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Ebstein奇形に合併する三尖弁逆流に対する弁形成術として,Carpentier法による修復法は広く受け入れられている術式である.今回われわれはCarpentier法による修復が困難であった成人Ebstein奇形の2手術例を経験したので,その修復法について文献的考察を加えて報告する.症例1は63歳女性,TR IV度でASDを合併していた.形態的にはCarpentier分類Type Dで前尖の約40%がplasteringしていた.Carpentier法による修復を試みたが逆流が残存し弁置換術を行った.症例2は53歳女性.Type Bであったが,前尖にcleftがあり分葉しており前尖を弁輪より切離し再縫合するCarpentier法は不適切と判断した.中隔尖先端は機能しうる組織が残存しており,これに前尖を接合させるように弁輪形成を行った(Hetzer変法).両症例とも前尖の高度の奇形を伴っており,Carpentier法が困難な症例と考えられた.このような症例には後尖も含めて機能しうる弁尖部分を最大限に利用して,中隔尖,後尖側の弁輪の高さをその付着部に移動させて再構築を行うHetzerらの方法が有効な選択肢となりうると思われた.

A 70-year-old man developed meticillin-resistant staphylococcus aureus (MRSA) mediastinitis after prosthetic graft replacement of the ascending aorta. The sternal wound was reexplored and a single-stage procedure of irrigation, debridement, and omental transposition was performed. Ten months after the first operation, he suffered recurrence of pyrexia and the presence of false aneurysm originated from the distal suture line was diagnosed by the chest computed tomography (CT) scan. Re-replacement of the ascending aorta and proximal hemiarch with rifampicin soaked Gelseal was successfully performed. Hypothermic perfusion with circulatory arrest through peripheral cannulation and left ventricular venting via a left anterior thoracotomy was useful to obtain safe reentry in the operation of retrosternal false aneurysm.

Severe atherosclerotic disease of the ascending aorta is one of the risk factors of dissection of the ascending aorta and cerebral embolism during cardiac operations with cardiopulmonary bypass. Aortic dissection is rare, but once it happens, the mortality rate is high. For the patient with severely atherosclerotic or strongly calcified aorta, we should avoid cannulation into the aorta or clamping of it. In this case, we experienced aortic dissection although we chose the arterial cannulations into the axillary arteries because of the strong calcification of the ascending aorta and the abdominal aorta. The dissection was caused by the cannulation into the axillary artery. Transesophageal echocardiography (TEE) showed the dissection during the operation and the ascending aorta was replaced soon. Early diagnosis and treatment saved the patient. This case showed the following points: 1) cannulation into an axillary artery is not always safe; 2) TEE is very useful to detect the complicated dissection during operation; 3) replacement of the ascending aorta alone can be one of the choices for the treatment of aortic dissection caused by cannulation into an axillary artery.

A 44-year-old man complained of chest oppression and systolic murmur. Echocardiography showed subaortic stenosis with outflow gradient of 135 mmHg, interventricular septal thickness of 21 mm, left ventricular posterior wall thickness of 11 mm, and 2/4 mitral regurgitation. Selective coronary angiography demonstrated 75% stenosis in left anterior desending branch. Coronary artery revasculization comcomitant with left ventricular myotomy-myectomy was performed. He had a good recovery from operation, and was discharged in 19th days in NYHA class I. Echocardiography one month after operation showed mild outflow pressure gradient, light systolic anterior motion of mitral anterior leaflet, and 1/4 mitral regurgitation. Careful operative management, including myocardial protection, avoiding perporation of ventricular septum, and postoperative medical care are mandatory to this group of patients. The use of cathecholamine and Ca-blocker will be attentioned because of the increasing the left ventricular pressure gradient.

Between January 1994 and August 1999, we experienced 16 cases of coronary artery bypass grafting (CABG) in severe left ventricular dysfunction with left ventricular ejection fraction (LVEF)or = 40%. Four had additional endoventricular patch plasty in large postinfarction akinetic scars, the so-called Dor approach, to CABG (group D). Eleven had only CABG, or CABG and mitral annuloplasty (group C). One had linear repair after the resection of the left ventricular aneurysm. One died of sustained low output syndrome 5 months after the operation in group C. Fractioning shortening and left ventricular diastolic diameter were not changed after the operation in group C. On the other hand, in group D, there were no complications after the operation, LVEF was significantly improved from 31.5 +/- 4.9% to 62.5 +/- 5.9% (p0.01) and the left ventricular end-diastolic volume index was reduced from 118 +/- 23 ml/m2 to 74 +/- 12 ml/m2 (p0.01). The Dor approach is considered to be a safe and effective additional procedure to CABG in severe patients with a large akinetic antero-septal segment.

Although the postoperative outcome in patients with incomplete atrioventricular septal defect (iAVSD) is excellent, deterioration of mitral valve regurgitation (MR) is still remained to be resolved. Therefore, this study was undertaken to compare surgical procedures for mitral cleft repair with their long-term results of MR. From 1991 to 1996, 52 patients underwent surgical repair of iAVSD. Age at operation ranged from 2 months to 62 years old with mean age of 14.2 years. Mean follow-up period was 8.6 +/- 4.4 years. All patients underwent patch closure of ostium primum defect. Two patients did not have cleft (Group A). Seven patients did not close the cleft at all (Group B), while 40 patients had the repair of valve by closing cleft near septal attachment only (Group C). The latest 3 patients had the complete closure of cleft from annulus to margin of leaflet where chorda is attached. MR was evaluated by echocardiography grading 0 to IV and regurgitation more than grade II was considered to be significant. In Group A, MR remained grade I. In Group B, MR was deteriorated in 5 patients (71%). Consequently, 6 patients (86%) had grade II or more regurgitation and 4 patients (57%) revealed grade III/IV regurgitation including one (14%) reoperation. In Group C, MR was deteriorated in 10 patients (55%). Consequently, 22 patients (86%) had grade II or more regurgitation and 5 patients (13%) had grade III/IV regurgitation including 3 (7.5%) reoperations. In Group D, no deterioration of MR was noted and all had grade I or less regurgitation. These results suggest that the closure of cleft near septal attachment is not sufficient to prevent MR in late phase and the complete closure of cleft from annulus to margin of leaflet, where chorda is attached, would be useful to prevent the deterioration of MR in late phase.

Background CTLA4 immunoglobulin (CTLA4 Ig), which binds with high affinity to B7-1 and B7-2, interrupts T-cell activation by inhibiting the costimulatory signal. CTLA4Ig has been used to achieve antigen-specific tolerance induction in cardiac allografts. On the other hand, we have shown that short-term administration of deoxyspergualin (DSG) and daily cyclosporine (CsA) induces long-term survival of cardiac xenotransplants. We hypothesized that the combination therapy of DSG and adenovirus-mediated CTLA4IgG might induce long-term, survival or tolerance in cardiac xenotransplantation. Objectives Syrian hamster hearts were transplanted heterotopically into Lewis rats. We compared the survival time and immunopathology of the following five groups: (1) no treatment; (2) DSG (5 mg/kg per day intramuscularly [IM], days −1 to +7) alone; (3) CsA (15 mg/kg per day IM, day 0 to rejection) plus DSG; (4) AdexLacZ (LacZ-adenovirus 1 × 10 9 (PFU intravenously [IV], day −7) plus DSG; and (5) AdexCTLA4IgG (CTLA4IgG-adenovirus 1 × 10 9 PFU IV, day −7) plus DSG. Results The survival times were: (1) no treatment, 3.7 days; (2) DSG alone, 12.4 days; (3) CyA plus DSG, >100 days; (4) Adex LacZ plus DSG, 11.0 days; and (5) AdexCTLA4IgG plus DSG, 23.6 days. Adenovirus-mediated CTLA4IgG therapy with DSG prolonged survival time significantly compared with DSG alone or AdexLacZ plus DSG, but CTLA4IgG therapy was not as effective as CsA. Immunopathology showed the deposition of C3 and IgM on the endothelium in the AdexCTLA4IgG plus DSG group. Conclusions We showed that the effectiveness of adenovirus-mediated CTLA4IgG gene therapy in cardiac xenotransplantation in less than that of CsA. Combination therapy with inhibition of the B7/CD28 constimulatory signal and DSG administration might not be sufficient for long-term survival or tolerance in cardiac xenotransplantation.

Evoked spinal cord potentials elicited by direct stimulation of the cord were used to monitor spinal cord ischemia in 68 patients undergoing temporary occlusion of the thoracic aorta (29 thoracic nondissecting aortic aneurysms, 9 nondissecting thoracoabdominal aneurysms, and 30 dissecting aneurysms). "Immediate" postoperative paraplegia developed in three patients and "immediate" paraparesis developed in one, whereas "delayed" paraplegia developed in two others. During aortic crossclamping, four response patterns of the spinal cord potentials were obtained: (1) no change (n = 53), (2) change with return (n = 10), (3) change with inconsistent return (n = 2), and (4) change without return (n = 3). Neurologic complications occurred in 2%, 0%, 100% of these groups, respectively. Delayed paraplegia developed on the second postoperative day in only one patient with a false-negative result, and the potentials correlated well with this patient's clinical neurologic recovery. The aortic crossclamp time was significantly longer in the patients with "change with inconsistent return" and "change without return" than in the other two groups (p0.01). Femoral artery pressure and the cardiopulmonary bypass flow rate were also significantly lower in these groups than in the other two groups (p0.02 and p0.01, respectively). We conclude that intraoperative monitoring of direct spinal cord responses is useful for the early detection of spinal cord ischemia for assessing the efficacy of surgical countermeasures.