To test the hypothesis that neutrophils play a role in lung injury during cardiopulmonary bypass, granulocyte elastase and myeloperoxidase release from pulmonary circulation were measured, as well as the respiratory index, before and after cardiopulmonary bypass. The production of granulocyte elastase and myeloperoxidase in the pulmonary circulation, and the respiratory index also elevated significantly after cardiopulmonary bypass. Furthermore, the level of granulocyte elastase and myeloperoxidase released from pulmonary circulation correlated with the changes of the respiratory index and preoperative pulmonary artery pressure. These data indicate that neutrophils play a major role in pulmonary dysfunction occurring after cardiopulmonary bypass, which is accentuated in patients with pulmonary hypertension.

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There have been many reports radial artery grafts (RA) are useful in CABG, but there were very few reports about hand grasping power (GP), edema and sensory disturbance after surgery. From January to April, 1999, RA were used for 14 patients (R group) and were not in 16 patients (C group) among a total of 30 coronary artery bypass grafting procedures. The patients in the two groups were statistically similar. RA were anastomosed to #12 in 9 patients and #14 in 5. GP and the circumference of forearms were examined and sensory disturbance was also checked preoperatively and at 1, 2 and 4 weeks postoperatively. In both groups, left GP decreased slightly after surgery but gradually recovered. Four weeks after surgery, it was 26.2±9.6kg in the R group and 26.2±7.5kg in the C group (NS). The difference between left and right circumference of forearms, which indicates the degree of edema, was significantly larger in the R group than in the C group (3.5±3.6mm vs. -0.5±3.8mm, 1 week postoperatively, p<0.05). However, it gradually improved in the R group (2.1±2.6mm at 2 weeks and 1.9±2.6mm at 4 weeks postoperatively). No sensory disturbance was seen at any time. Therefore we conclude that using RA in CABG is not only useful but is also safe and does not increase postoperative risk.

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Background and aims of the study: Mechanical valves require anticoagulation therapy, and bioprostheses may need reoperation due to structural valvular deterioration (SVD). In older patients, the rate of SVD seems to be lower than in younger patients. The aim of this study was to evaluate a 12-year clinical experience of the Carpentier-Edwards pericardial bioprosthesis in the aortic position in patients over 60 years of age. Methods: A total of 652 patients over 60 years old (453 men, 199 women; mean age 72.2±6.7 years) underwent isolated aortic valve replacement with the Carpentier-Edwards pericardial bioprosthesis in our institution between July 1984 and December 1995. The main indication for valve replacement was idiopathic calcific stenosis in 476 cases (75%), while dystrophic insufficiency was present in 124 of the cases (19%). Other conditions were rheumatic, congenital, prosthetic valve dysfunction and endocarditis. All patients, except one, were followed up for an average of 4.36 years after surgery resulting in a total follow up period of 2, 802 patient-years (pt-yr). Results: The operative mortality rate was 3.1% (20/652) including 138 late deaths. Thirty patients died of valve-related causes (14 sudden deaths, 11 thromboembolisms, 3 prosthetic valve endocarditises (PVE) and 2 bleeding events). Twelve years after surgery, the actuarial rate of freedom from valve-related death was 76±24%. Valve-related complications included 37 thromboembolic episodes (1.4%/pt-yr), 9 bleeding events (0.4%/pt-yr), 14 PVEs (0.4%/pt-yr), 2 structural valve failures (0.07%/pt-yr) and 8 reoperations (0.3%/pt-yr). Twelve years after surgery, freedom from thromboembolism was 80±12%, freedom from bleeding events was 96±3%, freedom from PVE was 96±2%, freedom from structural valve failures was 98±2% and freedom from reoperation was 96±4%. Conclusion: With a low rate of structural valve failure 12 years after surgery and a good clinical performance, the Carpentier-Edwards pericardial bioprosthesis is a reliable alternative for patients over 60 years of age.

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Rheumatic tricuspid stenosis has become rare recently. A 54-year-old woman had undergone mitral valve replacement with a Carpentier-Edwards bioprosthesis for mitral stenosis 22 years previously and had undergone repeat mitral valve replacement for prosthetic valve failure 10 years later. She was admitted with severe leg edema. Cardiac catheterization revealed pulmonary hypertension and tricuspid stenosis with a diastolic pressure gradient of 6mmHg across the tricuspid valve. Tricuspid valve replacement was performed with a Hancock bioprosthesis. The postoperative course was uneventful and her edema improved markedly. This case suggested that careful follow-up to detect progression of tricuspid stenosis is necessary in patients with rheumatic valve disease and pulmonary hypertension.

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A 45-year-old man presented with cough and dyspnea. He had undergone reconstruction of the ascending aorta for acute aortic dissection (DeBakey type I) 5 months previously, at which time we used the gelatin-resorcin-formalin glue (GRF glue) for reconstruction of the wall layer. Preoperative transesophageal echocardiography and aortography revealed aortic regurgitation due to redissection of the aortic root. Intraoperatively, dehiscence was noted between the right coronary sinus including the coronary ostia and the non-coronary sinus. These intraoperative findings suggested that the pathology leading to the redissection was related to the previous use of GRF glue. The redissected segment appeared to be necrotic on macroscopic examination intraoperatively, however histological examination revealed only degenerative changes, and there was no evidence of the glue. He was treated by the modified Bentall method and had a good postoperative course after discharge. In this case, it is also conceivable that tissue necrosis resulted from the use of too much formalin.

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Rheumatoid arthritis and interstitial pneumonitis were diagnosed in a 72-year-old man and thoracic computed tomography revealed an aortic arch aneurysm 50mm in diameter. Steroid therapy gave symptomatic relief and improved laboratory findings, but hyperglycemia and hypertension developed. Two months later the thoracic aneurysm ruptured, and computed tomography revealed expansion of the aneurysm to 60mm in diameter and surrounding hematoma. Emergency total arch replacement was performed successfully with deep hypothermic cardiopulmonary bypass and selective cerebral perfusion. The steroid therapy was considered to be responsible for the rapid expansion and rupture of the thoracic aneurysm. When prescribing steroids for a patient who has a concomitant atherosclerotic cardiovascular disease, we should not only control the steroidal side effects strictly, but also carefully watch the course of the atherosclerotic lesion.

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Celiac artery aneurysm is very uncommon. We report an even more rare case in which a life threatening ruptured aneurysm was treated successfully by an emergency interventional procedure. A 72-year-old man was transferred to our hospital with a chief complaint of severe epigastralgia. In the emergency room, the patient was already in shock and emergency CT scan suggested severe intraperitoneal bleeding. The diagnosis of ruptured celiac artery aneurysm was confirmed by subsequent angiographic examinations and immediate hemostasis was successfully achieved by transcatheter arterial embolization. One year after the embolization, the patient remains asymptomatic and follow-up CT scans revealed reduction in size and thrombotic occlusion of the aneurysm.

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A 62-year-old man was transferred to our institution with ventricular fibrillation. Percutaneous cardiopulmonary support (PCPS) was established and he underwent successful percutaneous transluminal coronary angioplasty. Since his left ventricular function did not recover, he was placed on a left ventricular assist system (LVAS). Under general anesthesia, a 10-cm longitudinal incision was made on the right parasternum. The third and fourth cartilages were completely resected. The pericardium was incised longitudinally. At first, an inflow cannula was insected to the right side of the left atrium. The ascending aorta was then partially excluded and an outflow cannula with a 10mm Gore-Tex prosthesis was anastomosed end-to-side to the aorta with a continuous Gore-Tex suture. After the pump was established, PCPS was gradually discontinued. During 9 days of support, his left ventricular function recovered and subsequently he was weaned from LVAS. Unfortunately, he died two days after LVAS removal. We think this procedure is useful because it is easy to perform, reduces the bleeding, shortens the operating time.

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A 69-year-old man was admitted for treatment of thoracic aneurysm. DSA revealed multiple aortic aneurysms: three true aneurysms which were located at the distal arch, the thoraco-abdominal aorta at the diaphragm level and the infrarenal abdominal aorta, 60mm, 55mm and 55mm in diameter, respectively and two pseudo-aneurysms which were located in the abdominal aorta just below the right renal artery and the right common iliac artery. We decided to perform a two-staged operation. Before the first operation, 1, 200ml of autologous blood was stored for perioperative blood transfusion. Initially, total arch replacement was performed using deep hypothermic circulatory arrest and antegrade selective cerebral perfusion. One month after the first operation, total thoraco-abdominal aorta replacement was performed by a retroperitoneal approach with mild hypothermia. The Th 9, 10 and 11 intercostal arteries were reconstructed. Distal anastomosis was performed at both common iliac arteries. Blood transfusion was not required for blood pooling and reduction of priming volume in the cardiopulmonary bypass system.

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A 66-year-old woman with aortic stenosis and idiopathic thrombocytopenic purpura (ITP) underwent concomitant splenectomy and aortic valve replacement (AVR). High-dose trans-venous gamma-globulin therapy (400mg/kg/day) was performed for five days before surgery. The number of platelet, which was 6.0×10⁴/mm³ on admission slighty increased to 7.0×10⁴/mm³ before surgery. The aortic valve was replaced by an ATS 19mm prosthesis using cardiopulmonary bypass. Platelets were transfused postoperatively. Perioperative hemorrhage was moderate, and the postoperative course was uneventful. This was the second case we treated by concomitant cardiac surgery and splenectomy. It was safely performed after high-dose trans-venous gamma-globulin therapy.

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A 62-year-old woman presented with acute chest pain. An enchanced CT scan showed type A closing aortic dissection. An ulcer-like projection (ULP) was observed in the abdominal aorta above the superior mesenteric artery on aortography. At 3 months after onset, recurrent chest pain appeared. An enchanced CT scan showed a false lumen in the ascending aorta and a new ULP and localized false lumen were opacified in the distal ascending aorta on aortography. The graft replacement of the ascending aorta was performed using open distal anastomosis under circulatory arrest and retrograde cerebral perfusion. Two intimal tears were found in the aortic root and distal ascending aorta. The patient recovered without complications. Postoperative CT scan and aortography revealed no residual false lumen.

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A 53-year-old woman had dyspnea on effort since half a year previously and was categorized as NYHA II. She had suffered from chronic atrial fibrillation (AF) for three years. She had undergone aortic valve replacement using a Starr-Edwards ball valve (SEV) for aortic regurgitation and mitral commissurotomy for mitral stenosis 29 years previously. Echocardiography revealed mitral stenosis with an orifice area of 0.9cm² and neither dysfunction of the SEV nor abnormal findings on the valve itself. She underwent mitral valve replacement and left atrial maze procedure for AF. Because of the intraoperative findings of the cloth wear-covered SEV cage, redo aortic valve replacement was performed simultaneously. St. Jude Medical valves were used for valve prostheses. There was no complication and the ECG returned to sinus rhythm postoperatively. These has been no report of a patient with such a long period between SEV implantation and replacement in Japan. This experience made us realize again the importance of attention to the cloth wear covered cage during long term follow up for SEV.

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Aortic valve preservation is indicated in cases of aortic regurgitation caused by sinotubular junction (STJ) dilatation with ascending aortic aneurysm. We performed aortic remodeling using a tailored Dacron graft for the rupture of a large ascending aortic aneurysm. The patient was a 68-year-old woman. She was admitted in shock with cardiac tamponade. Chest CT showed a large ascending aortic aneurysm, 11cm in maximum diameter. Echocardiography demonstrated moderate cardiac effusion and massive aortic regurgitation. The ascending aorta was dilated from the STJ to the innominate artery, but the aortic valve appeared normal. We decided to preserve the native aortic valve. We performed aortic root remodeling using a 26mm Dacron graft (Yacoub's procedure). An intraoperative endoscopic study revealed the disappearance of aortic regurgitation (AR). The coronary arteries were reconstructed by the Carrel patch technique. Postoperative aortography revealed trivial AR, and the patient was discharged two weeks after the operation. We conclude that this technique avoids the complications associated with mechanical valve implantation and necessary lifetime anticoagulation.

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A 69-year-old woman, who had undergone mitral valve replacement, developed acute congestive heart failure and was transferred to our institution. Cineradiography demonstrated that two leaflets of the St. Jude Medical valve were stuck in a closed position. Emergency redo mitral valve replacement was performed with a CarboMedics valve. Postoperative hematological studies yielded a diagnosis of antiphospholipid syndrome. Although postoperative anticoagulant therapy was performed more carefully than usual, the prosthesis became stuck again. Therefore, a third operation was performed using a tissue prosthesis. We concluded that mitral valve plasty should be a first option for patients with antiphospholipid syndrome undergoing mitral valve surgery. Should prosthetic valve replacement be required, a tissue prosthesis would be best.

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A 74-year-old man had an inflammatory pseudoaneurysm of the ascending aorta. He was admitted to a local hospital because of loss of appetite. Following intravenous hyperalimentation, he was placed under ventilatory support because of acute respiratory failure. Since his high fever and respiratory failure continued, he was transferred to our hospital. Computed tomography revealed a sealed rupture of an aneurysm in the ascending aorta. During the operation, we identified the ascending aortic aneurysm but it was very tightly attached to the surrounding wall in the perianeurysmal space. To avoid excessive hemorrhage, we closed the communication between the aneurysm and the aorta with a Dacron graft patch under deep hypothermia with circulatory arrest. He was discharged 42 days after operation without any complications. A pathological evaluation of the aneurysmal wall revealed an inflammatory pseudoaneurysm with a thick and inflammatory infiltration in the adventitia.

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