The stump pressure of the inferior mesenteric artery (IMA) was measured before and after aortic cross clamping during infra-renal abdominal aortic aneurysmal surgery in 50 cases. We analyzed the hemodynamics in IMA-supplied areas, and established an appropriate index to indicate intestinal ischemia. The IMA stump pressure after aortic cross clamping decreased significantly (p<0.0001), by 11% on an average. This means that the collateral blood supply from the internal iliac artery (IIA) is 11% of the total pressure and the collateral blood supply from the superior mesenteric artery (SMA) is 89%, therefore the SMA supply dominates that of the IMA. Intestinal ileus due to ischemia occurred in one patient who had the highest rate of pressure decrease after aortic cross clamping. The cause of ileus might be poor collateral blood supply from SMA and insufficient IIA blood flow preservation. The IMA stump pressure might be an index to predict intestinal ischemia. We analyzed the IMA stump pressure in 38 cases without IMA reconstruction who had no ischemia. The ratio of 0.6 in IMA stump pressure versus systemic pressure could be a safe index suggesting sufficient blood flow in IMA-supplied areas. IMA reconstruction and IIA preservation should be performed to maintain an IMA stump pressure ratio of 0.6.

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Eight cases of isolated iliac artery aneurysms treated between January 1991 and December 1997 were reviewed. All patients were men and their ages ranged from 51 to 85 years (mean 69.6 years). The incidence rate relative to abdominal aortic aneurysm during the same period was 9.3%. The location of the iliac artery aneurysms was the common iliac artery in 6 patients and common and internal iliac artery in 2 patients. Rupture occurred in 3 patients (37.5%). Aneurysms ranged in size from 25mm to 55mm (mean 39.1mm) in 5 non-ruptured cases and from 50mm to 90mm (mean 71.7mm) in 3 ruptured cases (p<0.05). The operative procedures for common iliac artery aneurysms were aneurysmorrhaphy with prosthetic graft replacement in 7 patients and with common iliac-external iliac artery anastomosis in 1 patient. For internal iliac artery aneurysms, obliterative endoaneurysmorraphy was performed in 2 patients. Hartmann's operation with sigmoid colostomy was concomitantly performed in 1 case of rupture. Seven patients had good postoperative courses, however, one case of rupture that underwent Hartmann's operation died of multiple organ failure on the 13th postoperative day. Early diagnosis and elective surgery before rupture are recommended.

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Cardiac operations involving cardiopulmonary bypass can cause a systemic inflammatory response such as elevation of inflammatory cytokines, which can cause organ failure. We investigated cytokine production and its inhibition by ulinastatine in patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass. Thirty-three patients received either ulinastatine (300, 000 units, intracoronary artery injection immediately after aortic closs-clamping, UTI group, n=16) or no ulinastatine (control group, n=17). Arterial blood samples were obtained at aortic closs-clamping, 5 minutes after aortic declamping, and 6, 12 and 18 hours after surgery and there were assayed for interleukin-6 (IL-6), interleukin-8 (IL-8), and polymorphonuclear leukocyte elastase (PMNE). In addition, we examined liver function (GOT, GPT, and total bilirubin), renal function (blood urea nitrogen and serum creatinine), and oxygenatory function (PaO₂/FIO₂) postoperatively. IL-8 levels at 5 minutes after aortic declamping and maximum IL-8 levels were significantly lower in the UTI group than in the control group (25.5±12.8 vs. 47.8±38.9pg/dl, p<0.05, and 28.6±13.2 vs. 58.4±40.0pg/dl, p<0.05). Blood urea nitrogen on the second post operative day (POD) and three POD and creatinine on the second POD were also significantly lower in the UTI group than the control group. Furthermore, IL-8 and PMNE levels significantly correlated positively with blood urea nitrogen and creatinine. There was significant negative correlation between IL-8 and oxygenatory function. These results shows that the ulinastatine can inhibit IL-8 levels following cardiac surgery. To combat the increase of inflammatory cytokines such as IL-8 after cardiopulmonary bypass, the ulinastatine should be used for anticytokine therapy to protect the kidneys, lungs, and other organs, and thereby decrease the risk of complications.

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A 37-year-old woman with Noonan's syndrome underwent surgery for patent ductus arteriosus (PDA) and ventricular septal defect (VSD) with cardiomyopathy. Preoperative examination showed a small left-to-right shunt ratio (L→R) and mild pulmonary hypertension. However she had severe heart failure and repeated upper respiratory infections. The cardiomyopathy of this patient was the dilated type rather than the hypertrophic obstructive type which is usually seen in Noonan's syndrome. Postoperative cardiac functions did not improve significantly. This report discussed the operative technique, indications, and cardiac function aspects associated with Noonan's syndrome.

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This paper describes a very rare case of both ventricular septal defect (VSD) and atrial septal defect (ASD) associated with pulmonary hypertension (PH) successfully repaired via a right thoracotomy in infant with right lung aplasia. A 4-month old infant was admitted to our hospital because of congenital heart disease and right lung abnormalities. Roentogenograms revealed complete opacity of the right hemithorax, with a shift of the mediastinum and the heart to the right. Computed tomography of the chest showed the absence of the right lung and a right bronchus remnant. Therefore, a dignosis of aplasia of the right lung was made at this point. Echocardiogram confirmed VSD and ASD, both of which were 5-mm in diameter, and associated with PH. At the age of 1 year and 7 months, cardiac catheterization was performed, showing pulmonary hypertension with a systolic pulmonary-to-systemic pressure ratio (P_p/P_s) of 0.66. Tolazoline hydrochloride decreased pulmonary vascular resistance (R_p) from 6.92 units·m² to 3.11 units·m². The operation, under cardiopulmonary bypass, was performed via a right thoracotomy approach, because of severe counterclockwise rotation of the heart. VSD and ASD were closed by primary suturing. This approach offered excellent exposure of the intracardiac anatomy in our case. An intraoperative pressure study showed normal pulmonary arterial pressure, the P_p/P_s decreased to 0.33. The postoperative course was uneventful.

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A 68-year-old woman complained of hemoptic shock and recovered with conservative treatment. Ruptured descending aorta into the left lung was diagnosed. Graft replacement of the descending aorta was successfully performed. We speculated that spontaneous rupture of the descending aorta into the left lung might have occurred due to high blood pressure affecting the weak aortic wall with sclerotic change, causing hemoptysis. The ruptured descending aorta was successfully replaced without dissection between the ruptured aorta and the left lung. The postoperative course was uneventful with neither pulmonary nor infectious complications.

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A 65-year-old man suffered abdominal pain and anterior chest pain due to a ruptured abdominal aortic aneurysm (AAA) and acute myocardial infarction. Abdominal CT scanning demonstrated infrarenal AAA measuring 6.0cm in diameter with retroperitoneal hematoma. Coronary angiography was performed revealing total occlusion of the left anterior descending and 90% stenosis in the circumflex coronary artery. The operation was performed immediately after CAG. After median sternotomy, cardioplumonary bypass was initiated using moderate hypothermia (32.0°C). After completion of CABG, AAA replacement using a Y-shaped prosthesis was performed during extracorporeal circulation. Extracorporeal circulation protects the heart from the hemodynamic changes after aortic clamping or declamping during abdominal aortic surgery. Our experience shows that one-stage operation is a feasible option for patients with AAA and coronary artery disease accompanied by impaired left ventricular function.

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A 61 y. o. male was admitted as a diagnosis of Stanford type A dissecting aortic aneurysm 6 day after the occurrence. An urgent operation was performed next day and the ascending aorta was replaced. Oral intake was initiated after uneventful postoperative 6 day-period. However, paralytic ileus became obvious associated with spiked fever over 38°C. Second trial after the suspension of oral intake also failed in the same result and turned out sepsis caused by Enterococcus faecium. The angiogram revealed the intact celiac axis and superior mesenteric artery (SMA), and the remarkably narrowed true lumen of the aorta. Although the clinical symptom was not typical, we thought that the ileus was induced by abdominal angina. At 78th postoperative day the fenestration of the abdominal aorta and the bypass grafting with saphenous vein between SMA and the abdominal aorta were performed. The symptom and sign of ileus subsided after the operation.

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A 79-year-old woman with aortic stenosis due to a calcified small aortic root and severe coronary stenosis (at the left anterior descending artery) underwent aortic valve replacement with a 19mm CarboMedics “Top Hat” supra-annular aortic valve and coronary artery bypass grafting. The postoperative course was uneventful. It was found that by using the CarboMedics supra-annular aortic valve, at least one more large sized valve could be implanted compared to the standard aortic valve. This valve is useful in difficult cases to enlarge the narrow aortic annulus, such as in patients with a severe calcified small aortic root, left ventricular dysfunction or elderly cases. In addition, the operative risk may be decreased and operative time shortened using this valve.

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Blow-out type free wall rupture is a severe complication after acute myocardial infarction and its prognosis is poor. A 68-year-old man was admitted to our hospital for extensive anterior acute myocardial infarction with cardiogenic shock. Echocardiogram and CT strongly indicated the presence of intrapericardial fluid, and we had to perform an emergency operation. Before median sternotomy, we cannulated the femoral artery and vein, and cardiopulmonary bypass was started. We resected the ruptured and necrotic left ventricular myocardium and employed the feltstrip sandwich method. Postoperative recovery of cardiac function and consciousness was satisfactory and he was discharged from hospital on the 37th postoperative day. PCPS or femoro-femoral bypass and consecutive surgical therapy can be a useful method for the treatment of left ventricular free wall blow-out rupture.

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Hybrid revascularization by MIDCAB and stent was performed in a 70-year-old man for reperfusion in the treatment of graft stenosis after CABG. The right SVG, which supplied coronary blood flow, was immediately under the median incision site, and was approached safely by the present method. After intervention, bleeding in the left thoracic cavity occurred, but this was treated conservatively. During intervention after cardiac surgery, transient heparinization of blood was performed for prevention of coagulation. Since strong anticoagulative treatment was continued thereafter, the patient was easily bled. Therefore, it appeared preferable to take time after cardiac operation or insert an indwelling drainage tube into the pleural cavity to monitor hemorrhage. The present method appears useful for patients undergoing re-operation or of high risk.

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Five infants underwent intracardiac repair of truncus arteriosus (TrA) from June, 1993 through May, 1998. The patients weighed 2.4 to 5.71kg (mean 3.47) and their ages at operation ranged from 6 to 133 days (mean 38.2). The anatomical type of TrA was type I (Collet & Edwards classification) in all cases. We employed the Barbero-Marcial procedure for 4 infants and truncal valve replacement using a homograft for one in whom moderate truncal valve regurgitation (TrVR) and severe stenosis was detected by preoperative echocardiography. There was one operative death in an infants who presented with cardiogenic shock and moderate TrVR on admission. No patients in whom preoperative echocardiographic study showed less than mild TrVR died after surgery. Close observation after surgery is necessary because aggravation of TrVR may occur on a long-term basis.

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A 59-year-old man has had a heart murmur for a long time. Four years previously coronary artery-pulmonary artery fistula was diagnosed as the cause of arrhythmia, by coronary angiogram. Despite two coil embolizations some fistulae recanalized and dilated. The coronary artery connected with the main pulmonary trunk and a part of plexiform angioma on the right ventricule outflow tract. Under heart beating, we ligated the origin of each fistulae with direct closure of the ostia from inside pulmonary artery. His symptoms finally improved.

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An 81-year-old patient, who had a postinfarction left ventricular aneurysm with thrombus underwent left ventricular aneurysmectomy with right coronary artery bypass grafting (CABG). Preoperative examination showed 99% stenosis of the left coronary artery (#7) and 90% stenosis of the right coronary artery (#3). The operation was performed because angina was not improved and formation of thrombus was suspected on the wall of the aneurysm. The operation was performed under cardiopulmonary bypass and by antegrade and continuous retrograde cardioplegia. The aneurysm was resected and a relatively fresh thrombus which was detected on the endocardium of the aneurysm was extracted. The left ventricle was closed by direct linear suture with felt reinforcement. Because the area of resection included part of the left anterior descending artery, only right CABG (#3) with a saphenous vein was done. Weaning from bypass was very easy and the postoperative course was uneventful.

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A 49-year-old woman with systemic lupus erythematosus (SLE) underwent grafting for abdominal aortic aneurysm. She had been receiving steroid therapy for 23 years. The abdominal aneurysm was a saccular type, 7cm in width. It had thick mural thrombi with focal calcification, however, no inflammatory findings were recognized around it. Replacement with 16mm Dacron tube graft was performed. The postoperative course was uneventful. Pathological examination showed only atherosclerotic change with no specific inflammation in the aneurysmal wall. It is rare that SLE patients have aortic aneurysm. However, SLE patients should be carefully followed because of their premature atherosclerotis.

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