Background: Operative blood loss during open-heart surgery has been decreasing recently. We have stopped predonated autologous blood transfusions to reduce hospital stay and cost. Material and methods: In 70 consecutive elective open-heart cases, we used intraoperative hemodilutional autologous transfusions and intraoperative autotransfusions to avoid homologous blood transfusion. Predonated autologous blood transfusion was not used. All patients received an infusion of high-dose tranexamic acid prior to and after cardiopulmonary bypass (CPB). Results: Homologous blood transfusion was not required in 77.1% of patients who underwent open-heart surgery. When further classified, 84.5% of patients who underwent primary open-heart surgery, 41.7% of patients who underwent a reoperation, and 33.3% of patients who were preoperatively anemic did not require homologous blood transfusion. In patients who undergo reoperation and who are preoperatively anemic, the rate of homologous blood transfusion is high. Therefore, during the reoperation, intraoperative autologous blood transfusion should be used before starting CPB, and iron should be given to anemic patients prior to reoperation. Conclusion: Our strategy of blood conservation consists of intraoperative hemodilutional autologous transfusion, intraoperative autotransfusion, infusion of high-dose tranexamic acid prior to and after CPB and, avoiding predonated autologous blood transfusion. Based on our experience, predonated autologous blood transfusion is usually unnecessary for cases who undergo surgery for the first time and are not anemic. Predonated autologous blood transfusion should be reserved only for high risk patients with anemia and reoperation cases. For further blood conservation, we need to study the safety limits of non-transfusion in open-heart surgery.

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Four patients, 13 to 53 years old, with congenital venous malformation including Klippel-Trenaunay syndrome underwent surgical treatment followed by sclerotherapy. They developed marked dilatation of varicose veins with spots, and complained of pain, dullness, and bleeding. Two patients also had hypertrophy of the diseased leg. Phlebography and color Doppler ultrasonography were performed in all patients to precisely determine the abnormal vein and incompetent communicating veins which were then resected and/or ligated with minimal skin incision. In two patients, additional ligation of incompetent communicating veins was necessary. One to two weeks after surgical therapy, sclerotherapy was performed with 1-2% polidocanol. Symptoms improved after treatment, even in a patient with claudication before operation. Surgical therapy for congenital venous malformation was feasible and satisfactory, with the aid of meticulous identification of abnormal veins and communicating veins by not only phlebography but color Doppler ultrasonography.

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To evaluate peripheral occlusive diseases quantitatively, we performed color duplex sonography. Between July 1996 and July 1998, we examined 68 limbs of 40 patients using color duplex sonography in addition to intraarterial digital subtraction angiography for evaluation of peripheral arterial occlusive disease. We classified the wave form of blood flow into four types (Type I-IV). Furthermore we measured the systolic velocities of the dorsal pedial and the posterior tibial arteries as well as the brachial artery. We also calculated the flow volume, and the ratio of systolic velocities and flow volume of lower to upper extremity (AVI, AFI). The waveform was significantly higher in Fontaine class III and IV, and showed remarkable improvement after arterial reconstruction. The value of AVI as well as AFI showed lower in Fontaine class I, II, III, and IV in order. In four limbs classified as Fontaine class II or more with normal ankle pressure index, the values of AVI were rather lower. On the other hand, three limbs with normal values of peak AVI (>0.9) and lower API (<0.75) were in Fontaine class I. The types of waveform correlated with clinical symptoms, and showed a remarkable regression after arterial reconstruction. The new AVI and AFI values had better correlation with clinical symptoms than API.

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Here we present a long-term follow-up of 50 operative survivors, who underwent surgery between December 1975 and March 1994 for the placement of an extracardiac conduit. Twenty-six patients received conduits with various valves (VC group). The valves used were the Hancock valve in 9 patients, the St. Jude Medical valve in 5, and a valved roll made of equine pericardium in 10. Twenty-four patients received valveless Dacron conduits (NVC group). Another group of patients, also with discontinuity between the right ventricle and the pulmonary artery, who were operated on without the use of a conduit, is presented here for comparison (NCR group: 16 patients). The follow-up period for the NCR group was shorter than for the other groups. There were a total of 4 late deaths in the conduit groups, and none in the NCR group. Freedom from reoperation due to conduit stenosis was analyzed by the Kaplan-Meier method. In the VC group, freedom from reoperation at 5, 10, and 15 years, was 87.8%, 50.8%, and 31.2% respectively. In the NVC group, freedom from reoperation at 5, 10, and 15 years was 100%, 95.7%, and 60.4%. There were statistically significant differences between the values in these 2 groups. In the NCR group, only one patient (6.25%) underwent reoperation due to stenosis in the right ventricular outflow tract. Although the rate of freedom from reoperation was lower in the valveless conduit group than in the valved conduit group, the majority of patients who receive a conduit between the right ventricle and the pulmonary artery will eventually require reoperation. Avoiding the use of an extracardiac conduit, and creating continuity between the right ventricle and pulmonary artery with autologous tissue is a useful alternative and may reduce the need for reoperation.

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A 40-year-old woman presented with Salmonella enteritidis endocarditis involving the mitral valve. A severe degree of congestive heart failure developed despite appropriate medical and antibiotic treatment, and resulted in urgent surgical intervention in the active phase of the infection. She underwent successful mitral valve replacement with a mechanical valve, followed by additional antibiotic infusion with adequate distribution to the biliary system to prevent late reactivation of the organism. Although antibiotic therapy is fairly effective for patients with Salmonella enteritidis, early rather than procrastinated surgical treatment is recommended to minimize damage to the valve and surrounding structures.

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Papillary fibroelastoma is a rare, benign heart tumor. We successfully treated a patient with multiple fibroelastomas derived from both the mitral valve and the chordae by surgical excision. A 59-year-old man was admitted to our hospital with a history of myocardial infarction three years before admission. Preoperative transthoracic and transesophageal echocardiograms showed multiple, mobile, rounded cardiac tumors in the left ventricular cavity and the mitral valve. Under cardiopulmonary bypass, we performed prosthetic mitral valve replacement after excising the valve with the tumor. The patient was discharged and remains asymptomatic. Histologic examination of 6 specimens of the excised tumor confirmed the diagnosis of papillary fibroelastoma. When papillary fibroelastoma is diagnosed, surgical treatment must be considered because of the high risk of embolization.

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A 44-year-old woman with Marfan's syndrome presented complaining of severe back pain. Angiography revealed annulo aortic ectasia, aortic regurgitation, acute aoric dissection (DeBakey IIIb) and distal aortic arch aneurysm. One month after admission, she underwent cardiopulmonary bypass was established through the femoral artery, the superior and inferior vena cava. The heart was arrested by aortic cross clamping and retrograde cold (20°C) cardioplegia. At first, a modified Bentall's procedure was done in addition to a Carrel patch procedure. After this procedure, the heart was perfused continuously (300ml/min) with warm (37°C) blood until the end of the cardiopulmonary bypass. The heart recovered a sinus rhythm spontaneously. Subsequently, aortic arch replacement and the elephant trunk method was done with the aid of deep hypothermia and circulatory arrest. The patients is well 1 year after the operation. This technique is useful for patients who require prolonged aortic cross clamping time.

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In 46-year-old man who had had general fatigue due to hypertension for about 20 years, only hypertension of the upper part of the body had been pointed out; the blood pressure of the upper limbs was 190mmHg and that of the lower limbs was 80mmHg. Computed tomography showed severe aortic stenosis with advanced calcification from the proximal descending thoracic aorta to the infra-renal abdominal aorta, the minimum caliber of the aorta being only 5mm. Hypertension was not controlled in spite of administration of 5 anti-hypertensive agents. Because renal factors were not related to hypertension, we chose a minimally invasive procedure: axillo-bifemoral artery bypass. After operation, the difference of blood pressure between upper and lower limbs reduced and symptoms disappeared. There are many case reports of aorto-aortic bypass for atypical coarctation, but we think that the less invasive axillo-bifemoral artery bypass is also an alternative procedure.

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A 51-year-old man underwent arch replacement for a thoracic aortic succular aneurysm in December 1996. The pathological examination indicated aortitis to be the cause of the aneurysm. At that time we did not surgically treat the abdominal aortic aneurysm (AAA) which was only 32mm in diameter. Sixteen months after the first operation, he complained of a pulsatile tumor in his left leg. Angiography revealed an aneurysm of the left superficial femoral artery. The artery distal to the aneurysm was occluded, and the left popliteal artery received collateral blood flow from the deep femoral artery. The size of the AAA increased to 48mm, an indication of repair. Aneurysmectomy of the left superficial femoral artery and replacement of the abdominal aorta were performed simultaneously. The operative findings showed that the aneurysm of the left superficial femoral artery had been ruptured and formed a pseudoaneurysm. The pathological findings demonstrated both aneurysm aortitis. After the second operation, he was given steroid therapy to control the inflammatory reaction and he has been well for one year.

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A 61-year-old woman was admitted to our hospital because of acute heart failure. The angiogram showed an enlarged aortic root and aortic incompetence which indicated annulo-aortic ectasia. An aortic valve-sparing operation was impossible because of severe prolapse of the aortic valve and the patient hesitated to have anti-coagulation therapy. Thus we performed aortic root replacement with the Freestyle™ stentless porcine valve (Medtronic Inc.). We plicated each original commissure in order to narrow the enlarged annulus and attach the Freestyle valve to the annulus directly by continuous suture. There was no significant difference in surgical technique and aortic cross-clamping time, compared to conventional operation. Aortic root replacement with the Freestyle valve seems an attractive option especially for elderly patients or cases in which of contraindicated for anti-coagulation therapy.

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A 45-year-old woman with an 8-year history of systemic lupus erythematosus (SLE) was admitted with complaints of sudden onset of chest and back pain and syncopal attack. Aortography showed DeBakey type I acute aortic dissection. She has been maintained on a small dose of corticosteroids (prednisone 5mg/day). After antihypertensive drug treatment, a replacement of the total aortic arch and arch vessels was successfully performed. The postoperative course was uneventful and she has had no relapse of SLE.

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An 81-year-old-woman was successfully treated with simultaneous minimally invasive direct coronary artery bypass (MIDCAB) and colectomy. The patient complained of effort angina and tarry stool and had a combination of Bormann type II transverse colon cancer with oozing bleeding and long segmental stenosis of the left anterior descending coronary artery (LAD). Angiography suggested that the anastomotic site on the LAD extramusclarly presented on the tortours LAD. We therefore carried out one-stage operation of MIDCAB and colectomy. First, MIDCAB to the LAD using the left internal thoracic artery was performed via left anterior thoracotomy. After closing the left thoracic wall, we carried out transverse colectomy with lymph node resection via upper median laparotomy. The total operation time was 3hr 30min, 2hr 10min for MIDCAB and 1hr 20min for Colectomy respectively. Postoperative coronary angiography showed good patency of the LITA. The resected colon specimen showed moderately differentiated adenocarcinoma: ss, n1, Po, Mo stage 3a. She was discharged 15 days after the operation.

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A 61-year-old man was admitted with acute cardiac failure associated with atypical aortic coarctation and severe left ventricular hypertrophy. Angiography and MRI showed that all branches from the aortic arch were occluded, and that cerebral circulation was supplied via collateral flow from small aortic branches either proximal or distal to the coarctation and by the right vertebral artery receiving retrograde flow from the right internal thoracic and right thoracodorsal arteries. Cerebral CT revealed massive cerebral infarction in the perfusion area of the right mid-cerebral artery. Aortitis syndrome was diagnosed from these findings, and ascending-abdominal aortic bypass grafting with aorto-right subclavian bypass was performed after successful conservative treatment for cardiac failure. Because of remarkable increase in the aortic blood pressure on partial clamping of the ascending aorta, proximal aortic anastomosis was performed under extracorporeal circulation. Near infrared spectroscopy (NIRS) was used to monitor the intraoperative cerebral circulation. The perfusion flow rate was maintained in order not to reduce the regional brain oxygen saturation below the critical level. No cerebral complication was encountered postoperatively. Cases of aortitis syndrome with occlusion of all arch branches are rare. NIRS was suggested to be useful to evaluate cerebral circulation during operation in such cases in which cerebral blood flow can be severely affected.

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We successfully performed one-stage definitive repair for 3 infants weighing 4.2, 6.1 and 5.2kg with complex coarctation without homologous blood transfusion. The priming volume of the bypass circuits was 195ml, and their lower hematocrit values during cardiopulmonary bypass were 15, 16 and 13%, respectively. In order to diminish the aortic cross clamp time, the aortic arch was repaired with the heart beating, using isolated cerebral and myocardial perfusion methods. The base excess in each patient decreased to -9.4, -8.0 and -4.9mEq/l during the rewarming phase, however, their postoperative hemodynamic and respiratory conditions were satisfactory. They have grown without any sequelae for at least 2 months.

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We report a 66-year-old woman with circulatory collapse due to acute pulmonary thromboembolism, in whom a left nephrectomy for a renal tumor was scheduled. Following preoperative renal angiography. The patient suffered sudden shock resulting from pulmonary thromboembolism (PTE) following release of compression of the puncture site. The patient was transported to the ICU, and percutaneous cardiopulmonary support (PCPS) was instituted immediately for resuscitation. Hemodynamics were stabilized by PCPS and percutaneous thrombectomy was attempted. However, perforation by a catheter inverted to the extracardiac space occurred, which neccesitated emergency surgical hemostasis. PCPS was converted to cardiopulmonary bypass (CPB). The injured right ventricle and right atrial walls were repaired, and pulmonary thrombectomy was performed via the pulmonary trunk. CPB was easily terminated and her postoperative course was uneventful with anticoagulant therapy. Left nephrectomy was performed two months later. PTE recurred due to the interruption of anticoagulation for surgical treatment of a renal tumor. Percutaneous pulmonary thrombectomy and thrombolysis therapy were effective and a Greenfield filter was inserted into the inferior vena cava to prevent recurrence.

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