We developed a percutaneous left ventricular assist system (PLVAS) using a centrifugal pump. PLVAS is the transseptal left atrial-femoral artery bypass to unload the left ventricle using a centrifugal pump. This PLVAS can be implanted through the inguinal vessels under fluoroscopy and also in 2 cases additional transesophageal echocardiogram guiding was performed. This PLVAS was applied to 6 patients with profound heart failure and refractory cardiogenic shock. The implantation of PLVAS required 30-60 minutes. The PLVAS assist flow was maintained at 3.0-4.0l/min. One patient with acute myocardial infarction survived and has been doing well for more than 1 year. The complications directly related to this procedure were minimal. PLVAS appears to be useful for patients with severe heart failure and may be useful as a short-time support or bridge to other more aggressive forms of life support.

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Various types of surgical techniques have been reported for the closure of complicated PDA, since Morrow first described an innovatory operative method. At our institute, extracorporeal circulation has been frequently used as a support measure for these operations to ensure the safety of the operation. Ten patients with complicated PDA were operated under extracorporeal circulation. All patients but one were adults. The reason for use of extracorporeal circulation included age, presence of atherosclerosis or calcification of the ductus, short neck ductus, ductal aneurysms, right sided descending aorta and recanalization after previous ligation. The ductus was approached through the left lateral thoracotomy in 8 patients and median sternotomy in 2. The Morrow procedure was performed in 2 patients. No hospital death occurred, although the mean duration of the hospital stay after the operation was longer in these cases than in cases with simple PDA. We conclude that the use of extracorporeal circulation is safe and effective for the closure of complicated PDA.

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In 712 patients with previous coronary artery bypass grafting, 34 patients (4.8%) had PTCA and 11 (1.5%) had reoperations for recurrent angina from 1974 to August 1992. Eighty-two percent of the patients undergoing PTCA had unstable angina, indicating the preference of PTCA as the repeat intervention for patients with recently recurrent angina. Approximately 50% of recurrent angina occurred because of graft failure within one year after CABG. The other recurrences were attributed to progression of native coronary disease and occurred 4 years postoperatively. The short-term patency rate of revascularization was 86% in PTCA and 92% in reoperation respectively. There was no significant difference between them. Although the success rate of PTCA for the failure of the saphenous vein graft was generally high, reoperation should be chosen for stenosis at the proximal anastomosis site because the incidence of restenosis was high. There was no procedure-related death in either group, though there was one acute myocardial infarction in each group. PTCA should be chosen only for the patients with recently recurrent angina. However reoperation, because of its excellent long-term patency, should be considered when the patient develops restenosis at the site of PTCA within one year.

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Single administration of warfarin at 0.1mg/kg was carried out at an early stage after cardiac operation, and changes in the blood vitamin K levels, blood coagulation factors and the blood warfarin levels within 24 hours of administration were evaluated to determine an ideal mode of initiating the administration and the initial dose in warfarin therapy at an early postoperative stage. The study group consisted of 30 postoperative cardiac cases, and 20 healthy individuals as controls. The results showed that anticoagulant effects cause close to the therapeutic range within 24 hours of administration of oral warfarin therapy in prothrombin time of the postoperative cases. As regards the blood vitamin K levels, both vitamin K₁ and K₂ levels were more depressed in the subjects than in the control group. Differences in the vitamin K level seemed to play a key role in the difference in anticoagulability between the two groups. It was thus implied that the risk of an abrupt decline in coagulability and a decrease in the level of vitamin K parallels the starting level of warfarin instituted in the wake of a cardiac operation. To conclude, safe and effective warfarin therapy should be started at a 0.1mg/kg dosage level at an early stage after the cardiac operation.

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A recent study evaluated the effect of pleurotomy for harvesting internal thoracic arteries (ITAs) on pulmonary complications after coronary artery bypass grafting (CABG). Fifty consecutive patients with pleurotomy (group I) were studied retrospectively and compared with a control group of fifty patients undergoing CABG without pleurotomy during ITA harvest (group II). Group I was divided into two groups; forty patients using left ITAs with left open pleurotomy (group Ia), and ten patients using bilateral ITAs with bilateral open pleurotomy (group Ib). On the other hand, group II includes 22 patients without pleurotomy (group IIa) and 28 patients with closed pleurotomy (group IIb). In group I, ITAs were dissected from the chest wall with mediastinal pleura and then isolated from the pleura by pleurotomy. Before sternal closure, an L-shaped pleural tube was inserted into the deep costophrenic sinus and the pleurotomy remained open. In group II, ITAs were simultaneously dissected from the chest wall and mediastinal pleura, and if the pleura was damaged, the pleurotomy was approximated before sternal closure. There was no significance in the number of bypass grafts, aortic crossclamp time, cardiopulmonary bypass time and temperature. ITA harvest time with open pleurotomy was shorter than that of closed pleura (15min versus 25min). Postoperatively, the ventilation time and duration of chest drainage also showed no significance, however group Ia and Ib showed significantly more fluid accumulation removed by chest drainage (Ia, 288±193ml; Ib, 285±198ml, versus IIb, 169±98ml). On postoperative day 30 no pleural effusion was observed in group I but it was seen in one case in group IIb which had diaphragm paralysis. In conclusion, open pleurotomy results in minimal pulmonary complications with optimal chest drainage and offers significant advantages for harvesting ITAs.

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We have operated upon 17 cases of distal arch aneurysm, including 3 cases of rupture, during the past 6 years. Operative adjuncts during aortic cross clamping were left heart bypass with a centrifugal pump (LHB, 6 cases), retrograde cerebral perfusion (RCP, 5 cases) and selective cerebral perfusion (SCP, 6 cases). LHB was applied to localized, the aneurysm apart from the left subclavian artery. It was safely performed during operation, but cerebral embolism happened in 2 cases with aortic cross clamping. RCP was performed in emergency cases of rupture or impending rupture. Recently 3 cases were operated by left thoracotomy under RCP. One case, an 85-year-old female, was perfused for 100min by RCP, became unconsciousness and died by multiple organ failure. Although this method was simple and easy to prepare, the efficacy of cerebral perfusion is unclear and a perfusion time of less than 90min is thought to be safe. SCP was performed in 6 cases of large aneurysm, including four cases of total arch replacement. There was one operative death, but minimum complications in the survivors. Distal arch aneurysm varies in shape, location and size. Operative adjunct must be selected based on the condition of the aneurysm.

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A 49-year-old man presented in emergency center with complaints of severe lumbago and severe pain of the right lower limb. Symptoms were suggestive of hernia nuclei pulposi and he was referred to orthopedic department of our hospital. His pain was not relieved by analgesics and the right lower leg was cyanotic with a swollen, hard, and tender calf. On palpation a pulsating mass was revealed in the mid-abdomen. He was transferred to the cardiovascular floor. CT and IA-DSA revealed an abdominal aortic aneurysm and no occlusion of the major arteries of the right lower leg. The serum glutamic oxaloacetic, lactic dehydrogenase levels all increased especially the creatinine phosphokinase increased to 46, 460IU/l, and the urine myoglobin level was 4, 200ng/ml. Myonephropathic metabolic syndrome (MNMS) was suspected. Urine volume was maintained with fluid infusion and diuretics. The blood urea nitrogen and potassium levels remained within normal limits throughout the course. The immediate recognition of MNMS and treatment of the condition were successful in preventing serious complications. But all the toes of the right foot became necrotic and they were amputated. Two months after admission, replacement of the abdominal aortic aneurysm was performed successfully. The patient was discharged in good condition one month after the operation.

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A 75-year-old woman was admitted with complaints of progressive portprandial abdominal pain and weight loss. A bruit was audible in the epigastrium. Angiogram showed narrowing of the lower abdominal aorta with complete occlusion of the celiac, the superior and inferior mesenteric arteries. A 6mm Gore-Tex graft was first anastomosed from the supraceliac abdominal aorta to the superior mesenteric artery. A saphenous vein graft was then inserted proximally to the Gore-Tex graft and distally to the celiac artery. The postoperative course was uneventful. During two years of observation symptoms have disappeared and patient returned to a normal weight.

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A case of deep femoral artery aneurysm under continuous oxygen therapy for chronic respiratory failure was treated successfully by arterial ligation. The ligation of the deep femoral artery was easy and simple. This procedure may be indicated in poor risk patients or cases of ruptured aneurysm.

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We report a 57-year-old male who suffered from ascending aortic aneurysmal dilatation complicated with acute localized dissection. He had received aortic valve replacement with a prosthesis for severe aortic regurgitation resulting from valve degeneration and annular dilatation 4 years previously at which time the maximal ascending aortic diameter had been 45mm so that a procedure for the aorta itself was not done. On the present occasion an aortogram showed a maximal aortic diameter of 90mm and localized dissection from above the right coronary ostium to near the connection to the brachiocephalic artery. A successful composite valve-graft replacement of the ascending aorta (Bentall procedure with Piehler's modification) was carried out on a semi-emergency basis. This experience with this case implies that certain intervention for associated moderate aortic dilatation should be considered when an aortic valve replacement is performed.

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Left ventricular rupture is one of the major lethal complications of mitral valve replacement. A case of successful repair of postoperative left ventricular rupture following mitral valve and aortic valve replacements, tricuspid valve annuloplasty in chronic renal failure is described. The patient was a 58-year-old male and suffered from mitral stenosis and regurgitation with left atrial thrombi, aortic stenosis and regurgitation, and tricuspid regurgitation. It has been 13 years since the patient was operated on for mitral stenosis with open mitral commissurotomy. Mitral valve and aortic valve replacements, tricuspid valve annuloplasty was performed under cardiopulmonary bypass and cardioplegic arrest using the extracorporeal ultrafiltration method (ECUM) and continuous venovenous hemodialysis (CVVH). The patient has been in good condition during weaning from cardiopulmonary bypass. After the operation, left ventricular rupture occurred due to transient high blood pressure in the operating room. The patient was quickly put back on cardiopulmonary bypass. In this case, the rupture occurred although no technical errors were thought to be made. The site of the rupture was type II in the Treasure classification. The left ventricular rupture was repaired with the patch closure method under cardiopulmonary bypass and cardioplegic arrest. The postoperative cardiac function was relatively well preserved. More attention should be paid to cases in this type of condition; mitral stenosis, long history, multiple valve replacements, and chronic renal failure. This patient died from sepsis caused by the infectious route of continuous ambulatory peritoneal dialysis (CAPD) on the 61st postoperative day.

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Three patients with subclavian artery obstruction caused by arteriosclerosis underwent surgical reconstruction based on their specific anatomic characteristics. Subclavian artery transposition was performed in a patient with a short segmental occlusion of the proximal subclavian artery. The patient with a long segmental occlusion, from the origin of the internal thoracic artery to the origin of the thoracoacrominal artery, underwent bypass-grafting between common carotid artery and axillary artery. The graft was passed lateral to the anatomical tract to prevent compression by the scalenus and subclavian muscles. Because the branchial plexus also can be compressed in the thoracic outlet, the scalenus muscles were detached at the first rib in both methods. It is important to consider the specific cause of subclavian artery occlusion when planning corrective surgery. Ischemic and neurologic symptoms improved using both techniques.

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A 51-year-old female inserted a needle through the chest wall in a suicide attempt. Chest roentgenogram showed the needle located in the cardiac shadow and chest CT showed the needle penetrating into the ventricular wall. We removed the needle through median sternotomy. The needle had penetrated the right ventricular myocardium 2mm from the LAD. The tip of the needle reached the diaphragm and the surface of the diaphragm had been injured by the needle. The needle was removed without any difficulty and she was discharged 14 days after the operation.

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A 71-year-old man was successfully operated by a simple technique for a saccular aneurysm of innominate artery. The aneurysmectomy and graft replacement was carried out using simple clamping and caused no cerebral accident. The preoperative angiographic Matas' test showed good contralateral cross-filling. This simple technique can be useful in selected cases of innominate artery aneurysms for which surgical approaches are apt to be complicated.

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In von Recklinghausen's disease vascular involvement is rare, especially rupture of peripheral arterial aneurysms. A 65-year-old man with previously diagnosed neurofibromatosis was admitted because of left lateral neck and left shoulder pain. Computed tomography and selective left subclavian angiography revealed ruptured aneurysm of left costocervical artery, and therefore an emergency operation was performed. Left costocervical artery was exposed and proximal ligation of the aneurysm was performed. Angiography is a most useful and important procedure in operations for vascular involvement in von Recklinghausen's disease.

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