Transcatheter embolization of 25 aortopulmonary collateral arteries (7 bronchial arteries and 18 intercostal arteries) was attempted prior to intracardiac repair in 7 patients. The underlying disease was tetralogy of Fallot in 3 patients, pulmonary atresia with ventricular septal defect in 2, double-outlet right ventricle with ventricular septal defect and pulmonary stenosis in 1 and tricuspid stenosis with pulmonary atresia in 1. The intervals between embolization and intracardiac repair ranged from 0 to 17 days (mean 4.5 days). Embolization resulted in total occlusion in 7 bronchial arteries and 17 intercostal arteries, with an overall success rate of 96%. Complications included a coil dislodgement from a collateral artery into the aorta in one patient, necessitating surgical removal of the dislodged coil from the femoral artery, an exacerbation of cyanosis and dyspnea on exercise in 5, and slight fever in 2. In one patient with tetralogy of Fallot, who had 5 collateral vessels, transcatheter embolization caused hypoxemia, bradycardia and hypotension and therefore intracardiac repair was performed immediately after embolization. Aortopulmonary collateral arteries in patients with congenital heart disease can be effectively treated by transcatheter embolization. Embolization should be performed just before intracardiac repair because an excessive decrease in arterial oxygen saturation after embolization may require an emergency operation.

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Between 1984 and 1994, 58 patients underwent operations for type A aortic dissection. A sutureless ringed intraluminal graft was used in 9 of the 58 cases. The patients ranged from 47 to 74 years old (mean, 60.4 years). Six patients were discharged from the hospital and three patients died. The operative mortality rate for the 9 patients was 33.3% and for the other 49 patients it was 20.4%. Post-operative aortograms revealed a remaining false lumen in 5 of the 6 discharged patients. The result of the operation with the sutureless ringed intraluminal graft was not satisfactory. Therefore, we prefer to resect and replace the dissected aorta using the prosthetic graft rather than repair with the sutureless ringed intraluminal graft.

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Twenty patients undergoing primary elective coronary artery bypass grafting were randomly divided into two groups to evaluate the hemostatic effect of aprotinin. Low dose aprotinin (1×10⁶KIU) was used during cardiopulmonary bypass in one group (11 patients), and the others were not given any. There was no need for reoperation due to bleeding and no difference of graft patency in the two groups. Changes in platelet, fibrinogen, thromboxane B₂ and antiplasmin values were similar in both groups. Postoperative blood loss was significantly lower in the aprotinin treated patiens (p<0.05) and postoperative blood use was also significantly lower (p<0.01). We conclude that low-dose aprotinin had a beneficial effect for reducing postoperative blood loss and blood use, though we did not find any changes in the results of laboratory tests.

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Lipoprotein(a) [Lp(a)] has been considered as an independent risk factor for arteriosclerotic diseases. With an anticipation that Lp(a) would also serve as a risk factor for abdominal aortic aneurysms (AAA), we analyzed serum and tissue Lp(a) levels of patients with AAA in relation to those in healthy individuals. Serum Lp(a) levels were significantly higher in the AAA group (53.2±60.8mg/dl) than in the healthy controls (14.6±13.6mg/d) (p<0.001). The Lp(a) level in the aneurysmal wall of patients with AAA was 49.8±38.2ng/mg. There was a significant correlation between serum and aneurysmal wall Lp(a) levels in AAA patients (r²=0.79, p<0.01). Immunohistochemical examination revealed Lp(a) in the extracellular matrix of the middle layer of the tunica intima, but not in the tunica media or externa.

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A total of 35 patients who underwent mitral valve replacement were followed up for more than 5 years. Their hemodynamics and valve function were analyzed using transthoracic and esophageal Doppler ultrasound echocardiography and cineangiography. They were classified and evaluated according to valve function. The tilting disk valve replacement group (group I) consisted of 24 cases, the bileaflet valve replacement group (group II) consisted of 11 cases. There were 4 mechanical valve dysfunction cases in group I. The function of group II tended to be superior to group I, even excluding those with valve dysfunction. However, the hemodynamic recovery of the latter was as good as that of group II. The left cardiac function parameters of LVEF, %FS and CI were comparable in both groups, but in valve dysfunction cases LVEDVI decreased because of prosthetic stenosis and there was some right ventricular overload with severe tricuspid regurgitation.

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Problems with postoperative respiratory management of three patients after division of double aortic arch are described. Tracheomalacia was present in two of three cases with intracardiac anomalies of different types. Intracardiac anomalies of each patient were as follows: Patient 1, ventricular septal defect (VSD), atrial septal defect and pulmonary valve stenosis (PS); Patient 2, VSD, corrected transposition of the great arteries with PS; Patient 3, VSD with pulmonary hypertension (PH). In patient 1 and 2, no concomitant surgical intervention was performed for tracheomalacia. In these patients respiratory support had been continued for 41 and 60 days respectively. In patient 3, remaining VSD with PH was the cause of unexpected respiratory problem even after the successful division of the double aortic arch, and necessitated emergency VSD closure 49 days after the initial operation. The patient was extubated on postoperative day 12. Tracheomalacia is a life-threatening problem even after surgical division of the double aortic arch. Although prolonged respiratory support was needed, our two cases were successfully extubated without concomitant surgical intervention of tracheomalacia. Severe cases should be operated on simultaneously with the relief of vascular ring and tracheomalacia. Intracardiac anomalies are also the causes of prolonged intubation. Patient 3 should have been treated by pulmonary artery banding along with the division of aortic arch. In conclusion, precise evaluation of the existence and severity of the tracheomalacia and intracardiac anomalies is of utmost importance to overcome postoperative respiratory failure and for eventual satisfactory results.

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We studied 90 consecutive cases undergoing open heart surgery with preoperative collection of autologous blood and ultrafiltration during extracorporeal circulation. Among the 58 out of 90 patients (64.4%), open heart surgeries were achieved without homologous blood. We evaluated 13 factors (age, height, weight, body surface area, cardiopulmonary bypass time, aortic cross clamping time, dilutional rate, Hct before predonation, lowest Hct during cardiopulmonary bypass, amount of predonated autologous blood, term of autologous blood predonation, amount of bleeding during surgery, amount of bleeding after surgery) in connection with open heart surgery without homologous blood. Among these factors, age, body surface area, cardiopulmonary bypass time, aortic cross clamping time, lowest Hct during cardiopulmonary bypass, amount of predonated autologous blood, amount of bleeding during surgery and amount of bleeding after surgery demonstrated differed significantly between the only autologous blood transfusion group and the homologous blood transfusion group. According to the evaluation by multivariate regression analysis of these factors, the amount of bleeding after surgery was the most contributor to open heart surgery without homologous blood, followed by amount of bleeding during surgery and body surface area. We concluded that open heart surgery without homologous blood may be achieved in more patients by understanding these factors. Autologous blood predonation by the “leapfrog” method, control of the dilution rate by ultrafiltration during extracorporeal circulation and fresh autologous blood transfusion after extracorporeal circulation were effective to achieve open heart surgery without homologous blood.

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Four patients with d-TGA after atrial switch operation were treated with transvenous DDD pacemaker implantation for their postoperative dysrhythmia; complete atrioventricular block (CAVB) in two, sinus bradycardia with grade I atrioventricular block in one after the Mustard procedure and CAVB with sick sinus syndrome after the Senning procedure in one. From an anatomical point of view, the left atrial appendage was the only suitable anchoring site for the atrial lead. The patency of this cavity should be assessed by echocardiography and/or angiography before implantation. As for the ventricular lead, active fixation is recommended because of the relatively smooth endocardial surface of morphological left ventricle. Otherwise, transvenous DDD pacemaker implantation for patients after atrial switch operation was safely performed without any technical difficulties and with few complications.

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Bypass grafting from the ascending thoracic aorta to the common iliac artery was performed to manage proximal hypertension in a patient with atypical coarctation of the thoracic aorta. The patient's history was significant for an acute aortic thrombosis at the level of the diaphragm for which she underwent an axillo-bifemoral bypass grafting as an emergency operation. Although she was doing well following the initial bypass grafting, the second bypass grafting was required to treat proximal hypertension refractory to medical management. The axillo-femoral bypass graft had a smaller diameter and a longer subcutaneous distance, and the blood supply to the abdominal viscera may have been insufficient. The proximal hypertension was well controlled following ascending thoracic aorta to common iliac bypass, because the diameter (16mm) of the graft is larger than that of the axillo-bifemoral bypass graft (8mm).

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Localized aneurysm of the deep femoral artery is an extremely rare disease. A case of arteriosclerotic aneurysm of the bilateral deep femoral artery was reported. A 72-year-old man complained of pulsatile masses in his abdomen and left groin. Radiologic studies revealed an abdominal aortic aneurysm and one of the left deep femoral artery. Proximal and distal ligation of the left deep femoral artery aneurysm and partial excision of the aneurysmal sac were performed without revascularization 2 weeks after the resection of his abdominal aortic aneurysm. Three years later, ligation and division of the right deep femoral artery aneurysm and reconstruction of blood flow were performed using a 6mm EPTFE prosthetic graft. The postoperative course was uneventful and histological findings revealed arteriosclerosis. The literature of the deep femoral artery aneurysm was briefly reviewed.

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A 51-year-old man was admitted with symptoms of sudden back pain and abdominal pain. Echocardiography and aortagraphy demonstrated enlargement of the aortic annulus, aortic regurgitation and Stanford type B aortic dissection. Since an entry of the aortic dissection was located at the root of the left subclavian artery, a one-stage operation consisting of aortic root replacement and total arch replacement was scheduled. The aortic root replacement using Piehler's modification was first performed followed by total arch replacement combining with the closure of the entry in the distal aortic arch was followed under selective cerebral perfusion. All procedures were complished through median sternotomy. The postoperative course was uneventful and aortography showed good reconstruction of the coronary arteries and the cervical arteries and thrombo-exclusion of the false lumen in the descending aorta. This method was useful for in this case of annulo aortic ectasia with Stanford type B aortic dissection.

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A 67-year-old man had ischemic cardiomyopathy. He had New York Heart Association class III heart failure with pleural effusion. Further examinations revealed an enlarged left ventricle with markedly reduced ejection fraction (6.2%) and 3-vessel coronary disease. He underwent single coronary bypass grafting, using the gastroepiploic artery (GEA) to RCA without cardiopulmonary bypass. He showed a remarkable improvement of cardiac function. He was discharged from our hospital (NYHA class I) on the 40th postoperative day and lives an almost normal life now. Coronary artery bypass grafting without cardiopulmonary bypass is one of the useful surgical techniques for patients with ischemic severe left ventricular dysfunction.

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We report an 81-year-old woman with giant left atrial myxoma who had been admitted with congestive heart failure. Diagnosis was established by echocardiography and a moderate degree of tricuspid valve regurgitation was also found. The tumor was extensively attached to the atrial septum, and was excised completely including endocardium. She had concomitant tricuspid annuloplasty. Atrial fibrillation occurred on postoperative day 10, but conversion to a sinus rhythm was seen on postoperative day 19. She was discharged in good condition on postoperative day 36. Even in a patient over 80 years old with congestive heart failure, aggressive surgical treatment of left atrial myxoma should be performed.

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Cardiac rupture remains a severe complication after acute myocardial infarction (AMI) and its prognosis is poor. Between February 1985 and February 1995, six male patients (age range, 59 to 76 years, average 65.2) underwent repair of heart rupture after AMI at our clinic. The time interval between heart rupture and emergency surgery ranged from one hour to 24 hours (average 11 hours). Two patients did not recover from the initial shock, and were treated by emergency operation under IABP or PCPS. These two patients both had the blow-out type of heart rupture, and were treated by the felt-sandwich method. Neither patient was cured, due to uncontrollable bleeding. The other 4 patients recovered from circulatory catastrophe after pericardial drainage, and surgery was then carried out. One blow-out type patient died of bleeding. Two cases of hemorrhagic dissecting type were successfully treated by the felt-sandwich method. One oozing type case was treated with fibrin-glue and good results were obtained. The hemorrhagic dissecting type or oozing type showed good results but the blow-out type showed poor results. Initial pericardial drainage after establishing the diagnosis and gentle handling of the heart is essential to obtain good results. For the blow-out type of repture, other strategy is needed to control bleeding and facilitate recovery from shock.

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A 36-year-old man was transported to our hospital with severe anterior chest and abdominal pain of sudden onset which was diagnosed as Stanford type B acute aortic dissection with visceral ischemia. Aortogram revealed occlusion of celiac, superior mesenteric and inferior mesenteric arteries with aortic dissection. At first, fenestration of the abdominal aorta above the inferior mesenteric artery was immediately carried out, but the abdominal pain continued. Therefore, bypass grafting for the superior mesenteric artery with saphenous vein was performed the next day. The patient's postoperative course was complicated with acute renal failure and paralytic ileus, which were treated medically and he was discharged in good condition.

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