Infants with complete atrioventricular canal (CAVC) and severe congestive heart failure, not responding to medical managements, presents a difficult management problem. Between December, 1980, and August, 1987, 16 infants with CAVC presenting severe congestive heart failure underwent pulmonary artery banding. Average age at operation was 1.7 months (0.5 to 4) and average weight was 3.5kg (2.5∼4.9). Only four patients were older than 3 months of age at operation. Pre-operative cardiac catheterization and echocardiogram demonstrated that seven patients had mild to severe left atrioventricular valve regurgitation. Hospital death occurred in one patient (6%) due to rupture of the pulmonary artery. Of three late deaths, one patient had congestive heart failure, and one patient complicated with partial obstruction of right pulmonary artery died suddenly of an upper respiratory infection 11 months after rebanding. Survivors have been followed 18 to 94 months and all patients are growing at an increased rate postoperatively. In five patients of 12 long-term survivors who have undergone cardiac catheterization 37 to 83 months after the operation, pulmonary/systemic systolic pressure ratio (PP/PS) were 0.2∼0.42 (average 0.28). It is concluded that the pulmonary artery banding in infants with CAVC can be performed with low operative and late mortality and can provide good relief of symptoms and allow normal growth and development. It should be emphasized that early surgical palliation is mandatory to prevent the development of pulmonary hypertension and pulmonary emphysematous change.

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Pulmonary stenosis is the most frequent problem after arterial switch operation for TGA. We experienced four cases of late severe pulmonary stenosis out of twelve patients. All four had supravalvular stenosis either at anastomotic site or at previously banded segment. One patient had associated valvular stenosis and another had bilateral branch stenosis. It is possible that valvular stenosis was due to retraction of equine pericardial patch and branch stenosis was due to overdistension. All four cases were successfully reoperated on 13∼39 months after switch operation. To prevent late pulmonary stenosis, we now alter technique of switch operation in two points. First, the great arteries are anastomosed with interrupted U-shaped sutures from outside of the vessels in whole circumference. Second, both coronary arteries are transferred with punched-out method to save tissue of Valsalva sinus, and the defects are closed with autologous pericardial patch.

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A case of quadricuspid aortic valve is reported. The anomaly was unexpectedly found during surgery for aortic valve replacement in a 33-year-old man with aortic insufficiency. The supernumerary cusp was positioned between the right and the left coronary cusps. These three cusps were fairly uniform, although the non-coronary cusp was smaller. The cusps were excised and replaced with a Björk-Shiley valve. Congenital quadricuspid aortic valve is a rare abnormality, and only 39 cases have been reported. Most patients developed aortic insufficiency after reaching adulthood and nine patients had aortography or echocardiography. We propose to group congenital quadricuspid aortic valve into two types. Type 1: the supernumerary cusp is located anteriorly, that is, between the right and the left coronary cusps. The present case belongs to this type. Type 2: the supernumerary cusp is posterior and is situated between the right and the non-coronary cusps. In this type, the supernumerary cusp is always smaller than the other cusps.

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A 16-year-old female who complained of hoarseness and left back pain. An abnormal shadow in the left superior mediastinum was observed in chest X-ray films. Thoracic aortogram revealed elongations of the aortic arch and two sacculated aneurysms located in the minor curvature of the arch. She was operated by median sternotomy and left collar incision. The left vagal nerve laid between the two aneurysms. The proximal aneurysmal wall seemed to be of normal thickness, but the distal aneurysmal wall was so thin that the intraluminal blood stream was visible. Aneurysmectomy and insertion of a Dacron patch were successfully performed under cardio-pulmonary bypass with selective cereberal perfusion. The postoperative course was uneventful.

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A Successful surgical repair of a ruptured ventricular septum concomitant with a left ventricular free wall rupture secondary to myocardial infarction was performed on a 81-year-old woman. Anterior myocardial infarction was accompanied with a ventricular septal rupture, 7mm in size, and hemorrhagic dissection type left ventricular free wall rupture. Acute ventricular aneurysm formation of the left ventricle was also noticed. A review of the literature reveals that in surgical cases, the hemorrhagic dissection type ventricular rupture in left ventricle was usually concomitant with ventricular septal rupture.

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A case report of spontaneous dissection of the superior mesenteric artery (SMA) in a 53-year-old man who complained of sudden colic-midabdominal pain is presented. In this case, ultrasonography is very usefull for early diagnosis of dissection, and this is successfully treated by Ao-AMS bypass with excision of the proximal segment of SMA. Postoperatively the patient has no symptoms for 2 years.

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A rare case of secundum type atrial septal defect associated with cleft of the anterior mitral leaflet in 63-year-old man is reported. The electrocardiogram showed right bandle branch block and indeterminate QRS axis. Preoperative cardiac catheterization revealed left to right shunt at the atrial level and moderate mitral regurgitation due to a cleft in the anterior mitral leaflet. Marked tricuspid regurgitation due to a dilated annulus concomitantly existed. The valve deficiencies were repaired and the atrial septal defect was closed at operation. Forty cases of secundum type atrial septal defect associated with cleft mitral valve were discussed about their electrocardiograms and operative indications.

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The patient is a 47-year-old male who presented with abnormal shadows in his chest X-ray. On the third intercostal space, diastolic regurgitant murmur and systolic ejection murmur were heard. X-ray of the chest showed a projection of the right second costal arch in addition to the right atrium shadow. Cardiac catheterization showed no abnormalities except for a rise in the left ventricular end diastolic pressure which was 18mmHg. The patient was found to have Grade II aortic regurgitation. All there findings diagnosis of the case as extra-cardiac right Valsalva sinus aneurysm with aortic regurgitation. Incision of the aneurysm, showed a Valsalva sinus aneurysm having an opening of approximately 3cm just above the right aortic valve ring with the orifice of the right coronary artery occluded. Complete patch closure was performed with elevation of the aortic valve ring. No reconstruction for the right coronary artery was made.

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The total correction of tetralogy of Fallot (TOF) after the right ventricular outflow tract construction without ventricular septal defect closure which is called central palliation is rarely reported. A case of TOF had been undergone the central palliation because of left ventricular hypoplasia in a 30 year-old woman, 19 years after Blalock-Taussig's shunt. She was performed successfuly on the total correction of TOF and pulmonary valve replacement at 35 years old, 5 years after the central palliation.

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Congenital heart disease of partial anomalous pulmonary venous drainage of entire left lung without other cardiac anomaly was very rare. 21-year-old man, who was pointed out heart disease 6 months ago, was diagnosed as partial anomalous pulmonary venous drainage of entire left lung without other cardiac anomaly by cardiac catheterization and angiography. The patient underwent surgery through the left forth intercostal incision without cardiopulmonary bypass. The end-to-side anastomosis was made between the vertical vein and the left atrial appendage following ligation of the vertical vein near the innominate vein. Surgical treatment was satisfactory in the postoperative angiography which was shown widely patent anastomosis. He was discharged with uneventful postoperative course and returned to full activity.

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Progress in vascular surgery has been owing to the development of vascular prosthesis. However, clinical results of small-caliber synthetic vascular prostheses, which were applied to coronary surgery and infrainguinal arterial reconstruction, have been still inferior to those of autogenous vein graft. Since Maruyama succeeded in culturing vascular endothelial cells from human umbilical cord vein in 1963, tissue culture of vascular endothelium has played an important role of clarifying various aspects of thrombosis, fibrinolysis and atherosclerosis. In order to improve the patency rate of small-caliber vascular graft, the idea to connect tissue culture with synthetic material was occurred to mind. Since 1978 endothelial cell seeding has been investigated for the purpose to provide native antithrombogenicity to synthetic vascular prosthesis. There were many reports about the better patency, the earlier endothelialization and the less platelet adhesion on the luminal surface of the experimentally seeded graft. Recently “prelined graft”, which is made from in vitro seeding of cultured endothelial cells, has been paid attention to rather than the classical technique of endothelial seeding with preclotting method. In our bioresearch laboratory vascular endothelial cells were derived enzymatically from canine external jugular veins. They were cultured to confluency and seeded in vitro to small-caliber vascular prostheses by the rotation method. Experimental results of animal implantation in 8 weeks revealed that the endothelial seeded graft had superior patency to control graft. Seeded endothelial cells were observed histologically to form monolayer lining at the middle portion on the inner surface. Their function was confirmed by the peroxidase antiperoxidase reaction to identify Factor VIII related antigen in the cell body. Subendothelial structure was examined thinner in the intimal area of good endothelial coverage. There are several problems about hybrid vascular prosthesis, which is concomitantly composed of synthetic material and cultured vascular cells. First, experienced technique of tissue culture should be mastered for harvesting cells and maintenance of the experimental graft. Study of vascular smooth muscle cell and extracellular matrix should be also advanced in pararell with that of endothelial cells. Synthetic material should be searched in pursuit of biodegradable or bioresorbable graft which is expected to have cell affinity. Concerning the cell attachment, necessity of coating substance on the graft such as adhesive protein should be reconsidered. Seeded endothelial cells should be evaluated from the immunological point of view before clinical application, because cultured cells from human vascular wall may acquire various antigenicity in the course of tissue culture. Seeding of cultured endothelial cells in vitro will be an evolutionary trend for the development of small-caliber synthetic vascular prosthesis.

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In order to synthesize biocompatible materials that are used for artificial organs, hybridization of materials with biologically active substances seems to be most effective. To prevent coagulation upon blood/materials contact, hybridization with the materials of the repressor of coagulation factors or platelet and the activator of fibrinolysis has been done. Simultaneous hybridization of two kinds of biologically active substances has also been found effective. Recently, cell/materials hybridization is particularly popular. For this type of hybridization composite materials have been developed that are convenient for cell lining or in vivo compatible with living cells. This method will lead to the control of cell functions with suitable materials and a future development is expected.

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High performance biomaterials have been expected to play a substantial role in near future-directed cardiovascular medicine. Man-made or hybridized biomaterials serve to impart biocompatibility and functions to advanced artificial organs. In this paper, more than several years-efforts of biomaterial research in the Artificial Heart Group at the National Cardiovascular Center was summarized. These include ventricular assist device, surgical adhesive, anaphylatoxin scavenging device, hybrid artificial graft based on organ reconstruction technology.

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Adhesion of tissues are carried out by themselves through wound healing processes. The processes are disturbed when there are synthetic materials including adhesives between the tissues. But we have to use cements to fix a tissue with an artificial material, sometimes. Mechanical fixation is main mechanism here. The author can develop adhesives to tooth substrates recently and the mechanism is investigated. Biocompatible monomers promote the interpenetration of monomers into the subsurface of tissues and they are polymerized in situ to form hybrid of tooth substrate and the copolymers. The hybrid can intermediate the tooth with the cured adhesive and the adhesion can take place.

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