Continuous retrograde cerebral perfusion (CRCP) during hypothermic circulatory arrest is a useful adjunct for brain protection during aortic arch surgery. According to our experience, no correlation was observed between perfusion pressure and flow rate. Internal jugular vein valves can restrict the flow of CRCP. We performed a study of internal jugular valves, morphologically in autopsy specimens and functionally in clinical patients. Apparently good venous valves were observed in 18 out of 30 cases (60%) on the right side and in 10 out of 29 cases (34%) on the left side. Of 32 autopsy cases, all but one had venous valves at the venous angle. Angiography of the right brachiocephalic vein revealed internal jugular vein valves in only 15 of 38 patients (39%), and in 34 of the 38 patients (89%) some regurgitation of the valve was demonstrated. In 4 patients (11%), no regurgitation was observed. These results show that internal jugular vein valves can restrict the flow of CRCP in some cases and this may be one possible cause of the lack of correlation between perfusion pressure and flow rate.

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Postoperative cardiac function and the occurrence of arrythmia depend upon myocardial protection during open heart surgery in severe concentric hypertrophy. The effect of myocardial protection was evaluated in terms of several released cardiac enzymes before and after reperfusion, and postoperative left ventricular (LV) cardiac function from cardiac pool scintigram in 21 cases with aortic stenosis (AS Group). These data were compared with 20 cases with aortic regurgitation (AR Group). Heart weight and aortic cross-clamping time were not significantly different in these two groups. The enzymatic values in peak total creatine-kinase (CK) and peak CK-MB fraction were higher in the AS group than in the AR group, and peak GOT was significantly elevated in the AS group (peak GOT: 93±32 in AS group, 64±17IU/l in the AR group, p<0.01). Among the cases in the AS group, six cases with LV small cavity (LVDd<4cm) and severe concentric hypertrophy were associated with high values of released enzyme and the occurrence of ventricular arrythmia. Postoperative cardiac function was estimated from both systolic parameters such as LV ejection fraction (LVEF) or peak ejection rate (PER) and diastolic parameters such as peak filling rate (PFR) or early diastolic filling rate (1/3PFR). Postoperative LVEF and PER improved to normal control levels in the AS group with preoperatively depressed systolic function, although values were decreased in the AR group with impaired systolic function. The postoperative early diastolic peak filling rate did not recover to control levels in the AS group as well as the AR group, and was impaired in the AS group with severe concentric hypertrophy due to elevated chamber stiffness and the delay of time to peak filling rate. In severe concentric hypertrophy, we used several techniques for myocardial protection of terminal blood cardioplegia, and gradually increased reperfusion pressure and LV venting after reperfusion. Late results revealed a good clinical course in all 21 cases except for the occurrence of arrythmia in three.

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Cardiac cachexia is a terminal clinical stage of valvular heart disease, and there is high incidence of postoperative mortality and morbidity. Cardiac cachexia was considered to be present when patients with mitral lesions showed all of the following criteria; 1. mitral valve disease associated with relative tricuspid regurgitation, 2. lean body below 80% of %standard weight, 3. NYHA functional class IV, 4. marked hepatomegaly and congestive liver dysfunction (ICG retention rate over 30%.) Ten patients satisfying the criteria were divided into two groups according to the interval of postoperative respiratory care. Group 1 (n=5), patients necessitating mechanical ventilation for more than 5 days after operation, Group 2 (n=5), patients requiring ventilation up to 5 days after operation. Pre- and postoperative nutrition, respiratory and circulatory states were evaluated for these two groups. In pre- and postoperative periods, intravenous hyperalimentation was administed in two groups, during the postoperative period, two patients of group 1 required tube feeding. In the pre-operative period, three patients in group 1 needed respiratory care (1 intra-tracheal intubation and 2 oxygen mask inhalation). The results were as follows; 1. The duration of illness was longer in group 1 than in group 2. 2. In the postoperative period, there was no difference in the amount of catecholamine, postoperative course and prognosis between groups 1 and 2. Surgery for valvular disease is possible even in cases of cardiac cachexia, if sufficient management of nutritional state, respiration and circulation can be maintained.

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Periannular abscess and mycotic aneurysm due to infective endocarditis are very difficult conditions to treat surgically. Beginning in 1983, we introduced a translocation technique on 9 such cases. In particular, 7 patients who underwent a new sutureless translocation technique all showed an uneventful course and were discharged. There was no hospital death, but four patients died in the late period (2 heart failure, 1 ventricular tachycardia and 1 thrombotic valve). The sutureless translocation method consists of insertion of a composite valve into the ascending aorta (a ring was detached from an intraluminal ringed graft and a prosthetic valve was sutured to it at that point) and coronary artery bypass grafting to the right and left coronary arteries. Our new technique was simple, required only a short aortic clamping time (mean 173.9min) and there was no significant bleeding. This new translocation technique provides a solution for the treatment of periannular abscess and mycotic aneurysm due to infective endocarditis.

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Renal damage caused by hemolysis during cardiopulmonary bypass (CPB) was investigated, and the preventive effects of haptoglobin in regard to this condition was also evaluated. Nineteen patients who underwent open heart surgery were divided into two groups: a control group (n=11) and a haptoglobin group (n=8). In the control group, the level of plasma-free hemoglobin increased significantly after CPB (p<0.01), and this level was strongly correlated with renal tubular leaking enzymes: NAG (r=0.76) and γ-GTP (r=0.81), in the Intensive Care Unit or on the first day after surgery. On the contrary, in the haptoglobin group, in which 4, 000 units of haptoglobin was added in the priming solution of CPB, no increased level of plasma free hemoglobin was observed. Furthermore, leak age of renal tubular enzymes were statistically less (p<0.05). It was concluded that free hemoglobin was a cause of renal damage during CPB and the damage was preventable by the administration of haptoglobin.

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The infected arterial aneurysm has a fulminent infectious process frequently resulting in death if not properly treated. We reviewed 10 patients to identify the aneurysm location, etiology, bacteriology, and the mortality of surgical treatment. The abdominal and thoracic aorta was the most common site (6 cases). The primary causes were infected endocarditis, acute cholecystitis, abscess in the psoas muscle and depressed immunocompetence, but there was no case of iatrogenic trauma. Eight patients had positive blood or aneurysmal wall culture, Staphylococcus aureus, Staphylococcus epidermidis and salmonella being the most frequent bacteria identified. The proper treatment of infected arterial aneurysm remains controversial. Three methods of surgical treatment were performed; one, en bloc aneurysmal excision with in situ prosthetic graft replacement, two, open aneurysmal resection and irrigation with large amount of diluted popdon iodine solution followed by in situ prosthetic graft replacement with wrapping by an omental pedicle. Three, extraanatomical bypass grafting. Six of 7 patients in whom the infection subsided with antibiotic therapy showed good long term results. However, 3 patients with uncontrollable infection died 1 to 3 months after operation.

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Two cases of granulocytosis after cardiac surgery were treated successfully with a recombinant granulocyte colony stimulating factor (rhG-CSF). Case 1 was a 65-year old man who underwent a double valve replacement due to infective endocarditis. As his white blood cell counts decreased to 1, 000/mm³ on the 24th postoperative day due to long-term antibiotic therapy, 125μg of rhG-CSF was given intracutaneously for 7 days. White blood cell counts increased after the 27th postoperative day and reached 15, 500/mm³ on the 30th postoperative day. The patient became afebrile immediately after administration of rhG-CSF. Case 2 was a 70-year-old man who suffered pneumonia after aortocoronary bypass surgery. As his white blood ceell counts decreased to 2, 300/mm³ on the 21st postoperative day, 80μg of rhG-CSF was given intracutaneously for 7 days. He became afebrile after the 22nd postoperative day and his white blood cell counts increased 18, 200/mm³ on the 28th postoperative day. rhG-CSF not only increases white blood cell counts but also reduces infectious symptoms and therefore is effective in managing granulocytosis after cardiac surgery.

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A 59-year-old man, who had received graft replacement for the “inflammatory” abdominal aortic aneurysm two years previously was admitted to our hospital because of preshock caused by intermittent intestinal hemorrhage. Gastrointestinal endoscopy revealed an ulcer at the 3rd portion of the duodenum. As aortoenteric fistula was diagnosed and he underwent an emergency operation. After initial axillo-bifemoral bypass grafting, the aortic graft was removed and the aortic stump was closed directly. The duodenal rent was closed by Albert-Lembert suture, He survived the operation and was discharged. We suggest that extra-anatomic bypass is safer than in situ graft replacement in patients with secondary aortoenteric fistula after operation for “inflammatory” abdominal aortic aneurysm, because adjacent organs adhere firmly to the proximal suture line in such cases.

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This is a rare case of abdominal apoplexy encountered in a 50-year-old man who had aortic and mitral valve replacement due to dominant regurgitation resulting from infective eneocarditis. On the 4th day after the operation, retroperitoneal bleeding, probably due to rupture of the splenic artery aneurysm, occurred and he developed shock. On the 28th day, there was bleeding in the digestive tract and blood pressure was low, probably due to rupture of the microaneurysm of the small artery distributing to the ileum. Rupture of an abdominal vessel without a recognizable external cause is called abdominal apoplexy, and our case was caused by mycotic aneurysm caused by infective endocarditis. Angiography facilitated the accurate diagnosis.

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Two hemodialysis patients underwent coronary artery bypass grafting. Emergency coronary artery bypass grafting was performed in one patient with unstable angina and acute left ventricular failure. The other patient underwent a combined operation of coronary artery bypass grafting and replacement of abdominal aortic aneurysm. In both patients, hemofiltration was used during cardiopulmonary bypass. In the early postoperative periods, peritoneal dialysis and extracorporeal ultrafiltration method (ECUM) were used in Case 1, while Case 2 was treated by hemofiltration and ECUM. Postoperative coronary angiography showed that all grafts of both patients were patent, and both patients weve discharged from hospital without angina.

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A 65-year-old man was referred to our service complaining of intermittent claudication of his left leg. During preoperative examinations, he was found to have bilateral isolated internal iliac artery aneurysms. As it was strongly suspected that ischemic colitis or gluteal ischemia would be caused if his bilateral internal iliac arteries were ligated during aneurysm surgery, his right internal iliac artery was reconstructed using a prosthetic graft. His postoperative course was uneventful. As aneurysm of the internal iliac artery is rare, there are few reports about reconstruction of the internal iliac artery. Technical details and pitfalls of internal iliac artery aneurysm surgery were discussed.

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This is a case report of a 57-year-old woman with high aortic occlusion (HAO) who had acute symptoms of severe ischemia of the lower extremities and the intrapelvic organs. Generally, HAO is a chronic ischemic disease of the lower extremities and the intrapelvic organs; therefore, acute HAO is relatively rare. Acute thrombotic occlusion of a major collateral artery might be the cause of acute HAO. Laser Doppler flowmetry of the sigmoid colon was useful to evaluate the ischemia of intrapelvic organs. Thrombectomy of the juxtarenal portion with the suprarenal aortic cross clamp was performed within four minutes, then the clamp was moved to the infrarenal portion. The remaining occluded aorta was replaced with a Y-shaped knitted Dacron graft. She had no symptoms after the surgery except renovascular hypertension. Seventy five percent stenosis of the right renal artery was exacerbated to 99%. Vascular clamping of the right renal artery might have been the cause of severe stenosis. Percutaneous transluminal renal angioplasty was successfully performed after the surgery. Aggressive renal artery reconstruction during surgery is recommended in cases with moderate or severe renal artery stenosis.

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A thirteen-day-old neonate was admitted because of systolic heart murmur, tachycardia, tachypnea and sucking weakness. The chest X-ray film demonstrated remarkable cardiomegaly and pulmonary congestion. Echocardiography detected marked thickening and stenosis of the aortic valve, and left ventricular dysfunction (EF=10%). The pressure gradient between left ventricle and ascending aorta was presumed 130mmHg with pulsed Doppler echocardiography, Since he did not respond to conservative treatment, an emergency open aortic valvular commissurotomy under cardiopulmonary bypass was performed the day after admission. We made incisions of 1mm in the left side and 0.5mm in the right side commissure of the adherent bicuspid aortic valve. After the procedure, left ventricular function improved (EF=57%), and the pressure gradient was reduced to 62mmHg. He showed good recover from the congestive heart failure. There are few reports about operative treatment of congenital aortic valve stenosis in neonates. This is considered to be the third youngest successful operative case of open aortic valvular commissurotomy in Japan.

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We present three cases of injured iliac arteries due to blunt abdominal trauma in traffic accidents. We performed emergency operations on these patients. Two of them received interposition of artificial prosthesis, and one received extraanatomical bypass. Fasciotomy was needed for compartment syndrome in 2 cases and one of them suffered a fractured pelvis with rupture of the ipsilateral femoral vein. One case was complicated with laceration of the mesentery. The postoperative course was almost uneventful in 2 cases but one died 8 days after operation because of subsequent multiple organ failure due to renal failure with necrosis of the small intestine of unknown cause. The diagnostic difficulties in such injuries depend on the existence of complications and different obstructive mechanisms from the penetrating injuries. Adequate and prompt diagnosis based on the clinically suspicious signs including weakness and discrepancy of the pulse are required.

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Between January and December 1991, six patients aged 80 years or older underwent coronary artery bypass grafting (CABG). Five cases were female, the mean age was 83 years, and the oldest was 90 years of age. Of these patients, five were of 3 vessels disease, three of whom had left main trunk lesions as well. Five cases were classified as NYHA-IV, four of whom required inotropic support, and two needed IABP support preoperatively. Emergency CABG was performed in five patients. As a result, all patients needed extensive postoperative care and extended hospital stays. However, five cases survived, and there was one hospital death due to severe left ventricular dysfunction (hospital mortality; 16.7%). We conclude that CABG in patients 80 years or older, although associated with longer ICU and hospital stay, can give good operative results and that patients should not be denied CABG because of age alone.

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