A study of postoperative arrhythmias observed in 286 cases of atrial septal defect and 247 cases of ventricular septal defect was presented.
The most frequent postoperative arrhythmia in atrial septal defect was sick sinus syndrome (30% in immediately postoperative and 10% in follow-up period). The preventives of this sequela include more cranial placement of the superior vena caval snare and right atriotomy away from the sinus node.
Various conduction disturbances were observed as important postoperative sequelae in 40% of cases of ventricular septal defect. Right bundle blanch block was the most frequent disturbance. Prognosis of patients with bifacicular block or transient heart block have been not so poor. The preventives of the conduction disturbances include precise morphological apprehension and application of electrophysiological technique

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With the progress in gamma camera and computer system, nuclear medicine has been applied for diagnostic tool in ischemic heart disease.
There are two devices for cardiac images; (1) Radionuclide angiocardiography (RNA) by in vivo ^99mTc-RBC labeling (2) Myocardial imaging by ²⁰¹Tlcl.
RNA can evaluate the kinesis of wall motion of left ventricle with gated pool scan and also detect reserve of cardiac function with exercise stady. Myocardial imaging at rest can identify myocardial necrosis and the imaging in exercise can detect myocardial ischemia.
The elaborateness and reproducibility of cardiac image in nuclear medicine will play the great role to evaluate clinical stage of ischemic heart disease by not only imaging but also functional diagnosis

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Recent tendency showed shortening interval between the onset of acute myocardial infarction and the arrival at hospital. Laboratory findings should be re-evaluated from the view point of patient's behavior.
Eighty-seven patients, age ranged from 42 to 84, were subjected. The distribution of the patients with acute myocardial infarction on time course could be simulated as P=0.18e^0.18t. The cases with peak CPK were most frequently found around 15 hours after the onset. CPK on arrival (X) and the difference of CPK one hour after the arrival (Y) could be used for the diagnosis of acute myocardial infarction even if absolute value of CPK remained within normal. When discrimination function, f=0.045X+0.123Y-0.84, was plus, the case was acute myocardial infarction and, if not, it could be ruled out. The sensitivity was 95% (P<0.01).
The number of the patients who could not be admitted to CCU was estimated by Erlang equation in relationship with the average days of CCU stage. The reason for prolonged CCU stage contained delayed laboratory information in 22.5% and if it was more than 11 days, 3 cases were refused to be admitted as results of Montecarlo simulation.
The changing aspect of the patients with acute myocardial infarction making absorption wall death was analized by using Marcovian chain.
The probability of recognizing premature ventricular contraction in relationship with length of EKG recordings was calculated. It showed that it was less in Standard 12 leads recording conventionally performed

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The diagnosis of ischemic heart disease, especially of angina pectoris, can be done very precisely by the advanced technique of coronary cineangiography (CAG). Various types of angina pectoris, of which we have seen many cases in our hospital, are presented with special reference to CAG, and problems about their diagnoses are discussed.
The cases are as follows:
1) Angina of effort. In typical cases three vessel disease was demonstrated in CAG. 2) Variant angina. During attacks of chest pain ST elevation in monitoring EKG was recorded. 3) Angina in hypertrophic cardiomyopathy. “Muscular bridge” was demon- strated in left anterior descending branch.
The diagnosis of angina pectoris is rather easy because its diagnosis depends primarily on the clinical history. But when spasms of the coronary arteries are concerned, some confusions may arise and the help of CAG is needed

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The clinical findings were evaluated in 12 cases undergone cardiogenic shock in the patients with ischemic heart disease admitted to CCU of our hospital between Jan. 1, 1978 and July 30, 1981.
All these cases had myocardial infarction; acute in 11 cases (including 3 cases with recurrent MI) and chronic in 1 case. 10 of 12 patients died. The infarct of such patients who died were transmural and widely extended. The patients who died were elderly and were averaged 70 years of age. Most of these patients had a history of cardiovascular disorder and risk factors in which hypertension and previous congestive heart failure were the most common.
Decreased cardiac index, increased end-diastolic pressure of pulmonary artery and decreased PO₂ were commonly seen. By auscultation, rales were found in the lungs of all patients who died.
Assisted circulation device was applied in 4 cases resulting improvement of vascular circulatory dynamics. However following termination of its assistance, all these patients got worse resulting death. Delay to start this method for these patients was considered to be one of the responsible reasons for these unsatisfactory outcome.
Autopsy was obtained in 6 of 10 cases who died. The particular finding which was shared by all cases in autopsy was that the focus of myocardial infarct extended widely. The obstruction of the proximal coronary artery by fresh thrombus was found in 4 cases.
We considered that the prevention of shock was the most important factor to improve the therapeutic result and will be provided by followings: 1) early admission to CCU in patients with myocardial infarction, 2) agressive therapy to prevent the progression of MI. Specifically once the patient undergoes shock, assisted circulation should be applied as soon as possible without hesitation, if clinically indicated

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Extraanatomic bypass technique were utilized in surgery for distal aortic arch aneurysms and dissecting aneurysms.
Graft replacement of the distal aortic arch aneurysm sometimes imposes difficult tasks at the proximal anastomosis because of friable aortic wall and restricted exposure.
Recently, we have performed two such cases employing the technique which is composed of ascending to descending aortic bypass with simple closure of the distal aortic arch. The repair was accomplished during temporary external shunt placed between ascending aorta to femoral artery. The first case has been doing quite well, five years post-operatively.
Two patients with DeBakey type 3 dissection with extraordinary huge false lumen underwent ascending aorta-abdominal aorta (biiliac arteries) bypass and semi-isolation of the aneurysm. This method was recently deviced by Carpentier and colleagues and they named it as thromboexclusion by flow reversal. Although there are controversies of effective thrombus formation in false lumen, both patients have done well so far

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Among the surgical cases of the aortic aneurysm in our hospital, several patients were operated upon with some technical device for the reconstruction of blood flow. Such clinical experiences are described and discussed in relation to prognosis.
1) Giant aneurysms of the thoracic descending aorta extending into the abdominal aortic wall. While the aortic aneurysm was replaced with a prosthetic graft, the major intercostal artery was preserved and reconstructed in order to avoid spinal cord ischemia in one patient. Another patient with dissection of the aorta had radical operation, with the method of proximal anastomosis to the aortic arch and distal anastomosis to just above the origin of the celiac artery. Two patients are doing well postoperatively, five years and three and a half years respectively.
2) A patient very advanced in age with the abdominal aortic aneurysm had a surgery of replacement of Y shaped prosthetic graft with reconstruction of the bilateral internal iliac arteries. But, he developed severe stricture of the sigmoid colon three months after surgery. Since then, it has been made a rule that the inferior mesenteric artery shoulb be reimplanted into the side of the aortic graft for the case of inferior mesenteric artery following aneurysmectomy and reconstruction of the aorta. The method is that the inferior mesenteric artery is divided in a soft portion, spatulated and sutured to the graft wall. Such 4 cases are doing very well postoperatively.
3) A 3-years-old girl with the abdominal aortic aneurysm probably caused by Kawasaki's disease with the age of five months. The aneurysm was dissected and a Y shaped vascular prothesis with 10×6mm in size was inserted. Since the right external iliac artery was very narrow, a longitudinal incision was made on the facing sides of the external and internal iliac arteries respectively and the respective cut margins on the anterior and posterior surfaces were sutured continuously to make a single anastomotic stoma; and then the stoma was anastomosed to the graft in end-to-end fashion. At the age of 11 postoperatively she has grown well as a normal healthy girl.
4) Three patients with Marfan's syndrome accompanied by dissecting aneurysm of the ascending aorta were successfully operated upon. In the first case aortic valve replacement and aneurysmectomy were performed in wedge shaped resection, leaving the posterior wall of the aorta with dissection of proximal side above the origin of the coronary arteries and direct anastomosis to the normal distal aorta. Although angiogram of the third year after surgery revealed slightly dilated sinus of valsalva, the patient is doing well seven years postoperatively. The other two patients underwent Bentall's operation. One of the patients is doing well five years postoperatively. Another patient suddenly died of rupture of aneurysm of the thoracic descending aorta three and a half years after surgery. The latter patient had a past history of surgery of abdominal aortic aneurysm. Prognosis of the dissecting aortic aneurysm with Marfan's syndrome seems to be influenced by occurrence and development of cardiovascular lesions

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Ten patients ranging from 28 to 64-years-old with the dissecting aneurysms of the thoracic aorta have undergone surgical treatment at the chronic period in the Chiba National Hospital during the last 11 years. Their types of the aneurysms were a case of the DeBakey type I, four cases of type II, a case of type IIIa and four cases of type IIIb.
Surgical methods and circulatory support: Type I -The procedure consisted in resection and graft replacement of the ascending aorta and arch, using the cardiopulmonary bypassm, oderate hypothermia and coronary perfusion. Type II-All four patients underwent the surgical repair by methods of Bentall procedure with the use of cardiopulmonary bypass, moderate hypothermia and cardioplegia. Type III-Four out of five patients underwent the partial resection of aneurysmsi, ncluding the entry, and were replaced with prosthesis. One patient underwent the closure of the entry with patch, using the temporary external by-pass and moderate hypothermia.
Results: Three cases (one of type II, two of type III) have been postoperatively followed up from 2 to 11 years. Number of the late deaths was two, whose causes of deaths were heart failure and heterotopic rupture. Number of early deaths was five, whose causes of deaths were postoperative perfusion lung edema (type I), stenosis of the graft-coronary anastomosis by methods of Bentall procedure (type II ), postoperative hemorrhage and lung complication (type II), rupture of anastomosis (type IIIb) and renal failure with paraplegia (type IIIb)

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During the period from October, 1977 to December, 1981 49 cases of thoracic aneurysm, 4 cases of thoraco-abdominal aneurysm, 53 cases of abdominal aneurysm were operated at the National Cardiovascular Center. The classification of thoracic aneurysm were 26 cases of dissecting aneurysm (11 cases of DeBakey type I, 4 cases of type II and 11 cases of type III), 19 cases of saccular aneurysm (including 3 cases of pseudoaneurysm) and 4 cases of annuloaortic ectasia. Deaths were occurred in 14 patients, resulted in 29% of mortality rate. Among 4 cases of thoracoabdominal aneurysm, one patient was lost by surgery. The oprative procedure for this type of aneurysm were performed according to modification of Crawford and Hardy method in one patient respectively and extra-anatomical by-pass in two patients. In 53 cases of abdominal aneurysm surgery, 43 cases were operated as elective, death was accounted in one, which made 3% of mortality rate. On the other hand, 10 patients of ruptured aneurysm were operated as emergency and 7 patients died. The early diagnosis and treatment are quite important in this particular situation. The reconstruction of abdominal aorta were undertaken with Y graft in 46 patients, the con-comitant reconstruction of major branchs were attempted total of 9 cases, 4 of inferior mesen-teric, 3 of internal iliac and 2 cases of renal artery. It is our policy to preserve at least one major branch for the prevention ischemic complication of intestine and we have not experienced of this disastrous complication so far. As for the surgery of thoracic and abdominal aneurysm, we have been applying autotransfusion method to recover blood during procedure, have saved in total of 58% of blood loss in average

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From April 1970 to April 1980, 11 patients with aortic aneurysm were treated with surgical procedure at Nagasaki-Chuo National Hospital.
The localization of lesion was 4 cases with thoracic aorta (ascending in 1, arch in 1 and descending in 2) and 7 cases with abdominal aorta.
These patients were 62.3-years-old in average at the time of the operation. Etiologically, arteriosclerosis was in 6, arteriosclerosis with syphilis in 3, syphilis in 1 and Marfan's syndrome in 1.
In 10 of 11 patients were replaced by artificial grafts. Only one of these patients was performed by aneurysmectomy with Teflon mesh wrapping under extracorporeal circulation.
Four of 11 patients had ruptured aneurysm in the abdominal aorta below renal artery, averaged 68.2 years, which was considerably higher than 59 years of age for 7 non-ruptured patients. These cases were hospitalized in shock condition and underwent emergency oper-ation without angiography for rupture into retroperitoneal cavity. Two died from cardiac failure within 24 hours after operation and another one died from abundant bleeding in digestive tract at 18 days postoperatively.
Remaining one case revealed perforation into the lumbar vertebra, who could not get non-parenteral nutrition because of pain. After various examination, the patient was hospi-talized at 18 days after symptomatic eruption, and received successful operation.
The patients with ruptured aortic aneurysm are mostly in poor condition and the systemic condition is so aggravated, that the prognosis is generally unsatisfactory

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The surgical department of Zentsuji National Hospital has treated a total of 90 vascular cases from April 1976 till May 1981, which are classified into the following three groups. The first is 15 aortic diseases including 10 aortic aneurysms.
The second is 19 peripheral artery diseases. The third is 56 following cases; distal spleno-renal shunt operation upon portal hypertension, shunt operation of left adrenal-middle colic vein upon the recrudesce of brest cancer, and surgical treatment to varix of legs.
In this study, we have chosen 10 cases of the aortic aneurysm out of these 90 cases. 9 cases were the aneurysms of the abdominal aorta located below the diverging point of renal arteries and none of them was ruptured. 1 case was an aneurysm of the thora-coabdominal aorta, and this is the first successful case of Crawford operation in Japan. Male and female patients were in the ratio of 9:1, and their age was from 55 to 76. The highest number of chief complaints were abdominal tumors with pulsation, and the others were abdominal pain and abdominal distension, etc.
As for the operative method, we replaced with Y-typed artificial blood vessels in all cases of aneurysms of the abdominal aorta. Though we used to cut off the sacks, recently we embed artificial blood vessels into the sacks. In one case of aneurysm of the thora- coabdominal aorta, we intraluminally reconstructed the blood circulation according to Crawford type II operative method.
The operative mortality were 2 cases of aneurysms of the abdominal aorta; one patient lost on the fourth day after operation under our diagnosis of myocardial infarction and the other lost on the fifth day under our suspicion of dissecting aneurysm of the aorta. One of the other 8 cases lost of the different disease (gastric cancer) but seven including one case of an aneurysm of the thoracoabdominal aorta are now all in good health; the longest is 4 years and 5 months.
In addition we report the following fact. Because the radionuclide aortography, noninvasive diagnostic technique, is useful in treating the aortic aneurysms, we make use of this method (using Searle LFOV, and ^99mTO₄ or ^99mTc-albumin 15-20 mci as radioisotope) in the diagnosis of the aortic aneurysms and the care after operation

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Sixty-three-years-old female patient with dissecting thoracic aneurysm had acute myocardial infarction and came to a state of lull.
After two weeks of first attack of myocardial infarction, she had seven times of repeated attack of angina pectoris accompanied with atrial fibrillation during 18 hours. Sublingual nitroglycerin (SNTG) was effective with incomplete release. 20 hours later from the first attack intravenous nitroglycerin (INTG) was continuously administered and the attack was completely controled. 40 hours later, INTG was suspended due to absence in stock. For the following 8 hours, she had had four times of variant angina attack accompa-nied with complete atrio-ventricular block, for which SNTG were given every times of attack. INTC was then begun to administer again continuously for 52 hours, resulted disappearance of attack.
In summary, INTG for this patient was effective as follows: 1) a rapid action with absence of side effect, 2) easy to control the dose of administration and 3) to ensure the maintenance of effective dose (0.7μg/kg/min)

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We investigated hemodynamics and clinical features of cardiogenic shock caused by acute myocardial infarction. The cardiogenic shock patients tend to fall into severe con-dition easily, and are difficult to be successfully treated by non-invasive procedures today.
Patients and methods
We studied 10 patients of cardiogenic shock immediately after the onset of acute myo-cardial infarction. Hemodynamics monitoring was studied by means of Swan-Ganz catheter. The effectiveness of dopamine hydrochloride for cardiogenic shock is estimated by hemodynamics and clinical signs.
Results
Ten patients of cardiogenic shock were treated by non-invasive procedures, and 7 patients of them were recovered from critical condition. Hemodynamics of them varied with individual difference. A few of patients needed a large dose of dopamine hydrochloride for a long period, whereas the others required common dose of vasopressive drugs. Several patients had arrhythmias and cardiac failure as well as cardiogenic shock as complications of acute myocardial infarction. Some of them have no choice but to have artificial pace-maker. The cardiac output is the most reliable index of the clinical course and hemodynamics of the cardiogenic shock.
Conclusion
Dopamine hydrochloride, diuretics and nitrates are effective for the cardiogenic shock. It is important to treat arrhythmias and cardiac failure as soon as possible to save the patients from the life threatening state. Taking an accurate measurement of hemodynamics and treatment without delay enable the patients to be recovered before they fall into irre-versible shock. There are cases who relieved with a larger dose of dopamine hydrochloride than the usual dose, 3 cases of the fatal result include the patients who had the dissemi-nated intravascular coagulation, severe adult respiratory distress syndrome and renal failure

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A 41-years-old woman was admitted to our hospital because of severe congestive heart failure. She had neither heart murmur nor hypertension. EKG on admission was sinus tachycardia with frequent ventricular premature contractions and chest X-ray showed cardiomegaly with pulmonary congestion. Clinical impression was myocarditis.
Intravenous injection of lidocaine against frequent ventricular premature contractions provoked shock and ventricular tachycardia so we used disopyramide, which induced severe liver injury (GOT 10, 290u/l, GPT 5, 460u/l, T. Bil 30mg/dl). Her condition deteriorated. So isosorbide dinitrate 20mg/day was given to improve cardiac performance. Three weeks after receiving vasodilator therapy, her urinary output increased, pulmonary congetsion decreased, and her symptoms improved. The use of isosorbide dinitrate in addition to diuretics and digitalis against refractory congestive heart failure was worthwhile. But in this case she complained of headache and nausea, so it was necessary to discontinue this therapy

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The chronic heart failure has increased preload and afterload. To determine whether the combination of isosorbide dinitrate (20-30mg/day) and hydralazine (200-300mg/day) affect on chronic heart failure, we evaluated with the hemodynamic parameter using Swan-Ganz catheter before and after treatment of 4 weeks. The subjects were 16 congestive cardiomyopathy and 4 myocardial infarction. The mean age of the patients was 51. 9-years-old.
The combination of isosorbide dinitrate and hydralazine reduced the total peripheral resistance from 2, 305±910 (mean±SD) to 1, 295±321 dynes/sec/cm⁵. The pulmonary capillary wedge pressure and the right atrium pressure were decreased from 32.4±6.7, 13.2±4.8 to 20.8±7.7mmHg, 7.10±4.2mmHg respectively (P<0.01). The cardiac index was increased from 1.93±0.55 to 3.17±0.66 liter/min/M² (P<0.01). The stroke volume index was increased from 20.3±7.0 to 33.2±6.5ml/beat/M² (P<0.01). The heart rate and the mean blood pressure were unchanged. The functional activity was improved significantly.
The results suggest the combination of isosorbide dinitrate and hydralazine improve the cardiac function. So the combination of vasodilator therapy can be used effectively and safely as the sole agent in the treatment of severe congestive heart failure

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Acute hemodynamic effects of hydralazine (10mg, intravenous, 8 cases), nifedipine (10mg, oral, 9 cases), prazosin (2mg, oral, 8 cases) and captopril (25mg, oral, 9 cases) were evaluated in patients with chronic refractory congestive heart failure. Heart rate (HR), mean blood pressure (MBP), mean pulmonary artery pressure (MPA), pulmonary capillary wedge pressure (PCW), cardiac index (CI), stroke volume index (SVI), left ventricular stroke work index (LVSWI), systemic vascular resistanse (SVR) and pulmonary vascular resistance (PVR) were evaluated at base-line state and 0.5, 1, 2, 3, 4, 5 and 6 hours after each drug administration.
Hydralazine significantly increased HR, CI, SVI and LVSWI throughout the 6 hours period of evaluation and significantly decreased SVR and PVR. MPA and PCW did not show significant change.
Nifedipine showed no change in HR, MBP and LVSWI. Significant increase was observed in CI and SVI at 2 hours and 0.5 hours after dosing respectively. MPA and PCW showed no change during the period when CI and SVI increased significantly. SVR sig-nificantly decreased for 2 hours after dosing, but PVR showed only slight significant change at the point of 4 hours after loading of nifedipine.
Prazosin had no effect on HR. CI, SVI and LVSWI showed significant increase and MBP, MPA, PCW and SVR showed significant decrease.
Captopril significantly decreased HR, MBP, MPA and PCW for 5 hours after drug administration. SVR decreased significantly for 2 hours but PVR showed no significant change. LVSWI decreased significantly at 4 and 5 hours after dosing, probably because of its hypotensive effect. All four drugs had significant correlation between percent decrease in SVR and maximum percent change in CI, but significant correlation between initial value of SVR and maximum percent change in CI was observed only in captopril.
The above data showed that hydralazine and nifedipine affect predominantly impedance vessels, and prazosin and captopril affect both impedance and capacitance vessels. Hydralazine and captopril seemed more potent than nif edipine and prazosin as vasodilator. Since negative chronotropic and hypotensive effects of captopril were very profound in some cases, initial administration of captopril may require close observation

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