We used the Fogarty 2Fr IMAG Kit^® on 14 patients who underwent aorto-coronary bypass grafting. The free flow of the left internal thoracic artery (LITA) after dilatation using Fogarty balloon catheter was 7.4 times greater than before dilatation. There was no statistical differences in catecholamines used postoperatively and postoperative cardiac output in the groups of cases with and without dilatation. String sign was appeared in 4 patients with dilatation of LITA. Fogarty balloon catheter save effective dilatation of LITA in certain selected cases.

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The severity of mitral regurgitation (MR) and tricuspid regurgitation (TR) was evaluated semiquantitatively by Doppler color flow imaging. The maximum MR area/body surface area (MRA/BSA) correlated significantly to the severity of angiographyic changes (tau=0.897). The maximum TR area/body surface area (TRA/BSA) also correlated significantly to the severity in angiography (tau=0.874). The cutoff values were 0.5, 2, 4, and 8cm²/m² for MRA/BSA and 1, 2.5, 5, and 10cm²/m² for TRA/BSA. Fourteen children (mean age 4.2 years) underwent repair of partial atrioventricular septal defects (P-AVSD) from 1985 to 1992. The cleft in the anterior leaflet was closed in the mitral valve; other procedures such as annuloplasty were not performed. They have been followed for periods from 7 months to 7 years and 5 months (mean 4 years); they were examined by echo cardiography and the Holter electrical cardiogram at the end of the period. MR had reduced to grade 0-II in all cases. No patients were given any medication, and all remained in NYHA Functional Class I. Paroxysmal supraventricular tachycardia developed in only one patient. We concluded that no annuloplasty in mitral valve is needed in children suffering from P-AVSD.

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The long-term results of a “tighter” tricuspid annuloplasty (TAP) by De Vega's technique for secondary tricuspid regurgitation (TR) were studied. From June 1985 to July 1993, 122 patients underwent TAP following mitral valve surgery in our clinic. The analysis was performed on 50 patients who were followed up for more than 5 years (a mean of 75.1 months ranging from 60 to 96 months). The patients consisted of 13 males and 37 females with a mean age of 53.7 years (range from 28 to 71 years). The echocardiogram taken after long-term follow-up showed that the right ventricular inflow peak velocity at rest was a mean of 0.72m/s ranging from 0.53 to 1.04m/s, while the mean pressure half time was 76.7±14.9msec. Significant residual TR was observed in 16% at 1 month, 6% at 1 year, 10% at 3 years, and 12% at 5 years or more after operations. We conclude that a “tighter” TAP by De Vega's technique for secondary TR seems to be effective for the long-term reduction of residual TR and is not a causative factor for tricuspid stenosis.

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Fifty-three patients who had received aortic valve replacement (AVR) using tilting disc valve prostheses (Lillehei-Kaster valve, Omniscience valve, Omnicarbon valve), underwent replacement of their aortic valve prostheses over the past 13 years. The indications for reoperation were non-structural opening failure in 35 patients, thrombosed valves, including 2 stuck valves in 8, prosthetic valve endocarditis (PVE) in 7 and perivalvular leakage (PVL) in 3. The interval periods until reoperation for opening failure and thrombosed valve were 112 and 118 months respectively, and for PVE and PVL were 21 and 25 months. There were 7 hospital deaths (13.2%). Surgical results in cases of active PVE with root abscess and stuck valve required emergency operation were significantly worse than these for nonstructural opening failure. Opening failures, which accounted for two-thirds of the indications for reoperation was found to be due to subvalvular pannus formation on minor orifices which hindered the disc from opening properly. It was suggested that reoperation for these types of prosthetic valve should be done before they develop into emergency cases, taking account of these valve-related complications.

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Ionescu-Shiley pericardial xenografts implanted in the mitral position between April 1980 and October 1984 were studied. In some cases the cusp was torn in a relatively early postoperative phase, thus requiring an emergency operation. Functional disorders, such as caused by the calcification of the cusp, advance at a relatively moderate pace, and the prognosis of a second operation in cases with valve dysfunction and a chronic course was favorable. The actuarial probability of freedom from reoperation was 88.5±8.7% at 5 years and 55.7±14.5% at 10 years. The structural deterioration of the pericardial valve increased about 5 years after replacement. This tendency was the same as in other bioprostheses. At 10 years the overall actuarial survival rate was 67.2±12.1%. Freedom at 10 years from thromboembolism was 84.6±9.8%. For cases whose the course is under observation at present, the strategy is to recommend an additional operation as far as possible, while continuously observing the function of the valve.

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Graft rejection is a crucial complication after heart transplantation. The Billingham rejection grade scoring system is commonly used around the world for estimating graft rejection. To develop a more precise method to decide the rejection grade we attempted to decide the rejection grade by measuring the residual myocardial area after heart transplantation. The hearts of F344 rats were heterotopically transplanted into the abdominal cavity of Lewis rats. Cyclosporin A was administered intramuscularly for 20 days after heart transplantation. The grafted hearts were harvested 30, 40, 50 and 60 days after transplantation and the rejection grade was evaluated by Lurie's method. The same specimen was stained with the azan-Mallory method and the percentage of residual normal myocytes was calculated using a computerized image analyser. The rejection grades worsened with time after transplantation. In contrast, the percentage of residual normal myocardial area decreased with time after transplantation. There was a significantly negative correlation between the rejection grade and the percentage of residual normal myocytes (r=0.76). In conclusion, the assessment of graft rejection by measuring residual myocardial area is useful.

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Pre- and postoperative left ventricular (LV) function was assessed by Doppler echocardiography in 95 infants who underwent open heart surgery during the past two and half years. The patients were divided into three groups: 43 patients with ventricular septal defect (VSD group), 37 with atrial septal defect (ASD group) and 15 with the tetralogy of Fallot (TOF group). Echocardiography was performed before and at an early stage after surgery (average: 11.6 days) in all cases. The forward flow velocity pattern was evaluated by Doppler echocardiography, placing the sample volume at the pulmonary vein (PV) and the LV inflow portion. At the PV, the peak velocity of the S wave during systole (p-PV_S) and the D wave during diastole (p-PV_D) in patients with ASD were significantly lower (p<0.01) postoperatively. In patients with VSD, only p-PV_D was significantly lower (p<0.05) postoperatively, showing a decrease of pulmonary blood flow. These results are thought to reflect a difference in the compliance of the left atrium between the two groups. At the LV inflow portion, the ratio of peak velocity of the wave during atrial systole to R wave on rapid inflow during diastole (A/R) was significantly lower in patients with VSD (p <0.01) postoperatively. At the same time, LV ejection fraction and fractional shortening were significantly lower (p<0.01), but these values remained within the normal range. These results suggest that LV can maintain a sufficient systolic performance against the decrease in preload and the increase in afterload as well as the improvement of diastolic function during the early period after surgery in the VSD group. In patients with ASD or TOF, there were no significant differences in parameters of LV function between preoperative and postoperative periods.

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Three cases of isolated iliac aneurysms were reported. The first case was a 28-year-old man who was transferred to our hospital in shock. The ruptured left iliac aneurysm was replaced with a prosthetic graft. It was assumed to be a rupture of a false aneurysm. The second case was a 60-year-old man who complained swelling of his right leg and dyspnea on exertion. Angiography revealed tht those symptoms were due to right iliac aneurysm with AV fistula. The aneurysm was replaced with a bifurcating graft and the AV fistula was closed concurrently. The third case was a 55-year-old man who had no symptoms. He had been followed up for hepatitis type C with periodical echogram. The echogram showed dilatation of his bilateral iliac arteries. On a diagnosis of bilateral iliac aneurysms, bifurcating graft replacement was performed. All of these three cases recovered successfully and were discharged. Because the greater part of the cases of isolated iliac aneurysms have few symptoms, many cases were first diagnosed through the event of its rupture. The number of cases of isolated iliac aneurysm with no symptoms will increase with advanced availability of abdominal echogram and CT scanning.

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When we surgically treat cases for dissecting aortic aneurysm with an inheritable connective tissue disorder like Marfan's syndrome, we should choose the surgical procedure carefully, paying paticular attention to whether to extend the operation, because there is every possibility that the lesion might be progressive. A 41-year-old woman with Marfan's syndrome, type A chronic aortic dissection, rapidly dilating to 80mm in diameter, and with aortic valve regurgitation was operated on with a total aortic arch replacement and the modified Bentall procedure. In the procedure, the aortic root and valve were replaced with a composite graft with a prosthetic mechanical valve, and the coronary arteries were reconstructed by direct anastmosis. In this case, the infrarenal abdominal aorta had already dilated to 40mm in diameter. In many cases with Marfan's syndrome, it was reported that the lesion was progressive and the residual dissection or new aneurysm would usually dilate and eventually rupture postoperatively. Reoperation involve a high risk. With those factors in mind, we chose total aortic replacement, including the distal aortic arch, to where the dissection would not extend. The most important thing for patients with Marfan's syndrome is the development of new or reccurrent problems. We consider that the operation designed to dissect aortic aneurysm for those patients should be performed as extensively in the surgical field as possible.

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A 77-year-old woman with aplastic anemia who suffered from abdominal aortic aneurysm successfully underwent aneurysmecotmy. The preoperative transfusion of G-CSF, 6 usits of red cell and 3 units of platelet restored blood analysis to a normal level prior to operation. During the operation, 840ml of blood was lost, 9 units of red cell and 6 units of FFP were transfused, and 9 units of platelets were given on the operative day. The postoperative course was uneventful.

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We treated a patient with recurrent isolated tricuspid regurgitation (TR) by repeated tricuspid valvoplasty (TVP) and tricuspid annuloplasty (TAP). The patient was a 56-year-old man who had undergone TVP eight years previously. Although the tricuspid annular dilatation was not seen in the first operation, the annular dilatation with elongation of chordae was apparent at this time. The chordal plasty with ePTFE threads and TAP with Carpentier-Edward's ring were carried out successfully. Since the annular dilatation may aggravate TR in the natural course of this disease, the combination of TVP and TAP is more effective than TVP alone.

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A 69-year-old man, who had undergone coronary artery bypass grafting using the right gastroepiploic artery 2 years previously, was hospitalized with acute epigastralgia. Gastroscopy showed an early gastric cancer in the greater curvature of the corpus and ultrasonography of the abdomen revealed acute cholecystitis due to a stone impacted in the cystic duct. The subtotal gastrectomy and the cholecystectomy with preservation of the right gastroepiploic artery graft were performed. The surgical margin of the resected specimen was negative for cancer. The postoperative course was uneventful. After coronary artery bypass grafting using the right gastroepiploic artery, annual gastroscopy is recommended.

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The patient was a 61-year-old male, who underwent thoracoabdominal aortic aneurysm repair with Gelseal Triaxial prosthetic graft 2 years previously. False-aneurysm due to prosthetic graft dilatation was diagnosed. The direct closure of the ostium of the disruption of the anastomosis was successfully performed by an emergency operation. The postoperative course was uneventful. This case suggests that prosthetic graft dilatation may cause false-aneurysm at the site of end-to-side anastomosis.

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We present a rare case of mitral stenosis with bilateral pulmonary arteriovenous fistulae (PAVF). A 55-year-old female who complained of dyspnea did not have pulmonary hypertension. She underwent successfully mitral valve replacement with an artificial valve 2 months after transcatheter coil embolization for PAVF. The combination with mitral valve replacement and transcatheter embolization is regarded as a useful procedure for mitral valve disease associated with PAVF.

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A case of ruptured dissecting aortic aneurysm (DeBakey IIIa) involving a right-sided aortic arch is reported. A 54-year-old man was admitted to our hospital with a complaint of severe back pain. Roentgenogram and enhanced computed tomography of the chest revealed a right-sided aortic arch, right descending thoracic aorta and right pleural effusion. Thoracocentesis of the right thoracic cavity revealed bloody fluid. The ruptured dissecting aortic aneurysm was suspected. The enhanced CT of the chest revealed leakage of the contrast medium at the level of the bifurcation of the trachea so aortography wasn't performed. There was a 2cm intimal tear in the descending aorta. Resection and grafting of the aneurysm via right thoracotomy was performed. The patient made an uneventful recovery and was discharged 4 weeks later. It is pointed out that the operative method and/or decision of the method of approach for the aneurysm involving a right arch are difficult because of the aberrant left subclavian artery and/or tortuous descending thoracic aorta. Impeccable judgement is needed for emergency operation of ruptured dissecting aneurysms like the present case.

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