Hemolysis, hemoglobinuria, skin eruption and hypotension were noticed following transfusion of 11 units of fresh blood during mitral valve replacement in a 57-year-old man. Irregular antibody incompatibility was suspected. Further investigation revealed anti Lewis-a antibody. Three of 11 units of transfused blood were positive for the indirect Coombs test. The patient recovered without renal failure, and was discharged. One year later, he had urgent re-MVR due to malfunction of the prosthetic valve. Hemolytic transfusion reaction had occured after the administration of donor blood which had been showed to be compatible by cross matching. This means that antibody titer diminishes with time, and that posttransfusion screening tests should minimize the unexpected hazards of incompatible blood transfusion. We recommend that antibody screening tests should be routinely performed after open heart surgery, to minimize the risk of hemolysis during future reoperation.

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In 5 cases of profound left ventricular failure, simultaneous application of a percutaneous cardiopulmonary support system (PCPS) in which the entire circuit was coated with heparin, and intra-aortic balloon pumping (IABP) were performed. No case responded to therapy consisting of large amounts of inotropic agents, followed by IABP. With the assistance of the PCPS (mean flow rate 2.3l/min) combined with moderate doses of inotropic agents and IABP, the hemodynamics of all 5 patients were stabilized. Using low amounts of heparin, the activated coagulation time during PCPS was maintained between 150 and 200 seconds. No complications directly related to this procedure such as thromboembolism and bleeding were observed. Four cases have been successfully weaned from the PCPS. Of the four, two cases are long-term survivors and are currently functioning normally in society. At present, the indications, optimum parameters for PCPS flow rate, and when to start weaning from the PCPS have not been established. However, we conclude that simultaneous use of PCPS and IABP is useful to maintain adequate systemic circulation in cases not responding to medication and IABP.

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The purpose of this study was to determine the effect of intraoperative autologous blood salvage during elective abdominal aortic aneurysm repair with Cell Saver 4 (Heamonetics Inc.). Fifty patients prospectively received intraoperative autologous transfusion (Group CS; n=50, 1991-94) and 25 received no intraoperative autologous transfusion (Group NCS; n=25, 1983-91). Only 7 patients in Group NCS received no homologous blood (28%), while 43 in Group CS received autologous blood transfusion (86%). There was no difference between the groups with respect to postoperative platelets counts or serum concentrations of total protein, albumin, BUN and LDH. We conclude that the use of the Cell Saver 4 reduces perioperative homologous blood during elective aortic aneurysm repair.

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We studied 6 surgical cases of dissecting aortic aneurysm with organ ischemia, consisting of 4 cases of DeBakey type I dissection and 2 cases of DeBakey type III b dissection and the average age was 62 years old. The ischemic organs were, the brain and upper extremities, intestine and kidney, kidney, kidney and lower extremity, and bilateral lower extremities, respectively. We performed the graft replacements of the ascending aorta or ascending aorta and arch for DeBakey type I dissection, and bypass or Y-graft replacement for DeBakey type III b dissection. In one case of DeBakey type I dissection we performed a second Y-graft replacement two days after the first operation. MNMS (myonephropathic metabolic syndrome) developed in two cases of 3 lower extremity ischemia. The results were unsatisfactory because 3 patients died. To improve of the outcome of surgical treatment in case of dissecting aortic aneurysm with organ ischemia, preoperative appropriate diagnosis and appropriate surgical planning are necessary.

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The natural course of abdominal aortic aneurysm was studied in 33 patients by measuring the diameter size of aneurysms by computed tomography during period of 3 to 36 months. The ratio of the increase in diameter of aneurysms was calculated at each period (total 69 periods). The expansive ratio which had a diameter of over 5cm (1.38cm/year) exceeded that of under 5cm (0.41cm/year) by more than three times. Saccular aneurysms tended to expand more rapidly than fusiform aneurysms, and particularly this tendency was obvious in small size of aneurysms. The expansive ratio of patients with hypertention was lower than that of the patients without hypertension. The age of patients had no effect on the expansion ratio. Since operative mortality for ruptured abdominal aortic aneurysm is high, surgery before rupture is essential to reduce the mortality of abdominal aortic aneurysm. We decided that the patient should be operated when the aneurysms develop a diameter of 5cm in cases of fusiform aneurysms and 4cm in cases of saccular aneurysms. In addition it is necessary to consider age, possible complications and other conditions of each case in order to determine the timing of surgical repair.

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The purpose of this study was to estimate the postoperative growth of untreated segments of the dissected aorta with non-thrombotic communicating false lumen, and also to evaluate the clinical outcome in relation to the aortic enlargement after surgery. Nineteen patients who underwent surgical treatment of aortic dissection were studied with enhanced CT scans and angiograms during the postoperative follow-up period. In Stanford type A patients, mean aortic dilatation rate calculated at the segment showing maximal dilatation was 5.1mm/year during 13-82 months (average, 41 months) after surgery, as a sequela of enlargement of the false lumen. Differences in the aortic dilatation rates between the different segments of the aorta were observed and these were per annum 4.8mm in the ascending aorta, 5.4mm in the transverse aortic arch, 4.3mm in the proximal descending aorta, 2.7mm in the distal descending aorta and 2.4mm in the abdominal aorta. In all patients, major communications were detected at the perianastomotic sites on angiography. In Stanford type B patients, false lumens with small communications were observed to show gradual thrombotic occlusion, but no significant aortic dilatation was detected during the follow-up period (13-70 months, average: 44 months), except three cases of sudden death who had major communications. Nine late events related to dissection, consisting of 4 sudden deaths suspected to be due to aortic rupture, 2 intestinal necroses and 3 cerebral infarctions, occured in 6 patients (32%), among which three patients had undergone arterial fenestration, one of whom had double barrel anastomosis. In the remaining two, major leakages were recognized at distal aortic anastomotic sites on postoperative angiography. The results of this study, we stress the importance of periodic check-ups using enhanced CT scan and if necessary, angiography after surgery of the patients having communicating false lumen. Early detection of progressive aneurysm formation and timely surgical reintervention can yield a good prognosis.

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We investigated the quality of life (QOL) after thoracic or thoraco-abdominal aneurysmectomy in patients who had undergone the procedure within the past 15 years. We compared preoperative to postoperative performance status (PS). Defining PS in the following manner: one increase in that PS grade indicated mild worsening while an increase is by 2 or more indicated severe worsening. Maintenance was indicated by no change of PS after surgery. The QOL maintenance rate was calculated based on the following formula.
QOL maintenance(%)=No. of no change case/No. of operated cases-No. of death×100
There were a total of 74 cases in whom follow-ups could be carried out after surgery. Among them, there were ascending and aortic arch aneurysms in 19 cases, descending aortic aneurysms in 20 cases, dissecting aneurysms in 27 cases and thoraco-abdominal aortic aneurysms in 8 cases. The QOL maintenance rate in the type B dissecting aneurysms was comparatively high (85.7%). There were cases of severe worsening of PS in the ascending and aortic arch aneurysms and type A dissecting aneurysms and the QOL maintenance rate was 50% in each other. We should obtain high operative results due to improve the QOL maintenance rate, and devise the operative procedure without functional disorders of the organs after surgery.

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We encountered an unusual disruption of an expanded polytetrafluoroethylene (EPTFE) axillofemoral bypass graft apart from that anastomoses. We suspected the possible robe of the physical effects of body movement provoking the disruption of the axillofemoral bypass graft and therefore examined the physical effect of body movement on the axillary-to-femoral artery graft in 15 healthy men. At the lower part of the graft, the physical effect was significantly stronger. The disruption of this axillary-to-femoral artery graft was associated with the physical effect of body movement.

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To evaluate viability and severity of ischemically damaged myocardium, myocardial single emission tomography (SPECT) using 123I-BMIPP (BMIPP), a new tracer of myocardial metabolism of fatty acid, was performed before and after coronary artery bypass grafting (CABG). 201Tl myocardial SPECT (Tl) and left ventriculography (LVG) were also used. Thirty-three revascularized areas in eight patients were investigated. (1) Areas showing good redistribution on Tl and normal uptake on BMIPP indicated good viability and simple ischemic myocardium. Postoperative uptake of both tracers returned to normal levels. (2) Areas showing good redistribution on Tl and severely decreased uptake on BMIPP indicated jeopardized myocardium with severe ischemia. All such areas were seen in patients with unstable angina. Postoperative uptake of both tracers returned to normal levels. (3) Areas showing poor redistributionor severely decreased uptake on Tl and slight uptake on BMIPP indicating hibernating areas. Postoperative uptake became normal or better than preoperative uptake on Tl necrosis. However on BMIPP, the uptake was unchanged or recovered slightly. (4) Areas showing complete defect in Tl and BMIPP indicated necrosis and had no viability. Postoperatively the defect in both tracers were unchanged. Therefore, these areas required no revascularization. The ischemic state of myocardium could be assessed by evaluation of uptake patterns of BMIPP and Tl using myocardial SPECT. Therefore, using this new tracer of myocardial fatty acid metabolism “BMIPP”is useful for deciding culprit and viable lesions requiring coronary revascularization and evaluating therapeutical effects.

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During a twelve-year period (1982-1993), 15 axillo-femoral bypass surgeries have been performed for aortoiliac occlusive disease. All patients were men, with an average age of 71.2 years. Axillo-bifemoral bypass was performed in 10 cases, and axillo-unifemoral bypass in 5 cases. In Additional femoro-popliteal bypass was required 3 cases. All cases had some accompanying disease, so they were considered to be high risk cases for anatomic bypass surgery. In the 12 elective cases, 2 hospital deaths (16.7%) occured due to the accompaning disease (atrial fibrillation and lung canser). At discharged leg symptoms had improved in 10 patients. In the long term postoperative phase, 4 patients died due to accompanying disease, and one was lost to follow up. Excluding these patients, the long term patency in the 5 surviving patients was 100%. In this series, we encountered a case of perigraft seroma, which is rare. The intractable perigraft seroma disappeared after the reoperation with another material graft. Axillo-femoral bypass is preferable for high risk patients with aortoiliac occlusive disease. In cases of severe respiratory dysfunction, it can be performed under epidural and local anesthesia.

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We performed 3 operations for Stanford A type aortic dissections which were confirmed as acute thrombosed type by contrast chest CT. Initially conservative therapy was chosen in all patients. In case 1, a 64-year-old woman received ascending aortic replacement with a Hemashield^® vascular prosthesis 3 days after admission, because of increasing diameter of the ascending aorta and sustained back pain. In case 2, a 54-year-old woman, we replaced the total aortic arch with Hemashield^® graft, on an emergency basis since recanalization of the false lumen was revealed by contrast CT and D.S.A. 3 days after admission. In case 3, a 52-year-old woman, cardiac tamponade occured on the 30th admission day even though anti-hypertensive treatment had been effectively performed immediately after onset. Emergency D.S.A. revealed an“ulcer like projection” in the ascending aorta, so following pericardiocentesis, we resected and directly anastomosed the ascending aorta at the entry site 34 days after onset. Generally, acute thrombosed aortic dissections should be treated conservatively. Here we reported 3 operations for acute thrombosed Stanford A type aortic dissections even under good B.P. control, suggesting the importance of careful and long term observation for acute thrombosed aortic dissections.

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We report two surgical cases with corrected transposition of the great arteries associated with ventricular septal defect and pulmonary atresia undergoing total correction including reconstruction of the central pulmonary artery after reconstruction of the left pulmonary artery for non-confluent pulmonary arteries. Both patients underwent reconstruction of the left pulmonary artery using 13 or 12mm diameter heterologous pericardial conduit at age of 5 year, respectively. At surgery, after the left pulmonary artery was exposed between the upper and lower lobe of the left lung, the conduit was connected with the left pulmonary artery along the pericardium. Continuity between the conduit and the left subclavian artery or the ascending aorta was established with 5 or 6mm diameter Micronit grafts, respectively. Total correction was performed at 2 years and 10 months after the initial surgery, respectively. In a patient with {I, D, D} type corrected transposition of the great arteries, the central pulmonary artery was established with another 16mm diameter heterologous pericardial conduit, which ran in front of the left superior vena cava. The ventricular septal defect was closed via the right atrium. In another patient with {S, L, L}, the central pulmonary artery was established with the reconstructed conduit of the left pulmonary artery, which ran behind the left phrenic nerve. The ventricular septal defect was closed via the right atrium with the De Leval procedure. In both patients, continuities between the left ventricle and the central pulmonary artery were established with tricuspid valved porcine pericardial conduit and equine pericardial conduit. Postoperatively both patients had uneventful recovery with left ventricular/right ventricular systolic pressure ratios of 0.4 and 0.35, respectively.

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A 58-year-old male was unable to walk because of progressive pain in both lower extremities that rapidly became cold and clammy. Femoral, popliteal and ankle pulses ware absent, and there was a pulsatile tumor in the abdomen. Abdominal CT showed an abdominal aortic aneurysm that measured 50mm in diameter. Aortogram revealed total infrarenal aortic occlusion. The patient underwent emergency aorto-bifemoral bypass with a bifurcated artificial graft. Several days after the operation, renal failure appeared because of MNMS. He was weaned from hemodialysis at one month and was discharged from hospital about 1 year after the operation.

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A 61-year-old male had received aortic valve replacement due to AR in 1987 and the operative findings showed the enlargement of the ascending aorta and maximum diameters of 4cm in the ascending aorta. He had been doing well until 1992 when he sufferred cerebral infarction and aortic root dilatation reached a maximum diameter of 7.5cm demonstrated by CT. Cabrol's operation using the previously replaced aortic valve was carried out because the prosthetic valvular function was normal and the type of coronary arteries was balanced. Postoperative angiography showed good patency at anastomosis of bilateral coronary arterial orifices and he had a satisfactory postoperative course. The dilatation of the ascending aorta over 4cm accompanied with AR may need not only AVR but also aortic root replacement.

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A 51-year-old woman with a 12-year history of chronic hemodialysis and secondary hyperparathyroidism suffered dyspnea induced by massive mitral regurgitation due to severe circular mitral annular calcification. Her anterior mitral leaflet was resected and successfully replaced with a 25mm SJM valve in the supra-annular position. The posterior leaflet was heavily calcified and adhered to the left ventricle. The flangeless prosthesis was directly implanted into the left atrial wall on the calcified annulus. Postoperative cine fluoroscopy and echocardiography showed good hemodynamic performance of the prosthesis without perivalvular leakage. In cases of mitral annular calcification due to chronic renal failure, the SJM valve is a more suitable valve prosthesis for replacement of the mitral valve in the supra-annular position. Supra-annular mitral valve replacement without a flange may give superior valve-performance compared to valves with a flange considering thrombogenicity and left ventricular function. However, we may still have to consider the indication of a supra-annular mitral valve replacement with a flange in cases with wide mitral annular calcification in the giant left atrium.

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