Ischemic mitral regurgitation (IMR) is a serious and increasingly common clinical disorder, but at present, the relationship between left ventricular shape and IMR is not completely understood. Thirty patients with moderate or severe IMR who underwent mitral valve surgery combined with coronary artery bypass grafting were studied retrospectively. Left ventricular shape, left ventricular regional wall motion, hemodynamic index, condition of the coronary artery, severity of IMR and long term results were assessed using ventriculography and angiography. Left ventricular shape at end diastole and end systole were quantified based upon the ratio of the major-to-minor axis and the sphericity index. Hospital mortality rate was 13.3%, 5 years survival rates were 10.5%, and 5-year rate of freedom from congestive heart failure (CHF) were 7.8%. Significant difference between cardiac deaths (n=11) and survivors (n=19) included requiring intensive care admission, requiring intra-aortic balloon pumping, recurrent myocardial infarction, the ratio of the major-minor axis at end diastole, the sphericity index at diastole, and the sphericity index at end systole. Multivariable regression analyses were performed with the Cox proportional hazards model. Significant determinants of survival were the sphericity index at end systole and LV regional wall motion at the site of the anterobasal segment or apex. These findings indicate that the shape of the LV and LV regional wall motion in IMR may be important determinants of prognosis and suggest that surgical attention to shape may be helpful for mitral valve surgery.

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A total of 104 patients underwent surgical or endovascular surgery (percutaneous transluminal angioplasty: PTA or atherectomy: ATE) between November 1989 and May 1997. In the bypass group, early patency was 96.7%. Actuarial patency for the bypass group was 90.7% at 2 years, 88.1% at 4 years, and 83.2% at 6 years. For iliac lesions, it was 89.6% at 2 years, 85.9% at 4 and 6 years, and for femoral lesions, it was 94.1% at 2 and 4 years, and 80.1% at 6 years. In the PTA group, the early success rate was 76.2%. At 2 years, patency was 23.8%. For iliac lesions it was 30.6% at 2 years, and for femoral lesions, it was 15.6% at 2 years. In the ATE group, the early success rate was 95.0%. At 2 years, patency was 48.9% and at 4 years, it was 39.1%. For iliac lesions, it was 50.0% at 2 and 4 years, and for femoral lesions, it was 49.0% at 2 years and 36.7% at 4 years. Early patency for the bypass group was significantly better than the early success rate for the PTA group. Long term patency for the bypass group was significantly better than for other group. In early results and long term patency, there were almost no differences between the PTA group and the ATE group. In conclusion, bypass shows superior results in comparison with PTA and atherectomy in patients with chronic occlusion of the iliac and the femoral arteries.

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Three cases of aortic arch aneurysm complicated by aberrant right subclavian artery (ARSA) are reported. Two patients underwent emergent operations with diagnosis of a Stanford type A acute dissection and a ruptured distal arch aneurysm. The third patient underwent an elective operation under a diagnosis of distal arch aneurysm and right subclavian artery aneurysm. In all cases, deep hypothermic circulatory arrest with retrograde cerebral perfusion through median sternotomy was applied. The first patient with acute aortic dissection underwent total arch replacement and elephant trunk installation into the descending aorta. No ARSA was recognized. The other 2 patients underwent distal arch replacement with reconstruction of bilateral subclavian arteries. The in-situ reconstruction of the ARSA was performed in one patient and bypass grafting from the ascending aorta was done in the other patient. There were 2 hospital deaths. The postoperative angiogram of the first patient showed that the ARSA was occluded. One other patient needed a tracheostomy because of pulmonary complications and he died of asphyxia. The last patient died of esophageal perforation secondary to pressure necrosis.

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Re-do open cardiac surgery may sometimes require complete ablation around the pericardium for the 2 major reasons of attaining better myocardial protection and obtaining effective DC cardioversion. However, this ablation may increase postoperative hemorrhage which may require blood transfusion. Hypothermia is based on the concept of myocardial protection during open heart surgery by suppressing myocardial metabolism, but recently the approach has been changed to maintaining myocardial metabolism with aerobic or anaerobic energy production. We have already reported that histidine-buffered cardioplegia which promote anaerobic glycolysis, provided an excellent functional recovery of myocardium post-ischemia with lower inotropic requirements in a range from 10°C to 37°C of myocardial temperature. Based on our theoretical background and clinical data, we tested the efficacy of this type of cardioplegia in patients receiving multiple surgical procedures with minimum ablation after sternotomy. First case, who had undergone a Bentall procedure for annulo-aortic ectasia 14 years previously had a thrombotic valve and mitral regurgitation. Aortic valve plasty and mitral valve replacement (MVR) was performed. The second case who had undergone MVR 15 years previously had malfunction of the prosthetic valve and underwent re-MVR. The third and fourth cases had ventricular septal defect (VSD) which were closed using Teflon patches. The third case had patch closure during second operation for residual shunt. The fourth case received tricuspid valve replacement (TVR) for tricuspid regurgitation due to a pacemaker lead implanted into the right ventricle through the left subclavian vein. The fifth case received coronary artery bypass surgery in a second operation for restenosis of the graft and progressing atherosclerosis. All hearts started beating spontaneously without DC cardioversion after the aortic unclamp. Ventricular fibrillation occurred in the first case while the patient was weaned from cardiopulmonary bypass and treatment was performed by aortic cross clamp, infusion of the cardioplegia followed by aortic unclamp to start own beat again. Two of 3 patients who were able to donate their own blood preoperatively did not require homologous blood transfusion. Due to advantages such as excellent myocardial protection under hypothermic or normothermic condition, ease of use and relatively lower potassium concentration, histidine-buffered cardioplegia can be an excellent candidate for myocardial protection in re-do cases with less ablation technique.

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A 45-year-old woman who was a Jehovah's Witness was admitted to our hospital with a complaint of palpitation and sort on-effort. A ruptured aneurysm of the sinus of Valsalva (RASV) associated with stenosis of the right ventricular outflow was diagnosed. Operative findings revealed a RASV with a double chambered right ventricle (DCRV) and a ventricular septal defect (VSD). RASV, DCRV and VSD were successfully repaired with extracorporeal circulation without use of homologous blood. We reported this case because congenital combination of RASV, DCRV and VSD is very rare.

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A 69-year-old man complained of abdominal pain with inflammatory reaction. Abdominal aortic aneurysm (AAA) with a left main trunk lesion was diagnosed and he successfully underwent Y-graft replacement of the abdominal aorta and coronary artery bypass grafting. Finally AAA was classified as “inflammatory” by histopathological findings. We present this case of “inflammatory AAA” associated with coronary artery disease, and discuss it with a review of literatures.

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We report an alternative way to preserve autologous blood with the aid of erythropoietin for a patient with anemia combined with irregular antibody who need the CABG operation. A 62-year-old woman was given a diagnosis of angina pectoris due to three-vessel coronary artery disease. All blood reserved for the coronary operation was incompatible on the crossmatch test and an irregular antibody was suspected. Antibody screening tests revealed anti-drug antibody and anti-P1 antibody. The operation was postponed because she had anemia. After 800ml of autologous blood was collected with administration of erythropoietin and iron for a month, the operation was performed. Two saphenous vein grafts were anastomosed to the left anterior descending artery and circumflex branch respectively. Total blood loss was 580g. Her postoperative course was uneventful and hemoglobin level was ranged from 7 to 10g/dl without any homologous blood transfusion.

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A 76-year-old man was admitted to our hospital because of sudden upper abdominal pain and shock status. The patient had undergone Miles' procedure with a colostomy on the left lower abdomen due to rectal cancer at the age of 70 years. CT scans revealed a thoracoabdominal aortic aneurysm. In view of the clinical findings, ruptured aneurysm requiring emergent operation was diagnosed. A left spiral skin incision was made, keeping away from the colostomy. An extraperitoneal approach was selected. The thoracoabdominal aorta was replaced with an artificial graft under partial extracorporeal circulation with femoral arterial and venous cannulation. The postoperative course was uneventful. No paraplegia occurred in spite of no reconstruction of the intercostal arteries due to severe atherosclerotic changes of the aortic wall. The fact that bleeding due to ruptured aneurysm was localized in the extrapleural and extrapritoneal spaces seemed to be an advantageous factor for the success in this case.

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A 56-year-old man with uncontrolled diabetis mellitus was admitted with general fatigue and high fever. Abdominal CT and aortography showed a saccular aneurysm in the left common illiac artery. Salmonella choleraesuis infection was diagnosed on the basis of blood culture. We performed a two-staged operation because of the tight inflammatory adhesions and the abcess formation around the aneurysm. First we performed surgical treatment of the aneurysm and extra-anatomical bypass grafting (F-F crossover bypass). Then the in situ graft replacement was performed, 4 weeks later. After the second surgery, antibiotics were administered for 6 more weeks. The patient remains asymptomatic for 6 months after the record operation.

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A 53-year-old man who had angina pectoris and juxtarenal aortic abdominal aneurysm was referred to our department. Because the coronary angiography showed severe triple vessel disease, coronary bypass grafting was performed prior to aneurysmectomy. Contrast enhanced computed tomography revealed a retroaortic left renal vein located behind the posterior wall of the aneurysm. The postoperative course was uneventful. Because of its complicated embryological development, the anatomy of the renal veins shows extensive variability. The incidence of retroaortic left renal vein was 2%. Large lumbar and retroperitoneal veins often joined it to form a complex retroaortic venous system. These veins are particularly vulnerable to injury during circumferential dissection of the proximal parts of the aorta. Unawareness of this anomaly and vigorous attempts at encircling the aorta with clamps can result in laceration of the vein. Subsequent catastrophic hemorrhage may lead to unfavorable results, nephrectomy or death. Therefore, preoperative evaluation by a contrast enhanced CT scan and adequate intraoperative management based on a understanding of the potential anatomical variations are imperative. We recommend crossclamp of the aorta proximally with a vertical clamp to avoid circumferential dissection with possible injury to a retroaortic left renal vein. Injury may necessitate division of the aorta to obtain exposure for venous repair. In addition, this anomaly may be related to aorto-left renal vein fistula syndrome and left renal vein entrapment syndrome.

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We report a case of an overlapping ulcerative colitis and aortitis syndrome. A 28-year-old woman with ulcerative colitis in the region from the rectum to the sigmoid colon developed left anterior cervical pain. A cervical contrast-enhanced computed tomography and an arch aortography showed diffuse narrowing of the left common carotid artery and segmental stenosis of the left subclavian artery involving the orifice of the vertebral artery, which defined the diagnosis as aortitis syndrome. HLA was positive for BW 52, which is frequently found in patient with this type of overlapping syndrome. Treatment with prednisolone was begun at an initial dose of 20mg/day, with gradual tapering to 5mg/day at 11 months later, when her symptoms had subsided and laboratory findings of inflammation had disappeared. One year later, she became apathetic in mental activity, and had a poor memory. She also complained of numbness on the left side of her face. Angiography confirmed the progression of the left common carotid narrowing causing the deterioration of her cerebral ischemic symptom. A saphenous vein bypass graft was placed between the right subclavian artery and the left common carotid artery. The postoperative course was uneventful and she had complete symptomatic relief and recovered active ordinary life. Postoperative angiography revealed the well functioning bypass graft.

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A 71-year-old woman with Lutembacher syndrome was admitted for severe congestive heart failure and cardiac cachexia. The preoperative cardiac catheterization showed a huge secundum atrial septal defect (Qp/Qs=3.08) with mitral valve stenosis, tricuspid valve regurgitation, atrial fibrillation and severe pulmonary hypertension. Patch closure of atrial septal defect, mitral valve replacement (SJM 25mm) and tricuspid annuloplasty (Key's method) were performed. However, she suffered prolonged respiratory failure postoperatively. Enforced alimentation for cardiac cachexia and careful administration for sustained heart failure resuscitated her severe postoperative status. The postoperative cardiac catheterization showed sufficient decrease of pulmonary pressure. Reports of successful surgical correction for Lutembacher syndrome in elderly are extremely rare. This is the oldest case of successful correction for Lutembacher syndrome in Japan. From our experience, the surgical treatment for Lutembacher syndrome should be considered even in elderly patients.

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We report a case of a 16-year-old boy with Marfan's syndrome who underwent Bentall's procedure on a diagnosis of acute aortic dissection (DeBakey type II). He was readmitted with pyrexia 5 months after the initial operation. Methicillin-resistant Staphylococcus epidermidis (MRSE) was detected by blood culture and transesophageal echocardiography revealed a vegetation adherent to the entry of a remaining false lumen just distal to the distal anastomosis. Although antimicrobial therapy was employed, an arterial embolism developed in the right popliteal artery. CT scan revealed dilatation of the false lumen, and consequently, emergency surgery was performed. The intima of the distal aortic end was partially out of the suture line and the vegetation adhered at that point. Re-replacement of the ascending aorta, omental transposition, and embolectomy of the right femoral artery were performed and resulted in a satisfactory course.

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We present a case of sigmoid colon to skin fistula following surgery for abdominal aortic aneurysm that was believed to have resulted from nonocclusive mesenteric ischemia involved in low cardiac output syndrome. A 65-year-old man underwent surgical treatment for an abdominal aortic aneurysm. Although the patient had operative risks of renal dysfunction and left ventricular dysfunction due to an old myocardial infarction, the abdominal aortic aneurysm was 6cm in diameter and threatened to rupture, thus prompting surgical removal. For the operation, the abdominal aorta was clamped above the renal arteries and the aneurysm was replaced with a Y-shaped prosthetic graft following the aneurysmectomy. Among the vessels supplying the sigmoid colon, both the inferior mesenteric artery and the left internal iliac artery had become obstructed and thus only the right internal iliac artery could be successfully reconstructed. The patient suffered from low cardiac output syndrome after surgery and subsequently experienced renal dysfunction, liver dysfunction and a disturbance of the peripheral circulation. On postoperative day number 7, the patient complained of watery diarrhea occurring several times a day and abdominal distension as a result of the ischemic colitis. On day number 16, the sigmoid colon to skin fistula developed. Oral intake was discontinued and nutritional support thereafter consisted of intravenous hyperalimentation. In addition, enteral nutrition using an elemental diet was begun. The fistula was successfully closed two weeks later and the patient recovered with no further complications.

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A 49-year-old man who had no history of cardiac disease or intravenous drug abuse was referred to our hospital complaining of fever despite antibiotic chemotherapy. Blood culture was positive for Streptococcus agalactiae, and transesophageal echocardiography revealed vegetation attached to the tricuspid valve and moderate tricuspid regurgitation. Two-thirds of the anterior leaflet and a part of the posterior leaflet of the tricuspid valve were excised with the vegetation, and the remaining anterior leaflet was sutured to the posterior leaflet after annular plication. DeVega's annuloplasty was added to a diameter of two fingers. Following this procedure tricuspid regurgitation was minimal.

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