Objective. We investigated whether the aging-related decrease in gap junction expression affects myocardial response against ischemia-reperfusion injury of the rabbit myocardium. Methods. Isolated aged (≥135 weeks) or mature (15-20 weeks) rabbit hearts were perfused with Krebs-Henseleit solution via a Langendorff apparatus, and were divided into five groups as follows: 7 mature hearts served as mature controls (Group A), 7 mature hearts underwent ischemic preconditioning (IPC) consisting of two cycles of global ischemia for 5min followed by reperfusion for 5min (Group B), 7 aged hearts served as aged control (Group C), 7 aged hearts underwent IPC (Group D) and 7 mature hearts received 1mM of gap junction uncoupler heptanol for 5min (Group E). Then, all hearts were subjected to 1h of left anterior descending coronary artery occlusion followed by 1h of reperfusion. Left ventricular pressure, ischemic zone monophasic action potential and coronary flow were measured throughout the experiment and the infarct size (IS) was determined at the end of the experiment. Gap junction expression was investigated by the electron microscopy. Results. The IS of Group A was 39.1±3.8 (%) and that of Group B was 26.9±3.8 (%)^* (^*p<0.05 vs. Group A). The IS of Group C was 19.3± 1.6(%)^*. That of Group D was 43.6±5.8 (%)^# (^#p<0.05 vs. Group C). IS of Group E was 24.3±1.6 (%)^*. Electron microscopic findings demonstrated that gap junction expression in aged hearts was less prominent than in mature ones. Conclusion. These data suggested that aged myocardium might be more tolerant of ischemic insult than that of mature heart, and that the mechanism might be related to the aging-related change of gap junction expression.

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This report describes the surgical technique for partial left ventriculectomy (PLV) and perioperative management. We have performed PLV to treat end-stage non-ischemic cardiomyopathy in 6 patients (4 men and 2 women, mean age: 59 years) since February 1998. Preoperative New York Heart Association (NYHA) functional class was III or more in all patients. On echocardiography, the mean left ventricular diastolic dimension was 75mm, and the mean ejection fraction was 29%. One patient was operated on with cardiogenic shock, and 5 were elective cases. A wedge of the left ventricular muscle was removed from the apex to the base of the two papillary muscles. Associated surgical procedures were as follows; mitral valve reconstruction in 5 patients (4 replacements and 1 annuloplasty), tricuspid annuloplasty in three, and aortic valve replacement in one. Five elective patients were successfully weaned from cardiopulmonary bypass, but one emergency surgery case required intraaortic balloon pumping. Two patients died in the hospital: one elective case was due to multiple organ failure, and one emergency case due to low output syndrome. Three of 4 survivors returned to NYHA functional class I-II, and 1 remained in class III. We are very cautious to ensure that extended PLV does not to lead to serious diastolic dysfunction. The complete reconstruction of the mitral valve and the preservation of annular-chordal-papillary muscle continuity result in the maintenance of left ventricular function and geometry. The practical principles in the post-PLV period are to maintain adequate preload and to avoid excessive afterload. Further studies are required to further enhance outcome.

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The early and mid-term survival after thoracic aortic surgery and the influence of age on operative mortality were examined in 93 consecutive patients from August 1994 to June 1999, together with assessment of postoperative quality of life (QOL). The mean age was 63.8±11.6 years old (range 26 to 84 years) and 65 patients were male. Aneurysms were atherosclerotic in 43 patients and aortic dissection was present in 50. Forty-eight (52%) required emergency operation. Operative procedures consisted of ascending aorta or hemiarch replacement in 23 patients, Bentall's operation was performed in 4, total arch replacement in 31, distal arch replacement in 9, descending aorta replacement in 13, replacement of the thoracoabdominal aorta in 6, and patch repair in 7. These patients were divided into two groups: the under 70 group (Y group, n=61) and the 70 or older group (O group, n=32). Current QOL of the survivors was assessed using the Asanoi method with a mailed questionnaire. There were 13 early deaths (14%). There were 10 late deaths (5.6%/P-Y (Patients-Years)). The actuarial survival rate of the Y group was significantly higher than that of the O group (p=0.0412). Perioperative stroke was seen in 11% of the Y group and 16% of the O group. These patients had a high mortality rate (Y group 43%, O group 100%) during early and long term follow-up periods. The postoperative NYHA category and exercise ability of the O group were better than those of the Y group. We obtained satisfactory answers concerning the results of operation in the majority of current survivors. Patients aged 70 years and older could undergo thoracic aortic surgery with reasonable risk. QOL following operation was satisfactory except in patients with merged perioperative stroke.

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Although the results of surgical treatment for acute type A dissection have improved because of progress in surgical techniques, the prognosis is still very poor and optimal therapeutic approach is still not clearly established for cases of acute dissection complicated with malperfusion. Of 134 patients who presented with acute aortic dissection between January 1986 and June 1999, 57 had acute type A dissection and 10 had acute type A dissection with malperfusion. Patient age ranged from 53 to 78 (average, 64.6) years. There were 6 men and 4 women. There was accompanying cerebral ischemia in 3 cases, coronary ischemia in 1, visceral ischemia in 5, renal ischemia in 2, ischemia of the extremities in 7, and multiple organ ischemia in 5. One patient died before surgery, and another patient died after sternotomy due to aortic rupture. The other 8 patients underwent surgical operations. The following surgical procedures were performed: bypass grafting to the superior mesenteric artery was performed in 1 patient, stent implantation to the right coronary artery followed by ascending aortic replacement (19th day after onset) was performed in 1, and aortic repair (5 ascending aortic replacements and 1 hemiarch replacement) in the acute phase was performed in 6. The mortality rates were 66.7% (2/3) in patients with cerebral ischemia, 0% (0/1) in the patient with coronary ischemia, 80% (4/5) in those with visceral ischemia, 100% (2/2) in those with renal ischemia, 42.9% (3/7) in those with ischemia of the extremities, 80% (4/5) in those with multiple organ ischemia, and 50% (5/10) in all cases. All patients whose base excess (B.E.) was less than -10mEq/l on admission died (4/4). We conclude that in order to improve surgical results in patients with acute type A dissection with malperfusion, different approaches may be required for each patient. The combination of aortic repair and percutaneous reperfusion are important. Arterial blood gas analyses were simple, and the values of B. E. at admission were useful to determine the surgical strategy in these patients and to predict their prognosis.

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We report a case of successful medical treatment for graft infection after abdominal aortic aneurysm repair. A 63-year-old man with a ruptured abdominal aortic aneurysm underwent a prosthetic graft replacement via a retroperitoneal approach. He became febrile on the 26th postoperative day (POD). A CT scan demonstrated fluid collection around the grafts. Re-operation was performed and gross pus was found around the prosthetic graft. After all pus and nonviable tissue were removed, two irrigation tubes and a drainage tube were placed adjacent to the graft for continuous irrigation with 0.5% povidone-iodine and super-acidic solution. Inflammatory reactions were gradually improved, and the patient discharged on the 88th POD.

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A 71-year-old woman was admitted with sudden onset of abdominal pain. CT scan image and symptoms showed an impending ruptured suprarenal abdominal aortic aneurysm therefore we performed an emergency operation. The abdominal aorta was replaced with a trunk prosthetic graft with four branches for visceral and lumbar arteries. The post-operative course was uneventful. Pathological examination showed that the aorta had severe atherosclerotic changes. The fibrous tissues increased in the aneurysmal wall which was not consistent with the normal aorta. Intima and media of the aorta everted into the aneurysm. These findings suggested that aneurysm was caused by a penetrating atherosclerotic ulcer.

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A 32-year-old man was admitted with dyspnea on exertion and a prolonged common cold. Swelling of mediastinal lymph nodes, pericardial thickening and pleural effusion were detected by chest CT. Mycobacterial culture of sputa and pleural effusion were negative. Serum adenosine deaminase (ADA) activity was normal. A tuberculin test showed a positive reaction (20×15mm). Viral antibody titers (Coxsackie A9, echo 3, influenza B) were negative. Ten days after admission, the patient had pyrexia and low cardiac output symptoms. Right ventricular pressure curve cardiac catherterization showed a“dip and plateau”pattern which indicated constrictive pericarditis. We performed subtotal pericardiectomy (from the right phrenic nerve to the left phrenic nerve). Pathological examination of pericardium showed Langerhans' giant cell infiltration and caseous necrosis which could be diagnosed as tuberculosis. Although the patient had transient pleural effusion, symptoms disappeared postoperatively. At present there are no signs of recurrent infection.

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Ischemic colitis is a serious complication of abdominal aortic surgery. Patients with bilateral internal iliac aneurysm have a high risk of ischemic colitis after operation. A 72-year-old man had infrarenal abdominal aneurysm, bilateral common and internal iliac aneurysm and an occluded right internal iliac artery. We examined the flow of the superior rectal artery during operation by transanal Doppler, and intramucosal pH of the sigmoid colon by a tonometer after operation. The flow of the superior rectal artery did not change after clamping of the left common iliac artery, clamp of the infrarenal aorta. He underwent uneventful abdominal aortic aneurysmectomy, Y-grafting and exclusion of bilateral internal iliac aneurysms. The intramucosal pH of the sigmoid colon returned to the normal range 25h after surgery. He had no complications after surgery. Transanal Doppler examination was essential for the successful prevention of postoperative colonic ischemia, and intestinal intramural pH by tonometry was an early reliable marker of the absence of ischemic colitis.

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A 61-year-old woman was admitted with abdominal and low back pain. The patient underwent graft replacement for inflammatory abdominal aortic aneurysm. One month postoperatively, the patient fell into hypovolemic shock with massive melena and hematemesis. Laparotomy and duodenotomy revealed a fistula between the third portion of the duodenum and the distal anastomosis of the vascular prosthesis. The fistula of the aorta was repaired with omentopexy, gastrojejunostomy and Braun's anastomosis. One month later, aortoduodenal fistula recurred. The vascular prosthesis was partially removed and the aorta was closed at the infrarenal level. After the closure of the posterior duodenal defect, a left axillo-femoral bypass was constructed. She fully recovered and discharged.

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We report a very rare case of placement of a superior vena caval (SVC) filter for upper extremity deep venous thrombosis. A 67-year-old woman with left axillary pain was admitted. Lower extremity deep venous thrombosis was diagnosed. CT scan and venography revealed acute thrombosis of the left brachial, axillary, subclavian, common jugular and innominate veins. We performed thrombolytic therapy and placement of a temporary filter within the SVC, because CT scan and a ventilation-perfusion scan revealed pulmonary embolism. After one week, due to lack of improvement, we placed a Greenfield filter within the SVC. It is necessary to place a SVC filter in high risk patients if anticoagulation therapy fails or if there is recurrence, proximal/wide range thrombosis, or pulmonary embolism.

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Shprintzen-Goldberg syndrome (SGS) is a rare disorder with many characteristics of generalized connective tissue dysplasia. SGS is characterized by Marfanoid habitus with craniosynostosis and mental retardation. Patients with SGS have cardiovascular disorders similar to Marfan syndrome (MFS) and those disorders seem to play an important role in the prognosis of SGS. To our knowledge, only 19 patients with SGS have been reported, and 7 of them had cardiovascular disorders. The major cardiovascular disorders of SGS are aortic root dilatation and mitral valve prolapse. We reported the first case of SGS successfully treated surgically for cardiovascular disorders. Since then, we performed another operation in a patient with SGS. In this paper, we report our surgical results in patients with SGS.

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A 75-year-old woman underwent endovascular stent-grafting for a descending thoracic aortic aneurysm, followed by video-assisted thoracoscopic right upper lobectomy for concomitant lung cancer in a later procedure. Two custom-made endovascular spiral Z stents covered with woven Dacron (DuPont Co., Wilmington, DE, USA) were delivered via the femoral artery under local anesthesia using pull-through technique. Intraoperative angiograms showed successful exclusion of the aneurysm without any endoleakage. Conventional surgical treatments for both diseases in this patient would have required bilateral thoracotomy either in a simultaneous or staged fashion and entail risks of postoperative pulmonary dysfunction and progression of the cancer. Endovascular stent-grafting offered potential superior operative results and quality of postoperative life in this patient with concomitant descending thoracic aortic aneurysm and cancer of the right lung.

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A 54-year-old man consulted our hospital because of nocturnal and mild exertional chest pain. Echocardiography demonstrated a mobile mass in the right atrium. There were no abnormal findings on the coronary angiogram. Because of the large size of the mass, surgical removal was carried out and a yellowish, globular tumor, sized 20×15×13mm, attached to the anterior tricuspid leaflet with a short stalk was excised. Postoperative recovery was uneventful. The patient was discharged from the hospital with no symptoms. The diagnosis of papillary fibroelastoma (PFE) was confirmed on histologic examination. PFE is a well-known tumor that usually arises on the heart valves. Although, historically, this tumor has incidentally been discovered at necropsy, clinical case reports have recently increased. However, the vast majority of clinically reported PFEs were the cases of the left side of the heart, for which the operative indication is quite definite because of serious complications such as cerebral or myocardial infarction caused by this tumor, irrespective of size. On the contrary, only a small number (17 cases) of the right heart PFEs have been reported in the literature and its operative indications are unclear. Review with regard to the operative indications for the right heart PFEs was made based on the total of 18 cases including our patient.

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A 47-year-old man was admitted with symptoms of angina pectoris. After evaluating the patient, coronary artery bypass grafting (CABG) was performed. First, the left internal thoracic artery (LITA) was grafted to the obtuse marginal branch (OM), and then the right gastroepiploic artery (RGEA) was grafted to the posterior descending branch (PD). Just after completing anastomosis, we performed intraoperative thermal coronary angiography. The RGEA-PD was patent. However, the LITA-OM was not patent on thermal coronary angiography. After a re-anastomosis was done at the LITA-OM, thermal coronary angiography was again performed and the LITA-OM was found to be patent. The postoperative course was uneventful, and all grafts were patent on postoperative angiography. In conclusion, intraoperative thermal coronary angiography was found to be useful for CABG.

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A 64-year-old man had been followed up under the diagnosis of chronic idiopathic thrombocytopenic purpura (ITP), and infrarenal abdominal aortic aneurysm with a maximum diameter of 85mm since August in 1998. He suffered from sudden abdominal pain in August 1999, and as impending ruptured abdominal aortic aneurysm was diagnosed based on the CT findings showing left retroperitoneal hematoma and leakage of contrast medium from the aneurysm. We decided to perform elective surgery. Since he was not in shock and had a low platelet count (2.5×10⁴/mm³), medical treatment was indicated for hypertension and thrombocytopenia prior to surgery. High-dose immunogloblin infusion and platelet transfusion was begun two days before the operation and increased the platelet count to 6.1×10⁴/mm³, resulting in a successful elective operation.

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