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Intraductal papilloma is a rare benign salivary gland tumor. This lesion is commonly observed in the duct of the minor salivary gland, predominantly in lip and buccal mucosa, but the case in the sublingual region is quite rare. This report shows a first case of intraductal papilloma developed in minor salivary gland of sublingual region. A 47-year-old Japanese male was referred to our hospital with painless submucosal nodule in the right sublingual region beside Wharton's duct orifice. The excised specimen was histologically diagnosed as intraductal papilloma of minor salivary gland, according to the microscopic finding of the papillary growth of ductal epithelium into the ductal space with fibrovascular core. Immunohistochemical study showed the tumor cells originated from ductal luminal cells because of positive Cytokeratin 18 and 7 staining in both types of cells.

Surgical treatment for ischemic heart disease (IHD) has changed after the administration of off-pump coronary artery bypass grafting (CABG) [OPCAB] and left ventricular restoration (LVR). We studied the development of the treatment and the surgical results.Since May 2000 when the indication for OPCAB and LVR was defined, surgical treatment for IHD has been performed in 1,251 patients. The age ranged from 32 to 91 (mean 66 +/- 10) years and there were 977 men and 274 women. The elective operation was 1,130 and emergency 121. Definite indication for OPCAB was calcified ascending aorta, significant cerebrovascular disease, hemorrhagic tendency, and single vessel lesion. Conventional CABG (C-CAB) was the first choice and morbidity and surgical results were examined.OPCAB was performed in 297 (29.9%) and combined operation with CABG was required in 258 patients (20.6%). In elective operation, hospital mortality was one in OPCAB and one in C-CAB. In OPCAB and C-CAB, stroke was none and one, and mediastinitis was 0 and 0, respectively.The technique for OPCAB is necessary for CABG; however, it is not appropriate to persist with only OPCAB for CABG. Combined operation is often required with CABG and it is essential to perform precise C-CAB.

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.

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.

The aim of this study was to propose and validate a new method of making fused images from CT and FDG PET images for the upper abdominal area with no body surface marker. PET and CT were carried out in patients with pancreatic cancer (N = 5) and mass-forming pancreatitis (N = 2). First, we determined the midsagittal plane from PET and CT data. From the difference in location of the midsagittal planes, rotations of Y (from back to front) and Z axes (from foot to head) and X translation (from right to left) were calculated. An upper pole of the kidney was determined from PET and CT data. It showed Y and Z translations. The images of the three-dimensional data sets were fused on a workstation. Reproducibility was assessed with randomly misaligned PET and CT data sets. Pancreatic cancer and its lymph node metastases were identified easily on fused images. In reproducibility assessment, the average error of rotation was 0.77 degree. The average errors of translation were 3.43, 4.70, and 9.23 mm on the X, Y, and Z axes, respectively. In conclusion, this PET/CT image registration technique is feasible and practical. It allows precise anatomical assessment of normal and abnormal FDG accumulation.

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.

To investigate the usefulness of helical CT with low-dose and single-breath-hold scanning for lung cancer screening.Twenty-four helical CT scans of the lung were performed using various parameters in 10 healthy volunteers. The effects of tube current and pitch were evaluated by assessment of image quality and detection of simulated nodules. Screening helical CT was performed at 120 kVp, 50 mA, 1 sec/rotation, 10 mm collimation, and a pitch of 2.0 in 110 patients. The ability of this method to detect nodules and masses, focal parenchymal opacities, and diffuse fibrotic changes was evaluated using conventional CT as the gold standard.A reduction in tube current to 50 mA did not significantly change the assessment of image quality or detection of simulated nodules. Although these factors were degraded by increasing the pitch, there was no significant difference between 1.5 and 2.0. Screening helical CT permitted the entire lung to be scanned with ease during a single-breath-hold in all patients. This method detected 177 of 196 nodules and masses (87 of 91 lesions greater than 5 mm in diameter), 54 of 57 focal parenchymal opacities, and 15 of 15 cases with fibrotic changes.Screening helical CT with low-dose and single-breath-hold scanning shows promise for lung cancer screening.

In this report, we describe a patient who underwent coronary artery bypass grafting (CABG) through bilateral thoracotomy and distal median sternotomy, because he had received terminal tracheotomy as a treatment to prevent aspiration pneumonia due to Wallenberg's syndrome. On the first day after the terminal tracheotomy, he suddenly complained of severe anterior chest pain. Emergency coronary angiogram revealed complete occlusion of the proximal right coronary artery (RCA), severe stenosis of the left anterior descending artery (LAD) and the large first diagonal branch. Catheter intervention for RCA was attempted but it was unsuccessful, and therefore he was required to have urgent operation. The patient had received total laryngectomy and terminal tracheotomy two weeks before urgent CABG, and the large hole of the tracheotomy was just placed above the incisura juglaris of the sternum. So high risks of sternal infection and severe mediastinitis after ordinary median sternotomy were considered and we applied the bilateral thoracotomy approach. To our knowledge, this is very rare but effective approach to vascularize both right and left coronary artery and to use both left internal thoracic artery (LITA) and gastroepiploic artery (GEA) graft. It seemed that this approach is safe and effective for cardiac surgery in such situations that median sternotomy is not favorable as in the described patient or in patients having reoperation.

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.

In order to reduce radiation dose in the application of CT for lung-cancer screening, we investigated the potential of low-dose screening helical CT (SHCT) by reducing the tube current and using an additional 10 mm aluminum filter. Six healthy volunteers were scanned at various tube currents (50 mA, 30 mA, 20 mA) with and without the filter. In comparison with the images at 50 mA without the filter, we evaluated the visualization of normal anatomical structures and the detection of simulated nodules at low-dose SHCT. Although a bias toward unclearness in the visualization of small anatomical structures was noted at 20 mA with use of the filter, no structure was assessed as having no visualization at any low-dose scan. Detection of simulated nodules was not degraded significantly by reducing the tube current to 20 mA and using the filter. Further reduction of radiation dose at SHCT may be achieved by the application of small tube current and an additional filter.

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.

The detectability of various abnormal findings in helical screening CT(HSCT) with low-dose and single-breath-hold scanning of the lung was examined using conventional CT as a gold standard. In 75 patients, HSCT was obtained with scanning parameters of 120kVp, 50 mA, 10 mm-collimation. 20 mm/second and 1 sec/rotation. Conventional CT was obtained with 150 mA and 10 mm-slice contiguous scanning HSCT depicted 141 of 159 focal lesions in nodules and masses (65 of 69 lesions more than 5mm in size), 44 of 47 in infiltrative lesions, 11 of 11 in reticular lesions and 23 of 39 in bullae and blebs. There were only 3 false positive lesions in nodule and mass. Sensitivity, specificity and accuracy of HSCT for diffuse lesions were 100% (11/11), 95% (61/64) and 96% (72/75) for fibrotic change and 75% (9/12), 100% (63/63) and 96% (72/75) for emphysematous change, respectively. Since the detectability of HSCT was good for abnormal findings, showing increased attenuation in comparison with the lung parenchyma, it was considered to be a promising method for lung-cancer screening.

In order to examine the use of helical computed tomography (CT) in lung cancer screening, we evaluated the effects of tube current and table feed speed on image quality. CT images of normal volunteers, which were scanned under various tube currents (150mA, 100mA, 50mA) and various table feed speeds (15mm/sec, 20mm/sec, 25mm/sec, 30mm/sec), were visually evaluated by experienced diagnostic radiologists. The images were not affected by decreasing the milliamperage. However, as table feed speed increased, images were evaluated as significantly worse. Particularly, since the degradation of the images scanned at greater than 25mm/sec was remarkable, they were judged to be unacceptable for detection of the abnormality. In conclusion, a tube current of less than 50mA and table feed speed of less than 20mm/sec are suitable in the application of helical CT for lung cancer screening.

For coronary artery revascularization, the long term patency rate of internal thoracic artery (ITA) is excellent and arterial conduit for coronary bypass grafting (CABG) has been actively pursued. Application of the right gastroepiploic artery (GEA) is on the increase but, the patency of the GEA graft is more technically demanding than that of ITA. To improve early postoperative graft patency for coronary artery bypass grafting (CABG) for arterial graft, we modified the technique for anastomosis and demonstrated the patency by postoperative angiogram in 26 consecutive patients receiving CABG. The graft was anastomosed to the coronary artery using two 8-0. Prolene sutures for arterial graft and 7-0 Prolene sutures for saphenous vein (SV) graft. The heal and toe sides of the graft were sutured separately by the parachute technique (double parachute technique), followed by running suturing and typing at bilateral sides. The number of distal anastomoses was 3.4/patient and 44 arterial grafts and 40 SV grafts were used for coronary revascularization. Arterial grafts consisted of 33 ITAs, 9 GEAs, and two inferior epigastric arteries. The angiograms taken 10 to 14 days after operation demonstrated 100% patency rate of arterial grafts and 39 out of 40 SV grafts were patent. The overall patency rate in the early postoperative period was 98.8% The "double parachute" technique for CABG is highly accurate anastomosis with good visualization and the patency rates for all kinds of grafts were found to have improved.

The usefulness of the free inferior epigastric artery (IEA) as a coronary bypass graft was studied. Among 149 patients for coronary bypass grafting (CABG) between October 1992 and December 1994, the free IEA was used in 12 patients. The mean number of distal anastomosis was 3.7 per patient. The mean distal size of the IEA was 1.3 mm in diameter and the mean length was 9.4 cm. The IEA graft was anastomosed to the obtuse marginal branch in 5, to the diagonal branch in 4, and the right ventricular branch in 3. The proximal anastomosis of the IEA was constructed to the ascending aorta in three and to the saphenous vein (SVG) or to the internal thoracic artery (ITA) in 4 or 5, respectively. Postoperative angiogram demonstrated patent graft in ten and occluded graft in two in whom the size of IEA was less than 1.0 mm in distal diameter and the IEA was anastomosed to the aorta or to the SVG. The IEA was considered to be useful alternative arterial graft when it was used as "interposed graft" of which proximal anastomosis was made to the ITA and size-matching of the graft to the coronary artery was appropriate. The long-term patency of the graft can determine the true efficacy of the IEA for CABG.

Computed tomographic (CT) findings of pancreatic ductal adenocarcinoma were studied with the combined method of early enhancement CT and high dose enhancement CT in 72 carcinomas. Common Findings were change in pancreatic contour, abnormal attenuation in a tumor and dilatation of the main pancreatic duct. The incidence of abnormal attenuation and dilatation of the main pancreatic duct and bile duct was constant regardless of tumor size. The finding of hypoattenuation at early enhancement CT was most useful for demonstrating a carcinoma. However, this finding was negative in ten cases, five of which showed inhomogenous hyperattenuation at high dose enhancement CT. The detection of change in pancreatic contour and dilatation of the main pancreatic duct was most frequent at high dose enhancement CT. The finding of change in pancreatic contour and/or abnormal attenuation in a tumor could be detected in 47 cases at plain CT, 66 at early enhancement CT and 65 at high dose enhancement CT. Since the four cases in which neither finding was detected by any CT method showed dilatated main pancreatic duct, there was no case without abnormal CT finding. This combined CT method will be a reliable diagnostic technique in the imaging of pancreatic carcinoma.

Iron metabolism may be altered in patients with chronic active hepatitis C. In an attempt to evaluate whether excess iron contributes to liver injury, we used phlebotomy for removal of iron from patients with chronic hepatitis C.All 10 patients had histochemically detectable iron in the liver and underwent an initial period of weekly or monthly phlebotomy of 200 or 400 ml. A serum ferritin level of 10 ng/ml or less was chosen as the endpoint, and maintenance phlebotomy was performed if the level rebounded.The treatment reduced mean serum alanine aminotransferase activity from 152 +/- 49 to 55 +/- 32 IU/L; this level became normal in five of the 10 patients. Anti-HCV antibodies could be detected in all patients throughout the study. Histologic abnormalities of the liver were unchanged except for disappearance of iron deposits from seven of the patients studied.Our findings suggest that iron removal may be beneficial for patients with chronic active hepatitis C and histochemical iron in the liver.

Between August 1981 and August 1992, operation for ventricular septal perforation (VSP) after acute myocardial infarction (AMI) was performed in 12 patients and the results were studied. During this period, medical treatment was attempted as a standard therapy for more than two weeks after AMI, followed by operation. However, only four patients received elective operation two weeks after the onset of AMI. Regarding the relationship between the preoperative circulatory status and timing of surgery, elective operative could not be performed in seven patients showing a pulmonary to systemic flow ratio (Qp/Qs) of more than 3.0, while four out of five patients with a ratio of less than 3.0 received operation more than two weeks after the onset of AMI. Two patients with severe right heart failure after the repair of VSP died on table without weaning from the pump. Ten operative survivors were weaned from the pump without any difficulty of hemostasis and intraaortic balloon pumping was removed after operation. However, three patients died of multiple organ failure which had been deteriorating before operation. Postoperative activity improved to New York Heart Association Functional Class I or II in six survivors for the late follow-up period. In the case of high Qp/Qs due to VSP, early operation is recommended to prevent multiple organ failure.

Emergency coronary artery bypass grafting was performed in a 61 year old man who developed acute severe cardiac and respiratory dysfunction after myocardial infarction. At operation cardiac arrest was obtained by warm blood cardioplegia in antegrade intermittent fashion. The left anterior descending artery, diagonal branch, and right coronary artery were revascularized by saphenous vein (SVG). After declamping the aorta, spontaneous heart beating was obtained and postoperative course was uneventful. Postoperative examination showed patent all SVGs and improved cardiac function. Although the delivery of the warm blood cardioplegia was controversial, our recent study revealed that the intermittent antegrade delivery of warm blood cardioplegia showed no ischemic changes of the heart during the procedure.

Mitral lesion in 47 patients who received reoperation after an initial open mitral commissurotomy (OMC) for mitral stenosis (MS) was studied. The diagnosis before OMC consisted of pure MS in 38 patients, with mild mitral regurgitation (MR) in 8 and with moderate MR in 1. At OMC the diameter of the mitral orifice was a mean of 1.3 +/- 0.5 cm and a mobile cusp was found in 12 and a thickened cusp in 35 patients. Subvalvular fusion was seen in 15 patients, calcification of cusp or subvalvular region in 10 and left atrial thrombus in 6. After OMC, the diameter of the mitral orifice was opened to a mean of 3.2 +/- 0.3 cm. The interval between the initial operation and the time of reoperation was a mean of 124 months. The mitral lesion necessitating reoperation was MS in 18, moderate to severe MR in 10, and MSR in 19. At reoperation the mitral orifice ranged in diameter from 0.8 to 4.2 cm (mean, 2.3 +/- 0.8 cm). There was no correlation between the occurrence of MR or restenosis and the subvalvular division at initial OMC. Left atrial thrombus was identified in four and calcification in 17 patients. At reoperation 46 patients received mitral valve replacement, while only 1 received a second OMC. The removed valve showed no pathological findings of active rheumatic lesion but more severe calcification and hyalinization of the valve than those at initial operation. There were three early deaths (6.4%) after reoperation. The recurring mitral lesion seemed to consist of deteriorated pathological changes of the valve and MR and thus mitral valve replacement was recommended to provide a favorable operative result for non-flexible lesion after OMC.

We studied clinical and immunological changes of the post-transfusional syndrome like graft versus host disease (GVDH) in six patients after open heart surgery and in one patient after hepatectomy. In the patient with hepatocellular carcinoma, transcatheter arterial embolization had been previously done. All patients received homologous blood transfusion during and after surgery and erythroderma associated hyperthermia occurred approximately 10 days after operation. Patients receiving open heart surgery died on between postoperative 17th and 21st day. One patient with hepatectomy died on the 29th day after operation. Skin biopsies in all patients showed the findings of acute GVHD. The number of CD3+ and CD4+ T lymphocytes decreased at postoperative day 1, however, the number of CD3+ T lymphocyte increased in three patients after postoperative day 14. The postoperative value of interleukin-2 production was low in patients in whom the value was measured. The immunological status in host has not been clearly resolved. However, the postoperative changes of lymphocytes subsets were abnormal and IL-2 production in two patients showed low level. Therefore, it was considered that pre and postoperative measurement of cell-modiated immunity might predict the occurrence of the post-transfusional GVHD and might be one of useful examinations to prevent the disease.

Erythroderma as a manifestation of graft-versus-host disease after cardiac operations with blood transfusion may occur more frequently in Japan than in other countries. We have seen this problem in five patients who, after heart operations, died with symptoms and signs characteristic of graft-versus-host disease: cutaneous eruption, fever, diarrhea, leukopenia associated with agranulocytosis, and liver dysfunction. In the three patients seen most recently, skin biopsy showed findings similar to those of graft-versus-host disease after bone marrow transplantation. In addition, immunologic investigation showed remarkable differences in the findings in these patients and in those who did not have a graft-versus-host disease-like syndrome after cardiac operations. In particular, interleukin-2 production in response to mitogen stimulation was markedly diminished after operation in our patients, and the ratio of OKT4+ cells to OKT8+ cells in peripheral blood was low, reflecting increased numbers of OKT8+ cells after the occurrence of symptoms. The results raise the possibility that transient depression of cellular immunity after cardiac operations with blood transfusion may contribute to the occurrence of postoperative acute graft-versus-host disease.

It has been reported recently that cardiac operations can be followed by a transient impairment of cell-mediated immunity. In this study we examined indices of cell-mediated immunity in patients undergoing cardiac operations. Twenty-five of the patients received erythropoietin (200 U/kg) daily for 2 weeks before and after operation, and 30 matched control patients did not receive erythropoietin. On postoperative day 1, the numbers of total T cells and helper/inducer T cells were significantly higher in erythropoietin-treated patients than in control patients. The ability of patients' cells to make interleukin-2 in vitro increased after erythropoietin injection in the preoperative period. By postoperative day 1, erythropoietin-treated patients exhibited a fall in interleukin-2 production that was significantly less than that in control patients; levels increased by day 2 to a mean value twice that of the preoperative baseline and more than four times the corresponding mean level in the control groups, and levels returned to the baseline range by postoperative day 14. Levels of interleukin-2 production in erythropoietin-treated patients were significantly higher than those in control patients at each interval tested through postoperative day 7. These findings indicate that erythropoietin treatment not only augmented levels of circulating erythrocytes but also improved indices of cell-mediated immunity. Although the mechanism responsible for this effect remains to be determined, the finding suggests that erythropoietin might help to ameliorate or prevent the impairment of immune function that can occur after cardiac operations.

Since April in 1988 coronary artery bypass grafting (CABG) was performed in 177 patients and the clinical results were compared in SVG-group (n = 37) in which only saphenous vein graft (SVG) was used as a graft conduit and AG-group in which one arterial graft (AG-1 group, n = 92) or more than two arterial grafts were used (AG-2 group, n = 48). In SVG-group the age was older than that in AG-group, while coronary vessels were most involved in AG-2 group and the mean number of distal anastomosis increased more in AG-group. The total pump time and aortic cross clamping time showed no significant differences among the groups. Furthermore, the occurrence of perioperative myocardial infarction, requirement of intra-aortic balloon pumping, frequency of re-chest open for hemorrhage, or sternal infection showed no significant differences among the groups. Postoperative hospital deaths were in four (three cardiac deaths) of SVG-group and four (one cardiac and two graft-versus-host disease) of AG-group. These results suggest that the use of AG does not increase surgical risk and AG can be positively used for CABG.

The change of cell-mediated immunity was studied in patients receiving open heart surgery with or without administration of recombinant erythropoietin (rEPO). Group I was not administered rEPO in 30 patients, and Group II was done intravenously with 200U/kg/day of rEPO for 6.4 +/- 2.4 days before operation and also for 7.2 +/- 3.6 days after operation in 20 patients. The ratio of reticulocyte increased in all patients receiving rEPO. In both groups the ratios of OKT3 and OKT4 positive T lymphocytes decreased significantly on postoperative day 1. However, the ratios in patients with rEPO increased more significantly than in those without rEPO. Lymphocyte blast formation which was indicated by PHA-SI (phytohemagglutinin stimulation index) increased after administration of rEPO. The postoperative PHA-SI in both groups showed similar changes. The level of interleukin-2 (IL-2) production increased after the administration similar to PHA-SI change. The level of it decreased on postoperative day 1 and increased on postoperative days 3 and 7. We administered 200U/kg/day of rEPO for 7 days in a patient with postoperative erythroderma after open heart surgery and the level of IL-2 production was found to also increase in patient according with recovery of symptom. In conclusion, our data suggested that the rEPO might effect on not only erythrocyte but also lymphocyte activation.

Between January in 1988 and September in 1990, 65 patients underwent reoperation for acquired heart disease. Previous operations were closed mitral commissurotomy in 19, open mitral commissurotomy in 19, mitral valve replacement in 22, aortic valve replacement in one, and mitral repair in 4. After median sternotomy performed by hand-operated chisel and hammer, minimized dissection of the adhesive lesion was achieved. During the sternotomy, two patients required additional right thoracotomy because of marked median sternal adhesion and major cardiovascular injury occurred in three patients. Cardioplegic solution was introduced in normograde fashion except in two patients. In two patients with previous MVR by porcine prosthesis severe calcification was found in the left atrial wall and the prosthesis was not removed in one. Postoperative complications were low cardiac output syndrome requiring intra-aortic balloon pumping in two, re-thoracotomy due to hemorrhage in one, and mild air embolism without neurological damage in two. There was one early death (1.5%) but no late death. Although perioperative complication seemed to increase in reoperation, post-reoperative results was as good as those in the primary cardiac operation and reoperation on cardiac surgery should be performed before losing the indication for operation.

During 10 years between 1981 and 1990 surgical treatment was performed in 77 elderly patients (emergency 19) for cardiovascular disease at the 2nd Dept of Kurume Univ. Hospital. The 58 elective patients were studied. There were CABG in 29; valve replacement in 18; aneurysm operation in 11. The control patients were consisted of CABG in 60; valve replacement in 40; and aneurysm operation in 20 patients whose age were under 60 years. In the elderly group, operative mortality was 3 in 58 (5.2%) and there were no significant differences compared to that in the control patients. However, low output syndrome or respiratory complication was relatively prevented in the elderly patients and careful post operative management was required. The late results in the elderly patients NYHA or exercise tolerance was improved well. The 5 years actuarial survival rate was 93.3% in ischemic heart disease group, 87.7% in valvular heart disease group, and 90.0% in thoracic aneurysm group. No significant difference was seen compared to these results in control patients and no significant differences among these diseases.

During the last two years and six months, ten patients underwent operation for both coronary artery disease and non-cardiac surgery. There were six patients with vascular disease, three with gastric cancer and one with cholelithiasis. Six patients had simultaneous operation of both coronary artery bypass grafting (CABG) and non-cardiac surgery, and four underwent non-cardiac surgery mean of 105 days after CABG. The number of significant lesions of coronary artery in patients with simultaneous or two-staged operation was 2.2 +/- 0.8 or 2.8 +/- 0.5 per patient, respectively. The operative time in patients with simultaneous operation was 361 +/- 49 minutes. However, in patients with staged operation the time for cardiac surgery was 380 +/- 36 minutes and the time for non-cardiac operation was 388 +/- 83 minutes. There were no patients with complications after either cardiac or non-cardiac operation. In patients having surgical indications for both coronary artery and non-cardiac diseases, CABG should be performed prior to the non-cardiac surgery. In patients with normal cardiac function and sufficient operative time after CABG, concomitant operation seemed to be recommended. In case with advanced malignant disease or incompetent cardiac function, staged operation would be selected for good surgical result.

Two hundred and eighty two survivors after complete correction of tetralogy of Fallot were analyzed in late follow up periods. The method of the reconstruction of right ventricular outflow tract was non-transannular path (NTAP) in 110 patients and transannular patch in 172. In the group of TAP, pulmonary regurgitation occurred in all and the cardio-thoracic ratio was larger than the ratio in the group of NTAP (p less than 0.05). Postoperative ECG at rest showed complete right bundle branch block (CRBBB) in 224 patients and 6 of them showed sudden death in their follow up period. However, there were no sudden deaths in 41 patients without CRBBB. The rate of reoperation after intracardiac repair was 4.25% and the causes were residual pulmonary stenosis and residual ventricular septal defect, and there were no significant differences of the reoperation rate between NTAP-group and TAP-group.

We have experienced two patients of ischemic heart disease associated with renovascular hypertension. Patient 1 (60-year-old man) underwent LV aneurysmectomy and triple aortocoronary bypass grafting (saphenous vein to diagonal branch, left internal mammary artery to obtuse marginal branch, and right gastroepiploic artery to right coronary artery). Seventy five days after the initial cardiac surgery endarterectomy for the left renal artery and bifurcated Dacron graft implantation for the iliac artery obstruction were performed. Patient 2 (62-year-old woman) underwent simultaneous operation of both right nephrectomy and triple aortocoronary bypass grafting (saphenous vein grafts to obtuse marginal branch and right coronary artery, and left internal mammary artery to left anterior descending artery). Their postoperative courses were uneventful except unstable and high blood pressure for four to seven days after the operation. It appears that it should be decided to achieve either simultaneous or two stage approach for ischemic heart disease associated with renovascular hypertension based on the preoperative cardiac function. And both postoperative cardiac function and hypertension should be carefully managed until the blood pressure becomes stable after the surgery.

A 55-year-old female with massive aortic regurgitation and ostial stenosis of the right coronary artery due to aortitis syndrome was reported. The patient was admitted to the hospital with anterior chest pain and dyspnea on exertion. Retrograde aortogram showed massive aortic regurgitation and selective coronary angiogram revealed ostial stenosis of the right coronary artery. She was treated with aorto-coronary bypass (A-C bypass) and aortic valve replacement (AVR) with St. Jude Medical prosthetic valve. At operation, ostial stenosis of the right coronary artery due to aortitis syndrome was confirmed. Aortic valve replacement with a prosthetic valve and saphenous vein grafting to the distal right coronary artery were performed. Steroid therapy was started immediately after the operation. She recovered well and no complications was recognized after the operation.

Albumin (ALB)-positive cells were identified by an immunoperoxidase technique in 52 of 53 autopsy cases and in all of 13 surgical cases of hepatocellular carcinoma (HCC). The distribution pattern of ALB-positive cells could be classified into three groups: diffuse, localized, and sparse. The diffuse type was the most common pattern and was usually seen in well or moderately differentiated HCC, showing a trabecular growth pattern. The localized or sparse patterns were more frequent in poorly differentiated HCC showing a compact growth pattern. alpha-Fetoprotein (AFP)-positive cells were detected in 37 of the 53 autopsy cases of HCC and 11 of the 13 surgical cases. The number of AFP-positive cells and the intensity of the immunoperoxidase reaction were roughly proportional to serum AFP levels in most cases. In most regions of HCC, there seemed to be an inverse relationship between the number of ALB- and AFP-positive cells, suggesting tht most HCC cells synthesized only one of the two antigens studied. ALB-positive hepatocytes were found in all of the normal or cirrhotic livers examined and in the tumor-free regions of the HCC-containing livers. In contrast, AFP was not detected in nonneoplastic hepatocytes.

A case of abdominal aortic aneurysm in which dissection developed in retrograde fashion into the thoracic aorta is reported. The aortogram showed findings similar to DeBakey Type-IIIb dissection. No intimal tear was seen in the thoracic aorta; however, the origin of the intimal tear was found in the abdominal aorta. Renal hypertension also developed due to distal dissection of the right renal artery. Closure of the primary intimal tear, partial closure of the false channel and removal of the right kidney were performed therefore, reattachment of vessels was not required. This was the first case in which a primary tear was seen in the abdominal aorta in our 37 surgical cases of dissecting aortic aneurysm. Three cases of retrograde dissection of abdominal aortic aneurysm have been reported in the English literature as far as we have determined. The importance of accurate detection of the origin of the intimal tear is emphasized.

We studied two unusual cases of malignant histiocytosis (MH). In one case, a solitary intracranial tumor developed in a 20-year-old man eight months before the characteristic symptoms of MH appeared. In the other, a 73-year-old man had multiple nodular skin lesions four months before malignant histiocytes appeared in his blood. In both, the tumor cells were identified as malignant histiocytes by light and electron microscopic, cytochemical, and cytoimmunological criteria.

Eighty-nine patients received mitral valve replacement with Carpentier-Edwards porcine bioprostheses between 1975 and 1983. Eighty-three patients (93.3%) were followed up after the operation; early death (within one month of operation) occurred in 6 patients and late death in 2 patients. After the operation, 64 survivors (85.3%), who did not require reoperation, exhibited improved symptoms according to the NYHA functional class. Of the 6 patients (6.7%) who required reoperation, 5 patients underwent reoperation 50 to 85 months after the implantation. Pathologically, all the removed valves showed degeneration of collagen and elastic fibers, no host endothelialization and mild to moderate infiltration of inflammatory cells. Thrombus in the left atrium was detected in one case. Destruction of the cusps was seen in three cases and calcification of the cusps developed in three cases. In general, the Carpentier-Edwards porcine bioprosthesis provided good clinical improvement over the periods studied. However, morphological changes of the bioprosthetic valve, such as destruction collagen and elastic fiber, and inflammatory cell infiltration of the cusps, seems to occur more frequently with the passage of time. We therefore suggest that patients with this prosthesis should be followed carefully, particularly at late intervals after implantation.