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Many studies suggest that single-dose and multidose cardioplegia are protective in the ischemic adult heart, but in the neonatal heart single-dose cardioplegia is only protective, whereas multidose cardioplegia is damaging. We examined three clinically used cardioplegic solutions to compare the protective properties of single-dose and multidose cardioplegia in the neonatal rabbit heart (aged 7 to 10 days). The clinical solution studied were St. Thomas', Typers' and Bretschneider's solutions. In isolated working hearts (n = 8/group), cardiac function was assessed prior to 10 hours of ischemia (20 degrees C) and again after 35 min reperfusion (15 min Langendorff, 20 min working). All hearts received a pre-ischemic infusion (10 ml) of cardioplegic solution. The cardioplegic solution was given either as a single infusion (single-dose) or as repeated infusions (multidose) with 5 ml of cardioplegic solution every hour. The changes in coronary vascular resistance (CVR) during repeated cardioplegic infusions were measured in the multidose groups. During 15 min of Langendorff reperfusion, creatine kinase (CK) leakage and CVR were evaluated in all hearts. The results revealed that single-dose cardioplegia provided significantly better functional recovery than multidose cardioplegia in hearts given St. Thomas' or Tyers' solutions, while using Bretschneider solution single-dose cardioplegia Tended to provide better functional recovery. Post-ischemic CK leakages were higher in hearts given Bretschneider's solution in both single-dose and multidose cardioplegia. In hearts given St. Thomas' and Tyers' solutions, post-ischemic CVR in the single-dose group is lower than that in the multidose group, whereas post-ischemic CVR was lowest in the multidose group using Bretschneider's solution. Among multidose groups, CVR prior to reperfusion was lowest in Breschneider's solution as well. In conclusions, these results confirmed that, using the clinical solutions studied, single-dose cardioplegia provided better functional recovery than multidose cardioplegia in the neonatal rabbit heart. However, low CVR in Bretschenider's multidose cardioplegia suggested the better protection in coronary vasculature although functional recovery was poor.

In the last decade, the indications, risks and limitations of arteriography were dramatically changed because of the improvement of contrast agents and the advent of digital subtraction angiography (DSA). The most widely used contrast agents, at present, are nonionic monomers which have low osmolality and consequently cause less sensation of heat, vasodilatation and pain of injection. These alleviate the pain of angiography for patient and the serious complications were markedly decreased, however, the adverse effects of contrast mediums still remains, particularly the late onsets of adverse effects. The advent of DSA made it possible to perform arteriography in the outpatient department since the catheter size became thin and consequently less invasion for patients. Because the diagnostic procedure was specialized and individualized, the arteriography of lower extremities is often performed by radiologists. The arteriography for patients having arteriosclerosis obliterans (ASO) requires the precise understandings of pathophysiology and vascular anatomy. Therefore, the vascular surgeons and radiologists have to discuss before examinations, which could provide correct anatomical information and minimize the invasion.

A 37-year-old man who had undergone modified Bentall operation in December 1986 had redo operation for ascending aortic aneurysm. Initial operation, in other institute, included aortic root replacement using composite graft and reconstruction of coronary arteries. Left coronary ostium was directly anastomosed to composite graft while a saphenous vein was grafted between composite graft and right coronary artery concomitant with closing right coronary ostium. In addition, composite graft was wrapped with native aortic wall and Cabrol trick was carried out. In December 1994, this patient required redo operation for a 90 mm size of ascending aotric aneurysm which had been used for wrapping in the initial operation. The findings at reoperation revealed patent Cabrol trick, occluded saphenous vein graft, dehiscent proximal anastomosis of saphenous vein graft and partial dehiscence of distal anastomosis of composite graft. The repairs included new saphenous vein grafting to right coronary artery and re-anastomosis of distal site of composite graft. Cabrol trick was closed and composite graft was not wrapped. His post-operative course was excellent and post-operative scintigram indicated ameriolation of inferior wall ischemia.

Dissection of the interventricular septum is an uncommon manifestation, which is rarely associated with infective endocarditis, aneurysm of sinus of Valsalva and thoracic trauma. We report a 34-year-old male case with aorto-left ventricular communication due to infective endocarditis. The patient had chief complaints of dyspnea on exertion and precordial discomfort. Preoperative laboratory data showed normal white blood cell counts, a slightly elevated CRP, and negative blood culture in bacterial examinations. Echocardiogram revealed progressive dissection of the interventricular septum and stenosis of the left ventricular outflow tract. Disturbance of conduction including progressive atrioventricular block and bundle branch block were found in the electrocardiogram. The dissection extended over 2 x 2 x 2.5 cm in diameter, with an entry located at the basis of the right coronary cusp and reentry communicated to the left ventricle. Operative procedures included the aortic valve replacement with prosthetic valve due to severe inflammation, in addition to resection of the dissecting cavity. Pathological examination of the resected tissue accorded with infective endocarditis in active phase, showing necrosis, small cell infiltration and microabscess. However, a bacterial colony was not found in the surgical specimen. Postoperative course was uneventful and the patient was discharged in satisfactory conditions.

The effect of global ischemia and reperfusion on the expression of cytokine genes and cell adhesion molecules by myocardial tissues and neutrophils was studied by using the Langendorff model. Although cardiac function deteriorated after reperfusion of ischemic hearts, there was no evidence of inflammation and myocardial degeneration, which is in contrast to previous findings that neutrophil-mediated inflammation is a critical step in post-ischemic reperfusion injury in regional ischemia. Flow cytometry analysis demonstrated that the global ischemia and reperfusion did not affect the expression of adhesion molecules on neutrophils. We also examined the expression of various cytokines which are involved in inflammatory responses. Only interleukin 1 alpha was induced after the reperfusion of the ischemic hearts. These results suggest that neutrophils barely contribute to the myocardial dysfunction and IL-1 alpha may play a role in post-ischemic myocardial dysfunction during the early stage of reperfusion.

The Registry of the International Society for Heart and Lung Transplantation reported that 31,157 transplantations were performed throughout the world until 1993, including 26,704 heart transplantations, 1,567 heart-lung transplantations, 1,943 single lung transplantations and 943 bilateral or double lung transplantations. Heart transplantations were carried out at two hundred fifty-one institutes in the world and more than 3,000 patients received heart transplantations every year. The number of heart transplantations, however, became plateau in 1988 and since 1991 the number of operations rather decreased because of the shortage of donor hearts. Indications for adult heart transplantation include coronary artery disease in 47.2% and cardiomyopathy in 43.5%, representing the most frequently reported indications. Retransplantations represent only 2.3% of the total heart transplantations. The results for heart transplantation reveal that the 1, 3, 5, and 12-year actuarial survival are 80%, 72%, 64% and 40%, respectively. Comparing the data before and after 1982 when cyclopropane was introduced for transplantations, a substantial improvement in actuarial survival is obtained. For instance, 3-year actuarial survival before 1981 was 40% whereas since 1982 3-year actuarial survival is improved up to 75%. However, the patients in the older age (more than 65 years old) and pediatric patients, particularly less than one year old, have a significant reduction in outcome compared with younger adult patients and the outcome of heart retransplantation was still poor. Because of the shortage of donor heart quite a large number of patients develop hemodynamic deteriorations before transplantation and mechanical assist device is one of strategies to treat these patients as bridge to heart transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

We experienced 8 cases who required reoperations, including 2 re-redo operations, after repairs of infrarenal abdominal aortic aneurysms. Of 8 patients, one patient developed a new aneurysm due to atherosclerosis in thoraco-abdominal aorta involving all visceral arteries and other 7 patients had aneurysmal formations at proximal anastomotic sites, including 3 suprarenal, 2 juxtarenal and 2 infrarenal aortic lesions. Etiology at initial operation in patients who subsequently developed anastomotic aneurysms included vasculo-Behçet disease in 4, atherosclerosis in 2 and dissecting aortic aneurysms type III due to Marfan syndrome in 1. At reoperation, all who had vasculo-Behçet disease had ruptures of anastomotic sites and 2 patients underwent repairs of dehiscent patch, 1 extra-anatomic bypass between ascending and abdominal aorta and 1 interposition of graft. One patient who had graft infection after repair of abdominal aortic aneurysm required axillo-femoral bypass with removal of infected graft. A patient who had dehiscence of proximal anastomosis after repair of aortoiliac occlusive disease required interposition of graft. Two patients, Marfan syndrome and aneurysm in thoraco-abdominal aorta, underwent graft replacement of thoraco-abdominal aorta concomitant with reconstruction of all visceral arteries. There were 8 patients who required reoperations for aneurysms at distal anastomotic sites after repairs of abdominal aortic aneurysms. Five patients underwent repairs of new aneurysms, including replacement of total arch in 3, descending aorta in 1 and iliac artery in 1. In all cases, no hospital death was noted, however, late deaths were occurred in vasculo-Behçet disease, Marfan syndrome and graft infection. Thus, late result depends on etiology of disease. Although patients who requires reoperation after repair of abdominal aortic aneurysms have higher operative risk factors, early and late results are satisfactory compared to initial operations.

This article discusses physiological diagnostic methods in the intractable vasculitis, including Buerger's, Takayasu's and vasculo-Behçet disease. Clinical manifestations of these diseases depend on the lesions of the diseased arteries or veins such as obstruction of the extremities often occurring in Buerger's disease, the obstruction of aortic arch branches in Takayasu's disease and the deep vein thrombosis in vasculo-Behçet disease. Measurements of segmental blood pressure and flow allows a detection of peripheral vascular disease and non-invasive diagnostic techniques, such as the doppler ultrasonic techniques and strain-gauze plethysmography, permit accurate evaluation of arterial occlusive disease and estimation of its physiological significance. Noninvasive diagnostic techniques, together with clinical symptoms and physical examinations, make possible correct diagnosis and subsequently appropriate treatment.

Evoked spinal cord potentials elicited by direct stimulation of the cord were used to monitor spinal cord ischemia in 68 patients undergoing temporary occlusion of the thoracic aorta (29 thoracic nondissecting aortic aneurysms, 9 nondissecting thoracoabdominal aneurysms, and 30 dissecting aneurysms). "Immediate" postoperative paraplegia developed in three patients and "immediate" paraparesis developed in one, whereas "delayed" paraplegia developed in two others. During aortic crossclamping, four response patterns of the spinal cord potentials were obtained: (1) no change (n = 53), (2) change with return (n = 10), (3) change with inconsistent return (n = 2), and (4) change without return (n = 3). Neurologic complications occurred in 2%, 0%, 100% of these groups, respectively. Delayed paraplegia developed on the second postoperative day in only one patient with a false-negative result, and the potentials correlated well with this patient's clinical neurologic recovery. The aortic crossclamp time was significantly longer in the patients with "change with inconsistent return" and "change without return" than in the other two groups (p < 0.01). Femoral artery pressure and the cardiopulmonary bypass flow rate were also significantly lower in these groups than in the other two groups (p < 0.02 and p < 0.01, respectively). We conclude that intraoperative monitoring of direct spinal cord responses is useful for the early detection of spinal cord ischemia for assessing the efficacy of surgical countermeasures.

To investigate lung injury in adult open heart operations during extracorporeal circulation, we measured plasma chemiluminescence levels. Nineteen patients were divided into two groups depending on preoperative pulmonary artery pressure: a pulmonary hypertension group (n = 11) and a control group (n = 8). Plasma samples were taken simultaneously from arterial and central venous lines at six different points during and early after operation. Arteriovenous difference of chemiluminescence (counts/10 seconds) increased significantly only in the pulmonary hypertension group (from -19.1 +/- 8.3 at the end of cross-clamping to 23.7 +/- 12.4 at the end of bypass; p < 0.01). There was a positive correlation between peak values of arterial plasma chemiluminescence and postoperative respiratory index in the pulmonary hypertension group (p < 0.05). In addition, during the first 12 hours postoperatively, arteriovenous difference of chemiluminescence in the pulmonary hypertension group changed significantly from negative to positive values (p < 0.05). These data suggest that free radical activity (detected by chemiluminescence) was deeply involved in lung injury during and also early after open heart operations, especially in pulmonary hypertensive patients.

Treatment of arteriovenous malformations of the finger is difficult because complete resection of malformations by ligation or en bloc resecting methods is impossible. We used an extended wrap-around flap consisting of a combined wrap-around flap and a dorsalis pedis flap to reconstruct the soft-tissue defects following complete resection of a recurrent malformation in the index finger. This method has two advantages: no postoperative recurrence of the malformation is expected, and the affected finger can be preserved. However, it is indicated only for malformations with no invasion to the bone and localized in one finger.

Implantations of automatic implantable cardioverter defibrillator were performed in five patients with life-threatening ventricular tachyarrhythmias. Preoperative diagnoses of arrhythmias were sustained ventricular tachycardia (VT) in two cases, ventricular fibrillation (VF) in two cases and sustained VT+VF in one case. Four of five cases had basic diseases respectively (broad anterior myocardial infarction, dilated cardiomyopathy, arrhythmogenic right ventricular dysplasia, hypertrophic cardiomyopathy), and the other case was idiopathic. Preoperative CTR were 43-65% (mean 57.4%) and left ventricular ejection fraction were 26-76% (mean 51.2%). Implantation of AICD was indicated for patients who survived circulatory arrest or life-threatening VT. Median sternotomy (3) or left antero-lateral thoracotomy (2) were performed for implantation of large-small patch electrodes for defibrillation. AICD generators were implanted in the pocket under abdominal rectal muscle in all cases. Postoperatively myocardial insufficiency, pericarditis, pleuritis occurred in three cases respectively. In the follow-up periods (2-25 months, mean 13 months), AICD worked effectively in two patients with spontaneous VT (6 months, 1 year after operation) and no cardiac death was experienced. We concluded that AICD system is effective for the life-threatening ventricular tachyarrhythmias, although the further estimation in longer follow-up periods are warranted.

We have compared the protective properties of three cardioplegic solutions (St. Thomas' Hospital, University of Wisconsin, and Bretschneider) for the long-term hypothermic preservation of the rat heart. Hearts (n = 8 per group) were excised and arrested by an infusion (10 ml at 4 degrees C) of cardioplegic solution. After 4, 6, or 8 hours of storage at 4 degrees C, they were reperfused in the Langendorff mode for 15 minutes and then in the working mode for 20 minutes. After 4 hours of storage, postischemic cardiac output in the St. Thomas' and Wisconsin groups was 68.8 +/- 4.6 and 63.7 +/- 3.0 ml/min, respectively (NS); nonischemic aerobic control cardiac output was 83.2 +/- 2.6 ml/min. In the Bretschneider group, cardiac output was only 43.4 +/- 3.6 ml/min (p less than 0.05 compared to the other groups). Extending storage to 6 or 8 hours led to further decreases in recovery of function in all groups (cardiac output in the St. Thomas' and Wisconsin groups was 53.7 +/- 3.2 and 52.2 +/- 5.1 ml/min after 6 hours and 39.9 +/- 2.2 and 45.8 +/- 2.5 ml/min after 8 hours, respectively; NS). With the Bretschneider solution the cardiac output was again lower (37.6 +/- 3.0 and 22.3 +/- 4.1 ml/min, respectively). Creatine kinase leakage tended to be greater in the Bretschneider group, but adenosine triphosphate and creatine phosphate contents were well preserved in all groups. In further studies, hearts (n = 8 per group) were infused with the three solutions and stored at 4 degrees C for 8 or 10 hours; they were then heterotopically transplanted into the abdomens of homozygous recipients. After 24 hours of reperfusion, the hearts were excised and taken for ex vivo functional and metabolic studies. Recovery of contractile function was similar in all groups, but the tissue content of adenosine triphosphate tended to be greater in the St. Thomas' and Wisconsin groups (15.0 +/- 1.5 and 14.7 +/- 1.0 mumol/gm dry weight in the 8-hour storage groups and 12.1 +/- 1.2 and 11.7 +/- 0.8 mumol/gm dry weight in the 10-hour storage groups, respectively) than in the Bretschneider groups (12.3 +/- 0.9 and 9.1 +/- 1.6 mumol/gm dry weight, respectively). Creatine phosphate content recovered completely in all groups. We conclude that all three solutions afford similar protection to the hypothermically stored rat heart, but that the St. Thomas' Hospital and University of Wisconsin solutions are marginally superior to the Bretschneider solution.

Free osteo-onychocutaneous flaps from the big toe have frequently been used for the reconstruction of distal phalangeal loss of the fingers. The thickness of the fatty tissue, however, makes these flaps bulky. We believe this disadvantage can be overcome with a free thin osteo-onychocutaneous flap from the big toe and consider this thin composite flap to be a superior method of reconstruction for the treatment of distal phalangeal loss.

Both single-dose and multidose cardioplegia are protective in the ischemic adult heart under normothermic and hypothermic conditions, but in the hypothermic neonatal rabbit heart single-dose cardioplegia only is protective, whereas multidose cardioplegia is damaging. The present studies in the isolated perfused working heart from neonatal rabbits (aged 7 to 10 days) were designed to characterize the interrelationships between temperature, frequency of cardioplegic infusion, and tissue protection. Hearts (n = 8/group) were subjected to 1, 1.5, 1.5, 3, 10, 12, or 18 hours of ischemia at 37.0 degrees, 34.5 degrees, 32.0 degrees, 28.0 degrees, 20.0 degrees, 15.0 degrees, or 10.0 degrees C, respectively. These times were selected to achieve approximately 55% to 75% recovery of cardiac output in hearts during normothermic reperfusion when single-dose (2 minutes) St. Thomas' Hospital cardioplegic solution was given at the onset of each ischemic period. Under these conditions actual recoveries of cardiac output were 55.7% +/- 5.6%, 68.5% +/- 6.8%, 73.8% +/- 4.1%, 54.6% +/- 5.3%, 56.3% +/- 7.5%, 59.5% +/- 7.7%, and 81.3% +/- 2.3% of the preischemic control values, respectively. By contrast, with multidose cardioplegia (given every 60 minutes in the 3- to 18-hour experiments and every 30 minutes in the 1- and 1.5-hour experiments) there was a temperature-dependent loss of protection when compared with single-dose cardioplegia; the recoveries of cardiac output were 75.7% +/- 1.5%, 78.4% +/- 4.8%, 65.0% +/- 5.8%, 36.7% +/- 5.8%, 34.6% +/- 7.5%, 25.9% +/- 6.0%, and 9.6% +/- 6.4%, respectively. These results were reflected in other indices of cardiac function and in changes in vascular resistance during cardioplegic infusion and reperfusion. To ascertain whether the progressive loss of protection was related to the degree of hypothermia or the duration of ischemia (which had to be increased as the temperature was lowered to permit a 55% to 75% recovery in the single-dose cardioplegia group), we conducted studies at a fixed temperature (20 degrees C) with variable durations of ischemia (6, 8, 10, and 12 hours). Finally, multidose and single-dose cardioplegia at 10.0 degrees, 20.0 degrees, and 37.0 degrees C were compared with hypothermia alone. We concluded that in the neonatal (in contrast to the adult) rabbit heart the protective properties of multidose cardioplegia relative to single-dose cardioplegia are progressively lost.(ABSTRACT TRUNCATED AT 400 WORDS)

Bilateral legs damaged by high-voltage electrical injury were treated by amputation and a free thin rectus abdominis myocutaneous flap with reduced muscle. Damaged arteries at 2 months after injury showed disappearance of endothelium, and a decreased number and morphological changes in smooth-muscle cells. Injured nerves and muscles showed early regenerating processes after total degeneration, and no progressive muscular necrosis. These results suggest that severe degeneration of the neurovascular bundle and muscle is unavoidable in high-voltage electrical injuries of the extremities. Therefore, early amputation, sequential debridement, late coverage by a flap, and prolonged rehabilitation are required in this injury.

A free vascularized deep peroneal nerve graft seems to be the most suitable method for repairing digital nerve defects involving severe finger damage. We report a patient in which this graft was used as a neurocutaneous flap. The advantages of this method are its excellent vascularity, minimal functional disturbance to the donor foot, and the possibility of versatile application.

A series of studies was undertaken to establish the optimal oxygenation of St. Thomas' Hospital cardioplegic solution (ST). Using an isolated working rat heart model of cardiopulmonary bypass and the cardioplegic arrest the effect of oxygenation of ST were investigated in this study. The effects of oxygenated ST with various O2/CO2 mixture (100% O2, 99% O2 + 1% CO2, 98% O2 + 2% CO2, 95% O2 + 5% CO2) upon post ischemic functional recovery were compared with those of non-oxygenated ST. Under both normothermic and hypothermic conditions, the pH of the St. Thomas' gassed with 99% O2 + 1% CO2 mixture was maintained at 7.8, and this cardioplegic solution showed highest percent recovery of aortic flow. On the contrary, the pH of St. Thomas' cardioplegic solution oxygenated with 100% O2 exceed 9.0 and it showed lethal effect upon postischemic cardiac function. Thus oxygenation of NaHCO3 containing crystalloid cardioplegic solution oxygenated with 100% O2 is rather harmful and the 99% O2 + 1% CO2 gas is the crucial gas mixture for clinical and experimental use with oxygenated ST.

In order to evaluate the immune response during and after open heart surgery, we have studied 34 patients who received open heart surgery under extracorporeal circulation. Age range of these patients were from 41 to 76 years. These patients were divided into three groups, depending upon existence of multiple organ failure (MOF), low output syndrome (LOS) and non-LOS and non-MOF diagnosed from our criteria. The following cytological and immunological study has been performed pre-operatively, immediately after and on 1, 2, 7 and 14th postoperative day; 1) the leukocyte differential cell count, 2) function test of neutrophils, 3) lymphocyte subpopulation and subsets, 4) serum level of complement fractions (C3, C4) and CH 50. By lymphocytes analysis, postoperative early reduction of OKT 3 (CD 3) and OKT 4 (CD 4) was observed in patients with poor prognosis. Patients with the postoperative high activity of NBT reduction test was developed into MOF. Complement activity (C3, C4, CH50) decreased during surgery and recovered to preoperative level in patients without LOS and MOF. However in MOF patients, these values showed lower level than that of patients without LOS and MOF. Our data suggested that lymphocytes and leukocytes tests were useful to evaluate the prognosis in open heart surgery.