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We investigated the relationship between left atrial spontaneous echo contrast (SEC) and cerebrovascular features in nonvalvular atrial fibrillation (NVAF). Few reports have been published to compare cardiac and cerebrovascular imaging in patients with NVAF. Forty-four patients with NVAF were studied using transesophageal echocardiography and non-invasive imaging including magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and transcranial color Doppler imaging (TCD) in the middle cerebral artery (MCA) territory. The symptomatic severity was divided into asymptomatic, transient ischemic attack (TIA), and stroke. The severity of the MRI findings was divided into normal, small, and large infarcts. The severity of the MRA findings was divided into normal, attenuation, and occlusion. MCA was bilaterally scanned and a side-to-side asymmetry ratio of pulsatility index (PI) was measured. The severity of SEC was divided into normal, SEC, and thrombi. Five patients with other thromboembolic risk or poor results of TCD were excluded. SEC and thrombi were detected in 12 (30%) and in 3 patients (5%), respectively. TIA and stroke were detected in 8 (21%) and in 17 patients (44%), respectively. Small and large infarcts were detected in 9 (23%) and in 18 patients (46%), respectively, on MRI. Attenuation and occlusion were detected in 14 (36%) and in 8 patients (21%), respectively, on MRA. PI ratio was 1.21 +/- 0.25. SEC severity was highly associated with PI ratio and MRA severity in monovariate analysis (P < 0.005), P < 0.01, respectively). SEC severity was highly associated with PI ratio and MRA severity in stepwise multiple regression analysis (P = 0.0001, r = 0.630, n = 39). In patients with NVAF, left atrial SEC was highly related to attenuation or occlusion on MRA and imbalance of cerebral blood flow on TCD in the MCA territory.

We report the case of a 66-year-old man who had a descending thoracic aneurysm, diagnosed as aortitis syndrome. He subsequently underwent an aneurysmectomy under simultaneous sensory and motor spinal cord monitoring. Spinal cord ischemia was diagnosed during prosthetic replacement of the aneurysm by changes in evoked spinal cord potentials and motor evoked potentials from the lumbar spinal cord enlargement and 2 pairs of intercostal arteries were reconstructed at the level of T9 and 10. After surgery, the patient developed paraparesis below T10, but the resulting neurological deficits were overcome with postoperative rehabilitation. Simultaneous monitoring of evoked spinal cord potentials and motor evoked potentials were useful in evaluating spinal cord ischemia during aortic aneurysm surgery and in determing whether intercostal arteries should be reconstructed.

A simple left atrial procedure for atrial fibrillation (AF) was performed in 16 elderly patients (age over 70 years old) with chronic AF associated with mitral and/or aortic valvular diseases. Chronic AF was eliminated upon discharge in 13 out of the 16 patients (81%). Twelve of the 13 patients (92%) whose AF had disappeared recovered the atrial kick of their right atrium, and 9 patients (70%) recovered the atrial kick of their left atrium. A simple surgical procedure to the left atrium was effective in the treatment of chronic AF associated with mitral valve disease in elderly patients. This simple procedure is preferable to other methods for the elimination of chronic AF with mitral valve disease in elderly patients.

We report a case of accidental entry of an implantable cardioverter defibrillator lead into the hepatic vein, which was not noted on fluoroscopy but was apparent when transesophageal echocardiography (TEE) was used incidentally. The lead was depicted in the hepatic vein as strongly echogenic, accompanied by an acoustic shadow. Additional bending of the stylet was helpful for successful advancement of the lead. TEE provides additional information in such cases, although indications for its use should be explored because of its possible complications.

A 70-year-old male with aortic regurgitation, chronic atrial fibrillation (Af) and chronic aortic dissection of the aortic arch was treated simultaneously. We found a limited dissection in front of aortic arch during operation. We performed total arch replacement using a branched prosthesis and aortic valve replacement in addition to a modified left atrial isolation for chronic Af under the aid of extracorporeal circulation, and selective cerebral perfusion. Left atrial isolation is a simpler procedure than maze procedure and left side maze procedure for eliminating Af. This simple procedure makes possible a simultaneous extended operation for complicated aortic and cardiac disease even in an elderly patient.

A right atrial separation procedure was performed to eliminate atrial fibrillation (AF) during concomitant repair of an atrial septal defect and aortic valve regurgitation in an elderly patient. This procedure consisted of a Y-shaped incision in the right atrium, followed by cryoablation of the tricuspid annulus and the atrial septum. Only excision of the left atrial auricular appendage was performed in the left atrium. Although this procedure was devised to eliminate chronic AF associated with a solitary atrial septal defect, it was effective to eliminate chronic AF associated with atrial septal defect and aortic valve regurgitation in an elderly patient.

Circulatory support using both intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) can improve general hemodynamics; however, sometimes brain damage occurs caused by hypoperfusion. Such cerebral hypoperfusion is likely to be caused by PCPS when applying the conventional femoral cannulation. We have developed a new IABP catheter which incorporates a conduit for PCPS with an outlet at the catheter tip, the goal of which is the improvement of cerebral perfusion. The hemodynamic characteristics of this new IABP catheter were compared with those of the conventional combination of IABP and PCPS. Studies were performed by mock test using a pulsatile artificial heart. A polyvinyl chloride tube acted as the aorta with 2 branches at the proximal and distal portions representing the upper and lower portions of the body. The IABP balloon was positioned between the 2 branches, and changes in flow at the 2 branches were examined at varying PCPS flow rates. Flow in the proximal branch using the new device was greater than it was using the conventional PCPS device. We conclude that cerebral perfusion could be improved with the use of this new special IABP catheter.

An 80-year-old man suffering from angina on exertion due to stenosis of the left main coronary artery, heart failure due to mitral valve regurgitation, and an abdominal aortic aneurysm (AAA) was successfully operated on with simultaneous surgical procedures. A coronary cineangiography revealed 90% stenosis of the left main coronary artery in segment 5, and 99% and 90% stenosis in segments 2 and 4AV, respectively, of the right coronary artery. Left ventriculography and aortography showed moderate mitral valve regurgitation and the presence of a fusiform-shaped AAA with a maximum diameter of 6 cm. It was thought that insertion of an intraaortic balloon pump (IABP) would prove difficult due to AAA; therefore, simultaneous surgery combining triple coronary artery bypass grafting (CABG), mitral valve plasty, and prosthetic replacement of the AAA was undertaken. The patient's postoperative course was uneventful, and subsequent angiography showed good patency of all coronary bypass grafts and the abdominal prosthesis, along with the disappearance of mitral regurgitation. This patient's clinical course suggests that an extended surgical procedure is effective for the treatment of complicated cardiovascular disease, even in very elderly patients.

Superior mesenteric artery occlusion (SMAO) is often fatal. An indicator which enables the early diagnosis of SMAO is needed. As we think putrefaction products must appear and increase in the blood and ascites in SMAO, changes in the concentrations of ammonia, one of the putrefaction products, were measured in this study. Thirteen adult mongrel dogs were used for the in vitro experiment. The jejunum, ileum, and ascending colon were resected and incubated in saline. Changes in ammonia concentrations in the saline were examined at various incubation times. In the in vivo experiment, 11 mongrel dogs comprised the SMAO group and another 10 mongrel dogs comprised the control group. Changes in ammonia concentrations in the blood and ascites were examined in both groups. In the in vitro experiment, ammonia concentrations in the saline bath increased in all samples. It was highest in the sample from around the ascending colon, and lowest from around the jejunum. However, at the end of experiment, this difference became insignificant. In the in vivo experiment, ammonia concentrations in samples of the blood increased early and significantly in the SMAO group, compared with the control group. Ammonia concentrations in samples of the ascites also increased significantly. The in vitro experiment showed that ammonia leaked from the ischemic intestines, and secondarily, a large amount of ammonia was produced from intestinal putrefaction. The in vivo experiment revealed that the ammonia level in the blood could be used as a good early indicator of acute mesenteric ischemia.

Despite the necessity of information regarding the abdominal aorta and visceral arteries during cardiovascular surgery, there has been no intraoperative modality available. We examined the feasibility and limitations of transesophageal echocardiography (TEE) for this purpose. In 21 consecutive patients, the celiac artery (CEA), superior mesenteric artery (SMA), and left and right renal arteries (LRA, RRA) were examined with TEE, and could be visualized in 21 cases (100%), 20 cases (95.2%), 14 cases (66.7%) and 14 cases (66.7%), respectively. Several attempts were needed for successfully visualizing the LRA and the RRA in 2 and 1 case(s), respectively. Three specific manipulations of the probe were helpful for visualizing these vessels: 1) an appropriate counterclockwise rotation and an upward flexion of the probe when the transducer entered the stomach; 2) a stiffening of the flexible portion of the probe at the position of upward flexion by fixing the handle of the TEE probe when the transducer was advanced; and 3) a lateral flexion of the probe to provide a rotation of the image in either the clockwise or counterclockwise direction and to optimize the assessment of the blood flow velocity in the branch artery. Inferior visualization of the renal arteries was a limitation of this method. Two solutions for this problem were 1) repeated attempts at visualization and 2) an examination of the blood flow in the renal parenchyma with color Doppler imaging. Because of possible damage to the gastric wall, it is recommended that this maneuver be conducted by an experienced sonographer.

Objective: Both blood flow monitoring and pressure monitoring are necessary to avoid inadequate cerebral perfusion during cardiovascular operations. Inasmuch as transcranial Doppler ultrasonography does not provide a consistently good signal, especially during cardiopulmonary bypass, we examined the blood flow through the central retinal artery, which has proved to reflect an obstruction of the carotid artery., Method: Twenty-eight consecutive cases were examined with a 5 or 7.5 MHz conventional echocardiographic probe. Correlation between the maximal velocity at the central retinal artery and systolic blood pressure was examined. The blood flow of the central retinal artery and retrobulbar vessels was examined during selective or retrograde cerebral perfusion or intraaortic balloon pumping., Results: Blood flow could be clearly visualized but disappeared below a certain pressure in every case. With data from 478 measuring points, systolic blood pressure correlated with maximal velocity (r = 0.6902, p < 0.0001). The blood pressure-axis intercept, known as "critical closing pressure," was 35.8 +/- 14.8 mm Hg, varying among individuals and bilateral eyes. Pulsatility index increased after cardiopulmonary bypass (1.095 +/- 0.245 to 1.525 +/- 0.268, p < 0.0001). Patency of the circle of Willis was confirmed by the blood flow during anastomosis of the ipsilateral artery. During retrograde cerebral perfusion, blood flow was detectable at the retrobulbar vessels. During intraaortic balloon pumping, the central retinal artery flow was augmented on inflation of the balloon., Conclusion: Orbital vessel monitoring provides the critical closing pressure of the central retinal artery and confirms patency of the circle of Willis. The eye can be "an acoustic window" into intracranial blood flow during cardiovascular surgery.

A case of pseudoaneurysm of the aortic arch which protruded to the retrobronchial space is reported. A 73-year-old female complaining of severe chest pain was transferred to our hospital, CT showed an abnormal mass which occupied the retrobronchial space and displaced the esophagus toward righ, associated with left pleural effusion. A pseudoaneurysm of the aortic arch was suspected. Angiography revealed an aortic arch aneurysm protruding to the retrobronchial space. Emergent total arch replacement was performed. We diagnosed it as an impending rupture of the aortic arch aneurysm with a specific shape.

We have developed a direct mechanical left ventricular assist device (DMLVAD) for severe left ventricular failure. The DMLVAD was attached to the left ventricle and compressed the heart by a pneumatic driving unit. In a mock circulation model with an extracted nonbeating heart, a cardiac output (CO) of 1.93 L/min was obtained at a driving pressure of 200 mm Hg. In a canine left ventricular failure model induced by injection of sodium hydroxide into the myocardium, the systolic arterial pressure, systolic left ventricular pressure, maximum LV dP/dt, peak flow, and CO increased by 21, 24, 58, 144, and 37%, respectively. The mean left atrial pressure also decreased by 15% when the DMLVAD was driven. These effects were most prominent when the mean left atrial pressure was over 15 mm Hg, and the driving pressure was over 100 mm Hg. Compression at late systole was more effective in obtaining greater CO. We suggest that the DMLVAD could be an optional circulatory assist device for patients with left ventricular failure awaiting heart transplantation.

A right atrial separation procedure was performed for the ablation of atrial fibrillation during the concomitant repair of an atrial septal defect. This procedure consisted of a Y-shaped incision in the right atrium, followed by cryoablation of the tricuspid annulus and the atrial septum without any procedures performed on the left atrium. This is a simple and effective method for the elimination of chronic atrial fibrillation associated with atrial septal defects in adults.

A 55-year-old woman, who was detected an enlargement of the aorta with body CT, was admitted to our hospital. Preoperative examination revealed that the aneurysm was expanded from ascending aorta to the abdominal aorta above the celiac artery. She underwent total arch replacement using elephant trunk technique. Forty-four days after operation, she underwent thoracoabdominal aortic replacement with monitoring for spinal cord ischemia by the use of the motor evoked potentials (MEP), the evoked spinal cord potential (ESCP) and the segmental evoked spinal cord potential (S-ESCP). Under the partial cardiopulmonary bypass with femoral venous drainage and femoral arterial cannulation on normothermia, the aneurysmal part of the aorta was segmentally cross-clamped and the three lumbar arteries and the celiac artery were reconstructed one by one. During the operation, the monitor showed no remarkable change, even while the aorta was cross clamped. Her postoperative course was uneventful without any spinal cord damage. Combined use of MEP, ESCP, and S-ESCP was useful for monitoring spinal cord injury during thoracoabdominal aneurysmal repair.

Chronic atrial fibrillation (AF) had been documented in a patient with atrial septal defect for 7 years. A right atrial separation procedure was performed for ablation of chronic AF, concomitant with repair of the atrial septal defect, and followed by atrial electrophysiological mapping. A horizontal transectional incision extending to the borders of the atrial septum and the tricuspid annulus was made. Cryolesions of the atrial isthmus between the margin of the upper incision and the tricuspid valve annulus were created at -60 degrees C for 2 minutes at a time. After the operation, the patient had restored normal sinus rhythm during a subsequent follow-up period of 48 months.

Background: We have devised a simple surgical procedure to be performed on the posterior wall of the left atrium for the treatment of chronic atrial fibrillation (AF) associated with mitral valve disease. The effectiveness of this procedure for serial mitral valve operations was then evaluated. We postulated that chronic AF associated with mitral valve disease could be attributable to a distended left atrium. The refractory period of the distended left atrium was significantly shorter in the left posterior atrial wall, especially at the base of the left atrial appendage and at the orifice of the left posterior pulmonary vein. We hypothesized that the left posterior atrial wall with its shorter fibrillatory cycle length would act as a driver for maintaining the AF, and therefore, surgical ablation of this critical area in the left atrium could terminate the chronic AF., Methods: The surgical patients were divided into two groups. In group 1 (control group), 15 patients with chronic AF were operated on by the mitral valve procedure only. In group 2, 36 patients underwent this procedure in combination with a concomitant mitral valve operation. The disappearance rate of the AF was estimated by electrocardiography, and atrial function was estimated by transthoracic and transesophageal echocardiography., Results: The chronic AF had been reduced significantly or eliminated at discharge in 4 of 15 patients (26.7%) in the group 1, versus 31 of 36 patients (86%) in group 2 (p < 0.05). In group 2, 29 of the 31 patients (94%) whose AF had disappeared recovered the atrial kick of their right atrium, and 21 patients (22/31; 71%) recovered the atrial kick of their left atrium., Conclusions: Surgical ablation of the posterior wall of the left atrium was effective in the treatment of chronic AF associated with mitral valve disease. This simple procedure could restore a sinus rhythm and also recovered atrial systolic function. We conclude that the left atrium may act as a driver for sustaining AF in mitral valve disease.

Intimal thickening and luminal narrowing of the coronary arteries are insidious complications of cardiac allograft. However, the pathogenesis of cardiac allograft vasculopathy (CAV) remains to be clarified. In this study, the protective effect of a prostacyclin analogue (beraprost sodium; BPS) on CAV was evaluated after heterotopic cardiac transplantation in rat. All recipients were treated with cyclosporine A (10 mg/kg/day intramuscularly). Eight rats received oral therapy with BPS of 50 micrograms/kg/day (BPS group) and another 8 rats received vehicle only (control group). All surviving cardiac grafts were removed on the 60th postoperative day and were examined to determine the severities of cellular rejection and CAV (> 50 microns in diameter). Additionally, 6-keto-prostagrandin F1 alpha and thromboxane B2 were compared between the two groups. There was no significant difference in the grading score for cellular rejection based on the ISHLT grading system (2.31 +/- 0.75 vs 2.47 +/- 0.65, p = 0.81). Although the endothelial cells were preserved in both groups, a deposition of fibrin-like dense materials was recognized in the subendothelial layers of the control group, but not in the BPS group. Intimal thickening was inhibited significantly in the BPS group. The intimal ratio (intimal area/sectional area of artery) was significantly lower in the BPS group than in the control group (0.134 +/- 0.03 vs 0.205 +/- 0.047; p < 0.01), without any difference in the medial ratio (medial area/sectional area of artery). alpha-actin positive smooth muscle cells (SMC) in intima were fewer in number in the BPS group than in the control group. The plasma thromboxane B2 level was significantly lower in the BPS group than in the control group (270 +/- 116 pg/ml vs 585 +/- 258 pg/mg; p < 0.01). It was concluded that BPS suppressed CAV development after heterotopic allogenic cardiac transplantation in rats.

An 82-year-old man suffering from chronic atrial fibrillation associated with valvular and coronary artery diseases was admitted to our hospital. Preoperative examination revealed that mitral and aortic valve replacement with tricuspid annuloplasty and coronary artery bypass were required, in addition to surgery for chronic atrial fibrillation. In order to shorten the aortic cross-clamp time and operative time, we performed left atrial isolation, which is a simpler procedure than maze procedure and the left sided maze procedure, because it requires incision of the posterior left atrium only. Since aortic stenosis was severe and the aortic annulus was small, we used a St. Jude Medical Hemodynamic Plus valve as the aortic valve prosthesis, which spares the surgical stress of the aortic annulus. Careful investigation of the patient disorder and selection of optimal surgical procedure makes possible an extended operation of complicated valvular disease even in a high elderly patient over 80 years old.

A new intravascular pumping oxygenator (IVPO) was developed for intravascular gas exchange and circulatory assistance in critically ill patients with respiratory and circulatory failure. The IVPO utilizes new silicone hollow fibers (diameter, 1 mm; membrane width, 50 microns) and consists of two driving tubes for the oxygenation and pumping of circulating blood. The performance characteristics of the IVPO were studied using an experiment ex vivo model. With a mean hemoglobin concentration of 10.5 +/- 2.3 g/dl, total oxygen transfer was 5.6 +/- 1.5 ml/min at a blood flow of 200 ml/min and 6.3 +/- 2.2 ml/min at a blood flow of 250 ml/min. Total CO2 transfer was 3.8 +/- 1.4 ml/min at a blood flow of 200 ml/min and 4.2 +/- 1.6 ml/min at a blood flow of 250 ml/min. Blood flow increased to a maximum of 250 ml/min during IVPO pumping. This preliminary experiment demonstrated that the IVPO has the capacity to function both as circulatory assist pump and as an intravascular hollow fiber oxygenator.

Background: A computerized 48-channel mapping system was used to investigate the characteristics of an atrial epicardial electrogram during chronic atrial fibrillation (AF) in patients with solitary mitral valve disease. We have devised a simple left atrial procedure to eliminate the chronic AF during a mitral valve operation., Methods: Using this mapping system, we performed intraoperative atrial mapping in 11 patients with chronic AF associated with mitral valve disease. The AF duration ranged from 0.4 to 15 years (mean, 8.0 +/- 4.5 years). A simple surgical ablation of the AF on the left atrium only was performed during the mitral valve operations., Results: The mean AF cycle length of the atria ranged from 129 to 169 milliseconds in the right atrium and from 114 to 139 milliseconds in the left atrium. The mean AF cycle length of the left atrium was shorter than that of the right atrium. Regular and repetitive activation was found in the left atria of 7 of 11 patients. The AF disappeared in all patients immediately after the operation, and 10 of these patients continued to have a sinus rhythm postoperatively (AF-free rate, 91%)., Conclusions: Computerized intraoperative mapping revealed a shorter mean AF cycle length in the left atrium. A simple left atrial procedure was effective in eliminating chronic AF associated with solitary mitral valve disease.

We have evaluated the usefulness of graphic diagnostic modalities (transthoracic echocardiography [TTE], high speed CT, transesophageal echocardiography [TEE], surface echocardiography [SE]) in acute type A aortic dissection and selected the adjunct to protect cerebral damage during operation followed by pre and intraoperative diagnosis. 1) Angiopraphy was undergone in only 5 cases of 22 cases of acute type A dissection. Intimal flap of the ascending aorta was completely diagnosed by TTE and CT. It was sometimes difficult to show the location of the intimal tear by TTE and CT (diagnostic sensitivity 64%, specificity 88%). However, TEE and SE showed the location of intimal tear in all cases (sensitivity 100%, specificity 100%) and also clarified the dissection of the coronary arterial orifice. CT and SE were useful to detect dissection of the cervical branches. 2) The adjunct for cerebral protection was selected by the diagnosis of the distension of the dissection. Retrograde cerebral perfusion was used in the cases with intimal tear in the ascending aorta (10 cases) and selective cerebral perfusion was selected in cases of the distended dissection, in which dissection involved the arch aorta and replacement of aortic arch was required (12 cases). Cerebral perfusion time and operative mortality was 48 min and 10% in the former and 72 min and 17% in the latter, respectively. Operative mortality was not different in both groups.

We report that a "pooled form" of retained intracardiac air, in addition to the "bubble form" of air, often is present in patients undergoing open heart operations. This "pooled form" of air can amount to several milliliters. The purpose of this study was to quantify the pooled air by echocardiographic methods in an experimental model. Incremental volumes of air were injected into two types of left ventricles (a geometric dome-shaped model and a canine left ventricular model) and were visualized by echocardiography. The heights and widths of each amount of air were measured with an echocardiographic probe and the volume of air was calculated using five different models to approximate the shape of the air. The coefficient for the correlation between the estimated volume and the injected volume was greater than 0.96 in every model, although some overestimation or underestimation occurred in every model. The cube and cylinder models were advantageous for smaller volumes and the hemiel-lipsoid and bullet models were most appropriate for larger volumes. The cube model was advantageous in determining whether the air volumes were more or less than 0.5 mL.

We supposed that chronic atrial fibrillation originated as a result of discontinuity of the refractory period of the dilated left atrium in the mitral valvular disease. We then performed left atrial only procedures to treat the chronic atrial fibrillation (AF) associated with mitral valve disease. These procedures were the left atrial isolation and the modified left sided maze procedure, consisting of isolation of all pulmonary veins and cryoablation to the posterior wall of the left atrium, in addition to excision of the left atrial appendage. Twenty-eight patients underwent these procedures over the past thirty months. Patient ages and the duration of AF ranged from 37 to 71 years and from 0.5 to 26 years, with an average of 8.3 years, respectively. Chronic AF disappeared in twenty-four patients (86%) at discharge. Three patients with severe tricuspid insufficiency had sustained AF and one patient had atrial flutter postoperatively. Three patients showed sick sinus syndrome postoperatively and two of these required a DDD pacemaker. Severe tricuspid regurgitation (p < 0.020) was the factor in recurrence of AF. Left atrial only procedures were effective in the treatment of chronic AF associated with mitral valvular disease.

A 73-year-old female began to suffer from effort-induced chest pain and later disabling angina pectoris. Coronary angiographic evaluation disclosed that both the right and left coronary arteries originated from the right sinus of Valsalva. The dominant right coronary artery had a normal course with a 90% narrowing in the first segment. The left main trunk crossed anteriorly the pulmonary artery conus, thereafter dividing into the left anterior descending and circumflex coronary arteries with two 99% narrowings in the seventh and eleventh segment. She underwent bypass of the left anterior descending and right posterior descending coronary arteries with the left interthoracic artery, the right gastroepiploic artery, and saphenous vein graft on cardiopulmonary bypass support. The postoperative course was uncomplicated.

We studied the protective effects of low power He-Ne laser irradiation on erythrocytes against the damage caused by experimental artificial heart-lung machines. The erythrocyte suspension in a closed circuit was perfused with a roller pump. One of two circuits was used for laser treatment and the other for control. The laser group demonstrated significantly higher erythrocyte deformability and erythrocyte ATP levels, and lower free hemoglobin and lipid peroxide levels. A laser output power of 8.5 mW was most effective in protecting the erythrocytes. A further morphological finding using a scanning electron microscope showed fewer echinocytes and more discocytes in the laser group. This finding was consistent with the results of physiological and biochemical tests. Low power He-Ne laser irradiation was shown to protect human erythrocytes from the damage caused by an experimental artificial heart-lung machine, raising the possibility of the clinical application of low power He-Ne laser treatment during extracorporeal circulation in cardiovascular surgery.

Among coronary vessels anomalies is the rare coronary artery fistula. Myocardial insufficiency resulting from fistula steal phenomenon can not be clinically distinguished from that of coronary atherosclerosis, if these conditions coexists in the same patient. The authors present a case of extracardiac left coronary artery fistula connecting the circumflex branch and left bronchial artery, with inferior wall myocardial insufficiency attributable to the right coronary artery atherosclerosis.

We describe herein the successful treatment of a patient with chronic atrial fibrillation (AF) associated with mitral valve stenosis and regurgitation, achieved by performing a modified maze procedure on the left atrium alone. The patient was a 51-year-old man who had suffered from intractable AF for 17 years, causing multiple cerebral emboli and palpitations. He had undergone open mitral commissurotomy and balloon commissurotomy 15 and 7 years ago, respectively. On admission, an echocardiogram revealed mitral valve restenosis and thrombosis in the left atrial appendage. Prosthetic valvular replacement was performed following isolation of all pulmonary veins with cryoablation to the posterior wall of the left atrium and excision of the left atrial appendage. Postoperatively, the AF disappeared and echocardiogram demonstrated a left atrial kick in the mitral valvular inflow without any evidence of thrombosis in the left atrium. Thus, we believe that our modified "left side only" maze procedure is a simple and efficient method for the treatment of chronic AF with mitral valve disease.

We report a case treated with thromboembolectomy using cardiopulmonary bypass for acute pulmonary embolism caused by nephrotic syndrome. A 19-year-old male with poorly controlled nephrotic syndrome was admitted associating with severe shock. An acute pulmonary embolism was diagnosed by ECG and echocardiography. Despite the intensive thrombolytic therapy, hemodynamics was deteriorated. Pulmonary arteriography demonstrated obstruction of left main pulmonary artery and partial defects of right pulmonary artery bifurcation and right middle-lower pulmonary arteries. An emergent thromboembolectomy using cardiopulmonary bypass was performed successfully. In conclusion, an emergent surgical treatment is required in the case of acute massive pulmonary thromboembolism which shows hemodynamic deterioration in spite of recent intensive medical treatment.

To clarify the physiologic roles of granulocyte colony stimulating factor (G-CSF) in increasing granulocyte after extracorporeal circulation (ECC). The serum levels of G-CSF, C3a, granulocyte elastase and granulocyte count were examined in 26 patients undergone open heart surgery. These patients were divided into two groups, the long perfusion group (11 patients) and the short perfusion group (15 patients). Granulocyte increased immediately after ECC and reached maximum 48 hours after ECC in both groups. C3a showed significant increase at the end of ECC and decreased rapidly after ECC in both group. G-CSF showed high levels 3 and 6 hours after ECC in the short perfusion group and moderate increase prolonged until 48 hours after ECC in the long perfusion group. Granulocyte elastase showed high levels 6 hours after ECC and decreased to the normal value 48 hours after ECC in the short perfusion group, and high levels prolonging until 48 hours after ECC in the long perfusion group. Increase of granulocyte count might be affected with increase of compliment (C3a) and G-CSF at the early and late phase after ECC, respectively. Granulocyte elastase increased differently by the duration of perfusion time.

A 57-year-old female with hypotension and consciousness disturbance was referred to our institute. Echocardiography and plain CT revealed cardiac tamponade, but no apparent evidence of aortic dissection was obtained. With sudden onset of hypotension, she was immediately operated without information of aortography, enhanced CT, and MRI. Approximately 200 g of pericardial hemorrhage and slight subadventitial hematoma was grossly found and surface ultrasonography revealed the mild localized intramural hematoma (crescent-shaped translucent layer of at most 5 mm in width) at the proximal ascending aorta. Because neither false lumen with blood flow nor intimal flap was found, pericardial drainage without aortic replacement was performed. However, DeBakey type II of aortic dissection with wide false lumen was found with CT and MRI within three weeks, and re-operation was carried out. The dissection ranged from the ostium of right coronary artery to the beginning of innominate artery, but did not involve the coronary arteries and major branches of aortic arch. The surface ultrasonography and transesophageal echocardiography, as well as preoperative CT and MRI, demonstrated that false lumen was thrombosed except at the anterior aspect of mid-portion of ascending aorta. The ascending aorta was replaced. A careful follow-up is mandatory for even a localized intramural hematoma, which can progress into aortic dissection in a short period.

In retrograde cardioplegia (RCP), some difficulty is occasionally encountered when inserting a catheter into the coronary sinus (CS). Although the usefulness of transesophageal echocardiography (TEE) for guiding the cannulation procedures has been previously reported by other authors, we have obtained additional findings by TEE monitoring of eleven patients during placement of the CS catheter. The diameter of the CS ranged from 5.5 to 10.7 mm, indicating that it was large enough for the CS catheter to be inserted and that the resistance at insertion was not due to narrow CS. The precise time for inserting the catheter, for which myocardial protection is delayed, ranged from 8 to 376 seconds, with an average of 98 seconds. Dislodgement of the catheter was found in two cases. In case of difficult cannulation, the catheter tip was found to be pushing the right atrial wall adjacent to the CS orifice or alternatively it entered the middle cardiac vein which had a common atrial orifice with the CS in this particular case. We found that the knowing the following technical problems helps appropriate monitoring: the catheter tip becomes unclear when it is not perpendicular to the ultrasonic beam, when surgeon's fingers are placed behind the heart, or when the blood is entirely exsanguinated. Finally we present the possibility of employing images of overflow out of CS during RCP infusion, detected by TEE, as an index of efficient perfusion at the interventricular septum.

The effects of passive (no pump) and active (using centrifugal pump) shunting on hemodynamics and metabolisms during cross-clamping of the descending thoracic aorta were compared in mongrel dogs. In Group I (control), the aorta was cross-clamped for 2 hours without shunting; in Group II (passive), a temporary shunt was placed between the left common carotid and left femoral arteries during cross-clamping; and in Group III (active), left heart by-pass, matching flow to that in group II, was performed. Hemodynamic and metabolic parameters were recorded prior to cross-clamping and following every 30 min for 4 hours. All animals in Group I suffered from hemodynamic instability, metabolic abnormal and neurologic injury and died within 12 hours. Hemodynamic changes were unstable in Group III than II, and three dogs in Group III, but none in Group II, suffered from neurologic injury. Metabolic changes between Group II and III were not significant. We conclude that passive shunting is superior to active shunting for aortic by-pass.

A 45-year-old female of mitral valvular disease with chronic atrial fibrillation was referred to our hospital. She had received previous closed mitral commissurotomy (12 years ago) and open mitral commissurotomy combined with aortic valve replacement (6 years ago). An echocardiogram showed restenosis and regurgitation of the mitral valve (valve area 1.2 cm2 by B-mode) and severe regurgitation of the tricuspid valve. She also complained of chronic atrial fibrillation since 35 years old. Mitral valve replacement with CarboMedics bileaflet valve (25 mm) and tricuspid annuloplasty by DeVega procedure was undergone via an extended transseptal approach and cryoablastion was added to the posterior wall of the left atrium along the rim of the left pulmonary veins and around the left atrial appendage for ablation of chronic atrial fibrillation. After completion of surgery, atrial fibrillation disappeared. Post operative echocardiogram showed apparent atrial kick of both atriumns in the inflow pattern of both ventricles. The patient continues to be well with normal sinus rhythm for 6 months after surgery. An extended transseptal approach is useful in mitral reoperation, in addition, it can be applicable for the surgery of chronic atrial fibrillation.

We have extendedly used arterial grafts in coronary bypass surgery because of their better patency rate. We have operated 134 cases of coronary bypass during recent 27 months. Postoperative angiography showed high patency rate in arterial grafts, such as 97% (59/61) of right internal thoracic artery (RITA), 98% (107/109) of left internal thoracic artery (LITA), 96% (83/86) of right gastroepiploic artery (RGEA), comparing with 86% (26/30) of saphenous vein graft (SVG). Pathological examination was done by specimens of grafts obtained during operation. Vasa vasorum was poorly developed in ITA and RGEA. ITA had several layers of elastic fiber in media and RGEA had smooth muscular media. Both arterial grafts showed low atherosclerotic scores (intima/media), 7.1% in RITA, 7.3% in LITA and 6.8% in RGEA. But some cases with hyperlipidemia and/or diabetes showed high score of atherosclerosis in arterial grafts. Endothelial cells were well preserved in both arterial grafts after harvesting, in contrast with poor endothelial preservation in SVG. Endothelial appearance of RGEA was similar to that of the coronary artery and different from that of ITA. RGEA is superior grafts for CABG as coronary bypass because of their structural superiority.

To evaluate left ventricular diastolic filling (DF) using transesophageal Doppler echocardiography in 40 patients with or without diabetes mellitus and/or hypertension, we measured DF after induction of anesthesia, before and after cardiopulmonary bypass (CPB), and at the end of coronary artery bypass surgery (CABS). In 13 patients with complete measurements, there was no significant change in DF but diastolic filling time became shorter and peak velocity during atrial contraction increased significantly following CPB. In the other patients, the assessment of DF could be performed accurately in CABS patients without diabetes and/or hypertension, but not in CABS patients with these disorders because of a high incidence of fusion of the E-A waves, which is an indicator of impaired DF. When heart rate (HR) was more than 75 beats·min -1 (RR interval of less than 800 ms), the incidence of fusion points was significantly higher in patients with diabetes and/or hypertension than without (13 of 29s 1 of 9,P<0.05). It is suggested that a slower HR (less than 75 beat·min -1 ) is desirable in CABS patients with these disorders to avoid impairment of DF due to either prolonged systolic time or isovolumic relaxation time.

Surgical isolation of the left atrium was performed for the treatment of chronic atrial fibrillation secondary to mitral valvular disease in a 65-year-old woman who underwent mitral valvular replacement. Left atrial isolation was simple procedure, prolonging the usual paraseptal atriotomy toward the both mitral valvular commissures anteriorly and posteriorly. The incision was conducted two centimeters apart from the mitral valve annulus, and cryoablation was added at the edges to ensure isolation of the residual left atrium. We suggest performing this simple procedure in patients with chronic atrial fibrillation undergoing mitral valvular replacement, in whom correction of irregular beat and compromised hemodynamics can be obtained.

The usefulness of transesophageal echocardiography (TEE) for guiding the placement of a pulmonary artery (PA) catheter was evaluated in 31 patients (TEE group); 31 patients who were treated before TEE guidance was used (control group). In the control group, use of the PA catheter was abandoned in two patients; because of an unstable condition and marked arrhythmias, respectively. The key findings for TEE guidance were: (1) pulsatile to-and-fro movement of the balloon, i.e., "shuttle movement" and (2) loss of shuttle movement at wedging of the balloon, i.e., "anchoring sign." When the PA catheter did not enter the right vertricle (RV), the balloon was found to be in the inferior vena cava or the right atrium (RA) without shuttle movement. Coiling of the catheter was suggested in the latter situation. Coiling also occurred in the RV, often associated with frequent arrhythmias. These findings indicate that the catheter should be withdrawn once. TEE allowed for readjustment of the catheter tip position by enabling the balloon to be wedged twice. An excessively deep placement of the catheter tip was seen in 5 of the controls, but in none of the TEE group. Biplane TEE was found to be advantageous for guiding PA catheter placement and for visualizing the RV inflow and outflow tract in a single view, with the shuttle movement of the balloon in its long axis. TEE acts as an "eye" in the operating room, as does fluoroscopy, enabling smooth placement of the PA catheter.

Buckling of the transesophageal echocardiography probe was encountered in 6 of 23 patients (26.1%), although no complication occurred. When buckling occurred, acquisition of images and manipulation of the probe became difficult, resistance was felt when withdrawal of the probe was attempted, and the probe was fixed in the extreme ante- or dorsiflexion. In this situation, the probe was carefully advanced into the stomach, in which the buckled probe was unfolded, and then withdrawn to the esophagus. Buckling of the probe tip is not uncommon at insertion of the probe, especially when using a flaccid probe in an anesthetized patient. A TEE operator should be aware of the possibility of buckling. Unusual resistance associated with buldging of the submandibular region is a sign of a folded-up probe tip. Use of laryngoscopy is recommended in order to avoid inserting the buckled probe into the esophagus.

To examine the effects of extracorporeal circulation using an artificial heart and lung machine on hepatic energy metabolism in patients with cardiac operation using hypothermia, the arterial blood ketone body ratio (AKBR) reflecting the hepatic mitochondrial redox state was determined in 12 patients who had undergone cardiac operation using extracorporeal circulation from March to August 1991. Changes in AKBR were compared with those before and after extracorporeal circulation. AKBR decreased significantly after the beginning of extracorporeal circulation (p < 0.001) and remained at a lower level throughout extracorporeal circulation. On termination of extracorporeal circulation, the initial level was immediately resumed. The extent of decrease in ketone body ratio at ten minutes before termination of extracorporeal circulation was correlated with short term postoperative hepatic insufficiency. The patients whose ratio decreased below 0.4 showed increased levels in glutamic-pyruvic transaminase at the end of the first and second week after operation. Changes in AKBR were significantly associated with those in blood pressure (r = 0.433; p < 0.005) and body temperature (r = 0.472; p < 0.005). It was concluded that blood pressure and body temperature influence the blood ketone body ratio during extracorporeal circulation.

Repair of acute aortic dissection with destruction of the right coronary ostia and aortic valve regurgitation is described. The patient was a 54 year-old female with Marfan syndrome, who was admitted to our hospital for acute dissection with annulo aortic ectasia, accompanied by myocardial ischemia of the inferior wall. Retrograde dissection to the aortic annulus and destruction of the right coronary ostia due to extended dissection were noted. Retrograde coronary infusion through the coronary sinus was conducted during replacement of aortic annulus by the Cabrol method in conjunction with supplementary vein grafting to the right coronary artery. Distal repair was carried out, supported by hypothermic circulatory arrest and retrograde cerebral perfusion through the superior vena caval cannula. Retrograde cerebral and coronary sinus perfusion have been shown to be quite effective for treating patients requiring complex reconstruction of the ascending aorta.

A 73-year-old woman received an aorta-coronary bypass operation using the free internal thoracic artery, and good patency was obtained. The free internal thoracic artery is usefull in case of short graft length and in case of multiple vessel disease.

Twenty-nine patients aged 18 years or older underwent radical operation for atrial septal defect between April, 1987 and March, 1992 at the First Department of Surgery, Hiroshima University School of Medicine. They were divided into two groups: Group-I consisted of 18 patients who were less than 49 years old, and group-II who were more than 50 years old. The two groups were compared with respect to the following: 1. sex, 2. symptoms, 3. chest X-ray (CTR), 4. renal function (BUN, Cr), 5. lung function (vital capacity, % forced expiratory volume in one second), 6. echocardiographic examination of MVP, MR, and TR, cardiac catheterization data (left-to-right shunt ratio, Qp/Qs, pulmonary artery pressure), 8. septal defect size and surgical method, and 9. postoperative arrhythmia. The following results were obtained in group-II as compared with group-I: 1. the ratio of women was higher (82% vs. 61%), 2. the ratio of symptoms was higher (82% vs. 44%), 3. cardiomegaly was more severe on chest X-ray (CTR 58 +/- 5% vs. 50 +/- 5%), 4. septal defect size was larger (4.9 +/- 2.1 cm2 vs. 3.3 +/- 1.6 cm2), 5. vital capacity was lower (91 +/- 14% vs. 105 +/- 14%), and 6. the incidence of postoperative transient arrhythmia was higher (55% vs. 6%). Group-II was subsequentry divided into two subgroups: 7 patients not using digitalis and furosemide, and 4 patients who did use digitalis and furosemide prophylactically. The incidence of postoperative arrhythmia was compared between the two subgroups.(ABSTRACT TRUNCATED AT 250 WORDS)

Using transesophageal echocardiography during open heart operations, we found another form of retained intracardiac air, "pooled air," in addition to the form of "bubbles" that had been reported by other authors. The pooled air was detected in all of 13 patients (100%); it was located at the right upper pulmonary vein in 13 (100%), left ventricular apex in 9 (69.2%), left atrium in 8 (61.5%), right coronary sinus of Valsalva in 8 (61.5%), left atrial appendage in 4 (30.8%), and left upper pulmonary vein in 3 (23.1%). The pooled air was found also in the pulmonary artery in 6 of 8 patients (75.0%) in whom the pulmonary artery was clearly visualized. In 1 patient, 5 mL of air was aspirated from the left ventricular apex, followed by a reduced size of the air on the transesophageal echocardiographic image. Because intracardiac air rapidly changes its locations and appearances, continuous monitoring is important, especially at weaning from bypass. The long-axis view of the heart is useful not only for detecting and locating the air, but also for guiding and evaluating the procedures to remove air.

The incidence and location of retained air in 35 patients who underwent coronary artery bypass grafting (CABG) were examined using B mode transesophageal echocardiography. The origin of air detected in the left atrium or left ventricle on weaning from a cardiopulmonary bypass was sought as far as the 4 pulmonary veins. Air appeared as: highly echogenic dots with high mobility, buoyancy and no disappearance in the blood flow. Retained intracardiac air was detected in 10 of the 35 patients: in the right upper pulmonary vein (RUPV) in 9 patients and in the left ventricular (LV) apex in 7. Six of the 7 patients with air retained at the LV apex also had air in the RUPV, suggesting that air from the RUPV collected again at the LV apex. Air from the RUPV was observed flowing into the left atrium on resumption of the pulmonary vein flow. Air at the LV apex appeared as a strong echo area which exhibited a pop-up motion in systole, while air bubbles gradually flowed into the ascending aorta. In one patient, the air at the LV apex was suddenly flushed into the ascending aorta when the heart was manipulated. Air retention is not uncommon in CABG and is mainly located in the RUPV. Retained air at the LV apex may remain indefinitely, and suddenly flow into the aorta with manipulation of the heart or a change of posture.(ABSTRACT TRUNCATED AT 250 WORDS)

The membrane oxygenator often develops impaired gas exchange after prolonged use because plasma proteins adhere to the membrane's surface and leak through its micropores. This study was performed to examine the efficacy of high-frequency jet ventilation (HFJV) in minimizing these problems in a "flat plate" type of membrane oxygenator. We first vibrated the membrane of the oxygenator by HFJV from 1 to 10 Hz to find the frequency most effective for optimal gas exchange in animals with partial extracorporeal circulation. These studies suggested that 6 Hz HFJV was preferable in our model. We subsequently performed in vivo extracorporeal oxygenation in dogs for 8 h using the membrane oxygenator with or without 6 Hz HFJV. Although the gas exchange capacity within the first 8 h was similar in the two groups, after 6 h a significant decrease in the red blood cell count and in the hematocrit was found in the group not receiving HFJV. Scanning electron microscopic examination of the membranes after 8 h of use disclosed that the membrane from the group receiving HFJV had less plasma protein and fibrin adhesion than that from the group not receiving HFJV. Moreover, it appears that with prolonged extracorporeal oxygenation, 6 Hz HFJV also protects against a decrease in the hematocrit of the passed blood and might lead to enhanced gas exchange. Our data suggest that good gas exchange can be maintained for periods even longer than 8 h if HFJV is used in conjunction with the membrane oxygenator.

During the past 5 years, 30 cases of thoracic aortic aneurysm were treated. Selective cerebral perfusion (SCP) and retrograde cerebral perfusion (RCP) were conducted for cerebral protection during aortic cross clamping. SCP was carried out in 5 cases of dissecting aneurysm (all Stanford type A, including a case of AAE) and 3 cases of arch aneurysm. RCP was conducted in 5 cases of dissecting aneurysm (4 Stanford type A, 1 Stanford type B with retrograde dissection) and 2 cases of aortic arch aneurysm. The mean cerebral perfusion time of SCP exceeded that of RCP (89 +/- 26 min in SCP versus 61 +/- 33 min in RCP p < 0.05). The hospital mortality rate was 38% (SCP) and 29% (RCP). Neurological complications were prolonged unconsciousness (1/8 in SCP, 1/7 in RCP) and transient paralysis (0/8 in SCP, 1/7 in RCP). Although the mechanism for the cerebral protective effect of RCP is unknown, this perfusion method is easy and safe, requiring little time for ascending and/or arch aortic reconstruction.

We report 5 cases in which intraoperative transesophageal echocardiography was instrumental in the early detection of a left ventricular wall-motion abnormality caused by acute dysfunction of a coronary artery bypass graft. The appearance of a wall-motion abnormality on transesophageal echocardiography preceded signs of myocardial ischemia when such signs were detectable with routine monitoring. By facilitating prompt, appropriate correction of technical problems, transesophageal echocardiography enabled the blood flow to be restored and the ischemic insult to be resolved without further complication.