We have long advocated the usefulness, accuracy and safety of carbon dioxide angiogrphy for patients with iodine allergy and renal dysfunction. In addition to its utility, no specialized apparatus is necessary for carbon dioxide angiography. Carbon dioxide as a contrast material has been adopted by consensus for use in endovascular revascularization. Here we report 4 cases of endovascular revascularization using carbon dioxide angiography. Two of the four patients had an iodine allergy, one had renal dysfunction, and the remaining one was complicated by diabetes mellitus. All patients exhibited intermittent claudication and were treated for iliac arterial stenotic lesions with percutaneous angioplasty and sequential endovascular stenting using carbon dioxide gas as a negative contrast material. All cases demonstrated improvement of the chief complaint. There were no direct or indirect complications of carbon dioxide angiography and endovascular intervention after the procedures. All 4 patients were discharged without event within 1 week after the endovascular intervention. Carbon dioxide is useful not only as an angiographic contrast material but also for endovascular intervention in patients with iodine allergy or renal dysfunction.

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Circulatory support devices have become an important component for transplantation programs as they successfully bridge unsalvageable patients who would otherwise die. Between October 1997 and April 2001, 6 patients in profound heart failure were treated with a percutaneous cardiopulmonary support system (PCPS), or with ventricular assist device (VAD), or with both PCPS and VAD. Two patients were treated only with a PCPS, and one weaned case survived. Another 2 patients, who had dilated cardiomyopathy, was treated with VAD. They improved hemodynamically, and their general conditions made them fit to be candidates for heart transplantation. Two other patients who had PCPS insertion before VAD died due to multiple organ failure. Before the application of VAD, the levels of total bilirubin were 14.9 and 20.9mg/dl respectively. In acute worsening of hemodynamics, PCPS is useful to maintain total circulation by quick application. However, long-term support with VAD should be considered to resuscitate impaired end-organ function by carefully selecting the timing of a VAD implantation.

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Homologous blood transfusion may increase generalized inflammation by stimulating a patient's immune system during an open heart operation using cardiopulmonary bypass (CPB). We examined the beneficial effects on lung function of having no homologous blood transfusion during pediatric open heart operations. Thirty-three consecutive patients with ventricular septal defect were divided into (a) an autologous blood transfusion (AB) group (n=16) consisting of patients in whom predonation of autologous blood was undertaken and so homologous blood was not transfused, and (b) a control group (n=17) consisting of patients in whom homologous blood was used with a leukocyte removal filter during and after operation. Patients' age, sex, body weight, and contents of primed solution of the bypass circuit were similar in the 2 groups. Arterial blood gas analysis was carried out several times and the respiratory index (RI) calculated. Postoperative duration of intubation, white blood cell counts, and CRP titer were also compared. RI immediately after CPB did not differ between the AB and control groups, but RIs 3 and 6h after operation were significantly lower in the AB than in the control group (0.43±0.08 vs. 0.79±0.15 and 0.38±0.07 vs. 1.60±0.17). Duration of intubation, white blood cell counts, CRP titer were not statistically different. The results suggest that avoiding transfusion of whole homologous blood elements works effectively for preventing lung dysfunction after CPB.

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When homo- or isograft was used as a right ventricle-pulmonary artery bypass in the Rastellitype procedure for congenital heart disease, reoperation was mandatory due to calcification and conduit stenosis after several years. However, the survival period of intimal cells or smooth muscle cells has not been clarified, nor has the question of whether the calcification is due to an immunoreaction or not. Thus, to observe the geometrical or pathological changes of the grafts, an experimental model of homograft transplantation was established using rats' aorta, where cyclosporine A (CsA) was given after the transplantation. The rats used were 8 or 9 weeks old. Male King rats were the donors, and female Lewis rats were the recipients. The descending thoracic aorta was transplanted to the infra-renal abdominal aorta. There were 2 experimental groups; one in which CsA was not given (n=35), and the other in which CsA was given (n=44). The animals were sacrificed at 1, 2, 4, 6, 8, and 12 weeks after the transplantation, and were examined by an optical microscope after slicing longitudinally. The area of the cross-section, intima and the media of the vessel were calculated by 2 ways; manually, and by computer. These data were used to calculate and analyze the percentage of intima-media area, the ratio of the intima/media area, and the percentage of intima area and media area. The effect of suppression of the percentage of intima-media area and the percentage of the intima area were revealed to be significant at an acute stage after brief high dose CsA administration. From this result, we suggest that there is a possibility of a rejective reaction participating in the intimal hyperplasia in the acute phase after homograft transplantation.

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A 59-year-old man was admitted to our hospital with numbness and calf claudication of the right leg. The enhanced CT scan and angiography revealed that the right internal iliac artery was unusually large caliber and distributed laterally, forming an aneurysm about 2.5cm in diameter. The right external iliac and femoral arteries were hypoplastic, and the superficial femoral artery terminated in several small branches, one of which coursed down to the lower leg as a saphenous artery. These findings established the diagnosis of a complete type persistent sciatic artery (PSA) with associated aneurysm. An excision of the sciatic artery with a right femoral-to-above-knee popliteal artery bypass grafting was performed. The PSA aneurysm is a rare vascular condition that can be successfully treated with reconstructive techniques if the diagnosis is correctly established.

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A 66-year-old man underwent replacement of the ascending aortic arch for acute aortic dissection (Stanford type A). During surgery, an ePTFE synthetic graft was anastomosed to the left axillary artery to transmit blood from the extracorporeal circulation. During arch branch reconstruction, the left axillary artery was anastomosed end-to-end to a Dacron synthetic graft and the ePTFE synthetic graft used to transport blood, and the terminal anastomotic site of the ePTFE synthetic graft was used. At about 3 months postoperatively, a bulge was noted below the left clavicle, and it was diagnosed as seroma based on CT and aspiration biopsy findings. His condition did not improve despite repeated paracentesis and drainage. The ePTFE was resected and replaced with a Dacron synthetic graft, resulting in case of his seroma.

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A 61-year-old man fell into out-of hospital cardiopulmonary arrest due to rupture of an abdominal aortic aneurysm, and was resuscitated onsite. On arrival at the emergency room, a fusiform type abdominal aortic aneurysm and massive hematoma in the retro-peritoneal space were detected by ultrasonography. Quickly, an aortic occlusion balloon catheter was placed at the proximal site of abdominal aorta through the left brachial artery, and then graft replacement of the aneurysm was carried out. The inferior mesenteric artery was occluded, and was not reconstructed. Five hours after the operation, left hemi-colectomy was carried out for ischemic necrosis of the descending to sigmoid colon. Although he was complicated by multiple organ failure; renal failure, liver dysfunction, severe infection, and brain infarction, he survived without a fatal disability. A rare case with ruptured abdominal aortic aneurysm who fell into cardiopulmonary arrest outside the hospital but survived after bowel necrosis and multiple organ failure is reported.

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A 70-year-old man was admitted suffering from chest and back pain. He was assessed by enhanced computed tomography (eCT) and a thrombosed acute DeBakey type IIIb aortic dissection with an ulcer like projection (ULP) was diagnosed and treated medically. Five days later, he complained suddenly of dyspnea and was diagnosed by eCT as having a pulmonary thromboembolism. Anticoagulant therapy was started reluctantly. The patient's symptoms improved, however, 16 days later he complained of severe chest and back pain. Enhanced CT showed enlargement of the ULP, which was diagnosed as an impending aortic rupture. Open stent-grafting was selected as a less-invasive treatment method. A stent-graft was introduced into the descending aorta via the transected aortic arch and the entry of the ULP was closed. Postoperative course was smooth and uneventful. We consider that open stent-grafting via the aortic arch is an alternative method for repair of acute type B aortic dissection with an ULP in the descending aorta, in cases where direct closure of the intimal tear is difficult.

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A 60-year-old man with constrictive tuberculous pericarditis rapidly progressing after his hospitalization underwent partial pericardiectomy, anterior to the bilateral phrenic nerves through a midline sternotomy without a cardiopulmonary bypass. The results of right cardiac examination a month postoperatively showed the cardiac diastolic dysfunction remained unchanged. However, the results after 6 months and also 3 years postoperatively showed the cardiac function recovered from the constrictive pericarditis. He is free from tuberculosis and heart failure. We should be aware of a sign of heart failure due to constrictive tuberculous pericarditis and take the surgical treatment into consideration. We regard the partial pericardiectomy without cardiopulmonary bypass as one of the effective treatments for constrictive tuberculous pericarditis.

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We experienced a case of extensively calcified mitral annulus and severe mitral regurgitation. A 75-year-old woman underwent successful debridement of an annular calcification with a CUSA^® and replacement of mitral valve with a MIRA^TM valve in a supra-annular position. Use of CUSA^® allowed safe removal of the calcification and prevented the tearing of the A-V groove vessels. In our technique, calcification is left to a certain extent to keep annular strength. Also the MIRA^TM valve has soft and rich sewing cuff, which enhances coaptation in highly calcified annuli and accommodates even fragile tissue. This makes it possible to implant valves even in severely diseased annulus conditions.

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A 74-year-old man was admitted to our hospital to undergo an operation for distal aortic arch aneurysm with chronic aortic dissection. The first operation was attempted through left lateral thoracotomy. Since the aorta had a severely calcified false lumen, conventional aortic replacement was considered to entail greater risk and graft replacement was given up. As an another option, endovascular stent grafting via the aortic arch through median sternotomy was selected as a second operation. Deep hypothermic circulatory arrest with selective cerebral perfusion was used during delivery and deployment of the stented graft through the aortotomy site. The distal stented graft was deployed into the true lumen at the ninth thoracic vertebral level. Neither endoleaks nor complications were observed. Postoperative computed tomography showed complete thrombosis of the distal aortic arch aneurysm and the false lumen. The postoperative course was uneventful. Transaortic endovascular stent grafting is an effective and less invasive treatment for aortic arch aneurysms with severely calcified aorta.

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We report a 64-year-old woman with fungal prosthetic valve endocarditis. She underwent the aortic valve replacement (SJM 19 A^®) with annular enlargement using autologous pericardium. She had a persistent fever and congestive heart failure 8 months after surgery. Echocardiogram demonstrated vegetations of the aortic prosthetic valve, perivalvular leakage and third degree mitral valve regurgitation. Double valve replacement was performed concomitant with aortic annular enlargement using a xenograft. The aortic valve prosthesis was found to be detached from the aortic annulus on the side of the left coronary sinus and also from the implanted autologous pericardium. There were vegetations on the aortic prosthesis and the autologous pericardium. Histopathological findings led to the diagnosis of fungal endocarditis of the aortic prosthetic valve and antifungal therapy was started on the second postoperative day. She is in good condition 5 years later without any relapse of inflammation and has been receiving antifungal treatment. The surgical method of aortoatrioplasty with double valve replacement was effective for fungal prosthetic valve endocarditis after aortic valve replacement with annular enlargement.

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A 63-year-old woman, had been referred to our hospital on diagnoses of mitral restenosis (MS) and tricuspid regurgitation (TR) 8 years after on percutaneous transvenous mitral commissurotomy (PTMC). Echocardiography revealed an additional finding of residual atrial septal perforation (ASP). Mitral valve replacement, tricuspid valve annuloplasty and direct closure of the ASP was performed. Though ASP is major complication of PTMC, few cases of ASP remain patent for such a long time. Since the patients with MS and residual ASP after PTMC present hemodynamics such as Lutembacher syndrome, there is a possibility of biventricular failure in an early phase along with progression of secondary TR. In a patient with residual ASP after PTMC, careful observation by echocardiography is mandatory, particularly regarding occurrence of regurgitation, restenosis, or both.

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Aortic dissection is a rare but potentially fatal complication of cardiac surgery. We report 3 cases of acute aortic dissection complicating open heart surgery. The incidence of complications was 0.18% of cardiac operation during 10 years at our institute (3/1, 647). The dissection is most frequently observed to originate in the ascending aorta, and can occur during operation. In our series, however, two of the three had their dissection entry in the descending aorta and another in the left subclavian artery. Their dissection mainly extended to the distal site of the aorta. Two of the cases were found by postoperative examinations (CT, US) and had had no symptoms or complications, and they were treated conservatively with antihypertensive therapy. One case died due to intrathoracic bleeding and a cerebrovascular event just after the onset of the complication on the 10 postoperative-day. We have to pay attention to this as one of the possible complications after open heart surgery, and intraoperative transesophageal echocardiography or postoperative examinations such as CT were useful for detecting them. We should also take care of hypertension after cardiac surgery in cases in which this is a potential factor such as Marfan's syndrome.

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Infected femoral artery aneurysm is difficult to treat because of the risk of reinfection and anastomosis. The treatment of choice has been a topic of much controversy. Revascularization is mandatory for limb salvage after excision of infected grafts. Revascularization requires various ingenious techniques such as retro-sartorius bypass and obturator bypass. We treated a patient with suspected infection of an aorta-femoral graft, using femoro-femoral crossover bypass in front of the pubis and inside of the thigh muscle. We performed complete debridement of infected tissue. After resterilization of the operative field once more and exchange of all the instruments we performed revascularization detouring around areas of focal infection, using autogenious vein graft through the front of the pubis and inside of the thigh muscle to reach the left superficial femoral artery.

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We report a rare case of brachiocephalic arterial aneurysm associated with rapid tracheal obstruction. A 68-year-old woman visited our hospital because of progressive dyspnea. She developed acute respiratory failure and emergency incubation was performed. CT revealed a large brachiocephalic arterial aneurysm causing severe tracheal stenosis by compression. Angiography revealed a saccular aneurysm behind the brachiocephalic artery. It also demonstrated a common trunk of the brachiocephalic and the left common carotid artery. Aneurysmectomy with arterial reconstruction using an 8-mm prosthetic graft was performed while monitoring of regional cerebral oxygen saturation without extracorporeal circulation. The postoperative course was uneventful and there was no postoperative neurological deficit.

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We encountered a case of ruptured penetrating atherosclerotic ulcer (PAU) that previously had focal ulceration. A 82-year-old man was followed on a diagnosis of distal arch true aneurysm with a diameter of 4.5cm on CT examination. He was admitted with sudden onset of back pain, but he had experienced no previous symptom. CT scan showed a ruptured penetrating atherosclerotic ulcer, therefore we performed emergency replacement of the thoracic descending aorta. The postoperative course was good. CT scan showed the thoracic descending aorta had focal ulceration with a width of 11mm and depth of 7mm at 6 months, however the width was 11mm and the depth was 11mm 1 month before rupture of the PAU. This suggested progression of the focal ulceration caused the PAU rupture.

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A 62-year-old man suddenly felt severe back pain. An enhanced computed tomography (CT) demonstrated an acute Stanford type B dissection and the true lumen was severely compressed by the false lumen. We started conservative therapy because there was no sign of organ ischemia. A 23 days from onset, he developed bilateral limb ischemia and renal failure because the compression of the true lumen increased. After bilateral axillo-femoral bypass the organ ischemia disappeared. Four months later, CT showed the dilatation of the true lumen and occlusion of the bilateral grafts. In spite of graft occlusion, there was no sign of organ ischemia.

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A 63-year-old woman, in whom a continuous heart murmur had been pointed out previously, complained of congestive heart failure. The patient had undergone surgical treatment for skin cancer on the anterior chest wall, and an autologous skin graft, which partly covered the lower sternum, had been implanted. Patent ductus arteriosus (PDA) was diagnosed by an enhanced chest computed tomography (CT), ultrasonic cardiography and catheterization study. The duct was 4mm in diameter and 5mm long. The Qp/Qs was 1.65 and the L-R shunt rate was 39%. The auto-skin graft was untouched and the heart was approached with a reverse T-shaped partial sternotomy. Normothermic circulatory support with cardiopulmonary bypass was established. The PDA was closed through a left pulmonary arteriotomy with a 0.4-mm-thick PTFE patch. Without clamping the calcified aorta, a balloon catheter was advanced into the aorta through the duct to block the arterial back flow. The follow-up has been conducted with enhanced CT every 6 months and the closed duct has been confirmed.

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We report a successfully treated case of double valve replacement for mucopolysaccharosis in a 27-year-old woman. Mucopolysaccharosis had been suspected since she was aged 11. Symptoms of heart failure and chest pain suggested valvular disease and she was referred to us. Echocardiography, aortography and cardioangiography showed aortic regurgitation (grade IV/IV) and mitral regurgitation (grade III/IV). She received double valve replacement and was discharged on the 38th postoperative day with symptom improvement. Although urinalysis was positive for heparan-sulfate, this case could not be diagnosed definitively as mucopolysaccharosis due to normal lymphocytic enzyme-activity. However, large amounts of mucopolysaccharoid deposits were present in her removed aortic and mitral valve leaflets, and her clinical picture corresponded with mucopolysaccharosis. Thus, it was considered that her ultimate diagnosis was combined cardiac valvular disease due to mucopolysaccharosis.

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