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Background Reoperative (redo) mitral valve surgery is still a continuing challenge to surgeons. The aim of this study was to detect the factors that affect late mortality or morbidity after redo mitral valve surgery in patients with rheumatic disease. Methods Between May 1983 and February 2003, 92 patients who underwent redo mitral valve surgery for rheumatic disease were enrolled. Risk factors influencing survival or cardiac events were investigated with univariate analysis and a Cox model. Results Operative mortality rate was 4.2%. Kaplan-Meier actuarial analysis demonstrated an 84.7% 5-year, a 69.5% 10-year, and a 65.9% 15-year survival. Multivariate analysis demonstrated that age at surgery and preoperative New York Heart Association (NYHA) class were found to be independent predictors of late deaths, and that higher age, advanced NYHA class, and previous mitral valve replacement were independent predictors of cardiac events. Conclusions Redo mitral valve surgery can be achieved with low early mortality. However, long-term results of redo mitral surgery are not necessarily satisfactory in patients with preoperative advanced NYHA class or with a previous mechanical heart valve, and especially in 60 years or older age.

Objectives: We review the outcome of coronary artery bypass grafting in patients with a severe atherosclerotic ascending aorta.Methods: Subjects were 31 patients averaging 69.4±6.9 years old studied from 1990 through 1998. Ascending aortic lesions were assessed using epiaortic echo and 2 types of aortic nonclamping techniques applied. In 29 patients operated on in the early years, bypass grafting was conducted on the hypothermic fibrillated heart in 22 and on the beating heart in 7. The remaining 2 underwent off-pump coronary artery bypass grafting more recently. For cases with multivessel disease, we used composite grafting.Results: Three patients developed mild stroke and 5 died within 30 days of surgery—4 from multiple emboli (1 accompanied by a stroke) and 1 from perioperative myocardial infarction. One hospital death occurred due to brain damage and multiorgan failure following unexpected rupture of a saphenous vein graft. No cardiac deaths occurred in the late stage of our series. Actuarial survival was .0% for 3 years and 68.0% for 5 years. Freedom from cardiac events was favorable in the remaining 25 survivors.Conclusions: Outcome was suboptimal for the risks involved. Recent technical advances, including coronary surgery on the beating heart with or without cardiopulmonary bypass using variable in-situ or free arterial grafts, associated with adequate evaluation of systemic atherosclerosis, should improve this outcome.

Objectives: The outcome of aortic arch repairs by means of three different approaches between 1990 and January 2000 was reviewed. Methods: In total 39 patients aged 71.5 ^ 6.2 years were operated on. The three different surgical approaches depended on the anatomical positions of the aneurysms and on their proximal or distal extension; a median approach was employed in 23 patients, whereas a left posterolateral approach was used in eight patients. More recently, in eight cases a left antero-lateral approach was applied. All patients underwent open aortic anastomosis without any clamp on or around the aortic arch. During the procedure, the brain was protected by a combination of profound hypothermic circulatory arrest and several techniques of retrograde cerebral perfusion. Results: Permanent cerebral dysfunction occurred in four patients: two in the median approach and two in the left postero-lateral approach. There were two hospital deaths (5.3%) and six late deaths, all of which belonged either to the median group or to the postero-lateral group. The antero-lateral approach did not produce any cerebral dysfunction, early death, or late death. Conclusions: The outcome of aortic arch repairs using profound hypothermic circulatory arrest and variable techniques of retrograde cerebral perfusion, by means of three different approaches, was satisfactory. Of the three approaches, the antero-lateral approach can be employed easily, whether aneurysms extend proximally or distally. q 2001 Elsevier Science B.V. All rights reserved.

Although the immediate results of radical operation for tetralogy of Fallot are excellent, long-term follow-up has shown that the number of repeated procedures has increased in many institutions. We describe patients who underwent a second or third procedure after radical operation for tetralogy of Fallot.Between April 1981 and August 1996, we operated on 44 patients for the second time and on 4 for the third time after radical operation for tetralogy of Fallot. Indications for a second and third procedure included right ventricular outflow tract obstruction in 38 patients, infective endocarditis in 4, and isolated residual ventricular septal defect in 3.One patient died after concomitant replacement of the pulmonary and tricuspid valves. Three patients who underwent sternotomy more than twice (before the second or third operation) underwent accidental cardiovascular trauma during this procedure (30%). Moreover, when patients underwent more than two sternotomy procedures before the repeated operation for tetralogy of Fallot, the total bypass time, interval between cessation of the cardiopulmonary pump to completion of the operation, amount of blood transfusion, and length of intensive care unit stay were significantly higher compared with those who underwent less than two sternotomy procedures (p0.05). Right ventricular outflow tract obstruction was the main indication for a second operation. After the second operation for right ventricular outflow tract obstruction in 35 patients, the preoperative right ventricle to left ventricle pressure ratio decreased significantly (from 0.75 +/- 0.13 to 0.51 +/- 0.12; p0.0001). However, the right ventricle to left ventricle pressure ratio did not significantly decrease in patients who underwent a third procedure to treat right ventricular outflow tract obstruction.The surgical results of a second procedure after radical operation for tetralogy of Fallot were acceptable. However, the risk of accidental cardiovascular trauma during dissection was high among patients who underwent sternotomy more than twice before repeat operation.

Background: β-blocker therapy for dilated or ischemic cardiomyopathy is now an accepted and effective treatment. However, little is known about its efficacy in patients with postoperative impaired left ventricular function. This retrospective study was designed to assess the effects of β-blocker therapy in patients after aortic valve replacement (AVR) for aortic regurgitation (AR). Methods: A total of 59 patients who underwent AVR for chronic AR were assigned to four groups. Twelve patients were treated with both ACE inhibitors and β-blockers, 12 patients with only ACE inhibitors, eight patients with only β-blockers, and 27 patients without β-blockers or ACE inhibitors. A postoperative echocardiographic study was performed one year after surgery. Results: The heart rate was significantly reduced in patients with β-blockers despite the use of ACE inhibitors after surgery. Postoperative left ventricular volume was more significantly decreased in β patients than in non-β patients despite the use of ACE inhibitors. There were also significant reductions in left ventricular mass index in ACE+β patients compared to ACE+non-β patients. However, there were no significant differences in NYHA functional class and survival rate between β patients and non-β patients. Conclusions: β-blocker therapy may improve cardiac performance by reducing cardiac volume and mass in patients with impaired LV function after AVR for AR.

The authors used profound hypothermic circulatory arrest and continuous retrograde cerebral perfusion for aortic surgery that involved the distal arch through a left thoracotomy. For the first seven patients, oxygenated blood from cardiopulmonary bypass was perfused retrogradely through a venous cannula positioned into the right atrium. In the last 11 cases, venous blood, provided by a perfusion from the lower body, was circulated passively in the brain with the descending aorta clamped. The period of profound hypothermic circulatory arrest was 34.6±11.1 min, and continuous retrograde cerebral perfusion was 31.3±11.1 min. Seventeen patients survived, but there was one early death. Two patients with a severely atherosclerotic aneurysm developed permanent neurological dysfunction. The combination of profound hypothermic circulatory arrest, continuous retrograde cerebral perfusion and open aortic anastomosis through a left thoracotomy protects the brain adequately, and facilitates evacuation of debris and air in the aortic arch. It produces satisfactory results for aortic surgery that involves the distal arch.

The early and mid-term outcomes of cardiac and thoracic aortic surgery were reviewed in seventy-two consecutive patients aged 75 years and older, together with assessment of postoperative quality of life. Twenty-six patients had ischemic heart disease, twenty had valvular heart disease, one had congenital heart disease, and twenty-five had thoracic aortic aneurysm. Twenty-five (34.7%) required an emergency operation. There were 6 early deaths (8.3%) and 11 late deaths (17.2%), of which the emergency cases had higher mortality of 5 early deaths (20.0%) and 3 late deaths (15.0%). In particular, most cases with a ruptured thoracic aortic aneurysm died eventually from various complications including neurological dysfunction. The others with a non-ruptured aneurysm also had atherosclerotic aortic or arterial lesions which caused a lethal cerebrovascular accident or ischemic heart disease. The quality of life of 51 of 53 survivors was assessed using the Rosser and Watts index being based on disability and distress scores. The response was satisfactory--the disability score was 2.6 +/- 1.9 and the distress score was 1.4 +/- 0.4. The patients with a thoracic aortic aneurysm had worse quality of life scores than those of the ischemic heart disease or valvular heart disease patient-groups because of various perioperative complications. Our experiences demonstrate that the results including the postoperative quality of life following cardiac and aortic surgery in the elderly is satisfactory except for emergency cases. The results would prompt us to operate, if possible, electively in their stable conditions, even on elderly over-75-year-olds.

Objective: To assess the value of monitoring of regional cerebral oxygen saturation (rSO 2 ) during aortic arch surgery using continuous retrograde cerebral perfusion (CRCP) in conjunction with profound hypothermic circulatory arrest (HCA). Methods: The rSO 2 of 12 consecutive patients was monitored non-invasively using near-infrared spectroscopy (NIRS) and the data were analyzed statistically. Results: The mean duration of HCA with CRCP was 62 ± 14. min. The mean CRCP flow rate was 226 ± 163 ml/min. Surgical outcomes were favorable with only a single hospital death (8.3% ). However, the rSO 2 decreased gradually in all patients during HCA, even combined with CRCP, and fell to 46 ± 8.7% on average. It did not change so greatly before HCA and returned finally to its initial level at the end of re-warming. Only one patient developed a permanent neurologic deficit; this patient showed the greatest decrease of rSO 2 from 56% to 29% after the longest HCA of 88 min. Two parameters, End-rSO 2 (the ratio of post- to pre-HCA rSO 2 ) and Δ-rSO 2 (the rate of decrease from preto post-HCA rSO 2 ) were obtained since the initial values of rSO 2 before surgery differed. There were linear correlations between the CRCP flow rate and each of these two parameters. A multiple regression analysis also revealed a linear equation relating the parameters, which allowed prediction of the safe duration of HCA in different conditions of CRCP and a more favorable adjustment of the CRCP condition in each patient. Conclusions: The study suggests that the combination of HCA and CRCP has a limit of safe duration in spite of its potential usefulness for brain protection, and that rSO 2 monitored by NIRS is useful in testing for adequate brain protection. It is hoped that monitoring of rSO 2 can facilitate prediction of the safe duration of HCA with CRCP and a more favorable adjustment of CRCP.

われわれはEPTFE人工血管を用いた右腋窩-大腿動脈バイパス術後, 右肋骨弓の尾側で非吻合部の人工血管断裂をきたした症例を経験した. この発生原因の一つとして, 体幹運動による人工血管への物理的負荷を考慮し, 健常者において実験を行った. 直立基本肢位にて, 右鎖骨中央より右ソケイ靱帯中央までの距離を測定し, この距離を3等分するようにマーカーを描いたものを基本位モデルとした. 次に, 各部位の距離が最長となる体位をそれぞれの部位での伸展位モデル, 最短となる体位を同様に屈曲位モデルとし, 各モデル間での各部位の距離の変化率 (%) を算出し検討した. 伸展位では中部で有意に伸展しており, 屈曲位では下部が有意に短縮していた. 腋窩-大腿動脈術後のグラフトでは, 体幹運動により, 中部および下部にて伸展, 屈曲の物理的負荷がかかるものと考えられ, この負荷により遠隔期に人工血管の断裂をきたす可能性が疑われた.

1983年より1994年9月までに当科において経験した待期的腹部大動脈瘤症例75例を対象とし, 自己血回収輸血装置の導入前後において術中無輸血で手術が可能であった症例を検討した. 装置の導入は1991年6月で, 導入前をNCS群 (n=25), 導入後をCS群 (n=50) とすると, 各群間に年齢, 手術時間, 瘤径, 出血量には差がなかったが, 無輸血手術率はNSC群で28.0%, CS群で86.0%と有意差をもって上昇した. 同種血輸血量は平均でNCS群で680±605ml, CS群で98±252mlと著明に減少し, 同種血輸血量の削減が可能であった. 術翌日の血小板数, 血清総蛋白, アルブミン, T-Bil, BUN, LDHの各値には装置使用の差は認められなかった. 装置使用にもかかわらず輸血に至った症例は50例中7例で, 400から1,000ml (平均685ml) の同種血輸血を必要とした. 今回の検討から自己血回収輸血装置の有用性が再確認されるとともに, 今後更なる無輸血率の向上には400から800ml程度の術前自己血貯血が必要と考えられた.

Aortoesophageal fistula occurring as a complication of a thoracic aortic aneurysm is difficult to repair because of the contaminated surgical field. We report the case of a 67-year-old man in whom an aortoesophageal fistula developed secondary to a dissecting thoracic aortic aneurysm. We performed in situ graft repair of the aneurysm, then covered the site with omentum and resected the esophagus to prevent graft infection. About 5 months later, the esophagus was reconstructed subcutaneously using an ascending colon pedicle. The patient recovered well and has resumed leading a normal life.

われわれは, 腹部大動脈瘤手術においては woven Dacron 人工血管の使用を原則としていたが, 1991年9月よりプレクロッティングの不要な zero porosity のゼラチン被覆 knitted Dacron 人工血管(Gelseal®) の使用を開始した. しかし, 術後6例中4例に不明熱の出現を認め, 術後人工血管径は最低25.0%, 最大43.8%, 平均31.8±7.2%とコラーゲン被覆 woven Dacron 人工血管 (Hemashield®) に比し有意 (p=0.0003) に拡大し, 1992年9月にてその使用を中止した. ゼラチン被覆 knitted Dacron 人工血管 (Gelseal®) の植込みに際しては, 胸部大動脈だけでなく, 腹部大動脈においても術後の拡大に注意し, 人工血管径をCTまたはエコーなどにより経過観察する必要があるものと考えられた.

後腹膜領域の吻合部仮性動脈瘤 (AFA) は大動脈瘤や閉塞性動脈疾患に対する人工血管置換術後の, 頻度は少ないが重要な遠隔期合併症の一つである. 今回われわれは15年前に他院にて解離性大動脈瘤 (DeBakey IIIb) にて胸部下行大動脈人工血管置換術を施行された際, 補助手段として用いられた上行大動脈-右外腸骨動脈一時バイパスの末梢側吻合部に発生した外腸骨動脈吻合部仮性動脈瘤の1手術例を経験した. 症例は60歳女性. 急速に拡大する右下腹部腫瘤にて紹介入院し, CT・血管造影検査にて外腸骨動脈仮性動脈瘤と診断し手術を施行した. 開腹にてアプローチし, 仮性動脈瘤を損傷せずに外腸骨動脈と一塊として摘出, 人工血管によって解剖学的に外腸骨動脈を再建した. 術後経過は良好で再発等を認めていない. 人工血管置換術後は一生涯にわたる定期的な経過観察が必要であると考える.

A droplet manipulation is one application of a surface acoustic wave (SAW) device. If a sensor fabricated on the SAW device, a digital microfluidic system is realized. For disposable application, three-layer structure of sensor plate/water layer/128YX-LiNbO3 was proposed. In this paper, first, an enzyme reaction is measured using the system. An interdigital electrode (IDE) is fabricated on the sensor plate which is glass plate. Urease droplet on the plate is manipulated and mixed with an urea droplet. Then catalytic reaction of the urease is measured. Second, an acoustic streaming which is generated is observed. Streaming velocities at different thicknesses of the glass plate and water layer thickness are compared. The results indicate that efficiency of droplet manipulation is improved by using a thin glass plate.

In 39 mongrel dogs, regional cerebral blood flow was measured during pulsatile and nonpulsatile deep hypothermic cardiopulmonary bypass with total circulatory arrest. Total circulatory arrest was performed at 20° C cerebral temperature for 40 minutes in 15 dogs, 60 minutes in 12 dogs, and 80 minutes in 12 dogs. Cerebral blood flow in both groups decreased as cerebral temperature fell and there was no significant difference in cerebral blood flow between the two groups during the cooling period. After circulatory arrest for 40 minutes, as cerebral temperature increased to 35° C, cerebral blood flow in both groups recovered to values as high as the respective initial values, which were measured just after the beginning of cardiopulmonary bypass for cooling (102.5% ± 10.2% in the pulsatile group and 97.2% ± 12.6% in the nonpulsatile group). After circulatory arrest for 60 minutes, cerebral blood flow in the pulsatile group increased to 141.8% ± 16.1% of its initial value when the cerebral temperature became 35° C, but it remained significantly lower (64.5% ± 9.2%) in the nonpulsatile group ( p

We evaluated cerebral metabolism during retrograde cerebral perfusion (RCP) and circulatory arrest during profound hypothermia, and also investigated the effects of perfusion pressure on RCP. Twenty-four adult mongrel dogs were placed on cardiopulmonary bypass and cooled to a nasopharyngeal temperature of 20 degrees C. At this temperature, hypothermic circulatory arrest (HCA; n = 6), and RCP with a perfusion pressure of 10 mmHg (RCP10; n = 6), 20 mmHg (RCP20; n = 6), and 30 mmHg (RCP30; n = 6) were carried out for 60 minutes. RCP was performed with oxygenated blood via the bilateral maxillary veins, and the retrograde flow rate was regulated to maintain a mean perfusion pressure of 10, 20, or 30 mmHg in the external jugular vein. At 60 minutes of RCP, we measured nasopharyngeal temperature; regional cerebral blood flow (rCBF); cerebral oxygen consumption, carbon dioxide excretion, and excess lactate; cerebral tissue adenosine triphosphate (ATP), adenosine diphosphate (ADP), adenosine monophosphate (AMP) and energy charge; and cerebral tissue water content. In the RCP10 group, there was excess cerebral lactate, and ATP and energy charge were low. In the RCP30 group, the water content of cerebral tissue was significantly higher than in other groups. In the RCP20 group, temperature was maintained in a narrow range, oxygen consumption and carbon dioxide excretion could be observed, there was no excess lactate, and ATP and energy charge were significantly higher than in the HCA group. In conclusion, RCP can provide adequate metabolic support for the brain during circulatory arrest, and a perfusion pressure of 20 mmHg is most appropriate for RCP.

In this paper, the fatigue crack growth characteristics of PSZ ceramics with multiple cracks is described concerning with the number of cracks, crack spacing and crack length. The stress distribution around the crack tips has been analyzed in the case of four point bending test model using the finite element method. It is confirmed that the maximum principal stress value of crack tips decreases with increasing the number of crack and narrowing the crack spacing. Also, the maximum principal stress value of crack tips which lead to fracture is changed by growth of other cracks, which are independent from failure. On the other hand, crack growth rate parameter m, -logC in multiple cracks are calculated from stress intensity factor K, which is analyzed by J-integral around the crack tip. It is found that the estimated life of PSZ ceramics with multiple cracks agrees with the fatigue life which is elucidated from fatigue test.

The main objective of this study is to evaluate the strength reliability of ceramics with machining damages under cyclic loading. The conceptual algorithm for application of linear fracture mechanics is proposed to the strength reliability evaluation of ceramic component. Also the machining damages in ceramic component are converted by the multiple cracks model with same crack length and crack spacing in order to analyze. The stress intensity factor on the ceramics with multiple cracks under the cyclic loading is discussed in connection with the crack spacing and the crack propagation length with no failure. On the other hand, the fatigue crack growth parameters C and m, and the fatigue fracture toughness value Kfc of ceramic component are calculated from the result of a cyclic four point bending test. Further, statistical characteristics of the C, m and Kfc for the ceramics with multiple cracks are estimated from Weibull distribution function in the ceramics with single crack, which was discussed in the previous paper. This analytical method could be applied to predict the life of ceramics with various machining damages. Two examples of the life of PSZ ceramics with laser and grinding damages are indicated using the analytical method proposed in this paper and by the repeated four point bending test, and then the experimental result has agreed with the analytical result.

There are no guidelines for the optimal therapeutic range of anticoagulant therapy in Japanese patients with mechanical heart valves. A total of 214 patients were followed retrospectively after mitral mechanical valve replacement (mean duration of follow-up, 4.8 years; total duration of follow-up, 1,027 patient-years). The target range of the international normalized ratio (INR) for oral anticoagulation was between 1.5 and 2.5. For all patients 10,416 measurements of the INR were obtained during the follow-up period and approximately 76% of the intensity measurements were within the target range. Thromboembolism occurred in 8 patients (0.8 per 100 patient-years) and major bleeding in 5 patients (0.5 per 100 patient-years). There was no correlation between the distribution of the INR and the occurrence of thromboembolic or bleeding complications. In the univariate analysis of the various risk factors, patients who had a tilting valve or did not receive antiplatelet therapy had an increased risk of thromboembolism. However, there were no risk factors with respect to bleeding complications. A target range of 1.5 to 2.5 INR appears to be the optimal range and is safe for thromboembolism or bleeding complications. Thromboembolism may be reduced by additional antiplatelet therapy, and a tilting valve needs more intense anticoagulation.

A 69-year-old man with coronary artery disease associated with abdominal aortic aneurysm underwent a one-stage operation utilizing a low-flow cardiopulmonary bypass. Ordinary cardiopulmonary bypass was abandoned as a result of severe atheromatous finding in the entire aorta. However, coronary artery bypass grafting without cardiopulmonary bypass was hazardous as a result of heart enlargement and deteriorating function. Therefore, the abdominal aortic aneurysm was first replaced with a bifurcated graft. Coronary artery bypass grafting with two arterial grafts was then performed successfully on the beating heart with the support of a low-flow cardiopulmonary bypass connected to the bifurcated graft.

We reviewed our surgical management of aortic arch aneurysms in 11 octogenarians. Seven operations (63.6%) were performed on an emergency basis for ruptured atherosclerotic aneurysm in 5 cases and for acute dissection in 2. Deep-hypothermic circulatory arrest, continuous retrograde cerebral perfusion, and open aortic anastomosis were employed routinely for brain protection during aortic arch replacement. There was one intraoperative death due to hemorrhage. One survivor died of bowel necrosis 47 days postoperatively and another suffered sudden death 5 months postoperatively. Both of these patients had been treated for a ruptured aneurysm and had suffered from postoperative neurological deficit. There were 2 late deaths due to unrelated events: subarachnoid hemorrhage and hepatic failure. The surgical outcomes were considered satisfactory, except in emergency cases of ruptured aneurysm where there was a high mortality and neurological morbidity. It is recommended that arch aneurysms at risk of rupture should be repaired electively before rupture, even in octogenarians, using deep-hypothermic circulatory arrest, continuous retrograde cerebral perfusion, and open aortic anastomosis.

The importance of statins in cardiovascular prevention has been demonstrated in various patient subsets. This study aimed to evaluate the effects of statins on long-term outcomes of Japanese patients undergoing their first coronary revascularization.A total of 9,225 patients undergoing their first coronary revascularizations during 2000--2002 were divided into 2 groups according to the use of statins at discharge; patients with acute myocardial infarction were not included. Statins was administered to only 28.5% (n=2,630) of the patients. The median follow-up period was 3.5 years. Patients on statin therapy showed lower all-cause (5.2% vs 10.0%; p0.0001) and cardiovascular (3.2% vs 6.2%; p0.0001) mortality than those without statins (n=6,595) by Kaplan-Meier analysis and log-rank test. After adjustment by multivariate analysis according to 29 variables, statin therapy remained as an independent predictor of reduced all-cause (relative risk ratio (RR) 0.71, 95% confidence interval (CI) 0.59-0.86, p=0.0005) and cardiovascular (RR 0.72, 95% CI 0.56-0.91, p=0.0067) mortality. The validity of RR of statin therapy in multivariate analysis was further confirmed by risk adjustment using propensity scores (all-cause mortality: propensity-adjusted RR 0.70, 95% CI 0.58-0.85, p=0.0003; cardiovascular mortality: propensity-adjusted RR 0.70, 95% CI 0.54-0.89, p=0.0038).Statin therapy started at hospital discharge was associated with increased chance of survival in Japanese patients undergoing their first coronary revascularization.

We report a case of sudden leaflet fracture of an Edwards-Duromedics mitral valve 17-years after its implantation. The patient had a history of an asymmetrical motion of the valve, five months earlier. A computed tomography scan showed two fragments that had embolized to the right brachiocephalic artery and left common iliac artery. An emergency mitral replacement surgery was successfully performed. Asymmetrical closure of the valve leaflet may have contributed to valve fracture.

A 46-year-old woman was admitted for surgery after diagnosis of a constrictive pericarditis. She had suffered from acute pericarditis and undergone pericardiocentesis to relieve pericardial effusion several times 10 years previously. Cardiac catheterization showed elevated mean right-atrial and pulmonary wedge pressures. Chest CT revealed only a calcified mass in the retrosternal space. At surgery, there was no severe adhesion between the pericardium and the epicardium, and the pericardium was thin and almost normal except over the right artio-ventricular groove, where a hard mass with an atheromatous content adhered to the epicardium. After resection of the mass, central venous pressure and pulmonary wedge pressure decreased. The mass was found to be an old hematoma by pathological examination. The patient was subsequently discharged from hospital in good condition.

近年, 血中トロンボモジュリンは血管内皮細胞の障害程度を示す新しい分子マーカーとして注目されている. われわれは腹部大動脈瘤手術中の血管内皮障害を調べる目的で血中トロンボモジュリンを測定したので報告する. 対象は腎動脈下の腹部大動脈瘤に待機的手術を施行した9例で, 性別は全例男性, 年齢は46～74歳 (平均64.9歳) であった. 血中トロンボモジュリンの測定は手術前, 大動脈遮断直前, 大動脈遮断解除直後, 大動脈遮断解除1時間後, 3時間後, 18時間後に, 一側の大腿静脈より採血し, EIA法にて行った. トロンボモジュリンは大動脈遮断直前には術前より有意に低下したが, 遮断解除3時間後に増加し, 術前値との有意差は消失し, 以後とくに有意な変化は認められなかった. これらの結果から, 腹部大動脈瘤手術中は血中トロンボモジュリン値が増加するような血管内皮障害は発生していないと考えられた.

Gastrointestinal complications (GICs) such as gastroduodenal ulcer, enterocolitis, and ischemic colitis after coronary artery bypass grafting (CABG) are rare, but are associated with high mortality and morbidity. The present study was performed to detect risk factors and to investigate outcomes following GICs after CABG.Between January 1992 and December 2001, 17 of 549 patients (3.1%) developed GICs after CABG with cardiopulmonary bypass, presenting with gastrointestinal bleeding due to gastroduodenal ulcer, enterocolitis, or ischemic colitis. We conducted a retrospective analysis of these patients.All patients required emergent treatment for hemorrhage by means of blood transfusion and endoscopic ablation and/or clipping. The following possible predictors of GICs were identified by logistic multivariate analysis: age over 70, diabetes mellitus (particularly insulin-dependent diabetes), history of cerebrovascular disease or history of renal failure and postoperative low output syndrome (LOS).Our results suggested that GICs after CABG with cardiopulmonary bypass are rare but can be lethal. Early diagnosis and prompt intervention can be difficult but are potentially life saving for patients in whom GICs develop.

The effect on left ventricular performance of mitral valve replacement (MVR) with preservation of continuity between the mitral annulus and papillary muscle was studied in patients with mitral stenosis (MS).Forty patients with MS who underwent MVR between 1986 and 1995 and had long-term echocardiographic follow up were studied retrospectively. Eighteen patients had conventional MVR (CMVR group), and 22 (PMVR group) had either preservation of autologous chordae tendineae (n = 6) or replacement of the chordae with expanded polytetrafluoroethylene sutures (n = 16).Preoperatively, there were no significant differences between the two groups in age, body surface area, left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), fractional shortening (FS) or ejection fraction (EF). At 3.1-6.5 years after surgery, periodic echocardiography showed significant differences (p0.05) in LVESD (35.8 versus 31.6 mm, respectively, in the CMVR and PMVR groups) and FS (31.8% versus 38.1%). At 6.6-9.7 years postoperatively, no significant differences were observed between the two groups in FS, but LVESD was significantly greater in the CMVR group than in the PMVR group (37.3 versus 31.5 mm).In the long term, MVR with preservation of continuity between the mitral annulus and papillary muscle improves systolic left ventricular performance in patients with MS.

A 2-year-old boy underwent surgical repair of tetralogy of Fallot. Topical cooling of the heart with ice slush was used during the operation. Diaphragmatic paralysis occurred after the operation, inducing severe respiratory distress. To avoid repeated intubation and tracheostomy, the patient was placed on nasal mask bilevel positive airway pressure (BiPAP) ventilation. After ventilatory support with BiPAP for 40 days, the patient recovered spontaneously from the paralysis. No sedation was required during this time. This report illustrates the usefulness of BiPAP for a pediatric patient with diaphragmatic paralysis after cardiac surgery.

To determine the change of serum concentration of vascular endothelial growth factor (VEGF) in patients with cyanotic congenital heart disease (C-CHD).Patients comprised four groups: group A, 19 patients without cyanosis; group B, 24 patients with C-CHD; group C, 17 patients who had C-CHD and underwent biventricular repair; and group D, 15 patients who had single ventricle and underwent a Fontan type operation. Blood samples were obtained from upper arm veins and serum VEGF was determined. We determined correlation between serum VEGF and arterial oxygen saturation and compared levels of serum VEGF among groups. In addition, age and hemodynamic variables derived from cardiac catheterization were analyzed in terms of correlation with serum VEGF.Serum VEGF significantly negatively correlated with arterial oxygen saturation (r = -0.62, p0.0001). Serum VEGF in B and D were significantly higher than those in A and C (median = 443 pg/mL in B and 302 pg/mL in D vs 180 pg/mL in A and 216 pg/mL in C, respectively). Serum VEGF was significantly negatively correlated with patient's age (p = 0.54, p0.04) in D, but significantly positively correlated with systemic venous pressure (p = 0.45, p0.01) in pooled data.Patients with C-CHD have increased serum VEGF in parallel with the degree of cyanosis. With biventricular repair, cyanosis and serum VEGF are normalized. However, with a Fontan type operation, cyanosis disappears but serum VEGF may not be normalized because of elevated venous pressure in association with younger age.

A successfully-treated case of acute type B aortic dissection associated with a mycotic aneurysm is reported. A 69-year-old man had a history of febrile illness and a high CRP level with increased enzyme activity of the hepatobiliary system before the onset. The culture of the abscess in the distal arch aneurysm revealed Bacteroides fragilis. A Dacron graft replacement between the distal arch and the proximal descending aorta was successfully performed with Teflon felt reinforcement, and the graft was covered with omental flap. The patient was discharged without recurrence of infection 2 months after the graft replacement.

For patients with a history of heparin-induced thrombocytopenia (HIT) who undergo cardiac or vascular surgery, the optimal anticoagulation substitute for heparin has yet to be established. Recombinant hirudin has been recommended; however, this agent is unsuitable for patients with renal dysfunction. Argatroban was used in the present patient who had a history of HIT and renal dysfunction and required peripheral vascular surgery. Argatroban was easy to monitor and control, regardless of renal function, and has advantages over other anticoagulants for such patients.

Background Whether preoperative tricuspid regurgitation (TR) will regress or progress late after surgery is unknown. The aim of this study was to evaluate predictors of significant TR late after mitral valve surgery. Methods A retrospective analysis was performed on a total of 174 patients who underwent mitral valve surgery without tricuspid valve surgery. Preoperatively, 46 patients (26%) had 2+ TR, and 128 patients (74%) had 1+ or less TR. Postoperative 3+ TR was considered significant TR. Variables were used to evaluate predictors of TR development by univariate or multivariate analysis. Results The mean follow-up was 8.2 years (range 1.0 to 14.5 years) after surgery. There was progressive TR (3+ or more) in 28 patients (16%) during the follow-up period. In univariate analysis, atrial fibrillation, rheumatic etiology, huge left atrium, left ventricular dysfunction, and preoperative 2+ TR were significant risk factors for TR development. Multivariate analysis identified preoperative 2+ TR, atrial fibrillation, and huge left atrium as statistically significant predictors for late TR after surgery. Conclusions Aggressive repair of accompanying TR should be undertaken at the time of initial surgery in patients with huge left atrium or atrial fibrillation, even if preoperative TR is 2+.

Aortobronchial fistula (ABF) is a rare condition that is almost always fatal in the absence of prompt and proper treatment. However, treatment remains challenging, particularly in the aortic arch. We present six operations for 5 such patients, in which no in-hospital deaths occurred. One patient with mycotic aneurysm died suddenly 10 months postoperatively. Another patient required reoperation 5-months after operation due to additional ABF. No pseudoaneurysms or graft-related complications were observed in the remaining patients. In patients with ABF, performance of operations as soon as possible after onset and minimal dissection of adherent lung tissue appear to improve outcomes.

This study compared the outcomes of combined coronary artery bypass grafting (CABG)/aortic valve replacement (AVR) and CABG alone in patients with moderate aortic stenosis and determined the possible indications for AVR at the time of CABG. Between December 1988 and January 2001, in Tenri Hospital, 41 patients with aortic stenosis underwent CABG: 26 patients underwent the combined procedure and 15 patients underwent CABG alone. The patients who underwent CABG alone were separated them into 2 groups on the basis of the results of annual echocardiography: the rapid progression group, defined by an increase of deltaP by >/=10 mmHg/year, and the slow progression group. Of the 15 patients who underwent CABG alone, the probability of survival at the end of the study in 2001 was 92% at 5 years and 74% at 10 years, and the respective event-free rates were 65% and 50%. Patients less than 70 years old and who were in the rapid progression group had a greater risk for re-operation. The study suggests that patients younger than 70 years old with risk factors for rapid progression should undergo CABG/AVR, and conversely, those older than 70 years old without the risk factors can undergo CABG only.

We report a 26-year-old patient with slowly developing perigraft seroma 15 years after a modified Blalock–Taussig shunt with an expanded polytetrafluorethylene graft. The mediastinal mass was first observed on a chest x-ray film 8 years after the shunt operation. The mass contained massive gelatinous or organic tissues with a severely calcified pseudocapsule, and it was adjacent to the calcified but functioning graft. No fluid collections were noted. The histological findings were compatible with a seroma. No recurrence was noted on last follow-up 1 year postoperatively.

Mitral regurgitation (MR) following endomyocardial biopsy is a rare and severe complication. A 70-year-old man with severe MR due to chordal injury caused by left ventricular endomyocardial biopsy is described. In this patient, a few chordae tendineae of the posterior-median papillary muscle were injured by the biopsy forceps. Due to the chordal rupture, both anterior and posterior leaflets were prolapsed and severe MR developed. MR was successfully treated by artificial chordal replacement using extended polytetrafluoroethylene sutures and ring annuloplasty. This mitral valve repair with artificial chordal replacement was considered suitable to treat MR resulting from iatrogenic chordal injury as the leaflets were not involved in the degenerative process and papillary muscle function was preserved. To avoid MR, the transvenous approach should be used routinely for endomyocardial biopsies; biopsy from the left ventricle is not justified.

Infectious endocarditis following cardiac surgery, particularly that caused by methicillin-resistant Staphylococcus, aureus is a rare and highly lethal complication. We report a case of a 2-year-old girl who developed methicillin-resistant S. aureus endocarditis and mediastinitis following the intracardiac repair of tetralogy of Fallot using Dacron patches. The patient enveloped severe bacteremia accompanied by disseminated intravascular coagulation and progressive enlargement of vegetation. Despite this condition, the patient was successfully treated by repair using double autogenous pericardial patches. Aggressive removal of foreign material and replacement with autogenous tissue resulted in a favorable outcome.

Objective: We reviewed the surgical management of acute type A aortic dissection between 1989 and 1998.Methods: Subjects were 28 consecutive patients (mean age: 61.8±10.7 years) with acute type A aortic dissection were studied. The mean duration between aortic dissection onset and surgery was 17.5±17.0 hours. In surgery, aortic pathology and flow patterns in dissected aortic channels were evaluated using transesophageal and epiaortic echo. Simple, safe combination of profound hypothermic circulatory arrest with retrograde cerebral perfusion and open aortic anastomosis was used for brain protection. Hypothermic circulatory arrest was 46.9±24.8 minutes. Aortic repair consisted in ascending aortic replacement in 5 patients, with hemiarch repair in 17, and total arch repair in 6. Intimal tears were resected in all but 2 patients. Concomitantly resuspension of the aortic valve was done in 9 and aortic root replacement in 2.Results: No operative (30-day) deaths occurred, although 2 died from unrelated hepatic failure during hospitalization or late-stage pancreatic cancer in the late stage. In cerebral sequellae, 1 patient suffered a stroke and 2 patients developed temporary neurologic dysfunction.Conclusion: Our experience demonstrated that the simplified conjunction of hypothermic circulatory arrest with retrograde cerebral perfusion and open aortic anastomosis, associated with real-time assessment by transesophageal and epiaortic echo, is safe and useful during emergency aortic repair for acute type A aortic dissection.

Background: Partial plication annuloplasty is the main technique for congenital mitral insufficiency because this technique allows the mitral anulus to grow, in contrast to ring annuloplasty. However, this technique is not satisfactory for mitral insufficiency with some anomalies of the mitral valve apparatus. Methods: Forty-one patients underwent partial plication annuloplasty for mitral regurgitation from July 1979 to December 1998. Mitral regurgitation associated with an atrioventricular defect, an atrioventricular discordance, and a univentricular heart was excluded from this study. Results: There were no early or late deaths. In early results, partial plication annuloplasty was more effective for mitral regurgitation with abnormality of the posterior leaflet (n = 14) or normal leaflet motion (n = 8) than with abnormality of the anterior leaflet and its apparatus (n = 14) or absence of chordae (n = 4). The mean follow-up period was 145.8 months. During the follow-up period, 2 patients underwent mitral valve replacement, and a third patient underwent mitral valve repair with partial plication annuloplasty after the first repair. The main cause of mitral regurgitation of 2 of the 3 patients was absence of chordae. The actuarial freedom from reoperation rate was 94.9% ± 3.6%, 91.9% ± 4.7%, and 91.9% ± 4.7% at 5, 10, and 15 years after the operation, respectively. Conclusion: Early and long-term results of partial plication annuloplasty were acceptable for congenital mitral insufficiency with any type of malformation of the mitral valve, and results were excellent with abnormality of the posterior leaflet and its apparatus or normal leaflet motion. However, late results were suboptimal for mitral regurgitation with absence of chordae. Other techniques, such as artificial chorda replacement, should be adapted in these cases. J Thorac Cardiovasc Surg 2001;122:229-33

Constrictive pericarditis (CP) is an unusual sequela of cardiac surgery, so the present study evaluated the clinical characteristics of patients with CP after coronary artery bypass grafting (CABG). Four hundred and sixty-three patients who underwent isolated CABG between January 1989 and March 1999 were examined retrospectively. The first choice of treatment for postoperative pericardial effusion was non-steroid anti-inflammatory agents, and an increased dose of diuretics. The second treatment choice was corticosteroids or pericardial drainage. When CP was suspected during the follow-up period (mean, 54+/-31 months), cardiac catheterization was carried out to establish the diagnosis. Of the 463 patients undergoing CABG, there were 11 (2.4%) who developed CP after surgery. The median time to the onset of symptoms after CABG was 4 weeks (range, 3-96 weeks). On univariate and multivariate analysis, normal left ventricular ejection fraction, warfarin administration, and early postoperative pericardial effusion were significantly associated with a greater potential of postoperative CP. The effusion was bloody in all cases of pericardial drainage despite warfarin therapy. Not draining the postoperative effusive pericardial effusion was a risk factor for the development of CP. Pericardial drainage for patients with significant effusion after CABG is important for the prevention of subsequent CP, especially in those patients being treated with warfarin or with normal left ventricular function.

Background Docarpamine (DOC) is a dopamine prodrug which can be orally administered. It has been found that oral docarpamine transforms into dopamine in vivo, and increases cardiac output and renal blood flow as effectively as intravenous dopamine. Methods We reviewed the records of 26 patients who had developed low cardiac output syndrome (LOS) after cardiac surgery and received docarpamine during the early postoperative course. Five patients discontinued docarpamine within 2 days due to arrhythmia. There were 3 hospital deaths. The remaining 18 patients were divided into two groups according to the timing of docarpamine administration. In group A docarpamine was administered during and after weaning from intravenous catecholamines, in group B only on demand after weaning from intravenous catecholamines. Results There were 12 patients in group A and 6 in group B, and the severity of LOS was relatively milder in group B than in group A. Stable hemodynamics and sufficient daily urinary output were maintained by oral administration of DOC in both groups just as well as by drip infusion of catecholamines. Conclusion Sinse continuous drip infusion of catecholamine commonly slows recovery in LOS patients, it is considered that switching from drip infusion of catecholamines to oral DOC administration is safe and useful for earlier recovery in LOS patients after cardiac surgery.

A 65-year-old woman with aortic stenosis, ischemic heart disease, and Graves' disease had complained of effort angina. She then suffered from liver dysfunction due to treatment with antithyroid drugs. One year after the start of radioiodine administration, she demonstrated unstable angina with palpitation and sweating. Laboratory studies revealed a recurrent hyperthyroid state, and a second coronary angiogram revealed progressive ischemic heart disease. Combined coronary artery bypass grafting, aortic valve replacement, and total thyroidectomy were performed. The postoperative course was uneventful without any problems associated with hyperthyroidism or hypothyroidism. Combined cardiac surgery and total thyroidectomy can be performed safely if the perioperative levels of thyroid hormone are maintained at euthyroid or hypothyroid levels. (Jpn Circ J 1999; 63: 1004 - 1006)

SUMMARY 1. To clarify the mechanism of the association between I/D polymorphism of the angiotensin-converting enzyme (ACE) gene and various cardiovascular diseases, ACE mRNA levels in human atrial appendages were assessed in relation to the genotype of the ACE gene. 2. Angiotensin-converting enzyme mRNA levels were positively correlated with age and tended to show a positive correlation with mean pulmonary pressure (niPA). Multiple regression analysis indicated that age and mPA, but not the genotype of the ACE gene, were predictors of ACE mRNA levels in human atrial appendages. 3. The present study indicates that I/D polymorphism of the ACE gene is not simply reflected in ACE mRNA levels and that further study is needed to determine the mechanism of the association between this polymorphism and various cardiovascular diseases.

A small (13.1 ± 1.3 cm) anterior midline incision is described for graft replacement of infrarenal abdominal aortic aneurysms. Stoney vasculature retractors were employed to achieve sufficient exposure. The operative outcome was satisfactory in 33 elective cases.

A novel technique for simultaneous tricuspid valve replacement and endocardial pacing is described. The technique was applied in a 67-year-old man who had previously undergone coronary artery bypass grafting and subsequent pericardiotomy via a left thoracotomy. He developed congestive heart failure due to tricuspid valve regurgitation as well as impaired left ventricular function with bradycardia. Endocardial pacing was successfully performed in conjunction with tricuspid valve replacement using a bioprosthesis via a right anterolateral thoracotomy.