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Cardiac surgery in a patient with myelodysplastic syndrome (MDS) increases the risk of bleeding and infection. Here we report a case of a 70-year-old man with MDS who underwent successful replacement of the aortic root with the valve-sparing technique and proximal arch for aneurysmal dilatation from the aortic root to ascending aorta with moderate aortic valve regurgitation. Perioperatively, a transfusion of red blood cells and an infusion of a grannulocyte colony-stimulating factor were required for his serious erythrocytopenia and leukocytopenia. Bleeding tendency was so severe that re-exploration to control postoperative surgical bleeding was performed and a large amount of blood cells were transfused. There was no infection on the postoperative course. Perioperative management for cardiac surgery in patients with MDS must be carefully programmed by a co-operative team consisting of cardiovascular surgeons and hematologists.

We describe the use of rib-cross thoracotomy and costal coaptation pins made with bioabsorbable poly-L-lactide for rib approximation. This thoracotomy provided an excellent intraoperative exposure of the entire descending aorta and thoracoabdominal aorta in patients with extended thoracoabdominal aortic aneurysm without increase in postoperative morbidity.

To investigate whether the use of a stentless porcine aortic xenograft can be an alternative for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure, 9 patients underwent the Ross procedure and RVOT reconstruction with a stentless xenograft since January 2000. After the aortic valve was replaced with a pulmonary autograft, a stentless xenograft with a xeno- pericardial roll was implanted in the RVOT. One patient required subsequent aortic valve replacement because of severe regurgitation of the pulmonary autograft. All patients recovered well from the operation. The right ventricle-pulmonary arterial pressure gradient was 18 +/- 7 mm Hg at discharge and was not significantly increased during the 2-year follow-up period. Although 1 patient died of ventricular arrhythmia 5 months after, his cardiac function was normal, and transpulmonary valve pressure was 19 mm Hg in the follow-up. The other 7 patients are currently in New York Heart Association functional Class I. Although long-term follow-up is required to explain the durability, the stentless xenograft with a pericardial roll is considered to be an alternative for reconstruction of the RVOT within 2 years after the Ross procedure.

One-hundred-one surgeries for aortic arch aneurysm were divided into 2 groups: 52 aortic dissection cases (AD) and 49 non-dissecting aneurysm (TA). In group AD, 30 cases were operated in acute phase (acute AD) and 22 were in chronic phase (chronic AD). Preoperative shock were observed in 21 cases (15 in acute AD mostly due to cardiac tamponade, 1 in chronic AD and 5 in TA due to rupture). Through median sternotomy, 59 total arch replacement and 25 hemi-arch replacement were carried out under deep hypothermia (16 degrees C:DH) and retrograde (RCP) or selective (SCP) cerebral perfusion or arch-first technique. Through thoracotomy, distal arch replacement were carried out with DH + RCP in 8 cases and with partial bypass in 9. Early mortality were observed in 7 patients (6.9%) and 24 months survival rates (Kaplan-Meier) were 86.1% overall, 76.1% in acute AD, 95.5% in chronic AD, 87.8% in TA. The survival rates in patients with preoperative shock was 61.2%, however, without shock, 92.9% in acute AD, 95.2% in chronic AD, and 91.4% in TA. Other than mortality, 4 re-operations for aortic arch, 4 operations for descending to abdominal aorta and 1 late hemiplegia were observed. Aortic event free ratio at 24 months was 55.4% in acute AD, 94.4% in chronic AD, and 75.7% in TA. For the further improvement of aortic arch surgery, early mortality and residual false lumen in acute aortic dissection and atherosclerotic aneurysm in descending to abdominal aorta are focused.

Objective: The potential benefits of adynamic cardiomyoplasty remain unclear. We determined whether unstimulated skeletal muscle wrap alone prevents or attenuates progressive left ventricular dilation in a canine model of congestive heart failure produced by repeated intracoronary infusions of doxorubicin., Subjects and Methods: 14 dogs were randomized in to 2 groups, 1 undergoing cardiomyoplasty (CMP group) and 1 that did not (CONT group). Intracoronary doxorubicin was administered weekly for 5 weeks to induce heart failure. Hemodynamic data was obtained before infusion and 5 weeks afterward. Echocardiography was done weekly., Results: Significant left ventricular dilation was observed in the CONT group--left ventricular end-diastolic diameter increased from 28.9 +/- 2.7 to 38.5 +/- 3.3 mm (p < 0.05). Significant left ventricular dilation was also observed in the CMP group--left ventricular end-diastolic diameter increased from 28.9 +/- 3.3 to 38.0 +/- 4.2 mm (p < 0.05). Dilation was slower in the CMP group than in the CONT group, however. Ejection fraction decreased from 58.0 +/- 13.8 to 29.9 +/- 13.7% in the CONT group, but was preserved from 56.0 +/- 8.8 to 51.9 +/- 10.3% in the CMP group., Conclusions: Adynamic cardiomyoplasty reduces ventricular dilation associated with heart failure without exacerbating left ventricular dysfunction.

Factor XII deficiency has been reported to be a risk factor for thromboembolism as a result of inactivation of fibrinolysis. We describe a case of a huge left atrial thrombus with mitral stenosis, which was successfully removed surgically in a Factor XII deficient patient.

We describe a 54-year-old male with severe coronary artery disease and cerebrovascular disease including right cerebellar infarction, total occlusion of the bilateral vertebral arteries, brainstem ischemia, and right cerebral infarction with significant right carotid artery disease. Repeated percutaneous transluminal coronary angioplasty had been performed, however, unstable angina was developed despite maximal medical treatment. Coronary artery bypass grafting was successfully undergone with use of propofol, application of the intra-aortic balloon pumping perioperatively, and mild hypothermic cardiopulmonary bypass with alpha-stat blood gas management. The importance of preoperative evaluation of the intracranial circulation and management of cardiopulmonary bypass are discussed.

A saccular aneurysm in the right-sided aortic arch with aberrant left subclavian artery is an uncommon disease, and surgical treatment is complicated. Three patients with Edwards type III-B right aortic arch and enlargement of the Kommerell's diverticulum underwent operations. Right thoracotomy was the preferred approach for this lesion and partial cardiopulmonary bypass is a safe and simple procedure when the aortic arch has mild atherosclerosis.

Papillary fibroelastoma is a small and rare benign intracardiac tumor that most frequently arises from the valvular endocardium. We report a patient with acute myocardial infarction in whom a papillary fibroelastoma in the left atrial appendage was detected by a transesophageal echocardiography during evaluation of the myocardial infarction. The roles of transesophageal echocardiography and surgical intervention are discussed.

In recent years much attention has been paid to a minimal invasive surgery even in the field of cardiac surgery. We have successfully treated a 59 year-old male who underwent transaortic video-assisted thrombectomy in the left ventricular cavity following acute myocardial infarction due to occlusion (No. 7) of the left descending coronary artery (LAD). After the LAD was recanalized by percutaneous transluminal coronary angioplasty (PTCA) and then stenting, this thrombectomy was carried out. Following initiation of cardiopulmonary support, thrombus in the left ventricular apex was safely removed by transaortic endoscopic guidance. This technique was useful especially for the patient with poor ventricular function due to acute myocardial infarction because of no left ventriculotomy. Endoscopic guidance technique is reported in detail.

A mobile and pedunculated left ventricular thrombus was developed after acute myocardial infarction in a 59-year-old man, and was successfully removed surgically through the aortic valve using a video-assisted thoracoscope. Transaortic video-assisted thoracoscopy greatly facilitated exposure of the interior of the left ventricle and preserved left ventricular function by avoiding ventriculotomy.

Dynamic cardiomyoplasty (DCMP) has been performed in more than seven hundreds cases world wide. However, despite symptomatic improvement in the majority of patients surviving the procedure, objective hemodynamic effects have not been consistently demonstrated. Previous studies reported that left ventricular function deteriorated and returned to preoperative level in the chronic phase. We previously reported that atrophy of the latissimus dorsi muscular flap (LDMF) was responsible for the effect of DCMP on improvement of cardiac function in the chronic phase. Ischemia of the muscle flap was proved to induce peripheral muscular atrophy of the flap, and thus preservation of the blood flow is important in preventing muscular atrophy. In the present study, we applied omental flap to LDMF, and postulated that the omentum would improve vascularity and perfusion of latissimus dorsi and prevent peripheral muscle atrophy. In dogs, the right and left latissimus dorsi muscles were dissected free from all attachment except for its thoracodorsal pedicles, and omental flap was wrapped around peripheral part of the left LDMF. Tissue blood flow, maximal muscle isotonic strength, morphologic features, and tissue vascular endothelial growth factor (VEGF) were examined in left LDMF with omental flap (OM group) and in the right LDMF served as the control (Control group). In the distal part of the LDMF, tissue blood flow of OM was significantly preserved than Control (86.4 +/- 6.5% in OM and 33.6 +/- 3.4% in Control, p < 0.05). Maximal isotonic tension was significantly higher in OM as compared to Control. Microscopic findings of H and E stained specimen from distal part of LDMF showed that muscle fibers were preserved in OM. And in the distal part, VEGF expression of OM was 49.6 +/- 7.9 pg/100 micrograms protein and significantly higher than that of Control. Our results indicated that induced endogenous VEGF expression in the LDMF by the omental flap preserved blood perfusion and muscular strength of the LDMF, and suggested that dynamic cardiomyoplasty might not lose its long-term direct cardiac assistance when an omental flap applied for the latissimus dorsi muscle flap.

Background: The aged myocardium accumulates significantly more cytosolic calcium [Ca2+]i during ischemia, and functional recovery is more severely compromised as compared with the mature heart. Cardioplegia ameliorates these phenomena. The mechanism by which increased calcium accumulation reduces functional recovery in the senescent myocardium is unknown, but it has been suggested that futile calcium cycling in the mitochondria leading to depletion of ATP stores during normothermic global ischemia may be involved., Methods and Results: To investigate the effect of cardioplegia on mitochondrial calcium ([Ca2+]mt) accumulation and the expression of cytochrome oxidase I (COX I) during global ischemia, mitochondria were isolated from mature (age, 15 to 20 weeks) and aged (age > 130 weeks) rabbit hearts after Langendorff perfusion. Five perfused heart groups were investigated: 30 minutes of global ischemia without treatment (control), with potassium (K, 20 mmol/L), magnesium (Mg, 20 mmol/L), or potassium and magnesium (K/Mg) cardioplegia. No significant difference in [Ca2+]mt was evident in mature hearts with any protocol. In aged hearts, [Ca2+]mt was increased in global ischemia but was ameliorated with Mg and K/Mg cardioplegia. COX I mRNA levels in aged hearts were lower in both control and global ischemia but were increased with cardioplegia. Maximal velocities for COX I were significantly increased with Mg cardioplegia both in the mature and the aged myocardium., Conclusions: K and/or Mg cardioplegia ameliorates [Ca2+]mt accumulation in aged hearts during normothermic global ischemia and increases COX I mRNA levels to a level not significantly different from that found in mature hearts.

To determine the permissible range of the St. Jude Medical 19 mm valve (SJM19) as an aortic prosthesis, transvalvular maximal pressure gradient (maxPG) and postoperative reduction of left ventricular (LV) hypertrophy were examined in 21 patients (body surface area [BSA] 1.28-1.56 m2, mean 1.42 m2). Doppler echocardiographically measured maxPG at rest was 31 +/- 16 mmHg, which showed no significant difference from the differences in patients' diseases (aortic regurgitation = AR or stenosis = AS), or BSA. The maxPG, also measured during dobutamine administration when they were less than 40 mmHg at rest, increased significantly from 21 +/- 11 mmHg to 32.1 +/- 15 mmHg, having no differences from the differences in diseases or BSA. Reduction of LV hypertrophy was achieved postoperatively (mean postoperative period of ten months), with the reduction rates of 26 +/- 19% in LV mass and 21 +/- 15% in LV cross-sectional area. No significant differences were found between the reduction rates and the differences in the patients' diseases or BSA. These results indicate that, following the implantation of SJM19, LV hypertrophy was reduced in patients with AR as well as with AS, when their BSA values were less than 1.6 m2. However, limited use is recommended because the increase in pressure gradient during exercise cannot be ignored.

Background: Previously, we have shown that normothermic global ischemia increases cytosolic calcium accumulation in both the mature and aged heart. Increased nuclear and mitochondrial calcium accumulation was shown to occur in the aged but not the mature heart, and these age-related differences were associated with increased DNA fragmentation and decreased cellular viability only in the aged heart., Methods: To investigate the relationship between increased mitochondrial and nuclear calcium and DNA fragmentation, mature and aged rabbit hearts were subjected to normothermic global ischemia with and without the addition of ruthenium red to block mitochondrial calcium influx. Cytosolic calcium accumulation was measured in a parallel experiment using fura-2., Results: Ruthenium red ameliorated mitochondrial calcium accumulation and was associated with both decreased DNA fragmentation and decreased nuclear calcium accumulation., Conclusions: Nuclear calcium accumulation was correlated with increased mitochondrial calcium accumulation but not increased cytosolic calcium accumulation in the aged heart. Modulation of mitochondrion "futile calcium cycling" may be of significance in the modulation of ischemic myocardial injury.

Previous reports have indicated that the senescent myocardium is less tolerant to surgically induced ischemia and that diminished functional recovery is associated with alterations in cytosolic calcium ([Ca2+]i) accumulation. Recently, increased [Ca2+]i has been suggested to alter nuclear calcium ([Ca2+]n) accumulation. To investigate the relation between [Ca2+]i and [Ca2+]n, we subjected mature and aged rabbit hearts to normothermic global ischemia, either without treatment or after treatment with potassium cardioplegia, magnesium cardioplegia, or a combination of potassium and magnesium cardioplegia. The relation between altered [Ca2+]n and DNA fragmentation was also investigated. Our results indicate that [Ca2+]i was increased during 30 minutes of normothermic global ischemia without treatment in both the mature and aged hearts (p < 0.05). Accumulation of [Ca2+]i during global ischemia was reduced with the use of potassium, magnesium, and a combination of potassium and magnesium cardioplegia (p < 0.05 versus untreated ischemia) in both the mature and aged hearts. Levels of [Ca2+]n were unaffected by global ischemia or cardioplegia in the mature myocardium; however, in the aged myocardium, [Ca2+]n was increased during global ischemia and with potassium cardioplegia and was associated with increased nuclear DNA fragmentation (p < 0.05). The use of magnesium and a combination of potassium and magnesium cardioplegia attenuated [Ca2+]n accumulation and nuclear DNA fragmentation (p < 0.05). Control of [Ca2+]i and [Ca2+]n was associated with enhanced functional recovery during reperfusion. These results indicate that during normothermic ischemia, there is increased [Ca2+]i and [Ca2+]n in the aged myocardium, and increased [Ca2+]n is associated with increased nuclear DNA fragmentation.(ABSTRACT TRUNCATED AT 250 WORDS)

The usefulness of dynamic cardiomyoplasty has been demonstrated repeatedly, both experimentally and clinically. Although clinical applications of dynamic cardiomyoplasty to ischemic heart disease have been reported, its effect on the coronary blood flow has never been discussed. Therefore, we tested the hypothesis that dynamic cardiomyoplasty might adversely affect coronary arterial blood flow through compression of the coronary arteries during systolic skeletal muscular contraction and incomplete relaxation of the skeletal muscle flap during diastole. Dynamic cardiomyoplasty was performed in seven mongrel dogs with the use of a left latissimus dorsi-muscle flap, paced synchronously with the R wave of the electrocardiogram. A 3F Doppler catheter was placed in the left main trunk of the coronary artery to assess the instantaneous changes of coronary flow velocity by fast Fourier transformation analysis, We compared systolic and diastolic properties during assisted versus unassisted cardiac cycles by calculating the peak velocity and the time-velocity integral. During assisted cardiac cycles, a significant enhancement of coronary arterial blood flow velocity was demonstrated by significant increases in both systolic and diastolic peak velocity (26.9% +/- 6.5%, p < 0.005; 4.0% +/- 1.6%, p < 0.05, respectively) and time-velocity integral (20.9% +/- 4.8%, p < 0.05; 10.0% +/- 4.6%, p < 0.05, respectively). Enhancement of coronary arterial blood flow velocity was associated with an increase in mean aortic pressure (16.4% +/- 1.3%, p < 0.005) and descending aortic flow (67.5% +/- 5.3%, p < 0.005). Also, the improved systolic coronary arterial blood flow velocity was consistent with an increase in systolic aortic pressure (15.8% +/- 1.5%, p < 0.005), and enhancement of diastolic coronary arterial blood flow velocity was associated with an increase in diastolic aortic pressure (8.6% +/- 2.3%, p < 0.01). We concluded that coronary arterial blood flow velocity was increased by the enhancement of cardiac function as a result of dynamic cardiomyoplasty, leading to an increase of coronary perfusion pressure and cardiac output.

We investigated whether or not dynamic cardiomyoplasty adversely affected coronary arterial blood flow (CABF) through compression of the coronary arteries by muscular contraction during systole and incomplete relaxation of the skeletal muscle flap during diastole. Dynamic cardiomyoplasty was performed in 20 mongrel dogs using a left latissimus dorsi muscle flap, paced synchronously with the R wave of the electrocardiogram. A Doppler catheter (3 F in diameter) was placed in the left main trunk of the coronary artery to analyze the instantaneous changes of coronary arterial blood flow velocity by fast Fourier transformation analysis. We compared both systolic and diastolic properties during assisted versus unassisted cardiac cycles by calculating the peak velocity and the time velocity integrate (TVI). A significant enhancement of systolic CABF was recognized by increases in the systolic peak velocity (26.5 +/- 29.2%) and TVI (20.2 +/- 38.6%). The improved systolic CABF was consistent with an increase in systolic aortic pressure (15.5 +/- 4.3%) and stroke volume (42.8 +/- 11.2%). CABF was also enhanced in diastole because a significant increase of diastolic peak velocity (4.4 +/- 9.4%) and TVI (11.0 +/- 16.7%) was observed. Enhancement of diastolic CABF was associated with the augmentation of cardiac function and the reduction of left ventricular end-diastolic pressure. It could be concluded that CABF was increased by the enhancement of cardiac function as a result of dynamic cardiomyoplasty leading to an increase of cardiac output and aortic pressure and a decrease of left ventricular end-diastolic pressure.

This study was undertaken to examine the effect of cardiac assist and left ventricular function after dynamic cardiomyoplasty (DCMP). In the first group (GI) of 10 mongrel dogs DCMP was drived immediately after wrapping both ventricles by latissmus dorsi muscle flap (LDMF). In the second group (GII) of 10 mongrel dogs DCMP was derived over 6 weeks after production of DCMP for achievement of complete adhesion between LDMF and myocardium. In the both groups, aortic pressure, cardiac output, left ventricular systolic pressure, and ejection fraction of the left ventricle were significantly increased by DCMP driving (p < 0.001). But left ventricular systolic pressure was remarkably increased in GII compared with that of GI (21.2 +/- 10.2% versus 14.0 +/- 9.6%, p < 0.001), and end diastolic pressure of the left ventricle was apparently decreased in GII (61.6 +/- 42.3% p < 0.05). Thus, satisfactory results were recognized that cardiac assist for left ventricular function was enhanced after completion of adhesion between myocardium and LDMF. Echocardiography in GII demonstrated that left ventricular systolic dimention was significantly decreased from 33.8 +/- 1.0 mm to 27.6 +/- 1.2 mm (p < 0.001). Thus, left ventricular fractional shortening was significantly increased from 24.0 +/- 2.4% to 38.0 +/- 2.6% (p < 0.001). However, left ventricle end-diastolic dimention was not changed even during DCMP driving. So disturbance in left ventricular function during diastole could not be recognized. In conclusion, especially after adhesion of both muscles of LDMF and myocardium, effect of cardiac assist was remarkably enhanced, and disturbance of diastolic function of the left ventricle could not be observed.

The purpose of the present study is to evaluate the effects of addition of a bridge external traction to our conventional sternocostal elevation technique in the surgical management of funnel chest in children. During the period from 1970 to 1979, a total of 29 children with funnel chest were treated surgically using sternocostal elevation technique (Group I). Operative technique consisted of total subperichondral resection of deformed costal cartilages (usually 3rd to 8th, bilaterally), transection of deformed portion of the sternum in 2-3 points and fixation of the sternum in elevated position using 2 Kirschner wires, and shortening resuturing of the opened perichondrium. Since 1980, an addition of the bridge external traction to our conventional sternocostal elevation technique was applied for about 10 days after operation in 82 consecutive children (Group II). The vertebral index (B/A = sagittal diameter of vertebral body/minimum sternovertebral distance), D/C ratio (maximum sagittal depth of depression of sternum/distance from anterior surface of the vertebral body to the sternum at Louis's angle) and E/C ratio (E = minimal sagittal distance from anterior surface of the vertebral body to the sternum) were measured in all cases and compared before and after operation and also between the two Groups. Preoperatively, there was no significant difference in all 3 indices between the two Groups. Postoperative B/A, D/C and E/C ratio in Group I were 0.28 +/- 0.06, 0.14 +/- 0.19, 1.09 +/- 0.32 (mean +/- SD), respectively. There were a significant drop in D/C ratio and a significant elevation in E/C ratio after operation.(ABSTRACT TRUNCATED AT 250 WORDS)

To evaluate the function of various types of mechanical heart valves (Björk-Shiley = BS, Medtronic Hall = MH, St. Jude Medical = SJM, Duromedics = DM), hemodynamic studies were performed in 236 patients with valve replacement in addition to the evaluation of the clinical results. In 144 patients with mitral valve replacement including patients with double valve replacement, the degree of the postoperative improvements of clinical symptoms and hemodynamics were similar in patients with BS, DM and MH valves. There was a tendency for the effective orifice area calculated from pressure-half time obtained by continuous-wave Doppler (CWD) echocardiography to be larger in MH or DM valves than in BS valve of the same size on the average. In 115 patients with aortic valve replacement including patients with double valve replacement, there was no significant difference in the degree of postoperative reduction of the left ventricular hypertrophy among the patients with BS, MH and SJM valves. The mean value of the pressure gradient (PG) across the valve at rest obtained by CWD was less than 20 mmHg in each type of valve without significant difference among the valves. PG well correlated with cardiac output (CO) in each type and size of valve, and the rate of increase in PG with the increase in CO was smaller in the larger-sized valve of the same type and also smaller in MH valve than in BS valve of the same size. The frequency of valve-related complications was extremely low in each type of valve except for a higher incidence of occult hemolysis in SJM and DM valves. Overall, there were no significant differences in the clinical results among the patients with valvular prostheses examined. However, MH valve had advantages in hemodynamics and a lower incidence of hemolysis.

We successfully performed a total resection of the pulmonary artery trunk and replaced it with an equine pericardial xenograft roll in a patient with a recurrent leiomyosarcoma. We believe, based on anatomic and embryologic principles, total rather than partial resection of the pulmonary artery trunk should be the treatment of choice for primary leiomyosarcomas of the pulmonary artery.

The authors manufactured an experimental catheter to obtain blood flow rate, measuring not only the flow velocity but also the vessel diameter. This catheter consists of 3F Doppler and 7F external sheath catheters, and four thin wires 3 cm in length are attached to the catheters at both tips at a 90 degrees pitch. After the insertion of the catheter into the vessel, vessel diameter is calculated from the maximal width of the wires, which are expanded to a spindle shape inside the vessel; the maximal width is corrected with calibration metal markers also attached at the proximal site of the external sheath catheter. The flow velocity of the blood is calculated with the FFT (Fast Fourier Transform) analyzer. In experimental circuits as well as in the canine aorta, wires were adequately expanded, and the catheter was placed at the center of the tube or the aorta. The blood flow rate, which was calculated as a product of flow velocity and vessel diameter, was well correlated to that from the electromagnetic flowmeter, not only in the experimental circuits, but also in the canine aorta.

Leiomyosarcoma of the esophagus is a rare neoplasm, with only 95 cases having been reported in the literature. Dysphagia is the most commonly noted symptom, however, because of its location in the submucosal layer, the tumor has usually grown to a considerable size by the time this presents. We report herein a case of a 39-year-old man who had no symptoms other than a 7 month history of a cough. After several investigations, the patient underwent resection of the thoracic and abdominal esophagus with lower lobectomy of the right lung through a right and left thoracotomy. The tumor measured 18 x 15 x 8 cm in length and weighed 1,500 g, being the biggest such tumor ever reported. Forty days after the first operation, an extended right hepatic lobectomy of the liver was performed for hepatic metastasis. He was discharged from the hospital 20 days after the second operation and is now doing well. The clinical features and surgical treatment of leiomyosarcoma of the esophagus are discussed herein.

To detect the genesis and the prognosis of left ventricular failure (LVF) following the valve replacement surgery to mitral stenosis (MS), preoperative values and postoperative courses were assessed in 90 patients with MS. The criteria for LVF were as follows: postoperative severe left ventricular (LV) dysfunction which required intra-aortic balloon pumping (IABP) support with large doses of catecholamine. Among these 90 patients, LVF had occurred in 13 patients, of which 6 had a definite cause of LVF (group A), but the other 7 patients failed to LVF despite uneventful operation (group B). Comparing the pre- and postoperative values in these two groups, the duration of IABP support was much longer in group A, and the weaning rate from IABP was also poor in this group. Long-term survival was achieved only by one patient in group A, whereas 5 out of 6 patients of group B survived long-term postoperatively. Evaluating the preoperative LV function in group B patients, depressed LV function [%fractional shortening (%FS) less than or equal to 27%] was observed in 5 patients. Among these 5 patients, three had low cardiac output; in other two, preoperative %FS was severely depressed. In such patients, the responses to preoperative dobutamine administration tests were poor, and the values of %fibrosis of the LV myocardium, which was demonstrated by intraoperative biopsy, was greater in them. In conclusion, the causes of postoperative LVF following the mitral valve replacement to MS was divided into two categories: one due to perioperative complication and another due to preoperatively impaired LV function.(ABSTRACT TRUNCATED AT 250 WORDS)

To investigate factors affecting surgical outcome of open heart surgery in neonates, a retrospective review was carried out on 38 patients operated in the 9 years period from May 1981 to August 1990, in our institution (TAPVR19, TGA7, HLHS7, and others 5). In the former 3 years and 9 month period, 12 patients were operated with the use of profound hypothermia and circulatory arrest (Group I) and in the latest 5 year and 5 month period, continuous deep hypothermic bypass was used in all but for 7 patients with HLHS (Group II). In the group of neonates with TAPVR, operative mortality improved to 7% (1 of 14) in Group II compared to that of 60% (3 of 5) in Group I. CVP and LAP measured immediately after cessation of cardiopulmonary bypass (CPB) were lower in Group II and the value of CPK-MB was significantly lower in Group II. There was a significant negative correlation (r = -0.695, p less than 0.05) between CPB time and urine volume for 72 hours after operation. A significant negative correlation (r = -0.899, p less than 0.01) was also obtained between CPB time and urine volume in the group of 7 neonates with TGA. There was no significant difference in urine volume between patients with TAPVR and TGA despite of significantly longer CPB time in patients with TGA. It is concluded that, 1) improved protection of cardiac and renal function was obtained in neonates operated with the use of continuous deep hypothermic bypass, 2) surgical outcome was influenced by the method of CPB, CPB time and differences in cardiac function ascribed to primary lesions.

We report the case of a 4-year-old girl with an anomalous origin of the left anterior descending coronary artery from the pulmonary artery in association with tetralogy of Fallot. Creation of an intrapulmonary tunnel from a newly created aortopulmonary window to the coronary ostium in the pulmonary trunk and total repair of tetralogy of Fallot were successfully carried out. The advantage of intrapulmonary tunnel technique (Takeuchi method) for this very rare combination is stressed.

An eight-year-old girl with partial atrioventricular canal defect and hypoplastic right ventricle was treated successfully by a palliative open-heart surgery. The preoperative right ventricular pressure was 58/7 mmHg (RVP/LVP = 0.67) and morphology of the right ventricle showed severe tricuspid stenosis and small outflow portion. The preoperative RVEDVI was 31 (41% of normal and tricuspid annulus was 17 mm (47% of normal). The right ventricular outflow was reconstructed with insertion of MVOP and the ASD was partially left open (the amplitude of the interatrial communication was 7 mm). Angiocardiogram two and half years after the operation demonstrated significant right ventricular growth with no right to left shunt through interatrial communication. The RVEDVI was 46 (56% of normal) and tricuspid annulus was 36 mm (90% of normal). This technique can be a procedure of choice in patient with right ventricular hypoplasia, who is not candidate for simple right ventricular reconstruction nor Fontan procedure, as the growth of the right ventricule is expected in the future.

Renovascular hypertension due to iatrogenic thoracoabdominal aortic dissection in an 8-year-old girl with aortic valvular stenosis is presented. A splenorenal arterial anastomosis without splenectomy was successfully performed. This procedure is considered best suited for children with thoracoabdominal aortic dissection as the autogenous graft is expected to grow and provide long-term patency. The spleen left in situ was expected to be advantageous, from the immunological aspect, at the time of open heart surgery for aortic valvular stenosis, which was anticipated in the near future in this child.

A 9-year-old boy had a successful surgical correction of truncal valve regurgitation and obstruction of extracardiac conduit which ensued previous Rastelli operation. He underwent Rastelli operation at the age of 10 months with the diagnosis of truncus arteriosus (Collet & Edwards Type I). At the age of 8 years, he was admitted because of slow weight gain and cardiomegaly (CTR 64%). Cardiac catheterization showed elevated RV pressure, increased pressure gradient across the conduit and severe truncal valve regurgitation. The extracardiac conduit was replaced with a 22 mm Hancock valved conduit and the truncal valve with 23 mm St. Jude Medical aortic valve. Postoperative catheterization revealed a normal RV pressure, only slight pressure gradient across the conduit and no truncal valve regurgitation. He is doing quite well 2 years after the operation.

During an 8-year period, 53 infants less than six months of life underwent repair of coarctation of the aorta (CoA). Preoperatively 58 percent of patients received intensive circulatory and/or respiratory care. The diagnosis was established by echocardiography and counter current aortography via a radial artery in the majority of recent cases and the surgical relief of CoA was effected within 24 hours of the diagnosis. The last 51 patients were managed under the policy of simple repair of the CoA in patients with significant VSD (Group II), with the addition of pulmonary artery banding for patients with complex cardiac lesions with VSD (Group III) or for patients with incremental risk factors in Group II such as prematurity of body weight of less than 1500 gm, other organ anomalies requiring major operation in neonate, pulmonary complications or severe malnutrition. There was no intraoperative death, one (2%) postoperative and five (10%) late deaths among the lost 51 patients. Only one (2%) showed sign of recurrence among 46 patients followed for 16-112 (mean 47) months.(ABSTRACT TRUNCATED AT 250 WORDS)

From March, 1982, through March, 1988, 8 infants less than 3 months of age underwent surgical treatment of interrupted aortic arch. Five patients had IAA type A and 3 patients had type B. Seven patients with associated VSD underwent staged operations and 1 infant with aortopulmonary window underwent primary repair off cardiopulmonary bypass. Aortic arch reconstruction was by subclavian aortic anastomosis (6) or large tube graft (8 mm) interposition (2) combined with pulmonary artery banding (5). All seven patients with associated VSD survived the first-stage operation. One patient subsequently underwent pulmonary artery banding, two underwent patch aortoplasty and four patients underwent intracardiac repair and removal of a pulmonary artery band, with six survivors (86%). The operative death occurred in an infant in whom modified Damus-Kaye-Stansel operation was carried out for severe subaortic stenosis, which rerouting all left ventricular blood through VSD and the main pulmonary artery into the ascending aorta and reconstructing right ventricular-distal pulmonary artery connection by a valved external conduit. All six surviving patients are doing well at present (mean follow up of 3 years) without any significant pressure gradient between the ascending and thoracic aorta. Based on these data we conclude: (1) Aortic arch reconstruction and pulmonary artery banding can be reliably performed even in critically ill infants with IAA and isolated VSD. (2) The primary repair will provide better chance of survival in infants with IAA associated with significant LVOTO, truncus arteriosus or aortopulmonary window that do not readily lend themselves to pulmonary artery banding.