In the past 13 years, 17 patients underwent reoperation after intracardiac repair, including reconstruction of the right ventricular outflow tract. Primary diagnoses of the cardic anomalies were tetralogy of Fallot (TOF) (8 patients), extreme type (TOF) (4 patients), TOF with absent pulmonary valve (1 patient), double outlet right ventricle (DORV) (2 patients), truncus arteriosus (1 patient) and transposition of the great arteries (TGA) (1 patient). Patients were divided into 4 groups based on the surgical procedures for reconstruction of the right ventricular outflow tract as follows: Group A, porcine valved conduit; Group B, autologous pericardial valve bearing tube graft; Group C, transannular patch; Group D, outflow patch with pulmomary valvotomy. The main reason for reoperation in groups A and B was pulmonary stenosis due to calcification of the porcine valve or shrinkage of the pericardial tube graft. Average periods between corrective surgery and reoperation were 7 and 13 years in groups A and B, respectively. Reoperation was performed for massive tricuspid regurgitation and residual shunt, 15 and 24 years after previous operations in groups C and D, respectively. Low cardiac output syndrome, proconged right heart and respiratory failure were major postoperative complications in groups A, B and C. Furthermore, one patient in group A and one other in group C died in the long-term period after reoperation. Both patients had had markedly dilated hearts associated with frequent PVCs. In conclusion, earlier reoperation for progressive and/or residual lesions should be performed to obtain better surgical outcome and quality of life of the patients.

View full abstract

This study was designed to clarify the usefulness and pitfalls of hypothermic management after Fontan's operation. Twenty-five patients who underwent Fontan's operation and received hypothermic management in an acute postoperative phase from 1974 to 1991 were divided into two groups; the alive (S) group and the dead (D) group. The lowest rectal temperature during the procedure was 32°C on average. There were no significant differences in preoperative indices of pulmonary circulation and renal function. After rewarming, PaO₂ and daily urinary output were increased and central venous pressure decreased significantly in the S group. In all S group patients, urinary output was increased during hypothermia irrespective of peritoneal dialysis. Anuria occurred 2 days on average after induction of hypothermia in D group. Urinary output in D group decreased significantly for 4 days compared to S group. On the other hand, it was possible to save two patients who underwent take-down of Fontan's operation within 6 hours after the onset of anuria. We conclude that hypothermic management is useful in serious cases after Fontan's operation and that daily urinary output in relation to body weight during hypothermia is most important as an index of post operative circulation.

View full abstract

We performed surgical treatment for 21 patients of airway obstructions associated with congenital heart disease from December 1986 to March 1993. In all patients perioperative bronchoscopy demonstrated the cause and site of airway obstructions. Seven patients with corrective cardiac surgery (7/7), 7 with palliative cardiac surgery (7/10) and 2 with surgery for airway diseases (2/4) could be weaned from respirators following surgical treatment. Five patients died postoperatively. A respirator was required in 16 patients (76%) preoperatively. The suspension of pulmonary artery with intraoperative bronchoscopy was carried out in 6 patients. Five (5/6) were successfully extubated earlier postoperative day (mean 8.4 days), whereas only five in 10 patients without that procedure could be weaned from the respirator at a mean of 2 months. Identification of potential airway obstruction and early extubation is needed to reduce the mortality and morbidity caused by airway obstruction associated with congenital heart disease. Preoperative bronchoscopy is useful for diagnosis of airway obstructions and essential for decision making concerning surgical treatment. To early extubation in patients with marked airway obstructions, we recommend appropriate choice of the surgical procedure combined the suspension of pulmonary artery.

View full abstract

Recently, modified Fontan operation is being used for asplenia syndrome. We reviewed 24 patients with asplenia syndrome who underwent surgical intervention. Eleven (45.8%) of them had total anomalous pulmonary venous connection (TAPVC) and 6 of these were accompanied by pulmonary venous obstruction (PVO). Surgical results were poor in the PVO group. In 4 cases with open heart palliation, that is atrium-common pulmonary venous chamber anastomosis, there were 2 operative deaths, 1 late death, and 1 survival. In 18 cases without PVO, statistical analysis (Fisher's exact probability) showed that pulmonary atresia (PA) was a definite risk factor for Fontan candidates (p<0.05). In 9 cases with pulmonary stenosis (PS group), there were 5 candidates for the Fontan type operation. In the other 9 cases with PA (PA group) there were no candidates for the Fontan type operation. Only the size and the morphology of the pulmonary artery were significant factors (p<0.05) for candidates of the Fontan type operation among the risk factors such as size and morphology of the pulmonary artery, pulmonary vascular resistance and pressure, atrioventricular valve regurgitation, and single ventricular function. Finally, in these 24 cases, there were only 5 candidates (20.8%) for a Fontan type operation. In conclusion, in order to increase candidates for Fontan precedures, it is important to maintain an adequate pulmonary blood flow. Earlier PDA division and pulmonary arteries plasty are the most importantin PA group. In both groups pulsatile bidirectional cavopulmonary shunts may be useful to increase effective pulmonary blood flow without ventricular volume overload, which leads to atrioventricular valve regurgitation.

View full abstract

We studied the effects of granulocytic elastase (GEL) and fibronectin (FN) on the coagulation and fibrinolytic system when using cardiopulmonary bypass (CPB). Blood sampling was performed before CPB (Pre), just after CPB (Post) the 1st postoperative day (PD1) and the second postoperative day (PD2). Laboratory parameters were GEL, FN, fibrinogen (Fib), prothrombin time (PT), fibrin degradation products (FDP), D dimer (D-D), α2 plasmin inhibitor plasmin complex (PIC) and antithrombin III (AT III). The level of GEL was highest and that of FN was lowest at Post. The levels of Fib, PT and AT III were lowest and that of PIC was highest just after CPB. The levels of FDP and D-D were highest on PD1. The levels of GEL and D-D correlated just after CPB and on PD1 and PD2. The level of GEL correlated with that of PIC on PD1. These results demonstrated that the level of FN decreased with CPB. And it was expected that CPB time affected the level of GEL. The levels of GEL affects D-D and PIC which are fibrinolysic factors particularly related to secondary fibrinolysis.

View full abstract

Quantitative histochemical analysis of the internal thoracic artery (ITA) and right gastroepiploic artery (GEA) was performed using microspectrophotometry. Arterial specimens from eight patients who underwent coronary bypass grafting using both ITA and GEA grafts were examined. There were seven men and one woman with a mean age of 60 years; ranging from 36 to 73 years. Concerning risk factors, 4 patients had hypertension, 3 had hypercholesterolemia and 2 had diabetes mellitus. The degree of intimal hyperplasia was calculated as follows; Intimal hyperplasia (%)=(I/I+M)×100 (I: area of intima, M: area of media). Quantitative histochemical analysis (smooth muscle cells, elastin, collagen and mucopolysaccaride) of arterial graft was measured by means of microspectrophotometry. Pieces of both the ITA and GEA grafts were obtained immediately before grafting. Each sample was stained with Azocarmin G, Weigert, van Gieson and Alcian Blue stains to identify smooth muscle cells, elastin, collagen and mucopolysaccaride, respectively. Intimal hyperplasia was significantly greater in GEA than ITA grafts (25.3 ±8.7% versus 6.8±3.5%, respectively; p<0.01). In quantitative histochemical analysis of the arterial grafts, the volume of smooth muscle cells was also significantly higher in GEA than ITA at both the intima (ITA; 38.8±7.9%E, GEA; 52.5±7.6%E, p<0.01) and media (ITA; 49.6±6. 5%E, GEA; 59.5±8.2%E, p<0.05). No significant differences in elastin, collagen or mucopolysaccaride content were observed. The greater amount of smooth muscle in GEA grafts may be one reason why the magnitude of intimal hyperplasia was greater in GEA than ITA grafts. Long-term follow-up is necessary to determine the course of atherosclerotic change in arterial grafts.

View full abstract

Seven children aged 3 to 14 years, underwent cardiac valve replacement with a St. Jude Medical valve prosthesis. In 4, the valve was placed in the aortic position, in 2 in the mitral position and in 1 in the aortic and mitral position. Three patients underwent Konno's procedure. We followed up them from 2.3 to 9.3 years (mean follow-up 6.0 years). There were no operative or hospital deaths. One patient died after delivery by caesarean section 9.3 years after the operation. All patients recieved warfarin and antiplatelet agents for postoperative anticoagulation and no thromboembolic or bleeding complications occured. All survivors did not need reoperation and they were in New York Heart Association functional class 1 without somatic growth retardation.

View full abstract

A 57-year-old male had single bypass graft to the right coronary artery with a saphenous vein graft 20 years previously. He noticed recurrent anginal pain since 1991 and thoracic aortic aneurysm was also pointed out in 1993. Coronary angiography showed that the saphenous vein graft was occlusion, accompanied with the distal portion of the occluded anterior descending coronary artery perfused by collateral flow from the circumflexus branch. The left ventricular function was moderately impaired (EF=38%). Re-do of coronary artery bypass grafting was done to the AV branch of the right coronary artery with the right gastroepiploic artery and the primary sequential grafting to anterior descending coronary artery and diagonal branch with left internal thoracic artery. One month after CABG, graft replacement of descending thoracic aorta was done because of thoracic aortic aneurysm. The postoperative course was uneventful except for the complication of chylothorax after the second operation. Postoperative angiography showed good patency of the left internal thoracic artery and right gastroepiploic artery and no abnormality of the graft anastomosis.

View full abstract

An 80-year-old male patient had complained of left abdominal pain since 1990, and an abdominal aortic aneurysm (AAA) 5.3cm in diameter was diagnosed by computed tomography (CT). The patient was NYHA class III with complaints of chest pain during exercise. Coronary arteriography showed that he had three-vessel disease. At that time, aneurysmectomy was not anticipated due to his age and because the AAA showed no tendency to enlarge. However, in October 1993, CT showed that the AAA rapidly enlarged to 6.8cm in diameter. Due to the greater risk of rupture of the AAA, aneurysmectomy was considered necessary. The operative mortality associated with aneurysmectomy in patients with coronary artery disease (CAD) is higher than that in patients without CAD. Therefore, coronary artery bypass grafting (CABG) was indicated prior to aneurysmectomy. The patient underwent CABG (two vessels) in December 1993, and aneurysmectomy was successfully performed in February 1994. He was discharged uneventfully 17 days after the operation.

View full abstract

We report 3 cases of aneurysms in which platelet consumption may last until surgical resection of the aneurysm, and two of whom manifest with clinical DIC. The unique features in these 3 aneurysms are that they had a vortical flow in the aneurysms and a lack of mural thrombus. Two had sharp bends at the base of the aneurysm, and one had saccular projected aneurysm. The vortical flows may prevented accumulation of mural thrombin. We examined plasma level of βTG and PF4 by direct puncture of the aneurysm in two cases. The platelet secreting granule levels were higher in the aneurysms than in other proximal arterial levels. We also measured plasma TXB₂ and FPA levels, and obtained a higher values in the aneurysm. We suspect that coagulation and fibrinolytic processes were acceleated in the aneurysms. Preoperative low dose heparin corrected the bleeding diathesis, and platelet transfusion was also effective, and surgical resection halted this coagulopathy. We concluded that DIC associated with aortic aneurysms may be caused mainly by platelet dysfunction. The vortex in huge aneurysms may cause chronic activation and consumption of platelets.

View full abstract

Cor triatriatum is an uncommon congenital malformation in which the fibromuscular abnormal septum divides the atrium into two compartments. Generally it is used to mean cor triatriatum sinister in which the left atrium is divided into two lumens. In typical cor triatriatum, an abnormal fibromuscular septum divides a proximal chamber that receives the pulmonary vein from a distal chamber that communicates with the left atrial appendage and the mitral valve. Several hypothesis were proposed concerning the mechanism of the abnormal septation of the atrium, but no single hypothesis could explain all the cases convincingly. We report the successful surgical treatment of a 6-month-old male patient with the rare variant of the cor triatriatum with pulmonary hypertension. The left pulmonary vein and superior right pulmonary vein drained into an accessory chamber which opened to the right atrium through a sinus venousus type atrial septum defect. The left inferior pulmonary vein drained into the true lumen which opened to right atrium through the patent foramen ovale.

View full abstract

A 52-year-old man suffering from Behçet's disease had undergone 6 operations for recurrent aneurysms of the bilateral iliac and femoral arteries. Thereafter, the patient underwent graft replacement for abdominal aortic aneurysm. Six years later he complained of lower abdominal pain and back pain. Abdominal CT-scan revealed abnormality of the proximal anastomotic site. The proximal suture line was completely dehiscent. The distal edge of infra-renal abdominal aorta was closed with interrupted mattress sutures. A right axillo-iliac bypass using a Dacron graft was performed for arterial reconstruction of the lower extremity. The patient has been free of recurrence for 4 years after the operation.

View full abstract

Two cases of ruptured abdominal aortic aneurysm (AAA) treated with retroperitoneal approach are presented. Case 1 was a 73-year-old man with an infrarenal AAA of 44mm in diameter, and case 2 was a 73-year-old man with a 54mm pseudoaneurysm after graft replacement for AAA. Both patients had a history of previous laparotomy and their aneurysms had ruptured into only the right retroperitoneal space. A left retroperitoneal approach permitted wide and rapid exposure of the aorta with minimal damage to the intestines and respiratory function. Their postoperative courses were uneventful.

View full abstract

Total replacement of the aortic root in patients with anomalous origin of the coronary arteries has not been reported. We report a 63-year-old male with anomalous origin of the right coronary artery from the left sinus of Valsalva in whom aortic root replacement was performed to correct a 60mm aortic root aneurysm and a grade 4/4 aortic regurgitation. In this operation with a composite graft (a 24mm Gelseal graft with a 23mm St. Jude Medical prosthesis), modified reconstruction of the coronary arteries was necessary not only because both coronary ostia were in close proximity but also because the proximal portion of the right coronary artery was intramural. We used a modification of Piehler's technique in which both coronary ostia were simultaneously anastomosed to a beveled 10mm Gelseal graft. In this anastomosis, a small piece of the autologous pericardium was interposed between the graft and the aortic wall surrounding the ostium of the right coronary artery to protect the intramural artery from injury. This modification in reconstructing the coronary arteries was technically easy and effective in the special setting of the anomalous origin of the coronary arteries.

View full abstract

A chronic contained rupture of an infrarenal abdominal aortic aneurysm eroded a lumbar vertebra. A 53-year-old man complained of severe back pain for 6 months. Recently the back pain had increased. The patient looked well but a pulsatile mass in the abdomen was palpable. A CT and MRI of the abdomen and lumbar spine revealed the infrarenal abdominal aneurysm which demonstrated destruction of the third and fourth lumbar vertebra. At operation, there was a true aneurysm of the native aorta with a rupture of the posterior wall, resulting in a retroperitoneal hematoma. An orifice of the ruptured pseudoaneurysma was 2×2cm in size. An aortobiiliac graft was implanted. The patient did well postoperatively and was discharged on the 32nd postoperative day.

View full abstract