The earlier the diagnosis of acute type A aortic dissection is made, the more frequent the complications of aortic root destruction and/or a compromised coronary artery are encountered. Only aortography is diagnostic in these lesions, however, recently this modality tends to be avoided in order to try to improve the survival rate of the patients by obtaining diagnosis by noninvasive modalities. Therefore, contrast-enhanced CT scans in 49 patients with aortic dissection were analyzed in order to detect the slightest signs suggesting aortic root lesions. In 4 of the 6 cases in which intimal flap was detected in the aortic root by CT and in 2 of the 14 cases with an aortic root more than 35mm in diameter, aortic root reconstruction and/or concomitant CABG were neccessary for the repair of the destroyed aortic root. The aortic root diameter was more than 40mm in 8 of 9 patients with aortic root destruction, with a mean value of 45.6±3.6mm (p<0.01). In summary, detection of a septum in the aortic root and/or an aortic root dilated more than 40mm on CT were important signs suggesting the dissection extending to the aortic sinus combined with aortic root destruction. In such cases aortic root reconstruction and/or concomitant CABG may be necessary.

View full abstract

The preoperative pulmonary arterial pressure of 38 patients aged over 50 undergoing surgical closure of a secundum atrial septal defect was studied. They were divided into three groups according to systolic pulmonary arterial pressure (PAP): Group A (PAP<30mmHg, n=14), Group B (30≤PAP<50mmHg, n=16), and Group C (PAP≥50mmHg, n=8). The mean age of group C patients was older than that of group A patients. With higher PAP, the Pp/Ps, Rp/Rs and cardiothoracic ratios increased, atrial fibrillation and heart failure (NYHA≥2) were more frequent, and PaO₂ levels declined. There were no differences in left to right shunt ratio and Qp/Qs among the three groups. The PAP and Rp/Rs were under 70mmHg and 0.30, respectively in all patients. High pulmonary blood flow seems to be the cause of pulmonary hypertension in most elderly patients because PAP and Rp/Rs decreased after surgery in all groups. Findings of cardiomegaly and heart failure also improved after surgery. Surgical intervention is recommended even in elderly patients with a ASD.

View full abstract

Preoperative hemodynamics in the lower limbs in 174 limbs of 103 patients were measured and investigated and the surgical results were evaluated. The subjects were divided into the C_4-6-group, which included 51 limbs with skin changes, and the C_{2, 3}-group, which consisted of 123 limbs without skin changes. Plethysmography showed that the maximum venous outflow was significantly higher, and the refilling time was shorter in the C_4-6-group compared to the C_{2, 3}-group. All C_4-6-group patients had reflux of the long saphenous vein, and the reflux velocity and volume was significantly greater than in the C_{2, 3}-group. Limbs with deep vein reflux accounted for 45% of the C_4-6-group. We performed angioscopic deep vein external valvuloplasty in 23 of those limbs. There was no case of reccurence of skin changes at a mean follow-up of 22 months. However chronic venous insufficiency often was associated with multisegmental reflux lesions and in such cases it might be necessary to perform multiple surgical procedures to eliminate the reflux.

View full abstract

Seventeen cases of palliative right ventricular outflow tract reconstruction were reviewed to determine the optimal outflow diameter in this procedure. The clinical diagnoses of these 17 patients were pulmonary atresia with ventricular septal defect in 8, tetralogy of Fallot (TOF) in 7, TOF with complete atrioventricular canal in 1, double outlet right ventricle with pulmonary stenosis in 1. Techniques of reconstruction were transannular patch in 7 (valved 2, non-valved 5), extracardiac conduit in 5 (valved 2, nonvalved 3), outflow patch in right ventricle in 3, and others in 2. Pulmonary artery growth was not related to the diameter of reconstruction of outflow and postoperative Pp/Ps. The pressure in pulmonary artery tends to be hypertensive when the outflow diameter was more than 90% of the normal value. On the other hand, the minimal outflow diameter in nine cases of primary repaired TOF was in the range of 0.41 to 0.68 (mean of 0.59). In conclusion, the diameter of outflow reconstruction should be 60 to 80% of the normal pulmonary valve.

View full abstract

From 1985 through 1994, 12 consecutive patients with Taussig-Bing anomaly underwent an arterial switch. Age at operation varied from 8 to 42 months (mean 21 months). Coarctation of the aorta was present in 6 patients (including 4 with hypoplasia of the aortic arch), interruption of the aortic arch in one, straddling mitral valve in one and subaortic stenosis in two. The relationship of the great arteries was D-transposition in 11 patients (oblique in 6 and anteroposterior in 5) and side-by-side in one. Eleven patients had previous palliative surgery. Pulmonary artery banding was done in 11 patients, Blalock-Hanlon in 3, carotid flap aortoplasty in 3, subclavian flap aortoplasty in 2, extended aortic arch anastomosis in 2 and ligation of PDA in 1. The Lecompte maneuver was adopted in all but one patient with side-by-side great vessels. Intraventricular reconstruction was done through the right ventricle in 11 patients and through the right atrium in one who underwent one-stage repair. There was one early death, which was related to thrombosis of the superior mesenteric artery. One patient with side-by-side great vessels died at home 6 months after the arterial switch operation. The suspected cause of death was myocardial infarction due to compression of the left coronary artery by the pulmonary artery. In the follow-up of 10 patients ranging from 1.8 to 9.4 years (average 6.3 years), one required reoperation for pulmonary stenosis. We conclude that two-staged arterial switch operation of Taussig-Bing anomaly with D-transposition can be performed with low mortality, but there seems to be some risk of the compression of the left coronary artery in the original Jatene method for Taussig-Bing anomaly with side-by-side great vessels.

View full abstract

We report a case of chronic DeBakey type I dissecting aneurysm with an aberrant right subclavian artery, in which replacement of the ascending aorta and the transverse aortic arch was performed under selective cerebral perfusion, resulting in complete obliteration of the false channel in the descending thoracic aorta. A 57-year-old female was admitted to our service complaining of chest and back pain. An aberrant right subclavian artery that originated from the descending thoracic aorta was identified. During operation, the dissected aortic wall of the aortic arch and the proximal descending thoracic aorta that involved more than half of its circumference was resected, the dissected intima was reapproximated at the distal stump, and the beveled distal end of the tubular ascending aortic prosthesis was secured to the cut edge. The postoperative course was uneventful, and she is leading a normal life now four years after surgery. It is rare to reconstruct the aortic arch for aortic dissection that occurred in a patient with aberrant right subclavian artery, and the technical details were reported.

View full abstract

A 44-year-old woman with heart murmur was admitted for cardiac examination. Echocardiography and cardiac catheterization including coronary angiography demonstrated atrial septal defect (ASD) and left coronary artery-main pulmonary artery fistula. At operation, the ASD was directly closed, and the proximal portion of coronary fistula was successfully ligated from the epicardial side and the fistula orifice was directly closed from inside the pulmonary trunk under the cardiopulmonary bypass. We report a relatively rare case of adult ASD with coronary-pulmonary artery fistula, with particular emphasis on the importance of consideration of the association of this anomaly in diagnosing congenital heart disease.

View full abstract

The 37-year-old woman underwent mitral valve replacement (MVR) with a Carpentier-Edwards bioprosthesis for hypertrophic obstructive cardiomyopathy (HOCM) 14 years previously. Since the 10th postoperative year, progressive right heart failure due to tricuspid valve regurgitation was recognized. Therefore, reoperation was recommended. At the time of reoperation in the 14th postoperative year, the cavity of the left ventricle was markedly diminished. In particular, deformitiy of the right ventricle was found. This was considered to be the effect of progressive septal hypertrophy. The mitral valve was replaced with a 25mm Carpentier-Edwards and the tricuspid valve with a 31mm Carpentier-Edwards bioprosthesis. Although the weaning from the cardiopulmonary bypass was uneventful, postoperative right heart failure occured with hyperbilirubinemia followed by multiple organ failure. She died on the 47th postoperative day. At autopsy, the intraventricular septal thickness was 24mm and the cavities of left and right ventricle were almost occluded by septal hypertrophy. This is considered to be a rare case of long-term survival after MVR in a patient with HOCM.

View full abstract

A 64-year-old man with a history of anterior blunt trauma 10 years previously was admitted to our hospital complaining of general fatigue. A plain chest roentgenogram showed pericardial calcification. Computed tomography and echocardiography showed the mass to be a calcified capsule in the anterior mediastinum compressing the right side of the heart. He underwent an operation through a median sternotomy. The mass was an organized hematoma encapsulated by a calcified fibrous and serous layer of the pericardium. The hematoma was resected together with the calcified pericardium under cardiopulmonary bypass. His postoperative course was uneventful. He had no history of hemopericardium but had experienced blunt chest trauma that seemed to have induced the subsequent localized constrictive pericarditis.

View full abstract

A 2-year-old boy was admitted to our service with a diagnosis of double-outlet right ventricle (DORV) complicated by mitral valve stenosis. On echocardiographic measurement, the mitral annulus was 11mm (69% of normal) in diameter and 1.67cm²/m² in annular area. He underwent intraventricular tunnel repair and patch reconstruction of the right ventricular outflow tract under cardiopulmonary bypass. No attempt was made to operate on the mitral valve. DORV with mitral stenosis is a rare cardiac anomaly, the last 20 years only 21 cases have been reported, of which only 4 were cases with hypoplastic mitral rings. Although the patient made an uneventful recovery and remains well 5 months after surgery, a close observation is required for the mitral valve stenosis.

View full abstract

A 29-year-old female with aortic regurgitation associated with aortitis syndrome and severe stenosis of bilateral carotid arteries was reported. She had no symptom of brain ischemia, although an aortogram revealed complete occlusion of the left common carotid artery and the left subclavian artery, and severe stenosis of the right common carotid artery. The intracranial major arteries were perfused totally by the right vertebral artery via collaterals. The transcranial Doppler method and perfusion cintigraphy revealed normal cerebral perfusion. Therefore, we performed conventional aortic valve replacement without reconstruction of carotid arteries. During cardiopulmonary bypass, the mean systemic blood pressure was kept higher than 60mmHg under moderate-hypothermic (tympanic temperature: 25°C) pulsatile perfusion with monitoring of the left middle cerebral artery flow velocity. The patient did not develop any cerebral complications during or after the operation.

View full abstract

A 5-year-old boy with tricuspid atresia who underwent the Björk procedure died due to right atrial thrombus and left pulmonary embolus 37 days after operation. It is suggested that thromboembolism may be a frequent complication after the Björk procedure due to the turbulent blood flow at the right atrio-ventricular anastomosis and also due to congestive blood flow. Anticoagulation therapy seems to be essential for postoperative management.

View full abstract

Three patients with hyperosmolar hyperglycemic non-ketotic diabetic coma (HHNKDC) following open-heart surgery are presented. Because the symptoms of HHNKDC are not specific, it is difficult to recognize this unique complication in the early postoperative stage. The mortality rate of this complication is high. Thus, HHNKDC should be recognized as early as possible after open-heart surgery, since it is curable if diagnosed at an early stage.

View full abstract

The case presented is a 76-year-old woman with a ruptured abdominal aortic aneurysm. We tried to pass a Fogarty balloon catheter from the left subclavian artery for proximal occlusion of the ruptured aneurysm but failed to inset the balloon into the descending aorta. Although the aneurysm was safely replaced with a gelatine coated dacron graft, she developed cerebral embolism and never regained consciousness and died two months later. Balloon insertion through the subclavian artery may cause complication through dislodgement of atheromatous plaque and may induce cerebral embolism.

View full abstract

A 42-year-old man with Budd-Chiari syndrome was admitted to our institute for reoperation. The patient had undergone a cavoatrial bypass 9 years previously, but early occlusion of the bypass graft was suspected as there was reappearance of dilated abdominal veins. Preoperative cavography showed occlusion of the bypass graft and well-developed collateral veins. The patient underwent direct reconstruction with endo-venectomy and patch angioplasty of the obstructed vena cava and hepatic veins using a ringed ePTFE graft. The markedly dilated tortuous subcutaneous veins of abdominal wall disappeared immediately after reoperation. Postoperative cavography showed the patency of the IVC and three hepatic veins, IVC-right atrium mean pressure gradient decreased from 16mmHg to 6.5mmHg. Direct reconstruction should be the first choice in surgical treatment for Budd-Chiari syndrome, and is also useful as a reoperative procedure.

View full abstract