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The inhibitory effect of ongoing rejection and the changes that occurred in mononuclear cell subpopulations were compared between four groups of rats treated with FK506 or steroids. Group 1 was given no immunosuppressive drugs, group 2 was given FK506 from the day of grafting, group 3 was commenced on FK506 on the 4th day after grafting, and group 4 was commenced on methylprednisolone (MP) on the 4th day after grafting. The graft survival times in groups 2 and 3 were significantly longer than those in groups 1 and 4, and there were fewer CD3+ and CD4+ T lymphocytes in the peripheral blood in the groups treated with immunosuppressive drugs than in group 1. In group 4, the levels in both the peripheral blood and thymus were significantly lower than those in the groups treated with FK506 despite the fact that graft rejection occurred soon after the discontinuation of steroid administration. Moreover, the levels of interleukin-2 receptors and macrophages in groups 2, 3, and 4 were significantly lower than that in group 1 postoperatively; however, the number of macrophages in groups 2 and 3 was significantly lower than that in group 4 on the 10th day after transplantation. The findings of this study demonstrated that FK506, even if administered after rejection has begun, might inhibit the subsequent extensive allograft rejection more specifically and effectively than steroids, and that the measurement of a marker for macrophages in the peripheral blood could be useful for the detection of rejection following allograft transplantation in rats.

人工弁置換術施行例において, 体外循環離脱時, および術後補助循環として intra-aortic balloon pumping (IABP) を施行した症例について, 適応および, 限界について検討を行った. その結果, 長期間心不全を有する心臓弁膜症に対する人工弁置換術後の急性左心不全に対するIABPの効果は, 術中, 術後の冠不全に起因する術後-過性の心機能低下症例に対しては有効かつ適切な補助循環であった. しかし, 心内操作の不備や不十分な心筋保護のために長時間の体外循環を余儀なくされた症例, また, 術前の右心不全が術後も遷延する症例では限界があり, これらの症例に対しては, むしろ左心バイパスおよび, 両心バイパス等の高度な補助循環が必要であると考えられた.

Forty-four patients with atrial septal defects, aged 7 months to 18 years (median 8.9), underwent biplane transesophageal (TEE) and transthoracic (TTE) echocardiography. The size of the defect and the shunt flow volume were measured by TEE and compared with the actual size at surgery (N = 14) or the shunt volume measured by the Fick method (N = 34), respectively. In all cases the location and morphology of the defect were clearly demonstrated by TEE; on the other hand, two patients with sinus venosus-type and multiple-type defects, respectively, and one with a small ostium primum defect did not have a complete diagnosis by TTE. The defect size determined by TEE correlated well with the surgical measurement. Similarly a significant correlation was demonstrated between the shunt volume measured by TEE and that obtained by the Fick method. In three patients transcatheter closure of the atrial septal defect by means of a clamshell device was accomplished successfully with TEE monitoring. We conclude that biplane TEE provides a better appreciation of cardiac anatomy and hemodynamic evaluation than TTE in this setting, and TEE is essential for monitoring during transcatheter closure.

A case of synchronous triple cancer of the rectum, esophagus and stomach was experienced. A 72-year-old man underwent resection of the lower rectum with a diagnosis of rectal cancer (Rb). This was in stage II(al, n(-), PO, HO, M(-)), showing the histological feature of well differentiated adenocarcinoma. The second carcinoma, an esophageal cancer, was diagnosed about one month after the first operation. Biopsy specimen revealed squamous cell carcinoma. He underwent lower esophageal resection with reconstruction by esophago-gastrostomy. The third carcinoma a IIa type gastric cancer was very small, therefore strip biopsy was performed. Triple carcinomas seen in the literature are discussed.

A recent progress in operative techniques and improvement in pre-, intra- and postoperative patient care have enabled the positive application of pancreaticoduodenectomy even to aged patients. Pancreaticoduodenectomy was performed for carcinoma in region of the head of the pancreas in 186 patients in the period from January 1965 to December 1990, including 135 patients under 70 years and 51 patients over 70 years. In this study, comparison was made between two 'age groups, aged group over 70 years and younger group under 70 years. Some underlying diseases were found before operation in 50.4% of younger and 62.7% of aged patients, giving a slightly higher percentage in the group of aged patients. Significant differences was observed between the groups for the time required for operation (p

心臓悪液質は, 心臓弁膜症の末期像であり, 術後管理に難渋し手術成績も不良な疾患群である. われわれは, 僧帽弁を主病変とし, るいそうを伴い, 術前NYHAがIV度, さらに, うっ血による肝機能障害を認める症例10例を心臓悪液質と定義し, 術後人工呼吸管理日数の違い (I群; 5日以上, 5例, II群; 4日以内, 5例) により2群に分け, 術前, 術後管理について検討した. 両群とも術前1週間前と術後にIVHを行い, I群の2例に術後経管栄養を行った. 術前より呼吸管理を要したのはI群の2例であった. その結果, 病脳期間が長いほど, 術後長期の人工呼吸管理が必要とする傾向にあったが, 術後カテコラミン使用量, 術後経過, 予後は両群間に差はなかった. これらのことより, 心臓悪液質症例に対しても, 術前, 術後の栄養, 呼吸, 循環管理を行えば, 通常の弁膜症症例と同様に手術ができると考えられた.

Erythroderma as a manifestation of graft-versus-host disease after cardiac operations with blood transfusion may occur more frequently in Japan than in other countries. We have seen this problem in five patients who, after heart operations, died with symptoms and signs characteristic of graft-versus-host disease: cutaneous eruption, fever, diarrhea, leukopenia associated with agranulocytosis, and liver dysfunction. In the three patients seen most recently, skin biopsy showed findings similar to those of graft-versus-host disease after bone marrow transplantation. In addition, immunologic investigation showed remarkable differences in the findings in these patients and in those who did not have a graft-versus-host disease-like syndrome after cardiac operations. In particular, interleukin-2 production in response to mitogen stimulation was markedly diminished after operation in our patients, and the ratio of OKT4+ cells to OKT8+ cells in peripheral blood was low, reflecting increased numbers of OKT8+ cells after the occurrence of symptoms. The results raise the possibility that transient depression of cellular immunity after cardiac operations with blood transfusion may contribute to the occurrence of postoperative acute graft-versus-host disease. (J T horac C ardiovasc S urg 1992;104:648-53)

It has been reported recently that cardiac operations can be followed by a transient impairment of cell-mediated immunity. In this study we examined indices of cell-mediated immunity in patients undergoing cardiac operations. Twenty-five of the patients received erythropoietin (200 U/kg) daily for 2 weeks before and after operation, and 30 matched control patients did not receive erythropoietin. On postoperative day 1, the numbers of total T cells and helper/inducer T cells were significantly higher in erythropoietin-treated patients than in control patients. The ability of patients’ cells to make interleukin-2 in vitro increased after erythropoietin injection in the preoperative period. By postoperative day 1, erythropoietin-treated patients exhibited a fall in interleukin-2 production that was significantly less than that in control patients; levels increased by day 2 to a mean value twice that of the preoperative baseline and more than four times the corresponding mean level in the control groups, and levels returned to the baseline range by postoperative day 14. Levels of interleukin-2 production in erythropoietin-treated patients were significantly higher than those in control patients at each interval tested through postoperative day 7. These findings indicate that erythropoietin treatment not only augmented levels of circulating erythrocytes but also improved indices of cell-mediated immunity. Although the mechanism responsible for this effect remains to be determined, the finding suggests that erythropoietin might help to ameliorate or prevent the impairment of immune function that can occur after cardiac operations. (J T horac C ardiovasc S urg 1992;104:278-83)

In this study, we discuss the clinical results of mitral leaflet advancement performed on 29 patients over the past 10 years and attempt to determine the indication. Preoperative diagnosis of mitral valve lesion consisted of mitral regurgitation in 21 patients and mitral stenosis in 8 patients. Mitral valve repair was applied to the anterior mitral leaflet in 2, the posterior mitral leaflet in 25, and bilateral leaflets in 2 patients. Reoperation was performed on 13 patients, and 1 patient died of renal failure immediately after reoperation. No reoperation was needed for 96.6% of the patients at 1 year, 89.5% at 5 years, 75.0% at 8 years, 63.8% at 10 years, and 52.6% at 15 years postoperatively. At reoperation, the repaired mitral leaflet was found to be calcified in 3 patients more than 9 years after the initial operation. Of the 12 survivors without reoperation, mitral stenosis associated with regurgitation was obvious in 6 patients. Of the 21 patients with preoperative mitral regurgitation, 90.0% showed no deterioration at 5 years, 79.7% at 8 years, and 69.1% at 10 years. On the other hand, for the 8 patients with mitral stenosis, the rates were 87.5% at 1 year, 62.5% at 5 years, 50.0% at 8 years, and 25% at 10 years. Our results suggest that mitral leaflet advancement shows satisfactory results in patients with mitral regurgitation but is not successful for patients with mitral stenosis in the long term because the repaired valve tends to be stenotic in the late postoperative period.

1988年5月から1990年10月の間に冠動脈バイパス術 (CABG) と弁手術を14例に同時に施行した. CABGに動脈グラフト (AG) を使用したものは9例 (AG群) で, 大伏在静脈のみの使用は5例 (SVG群) であった. AG群では, 平均年齢は63.3歳で, 末梢吻合枝数は2.2本であった. 同時に行った弁手術は, 弁置換術を5例に, 弁形成術を4例に施行し, 平均大動脈遮断時間は116分であった. AGは, 内胸動脈 (ITA) を8例, 右胃大網動脈を4例に用い, このうち, 両者の併用は3例で, SVGは5例に併用した. 2例で, pedicled AGが左前下行枝あるいは, 鈍縁枝に到達できず, SVGの併用を行った. AG群とSVG群とでは, 平均年齢, 大動脈遮断時間には有意差を認めなかったが術後カテコールアミンの使用は, AG群3例 (33%), SVG群3例 (60%) で, 有意にAG群に低値であった. AG群では, 術後死亡はなく, 遠隔期NYHAは, I度4例, II度5例へ改善した. CABGと弁手術の同時施行においても, AGの使用により, 術後の症状の改善は良好で安定した手術成績がえられたが, pedicled AGとした場合のグラフトの長さには十分な注意が必要であった.

肝後下区域(S6)の腹側表面に,癌腫の一部が露出し存在した22×21mmの小肝細胞癌に対して,新たに開発した手術機器を用いて,本邦で初めて,腹腔鏡下マイクロ波凝固壊死療法を行ったところ,本法は,小肝細胞癌に対する新しい治療法として,有用と考えられたので報告した.症例は63歳,男性.肝機能,および凝固系検査の術後推移をみると,術後1日目に,GOTは423K.U, GPTは241K.U, T. Bil.は2.1mg/100mlと上昇した.また,術後,凍結血漿をまったく使用しなかったため,HPTは42%, PTは48.3%に低下した.しかし,すべての検査値は,術後7日目には術前値に復した.胃管は,術翌日には抜去し,2日目より食事を開始した.術後3週目に撮影したCTでは,治療部は癌腫を含め,著しくlow density areaに陥り,まったくenhanceされず,治療効果も充分であると判断された.また,術後合併症はまったく認められなかった.

僧帽弁置換術後の左室破裂は, とくに遅発例に関して救命率も低く, 発生要因の解明および防止法の確立が急務である. 今回われわれは1965年9月より1991年8月までに, 当科において僧帽弁置換術を施行した1046例中, 術中および術後に左室破裂をきたした8例を対象に, その発生要因の検討を行った. 年齢は43歳から67歳 (平均58歳), 男性1例, 女性7例で, 破裂部位 (Treasure, Miller らの分類) は type I 5例, type II 2例, type III 1例, 左室破裂発症時期は, 体外循環離脱時3例, 閉胸時1例,術後11時間, 14時間, 18時間, 25時間のおのおの1例であった. 8例中3例は心拍動下に左室外側より修復, 5例は体外循環下に心停止を行い, 左室内腔より破裂部を修復した. しかし体外循環離脱直後に発生し, 心停止下に修復を行った2例 (おのおの低心拍出量症候群, 多臓器不全にて術後2日目, 44日目に死亡した) 以外は, 修復後もまったく止血不能であった. われわれはとくに最近の遅発例で, 血圧の上昇後に突然発生したこと, 組識学的にも心筋細胞の脱落, 変性を広範囲に認め, 心筋の脆弱性が認められたことから, 術後急性期の動脈圧の急激な上昇を避ける管理は, 発生防止の有効な方法となるものと考えている.

Anomalous origin of the right coronary artery is an infrequent anomaly. A case with anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva is described. This patient was also found to have a bicuspid aortic valve. The aortic valve was markedly calcified and stenotic. The aortic valve was replaced with a St. Jude Medical prosthesis.

感染性心内膜炎に起因する僧帽弁瘤を経験し,手術で良好な結果を得た.症例は53歳,男性である明らかなリウマチ熱の既往はなかった.大動脈弁閉鎖不全症の診断のもとに内科治療を受けていたが,経過中に感染性心内膜炎を生じた.そのときはじめて,心臓超音波断層検査で僧帽弁前尖の異常エコー像を指摘された.当科に紹介入院ののち諸検査を行い,僧帽弁瘤の診断で開心術を施行した.手術所見では,大動脈弁は感染性心内膜炎のために高度に破壊されており,僧帽弁前尖は全体が瘤をなし左房側へ突出していた.二弁ともにSJM弁を用いて弁置換術を施行した.術後の病理組織検査では真性僧帽弁瘤の診断を得た.僧帽弁瘤は本邦では自験例を含めて22例の報告をみるにすぎない.僧帽弁瘤の術前診断には心臓超音波断層検査が有用であった.また治療法としては外科手術が必要であり,とくに穿孔をきたす以前に弁置換術を第一選択とすべきである.

We report a case of primary duodenal carcinoma which had partial responce by preoperative chemotherapy. A 65-year-old man visited a near clinic with the chief complaint of lower abdominal pain. Inspection, palpation and upper gastrointestinal barium studies showed that the patient had a duodenal abnormality. Ulcerative lesion of the duodenum and colon carcinoma were suspected and refersed to our hospital. After admission the abdominal tumor became larger and jaundice developed. From preoperative endoscopy of the duodenum and biopsy, malignant lymphoma was considered most probable and chemotherapy (CHOP) was started. After 2 courses of chemotherapy, significant decrease in the abdominal tumor mass was noted. Pancreatoduodenectomy with partial resection of transverse colon was performed. Postoperative course was uneventful and additional chemotherapy was done. The patient is closely followed on ambulant basis.

Background . We examined the results of intermediate and long-term follow-up of 25 patients aged 3 months to 11 years (mean, 2.6 ± 2.3 years) who initially underwent conservative mitral valve repair for mitral regurgitation associated with ventricular septal defect between April 1973 and March 1991. Methods . The preoperative degree of mitral regurgitation was 2+ in 3, 3+ in 17, and 4+ in 5 patients, and the major causes of mitral regurgitation were annular dilatation and prolapse of the anterior leaflet. Annuloplasty was performed in all except 2 patients, suturing of the cleft was done in 3 patients, and posterior mitral leaflet advancement was done in 2 patients. In addition, the papillary muscle was incised and adhesive chordae were removed in 1 patient, and adhesive fused chordae were detached from a leaflet in 1 other patient. Results . There were no early deaths. Two patients with residual mitral regurgitation with or without mitral stenosis underwent reoperation for mitral valve replacement 2 months and 6 years after the mitral repair, respectively. Late death occurred in 2 patients, and the actuarial survival rate was 92.0% at 15 years after operation. The freedom from reoperation was 91.3% at both 10 and 15 years after the initial operation. Postoperative color Doppler flow imaging was performed in 22 of the 23 survivors, and results showed no mitral regurgitation in 4, mild regurgitation in 14, and moderate regurgitation in 4 patients. Four patients presently have mitral stenosis, with a mean transmitral pressure gradient greater than 10 mm Hg. The residual lesion of moderate mitral regurgitation with or without mitral stenosis developed in 6 of 11 patients in whom bilateral mitral annuloplasty was applied after the initial operation. Nineteen of the 22 survivors without reoperation were in New York Heart Association class I, and 3 were in class II. Conclusions . Clinical improvement was observed after conservative mitral repair in most pediatric patients with ventricular septal defect. However, careful follow-up for growth potential still appears to be needed to detect changes in mitral regurgitation and the development of mitral stenosis after valve repair, especially after bilateral annuloplasty.

A comparison was made of the histological findings for myocardial tissue of heterotopic transplanted rat hearts administered with FK506. ACI rats were used as donors and Lewis rats as recipients. FK506 was used for 6 days except for group I (control group). Group II received 0.32 mg/kg/day of FK506 from the day of operation while group III was given the same dosage from the 4th day after transplantation. Group IV was given 1.28 mg/kg/day of the agent from the day of grafting and group V received the same dose from the 4th postoperative day. The graft survival time was longer for all groups given FK506, but was significantly longer only for groups administered with FK506 from the day of operation. Histological studies performed 10 and 20 days after transplantation showed that a moderate rejection was seen in about half of the grafts receiving FK506 from the 4th day after grafting. An ultra-structural study of these cases showed that infiltrating large lymphocytes still remained in the interstitial tissues and that the cytoplasmic organelles of the myocytes had been focally destroyed. These results suggest that, although FK506 suppressed any further rejection, the effect might be limited and the myocardial changes of the cardiac graft might persist even after administration for ongoing rejection.

A study was conducted on 20 patients who underwent tricuspid valve replacement (TVR) with the St. Jude Medical (SJM) valve. Isolated TVR was performed on 9 patients, and additional mitral, or mitral and aortic valve replacements were performed on 11 patients. Four patients (20%) died in the early postoperative period, but there were no deaths related to the SJM valve in the tricuspid position. The mean follow-up period of the 16 survivors was 74.4 months, and there have been no deaths during the follow-up period. The postoperative actuarial survival rate was 80%, 10 years after surgery. Three patients, representing 0.25%/patient-months, developed valve thrombosis, the valve thrombosis-free rate being 72.8%, 10 years after surgery, while entrapment of a leaflet by endothelial pannus was found in one patient, representing 0.08%/patient-months. Thus, the incidence of all prosthetic valve-related complications was 0.34%/patient-months, and the postoperative complication-free rate was 65.3%, 10 years after surgery. The medium-term follow-up study of TVR with the SJM valve revealed no prosthetic valve-related deaths and a relatively low incidence of prosthetic valve-related complications. However, as with other mechanical valves, valve thrombosis was a major risk posed by the SJM valve in the tricuspid position.

We discuss here the effect of the addition of trinitroglycerin to the cardioplegic solution on the isolated rat heart after eight hours of storage. This effect was evaluated by measuring cardiac function as well as myocardial calcium and enzymes. Male Wistar rats were divided into three groups based on the concentration of trinitroglycerine in the cardioplegic solution. In the control group, the fluid used was a crystalloid cardioplegic solution (K+ 25 mEq/L) without trinitroglycerin and for groups I and II, trinitroglycerin was added at concentrations of 2 micrograms/ml and 5 micrograms/ml, respectively. All hearts were arrested with the cardioplegic solution at 4 degrees C and then immersed for eight hours in Euro-Collins' solution at 4 degrees C. The postperfusion coronary flow showed higher rates for groups I and II than for the control group (p0.05), while the difference between groups I and II was not significant. In group I, the total concentrations of creatine kinase-MB, lactate and malondialdehyde after reperfusion showed the lowest levels; this group also had the lowest content of myocardial calcium. These results indicate that the addition of nitroglycerin, especially at a concentration of 2 micrograms/ml, to the cardioplegic solution elicits better cardiac function for immersed rat heart.

Postoperative exercise performance was evaluated in 20 patients who underwent complete coronary revascularization with simultaneous right gastroepiploic artery and internal thoracic artery grafts for ischemic heart disease and exhibited patency of all grafts on postoperative angiograms. Three patients received only arterial grafts, and 17 simultaneously received a saphenous vein graft. Forty five right gastroepiploic artery grafts were harvested during this study, but two were not used because of foci of severe calcification. The right gastroepiploic artery was grafted to the distal right coronary artery in 17 patients and to the distal obtuse marginal branches in three patients, accompanied by an internal thoracic artery graft to the left anterior descending artery in seventeen, to the diagonal branch in three, and to the proximal right coronary artery in one patient. A postoperative exercise test with a bicycle ergonometer was administered 6 to 12 weeks after the operation, and the results are reported after conversion into metabolic units. The preoperative exercise test resulted in 3.6 +/- 1.9 metabolic units for 18 patients tested, and the postoperative metabolic units were 7.8 +/- 1.3 for 20 patients. Left ventricular wall motion was analyzed by regional ejection fraction before and after coronary artery bypass grafting in 14 patients who received an right gastroepiploic artery graft for the right coronary system. The mean regional ejection fraction of the posterobasal or diaphragmatic wall was 28.0% or 28.2% before operation and improved to 43.1% or 43.2% after coronary artery bypass graft, respectively. The flow of right gastroepiploic artery seemed to distribute adequately to the revascularized area. Long-term results have not yet been proved; the use of simultaneous right gastroepiploic artery and internal thoracic artery grafts, however, thus produced excellent results, as seen from improvements in both left ventricular wall motion and early postoperative exercise performance.

Between January 1982 and November 1992, 38 patients received simultaneous mitral valve replacement (MVR) and left atrial plication (LAP) because of giant left atrium accompanying mitral lesion. Their ages ranged from 33 to 70 years, and the mitral lesion was caused by rheumatic heart disease in all patients. MVR was performed with a St. Jude Medical prosthesis for all patients and the left atrial wall was plicated with running 3-0 Nespolene to reduce the width to 3 to 5 cm. Respiration requiring mechanical ventilation more than 48 hours after operation occurred in four patients (10.5%) and postoperative low cardiac output requiring a high dose of dopamine HCl or intraaortic balloon pumping in nine patients (23.7%). The left atrial diameter measured by echocardiogram was a mean of 7.3 +/- 1.0 cm before operation and 5.8 +/- 1.0 cm postoperatively. The cardiothoracic ratio on the chest roentgenogram registered a preoperative mean of 73.3% +/- 9.8% and was 65.7% +/- 8.4% after operation. The pre- and postoperative values were significantly different (p < 0.01). The postoperative exercise level was a mean of 5.3 metabolic units for 24 patients and the postoperative New York Heart Association functional classification indicated Class I or II for 37 patients with no evidence of left atrial thrombus except in the case of one early death. LAP with MVR for patients with giant left atrium due to mitral lesion appeared to result in improvement in respiratory and circulatory functions.

A case of transfusion-associated graft versus host disease (TA-GVHD) following hepatectomy for hepatocellular carcinoma is described in a 53 year-old male patient. The intraoperative bleeding was estimated to be 1220 ml, and he was transfused with 4 units of fresh whole blood. On postoperative day (POD) 12, a fever of 38 degrees C developed, followed by a systemic erythema on POD 14, and a marked progressive leukopenia starting from POD 19. The patient died of multiple organ failure (MOF) on POD 29. Just before death, the results of skin, bone marrow, and liver biopsies had no physical evidence of GVHD. TA-GVHD was found in the HLA typing of the patient's family. This TA-GVHD case was considered to be a reduced immunity due to severe surgical stress or preoperative transcatheter arterial embolization (TAE), in view of the fact that he was transfused with fresh whole blood during the operation. TA-GVHD has frequently been reported in patients after open heart surgery, but also after hepatectomy. It is therefore necessary to take all available means to prevent it by restricting the use of blood preparations as much as possible, and if hetero blood transfusions are performed, blood should be irradiated prior to transfusion.

The internal thoracic artery has been favored because of its superior early and late patency for coronary artery bypass grafting (CABG) in pediatric patients. We have studied the angiographic changes of the internal thoracic artery and its side branches before and after CABG with internal thoracic artery to the left anterior descending artery. The internal thoracic artery with remaining thymic or pericardial branches was patent but showed enlargement of the branches in the early period after the operation, and a postoperative exercise test suggested a remaining ischemic lesion in the bypass. Angiogram taken 1 year after CABG demonstrated the grown internal thoracic artery with disappearance of most of the side branches, which had been enlarged 1 month after the operation. Our findings suggest the importance of ligation of the whole proximal internal thoracic artery branches to maintain good early and late patency.

Morphological and functional changes of free arterial grafts in dogs were studied for 3 weeks after implantation and the changes were compared to those in implanted free vein grafts. In the arterial grafts, endothelial cells with abundant pinocytotic vesicles and some cytoplasmic folds were observed by transmission and scanning electron microscope and cell detachment was seen only at the site of anastomosis, while most cells were detached in the vein grafts. The site of mechanical damage in the arterial grafts was covered by regenerated endothelial cells which showed similar morphological findings to the normal arterial endothelial cells. In contrast, regenerated cells in the vein grafts started to cover the denuded area 7 days after the implantation and had completely covered it by 3 weeks. Prostacyclin was produced more abundantly in arterial grafts than in vein grafts at any phase after implantation. The level of prostacyclin production was between 30 and 40 pg/mg in any phase after implantation of free arterial grafts, while in vein grafts the level was 2.5 pg/mg at the day of implantation and increased to 13.6 pg/mg at 21 days. This study showed that the endothelial cells were well preserved and the level of prostacyclin production was high in the arterial grafts, and thus the grafts seemed to show potent anti-thrombogenicity after implantation. Although late changes in arterial and vein grafts were not investigated in this experimental protocol, these results may suggest that the arterial graft is superior to the vein graft even in the early period after its implantation as a free graft.

From 1978 through 1987, 321 patients who had functional tricuspid regurgitation (TR) associated with mitral or combined mitral and aortic valve disease underwent tricuspid annuloplasty with our modification of the original De Vega's annuloplasty technique. The modified De Vega's annuloplasty consisted of two separate semicircular sutures placed around the anterior and lateral aspect of the tricuspid valve. Preoperatively, 229 (71.3%) of the 321 patients were in New York Heart Association functional class III or IV. There were nineteen early deaths (5.9%), and 15 patients died during a follow-up period of 15 to 126 months (mean follow-up, 26 months). Five patients (1.5%) required reoperation because of biological mitral valve failure and recurrence of mitral stenosis. The severity of TR was evaluated by two-dimensional and pulsed Doppler echocardiography, and was classified on a scale of 0 to Grade 3 according to the maximal distance and the flow pattern of the regurgitant signals in the right atrium. Postoperative echocardiographic evaluation of TR was performed in 121 randomly selected patients late after operation. TR reduced to Grade 1 or less in 107 (88.4%) of the 121 patients after operation. Ninety-six percent of the survivors were in New York Heart Association functional class I or II, postoperatively. The actuarial survival rate for the 321 patients with the modified De Vega's annuloplasty including early deaths was 88.2% at 10 years and the actuarial rate of freedom from reoperation on the tricuspid valve was 97.6%. Our surgical experience indicated that the modified De Vega's annuloplasty, as the method of first choice, is a simple, reliable procedure and resulted in reduction of the severity of TR in 88.4% of the patients with functional TR.

For the past 25 years we have performed 61 reoperations in 58 patients with congenital heart disease who previously underwent total correction for the diagnosed ventricular septal defect, tetralogy of Fallot, atrioventricular septal defect, atrial septal defect, total anomalous pulmonary venous connection (TAPVC), and other involvement for 27, 11, 5, 4, 4, and 7 patients, respectively. Causes of reoperation included 43 events of valvular lesion, 29 of residual septal defect, 5 of conduit failure, 5 of venous obstruction, 3 of hemolysis, 3 of infective endocarditis, and 2 of prosthetic valve dysfunction. Although 5 early and 4 late deaths were encountered, the remaining 49 patients (3 in New York Heart Association (NYHA) Class 11 and 46 in NYHA class I or II) survived the reoperation . The patients were followed up by echocardiography and chest X-ray examination, and reoperation was indicated under the following conditions: moderate to severe valvular insufficiency; residual defect causing the shunt ratio to be over 30% or a systolic pulmonary pressure over 50mmHg; or a high pressure gradient over 50 mmHg across the right ventricular outflow tract. Early timing for reoperation seemed to be important in patients with pulmonary venous obstruction, prosthetic dysfunction, severe hemolysis and infective endocarditis.

Between January, 1982 and December, 1989, 102 reoperations (repeat median sternotomy) in 101 patients with valvular heart disease were performed at Kurume University Hospital. In these operations, the heart was not mobilized from the pericardium to prevent tearing the heart or great vessels. All operative procedures were performed through the pericardium which adhered tightly to the heart. Adequate left ventricular hypothermic protection was obtained without total dissection of the heart by cold crystalloid cardioplegic solution and topical cooling which was accomplished by filling the left pleural space with cold saline during the operation. As to the surgical results, the early mortality rate was 4.0%, and the late mortality rate was 5.2%. The causes of death were not related to the operative procedures or perioperative myocardial protection. There was no significant difference in the early mortality rate between the reoperations and the initial operations. These results suggest that reoperation for valvular heart disease should be performed before the hemodynamic condition of the patient deteriorates.

A follow-up study was conducted of 166 patients who had survived for more than 10 years after total correction of tetralogy of Fallot. The total number of patients in NYHA class I was 141 (85%); the other 25 patients had been medically treated or had followed a prudent life style. The factors which caused postoperative symptoms were residual lesions and ventricular arrhythmia. Ultrasonic echocardiography showed that among 72 patients with transannular patch, 68 (95%) showed moderate or severe pulmonary incompetence. There was a correlation of gamma = 0.43 between the severity of pulmonary incompetence and cardiothoracic ratio in the 48 patients without any residual lesions, while two cases with severe pulmonary incompetence showed obvious right ventricular failure. Ambulatory ECG monitoring was employed to study 53 patients. As a result, 21 patients were found to present solitary moderate or severe pulmonary incompetence, while premature ventricular contraction of Lown's grade 4A was seen in nine patients (42.9%). In conclusion, it is considered essential to carefully follow up patients after intracardiac repair of tetralogy of Fallot, especially those with severe pulmonary incompetence.

We examined the ultrastructure of right and left ventricular myocardial biopsies obtained prior to cardiopulmonary bypass in fourteen patients undergoing total correction of tetralogy of Fallot (TOF). Twelve patients were undergoing primary one-stage repair and two patients had had a previous Blalock-Taussig shunt operation. The ages of the patients ranged from 3 to 35 years. In left ventricular (LV) myocytes, the sarcolemma often formed pouches filled with mitochondria and the muscle fibers showed a disoriented arrangement. In addition, the myofibrils showed hypercontraction and the Z-bands were thickened; the degree of the myofibril contraction was more severe than that in right ventricular (RV) myocytes. These ultrastructural findings are similar to those observed in myocytes under hypoxic conditions. The number of lysosomes in LV myocytes, but not in RV myocyte increased in the older patients. While we have not established a causal relationship between the ultrastructural findings and clinical features in our cases, our observations are consistent with the possibility that early total correction of TOF may be required to prevent the development of hypoxic changes and degeneration of heart muscle.

ECC. We concluded that the pedicled GEA is an alternative graft for coronary revascularization in calcified lesions of the ascending aorta and, combined with the pedicled ITA, it can be useful to revascularize multivessel coronary lesions accompanying atherosclerosis of the aorta. Tadashi !somura, MlY' Kouichi Hisatomi, MlY' Akio Hirano, MlY' Ken-ichi Kosuga, MlY' Kiroku Ohishi, MlY' Masahiro Syukuwa, MIl' Jun Fukui, MIl' Second Department of Surgery Kurume University School of Medicine" Medical Department Sasebo Public General Hospitalb Fukuoka, Japan

Adriamycin-Lipiodol emulsion (ADR-LIP) was injected, percutaneously via a 20 gauge needle with ultrasonographic guidance, as part of the treatment of 4 patients with relatively small hepatocellular carcinoma (HCC). Lymph vessels extending from the tumor nodule to the abdominal lymph nodes were imaged immediately after the injection in 3 patients. Subsequent plain films of the abdomen and abdominal computed tomography demonstrated stagnant collections of ADR-LIP in the abdominal lymph nodes. Histologic examination of lymph nodes removed during partial hepatectomy or at autopsy in these cases revealed many large and small fat droplets, thought to be Lipiodol, as well as macrophages containing phagocytized lipid. Although lymphatic metastasis occur in HCC, these findings suggest that lymphatics may exist in HCC tissue during the relatively early stages of tumor growth.

During 6 years between January 1981 and December 1986, 31 patients with ruptured aortic aneurysm, in which 13 had thoracic aneurysms and 18 had abdominal aneurysms, were operated in our institution. Operative mortarity rate were 15.4% in the thoracic and 27.8% in the abdominal cases. A possible correlation between operative results and pre- and perioperative volume of blood transfusion was indicated. To improve the results, an appropriate maintenance of blood pressure and rapid treatment from the onset of the disease to the operation might be needed. But especially for thoracic and thoraco-abdominal aneurysms, a diagnosing the lesion and grasping the state of the main branch appeared important, and for this CT and DSA were of value. Aneusysm should be operated in earlier stage as far as general condition of a patient could permit.

We have experienced five complete repair cases of aortic dissections, four of which classified as DeBakey type III-b and one done as the type III-b like abdominal dissection were treated with entry and re-entry at the same time or in two-step procedure. Case 1 and 3 with major viseral branch from true lumen underwent graft replacement of decending aorta and clossure of re-entry. Case 2 with visceral branch from false lumen underwent graft replacement of decending aorta and abdominal aorta. Case 4 with abdominal dissection underwent clossure of entry and re-entry. Case 5 with aneurysmal change of the aortic dissected lesion underwent all replacement of dissecting aorta and reconstraction of visceral branch. Their postoperative courses are uneventful without complications such as paralysis and visceral ischemia, and DSA have demonstrated favarable results. We believe these methods are currently radical operations for type III-b dissection.

A case of double-outlet left ventricle {I, D, D} with a subaortic ventricular septal defect and pulmonary stenosis is reported. The diagnosis was made at operation and was reconfirmed postoperatively by two-dimensional echocardiography. Repair was achieved by patch closure of the ventricular septal defect and enlargement of the functional right ventricular outflow tract using a valved patch. The postoperative course was uneventful except for a transient complete heart block. To our knowledge, this represents the second instance of surgical treatment of double-outlet left ventricle {I, D, D} reported in the literature.

Buerger's disease is a vascular occlusive disease affecting mainly the extremities of younger people. It, however, rarely affects the arteries of the abdominal organs such as the celiac and mesenterium.Two patients suffering from Buerger's disease were admitted to our hospital with symptoms of abdominal angina. They had undergone amputation of the right lower thigh and lumbar sympathectomy.In angiography, occlusion was found at CA, SMA and IMA.One patient was treated with aorto-SMA bypass and the other with aorto-SMA bypass and aroto-lineal bypass.Pathologically, one had atherosclerosis and the other a mixed type of Buerger's disease and sclerosis.Postoperatively, they have been doing well and are free from abdominal pain.

We report a case of a 62-year-old woman with aortic regurgitation presenting dove-coo murmur. Operative findings revealed that an embanked protrusion acting as a fulcrum localized at the right coronary cusp of the aortic valve caused the thin, free edge to vibrate like the reed of a wind instrument, thus causing the murmur.

A 28-year-old female underwent Chiari's pelvic osteotomy and a 46-year-old female total hip replacement. Two weeks after the operation both cases complained of sudden onset of chest pain and dyspnea. They were transferred to ICU and were diagnosed as pulmonary embolism. They were saved by emergency operation. The first case took oral contraceptive one week before operation, and the second case was a obese female. They may be risk factors of pulmonary embolism. We must pay a great attention to pulmonary embolism that would be the severest complication after orthopaedic surgery.

The effectiveness of aortic valvuloplasty and the indications for aortic valve replacement were examined in 76 patients with ventricular septal defect associated with aortic regurgitation. Results of this study indicate aortic regurgitation is associated with rapid deterioration and that aortic valvuloplasty should be performed as soon as aortic regurgitation is detected. The data also suggest that aortoplasty is indicated if aortic valvuloplasty alone is inadequate for coaptation of the aortic cusps with thickening.

Among acquired valve diseases, surgical results are not quite satisfactory in combined valve diseases with tricuspid insufficiency. We classified tricuspid insufficiency into three grades depending on the degree of regurgitation through the tricuspid valve and surgical results including hemodynamic changes after surgery and prognosis were studied from the point of relation to the degree of regurgitation.

We had 49 cases of mitral valve replacement. Aortic valve replacement has been performed 30 cases. Double valve replacement was performed in 7 cases, which were all serious.94 artificial valve were used in the valve replacement of our cases, and 61 of them were a ball valve of Starr-Edwards. 26 were a disc valve of SAKAKIBARA (SAM).Postoperatively, anticoagulant treatment was given to all cases. On the surgical result of our artificial valve replacement, early death was seen in 22 (25.5%) and late death in 10 (11.6%) of 86 cases.Postoperative complication and cause of death were low cardiac output syndrome, hemorrhage, pulmonary edema, infection and embolism. On the Pre and postoperative changes of functional capacity by NYHA, the most of cases were improved to II or III grade.

We describe the operative and perioperative management of 11 patients with aortic regurgitation due to aortitis. All patients required aortic valve replacement because of severely uncoapted cusps secondary to dilatation of the ascending aorta. The right coronary ostium was narrowed in 5 patients and consequently necessitated a smaller coronary tip for the administration of cardioplegic solution. To implant the prosthetic valve, pledgeted 2-0 Tevdek sutures were placed through the aortic valve annulus either from the ventricular side or from outside the aortic wall. Steroids were administered to 4 patients preoperatively and 8 patients postoperatively. Postoperative dehiscence of the prosthesis was seen in 1 of the 3 patients not given any steroids. We conclude that it is important to arrest the inflammatory reaction before operation and if the aortic valve must be replaced, to reinforce the implanted prosthesis with pledgeted sutures. Also, we suggest the possible importance of steroid therapy.