Every acute dissection involving the ascending aorta (Stanford type A) must undergo emergency surgical repair. However, the surgical techniques must vary according to the clinical presentation of the patients or the anatomical patterns observed. Furthermore, surgery is generally difficult because of the poor condition of the aortic tissues. To reduce those difficulties many technical artifacts have been described. In 1977, we have proposed the use of Gelatin-Resorcin-Formalin (GRF) biological glue to reinforce the suture areas.
From January 1977 to July 1999, 212 patients (152 males and 60 females) aged from 15 to 80 years (mean age: 54+11 years) underwent an emergency operation for type A aortic dissection. One hundred seventy-eight patients (84%) were operated on within 4h after being referred to the hospital. Twenty-eight patients (13.2%) had Marfan's syndome. In 44 patients (20.7%), the aortic valve was replaced either independently (6 cases: 2.8%) or by means of a composite graft (38 cases: 17.9%). Because of the location of the intimal tear, the aortic replacement was extended to the transverse arch in 61 patients (28.7%).
Hospital mortality amounts to 21.6% (46 patients), 25% in patients with arch replacement and 19.4% in patients without arch replacement (n. s). Analysis of hospital mortality demonstrates that the main causes of death were cardiac tamponade, neurologic disorders and visceral malperfusion. One hundred sixty-six patients were discharged and surveyed from 5 months to 22 years postoperatively (Mean follow-up: 85+66 months). During this period of time, 25 patients (15%) had to be reoperated on for a total of 33 reoperations. Seven patients (28%) died at reoperation. At univariate analysis, presence of Marfan's syndrome (p<0.05) and absence of arch replacement (p<0.02) were determinant risk factors for reoperation. Emergency (p<0.01) and thoraco-abdominal replacement (p<0.04) were determinant risk-factors of death at reoperation. The freedom from reoperation (Kaplan-Meier, CI: 95%) is: 96% (90-98), 87% (79-92), 80% (70-88), 66% (51-78) at 1, 5, 10, and 15 years, respectively.
A total of 39 patients (24.3%) died during follow-up. Presence of Marfan's syndrome (p< 0.01), reoperation (p<0.02), stroke (p<0.05), cardiac failure (p<0.05) were determinant risk factors of late mortality. The late survival rate (K-M. C. I.: 95%), including hospital mortality, is 71% (64-77), 66% (58-73), 56% (47-64), 46% (36-56), 37% (28-44) at 1, 10, 15, and 20 years respectively.
During this experience extending over more than 23 years, the GRF glue has proved to be extremely useful, making the procedure much easier and safer. Nevertheless many factors appeared of importance in the pre, intra, and postoperative management of the patients. Cardiac tamponnade and visceral malperfusion must be properly diagnosed and treated. During aortic repair, the main intimal tear must be resected. The transverse arch must be checked and replaced whenever necessary. The aortic valve should be preserved whenever possible. During CPB, perfusing the aorta in the regular antegrade way seems to dramatically reduce the rate of malperfusion. The quality of the first emergency operation seems to have a major influence on the late results, especially concerning the rate of late reoperations and aortic ruptures. However, those late results depend also on the patient's basic condition, particularly in Marfan patients.

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This paper reviews the evolution of surgical technique that has occurred with the Fontan procedure since it was first introduced more than 25 years ago. Although there has been recent enthusiasm at some centers for a return to Fontan's original concept of use of a conduit to achieve the Fontan pathway, we continue to believe that the lateral tunnel with double cavopulmonary anastomosis is the preferred approach. The late incidence of arrhythmias with the lateral tunnel at 10 years follow-up is remarkably low. On the other hand conduits present a risk of outgrowth and pseudointima accumulation. Even small gradients, e. g. less than 4mm, will be poorly tolerated over the longer term and may result in an increased incidence of cirrhosis and protein losing enteropathy.
Overall there has been a remarkable improvement in the early and late results of the Fontan procedure over the last decade. The role of the bi-directional Glenn shunt as either a staging procedure or definitive palliation when performed in conjunction with supplementary pulmonary blood flow needs to be defined by a prospective randomized study. Likewise the role of the fenestration also needs to be defined by a prospective randomized study including careful studies of late exercise capacity and maximal oxygen consumption. Another issue that needs to be defined by careful prospective randomized study is the importance of anti-coagulation with coumadin versus aspirin in reducing the incidence of thromboembolism.

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Recently, the demand for better cosmetic outcomes in pediatric cardiovascular operations has been growing. Between May 1998 and April 1999, six children aged 2 to 6 years with an ostium secundum type of atrial septal defect underwent reparative operations that used an approach consisting of a lower mid-line skin incision with full sternotomy. A 4.2-5.8cm vertical skin incision (mean, 4.9±0.3cm) was made between the level of the nipple and the xyphoid process. Comparison between this series and a group of weight-matched patients who underwent conventional operations revealed no significant differences in operation time (166.0±12.0vs. 147±8.4min), cardiopulmonary bypass time (33.2±4.0vs. 32.2±2.4min), aortic cross-clamp time (13.8±2.3vs. 12.3±1.3min), or the reduction in the hemoglobin concentration in blood on the first postoperative day (1.7±0.3vs. 2.9±0.6g/dl). The surgical wound was not associated with any complications in our series, including wound infection or subcutaneous hematoma. Our technique appears to be safe and provide satisfactory cosmetic outcome.

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Intermittent cold blood cardioplegia with retrograde coronary perfusion was demonstrated in 11 CABG cases and the effects of myocardial protections were compared with 11 cases of antegrade perfusion. We evaluated the effects from the assistant perfusion time after aortic declamping, the incidence of occurrence of spontaneous beating, the dose of catecholamin required after CPB, and the changes in myocardial enzyme values. The two groups were similar in age, ejection fractions, and the extent of coronary artery disease. There were no cases of death and no PMI in all 22 cases, and the mean number of grafts and aortic clamping time were similar in the two groups. Concerning the effects of myocardial protections, there were no significant differences in any items in the two groups. We conclude that intermittent cold blood cardioplegia with retrograde coronary perfusion provides the same myocardial protective effects as the antegrade perfusion in CABG cases.

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To assess the indications and clinical outcome of minimally invasive coronary artery bypass grafting with mini-sternotomy and cardiopulmonary bypass (MICS-CABG) for patients with multiple coronary artery disease, left main trunk stenosis and/or concomitant heart diseases, we examined results in 17 patients (mean age 62.5 years) who underwent MICS-CABG. The average number of distal anastomoses was 2.2 anastomoses/patient. The category of the coronary lesions was the left main trunk in 6 patients, triple vessel disease in 7, double vessel disease in 3, and left anterior descending artery stenosis with aortic regurgitation in 1 patient. Each operative procedure through the mini-sternotomy was easily and completely performed in all patients. By means of postoperative coronary angiography, full patency without stenosis in all grafts was recognized in 95.0%. Immediately after the MICS-CABG, all patients showed quick recovery of respiration, and postoperative admission duration significantly decreased compared with standard CABG with full sternotomy. The above results suggest that MICS-CABG is one of the procedures of choice for patients with multiple coronary artery disease, left main trunk stenosis and/or concomitant heart diseases.

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We examined the surgical procedure and long-term results in patients who underwent intraoperative re-do for the completion of mitral valve repair. Between March 1993 and July 1996, 81 patients underwent mitral valve repair for pure MR using TEE evaluation. Of these, 12 patients that were judged to have more than mild residual regurgitation (MRA≥2.0cm² or MRL≥1.0cm) underwent intraoperative re-do. All of the patients were type 2, according to Carpentier's classification. Seven patients had degenerative disease and 2 had infective endocarditis. If the cause of residual MR was localized discoaptation, 5-0 suture plication with beating heart that increased the coaptation zone and resulted in decrease in the residual MR was useful. If the cause of residual MR was leaflet prolapse or dehiscence, intraoperative re-do was performed the cardiac re-arrest. Two patients of billowing valve underwent MVR and the other needed additional resection of leaflet, artificial chorda or suture. After intraoperative re-do, every procedure resulted in a reduction of MR except for 2 patients underwent MVR during the early postoperative stage, and of those all but one remaine no-to-mild MR in the late term (mean follow-up 26.2 months). In conclusion, 5-0 suture plication was effective for intraoperative re-do procedures, and basic mitral valve repair modification was necessary in about half of the cases. Intraoperative re-do was safely performed with no mortality or morbidity and it yielded good long term results. Intraoperative TEE evaluation was considered to be important.

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The purpose of this study was to evaluate the pathologic physiology of the brain during selective cerebral perfusion (SCP) during surgery for aortic dissection and aortic arch aneurysm. To evaluate the differences in cerebral blood flow and cerebral oxygen metabolism during SCP and normal cardiopulmonary bypass (CPB), we compared 10 patients undergoing selective cerebral purfusion (SCP group) with 20 patients undergoing normal cardiopulmonary bypass surgery (CPB group). In this study, the middle cerebral arterial blood flow velocity (MCAV) was continuously measured in both groups with a Labodop DP-100 trans cranial doppler velocimeter (TCD) during operation to measure the changes in cerebral blood flow. The tympanitic membrane temperature, the bladder temperature, the temporal arterial pressure, the internal jugular venous pressure and the arterial blood hemoglobin concentration were measured every 20min to evaluate the cerebral blood flow conditions. Further more the oxygen partial pressure (PaO₂), the carbon dioxide partial pressure (PaCO₂) and the oxygen saturation were also measured in arterial and internal jugular venous blood to evaluate the cerebral oxygen metabolism. The cerebral oxygen extraction rate (COER), and the cerebral metabolic rate for oxygen (CMRO₂) were calculated. The cerebral perfusion pressure and the brain temperature in the SCP group were lower than those of the CPB group, while PaCO₂ in the SCP group was higher than that of the CPB group during SCP. In spite of the low cerebral perfusion pressure and the decrease in cerebral metabolism in the SCP group, mean MCAV remained at levels similar to those of the CPB group during SCP. This suggests that the high PaCO₂ level may be a significant factor in the increased cerebral blood flow during SCP. In conclusion, MCAV in the SCP group was maintained by the high PaCO₂ levels during SCP, causing COER and CMRO₂ levels to be much the same as in the CPB group.

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Clinical cases of normothermic extracorporeal circulation (ECC) are increasing, but the possibility of brain damage is not clear.In emergencies, the brain protective effects of mild (33-34°C) hypothermic therapy have been clearly confirmed. Natural Temperature decrease ECC was conducted in this study, hoping to obtain the advantages of both normothermic ECC and brain protection by mild hypothermia. These were 12 cases at high risk of brain damage (10 cases of brain infarction and 2 cases of severe carotid artery stenosis). In all cases, coronary artery bypass grafting operation with natural temperature decrease ECC was performed. The average laryngeal temperature dropped to 33.0±0.3°C. There was no brain infarction or ICU syndrome. Evaluation of post-operative brain condition by the patients themselves and their families was good. The possibility of natural temperature decrease ECC for high risk cases of brain damage was demonstrated.

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A 26-year-old man was suffered a tendon injury in the left knee when playing American football 3 years previously and was treated consevatively. He was admitted to our hospital because of coldness and paresthesia in the left leg since 2 months previously. Femoral angiogram revealed severe stenosis of left popliteal artery and occlusion of the anterior and posterior tibial artery. CT and MRI examination revealed a tumor which protruded into the lumen of the left popliteal artery or dissection of left popliteal artery. Operation was performed by a posterior approach. The left popliteal artery was not compressed from the lateral side and there was a white thrombus in the popliteal artery. Thromboendartherectomy and autologus venous patch plasty was done. Histopathological findings of the stenotic lesion revealed an organizing thrombus, chiefly consisting of fibrin, and intima both of which were infiltrated by granuration tissue. It was suggested that the stenotic lesion was caused by arterial wall hyperplasia or thrombus formation during the healing process after blunt arterial injury. The post-operative course was uneventful.

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There are few reports on the long term efficacy of surgery for endocardial cushion defect (ECD) in elderly patients. We report a case with a successful course after ECD operation. A 70-year-old man was admitted with incomplete ECD, grade III mitral and tricuspid regurgitation, pulmonary hypertension and atrial fibrillation. The operative procedures included direct closure of the mitral cleft, pericardial patch closure for the ostium primum defect, direct closure of the tricuspid cleft and tricuspid annuloplasty. Pulmonary hypertension was improved after the operation, and he was discharged on the 41st day after the operation. Now, 3 years and 6 months after the operation, he has maintained an improved quality of life (QOL) with an uneventful postoperative course. The present report may suggest one solution for the long term effective treatment by operation for elderly patients who suffer from ECD, especially to achieve better QOL.

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Malignant hyperthermia (MH) and antithrombin III (AT III) deficiency are both rare, but once they occur, the patient's prognosis is very poor. A 67-year-old man was referred to our hospital with a diagnosis of unstable angina. A coronary angiography revealed stenosis of LMT and triple vessels. The patient was considered a candidate for CABG. He had been prescribed 50mg/day of dantrolene for frequent muscular convulsions of the lower extremities. He had had a high CK level for a few years. Therefore he was considered to be at high risk for malignant hyperthermia (MH). He underwent CABG (×4). Dantrolene was administered orally at a dose of 25mg and then 160mg intravenously before anesthesia and modified NLA was performed in order to avoid probable MH. During the operation, AT III deficiency was suspected because the reaction of ACT after heparinization was poor. AT III preparation (1, 500 units) was used and CABG under cardiopulmonary bypass was completed without any events. It was proved after the surgery that the AT III volume had been almost normal but its activity had decreased. His postoperative course was good. For possibly fatal MH and AT III deficiency, it is necessary and important to predict, prevent and diagnose as early as possible.

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Coronary artery bypass surgery and abdominal aortic aneurysm repair were performed simultaneously during cardiopulmonary bypass in two patients with severe left ventricular dysfunction. Both patients underwent coronary artery bypass surgery first, followed by abdominal aortic aneurysm repair during cardiopulmonary bypass. Combined surgery is reasonable for patients with combined coronary artery disease and abdominal aortic aneurysm. Aortic aneurysm repair during cardiopulmonary bypass for patients with severe left ventricular dysfunction also appears safe and effective.

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A 79-year-old man underwent aortic valve replacement by xenografts for active infective endocarditis with aortic regurgitation. Two months later, he developed congestive heart failure and uncontrolled infective endocarditis. The second operation was performed 3 months later, with an aortic valve translocation procedure because of aortic regurgitation due to aortic root abscess and prosthetic valve endocarditis. Six months after the second operation, the saphenous vein graft (SVG) to the left coronary artery (LAD) revealed a severe stenotic lesion at the proximal site. The stenotic vein graft fed almost the entire left coronary circulation. The third operation was performed via left thoracotomy, under hypothermic circulatory arrest with cardiopulmonary bypass. A new radial artery (RA) graft was anastomosed between the descending thoracic artery and the old SVG for LAD. The patient recovered without any major complications and postoperative angiography showed that the new RA graft was patent.

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A 55-year-old man was admitted to our hospital with angina pectoris. Coronary angiography revealed that the left anterior descending artery (LAD) originated from the proximal right coronary artery (RCA) which arose from the right coronary sinus of Valsalva, while the circumflex artery (CX) arose from the left coronary sinus of Valsalva. Multiple coronary lesions included total obstruction at the proximal RCA after branching the LAD, 75% stenosis at the origin of the LAD, and 90% stenosis at the proximal CX. These lesions were revascularized with the left interthoracic artery to the LAD, the radial artery to the RCA, and a couple of saphenous vein grafts to the CX. Postoperative angiography confirmed patency of all grafts. Anomalous coronary artery is found to be 0.62-0.83% by angiography. A rare anomalous coronary artery is documented in this article, which has been reported to be 4.4% of all anomalous coronary arteries.

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A 76-year-old man developed dysphagia and esophageal stenosis was diagnosed. A computed tomographic scan of the chest demonstrated a large aneurysm of the distal aortic arch. The patient had undergone left thoracoplasty 45 years previously for the treatment of lung tuberculosis, then the aortic arch with the aneurysm was displaced backward because of the narrowed upper thoracic cavity and the esophagus was sandwiched between the aortic arch and the spine. The patient was thought to be in danger of developing an aortoesophageal fistula, so an emergency operation was performed in spite of his age and general condition. He was successfully treated with graft replacement including reconstruction of three arch vessels and his severe dysphagia improved.

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Surgical treatment of abdominal aortic aneurysms in elderly patients aged over 90 is rare, and the surgical indications in such patients is controversial. Two cases of abdominal aortic aneurysm successfully treated surgically are reported. The first case was a 92-year-old woman, who manifested a severe abdominal pain without hypotension. An impending rupture of an abdominal aortic aneurysm was suggested on enhanced CT scan, and emergency surgery was indicated. The aneurysm was replaced with a woven Dacron Y-graft. Postoperatively, the patient's social activity returned to the preoperative level. The second case was a 91-year-old man, in whom an increasing abdominal aortic aneurysm had been pointed out on UCG and enhanced CT scan. Because he was socially very active for his age, elective surgery was indicated. The aneurysm was resected and replaced with a woven Dacron I-graft. Postoperatively, the patient overcame a respiratory complication and was eventually discharged without any physical complication. Although he was able to climb mountains before the surgery, he lost some physical activity after the surgery. Because of the potential decrease in physical strength especially in very elderly patients, the general risk evaluation did not always correspond to a precise evaluation and prediction of postoperative activity. It is therefore necessary to be flexible in deciding on the surgical indications in each case.

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We report a successful case of graft replacement for ascending and aortic arch aneurysm which developed 5 years after CABG. A 75-year-old woman, who underwent emergency CABG (LITA-LAD, SVG-RCA) 5 years previously, was admitted to our hospital due to an abnormal shadow on chest roentogenogram. Aortogram and coronary angiogram revealed ascending and aortic arch aneurysm and patent LITA and SVG. Graft replacement of the ascending and total aortic arch was carried out using four branched grafts (Gelweave 26/10/8/8^*8). Cardiopulmonary bypass was established with right axillary arterial perfusion and bicaval cannulation. Cardiac arrest was obtained with cold blood cardioplegia using both retrograde and antegrade techniques. Selective cerebral perfusion was used for brain protection. The patient was discharged without any complication on the 27th postoperative day.

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