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A case report of a patient with bronchogenic cyst who presented with cardiogenic symptoms was described. The precise diagnosis was finally made after completing various diagnostic procedures which included reconstruction computed tomography. The patient, a 30-year-old man, was admitted to our hospital because of palpitation, chest pain and fever of three weeks duration. An electrocardiogram (ECG) revealed evidence suggestive of left atrial overloading and frequent atrial premature beats. A chest roentgenogram showed an abnormal shadow behind the right upper portion of the heart and a cross-sectional echocardiogram revealed abnormal echoes with ill-defined margins in the left atrium. Computed tomography (CT) revealed the presence of the left atrial tumor but left atriography suggested that it was extracardiac and compressing the left atrium. Reconstruction CT was therefore performed and the cyst was diagnosed as being in a subcarinal position. A mobile calcified mass was also demonstrated by the CT. An operation was performed and a cyst, 6 X 3 cm, was removed almost completely and a histopathological diagnosis of bronchogenic cyst was made. In this particular case, ECG abnormalities which suggest atrial damage and the diagnostic usefulness of reconstruction CT are stressed.

Regional left ventricular work is a more precise indicator of function than is simple shortening fraction. Regional work of the ventricle normalized to a unit volume of myocardium (RWM) is given by the following equation: RWM = - intergral of sigma d[ln(1/H)], where sigma is the mean wall stress and ln(1/H) is the natural logarithm of reciprocal of wall thickness. This method has been previously validated in animal experiments and it is now extended to the clinical setting for the first time. In 10 normal subjects and 6 patients with anteroseptal myocardial infarction, ventricular minor axis and wall thickness were measured by echocardiography and recorded simultaneously with high fidelity left ventricular pressure. Then, regional work of the interventricular septum and of the posterior wall of the left ventricle was calculated from the measured pressure and dimension data. In normal subjects, regional work of the septum and posterior wall was 6.1 +/- 1.7 and 7.0 +/- 1.8 mJ/cm3, respectively; the average of the septal and posterior wall regional work multiplied by the left ventricular myocardial volume correlated well (r = 0.93) with the total mechanical work done by the entire left ventricle. In patients with anteroseptal infarction, septal regional work was greatly reduced (0.6 +/- 1.7 mJ/cm3), compared with posterior wall regional work in the same patients (6.1 +/- 1.8 mJ/cm3). This simple method can be applied clinically in assessing the functional state of different regions of the myocardium.

Constricting the tricuspid annulus to an optimal size and ensuring competency of the suture in situ are essential to the performance of a successful de Vega annuloplasty. An approach to this goal is presented. Important maneuvers include placement of the inside suture just on the ring portion, use of a 33 mm of 35 mm valve obturator to obtain an annulus of the desired size, and ligation of the knots at their roots to prevent potential loosening.

In a 48-year-old woman, the diagnosis of a right coronary arteriovenous fistula communicating with the coronary sinus was made noninvasively using two-dimensional, pulsed and color Doppler echocardiography. These noninvasive techniques were superior to angiography in delineating the cardiac chamber into which the fistula emptied.

Between January 1970 and March 1984, external conduit repair was performed in eighty-five consecutive patients for various complex anomalies. The age at operation ranged from 2 months to 47 years, and 41 patients were in an age group of 5 to 9 years. Among 85 complex anomalies, 20 cases of d-transposition with VSD + PS, 33 cases of Tetralogy of Fallot with pulmonary atresia, 11 cases of truncus arteriosus and 11 cases of 1-transposition were included. From January 1970 to December 1975, conduits used were aortic homograft in 1, formalin treated porcine valved conduits in 27, and valved conduits treated with 0.65% glutaraldehyde in 3 and from January 1976 to November 1982, 42 Hancock composite grafts were used. Since December 1982, valved conduits made of preserved pericardium treated with glutaraldehyde were employed. In sixty-one patients survived from operation, actuarial survival rate was calculated as 87% at five years, 82% at ten to fourteen years. However, systolic pressure of right ventricle after repair mostly affected actuarial survival rate which maintained 93% at twelve years in patients with systolic pressure lower than 80 mmHg, and reduced to 65% at fourteen years in patients with that higher than 80 mmHg. Although external conduit repair was valuable for surgical treatment in complex anomalies, proper selection of conduit material, prevention of infectious endocarditis, and pseudoendothelial proliferation in late stage were the problems to be solved in the future.

The simple, safe, and feasible procurement technique for the heart and liver with no warm ischemic time is reported. Fifteen mongrel dogs were used to form two recipients and one donor combination in each experiment. A midline incision is extended from the suprasternal notch to the pubis, and a catheter is advanced into the aortic root by means of the brachiocephalic artery for monitoring systemic arterial pressure and later for coronary vascular washout with a cold cardioplegic solution. Liver mobilization is carried out first when the core temperature of the liver reaches 27 degrees C, obtained with ice slush in the abdominal cavity. As the core temperature of the liver reaches 20 degrees to 22 degrees C, the aorta and inferior vena cava are clamped just above the diaphragm. After excision of the liver a second team harvests the heart while it continues to beat. The heart and liver were transplanted orthotopically after simple preservation into a cold solution for 12 and 6 hours, respectively. The maximum survival time was 7 hours in heart transplantation and 16 days in liver transplantation. Our method is a simple, safe, feasible technique for acquiring the heart and liver or other visceral organs for transplantation and may have broad clinical application.

When the incidence of thromboembolism (TE) as a complication was investigated in 171 patients with prosthetic heart valves using pyrolytic carbon, 10 cases were identified in a mean follow-up period of 2.43 years. Of these 10, two patients had died. The incidence of TE as a percentage per patient--year was 2.41 on the whole, 2.15 in patients with aortic valve replacement (AVR), 2.48 in patients with mitral valve replacement (MVR) and 2.52 in patients with double valve replacement (DVR). It is evident that TE is still an important complication following prosthetic heart valve surgery and the patient's return to society. TE tended to occur somewhat more often in cases of MVR and DVR than in those of AVR. TE was apt to appear early in the postoperative period, often within a year, and was often seen in the brain. To prevent TE, it is necessary to carefully control blood coagulation by the administration of anticoagulants.

An aenurysm of a diverticulum of the ductus arteriosus in a 33-year-old man was presented. The chest radiography revealed a mass obscurring the aortic window above the hilus of the left lung. His blood pressure was 130/70 mmHg, and there was no difference in pressures between the upper and lower or between the right and left extremities. A CT scan of the chest showed 30 X 34 mm angioma adjacent to the descending aorta and pulmonary artery. Aortography and contrast radiography of the right ventricle revealed a cystic pedunculated aneurysm at the superior portion of the descending aorta. The base of the left pulmonary artery was slightly displaced. There was no communication between the aorta and pulmonary artery, nor was any significant difference in pressure between the ascending and descending aorta. This case was diagnosed as an aneurysm of the diverticulum of the ductus arteriosus, and then it was resected. The abnormality was confirmed by the localization of the aneurysm and histopathologic findings, but the presence of the ligamentum arteriosum was not confirmed. This is the 23rd case of the aneurysm of the diverticulum of the ductus arteriosus in adults, and the first case in Japan in which the diagnosis was made in a living patient, followed by successful surgery.

To diagnose the cardiac rejection after the heart and lung transplantation, the histopathological assessment is the most reliable method at the present time. In this study, the heterotopic heart and lung transplantation was performed using rat model and the rejection process of heart allograft was sequentially examined at 1 day, 4 days, 7 days, and 12 days after the transplantation. The gross finding of both ventricles were observed to investigate the development process of the rejection. Then, the most typical findings in each period were analysed using a microscope with our criteria including three components, which are 1. Perivascular findings 2. Interstitial findings, 3. Myocyte degeneration. This study demonstrates that allograft rejection after heart and lung transplantation initiates from right ventricular free wall and spreads into outer layer of left ventricle as same fashion as orthotopic cardiac transplantation. The assessment of these 3 components using the indicators shown in this study might be very useful method to objectively determine the grades of rejection after the heart and lung transplantation.

Persistent fever during active-phase IE is an indication for surgical treatment in the light of the causative organism and the underlying disease. To counter worsening hemodynamics, surgery may be the only feasible way. Surgery is performed when the patient does not respond to vasodilators and he shows an FS of less than 25%. The introduction of translocation provides a solution for the treatment of active IE. Lesions, vegetations more than 5 mm in diameter, periannular abscess, and mycotic aneurysm that could never be overlooked by two-dimensional echocardiography may hasten the early-stage decision of ways to treat IE.

To evaluate the applicability of single lung transplantation as a treatment of pulmonary hypertension, we investigated the relationships between the pulmonary blood flow and resistance in allografts 10 days after single lung transplantation in dogs. In eight surviving recipients and five healthy dogs (control group), pulmonary flow-resistance relationships were investigated at flows in the range of 0.3 to 2.0 L/min at 0.1 L/min increments. Resistance decreased from 2585 to 746 dyne.sec.cm-5 in the successful group (five allografts receiving complete studies) and 2400 to 891 in the control group with an increase of flow. Lung water content of the successful group was 2.0 times that of the control group (successful group, 95.6 +/- 16.7 gm; control group, 47.8 +/- 7.5 gm), and water content of the other allografts (unsuccessful group), including allografts of dogs that died before investigations, was 2.2 times that of the successful group (unsuccessful group, 211.0 +/- 89.6 gm). The chest roentgenograms of the successful group showed mild or moderate consolidations, whereas those of the unsuccessful group showed severe consolidations, but no difference was found in pulmonary flow-resistance relationships between the successful and the control groups. These results show that the allografts, which have about twice the water content of normal lung, maintain adequate pulmonary vascular function. We concluded that single lung transplantation could be an effective treatment for pulmonary hypertension.

From July 1978 to June 1984, 540 St. Jude Medical valve prostheses were implanted in 462 adult patients. Overall operative mortality was 4.8% (22/462): 5.7% after aortic valve replacement (AVR) (8/140); 3.3% after mitral valve replacement (MVR) (8/244); and 7.7% after aortic and mitral valve replacement (DVR) (6/78). There were 16 late deaths among 440 operative survivors; six (38%) were valve related. The actuarial survival rate at six years was 94.5% in AVR and 93.5% in MVR. At five years it was 91.6% in DVR. The freedom from valve-related death at six years after AVR, MVR and at five years after DVR was 97.8%, 98.6% and 95.8%, respectively. The incidence of valve-related complications (expressed as %/patient-year (number of events] was as follows: thrombo-embolism (AVR 0.7 (2), MVR 2.0 (13), DVR 2.8 (5], valve thrombosis (AVR 0.3 (1), MVR 0.2 (1), DVR 0 (0], prosthetic valve endocarditis (AVR 0.3 (1), MVR or DVR 0 (0]. There were no cases of primary structural failure, serious anticoagulant-related hemorrhage or clinical event of hemolysis. The incidence of all valve-related complications in AVR, MVR and DVR was 1.3, 2.2 and 2.8%/pt-yr, respectively. The freedom from thrombo-embolism at six years after AVR and MVR and at five years after DVR were 91.4%, 92.4% and 88.7%, respectively. Re-operation was performed in only one patient with MVR because of valve thrombosis (0.2%/pt-yr after MVR, overall 0.1%/pt-yr). These results indicate that St. Jude Medical prosthesis has provided a satisfactory performance with acceptable risks of late complications in patients who were properly anticoagulated during six-year follow-up period.

The epoxy group of the epoxy compounds has an oxygen arm that can work as a flexible joint in a cross-linking bridge and can block not only the amino group but also the carboxy group of collagen peptide. The purpose of this study is to evaluate the anticalcification efficacy of the epoxy compounds as a cross-linking agent for xenograft bioprostheses. Porcine aortic leaflets were treated with 2% epoxy compounds and implanted in subcutaneous layer of 4-week-old rats. Measurement of calcium content showed that epoxy-treated implants received a minimal calcification: mean 0.64 micrograms/mg dry weight leaflet tissue (range 0.5-0.8; N = 7) at 1 month; mean 0.94 microgram/mg (range 0.3-1.3; N = 9) at 2 months; and mean 1.2 micrograms/mg (range 0.5-2.1; N = 10) at 3 months. Natural leaflets contained calcium of mean 0.43 microgram/mg. By contrast, glutaraldehyde-preserved implants were severely calcified: mean 91 micrograms/mg (range 41-130; N = 11) at 1 month; mean 136 micrograms/mg (range 73-205; N = 16) at 2 months; and mean 170 micrograms/mg (range 90-214; N = 21) at 3 months. The epoxy compounds provide more pronounced anticalcification effects than the glutaraldehyde under pressure load-free subcutaneous circumstances.

One hundred and thirty patients at our Heart Institute with infectious endocarditis during the past 5 years were reviewed to provide an overview of the spectrum of infective endocarditis and to assess the accuracy of echocardiography in detecting the infective valvular and endocardial lesions. Of the 130 patients, 36 (28%) had the previous cardiovascular surgery. The mean age of the patients was 34 years, and only 11% of the patients were over 50 years of age. Of the 94 patients who had no cardiovascular surgery before developing infective endocarditis, 6 underwent urgent surgery, 49 had elective surgery and the remaining 39 were followed up with medical treatment. The mortality rate of the 55 patients who were operated on was 5.5% as against 18.0% in 39 without surgery. Half of the 36 patients who had been operated on before developing endocarditis had prosthetic valves inserted. Of the 5 patients with bioprosthetic valve endocarditis, only one survived as a result of prompt medical and surgical treatment. Streptococci were still commonly found, about 75% in the group without surgery and 50% in the group with surgery. Gram-negative bacilli and fungi were found in patients with prosthetic valve endocarditis. In 61 patients, morphologic abnormalities confirmed at surgery or necropsy were compared with the preoperative echocardiograms. Vegetations were identified preoperatively in 50 (95%) of the 53 valves involved, and valve destruction was correctly predicted in all 23 cases. Mycotic aneurysm was detected preoperatively in only 3 of the 12 patients in whom it occurred. Thirteen patients, in whom vegetation was recorded, were treated successfully with antibiotics alone and they needed no surgical intervention during the 2-year follow up period. The presence of a vegetation in an echocardiography does not necessarily require surgical intervention in itself or predict the ultimate course.

A new model of the stent-mounted porcine aortic bioprosthesis was prepared with 0.625% glutaraldehyde while the valve was partially open. A radiopaque marker was attached to the center of the free margin of each leaflet so that the leaflet movements could be observed in an in vivo testing unit by fluoroscopic cinematography. This valve was compared with a porcine xenograft that currently is available commercially. While the heart was beating, the specially prepared leaflets showed some characteristics that contrasted with those of the currently used bioprosthesis. These features included (1) uniformity versus asymmetry of leaflet excursions under low flow conditions, (2) slower and more gradual closing (actual closing time averaging 536 msec versus 81 msec), and (3) more prolonged period of valve opening, the duration of opening averaging 60% versus 49% of the cardiac cycle. These features support the validity of open-position fixation as a means of further improving xenograft durability.

Various kinds of materials, such as glutaraldehyde-treated pericardial heterografts, have been used as a cardiac wall substitute. Some problems were encountered with their use. We clarified these problems in animal experiments and developed a new cardiac wall substitute to overcome them. As one of the best cardiac wall substitutes obtainable at present, glutaraldehyde-treated equine pericardium (Xenomedica, GA-graft), was sutured as a patch in the right ventricular outflow tract (Group 1: 16 dogs). A new cardiac wall substitute, which is composed of collagen-coated polyester mesh (CUFP), was sutured in the same fashion (Group 2: 19 dogs). The problems clarified in the GA graft were insufficient antithrombogenicity and poor healing of the neointima and the graft wall. The CUFP had sufficient antithrombogenicity and good healing quality as a cardiac wall substitute. CUFP should be rapidly infiltrated by host cells, to become a kind of host organ and therefore not degenerate with long-term use.

A 35-year-old male with tetralogy of Fallot, who had undergone left Blalock-Taussig shunt at ten year old, developed severe dysfunction of right ventricle with decreased right ventricular ejection fraction of 25% and frequent premature ventricular contractions of right ventricular origin. Following intracardiac procedure, the venoarterial assist circulation was successfully employed for 9 hours, until his hemodynamic conditions were improved. This experience reemphasized the importance of right ventricular protection and mechanical circulatory assist in the surgical treatment of Fallot's tetralogy in older children and adults who developed severe right ventricular dysfunction as a natural history of this disease.