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Thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAAs) is an alternative treatment option for high-risk patients. While conventionally performed via a transfemoral approach, it is sometimes difficult due to poor access routes. We report the case of a 90-year-old man who was incidentally diagnosed with a descending TAA while undergoing computed tomography for esophageal cancer. The patient had undergone Y-graft replacement twice. His Y-graft leg was highly angulated; therefore, a transfemoral approach was considered difficult. Consequently, transapical TEVAR was performed. The postoperative course was uneventful. Transapical TEVAR can be a useful treatment option for TAAs with poor access routes in super-old patients., (@ 2024 The Editorial Committee of Annals of Vascular Diseases.)

A 72-year-old female had persistent severe chest pain while climbing stairs. She was diagnosed as having acute coronary syndrome, and underwent an emergency coronary angiography (CAG). The right coronary artery (RCA) ostium was sub-totally occluded. Echocardiography revealed a 10 mm mobile mass at the right coronary cusp of the aortic valve. To avoid total obustruction on two drug eluting stents were placed at the RCA ostium so as to have the proximal end protrude into the right Valsalva sinus. Thus, her hemodynamic condition was stabilized. The tumor was surgically resected and the stents were easily removed. Pathologically, the tumor was papillary fibroelastoma. Postoperative aortic regurgitation was minimal echocardiography, and CAG showed normal RCA.

A 35-years-old pregnant woman with Marfan's syndrome visited the emergent department. She had sudden severe back pain. She was at the 20th week of gestation. An emergent chest computed tomo-graphy scan showed Stanford type B acute aortic dissection. After admission, strict blood pressure control was started. According to aortic valve insufficiency and fluid retention with pregnancy, acute heart and respiratory failure was getting worse. It seemed risky for both mother and the fetus to continue pregnancy. After sincere and detailed discussion between the patient and our multidisciplinary medical team, the patient decided to continue pregnancy. An urgent Bentall operation was performed. A careful attention was paid for the fetus during and after the surgery. Strict blood pressure control was also continued. The mother and the 30-week-gestation newborn recovered uneventfully. During four years of follow-up, thoracic and thoraco-abdominal aortic replacement was performed. The patient survived all of these procedures without any complication.

Graft replacement for thoracoabdominal aortic aneurysm(TAAA) is still an important technique, yet it has high risks of mortality, spinal cord ischemia, and pulmonary complications. In our hospital, thoracoabdominal aneurysm repair with grafting and endovascular treatment (TARGET) method was performed in patients with severe chronic obstructive pulmonary disease( COPD), severe pulmonary adhesions after descending aortic replacement, or those considered high risk from general condition to undergo a wide range replacement. In this method, thoracoabdominal aortic replacement near the diaphragm was followed by stent graft treatment of the residual proximal or distal lesions. Here the usefulness of this technique was reported.

Bronchial artery aneurysm(BAA) is quite rare, but its rupture is often lethal. Once it is found, treatments should be aggressively considered. A 67-year-old woman was diagnosed to have a 26 mm mediastinal BAA on computed tomography (CT) which was performed for screening. CT revealed a very short inflow vessel of the BAA and arteriovenous fistula at the outflow. Considering these features of the aneurysm, endovascular interventions deemed difficult and surgery was carried out. Because of the fragility, the aneurysm was resected together with the descending aorta and the graft replacement was performed under partial extracorporeal circulation. The patient has no untoward event for 1 year postoperatively. Although most recent reports advocate endovascular interventions, we think surgical treatment is a variable option in selected patients. Careful evaluation for each BAA case would be essential to determine the treatment strategy.

We performed coronary artery grafting, mitral valve plasty, and tricuspid plasty in a 75-year-old man who had double-vessel coronary disease and moderate mitral and tricuspid insufficiency. Preoperative transthoracic echocardiography revealed an ejection fraction of 34% and dyssynchronous wall motion of the septum and free wall. We placed pacing leads on the right ventricular outlet and posterior left ventricular wall for cardiac resynchronization therapy. The dyssynchrony disappeared postoperatively and the New York Heart Association functional class improved from IV to I.

Prosthetic valve fracture is a serious complication and may arise in patient post-valve replacement. We experienced an outlet strut fracture and leaflet escape of a Bjork-Shiley convexo-concave valve. We performed an emergency redo mitral valve replacement and successfully retrieved the fractured strut and escaped leaflet from superficial femoral artery and the abdominal aorta. The patient showed an uneventful postoperative recovery.

Background: Kommerell diverticulum is a rare aortic arch anomaly. The indications for operative intervention and surgical strategy are still controversial. The standard surgical procedure at our institution is total aortic arch plus descending aortic replacement using anterolateral thoracotomy with partial sternotomy. The aberrant subclavian artery is reconstructed anatomically or extraanatomically., Methods: From 2002 to 2014, 6 patients (1 woman), aged 55 to 78 years, underwent graft replacement through an anterolateral thoracotomy or anterolateral thoracotomy with a partial sternotomy approach for Kommerell diverticulum. All patients underwent graft replacement of the descending aorta or total aortic arch plus descending aorta in addition to aberrant subclavian artery reconstruction., Results: No hospital deaths or major complications occurred. Recurrent nerve injury developed at discharge in 1 patient. All patients were well during the follow-up period (range, 11 to 116 months)., Conclusions: Kommerell diverticulum and its associated symptoms were surgically treated with acceptable outcomes., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Spinal cord protection during thoracoabdominal aortic surgery is challenging for surgeons. We performed thoracoabdominal replacement using a strategy for maintaining spinal cord perfusion pressure. Here, we report our experience with this procedure and the surgical outcomes., Methods: Between January 2000 and December 2014, 130 patients [male: 91 (74.6%), female: 39 (25.4%); mean age: 66.6 ± 12.8 years] underwent thoracoabdominal replacement using cardiopulmonary bypass at Hiroshima Shimin Hospital, Japan. The surgical outcomes of these patients were analysed., Results: The in-hospital mortality rate of all patients was 2.5%. The incidence of postoperative paraplegia was 3.8%. Aortic event-free survival rates at 1, 3 and 5 years were 98.2%, 93.9% and 80.7%, respectively., Conclusions: The present study suggests that our strategy for maintaining spinal cord perfusion pressure provides acceptable outcomes., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: There are various treatment strategies for chronic-type B aortic dissection involving the aortic arch. Our aim was to review our surgical experience in the anterolateral thoracotomy with the partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch., Methods: From January 2000 to October 2015, 39 patients underwent the single-stage open surgery for chronic-type B aortic dissection involving the aortic arch using the anterolateral thoracotomy with partial sternotomy approach., Results: Among the 39 patients, 32 were men (82.1%; mean age at surgery, 61.3 ± 11.9 years), with a mean dissecting aortic aneurysm diameter of 50.21 ± 12.20 mm; 28 patients (71.8%) had patent false lumens of the descending aorta. The median interval from dissection occurrence until surgery was 34.05 ± 52.34 months. Twenty-one patients underwent descending aortic replacement plus total aortic arch replacement and 18 underwent descending aortic replacement (plus partial aortic arch replacement). Overall in-hospital mortality and postoperative stroke rates were 5.1% (2 patients) and 10.3% (4 patients), respectively. Survival rates at 1, 3 and 5 years were 94.7%, 94.7% and 90.2%, respectively. Aortic event-free rates at 1, 3 and 5 years were 90.9%, 90.9% and 80.2%, respectively., Conclusions: The anterolateral thoracotomy with partial sternotomy approach is a useful surgical procedure with acceptable outcomes for chronic-type B aortic dissection cases involving the aortic arch, when aortic remodelling using thoracic endovascular aortic repair cannot be performed., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: Antegrade cerebral perfusion during aortic arch surgery plays an important role in improving postoperative neurological outcomes. We report our experience using innominate artery cannulation for arterial perfusion during aortic arch surgery., Methods: From January 2008 to December 2015, 159 patients underwent aortic arch surgery using innominate artery perfusion and were included in the study analysis (mean age, 71.4 ± 9.1 years; male, 120)., Results: Total arch replacement was performed in 84.1% of all patients. The incidence of postoperative stroke was 2.5%, with an overall in-hospital mortality rate of 2.5%., Conclusions: Innominate artery perfusionis a safe and useful technique for aortic arch surgery., (© 2017 Wiley Periodicals, Inc.)

An 85-year-old woman was hospitalized by emergency for an acute Stanford type A aortic dissection. Computed tomography showed a primary entry on the ascending aorta and pericardial effusion. Although her hemodynamics was unstable due to cardiac shock, her family wished no open surgery considering her age and frailty. A couple of days later, her condition became stabilized with antihypertensive therapy. Since the dissection was limited within the ascending aorta, closure of the entry with the stentgraft was considered appropriate and much less invasive as compared with an open surgery. After obtaining informed consent with her family, thoracic endovascular aortic repair was performed with Gore C-TAG with 2-debranch. The procedure was completed without complications and the entry closure was confirmed by aortography. Her postoperative course was uneventful. Her physical activity restored to the preoperative level and she was discharged.

We report a case of a 77-year-old man with a thoracic aortic aneurysm, combined with chronic myelomonocytic leukemia, polymyalgia rheumatica, and atial fibrillation. Open surgery was considered as high risk because he was severely ill. Instead, partial debranching and stent graft( TEVAR) were performed by chimney method. He had no major complication after surgery, and was discharged on foot on the 15th postoperative day. In high risk cases of thoracic aortic aneurysm, TEVAR with debranching and chimney methods is effective.

Objective: Hypoxic perfusion before arrest, an indeterminate period of warm ischemia, and subsequent reperfusion are major causes of cardiac allograft dysfunction in non-heart-beating donors (NHBDs). The present study was undertaken to elucidate the cardioprotective effects of ET(A) receptor antagonist FR139317 for hearts obtained from asphyxiated NHBDs in a canine transplantation model., Methods: Hypoxic cardiac arrest was induced in 17 donor dogs. FR139317 (10 mg/kg) was given to 7 of the dogs over a period of 10 min before disconnecting the ventilator. The hearts were preserved with FR 139317-supplemented cardioplegic solution (FR group). The remaining 10 did not receive FR 139317 at any time during the experiment (control group). Orthotopic transplantation was performed after a mean myocardial ischemic time of 4h., Results: During the agonal period, the highest systolic pulmonary artery pressure in the FR group was lower than that in the control group (47 +/- 14 vs. 58 +/- 27 mmHg). All animals in the FR group were weaned from cardiopulmonary bypass, whereas only five of the controls were weaned, two of which were identified to have dominant right ventricular failure. After transplantation, recovery rates of the left ventricular end-systolic pressure-volume ratio (E(max)) and the maximum first derivative of pressure measured over time (max dP/dt) were not significantly different between the groups, but recovery rates of the cardiac index, left ventricular minimum dP/dt and exponential time constant of LV relaxation (tau) in the FR group were higher than those in the control group., Conclusions: The ET(A) receptor antagonist FR 139317 reduced pressure overload on the right ventricle by decreasing the peak pulmonary artery pressure before donor arrest. Cardioprotective effects of this agent for heart transplantation from NHBDs are manifested by preserved diastolic properties of the left ventricle.

Noonan syndrome presents with dysmorphic facial features, short stature, and cardiac abnormalities (most commonly pulmonic stenosis and hypertrophic cardiomyopathy). This report describes a rare case accompanied by a secundum atrial septal defect (ASD) and a ventricular septal aneurysm causing right ventricular (RV) pressure gradient. A 29-year-old mentally retarded man was admitted to hospital with exertional dyspnea. His somatic features included short stature (148 cm), hypertelorism, a shield chest, and thoracic scoliosis. Echocardiogram showed a secundum ASD with bidirectional shunting and a ventricular septum bulging toward the left ventricle in diastole, and then toward the RV in systole causing obliteration of the RV. The peak pressure gradient measured across the RV outflow by continuous wave Doppler was 30 mmHg. Cardiac catheterization revealed an elevated RV pressure without pulmonary hypertension and confirmed the pressure gradient. Right ventriculography revealed the septal excursion toward the RV in systole, leaving only a small residual cavity in the inflow and outflow regions of the RV. The ASD was closed with an autologous pericardial patch. A thin, fibrous portion of the ventricular septum was resected and replaced with a Dacron patch. From the histological examination, the RV cavity obliteration turned out to be produced by the excursion of the infarcted ventricular septum.

EPC-K1, a hydroxyl radical scavenger synthesized by phosphate linkage of vitamin E and vitamin C, prevents myocardial reperfusion injury in vivo; however, the direct effects of EPC-K1 on coronary arteries are unknown. These experiments were undertaken to define possible mechanisms through which EPC-K1 imparts its protective action on the coronary vasculature. EPC-K1 (10(-5) to 10(-1) mg/ml) induced concentration-dependent relaxation in contracted canine coronary artery segments with endothelium, but no change in tension of arterial segments without endothelium (p<0.05, ANOVA). Endothelium-dependent relaxation to EPC-K1 was inhibited by N(G)-monomethyl-(L)-arginine ((L)-NMMA) (10(-5) mol/L). Inhibition of relaxation by (L)-NMMA was reversed by the addition of (L)-arginine (10(-4) mol/L), but not by (D)-arginine (10 (-4) mol/L). Subsequent exposure of canine coronary artery segments with intact endothelium to hydroxyl radicals for 30 min (generated by FeSO(4) [0.56 mmol/L] + H(2)O(2) [0.56 mmol/L]) impaired endothelium-dependent relaxation. However, pretreating the vascular segments with EPC-K1 (10(-4) mg/ml) prevented hydroxyl radical-mediated endothelial cell injury and maintained endothelium-dependent relaxation. These experiments indicate that EPC-K1 stimulates the release of endothelium-derived nitric oxide, an endogenous vasodilator and inhibitor of platelet and leukocyte activation and adhesion, from the coronary artery endothelium. Additionally, EPC-K1 scavenges hydroxyl radicals that mediate endothelial cell injury. These 2 independent and important actions are possible mechanisms by which EPC-K1 prevents reperfusion injury in the ischemic heart.

We have preferably utilized monocusp valved outflow patch (MVOP) for right ventricular outflow tract (RVOT) reconstruction in pulmonary atresia with ventricular septal defect (PA + VSD). The purpose of this study was to evaluate the influence of the presence of major aorto-pulmonary collateral arteries (MAPCAs) on probability of MVOP reconstruction and development of RVOT restenosis in midterm. 49 patients underwent complete repair (either MVOP reconstruction or Rastelli procedure) of PA + VSD in our service. These patients were divided into 2 groups: group 1; 21 patients with MAPCAs, group 2; 28 patients without MAPCAs. There was one operative death (group 1). The probably of MVOP reconstruction was similar between group 1 and group 2 (71 vs 79%, p = 0.57, chi 2 test). Follow-up was completed for 48 survivors with the period ranged 3-108 months (mean 47 months). In group 1, one patient died suddenly at home 10 months after surgery. For 47 long-term patients, the ratio of freedom from RVOT restenosis was 72% (95% CI: 52-92%, Kaplan-Meier method) at 5 year. There was no difference between 2 groups (group 1; 73%, 95% CI: 45-100%, group 2; 74%, 95% CI: 48-99%, respectively, p = 0.85 by Log-Rank test). The presence of MAPCAs in PA + VSD was not a risk factor for either the probably of MVOP reconstruction or development of RVOT restenosis in midterm.

Objective: The results of our modification of the stage I Norwood procedure, in which we use only autologous tissue to reconstruct the aortic arch, were reviewed. A high-flow, low-pressure cardiopulmonary bypass protocol (with phenoxybenzamine), before and after a period of deep hypothermic circulatory arrest, was used., Methods: Between 1993 and 1999, 59 patients, aged 1 to 353 days (median 4 days) and weighing 1.7 to 6.8 kg (median 3.2 kg), underwent a modified Norwood procedure. The ascending aortic diameter ranged from 1.5 to 8 mm (median 3 mm). The modified Blalock-Taussig shunt was 3 mm in 21 patients (36%) and 3.5 mm or larger in 38 patients (64%)., Results: Deep hypothermic circulatory arrest and cardiopulmonary bypass times ranged from 15 to 64 minutes (median 37 minutes) and 44 to 144 minutes (median 88 minutes), respectively. Early postoperative survival was 83%. By univariate analysis, early mortality was associated with an ascending aortic diameter of 2.5 mm or less (P =.01). Weight, circulatory arrest and bypass times, diagnosis (hypoplastic left heart syndrome vs variant), shunt size, and date of the procedure did not affect survival. For a median follow-up period of 37 months (range 4-63 months), 42 (61%) patients underwent bidirectional cavopulmonary shunts, 10 (17%) had Fontan operations, and 1 patient underwent transplantation after a bidirectional cavopulmonary shunt. Eight patients subsequently died, for a 1-year actuarial survival of 72% (95% confidence interval: 60%-84%). Neoaortic arch obstruction was corrected in 3 patients (5%)., Conclusions: At intermediate-term follow-up, our modification of the Norwood procedure together with our perioperative strategies has resulted in acceptable outcomes with a low incidence of neoaortic arch obstruction. Patients with a small ascending aortic diameter have emerged as a high-risk group, but a recent technical modification may improve the outlook for these patients.

This study was designed to verify the effect of reperfusion of donor hearts in a perfusion apparatus after 60 min of global ischemia prior to heart transplantation. Thirteen dogs were exsanguinated from the femoral artery and cardiac arrest was achieved. The hearts were left in situ at room temperature (25 degrees C) for 60 min. In group A (n = 7), the hearts were excised and reperfused 60 min after cardiac arrest in the perfusion apparatus with substrate-enriched warm blood cardioplegia (WBCP) containing a hydroxyl radical scavenger, EPC, followed by 45 min of blood perfusion. Next, the hearts were preserved in cold (4 degrees C) University of Wisconsin (UW) solution. In group B (n = 6), the hearts were perfused with cold (4 degrees C) St. Thomas' solution 60 min after cardiac arrest and preserved in cold UW solution. Thereafter, all hearts in both groups were transplanted orthotopically to recipient dogs. In group A, 6 of 7 dogs were weaned from cardiopulmonary bypass (CPB). In group B, only 2 of 6 dogs were weaned from CPB. Moreover, 3 of the 6 hearts in group B did not start beating after transplantation (stone heart). This study suggested reperfusion of the donor heart in the perfusion apparatus with WBCP to be a beneficial preconditioning method when utilizing 60-min arrested hearts for transplantation.

Background: Evidence for complement activation in xenograft hyperacute rejection includes prolongation of graft survival after complement inactivation as well as component deposition and consumption during hyperacute rejection. The current investigations examined the endothelial production of vasoactive substances during heterologous serum exposure., Methods: Segments of canine coronary artery were exposed to either autologous canine serum for 90 minutes or heterologous porcine serum for 30, 60, or 90 minutes. After replacement of the serum with buffered saline, segments were contracted with phenylephrine (10(-6) mol/L) in the presence of indomethacin (10(-5) mol/L)., Results: Compared with responses of vessels exposed to autologous canine serum, receptor-dependent relaxation to acetylcholine was impaired in arteries after 60 or 90 minutes of exposure to porcine serum. Receptor-independent relaxation to calcium ionophore A23187 was not significantly impaired at any length of porcine serum exposure. Endothelial-independent relaxation to sodium nitroprusside was not impaired with either canine or porcine serum exposure. Oxyhemoglobin (10(-6) mol/L) abolished acetylcholine-mediated relaxation, indicating that nitric oxide was the predominant mediator of the impaired pathway. Basal release of nitric oxide after a 60-minute porcine serum exposure was reduced by half compared with coronary arteries exposed to autologous canine serum. Serum pretreated by either heat inactivation of complement or immunoadsorption with anti-C3 antibodies failed to depress endothelial-dependent relaxation on 60 minutes of exposure to canine coronary arteries. Scanning electron microscopy revealed an intact endothelial layer in coronary arteries exposed to either porcine or canine serum for 60 minutes., Conclusions: Hyperacute xenograft rejection impairs receptor-dependent relaxation of canine coronary arteries at 60 and 90 minutes. These data strongly suggest that impairment of endothelial production of nitric oxide during acute xenograft rejection is mediated by complement activation.

We experienced the case of a patient with d-TGA, small VSD who underwent arterial switch operation (ASO) at the age of 8 weeks. In pre-operative UCG, the LV posterior wall thickness was only 3.0 mm. LV systolic pressure had dropped to 29 mmHg at the time of operation. After arterial switch and VSD closure, myocardial contractility and coronary perfusion were good without any ST-T changes, however, the patient could not be weaned from cardiopulmonary bypass. Left ventricular assist device (LVAD) was then applied and LV training was performed with appropriate pre and after-load. On the 4th operative day, the patient was successfully weaned from LVAD. Training of the left ventricle with LVAD will be a useful life-saving method in the case of left ventricular failure after arterial switch operation.

A 53-year-old man with dilated cardiomyopathy underwent left ventriculoplasty (Batista procedure), a new surgical procedure, which reduces ventricular volume to improve left ventricular function. Left ventricular ejection fraction increased from 19.7% to 43.7%. Unfortunately, he died of pneumonia 12 days after surgery. This is the first such procedure in a human in Japan.

To treat end-stage dilated cardiomyopathy, we have performed volume reduction left ventriculoplasty (as introduced by Randas Batista in Brazil) in four patients since December 1996. All patients had end-stage idiopathic cardiomyopathy. Mitral valve replacement was also performed in three patients. In all four patients, improvement of left ventricular function was noted. One patient died of respiratory failure on the 12th postoperative day. The other three patients recovered successfully from the operation (i.e., they were discharged from hospital with the functional status in New York Heart Association Class I or II). We conclude that the Batista operation provides a real hope for patients with end-stage dilated cardiomyopathy.

This study was performed to determine if an "arrested" heart, resuscitated with cardiopulmonary bypass (CPB) after the cessation of beating, can be successfully transplanted, and whether a hydroxyl radical scavenger EPC can reduce ischemic and reperfusion injury during resuscitation of the arrested heart and following orthotopic heart transplantation. A total of 16 pairs of canines were divided into a control group of eight pairs and an EPC-treated group of eight pairs. Cardiac arrest of the donor heart was induced by the discontinuation of respiratory support after the induction of brain death. The cadaver heart was then resuscitated and core-cooled to myocardial temperature of 15 degrees C using CPB. The donor heart was harvested using cold cardioplegia and orthotopically transplanted. All of the transplanted hearts in the EPC group were weaned from CPB without any inotropic support after 60 min of bypass support, whereas all the animals in the control group required 5 micrograms/kg/min dopamine (P = 0.001). Moreover, cardiac function (Emax) 1 h after orthotopic heart transplantation was better preserved in the EPC group than in the control group, at 110 +/- 36% vs. 70 +/- 21% of the post brain death values (P = 0.02) These findings demonstrate that EPC reduces posttransplant reperfusion injury, and thus it may prove to be a valuable adjunct in this challenging model.

Background: A shortage of donor organs in clinical transplantation prompted us to study whether resuscitated "dead" hearts could be used for successful orthotopic heart transplantation., Methods: Donor hearts were resuscitated with cardiopulmonary bypass after 3 minutes (the control group; n = 8) or 60 minutes (the experimental group; n = 6) of hypoxic cardiac arrest after induction of brain death., Results: All the animals of each group were successfully weaned from cardiopulmonary bypass with 5 micrograms/kg/min of dopamine 1 hour after transplantation, and cardiac function with or without dopamine was better preserved in the experimental group than the control group (with maximum slope of pressure-volume relationship with dopamine: 198.0% +/- 36.8% versus 121.2% +/- 47.2%; maximum slope of pressure-volume relationship without dopamine: 130.6% +/- 41.5% versus 70.8% +/- 21.5% [mean +/- standard deviation] as percentage of values after brain death, respectively; p < 0.01 by unpaired t test)., Conclusions: These results indicate that cadaver hearts 60 minutes after anoxic arrest can be successfully reanimated and orthotopically engrafted with various methods and drugs.

A shortage of donor organs in clinical transplantation prompted us to study whether resuscitated dead hearts could be utilized for successful orthotopic heart transplantation. After 60 min of hypoxic cardiac arrest, one group of canine hearts was resuscitated (Res group, n = 6). The other group was harvested directly (Non-Res group, n = 6). In the Res group, cardiopulmonary bypass was utilized for resuscitation at 37 degrees C and the animals were then core-cooled to 15 degrees C. The hearts then were preserved in University of Wisconsin solution and orthotopically transplanted. Stable prostacyclin analogue (OP2507) and verapamil, a calcium antagonist, were added to the cardioplegia, and substrate-enriched warm blood cardioplegia and a hydroxy radical scavenger (EPC) were administered at the time of reperfusion of the transplanted heart. All animals in each group were successfully weaned from cardiopulmonary bypass with dopamine (5 micrograms/kg/min). Cardiac function without dopamine was better preserved in the Res group than the Non-Res group (Emax: 130.6 +/- 41.5% vs. 47.1 +/- 24.7%; mean +/- SD, as percent of postbrain death values, P < 0.01 by unpaired t-test). Cadaver hearts 60 min after anoxic arrest can be successfully re-animated and orthotopically engrafted. In addition, the core-cooling technique is useful. We believe this study serves as the key step in the clinical application of dead hearts to successful cardiac transplantation.

Recently continuous warm blood cardioplegia (BCP) has been reported as a superior method of myocardial protection, but it is unknown which is more effective antegrade or retrograde cardioplegia. This study was performed to investigate the efficacy of antegrade infusion via aortic root and retrograde infusion via coronary sinus with continuous warm BCP in regard to metabolism, oxygen extraction ratio, serum enzyme release, cardiac function, and myocardial edema. Fourteen adult mongrel dogs were subjected to total cardiopulmonary bypass and cross-clamp of the aorta for 120 minutes, and followed by 60 minutes reperfusion. The dogs were divided into two groups according to the infusion type of continuous warm blood cardioplegia: Group A, antegrade warm BCP, and Group R, retrograde warm BCP. Changes in excess lactate (delta XL), redox potential (delta Eh), and myocardial lactate extraction ratio showed that aerobic metabolism could be maintained in group A and could not in group R. Myocardial oxygen extraction ratio during aortic cross-clamp was same in group A and in group R, but at 5 minutes after reperfusion it was significantly higher in group A than in group R (41 +/- 8% V.S. 22 +/- 9%). The incidence of ventricular fibrillation (V.F.) after reperfusion was significantly lower in group A than in group R (1/7 V.S. 7/7). CPK-MB and HBDH releases during aortic cross-clamp and 60 minutes reperfusion were lower in group A than in group R, but not significant. Generations of lipid peroxides (A-Cs difference) were lower in group R than in group A, but not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Forty patients underwent coronary revascularization using bilateral internal thoracic artery (ITA) grafts between 1988 and 1992. A total of 111 coronary grafts were performed, or an average of 2.8 grafts per patient. Each patient received bilateral ITA grafts, and in 20 patients an additional 29 grafts were constructed with 18 autologous veins and 11 gastroepiploic arteries. The right ITA was grafted as a free graft in 20 patients. The ITA graft patency rate was 96 per cent (67/70) at the time of hospital discharge. The operative morbidity included 3 reoperations for bleeding, 1 perioperative myocardial infarction, 1 renal failure, 2 postcardiotomy shock, and 1 colon perforation. Two hospital deaths occurred; one due to colon perforation and the other due to postcardiotomy cardiogenic shock. One patient died of cerebral infarction 6 month after the operation. Thirty-four patients were in New York Heart Association functional class I, 2 were in class II and 1 was in class III. Cardiac function evaluated by echocardiography and scintigraphy showed significant improvement postoperatively. These data suggest that the use of bilateral ITA grafts is associated with an acceptable mortality and increases the versatility of arterial grafting.

Over the last 5 years, 12 patients received ventricular assist devices (VADs) while in postcardiotomy cardiogenic shock. There were 7 male and 5 female patients ranging in age from 22 to 73 years (average age, 54). Eight patients underwent surgery for valve replacements, 3 for coronary artery bypass graftings, and 1 for closure of a ventricular septal rupture. The duration of VAD support ranged from 6 h to 9 days (mean, 4.2 days). Ten patients were weaned from the VADs, and 6 survived. Univariate analysis indicated that renal failure, infection, and heart failure had a negative impact on those patients who survived. Multivariate analysis indicated that heart failure, renal failure, and preoperative left ventricular ejection fraction were the most important predictors of hospital death. The 6 survivors were followed for 4 to 42 months (mean, 25 months); 5 were in New York Heart Association (NYHA) Class I, and 1 was in Class II. The cardiac functions in 5 patients who lived over 1 year were assessed by echocardiography. Preoperative and postoperative UCG revealed that ejection fraction and mean velocity of circumferential fiber shortening increased significantly (p < 0.01). Also, the left ventricular diastolic and systolic dimensions decreased significantly (p < 0.05). However, the patients did not show further changes in these parameters during exercise. Eight patients who had double valve replacements were observed for comparison (control group). In the control group, exercise improved cardiac output and mean velocity of circumferential fiber shortening (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

We studied whether a cardiopulmonary bypass (CPB) and a core-cooling technique could resuscitate an arrested heart, and whether this procedure benefited canine cadaveric heart transplantation. Donor dogs were subjected to brain death by an intracranial balloon technique, and then, to cardiac arrest conducted by cutting off ventilatory support. In the control group (Group 1; n = 8), arrested hearts were flushed with cardioplegic solution and harvested thereafter without any resuscitation technique. In the experimental group (Group 2; n = 8), arrested hearts were once resuscitated using CPB, and then harvested using a core-cooling technique and cardioplegia. These hearts were transplanted orthotopically. Seven of eight recipients in Group 1 were weaned from CPB, and five of them finally became independent of dopamine administration. All recipients in Group 2 were successfully weaned from CPB, and also became dopamine free eventually. In Group 2, all post-transplantation hemodynamic values such as cardiac output during the period of dopamine administration were equivalent to those of post-brain death period. Chemical analysis of the serum and myocardial muscle demonstrated no difference between groups. We conclude that CPB combined with a core-cooling technique makes it possible to utilize an arrested heart as a donor organ for transplantation.

We report a case of renal cell carcinoma with a tumor thrombus extending into the right atrium, which was successfully removed with the use of extracorporeal circulation. A 68-year-old male presented with a one month history of abdominal distension. CT-scanning, selective renal angiography, vena cavography and echocardiography revealed a left renal tumor with a tumor thrombus extending into the right atrium through the inferior vena cava. Left nephrectomy and removal of the intra-atrial tumor thrombus were performed using extracorporeal circulation. Preoperative laboratory results showed elevation of the total bilirubin (17.0 mg/dl) due to congestion of the liver which was caused by obstruction of hepatic vein with the tumor thrombus. Postoperatively, the total bilirubin gradually decreased to 11.9 mg/dl on the third day, but increased to 22.2 mg/dl on the 9th day. So plasma exchange was performed on the 10th, 11th and 12th days, and the total bilirubin decreased to the normal range. The patient was discharged on the 50th day. For renal cell carcinoma with a tumor thrombus extending into the right atrium, effectiveness of operation using extracorporeal circulation and subsequent prognosis are discussed.

Thirty-two patients underwent coronary revascularization with bilateral internal thoracic artery (ITA) grafts. Each patient received 2.7 grafts in average including double ITA grafts. Seventeen patients had the right ITAs as free grafts. The other sixteen were treated with 13 autologous veins and 9 right gastroepiploic arteries in addition. Fifty-five grafts out of 56 (98.2%) were proved to be patent at the time of hospital discharge. The postoperative morbidity included three reoperations for bleeding and one perioperative inferior myocardial infarction. One patient died of colon perforation after surgery and another died of cerebral infarction late after surgery. These results exhibited that coronary artery bypass grafting with bilateral ITA grafts had relatively low risks and could contribute to complete revascularization in patients with diseased coronary arteries.

The left ventricular studies by Doppler echocardiography were performed in 50 patients with a Björk-Shiley (B-S) mitral valve and 50 patients after implantation of a St. Jude Medical (SJM) mitral valve; the effect of valve replacement on the hemodynamic performance at rest and during bicycle exercise was determined from serial echocardiographic data. Twenty-eight patients (56%) of the B-S group and 42 patients (84%) of the SJM group showed a good response to the exercise. There was no significant difference in the effective orifice area at rest among each sizes of the B-S valve. In the SJM valve, on the contrary, the effective valve orifice area increases in parallel to the size of the SJM valve. There was a clear relation between the valve size and pressure gradient. The pressure gradient directly depends on the valve size and the effective orifice area in the SJM valve. High pressure gradient group in both prostheses had a tendency to take negative values of percent increase in stroke volume. Further, there were no cases showing positive values of percent increase in end-diastolic volume among the patients whose pressure gradients were assumed to be more than 10 mmHg at rest. It is suggested that impairment of inflow caused by the artificial valve, prosthetic valve stenosis, is possibly a significant factor causing left ventricular dysfunction, notably a decrease in stroke volume during exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

A biventricular bypass type total artificial heart (BVB-TAH) utilizing two pusher-plate pumps was developed and implanted in a sheep for 48 days with excellent results. A Hall effect sensor was utilized to operate each pump independently with a full stroke at variable rates (VR). With this system, the animal's hemodynamics was kept physiologically, and all metabolic parameters except hemoglobin and hematocrit returned to normal three weeks after implantation. However, signs of infection appeared on the forty-second day, and consequently the animal fell into a state of shock. Even at that time the BVB-TAH maintained circulation by increasing pumping rate automatically. On the forty-eighth day, the animal could not stand and suffered from anuria; the experiment was then terminated after 1,140 h pumping. At autopsy, there was an enlarged heart with an atrophic change, 1,900 ml of pleural effusion, and 3,100ml of ascites fluid. Blood culture taken on the forty-seventh day yielded Acinetobacter calcoaceticus. The BVB-TAH operated in an independent VR mode maintained entire circulation, and has a capability of substituting the native heart function in any situation.

Pressure gradients and left ventricular function were assessed by Doppler echocardiography in 50 patients with Björk-Shiley mitral valve and 50 patients with St. Jude Medical valve prosthesis. There was correlation between pressure gradient and valve size, and between effective valve orifice area and valve size for St. Jude Medical valve. These correlations were not found in Björk-Shiley valve. Clinical improvement and cardiac function were quite satisfactory in 20 patients with Björk-Shiley valve and in 32 patients with St. Jude Medical valve whose pressure gradients were less than 10 mmHg. Twenty eight of 50 patients with Björk-Shiley valve and 42 of 50 patients with St. Jude Medical valve showed good response to the exercise test. Eight patients underwent reoperation because of unacceptably high gradient caused by thrombus and pannus formation. The patients who show high pressure gradient across the valve prosthesis should be followed up cautiously.

An operated case of primary mediastinal liposarcoma is reported. A 71-year-old male who was asymptomatic was unexpectedly pointed out a huge abnormal mass shadow in the mediastinum on the chest roentgenogram, when he caught a common cold. The CT scan showed the singular horseshoe-shaped tumor in the posterior mediastinum which was adjacent to the antero-lateral phase of the vertebrae. MRI was useful to our recognition of its whole shape and localization. Extirpation of the tumor via right postero-lateral thoracotomy was performed successfully. The pathological diagnosis was liposarcoma; well differentiated, lipoma-like type. Primary mediastinal liposarcoma is a very rare mediastinal tumor (0.2%). Thirty-six cases of primary mediastinal liposarcoma including our case have been reported at present in Japan, so far as we surveyed. It is generally known that liposarcoma has the low sensitivity to the radiotherapy and chemotherapy and has high incidence of recurrence. We think that this case needs the strict postoperative follow-up.