We studied the appearance of pleural effusion and inflammatory reactions after endovascular grafting in cases of aortic dissection. From December 1995 to January 2000, 16 patients with chronic double-barrel type aortic dissection (DeBakey type III b) were treated by endovascular grafting. In all cases, enhanced computed tomography (CT) of the chest was examined before operation and at about the 7th postoperative day (POD). Patients were divided into 3 groups. Group P: patients who had pleural effusion before the operation. Group E: patients who had new pleural effusion after the operation. Group N: patients who did not have any pleural effusion. In each group, onset of dissection, patient's age, maximum diameter of dissecting aorta, period of postoperative fever (above 37.0°C), and WBC counts and CRP value at POD 1, 3, 7 and 14 were compared. Four patients were in group P, 4 patients were in group F, and 8 patients were in group N. Period between onset and operation was 41.6±34.6 months in group P, 18.2±27.3 months in group E and 7.3±11.6 months in group N. There was no relation between the effusion and the period after onset. Postoperative fever continued for 5.0±2.0 days in group P, 13.5±2.6 days in group E and 2.5±0.3 days in group N. The period of fever of group E was significantly longer than in group N and P (p<0.01). WBC showed a peak on the first POD in each group. CRP showed a peak value on POD 3 in group P and N. There was no significance among the 3 groups about WBC and CRP, but group E showed slightly high CRP values on POD 7 and 14. No patient had complications regarding respiratory function. After endovascular grafting for aortic dissection, postoperative pleural effusion appeared in 25% of patients. They had prolonged postoperative fever, but there was no respiratory function complication. Endovascular grafting is a minimally invasive procedure with regard to respiratory function.

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To test the hypothesis that neutrophils play a role in ischemia/reperfusion injury during heart surgery, granulocyte elastase and myeloperoxidase release from coronary circulation were measured before and after aortic cross-clamping. The production of granulocyte elastase and myeloperoxidase across the coronary circulation elevated significantly after release of aortic cross-clamp. Furthermore, the level of granulocyte elastase and myeloperoxidase released from coronary circulation demonstrated positive correlation with the duration of the aortic cross-clamp. These data indicate that neutrophils play a major role in ischemia/reperfusion injury occurring during heart surgery.

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Acute type A aortic dissection presents a surgical emergency because conservative therapy is not effective in the majority of instances. Enhanced CT-scan of the chest is commonly available and is considered to be an optimal diagnostic method for this disease. The operative strategy is to resect the primary tear to close the entry site of the aortic dissection and replace it with a tubular Dacron graft. Therefore, the existence of the entry site is important in determining the operative procedure. Based on the numerical value of the enhanced CT-scan inspection, the present study seeks to preoperatively identify the location of the presumed entry site in aortic dissection. From May 1996 to June 1999, 21 consecutive patients (Marfan's syndrome excluded) with acute type A aortic dissection underwent surgical treatment. Nineteen patients were preoperatively examined by enhanced CT-scan: 11 men and 8 women, with a mean age of 61 years. CT-scan slices used for early diagnosis were of the ascending aorta, aortic arch, descending aorta, and thoracoabdominal aorta. The largest diameters of the whole and true lumen were measured from cross-sectional aortic images with a personal computer, and the areas of the whole and true lumen were obtained by the manual tracing method. The true ratio was calculated for the largest diameter and area of the whole lumen. The nineteen patients were divided into two groups according to the location of the entry site based on the operating views. Seven patients with the entry site in the ascending aorta were classified as group A, and twelve patients with the entry site further in the aortic arch and descending aorta were classified as group B. Comparisons were performed by non-parametric analysis. Moreover, a discriminant analysis was applied to evaluate the classification between the two groups. The ratio of the largest diameter of the true lumen in group A at the level of the ascending and descending aorta was significantly greater than that in group B (75.0±11.3 vs. 59.7±14.0%, 82.7±8.6 vs. 70.1±11.4%). Linear discriminant analysis resulted in the correct classification rate of 68.2%, and 77.3%, respectively. The ratio of the area of the true lumen in group A at the level of the aortic arch was also significantly greater than in group B (65.4±17.3 vs. 45.7±15.8%) and linear discriminant analysis resulted in the correct classification rate of 55.1%, When the entry site was located in the aortic arch, the diameter of the true lumen was seen to be smaller in the ascending and descending aorta, and the dissecting lumen appeared enlarged. When the entry site is located in the ascending aorta, the ratio of the area of the true lumen in the aortic arch was significantly higher (55.1%). Detailed examination of enhanced CT-scans is useful to determine the location of the entry site and the treatment strategy for this disease.

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This study was designed to evaluate the perioperative outcome of dialysis patients undergoing cardiac surgery, who were managed with our perioperative dialysis program. Between April 1994 and August 1999, 11 patients (7 men and 4 women with a mean age of 57.3±10.3 (36-73)) with hemodialysis (HD, n=8) and peritoneal dialysis (PD, n=3) underwent cardiac surgery. The duration of dialysis was 5.6±4.3 years. Operation included mitral valve replacement (n=1) and isolated coronary artery bypass grafting (n=10). Patients with HD had single hemodialysis on the day before operation. Patients with PD were maintained on PD in the usual manner until the day before surgery. Intraoperative hemofiltration during extra-corporeal circulation and normokalemic non-depolarizing cardioplegic solution were used in all patients to avoid post-operative hyperkalemia. All HD patients had dialysis on the first post-operative day (POD 1), and then every other day. PD patients had PD soon after arriving at the ICU. Levels of serum creatinine, urea nitrogen, acid-base balance were successfully controlled within acceptable ranges. No patients required emergency HD or any post-operative managements for hyperkalemia in the ICU. Six of 8 HD patients required an increase in vasopressor because of a tendency toward hypotension and 4 of 8 patients suffered from atrial fibrillation during the initial HD on POD 1. Eight of 11 patients could be extubated on the first POD. No hospital death occurred. The use of normokalemic cardioplegic solution was useful to avoid post-operative hyperkalemia. Our perioperative dialysis programme successfully managed the perioperative clinical course of dialysed patients undergoing cardiac surgery.

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We tried to identify the risk factors affecting the high mortality rates associated with ruptured abdominal aortic aneurysm (AAA). The subjects consisted of 18 patients, operated on for ruptured AAA, who were admitted to our hospital between 1992 and 1999. The preoperative factors, which were hemoglobin levels less than 9.0g/dl, creatinine levels higher than 2.1mg/dl, type 4 on the Fitzgerald classification, shock state lasting longer than 6h and a shock time index (the time from shock state onset to the beginning of operation divided by the time from complaint of abdominal pain to the beginning of operation) higher than 0.3, were associated with increased intraoperative and overall mortality rates. The postoperative factors, which were bleeding and blood transfusion more than 6, 000ml and an operating time of more than 400min, were associated with increased intraoperative and overall mortality rates. It is concluded that these risk factors were predictors of mortality and it is necessary to operate early because of the risk factors.

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We developed a new double-lumen balloon catheter for retrograde cerebral perfusion (RCP) via jugular vein cannulation. Between November 1996 and September 2000, 34 of 73 patients treated with surgical procedures for thoracic aortic aneurysms underwent RCP using the new catheter during circulatory arrest under deep hypothermia. Nine patients underwent a median sternotomy, and 25 underwent a left thoracotomy. In all cases, the new catheter installation under fluoroscopy was easy, and it took about 15min. The mean RCP time, pressure, and flow rate were 26.8min, 20.0mmHg, and 202.6ml/min, respectively. Our procedure using the new catheter was safe and easy in RCP during circulatory arrest in aortic arch replacement regardless of surgical approaches such as a left thoracotomy or median sternotomy.

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During a 9-year period from January 1991 through December 2000, 30 patients underwent surgical interventions for peripheral vascular injuries associated with catheterizations. Pseudoaneurysm, the most frequent complication, was seen in 19 patients (63.3%). This was followed by arteriovenous fistula in 6 patients (20%), uncontrolled hemorrhage in three (10%), arterial thrombosis in one (3.3%), and pseudoaneurysm complicated with arteriovenous fistula in one patient (3.3%). We performed repair of the puncture site in 26 patients (86.6%), followed by arterial ligation in two (6.6%), thrombectomy combined with percutaneous transluminal angioplasty and aneurysmectomy in one patient (3.3%) respectively. There was a tendency for patients to have diabetes mellitus or hypertension. Though secondary suture had to be performed in two patients with wound infection postoperatively, there was no other complication. In pseudoaneurysmal patients proximal arterial control followed by direct incision into the aneurysm cavity and tangential finger pressure over the hole in the artery was a safe method to control bleeding. In arteriovenous fistula patients aggressive repair resulted in good outcome. In uncontrolled hemorrhage and arterial thrombosis patients prompt intervention is essential. By using accurate techniques in arterial puncture and adequate arterial compression following removal of the catheter, the incidence of vascular injuries can be reduced.

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Between February 1999 and November 1999, 33 patients (age 67.0±7.6 years old) underwent off-pump CABG using coronary shunt tubes. The number of graft anastomoses per patient was 2.8±0.8. The operative mortality was 0%. There was no incidence of on-pump conversion, low cardiac output syndrome, IABP insertion, mediastinitis or stroke. The maximum CPK-MB during the perioperative period was 25.9±18.8IU/l. One patient had perioperative myocardial infarction probably due to native coronary artery spasm. In patients with off-pump CABG, the intubation time, the ICU stay and the hospital stay were shorter. The number of patients who were extubated in the operating room was higher and the cost was lower than those with on-pump CABG. An early phase study revealed patency ratios of 85% (the previous term) and 97% (the latter term). Off-pump CABG is a safe and effective means of revascularization with no mortality, minimal morbidity and good short-term patency.

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Minimally invasive cardiac surgery (MICS) has been developed to offer patients the benefits of open heart operations with limited skin incision, but this procedure tends to be more difficult than conventional methods. We tried to evaluate whether MICS would be reasonable as a standard operation for congenital heart defects. From August 1997 to March 2000, 42 patients with atrial septal defects (ASD) and 47 patients with ventricular septal defects (VSD) underwent total repair by the minimal skin incision and lower partial median sternotomy. Fifteen ASD patients and 6 VSD patients were enrolled by residents (resident group). Twenty-seven ASD patients and 41 VSD patients were treated by leading surgeons (staff group). We compared the clinical course of the patients between resident and staff groups. Operative time, bypass time and cardiac arrest time (VSD) of the staff group were clearly shorter than those of the resident group (p<0.05). Other clinical course parameters of the two groups showed no significant difference. The results of this study indicate that MICS for ASD and VSD is reasonable as a standard operation because there was no significant difference of postoperative clinical course except the time required for the operation.

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A case of left ventricular pseudoaneurysm formation at an atypical site in the left ventricle is described. A 32-year-old man underwent mitral valve replacement and he was taken to the intensive care unit (ICU) in good condition. Two hours later, he sustained massive bleeding from the chest drainage tubes, hypotension, and shock. We reopened the sternotomy in the ICU and found massive bleeding from the lateral wall of the left ventricle. Under cardiopulmonary bypass and cardiac arrest, the myocardial laceration was closed with Teflon felt-buttressed interrupted sutures and then the involved area was covered with a Xeno-medica^TM patch. Postoperative echocardiography, computed tomography, and left ventriculography revealed pseudoaneurysm formation at antero-lateral wall of left ventricle. Because the patient was asymptomatic, he was discharged from our hospital without reoperation. However we are closely following him in the outpatient clinic.

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We report the use of endovascular stent-graft treatment for a case of traumatic thoracic aortic dissecting aneurysm complicated with multiple injuries. A 65-year-old man who had fallen from a 6m high roof was admitted to our hospital with severe circulatory failure and deep coma. Examination showed right hemopneumothorax, hematoma around the thoracic descending aorta and abdominal cavity, and bone fractures of all right ribs, skull, right clavicle, pelvis and lumbar vertebra. The patient recovered without major neurological deficit, but a dissecting aortic aneurysm approximately 6.5cm in diameter occurred at the proximal portion of the descending aorta. Since we considered that conventional aortic repair would be difficult with high operative risks based on the complicated thoracic and head injuries, we performed an endovascular stent-graft treatment. The postoperative course was uneventful and the aneurysmal diameter has been decreasing to date.

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A 61-year-old woman with paresthesia and coldness of the right forearm came to our institute. Her right arm was strangulated and tracted by a vinyl string tied at her right brachium. No pulsation of her right radial artery was detected, and her forearm had swollen with subcutaneous hematoma. Her arteriography showed occlusion of the distal site of the right brachial artery, and just proximal to the brachial arterial bifurcation was enhanced by collaterals. She underwent emergency revascularization 6h after injury. There was a thrombus in the artery at the strangulated site, and the arterial intima was circumferentially dissected. The injured site of the artery was completely resected and interposed with basilic vein. Although 8h had passed from injury to reperfusion, myonephropathic metabolic syndrome did not occur after the operation. Her brachial arterial pulsation is now well palpable. The arterial occlusion was probably caused by the circumferential tear of the intima due to not only direct strangulation but also strong traction of the arm. It is necessary to resect a sufficient length of injured artery.

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A 52-year-old woman who had been treated for miliary pulmonary tuber culosis complained of left flank pain. Abdominal aortic angiography revealed a saccular type aneurysm in the supra-renal abdominal aorta. We resected the aneurysm and reconstructed the aorta by arificial graft patch under partial extracorporeal circulation. The left renal artery was reconstructed by an artificial graft. During the operation, the superior mesenteric artery and the bilateral renal arteries were perfused by blood from the extracorporeal circuit. On pathological examination, it was shown that the aneurysm was caused by tuberculosis.

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An 84-year-old woman was admitted on an emergency basis for dyspnea and cyanosis. Large left ventricular aneurysm with uncontrollable ventricular tachycardia was diagnosed. After intubation and intraaortic balloon pumping insertion, ventricular aneurysmal exclusion with patch plication (Dor's method) was successfully performed. The postoperative course was uneventful and the patient was discharged 2 months after the operation. Left ventricular function improved and ventricular tachycardia disappeared. The patient is now doing well with (NYHA functional class 2) eight months after the operation.

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A 30-year-old man with a fever, cough, and dyspnea, was admitted to our hospital. A ruptured aneurysm of the Valsalva sinus (Konno classification, type I) was diagnosed associated with infective endocarditis of the aortic valve accompanied by aortic regurgitation (AR, grade II), and a ventricular septal defect (VSD, subarterial type). The operation was performed as follows: the removal of the aortic and pulmonary valves involved with endocarditis, the resection of the right aneurysm of the Valsalva sinus, and the myectomy of the fragile tissue of the right ventricle around the VSD. As a result, the large deficit region with the VSD and the resected right Valsalva sinus was patched with double sheets of equine pericardium. Aortic valve replacement (a prosthetic valve, ATS 18 AP) was anastomozed to the closed patch with the aid of the sheet as a part of the aortic valvular ring, and pulmonary valve replacement (a prosthetic valve, ATS 23 A) was done to the native pulmonary valvular site. During the 13 months after the surgery, under strict control of warfarin administration, the patient's clinical outcome has been favorable without infection and congestive heart failure. This case had AR accompanied with the subarterial type VSD, and aneurysmal formation of the Valsalva sinus and its rupture, and also revealed progressive infective endocarditis of the aortic and pulmonary valves, which resulted in severe cardiac failure. Early and appropriate surgical treatment for the ruptured aneurysm of the Valsalva sinus is required for a better prognosis prior to prevent exacerbation leading to infective endocarditis and critical heart failure.

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We report two operated cases of papillary fibroelastoma of the aortic valve. Case 1: A 56-year-old man was referred to our hospital with hyperlipidemia. On echocardiogram, he was found to have a mobile mass attached to the NCC of the aortic valve. At operation, a sea anemone-like tumor was found attached to the free edge of the RCC and resection of the tumor was performed without valve replacement. Case 2: A 75-year-old woman was referred with heart murmur, and echocardiogram showed a tumor of the NCC of the aortic valve. At operation, the tumor was attached to the NCC and resection of the tumor was performed. On each case, microscopic examinations showed typical findings of PFE. The patients' postoperative courses were unremarkable.

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We report here a case of pseudo-false aneurysm of the left ventricle with ventricular septal perforation following myocardial infarction. An 85-year-old man was treated for acute inferior myocardial infarction three months previously. He was admitted due to an acute posterior myocardial infarction. Since a cardiac catheter study showed three diseased coronary arteries, a left ventricular aneurysm and a ventricular septal perforation, he underwent emergency surgery. The ventricular aneurysm was located on the right side along the posterior descending branch, and was 4×1.5cm in size. We ruled out a false aneurysm because there was no adhesion between the epicardium and the pericardium. The communication between the aneurysm and the left ventricle was then closed with a Gore-Tex patch, and the perforation of the right ventricle was closed directly. CABG was performed for the left anterior descending artery using a vein graft. The postoperative course was uneventful, and he was discharged on the 27th postoperative day. The pathological findings showed a pseudo-false aneurysm of the ventricle.

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A 31-year-old man underwent mitral valve replacement because of mitral regurgitation due to continued active infective endocarditis despite antibiotic therapy. Because cerebral mycotic aneurysm was suggested by preoperative IVDSA (Intravenous Digital Subtraction Angiography), cerebral angiography was performed on the first postoperative day. Cerebral mycotic aneurysm was detected in the middle cerebral artery and emergency aneurysm trapping was successfully performed. Although the patient had no neurologic deficit and postoperative cardiac function was stable, impending rupture of the mycotic aneurysm of the superior mesenteric artery occurred suddenly on the twelfth postoperative day. Endovascular treatment using the coil-embolization technique was immediately performed, and the postoperative course was uneventful.

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A case of mycotic aneurysm in the gastroduodenal artery associated with infectious endocarditis (IE) penetrating into the residual stomach is reported. A 50-year-old woman was transferred to our hospital because of sudden onset of hematemesis and bloody stool. She had had partial gastrectomy due to duodenal ulcer 6 years previously and aortic prosthetic valve replacement due to infectious endocarditis eight months previously. Emergency laparotomy was performed. Aneurysm of the gastroduodenal artery penetraing into the lumen of the residual stomach was found. The aneurysm had not been detected in the CT scan 8 months earlier. It was surmised that it was related to IE and had developed over the last 8 months. Aneurysmectomy was performed. The postoperative course was uneventful and she was discharged on the 22nd postoperative day. Mycotic aneurysm associated with IE developing into the gastroduodenal artery and penetrating into the stomach is rare. It is possible that a mycotic aneurysm could develop in any artery of a patient with IE. We should thus carefully examine patients with IE in order to detect mycotic aneurysms using angiography and the contrast-enhanced CT scan.

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Three surgical cases of postinfarction left ventricular free wall rupture (LVFWR) are described. Patient 1, a 76-year-old woman, developed LVFWR of the posterior wall after acute myocardial infarction (AMI). Coronary arteriography (CAG) revealed total occlusion of left circumflex artery (Cx) (#11). Direct closure of the myocardial tear was performed using cardiopulmonary bypass (CPB) and cardiac arrest. Patient 2, a 67-year-old man, developed LVFWR of the anterior wall after AMI. CAG revealed total occlusion of left anterior descending artery (LAD) (#7). He was placed on a percutaneous cardiopulmonary support system (POPS) prior to the operation and direct closure of the myocardial tear was performed with the heart beating. Patient 3, a 57-year-old man, developed LVFWR of the posterior wall after AMI. CAG revealed total occlusion of Cx (#13). He was placed on PCPS prior to the operation and direct closure of the myocardial tear was performed using CPB and cardiac arrest. Patients 2 and 3 who were placed on PCPS prior to the operation successfully underwent emergency operations. In all cases, 2-0 Prolene horizontal mattress sutures with Teflon felt strips were used through the infarcted area in order to close the myocardial tear.

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