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We recently reported that sub-acute myocarditis occurred following the initial two doses of mRNA-based vaccination against COVID-19 (0.3 mL Comirnaty®) in elderly Japanese patients with cardiac dysfunction. The present retrospective study of 76 patients shows that myocarditis following the initial doses persisted for 12 months, was associated with low levels of neutralizing antibodies, and was ameliorated by reducing the third vaccine dose. Low neutralizing antibody levels (P = 0.02, n = 25), no deaths occurred due to heart failure, and neutralizing antibody levels increased 41-fold (P < 0.001) compared with the initial doses. Reduced booster doses could facilitate the worldwide distribution of mRNA vaccines.

The present observational study assessed the occurrence of adverse cardiac events following vaccination of patients (n = 100) with an mRNA-based vaccine against coronavirus disease 2019 (COVID-19). Death and deterioration of heart failure were evaluated as side effects. The status of heart failure was assessed using the brain natriuretic peptide (BNP) ratio, for which the BNP or NT-pro BNP values were divided by their upper normal limits (UNL); values (i.e., post-BNP levels minus pre-BNP levels) ≥ 10-fold higher than the UNL denoted significant increment. Here we show that vaccination with an mRNA-based vaccine against COVID-19 was associated with a high risk of death or decompensated heart failure for elderly patients with a BNP ratio ≥ 4-fold higher than the UNL. Six and 15 patients expired and exhibited significant increment of the BNP ratio, respectively; these patients had a pre-BNP ratio ≥ 4-fold higher than the UNL. Forty-five patients with a pre-BNP ratio

We recently reported that sub-acute myocarditis occurred following the initial two doses of messenger RNA-based vaccination against coronavirus disease 2019 (0.3 mL Comirnaty®) in elderly Japanese patients with cardiac dysfunction. The present retrospective study of 76 patients revealed that myocarditis following the initial doses persisted for 12 months, was associated with low levels of neutralizing antibodies, and was ameliorated by reducing the third vaccine dose. Low neutralizing antibody levels (

A 65-year-old man was admitted to our hospital with acute type B aortic dissection that extended into both common iliac arteries with an occluded right common iliac artery and large bullae in bilateral upper lung fields. Femoro-femoral arterial bypass surgery with an artificial blood vessel was performed. Two days postoperatively, acute type B aortic dissection progressed to acute type A aortic dissection. Emergency total arch graft replacement (TAR) was performed through a median sternotomy on the same day. Immediately following TAR, the patient experienced hypoxemia. Acute respiratory distress syndrome (ARDS) was diagnosed following TAR for acute aortic dissection with pneumonia. Nitric oxide inhalation (NOI) therapy was commenced at 20 ppm from the fourth day post-surgery. However, 6 d following TAR, he developed bilateral pneumothorax due to ruptured bullae requiring chest tube management and thoracoscopic left upper lobe bullectomy. Eight days following TAR, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was initiated and NOI therapy was completed. V-V ECMO was withdrawn 18 d after TAR. Postoperatively, after 2 years 3 months, the patient remains ambulatory without assistance, walking to the outpatient clinic.

Objectives To evaluate the feasibility and efficacy of transcatheter aortic valve replacement (TAVR) in patients with small sinus of Valsalva (SOV). Background Patients with small SOV are considered unfavorable for TAVR since it carries risk of coronary obstruction after valve implantation. Therefore, these patients with small SOV were excluded from previous clinical trials. Methods Between February 2017 and February 2019, a total of 139 consecutive patients with severe aortic stenosis (AS) undergoing TAVR were prospectively enrolled in the Tokai Valve Registry. Patients with small SOV who were treated with smaller size of self-expandable transcatheter heart valve (THV) than expected by perimeter-based sizing were included in this study. Eleven patients (7.9%) were included. Results Mean age was 86.5 ± 3.8 years and median STS Score was 8.5% (interquartile range: 6.3-12.3%). Device success was accomplished in all patients and no coronary obstruction was observed. No moderate/severe paravalvular leakage, new onset conduction disturbance, and new permanent pacemaker implantation were noted. At 30-day follow-up, mean aortic valve gradient was 6.9 ± 1.7 mmHg and mean indexed aortic valve area was 0.95 ± 0.16 cm2 /m2 . Prosthetic valve performance was stable at 12-month follow-up. No severe prosthesis patient mismatch was documented at any time point. No in-hospital, 30-day, and 12-month mortality were observed. The median follow-up was 711 days (IQR: 547-803 days), and no patient was lost to follow-up. Conclusions Our preliminary experience suggests favorable safety and efficacy of TAVR utilizing self-expandable THV with intentional down-sizing in patients with severe AS and small SOV in a mid-term follow-up.

A rare case of adult PHACE syndrome with a distal aortic arch aneurysm was treated surgically. The patient had several anomalies including uneven cerebral blood flow, a small left common carotid artery and a narrowed transverse aorta. Under deep hypothermic circulatory arrest, aortic replacement with reconstruction of the left subclavian artery was performed uneventfully. Cystic degeneration of the tunica media was observed in the aneurysm wall.

There is uncertainty over the efficacy of additional surgical ventricular reconstruction (SVR) associated with mitral valve operation for non-ischaemic dilated cardiomyopathy (DCM). This study aims to assess mid-term outcomes of these non-heart transplant surgical approaches for DCM. We reviewed retrospectively 106 patients (median age 64, 44 females) who underwent isolated mitral annular plasty (MAP; n = 34), mitral valve replacement (MVR; n = 29), and SVR associated with MAP (SVR + MAP; n = 43) for DCM, in 11 Japanese hospitals. We analysed mid-term outcomes, specifically freedom from cardiac death and cardiac event. Hospital deaths occurred in 16 patients (15.1%) and cardiac deaths in 36 patients (34.0%) during the study period of 4.4 ± 3.5 years. Freedom from cardiac death at 7 years in patients undergoing MAP, MVR, and SVR + MAP were, respectively, 79.1%, 82.6%, and 29.5% (P

The purpose of this study was to assess the efficacy of echocardiography-guided ascending aortic central cannulation using the Seldinger technique during surgery for type A acute aortic dissection complicated by stroke due to cerebral malperfusion.Between April 2007 and December 2017, 208 patients with type A acute aortic dissection underwent echocardiography-guided ascending aortic central cannulation using the Seldinger technique. We analyzed 16 of these patients (7.7%; median age, 63 years; 8 men) with stroke due to cerebral malperfusion, including 10 in a comatose state (Glasgow Coma Scale ≤8) and 6 with hemiplegia (manual muscle test ≤1) on hospital arrival. The Modified Rankin Scale was used to evaluate activities of daily living.The median time from onset of symptoms to establishment of cardiopulmonary bypass was 327 (176-561) minutes. The median time from the start of surgery to establishment of cardiopulmonary bypass was 34 (30-44) minutes. The mortality rate was 6.3% (1/16). In patients with preoperative coma, the Glasgow Coma Scale improved significantly after surgery from 4.5 to 15 at 30 days (P .001). In patients with preoperative hemiplegia, 4 showed improved motor function on the manual muscle test score at 90 days. In all patients, Modified Rankin Scale scores improved significantly from 5.0 preoperatively to 1.0 after follow-up (P .001).Echocardiography-guided ascending aortic central cannulation using the Seldinger technique has potential as a rapid and reliable perfusion route during surgery for type A acute aortic dissection complicated by stroke due to cerebral malperfusion.

Background: We retrospectively analyzed the long-term outcomes and risk predictors of conventional coronary artery bypass grafting routinely employed for patients with left main disease. Methods: From January 2000 through December 2009, conventional coronary artery bypass grafting was routinely employed in 193 consecutive patients with left main disease. Long-term analyses were performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events which included all-cause death, stroke, myocardial infarction, and repeat revascularization. We also analyzed the effects of variables on major adverse cardiac and cerebrovascular events at 9 years after the operation. Results: The overall 9-year rates of combined outcomes (death, stroke, myocardial infarction), repeat revascularization, and major adverse cardiac and cerebrovascular events were 20.2%, 8.9%, 27.7%, respectively. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes at 9 years (hazard ratio 1.04, p = 0.033), repeat revascularization at 9 years (hazard ratio 1.11, p = 0.0030), and major adverse cardiac and cerebrovascular events at 9 years (hazard ratio 1.07, p = 0.0003). Conclusions: With our routine strategy of conventional coronary artery bypass for left main disease, patients revealed excellent long-term outcomes in terms of major adverse cardiac and cerebrovascular events. These results provide a suitable benchmark against which long-term outcomes of percutaneous coronary intervention for left main disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after coronary artery bypass for left main disease.

The aim of this study was to assess long-term outcomes of non-heart transplant surgical approaches to advanced ischaemic cardiomyopathy (ICM), including left ventricular restoration (LVR) and mitral valve operation.Since September 2002, 102 consecutive patients (mean age 65, 18 females) with advanced ICM [ejection fraction (EF)40%, left ventricular end-systolic volume index (LVESVI)60 ml/m(2)] were treated using non-heart transplant procedures. A total of 84 patients with asynergy of large scar exceeding 35% of left ventricular (LV) perimeter underwent LVR, and 30 patients with greater than or equal to moderate mitral regurgitation (MR) underwent mitral valve operation such as annuloplasty (n = 23) and valve replacement (n = 7). Patients were divided into four groups according to their interagency registry for mechanically assisted circulatory support (INTERMACS) profiles: Profile 1-2 (the highest levels of clinical compromise; n = 9), Profile 3-4 (n = 40), Profile 5-6 (n = 32) and Profile ≥ 7 (n = 21). We compared the four groups, looking at survival, major adverse cardiac and cerebrovascular event (MACCE), New York Heart Association (NYHA) status, LV volume and function.The overall 8-year survival including 3 hospital deaths (2.9%) was 64.3% without sudden death due to arrhythmia. Ninety-nine survivors showed significant improvement in the mean NYHA status, from 2.9 to 1.4, and the mean EF (33.2-41.7%) (P0.0001). The mean LVESVI was significantly reduced from 104.1 to 61.4 ml/m(2) (41% volume reduction) (P0.0001). Seven-year survival in patients with Profiles 1-2, 3-4, 5-6 and ≥ 7 were 50.0, 57.2, 60.3 and 95.2%, respectively (P = 0.13). Freedom from MACCE at 5 years in patients with Profiles 1-2, 3-4, 5-6 and ≥ 7 were 29.6, 47.0, 67.2 and 95.2%, respectively (P = 0.0067). The improvements in NYHA status were significantly greater in patients with higher levels of clinical compromise (P0.0001), although, there was no significant difference in LV volume reduction and functional improvement among the four groups. Patients with Profile ≥ 7 had significantly better survival at 7 years (hazard ratio (HR): 0.11, P = 0.046) and freedom from MACCE at 5 years (HR: 0.053, P = 0.0066) compared with patients with Profiles 1-2.Our non-heart transplant surgical approaches using LVR and mitral valve operation for advanced ICM yielded excellent long-term outcomes in terms of survival and NYHA status, even in patients who are potential candidates for heart transplantation or LV assist devices; and are encouraging in a very particular situation where heart transplantation is limited due to organ storage.

OBJECTIVES: We retrospectively analysed long-term outcomes after conventional coronary artery bypass grafting (CABG) between patients having left main (LM) disease who should have been assigned class II and those assigned class III recommendation for percutaneous coron- ary intervention (PCI) according to the 2010 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines. METHODS: From January 2000 to December 2009, conventional CABG was routinely employed in 180 consecutive patients with previous- ly untreated and stable LM lesion. A comparison between two groups (CABG for PCI class II and CABG for PCI class III) was performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, stroke (cerebral vascular accident (CVA)), myocardial infarction (MI) and repeat revascularization. We also analysed the effects of variables on MACCE at 8 years after the operation. RESULTS: The overall 8-year MACCE rates were significantly lower in the CABG for PCI class II group than in the CABG for PCI class III group (9.7% class II vs 31.1% class III; P= 0.0005). This was largely because of an increased rate of repeat revascularization (1.2% class II vs 13.8% class III; P = 0.0029). The cumulative rate of the combined outcomes of all death/CVA/MI was significantly lower in the CABG for PCI class II group (8.5% class II vs 19.2% class III; P= 0.048); there was no observed difference between the groups for all-cause death, CVA and MI. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes (Death/CVA/MI) at 8 years (odds ratio (OR) 1.05, P= 0.023), repeat revascularization at 8 years (OR 1.11, P= 0.0013) and MACCE at 8 years (OR 1.07, P< 0.0001). CONCLUSIONS: In our routine strategy of conventional CABG for LM disease, patients believed to be PCI candidates for LM disease have significantly better long-term outcomes as characterized by combined outcomes (Death/CVA/MI), repeat revascularization and MACCE. These results provide a suitable benchmark against which long-term outcomes of PCI for LM disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after CABG for LM disease.

Background A bypass between the left common carotid artery and the left subclavian artery has been made in some patients undergoing thoracic endovascular aortic repair that covers the orifice of the left subclavian artery. However, complications associated with temporary occlusion of the left common carotid artery are reportedly not uncommon. Methods Between January 2009 and September 2011, left external carotid-to-left subclavian artery bypass was made using a polytetrafluoroethylene graft in 15 patients undergoing a thoracic endovascular aortic repair that covered the orifice of the left subclavian artery. Adverse effects associated with the procedure were assessed, and patency of the bypass graft was determined by contrast-enhanced computed tomography before discharge and at least once during follow-up. Results All patients were discharged without any brain complications. All 15 bypass grafts were patent prior to discharge and during the follow-up period. One patient suffered temporary left recurrent laryngeal nerve palsy postoperatively. No other sequelae were associated with left external carotid-to-left subclavian artery bypass. Conclusion Left external carotid-to-left subclavian artery bypass is a promising procedure in patients undergoing thoracic endovascular aortic repair that covers the orifice of the left subclavian artery.

Objective The present study elucidates the relationship between the locations of rib defects and loss of respiratory function. Methods Ten sets of three-dimensional finite element models were produced from computed tomography data of 10 persons and categorized as normal type models. These models were modified by removing part of the ribs, and the resultant models were categorized as defect type models. Varying the location of the defects, six types of defect model were produced from each of the 10 normal models; the defects were made on the anterior-superior, anterior-inferior, lateral-superior, lateral-inferior, posterior-superior, and posterior-inferior regions of the thorax. To simulate respiration, contracture forces were applied to nonlinear springs modeling respiratory muscles for each of the normal and defect models. Difference in volume of the thoracic cavity between inspiration and expiration phases was viewed as the indicator of respiratory function and was defined as Δ V . The values of Δ V were compared between normal type models and their corresponding defect type models. Results Among the six types of defect, the degree of functional loss was greatest with those defects on the lateral-inferior part of the thorax, where Δ V of the affected side hemithorax drops to 38 to 45% of normal values, whereas Δ V was 62 to 88% with other defect models. Conclusion Thoraces that have defects on their lateral-inferior regions present lower respiratory functioning than thoraces with other defect locations. Hence, in treating clinical cases where defects are expected to occur in this region, effort should be made to minimize the area of the defect.

OBJECTIVES We analysed retrospectively the long-term outcomes of conventional coronary artery bypass grafting (CABG) as employed routinely for complex coronary lesions by observing patients with low (0-22), intermediate (23-32) and high (≥33) SYNTAX scores. The purpose of this study was to evaluate the correlation between the SYNTAX score and long-term major adverse cardiac and cerebrovascular events (MACCEs) including all-cause death, stroke, myocardial infarction (MI) and repeat revascularization after CABG. METHODS The study enrolled 396 consecutive patients with stable and untreated left main and/or three-vessel disease, who had been referred to our heart team from 2000 through 2009. They all routinely underwent conventional CABG. The three groups (low score; n = 159, intermediate score; n = 150, high score; n = 87) were compared, looking at the primary endpoint of MACCE and its components. We also analysed the effects of diverse variables on long-term MACCEs after the operation. RESULTS The cumulative 10-year MACCE rates in patients with low, intermediate and high SYNTAX score were 25.3, 35.8 and 48.1%, respectively. The Kaplan-Meier cumulative event curves showed a significantly higher MACCE rate after CABG in patients with a higher SYNTAX score than in those with a lower score (log-rank P = 0.0012). This was mainly because of a significantly increased rate of repeat revascularization in the higher SYNTAX score group (log-rank P = 0.0032). The cumulative rate of repeat revascularization at 10 years in patients having low, intermediate and high SYNTAX score were, respectively, 4.6, 15.7 and 16.8%. The cumulative rates of the combined outcomes of death/stroke/MI at 10 years did not show statistical differences between the three groups (22.3% with low, 25.0% with intermediate and 38.4% with high score, log-rank P = 0.063). In the multivariable analysis, the SYNTAX score [hazard ratio (HR) 1.03, P = 0.0043] and logistic EuroSCORE II (HR 1.34, P = 0.0012) were found to be significant predictors of long-term MACCEs. CONCLUSIONS The SYNTAX score is correlated with long-term outcomes, in terms of MACCEs, after conventional CABG for complex coronary lesions and is prognostic of long-term outcomes of CABG for patients with complex lesions.

Objectives We retrospectively analysed the long-term results and mid-term features of the surgical procedures on left ventricular (LV) volume, geometry, function and mitral regurgitation (MR) in patients with ischaemic cardiomyopathy (antero-septal dominant) who underwent LV reconstruction (LVR). Methods The LVR was mainly accomplished by the Dor procedure, modified by the Fontan stitch maintained by the base of the LV septum prior to the flattened-out elliptical patch closure. Other techniques such as the linear closure or septal anterior ventricular exclusion (SAVE) were used when indicated. Sixty patients were divided into three groups, undergoing LVR with the Dor procedure (n = 40), linear closure (n = 12) or SAVE (n = 8). The LV function, volume and sphericity (eccentricity index) were logged before the operation and 1 year after. Results Survivors (79% at 7 years) showed a significant improvement in the LV ejection fraction from 35.1 ± 8.1 to 43.5 ± 11.5% and NYHA status from 2.9 ± 0.7 to 1.3 ± 0.6. The LV end-systolic volume index was significantly reduced from 110.3 ± 35.9 to 57.8 ± 20.7 ml/m(2) in the Dor, from 71.9 ± 10.3 to 52.9 ± 19.4 ml/m(2) in the linear closure and from 93.1 ± 14.5 to 47.9 ± 15.7 ml/m(2) in the SAVE group. The postoperative changes in the Dor group are characterized by the reduction in the significantly larger LV volume and a more spherical chamber (systolic eccentricity index from 0.82 ± 0.10 to 0.80 ± 0.09), although not significantly so compared with other techniques. The MR grade measured on echocardiography was reduced (from 1.9 ± 0.8 to 1.7 ± 0.8), with postoperative moderate MR in four Dor patients. Conclusions Despite the more spherical LV change, LVR led to a significant volume reduction (45%), still maintaining its physiological shape that confirmed an improved LV function and better long-term results. The Dor procedure could significantly reduce the larger LV volume without losing the end-systolic elliptical shape and mitral valvular competence like other techniques without the Fontan stitch.

Objectives: The postoperative left ventricular end-systolic volume index and ejection fraction are benchmarks of surgical ventricular reconstruction but remain unpredictable. This study aimed to identify who could be associated with a higher long-term survival by adding surgical ventricular reconstruction to coronary artery bypass grafting than coronary artery bypass grafting alone (responders to surgical ventricular reconstruction). Methods: The subjects were 293 patients (median age, 63 years; 255 men) who underwent coronary artery bypass grafting for ischemic heart disease with left ventricular dysfunction in 16 cardiovascular centers in Japan. The relationships among surgical ventricular reconstruction, postoperative end-systolic volume index, ejection fraction, and survival were analyzed to identify responders to surgical ventricular reconstruction. Results: Surgical ventricular reconstruction was performed in 165 patients (56%). The end-systolic volume index and ejection fraction significantly improved (end-systolic volume index, 91 to 64 mL/m2; ejection fraction, 28% to 35%) for all patients. The postoperative end-systolic volume index and ejection fraction were estimated, and surgical ventricular reconstruction was found to be significantly associated with both end-systolic volume index (14.5 mL/m2 reduction, P < .001) and ejection fraction (3.1% increase, P = .003). During the median follow-up of 6.8 years, 69 patients (24%) died. Only the postoperative ejection fraction was significantly associated with survival (hazard ratio, 0.925; 95% confidence interval, 0.885-0.968), although this effect was limited to those with postoperative end-systolic volume index of 40 to 80 mL/m2 in the subgroup analysis (hazard ratio, 0.932; 95% confidence interval, 0.894-0.973). Conclusions: Adding surgical ventricular reconstruction to coronary artery bypass grafting could reduce the mortality risk by increasing ejection fraction for those with a postoperative end-systolic volume index within a specific range. The postoperative end-systolic volume index could demarcate responders to surgical ventricular reconstruction, and its estimation can help in surgical decision making.

Background: We have studied the acute and long-term efficacy of overlapping biphasic impulse (OLBI) stimulation for atrial pacing with VDD pacemakers and demonstrated the feasibility of DDD pacing in OLBI with diagonally arranged half-ring (Half-Ring) electrodes. We made two three-dimensional computational analysis models to verify our clinical studies. Methods and Results: Model I was composed of a heart, a pacemaker, and a human body. Model II was a cube with dimensions of 20 by 20 by 20 mm quarried from Model I for the detailed study of current density distributions. Laplace's equation was solved using the finite element method and the current density J was calculated. For Model I, the distal and proximal voltages were −10 V, 0 V in bipolar and −5 V, +5 V in OLBI, using Ring electrodes. In Model II, the actual measurements of electrode impedances obtained from the clinical study (1,180 Ω for Ring and 630 Ω for Half-Ring) were added to the analysis conditions. Model I showed that OLBI produced more concentrated current density distributions than those by bipolar. According to Model II, at the atrial myocardium position current density produced by Half-Ring was larger than that by Ring electrodes, 70 μA/mm2 versus 30 μA/mm2 in OLBI configuration. It also indicated that even if electrode impedances were equal between Half-Ring and Ring electrodes, the maximum current density produced by Half-Ring would be greater than that by Ring electrodes. Conclusions: It was considered that OLBI configuration with Half-Ring electrodes provides more effective current density distributions. (PACE 2010; 33:1063–1073)

The recent clinical application of c-kit-positive resident cardiac stem cells (CSCs) for severe heart failure patients revealed their remarkable and long lasting beneficial effects. Ultimately aiming at a combined therapy of left ventriculoplasty and autologous CSC transplantation, we have successfully isolated and cultivated endogenous stem cells from the right atrium and the infarcted left ventricle, respectively, of all subjects in the target population. Three independent parameters, population doubling time, BrdU incorporation, and colony forming ability, each of which indicates the growth property of cultured CSCs, correlated well in every sample. Overall, CSCs derived from both origins possessed a great proliferative potential with a non-significant superiority in the right atrial CSCs. This brief report provides a fundamental basis for regenerative therapy as a potential novel management of ischemic cardiomyopathy, following the ventriculoplasty.

縦隔内循環器官への浸潤,転移により循環障害をきたした心臓関連悪性疾患に対し,根治的あるいは循環動態改善のための姑息的外科治療が妥当かどうか検討した.2001年1月から2004年2月まで当科で手術を施行した症例は6例(男性4,女性2),年齢は17～72歳であった.疾患ならびに施行手術は,左房粘液肉腫に対し腫瘍摘出術,浸潤型胸腺腫による収縮性心膜炎に対し心膜剥離術,腎細胞癌に対し右房腫瘍塞栓摘出を伴う外科的根治術,癌性心膜炎による心タンポナーデではそれぞれ悪性リンパ腫に対し腫瘍切除,心膜開窓術,肺癌に対し心膜開窓術,腎細胞癌腎摘後遠隔期右室内再発に対し腫瘍切除,右室流出路再建術を施行した.術後観察期間は4日から30ヵ月であった.手術関連死亡は6例中1例(浸潤型胸腺腫)で,術後4日目に心不全で失った.耐術例は5例でいずれも手術後に明らかなQOLの改善が認められた.悪性リンパ腫の1例は術後化学療法中に敗血症により死亡したが,ほか4例は退院可能となり社会復帰した.3例が経過観察中に悪性疾患関連死亡となった(左房粘液肉腫:20ヵ月再々発,腎細胞癌:13ヵ月肺,肝転移,肺癌:8ヵ月癌性悪液質).循環障害をきたすような心臓関連悪性疾患症例の生命予後は不良であるが,これらに対する外科治療は患者のQOLの改善さらには延命効果が得られる点から妥当であり,同時に確定診断を確実に行い悪性疾患に対する集学的治療を行う意味で有用であると考えられた.

ObjectiveParaplegia remains a serious complication of thoracic and thoracoabdominal aortic operations. To avoid this dreadful complication, N-methyl-d-aspartate (NMDA) receptor antagonists have been examined in the ischemic or excitotoxic neuronal injury model. In the present study, we evaluated the protective efficacy of NMDA receptor antagonists that were infused segmentally after aortic clamping, as a spinoplegia, to reduce aspartate neurotoxicity in the spinal cord.MethodsInfrarenal aortic isolation was performed in New Zealand white rabbits. Group A animals (n = 7) were pretreated with the segmental infusion of MK-801, a noncompetitive NMDA receptor antagonist, followed by segmental aspartate (50 mmol) infusion for 10 minutes. Group B animals (n = 6) received pretreatment with CGS19755, a competitive NMDA receptor antagonist, followed by the same aspartate infusion as group A. Group C animals (n = 7) received vehicle only, followed by aspartate infusion as a control group. In addition, group D animals (n = 6) were pretreated with MK-801 that was administrated intravenously 1 hour before aspartate infusion. Neurologic status was assessed at 12, 24, and 48 hours after operation by using the Tarlov score. The spinal cords were procured at 48 hours for histopathologic analysis to determine the extent of excitotoxic neuronal injury.ResultsMost of the animals in groups A and D revealed full recovery or mild motor disturbance. Group B and C animals exhibited paraplegia or paraparesis with marked neuronal necrosis. In the Tarlov score at 48 hours, group A animals represented better neurologic function than group C (P < .01) and similar motor function to group D animals. Severe histopathologic change was not observed in groups A and D. Animals in groups A and D showed a greater number of motor neurons than animals in groups B and C (P < .01). The difference could be due to chance between group A and D animals (P = .08).ConclusionsThese results showed that the segmental infusion of noncompetitive NMDA receptor antagonist as an intraoperative spinoplegia could have a protective effect on the spinal cord neurons against excitotoxic neuronal injury in vivo. On the other hand, efficacy of the use of competitive antagonist was suggested to be limited in this model, probably because of the insurmountable obstacle of the blood-brain barrier.Clinical RelevanceParaplegia is a devastating complication during surgical repair of the thoracic and thoracoabdominal aortas. Excitatory amino acids neurotoxicity through the N-methyl-d-aspartate (NMDA) receptor is no doubt the pathologic hallmark of ischemic and postischemic spinal cord injury. Systemic administration of either a competitive or noncompetitive NMDA antagonist has been reported to have neuroprotective effect, in terms of preoperative treatment, with dose-related central sympathomimetic and sedative effects. Local administration, particularly of a noncompetitive NMDA antagonist, infused segmentally after aortic clamping could therefore be a potent intraoperative pharmacologic strategy to minimize the effective dose that retains NMDA antagonism without undesirable adverse effects. Our ability to reproduce this model could facilitate pharmacologic prevention or provide a new surgical technique as a spinoplegia for NMDA receptor-mediated neuronal injury.

We present a rare case of dissection of the sinus of Valsalva associated with an aortic annular abscess that perforated into the left atrium. A 61-year-old patient with infective endocarditis underwent emergent operation due to progressive heart failure, in whom echocardiography showed the dissection of sinus of Valsalva with aorto-left atrial communication. Procedure included autologous pericardial patch repair of the dissecting sinus of Valsalva and bioprosthetic valve replacement with a successful outcome. Microscopic examination showed excessive neutrophil infiltration in the aortic valve and annulus without involvement of the sinus of Valsalva.

Esophageal perforations of thoracic aortic aneurysms are most likely to be fatal. Patients with aortoesophageal fistula require urgent operation on both the esophageal perforation site and the aortic lesion to avoid terminal exsanguination and uncontrollable mediastinitis. We present a case of 71-year-old woman suffering esophageal perforation of aortic arch aneurysm with sentinel arterial hemorrhage, who has not developed patent aortoesophageal fistula. Computed tomography verified rupture of aortic arch aneurysm that had eroded the esophagus. She underwent successful graft replacement and remains well without signs of mediastinitis over one year after the event. It is possible, in selected cases of esophageal perforation of thoracic aortic aneurysm, to manage the esophageal lesion without any surgical intervention, such as primary closure, omental coverage and surgical discontinuity to achieve esophageal healing free of infection.

症例は60歳,女性.うっ血性心不全のため入院し体部CTと経胸壁心エコーにて左房腫瘍を疑われ,経食道心エコーにて左房腫瘍と左房内壁への腫瘍浸潤を診断された.肺水腫となり緊急手術にて心房中隔に付着した3.5×4.0×2.0cmの球状の腫瘍を摘出し,病理組織診断では粘液腫様の所見とring structureの形成のほかに細胞の密な部分も認めた.CA125値が術前167.7U/単位と高値を示したが術後80日で正常化した.術後14ヵ月の経胸壁心エコーにて腫瘍の再発を認め,経食道心エコーにより左房腫瘍と左房内壁に左心耳まで及ぶ腫瘍の浸潤像を認めた.再手術では左房腫瘍の再発と左心耳・右肺静脈まで及ぶ腫瘍浸潤を認め浸潤部位を含めた腫瘍摘出術を行った.病理組織所見では粘液腫様部分,ring structure形成部分に加え核分裂像と壊死巣を認め粘液肉腫と診断された.腫瘍の再発のため初回手術後20ヵ月に死亡した.きわめて希な左房粘液肉腫の症例を経験した.腫瘍の左房内壁への浸潤の診断には経食道心エコーが必須でCA125の有用性も示唆された.手術的切除を行ったが予後不良であった.

Objective: Much evidence has been gathered to show that neurotoxicity of excitatory amino acids is mainly activated through an N-methyl-d-aspartate (NMDA) receptor cascade. We evaluated the protective effects of NMDA receptor antagonists, MK-801 and CGS19755 on spinal cord neurons using the NMDA receptor mediated neurotoxicity model in vivo. Methods: New Zealand white rabbits underwent an infrarenal aortic isolation. Group A animals (n=7) received segmental aspartate (50 mM) infusion for 10 minutes. Group B animals (n=6) were pretreated with MK-801 (6mg/kg), a noncompetitive NMDA receptor antagonist, that was administrated intravenously for 3 hours beginning 1 hour before the segmental infusion of aspartate (50 mM) of 10 minutes. Group C animals (n=6) received pretreatment with CGS19755 (30mg/kg), a competitive NMDA receptor antagonist, that was administrated in the same fashion as group B, followed by the segmental infusion of aspartate (50 mM). Neurologic status was scored at 12, 24, and 48 hours after operation using the Tarlov score. All the animals were sacrificed for histologic assessment at 48 hours. Results: Group A animals exhibited paraplegia or paraparesis with marked neuronal necrosis. Group B and C animals showed significantly better neurologic function compared with group A (p=0.0013, A vs. B) (p=0.0011, A vs. C). Pathohistological change was not observed in group B and C animals. Conclusions: NMDA receptor antagonists can have protective effects on spinal cord neurons against aspartate induced neurotoxicity. This model may be useful in assaying protective agents in the spinal cord against neuronal injury mediated by NMDA receptors in vivo.

Background: Human c-kit-positive cardiac stem cells (CSCs) have been used to treat patients suffering from ischemic cardiomyopathy. This study aimed to investigate whether a long-term storage of cardiac tissues would influence the growth potential of the subsequently isolated CSCs. Methods: A total of 34 fresh samples were obtained from various cardiac regions [right atrium (RA), left atrium (LA), and/or left ventricle (LV)] of 21 patients. From 12 of these patients, 18 samples kept frozen for ~2 years were employed to prepare and characterize the CSCs. After confirming the specificity of the cell sorting by c-kit immunolabeling, the growth rate (number of doublings per day), BrdU positivity, and colony forming unit (CFU) were measured in each CSC population; the values were compared among distinct cardiac regions as well as between fresh and frozen tissues from which CSCs were derived. Results: Among independent measurements indicating growth potential, the growth rate and BrdU positivity remarkably correlated in freshly prepared CSCs. The cells obtained from every examined region displayed a high proliferative capacity with the growth rate of 0.48±0.19 and the BrdU positivity of 15.0%±7.6%. The right atrial CSCs tended to show a greater growth than those in the other two areas. Similarly, the CSCs were isolated from tissue blocks, cryopreserved for ~2 years, and compared with CSCs derived from the fresh specimens of the same patients. Importantly, we were able to obtain and culture CSCs from every frozen material, and their proliferative potential, represented by the growth rate of 0.47±0.22 and the BrdU positivity of 13.7%±7.9%, was not inferior to that of the freshly prepared cells. Conclusions: The long-term cryopreservation of cardiac tissues did not affect the growth potential of the derivative CSCs. Our findings should expand the therapeutic applications of these cells over a longer time span.

Background . Considerable evidence exists that neurotoxicity of excitatory amino acids is related to the neuronal injury, including paraplegia. However, little is known about aspartate neurotoxicity in the spinal cord in vivo. We evaluated the detrimental effects of exogenous aspartate on spinal cord neurons under metabolic stress. Methods . New Zealand white rabbits underwent an infrarenal aortic isolation. Group A animals (n = 7) received segmental aspartate 50 mmol/L) infusion for 10 minutes. Group B animals (n = 7) received saline as a negative control. Group C animals (n = 5) received segmental aspartate 100 mmol/L) infusion for 5 minutes. Group D animals (n = 7) were pretreated with segmental infusion of (+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]cycloheptan-5,10-imine (MK-801) (6 mg/kg), a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist for 1 minute, followed by segmental infusion of aspartate (50 mmol/L) for 9 minutes. Group E animals (n = 7) received vehicle only, followed by aspartate (50 mmol/L) infusion as a control of group D. Neurologic status was assessed at 12, 24, and 48 hours after operation using the Tarlov score. Results . Group A animals exhibited paraplegia or paraparesis with marked neuronal necrosis. Group B and C animals recovered fully. Group D animals showed significantly better neurologic function ( p = 0.0007) compared with group E animals that exhibited paraplegia or paraparesis. Conclusions . Exogenous aspartate can have detrimental effects on spinal cord neurons under metabolic stress. This model may be useful in assaying neuronal injury mediated by NMDA receptor in vivo.

The transcatheter creation of linear endocardial lesions in the atria has been attempted to restore sinus rhythm in patients with atrial fibrillation (AF). However, due to fluoroscopic limitations, there are a number of technical difficulties involved with using this procedure, which include determining the ablation site, orienting the catheter tip, and confirming tip-tissue contact. The present study was performed to assess the feasibility of employing a transthoracic approach to linear radiofrequency ablation using a video-assisted thoracoscopy system (VATS) to anatomically guide the experimental setting in beating swine hearts. AF was induced pharmacologically by aconitine solution. Epicardial radiofrequency linear ablation of the right atrium was conducted under VATS monitoring using an ablation catheter that was inserted and manipulated through trocar ports. The ablation energy setting was 80 degrees C with 30s duration per ablation. The thoracoscopic visual field for transthoracic ablation was adequate, and the ablation catheter was positioned and anchored safely on the atrial epicardium. The restoration of sinus rhythm was confirmed in the limb lead and atrial electrograms, and transmural heat degeneration was confirmed by postmortem histological examination in all specimens. Our results suggest the potential usefulness of VATS for providing adequate anatomical guidance in epicardial linear radiofrequency ablation.

We report herein the results of a retrospective study conducted on ten consecutive Japanese patients who underwent successful surgical relief of fixed subaortic stenosis between 1972 and 1994 at ages ranging from 8 months to 21 years, and followed for 3.6 years and 26 years. Associated cardiovascular defects were present in six patients, two had a history of infective endocarditis, a discrete fibrous ring was found in nine patients, and a redundant abnormal sheet was found in one. A stenotic structure was removed in nine patients and incised in one, while myotomy was additionally performed in one. There were no early complications or deaths. Cardiac catheterization revealed a significant decrease in the peak systolic pressure gradient from 84+/-22 mm Hg preoperatively to 32+/-22 mm Hg postoperatively (P = 0.0017). Reoperation of an aortic valve replacement with or without valvular annulus enlargement was required in four patients because of a small annulus with aortic insufficiency or infective endocarditis. Infective endocarditis was a major cause of late mortality (n = 1) and morbidity (n = 1), but the remaining eight patients have been asymptomatic. Thus, although this lesion is relatively rare in Japan, the typical discrete type may be more common than previously believed. While a relief operation is associated with low early mortality, the palliative aspect regarding pathology of the aortic valve should not be underestimated, including poor growth of the valve annulus, deterioration of aortic insufficiency, and infective endocarditis. The most appropriate operative procedure for reoperation remains to be evolved.

We present our experience in mitral valve replacement (including left-sided tricuspid valve in corrected transposition) in patients younger than 6 years of age. The long term results were examined with special focus on re-replacement of the valve. Between 1974 and 1995, we performed mitral valve replacement in 14 patients younger than 6 years of age, with no operative mortality. There were 3 late deaths, caused by endocarditis, valve thrombosis, and congestive heart failure, respectively. The five-year-survival rate after primary replacement was 85%, and the ten-year-survival rate was 75%, using Kaplan-Meier analysis. Ten patients (11 occasions) required repeated mitral valve replacements at 2 months to 17 years after the original replacement. The indication for the second or third mitral valve replacement was paravalvular leakage (2 patients), valve thrombosis (1 patient), degeneration in the porcine prosthesis (3 patients), and patient outgrowth of the original small prosthesis (5 patients). Again there was no operative mortality. One patient who suffered from multiple occasions of valve thrombosis died at two years after the second replacement. All patients who had outgrown the prosthetic valve received larger prosthesis at the second replacement than at the primary replacement. The actuarial percentage of freedom from valve-related events at 3 years, 5 years, and at 10 years, was 50%, 37%, and 8%, respectively. Conclusions: Mitral valve replacement in patients younger than 6 years of age can be performed relatively safely, but meticulous follow-up and appropriate decision making for re-replacement is mandatory for the long-term survival of these patients.

A 12-year-old boy was first admitted to Tokyo Metropolitan Children's Hospital at 2 days of age with the diagnosis of tricuspid atresia without pulmonary stenosis, normally related great arteries, ventricular septal defect, and persistent left superior vena cava (PLSVC). He underwent pulmonary artery banding at the age of 1 year and atrial septectomy at 2.9 years. At the age of 6.3 years, he underwent successful Bjork operation in conjunction with closure of a trial and ventricular septal defects. Late after surgery, however, he developed progressive intolerance to exercise (NYHA III), cardiomegaly, and depressed ST segments in the left precordial leads. Catheter examination at the age of 11.9 years disclosed moderately elevated pressures (15 mmHg) in the right atrium and pulmonary artery, depressed left ventricular function with ejection fraction (EF) of 0.48, and marked dilatation of the coronary sinus (CS). Right atriography revealed retrograde filling of the dilated CS up to the junction with PLSVC. With supposition that the combined elevation of the volume and pressure loads on CS had disturbed both coronary circulation and ventricular function, he, at the age of 12 years, underwent take down of the Fontan circulation and conversion to the total cavopulmonary connection (TCPC). His postoperative recovery was uneventful and, at 2.5 years after the latest surgery, he is leading a normal life. The findings of the chest roentgenogram and electrocardiogram reverted to normal and EF returned to the normal value (0.66). This experience draws us to conclude that conversion to TCPC is a safe and effective mean to salvage the patients with failed Fontan circulation. This experience also suggests that dilatation of CS is a predictor of the failed or failing Fontan circulation.

Background . Isolated congenital tricuspid regurgitation without downward displacement of the leaflet is a rare clinical entity. Degenerative cusps and lack of chordae may preclude valvuloplasty and require valve replacement. Methods . Three consecutive patients with isolated congenital tricuspid regurgitation underwent surgical repair between May 1995 and April 1997. Their ages were 23, 15, and 8 years old. Tricuspid valvuloplasty was feasible in all of them, with use of a gathering suture of the anterior leaflet, artificial chordae implantation, and ring annuloplasty. Results . All 3 patients survived and recovered well after the operation. The cardiothoracic ratios on their chest roentgenograms decreased from 0.64 to 0.52 in patient 1, from 0.58 to 0.48 in patient 2, and from 0.60 to 0.44 in patient 3. Postoperative echocardiograms showed competent tricuspid valves and the disappearance of regurgitation in all cases. Conclusions . Although malformation of the valve is extensive in isolated congenital tricuspid regurgitation, application of artificial chordae with conventional valvuloplasty technique can avoid the use of prosthetic valves by establishing the competence of the tricuspid valve.

1991年5月から1996年4月までの5年間に当院に搬送された発症後2週間以内のStanford A型急性大動脈解離25例(男性11,女性14名,平均年齢60.1±11.4歳)について,急性期治療を中心に検討した。当院ではA型大動脈解離の急性期は適応のある症例に対し手術をし,他の症例には内科的治療を施行しできるだけ慢性期に手術をしてきた。従来の急性期での手術適応は破裂,左心不全を伴う重症AR (aortic regurgitation),主要分枝の虚血を伴う重症合併症であったが,1994年以降は適応を拡大しAR合併例,経胸壁心エコーで大動脈基部にflapを認める症例も急性期での手術適応とした。急性期に手術をした症例は適応拡大以前の前期群14例では3例(21.4%),適応拡大以降の後期群11例では7例(63.6%)と急性期手術症例が増加した(p

We present a case of a 49-year old man who suffered from immediate paraplegia upon awakening from anaesthesia after surgery for acute aortic dissection Type A. A catheter was promptly inserted into the spinal canal for cerebrospinal fluid drainage, and the cerebrospinal fluid pressure was maintained

OBJECTIVES: Surgical ventricular reconstruction (SVR) for patients with severe left ventricular (LV) remodelling due to ischaemic cardiomyopathy is still controversial, because the Surgical Treatment for Ischaemic Heart Failure (STICH) trial demonstrated that SVR not only has no beneficial effect on survival compared with coronary artery bypass grafting (CABG) alone, but also is worse for those with a larger LV. Therefore, we assessed the impact of LV remodelling on the outcomes after SVR for ischaemic cardiomyopathy in Japan, using Di Donato’s LV shape classification. METHODS: From 2000 to 2010, 627 patients underwent SVR for ischaemic heart failure in 11 Japanese hospitals. To assess the patients with an LV ejection fraction (LVEF) of ≤35% like the STICH trial, considering the severity of LV remodelling, the patients with a preoperative LVEF of >35%, no preoperative LV volume assessment and no preoperative LV shape classification were excluded. Finally, 323 patients were selected as the study subjects. The LV shape was divided into three types according to Di Donato’s classification. Types 1 and 3 indicate the aneurysmal and globally akinetic LV, respectively. Type 2 is the intermediate shape. RESULTS: Type 1, 2 and 3 LV shapes were observed in 85 (26%), 104 (32%) and 134 (42%) of the patients, respectively. The preoperative LV volume and diameter increased if the LV became more akinetic (Type 3 > 2 > 1, P< 0.001). LVEF was lower in those with more akinetic LV (P= 0.002). The preoperative LV end-diastolic volume index and LVEF in Type 3 patients were 133 ± 47 ml/m 2 and 22 ± 7%, respectively. Mitral valve repair was more frequently performed for patients with the Type 3 LV shape (65%) than for the others (P< 0.001). The hospital mortality rates were 2.4, 2.9 and 7.4% for Type 1, 2 and 3 patients, respectively (P= 0.16). Kaplan–Meier analysis demonstrated no significant difference in mortality among the three groups (log-rank P= 0.37). The 5-year survival rates were 81, 70 and 73% for Type 1, 2 and 3 patients, respectively. CONCLUSIONS: The severity of LV remodelling did not affect survival after SVR plus CABG. The results of SVR were acceptable even for those with globally akinetic LV due to ischaemic cardiomyopathy.

A 39-year-old man presented with chest pain. Chest radiography and echocardiography indicated a possible cardiac tumor. Echocardiography, computed tomography, and magnetic resonance imaging revealed a tumor in the interatrial septum. The patient underwent tumor resection under cardiopulmonary bypass. A paraganglioma was diagnosed on the basis of histopathological findings.

Among 73 patients with ischemic cardiomyopathy [ejection fraction (EF)40%, left ventricular end systolic volume index (LVESVI)60 ml/m2], 65 patients with large scar underwent left ventricular reconstruction (LVR) including scarred endocardiectomy against arrhythmia and 13 with 3 + mitral regurgitation (MR) mitral valve surgery [mitral annular plasty (MAP): n = 9, mitral valve replacement (MVR): n = 4]. Eight-year survival including 1 perioperative death (1.4%) was 773% without death due to arrhythmia. 69 survivors revealed significant improvement in New York Heart Association (NYHA) class, and lefe ventricular (LV) function in pulmonary artery pressure (PAP) and EF. LV volume significantly reduced from 103.6 to 57.5 ml/m2 in LVESVI (44% volume reduction) [p0.0001]. Postoperative LV shape became significantly spherical [eccentricity index (EI) closer to 0], however, MR grade was significantly reduced from 2.0 to 1.6 (p0.0003). Freedom from all deaths including hospitalization for cardiac causes was 71.1% at 8 years. One patient required implantable cardioverter defibrillator (ICD) for spontaneous ventricular tachycardia (VT). Multivariate Cox's regression model showed that preoperative large left ventricular end diastolic volume index (LVEDVI) [hazard ratio (HR) 1.02], postoperative large LVESVI (HR 1.03) and preoperative high NYHA class (HR 3.05) were significant risk factors affecting all deaths including hospitalization for cardiac causes. Of 24 patients with 2.5 + MR, mitral valve surgery (MAP, MVR or MAP + LVR) demonstrated significant improvement of MR (3.6 to 1.3 in MAP/MVR and 3.5 to 1.0 in MAP + LVR) compared with isolated LVR (2.6 to 2.2), although, there was no significant change in LV volume reduction. Our surgical approach to ischemic cardiomyopathy revealed excellent long-term results without death due to arrhythmia. Risk factor analysis recommended earlier and more aggressive surgical approach to achieve both LV volume reduction, MR and arrhythmia control.

We have studied the acute and long-term efficacy of overlapping biphasic impulse (OLBI) stimulation for atrial pacing with VDD pacemakers and demonstrated the feasibility of DDD pacing in OLBI with diagonally arranged half-ring (Half-Ring) electrodes. We made two three-dimensional computational analysis models to verify our clinical studies.Model I was composed of a heart, a pacemaker, and a human body. Model II was a cube with dimensions of 20 by 20 by 20 mm quarried from Model I for the detailed study of current density distributions. Laplace's equation was solved using the finite element method and the current density J was calculated. For Model I, the distal and proximal voltages were -10 V, 0 V in bipolar and -5 V, +5 V in OLBI, using Ring electrodes. In Model II, the actual measurements of electrode impedances obtained from the clinical study (1,180 Ω for Ring and 630 Ω for Half-Ring) were added to the analysis conditions. Model I showed that OLBI produced more concentrated current density distributions than those by bipolar. According to Model II, at the atrial myocardium position current density produced by Half-Ring was larger than that by Ring electrodes, 70 μA/mm(2) versus 30 μA/mm(2) in OLBI configuration. It also indicated that even if electrode impedances were equal between Half-Ring and Ring electrodes, the maximum current density produced by Half-Ring would be greater than that by Ring electrodes.It was considered that OLBI configuration with Half-Ring electrodes provides more effective current density distributions.

Lymphoblastic lymphoma, an aggressive mediastinal mass, is recognized as serious threat to the patient in developing cardiac tamponade or airway obstruction. Surgical procedure is often required to relieve clinical emergency and to establish prompt pathological diagnosis. However, in such a patient, acute respiratory occlusion in the spine position can be a life-threatening complication during general anesthesia. We describe a 17-year-old man whose cardiac tamponade was treated by pericardial-pleural window through a left anterior thoracotomy in the lateral position. The patient recovered from hemodynamic compromise without showing respiratory occlusion during general anesthesia and remained in the lateral position until extubation. Pathological diagnosis was precursor T-lymphoblastic lymphoma. There were no complications attributable to the operative procedure. Further chemotherapy reduced the mediastinal mass in size after two weeks when the patient developed sepsis and died. Lateral position prevents respiratory occlusion during surgical procedure under general anesthesia in the patient of huge anterior mediastinal tumor with airway obstruction.

Although the aberrant right subclavian artery is the most common abnormality in aortic arch development, it is unusual to encounter this abnormality when repairing acute aortic dissection. We report a case of Stanford type A acute aortic dissection involving an aberrant right subclavian artery in a 45-year-old man. We used the elephant trunk procedure to surgically manage the intimal tear and aberrant right subclavian artery. This is, to our knowledge, the first report in Japan of surgical reconstruction of an aberrant right subclavian artery in conjunction with acute aortic dissection.

Background . It has been demonstrated that bilateral use of internal thoracic arteries (ITAs) confers better long-term results in patients than does unilateral use. However, routine use of bilateral ITAs has usually been avoided. Methods . Since 1997, we have used bilateral ITAs extensively for patients who required multivessel bypasses. Recently, 243 consecutive patients, including 127 diabetic patients, were reviewed. Results . Every patient received at least one ITA graft, and 200 patients (82%) received bilateral ITAs. The majority (93%) of ITA grafts were used as in situ grafts. The hospital mortality rate was 0.41%, and deep sternal infections were observed in 5 patients (2.0%). There was no difference in the incidence of chest wound infection between the group treated with bilateral ITA grafting and that treated by unilateral ITA grafting. Conclusions . These observations suggest that ITAs can be used bilaterally for treatment in the majority of patients who require multivessel bypass, with low mortality and morbidity.