In this report, we describe our surgical experience with seven cases of acute type A aortic dissection which resulted from retrograde propagation from tears in the proximal descending arota. As an emergency procedure, we used a ringed intraluminal prosthesis in six patients and five of these survived. All survivors underwent follow up CT scanning during a period ranging from 4 months to 5.6 years after surgery, especially to evaluate the fate of the false lumen on the residual aorta. In four patients, the arch dissection has been completely occluded by thrombosis, however, it remained patent in one patient 2.3 years postoperatively in whom reentry was found in the arch vessel at the time of operation. Enlargement of the false lumen beyond the descending aorta was found in two patients. On the other hand, the results have been excellent in the most recent patient who underwent complete graft replacement of both the ascending aorta and aortic arch including the primary tear. The authors believe, therefore, that the complete graft replacement of the ascending aorta to the aortic arch should be considered as the procedure of choice in these particular patients. Only such procedures enable the complete healing of both the ascending and arch dissection, and reoperation can be confined to the area distal to the descending aorta, if necessary.

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Transesophageal pacing (TEP) was performed in 54 patients with atheroscrelotic vascular disease to detect ischemic heart disease (IHD). Thirty patients had arteriosclerosis obliterans of the lower extremities (ASO) and 24 patients aortic aneurysm (AA). All patients underwent coronary arteriography. Sensitivity for the diagnosis of IHD was 90% and the specificity 67%, accuracy 83% in ASO and sensitivity 80%, specificity 93%, accuracy 88% in AA. In both vascular diseases the sensitivity was 87%, the specificity was 83%, and the accuracy was 85%. These results suggest that TEP is a useful screening test to detect IHD in patients with atheroscrelotic vascular disease who are candidates for surgery.

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Prostaglandin E₁ (PGE₁) was used continuously in adults from immediately after induction of anesthesia, during extracorporeal circulation, to the acute phase after open heart surgery. Using blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core as indices, the effects of afterload reduction and improvement of peripheral circulation were investigated. Subjects were 17 adults who underwent open heart surgery. PGE₁ was used in 7 patients and not used in 10. In the group using PGE₁, continuous injection of 0.015μg/kg/min of PGE₁ was started immediately after induction of anesthesia and was maintained during extracorporeal circulation until the acute phase after surgery. During extracorporeal circulation, perfusion pressure was kept at 50∼60mmHg and PGE₁ injection was controlled within the range of 0.015∼0.030μg/kg/min. At completion of extracorporeal circulation, the dose was fixed at 0.015μg/kg/min again. The degree of improvement of peripheral circulation was evaluated on the basis of hemodynamics, blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core, at induction of anesthesia (before using PGE₁) on completion of extracorporeal circulation, and in the acute phase after surgery. The value of blood flow in the toe determined by laser Doppler flowmeter was significantly higher in the PGE₁ group than in the non-PGE₁ group, from completion of extracorporeal circulation to the acute phase after surgery. Moreover, peripheral temperature was significantly higher in the PGE₁ group than in the non-PGE₁ group at completion of the extracorporeal circulation as well as immediately after surgery, and the temperature difference between periphery and core was significantly smaller. Continuous injection of PGE₁ enabled smooth control of perfusion pressure during extracorporeal circulation. Although there was no significant difference in peripheral vascular and total pulmonary resistance, the coefficients tended to be lower in the PGE₁ group. The use of PGE₁ during open heart surgery seems to be an effective method to improve peripheral circulation.

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A total of 183 patients who underwent surgical repair of secundum type atrial septal defect (ASD), were divided into 5 age groups. Hemodynamic parameters, arrhythmia, and abnormality of the atrio-ventricular valve function were compared among the 5 groups. Although the pulmonary to systemic blood flow ratio was not different, the pulmonary to systemic pressure ratio was higher in the sixth decade than in the third (p<0.05) and fourth (p<0.01). Pulmonary to systemic vascular resistance ratio increased with age, although the difference was not statistically significant. The cardiothoracic ratio, atrial fibrillation and tricuspid regurgitation (TR) also increased with age. These data suggest that ASD progresses with age. There were 41 patients who showed more than grade II TR, 10 patients underwent tricuspid annuloplasty (TAP), 1 underwent tricuspid valve replacement, and the other 30 patients had no treatment of the tricuspid valve. TAP with DeVega's (6 cases) or Carpentier-ring (1) method was effective. In 30 untreated TR patients, 9 patients remained with grade II TR after closure of the defect. Because TAP is an easy and very effective procedure, TAP should have been applied to all patient with TR more severe than grade II. There were 10 patients with mitral regurgitation (MR) of more than grade II. Two patients in whom mitral valve prolapse had been detected on ultrasound cardiography (UCG) before operation underwent mitral valve plasty successfully. Although MR decreased in 6 patients after only ASD closure, two patients remained with grade II MR. We now recommend that the mitral valve should be assessed under direct vision, and intraoperative trans-esophageal echo cardiography, and also that the mitral regurgitation test as well as preoperative UCG should be performed. Because ASD is progressive with age, surgical repair should be performed before age 40.

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A total of 961 patients underwent coronary artery bypass grafting (CABG) between 1982 and 1991, and we investigated perioperative cerebral infarction. The average age of operation in these case was 65±4 years. There was 9 patients with hypertension, 7 with diabetes mellitus and 5 with hyperlipidemia. Concerning cerebral infarction, there were 3 patients with multiple infarction, 6 with infarction of the mid cerebral artery area, 1 with infarction of posterior cerebral artery area, 1 with infarction of posterior cerebral artery area, 1 with infarction of pons and 1 with infarction of the ophthalmic artery. The courses of infarction involved atherosclerosis, hypoperfusion during cardiopulmonary bypass, thrombosis due to arterial fibrillation and thrombus on the left ventricular wall. Three patients who had critical cerebral infarction died after CABG. We consider that avoid perioperative cerebral infarction preoperative atherosclerosis, thrombus and to choose the proper procedure of the operation.

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Plasma concentrations of tumor necrosis factor α (TNFα), interleukin-1β (IL-1β) and interleukin-6 (IL-6) were measured successively during and after open heart surgery (13 cases). Plasma concentrations of TNFα did not increase during surgery but increased gradually after the 1st operative day reached the maximum level at the 7th operative day (128±15pg/ml, which was a 3-fold increase compared with the previous value). Plasma concentrations of IL-1β remained at the previous level during surgery and increased only once at 6 hours after operation. Conversely, plasma concentrations of IL-6 increased dramatically during cardiopulmonary bypass (CPB) reaching a peak at the end of CPB (260±200pg/ml, which was a 15-fold increase over the previous value) and recovered to previous values rapidly thereafter. Plasma IL-6 concentrations changed rapidly during surgery, while plasma concentrations of TNFα and IL-1β did not increase sharply. This may indicate that IL-6 may play a role as a mediator of acute inflammatory reaction.

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From January of 1987 to December 1992, twelve patients (7 males and 5 females, mean age, 52.8 years) underwent emergency surgery for DeBakey type I acute aortic dissection. The surgical procedure was resection of the initial intimal tear and replacement of the ascending aorta (four patients underwent hemiarch replacement). Operative mortality was 41.7% (5/12). Three died in the operating room due to heart failure (2) and uncontrollable bleeding (1). Another two early deaths resulted from extension of the residual false lumen. All surviving patients each had a patent double-channeled aorta and aneurysmal dilatation of the false lumen was noted in 3 patients. There were two late deaths, one due to rupture of the residual false lumen and the other, to stroke during re-operation for enlargement of the residual false lumen. It is apparent from these results that in type I acute aortic dissection extensive operation such as total arch replacement is necessary.

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We report a case who received a combined operation for abdominal aortic aneurysm (AAA) and colon carcinoma. The AAA was 7cm in diameter and the colon carcinoma was advanced without distant metastasis. To prevent contamination in the operative field, a temporary stoma was chosen instead of anastomosis for the partial colon resection. Since the patient suffered severe coronary three-vessel disease, we applied the same management as for cardiac surgery during the operation and postoperatively. There were no complications such as myocardial infarction. We assume that the number of patients with AAA complicated with malignant tumor or ischemic heart disease may increase in future. It is necessary to be careful and perform further investigations concerning operation method and perioperative management.

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Between 1988 and 1992, we experienced 4 cases of removal of renal or hepatic cell carcinoma tumor thrombi extending into the inferior vena cava and the right atrium, under cardiopulmonary bypass. We operated on 3 cases using profound hypothermia and circulatory arrest, and 1 case using moderate hypothermia and the Pringle maneuver. One case developed acute massive pulmonary embolism followed by cardiac arrest during the procedure of freeing the inferior vena cava and died on the second postoperative day due to low output syndrome. The postoperative courses of the other 3 cases were uneventful, and there was no major complication due to surgery. They were discharged and enjoyed normal daily lives. Two cases died due to recurrence of the tumor, 6 and 7 months after the operation, respectively. The merits and demerits of these two surgical methods were discussed. Appropriate selection of these methods and subjects allows safe and complete excision of tumor thrombi with satisfactory operative results.

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Cardiac angiosarcoma is a rare disease which occurs most often in young males and has a remarkably unfavorable prognosis. We experienced one male case aged 46 who had an initial symptom of cardiac tamponade due to rupture of the right ventricle. Hemostasis was made under extracorporeal circulation, and the patient was discharged temporarily. However, a large volume of hemoptysis occurred from right B₆ about 1 month after discharge, because of which resection of the right lower lobe was performed. Tumorous cells identical to those in the perforated cardiac region were detected in the resected tissue, and it was diagnosed histopathologically that the cardiac rupture was caused by angiosarcoma, resulting in pulmonary metastasis. Multiple pulmonary metastases were observed in bilateral lung following fields by CT, but administration of CDDP in iv×2 and in 150mg/day cyclophosphamide, the pulmonary metastases disappeared completely on CT on the 45th day. However, the metastases recurred soon thereafter without responding to chemotherapy, and the patient died 5 months after diagnosis of this disease because of exacerbated dyspnea.

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A 66-year-old man with an abdominal aortic aneurysm and coexisting horseshoe kidney is reported. The aneurysm was successfully replaced by a prosthetic graft without resection of the renal isthmus. Because of renal blood supply and location of renal isthmus, aortic reconstruction presents a significant technical problem. Preservation of multiple renal arteries may be facilitated by preoperative aortography, and retraction of the renal isthmus offers good operative exposure.

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The patient was a 56-year-old male with an 8-year history of Behcet's syndrome, who presented with chest pain. A saccular aneurysm (4×4cm) of the descending aorta was disclosed by X-ray and CT. Impending rupture of the aneurysm was suspected and emergency surgery was performed under cardiopulmonary bypass. The aneurysm consisted of a large thrombus, and a punched-out lesion on the aorta (φ10mm) was found beneath the thrombus. Closure with a Dacron patch was carried out successfully. Pathologic examination revealed the patient to have vasculo-Behcet's syndrome. Generally this desease has a poor prognosis, especially if an aneurysm is present, since sudden rupture can occur. Thus, prompt surgical treatment of the aneurysm should be considered. The patient was free of recurrence at the time of writing this report.

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A 53-year-old man underwent aortic and mitral valve replacement, but postoperative cardioangiograms unexpectedly demonstrated aneurysms that had developed right-anteriorly and exactly anteriorly to the ascending aorta. They were initially thought to be pseudoaneurysms formed at the sites of aortotomy for valve replacement and of the aortic hole made by the needle puncture for air-venting. Operative findings, however, strongly suggested that it was a DeBakey type II dissecting aneurysm with two entries at the same sites as described. It was found that almost all distal parts of the aneurysmal cavity, probably a pseudolumen, had been occluded with clots, leaving two round cavities at the entries, which were preoperatively observed as pseudoaneurysms. The entries were successfully closed with approximation of the aortic walls using cardiopulmonary bypass, and the patient survived the operation.

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The authors experienced a case of fatal cerebellar, and brainstem infarction accompanying clamping of the left subclavian artery during operation for thoracic aortic aneurysm. Autopsy of this case revealed that right vertebral artery became markedly hypoplastic distal to the posteroinferior cere bellar artery, and left vertebral and basilar arteries were occluded by thrombus formation. These findings indicate that clamping of the dominant left subclavian artery is responsible for severe vertebrobasilar ischemia producing the fatal brain infarction. Since the occurrence of this devastating complication, we have performed pancerebral angiography and balloon occlusion test of the left subclavian artery in patients who might undergo proximal clamping of the aortic arch between the left carotid artery and the left subclavian artery during operations for thoracic aortic aneurysm. Selective perfusion of the left subclavian artery is then planned for those with abnormal vertebrobasilar communications producing neurological signs.

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A 2-year-old girl who had been followed because of pulmonary valve stenosis since birth, underwent unsuccessful balloon valvuloplasty twice. The angiographic study showed thin cusps and remarkably thick and immobile filling defects in the main pulmonary artery, which indicated supravalvular PS or pulmonary valve dysplasia. Operation was done under conditions of a beating heart and total cardiopulmonary bypass. Pulmonary valve dysplasia was localized on the edge of all three cusps. After resection of the dysplastic lesion, the stenosis was released and slight regurgitation was observed by ultrasonography study.

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