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症例は69歳, 男性. 67歳時, 急性心筋梗塞 (AMI) で#7にステントを留置され, 68歳時, 不安定狭心症で#6にステントを留置されている. 今回, このステントとステントの中間の部分にAMIを発症したため緊急PTCAを行ったところ, 左冠状動脈主幹部 (LMT) 解離に伴う急性冠状動脈閉塞が発生した. 心原性ショックとなったため, PCPSにより循環を補助し, LADに perfusion catheter, Cxにガイドワイヤーを挿入して緊急冠状動脈バイパス術 (CABG) を施行した. 手術は, PCPS下に体外循環確立後, VfとしてSVGをLADに吻合し, perfusion catheter とガイドワイヤーを抜去した後, 大動脈を遮断し, SVGをCx#13に吻合した. LMT解離に伴う急性冠状動脈閉塞に対するCABGにおいては, 確実な心筋保護が問題となる. perfusion catheter によりLADの灌流を維持したままVf下にSVGをLADに吻合した後に心停止とした今回のわれわれの方法は, 有用であったと考えられた.

A newly devised hybrid graft with high antithrombogenicity for small caliber vascular grafts was developed. The design concept was based on the incorporation of a compliant open cell structured graft, autogenous endothelial cells (ECs), and artificial basement membrane. The latter, a gel complex of type I collagen and dermatan sulfate that showed enhanced adhesion and growth of ECs but reduced platelet adhesion, was coated onto a microporous polyurethane graft (internal diameter, 3 mm; length, 4.5 cm), with near-natural compliance. Ten seeded grafts were implanted bilaterally into the carotid arteries of dogs; anticoagulant or antiplatelet therapy was not administered. This hybrid graft showed a marked improvement in patency at 1 month compared with that of simply preclotted grafts (control specimens). This result was explained by the almost complete endothelialization when the graft was implanted, a high degree of adherent strength resistance to shear stress, and a high proliferative potential. Thus, this approach of combining biomechanical and cellular engineering designs may lead to an important functional small caliber graft.

A rupture of the ascending aorta which occurred in a woman on the 13th postoperative day following a right upper lobectomy with mediastinal lymph node dissection for lung cancer is reported herein. Fortunately, the patient was rescued from a cardiac tamponade and hemothorax by emergency operation. The operative findings suggested a traumatic rupture of the aorta, however, lymph node dissection of the mediastinum could not be excluded as a possible cause. Therefore, careful mediastinal lymph node dissection should be carefully performed in operations for lung cancer.

We present a patient who suffered from composite graft infection and mediastinitis. After replacement of the infected composite graft, in addition to administration of antibiotics, continuous irrigation of the mediastinum with solutions containing povidone-iodine and cefazolin sodium and transposition of the greater omentum were performed. His postoperative course was uneventful. Combined therapies including mediastinal irrigation and omental transposition should be considered after an operation for composite graft infection complicated with mediastinitis.

A subepicardial aneurysm is a rare complication of myocardial infarction that sometimes causes a left to right shunt at the ventricular level. We report on echocardiographic observations in two recent cases of inferior myocardial infarction complicated by rupture of a subepicardial aneurysm into the right ventricle (RV). Two-dimensional and color flow Doppler images in several planes offered diagnostic characteristics of the lesion, including discontinuity of the myocardium at the neck of the aneurysm, a narrow neck relative to the diameter of the aneurysm, and a back and forth flow at the neck of the aneurysm. These techniques also provided new findings, such as a two-chambered structure of the aneurysm and a circular flow pattern within the inner aneurysmal cavity. In addition, color flow Doppler imaging showed multiple shunt flows from the aneurysm to the RV. Echocardiographically diagnosed abnormalities were verified by and successfully treated with surgery in both cases. In conclusion, echocardiography with color flow Doppler imaging may have the potential to diagnose the anatomic and hemodynamic condition of a subepicardial aneurysm. (J Am Soc Echocardiogr 1997;10:192-96.)

We recently encountered a case of idiopathic constrictive pericarditis with severe ascites. At the time of pericardectomy, intraoperative monitoring of the pressurevolume (p-v) loops of the left ventricle by the conductance catheter method ~' 2 was useful to evaluate the effects of the procedure. The patient was a 58-year-old man. At 56 years old, he had discomfort in his chest and dyspnea with exertion. The symptoms did not improve with medical manage

We investigated the effects of coenzyme Q 10 and verapamil, either alone or in combination, on cardiac function impaired by repeated ischemic arrests and reperfusion in the isolated rat heart. In the group with a single ischemic arrest, the aortic flow, cardiac output, stroke volume, coronary flow, and heart rate recovered well (72% to 100% of the prearrest values). In the repeatedarrest group, the recovery of aortic flow (24%), cardiac output (30%), stroke volume (40%), or coronary flow (63%) was much poorer than that in the single-arrest group. Pretreatment with coenzyme Q 10 given intraperitoneally improved aortic flow, cardiac output, stroke volume, coronary flow, and heart rate. The addition of verapamil to the reperfusion solution also protected the cardiac function with a decrease in heart rate. However, combination therapy with coenzyme Q 10 and verapamil further increased the recoveries of aortic flow, cardiac output, stroke volume, and coronary flow to 57%, 61%, 77%, and 84%, respectively, which were better than the values after treatment with coenzyme Q 10 or verapamil alone. We, therefore, suggest that treatment with coenzyme Q 10 or verapamil, alone or in combination, in addition to St. Thomas' Hospital solution effectively protects cardiac function impaired by repeated ischemic arrests and reperfusion.

肝部下大静脈閉塞によるBudd-Chiari症候群を合併した肝細胞癌の1例を報告した.症例は46歳の男性,主訴は下肢の浮腫である.入院時現症では貧血,黄疸はないが,肝脾腫と両下肢の浮腫を認めた.検査所見ではT-Bilirubin 2.7mg/dl, ICG R15'28.6%と異常値を示し,腹部超音波検査,腹部CT,血管造影などの画像診断で肝右葉に肝細胞癌が認められた.また,下大静脈造影で肝部下大静脈は,1.5cmにわたり完全閉塞をきたしていた.右開胸と上腹部傍正中切開にて開胸開腹を行い,肝右葉腫瘤の核出と下大静脈右房間に人工血管を用いてバイパス手術を行った.切除肝には1.9×1.6cmの被膜におおわれた腫瘤が認められた.バイパス後の下大静脈圧は23cmH2Oから12cmH2Oに低下した.術後10ヵ月経た現在,再発はなく,グラフト内の血流も良好で症状の改善が認められている.

Aneurysms of the interatrial septum are uncommon lesions that are often accompanied by other cardiac anomalies or systemic thrombosis. The authors report 1 case of atrial septum aneurysm that was diagnosed by two-dimensional contrast echocardiography. At surgery a membrane-like, fenestrated aneurys mal protrusion to the right atrium without thrombosis was seen. The atrial septum was closed without using an artificial patch after some of the aneurysm with fenestrations was resected.