection and left thoracotomy were included. The femoral artery and the superior and inferior venae cavae were cannulated for cardiopulmonary bypass. An occlusion balloon was inserted into the distal part of the pseudoaneurysm to reduce the degree of aortopulmonary shunting. After systemic cooling, retrograde cardioplegia, and deep hypothermic circulatory arrest, the pseudoaneurysm was incised, and dissection proceeded until the distal part of the aortic graft was crossclamped and systemic circulation was resumed. The defect of the right pulmonary artery wall was 14 mm in diameter; it was closed with the anterior mitral leaflet taken from the aortic allograft. We found dehiscence in the anterior part of the proximal anastomosis, blackened aortic edge, and fragile aortic wall with dissection almost reaching the annulus. There were no findings indicating infection. The left coronary ostium was resected as a button. A Dacron polyester fabric tube composite graft with a mechanical valve was inserted into the aortic root, and the left coronary button was reattached to the graft. During rewarming, the right internal thoracic artery was anastomosed to the right coronary artery (Figure 2). The patient’s postoperative course included pneumonia, which improved with antibiotics, and he was discharged 47 days after operation. Histologic examination of the media of the dissected aorta revealed a homogeneous eosinophilic substance that seemed to be composed of glue, severe calcification, and fibrous tissue with hemosiderin deposition.

This report describes a 60-year-old male patient who developed early valvular obliteration of a cryopreserved aortic valve allograft with associated severe valvular leakage. The patient had previously undergone two operations for aortic valve insufficiency resulting from infective endocarditis, and prosthetic valve endocarditis: aortic valve replacement with a mechanical prosthesis was done 4 years ago, and two years later aortic root replacement with a cryopreserved allograft was performed. Perforation through the non-coronary cusp of the aortic allograft was found, and valve replacement was achieved using a mechanical prosthesis. The intraoperative findings, histological, immunological, and bacteriological studies of the resected cusps demonstrated negative for infection and rejection, therefore, the valvular perforation might have been caused by an injury or degeneration during management of the homologous graft. The patient showed neither aortic regurgitation on echocardiography nor recurrence of endocarditis 10 months after surgery.

Seven patients with malignant cardiac tumors were treated surgically in the Department of Cardiothoracic Surgery of the University of Tokyo between 1981 and 2000. Their treatments and outcomes are summarized and discussed. The ages of the patients ranged from 21 to 70 years old (mean: 49.5+/-15) and there were three males and four females. The histopathological diagnoses were hepatocellular carcinoma (HCC), spindle cell sarcoma, round cell sarcoma, osteosarcoma, renal cell carcinoma, and leiomyosarcoma. In four of the cases, the tumor extended or metastasized from other organs, while in the other three cases it originated in the heart. Before the cardiac operation, an above-knee amputation, left nephrectomy, transarterial embolization, or extended right hepatic lobectomy had been performed to treat the primary site of the tumor. Tumor resection using cardiopulmonary bypass was performed in every case. The NYHA classification of heart failure was significantly improved (preop: 3.3+/-0.8, postop: 1.9+/-0.7 [P

A 74-year-old man with an aortic arch aneurysm and a chronic type IIIb aortic dissection underwent total aortic arch repair without cerebral or cardiac ischemia. After confirming no atheromatous change in the ascending aortic wall, a custom-designed 4-limbed graft, prepared for both arterial return of cardiopulmonary bypass and reconstruction of the arch vessels, was anastomosed onto the right side of the ascending aorta. The 3 arch vessels were then bypassed sequentially during systemic cooling and monitoring cerebral perfusion with near-infrared oxymetry. After aortic cross-clamping, a stent graft was inserted into the distal arch from the distal ascending aorta, maintaining cerebral and cardiac perfusion. This procedure is indicated especially in a high-risk patient who has an aortic arch aneurysm without severe atheromatous change in the ascending aorta and the arch vessels.

This report describes a male patient with WPW syndrome who underwent surgical repair of sudden, severe mitral valve regurgitation through the posterior leaflet 20 months after successful RF catheter ablation for Kent bundle at the age of 14, and discusses the problem of valvular damage caused by this technique.

Open surgery using the endovascular stent-graft is a novel technique that lessens the invasiveness of surgery for the aortic arch. However, the outcome of this procedure remains uncertain.Between November 1996 and July 2000, a total of 19 patients underwent open surgery using an endovascular stent-graft for thoracic aortic aneurysms. There were 15 men (78.9%) and 4 women (21.1%). Patient age ranged from 29 to 82 years (mean 69.3 years, median 74 years). Atherosclerotic thoracic aortic aneurysms were present in 17 patients (89.4%) and aortic dissection in 2 patients (10.5%).Two patients (10.5%) died in the hospital and 4 patients (21.1%) presented with paraplegia postoperatively. Among the 4 patients with postoperative paraplegia, 1 case was complicated with intraoperative aortic dissection. The other 3 patients with paraplegia had spinal cord ischemic time of more than 60 minutes and intraoperative body weight gain of more than 4 kg. Of these 3 patients, hemodynamic instability after cardiopulmonary bypass was observed in 1 patient and cholesterin embolus in the anterior spinal artery was found at autopsy in another. On univariate analysis, age greater than 75 years was the only risk factor associated with paraplegia (p0.05). Autopsy findings for the 2 patients showed that the Adamkiewicz arteries were not blocked by the stent-graft in either patient.Intraoperative aortic dissection, embolization of the intercostal arteries, long ischemic time of the spinal cord, and excessive weight gain during operation may have been associated with the high incidence of paraplegia after open surgery using the endovascular stent-graft.

The short-term results after aortic root replacement with 11 cryopreserved aortic homografts was examined. Since 1998, the University of Tokyo Tissue Bank has supplied 11 aortic homograft valves. Nine of the recipients were male, and the average age was 51.2 years. Nine out of 11 patients had suffered from a serious condition of native or prosthetic valve infectious endocarditis. All of the patients underwent aortic root replacement, and the blood type between the patient and the homograft was matched in 8 of the patients. Only 1 patient died (9.1%) in the short-term due to sepsis. The preoperative degree of aortic valve regurgitation in all of the cases was third or fourth while the regurgitation disappeared after the operation in all of them. Thinking of the serious condition of our cases preoperatively, the 9.1% operative mortality was quite acceptable. Long-term follow-up is necessary to estimate the quality of the homografts.

Background . The effectiveness of blood conservation measures for thoracic aortic operations with deep hypothermic circulatory arrest has not yet been documented. Methods . From July 1997 to December 2000, 148 thoracic aortic operations were performed in our department. Sixty-one cases involving patients who underwent elective thoracic aortic operation with deep hypothermic circulatory arrest were reviewed retrospectively. Results . Seventeen patients did not meet the criteria for the blood conservation program and were excluded from the present study. Therefore, 44 patients were analyzed in this study. Overall, 50% of patients did not require operative homologous blood transfusion (HBT) and 43% did not require in-hospital HBT. Smaller amounts of autologous donation, greater blood loss, and a longer operation time were independent risk factors for HBT requirement. Among 16 patients who had made an autologous donation of 1,600 mL or greater, 75% did not require intraoperative HBT and 69% did not require in-hospital HBT. The overall perioperative mortality rate was 4.5%. As for postoperative complications, prolonged intubation and postoperative infection were significantly more frequent among patients who required in-hospital HBT. Conclusions . Our combined blood conservation measures were effective in avoiding HBT during major thoracic aortic operations with deep hypothermic circulatory arrest and may have reduced postoperative complications. The amount of the autologous donation was a strong predictor for avoiding HBT.

Objectives: We have conducted aortic valve-sparing operation for patients having aortic root dilatation and almost normal aortic valve leaflets since August 1998, and here report midterm results.Methods: Patients with dilated aortic annulus or Marfan’s syndrome were treated with reimplantation, and the remaining patients with remodeling. Either 24 or 26 mm graft was selected based on aortic annular diameter and leaflet size. Aortic valve competence was assessed regularly with echocardiography.Results: Five patients (age: 29±13 yr), including 4 with Marfan’s syndrome, had undergone reimplantation, and 3 (age: 46±18 yr) remodeling by December 2000. Mean follow-up was 18 (range: 10–32) months, and no postoperative death has occurred and no reintervention has been required thus far. All the patients in the remodeling group showed only a small pressure gradient through the aortic valve and decreased left ventricular diameter. Two in the reimplantation group showed a pressure gradient exceeding 20 mmHg. Two Marfan’s syndrome patients in the reimplantation group showed slightly increased diastolic left ventricular diameter and 3 slightly increased systolic left ventricular diameter. Although aortic regurgitation had diminished in all patients by discharge, moderate aortic regurgitation recurred in 1 non-Marfan’s syndrome patient in the reimplantation group because of degenerated aortic valve.Conclusion: Although postoperative aortic valve function was not perfect in all patients undergoing reimplantation, midterm results after aortic valve-sparing operation were generally satisfactory. Proper selection of patients, procedures, and graft size was thought to be important to ensure a favorable surgical outcome.

Three patients with noncardiac Child A cirrhosis underwent cardiac surgery. All survived surgery, but 2 died during follow-up periods. A 61-year-old woman who underwent successful double valve replacement died of diabetic coma and severe acidosis due to intestinal necrosis 18 months later. A 57-year-old woman who underwent successful mitral valve replacement died of liver failure induced by heart failure 9 years later. A 45-year-old man who underwent coronary artery bypass grafting is doing well 18 months after discharge. Proper perioperative management, including high-flow cardiopulmonary bypass, pharmacological and mechanical circulatory support, and mechanical respiratory support prevented further, potentially lethal, hepatic dysfunction, leading to good early surgical results. We concluded that patients with Child A cirrhosis could tolerate cardiac surgery. Subsequent surgical results, however, were unsatisfactory, and more careful follow-up is necessary to obtain better late results.

The ratio of arterial oxygen tension to inspired oxygen fraction (PaO2 / FiO2) is a useful indicator for weaning patients from mechanical ventilation and a reliable predictor of pulmonary dysfunction after cardiac surgery. The aim of this study was to elucidate the patient characteristics and variables that affect the PaO2 / FiO2 ratio. Between 1994-1998, 167 patients who underwent coronary artery bypass grafting (CABG) were examined retrospectively. Spearman's correlation coefficients were calculated between the PaO2 / FiO2 ratio and intubation period, and length of ICU stay. Patients were then divided into two groups with a PaO2 / FiO2 ratio < 350 and PaO2 / FiO2 ratio 350. Univariate analysis of the putative risk factors was performed. A logistic regression model was developed to evaluate factors that would influence the PaO2 / FiO2 ratio. A significant correlation was observed between the PaO2 / FiO2 ratio and intubation period, and length of ICU stay. Univariate predictors of a PaO2 / FiO2 ratio < 350 were low body weight, low preoperative PaO2, long operation time, high FiO2, low postoperative PaO2, history of smoking, hypertension and opening of pleura (p < 0.05). Excellent prediction was found with a model consisting of preoperative PaO2 and hypertension. Conclusion: The results of this study suggest that patients with a low preoperative PaO2 or hypertension may need more careful peri- and postoperative management since these factors are closely associated with the PaO2 / FiO2 ratio.

This communication describes our clinical experience with the hybrid method, a video-assisted anterior minithoracotomy approach developed for minimally invasive limited pericardiectomy to treat 8 patients with massive pericardial effusion. The average operating time was 37.2 minutes, and there was no procedure-related morbidity or mortality. The mean follow-up period was 5.6 months, and there have been no recurrences. The hybrid approach can be accomplished irrespective of pleural adhesions. It eliminates the need for hemipulmonary collapse, making it more advantageous than the totally port-access thoracoscopic approach.

Objective: To evaluate cardiac function at cardiopulmonary bypass weaning, we applied a new technique clinically to determine the approximated Emax without using a conductance catheter.Methods: Subjects were 5 patients. The left ventricular end-systolic pressure was obtained by overlaying the radial arterial pressure curve on the left ventricular pressure curve. Left ventricular end-systolic volume was assessed by a transesophageal echographic apparatus. At cardiopulmonary bypass weaning, volume loading was applied to increase left atrial pressure by a few mmHg while fixing the pump flow rate at half flow. Changes in left ventricular end-systolic volume and approximated left ventricular end-systolic pressure for total heart beat were plotted during this period, and the gradient of the regression line was taken as approximated Emax.Results: Approximated Emax ranged from 1.29 to 3.28 (mean 2.13 ± 0.72), and its correlation coefficient was 0.80 ± 0.06.Conclusion: Our new technique is useful in evaluating cardiac function during cardiopulmonary bypass.

A seventy-year-old man was admitted to hospital for ishchemic heart disease and abdominal aortic aneurysm. In the cardiac procedure, we employed a technique for conversion from minimally invasive coronary artery bypass grafting. This technique entailed cardiopulmonary bypass using standard instruments and technique, and the exposure for grafting was the same as for the simple minimally-invasive coronary artery bypass grafting. Moreover, the incision we reported in this case was simply extendible even to a full sternotomy if necessary.

Background: The hemodynamic effects of carbon dioxide (CO2) insufflation with hemipulmonary collapse were studied in consecutive thoracoscopic harvests of the left or right internal mammary artery (IMA), which were used for video-assisted coronary artery bypass grafting. Methods: Thirty-eight patients (30 male, eight female) with a mean age of 69.5 ± 11.5 years were selected, and 33 left and five right IMA were harvested thoracoscopically. After hemipulmonary collapse was established by single-lung ventilation, low-flow (2-3 L/min) CO2 was delivered at a constant intrapleural pressure of 8-10 mmHg. Using electrocardiography, a radial arterial catheter, a Swan-Ganz catheter, and transesophageal echocardiography, we obtained values for seven hemodynamic variables. Baseline data were collected during bilateral lung ventilation. Each variable was then measured during hemipulmonary collapse and insufflation. The significance of any changes was established with Student's t-test after correcting for baseline differences. Results: Insufflation facilitated IMA harvest by expanding the pleural space between the anterior chest wall and heart. Mean insufflation times were 40.8 ± 12.2 min on the left and 33.5 ± 8.5 min on the right. Significant increases from the baseline values were observed in the mean central venous pressure (L:4.7-9.0 mmHg, R: 5.1-14.0 mmHg, p < 0.05), the pulmonary arterial pressure (L: 11.3-17.3 mmHg, R: 12.1-19.9 mmHg, p < 0.05), and the pulmonary capillary wedge pressure (L: 7.2-10.5 mmHg, R: 6.5-10.0 mmHg, p < 0.05). On the right, but not on the left, slight decreases were noted in the mean arterial pressure and cardiac index (71.3-62.6 mmHg, 2.01-1.76 L • min-1 • m-2, p < 0.05). Conclusions: The hemodynamic effect resulting from one-lung collapse plus low-flow CO2 insufflation at 8-10 mmHg for 30-40 min is mild in both hemithoraces, although the impact is greater on the right.

A 3-year-old boy underwent mitral valve repair for congenital mitral stenosis through combined superior-septal atriotomy and apical left ventriculotomy. The operation was performed safely with excellent exposure of the subvalvular apparatus by the ventricular approach, while sufficient visualization of the valvular lesion was obtained by the atrial approach. Postoperative echocardiography demonstrated normal left-ventricular motion and no residual mitral stenosis.

Tuberculous pseudoaneurysm has been reported to be a fatal, but rare complication of tuberculosis. We report a case of a 68-year-old man who underwent successful surgical treatment for a tuberculous pseudoaneurysm of the thoracic aorta with bronchial communication, and review previous reports of patients who also underwent operation for similar lesions, focusing especially on the pathway of infection to the aorta.

Percutaneous transvenous mitral commissurotomy is widely performed as the first choice of the non-pharmacological treatments for mitral stenosis. Five patients have been identified who required mitral valve replacement after percutaneous transvenous mitral commissurotomy. The causes leading to mitral valve replacement were mitral regurgitation in three cases and insufficient commissurotomy in two. Massive mitral regurgitation is one of the most serious complications of percutaneous transvenous mitral commissurotomy. This report aims to elucidate the mechanism of massive mitral regurgitation occurring during percutaneous transvenous mitral commissurotomy. In every such case, there was a large tear in the posterior leaflet without any split in the commissures. The Japanese literature reports that 16 patients have undergone mitral valve replacement for massive regurgitation after percutaneous transvenous mitral commissurotomy; 14 of these cases had a tear in one of the leaflets and no evidence of splitting of the posterior commissure. These facts indicate that relative fragility of the leaflets as compared with rigidity of commissural fusion, especially in the posterior commissure, is an important factor of massive mitral regurgitation during percutaneous transvenous mitral commissurotomy. Copyright © 1996 Published by Elsevier Science Ltd.

Since 1986, a rotation-advancement flap method has been used in 11 patients with partial anomalous pulmonary venous drainage into the superior vena cava. This method consists of atrial partitioning, enlargement of the superior vena cava, and protection of the sinus node. The midterm postoperative sinus node function and hemodynamic changes were examined in this study. Postoperative angiograms showed normal pulmonary venous pathway and no stenosis in the superior vena cava. Cardiac rhythm was normal and no clinical symptoms appeared. (J Thorac Cardiovasc Surg 1996;112:1-7)

During operations on patients with extracardiac conduits, sternal reapproximation occasionally results in critical compression of the conduit and serious deterioration in hemodynamic function. Permanent splinting of the sternum with a methyl methacrylate resinous plate provides an adequate substernal space for the extracardiac conduit.

Narrow and wide QRS tachycardias associated with various rhythm disturbances were recognized during 24-hour ambulatory electrocardiographic monitoring in a 65-year-old man with coronary artery disease. Laddergram analysis revealed the presence of dual atrioventricular nodal pathways. Nonreentrant supraventricular tachycardia due to simultaneous fast and slow conduction through the dual atrioventricular nodal pathways was confirmed by electrophysiologic study. The atrial rate determined the occurrence of simultaneous conduction, and extrastimulation failed to induce a double ventricular response. Enhanced vagal activity was thought to play a critical role in provoking this phenomenon. Radiofrequency catheter ablation of the slow pathway eliminated the arrhythmias.

Renal cell carcinoma occasionally invades the inferior vena cava and rarely extends to the right atrium. However, despite the frequency of venous extension, it is unusual to recognize patients with massive pulmonary tumor embolus clinically. We describe a 60-year-old man who underwent pulmonary tumor embolectomy using cardiopulmonary bypass combined with profound hypothermia and intermittent low-flow perfusion. The patient is currently alive and well without implantation metastasis 6 months after the operation.

Gastric varices formed in a patient who had undergone a total cavopulmonary shunt operation 7 years previously. The varices were found to be due to development of collaterals from high-pressure systemic vein to low-pressure portal vein. Bleeding gastric varix can be a late complication of total cavopulmonary shunt.

In this study, we evaluated changes in the cerebral circulatory and oxygenation status during deep hypothermic total circulatory arrest (TCA) and retrograde cerebral perfusion (RCP) using optical topography, a form of multichannel near-infrared spectrophotometry, to monitor the broad area perfused by the middle cerebral artery. Seven patients underwent thoracic aortic surgery with TCA and RCP via the superior vena cava. Pressure-regulated RCP was performed under pH-stat. No postoperative neurologic complications occurred. Using optical topography, the relative changes in oxy-, deoxy-, and total hemoglobin (oxy-Hb, deoxy-Hb, total Hb) were simultaneously measured from 24 points in both hemispheres. Deoxy-Hb was used for evaluating the regional oxygenation status under RCP. The values of deoxy-Hb at the beginning of RCP were regarded as the basal values, and the rate of increase in deoxy-Hb per minute was calculated at each site. Deoxy-Hb/min during TCA was also calculated. In every case, both oxy-Hb and total Hb decreased and deoxy-Hb increased during TCA. When RCP was initiated, the decrease in oxy-Hb and the increase in deoxy-Hb were attenuated. The deoxy-Hb/min was significantly lower under RCP than during TCA in all portions. There was no significant difference of deoxy-Hb/min between any portions during RCP. Our results showed that the status of circulation and oxygenation might be uniform in the brain during RCP and better than that under TCA.

Epicardial potentials of the sinus node, the right atrium, and the right ventricle were recorded in dogs during cold potassium-induced cardioplegia. We found that the sinus node fibers were more resistant to the cardioplegia than were the other myocardial fibers. When the cardioplegia rendered the atrial muscle inexcitable, the high frequency atrial potential was delayed and then abolished in the sinus node electrogram, and a smooth tracing similar to the action potential of the sinus node cell appeared. These findings should be pertinent for the cardiac surgeon attempting to avoid surgically-induced sinoatrial arrhythmias.

In patients who have aortitis syndrome associated with aortic regurgitation, aortic valve replacement (AVR) is frequently complicated by perivalvular leakage (PVL). A 47-year-old male with aortitis syndrome and severe aortic regurgitation was treated by AVR, modified in such a way as to prevent PVL. The aortic cusps were not resected and were placed between Teflon pledgets and the aortic annulus. We believe that this technique is useful for preventing PVL in patients with aortitis syndrome in which the aortic annulus is severely inflammed.