[Ventricular septal defect with pulmonary hypertension and concomitant left atrial myxoma in elder patient: a successful surgical case report].

A 70-year-old man was admitted with syncope attack on exertion. Ventricular septal defect with pulmonary hypertension and left atrial myxoma were confirmed by ultrasonography and cardiac catheterization. Preoperative Pp/Ps was 0.95 and pulmonary vascular resistance was 16 units. Pulmonary vascular resistance decreased to 9.6 units by the administration of Isoproterenol and decreased to 8.5 units with PGE1. Patch closure of VSD and excision of left atrial myxoma were performed simultaneously. The patient recovered completely, although he suffered from pneumonia and jaundice due to liver congestion postoperatively. Cardiac catheterization before discharge revealed Pp/Ps 0.38 and PVR 10.1 units.

Oxygen uptake efficiency slope as a useful measure of cardiorespiratory functional reserve in adult cardiac patients.

In this study we aimed to elucidate the validity and usefulness of the oxygen uptake efficiency slope (OUES) in the evaluation of adult cardiac patients. Cardiopulmonary exercise tests were performed on a treadmill by 50 adult patients with chronic heart failure. The OUES was calculated from data for the first 75%, 90%, and 100% of exercise duration. The OUES is derived from the following equation: VO(2)=ax logV(E)+b, where VO(2) is oxygen uptake (ml/kg/min), V(E) is minute ventilation (l/kg/min), and the constant "a" represents OUES. We also determined the ventilatory anaerobic threshold (VAT). The correlation coefficient of the logarithmic curve-fitting model was [mean (SD)] 0.986 (0.009). The OUES could be used to discriminate effectively between New York Heart Association functional classes (P < 0.001). OUES and maximum VO(2) were significantly correlated (r=0.78, P < 0.01). Agreement between the OUES values for the first 90%, 75%, and 100% of the exercise was excellent (intraclass correlation coefficient = 0.99). Our results suggest that OUES is applicable to adult cardiac patients as an objective, effort-independent estimation of cardiorespiratory functional reserve.

Safety and efficacy of autologous platelet transfusion in cardiac surgery: comparison of cryopreservation, blood collection on the day before surgery, and blood collection during surgery.

In a group of 39 patients with ischemic heart and valvular disease (January 1997 to May 1998), three platelet collection methods were compared in terms of safety and effectiveness. The methods were: (i) collection of autologous platelets over several weeks and freezing them for storage until surgery (frozen group, 12 patients); (ii) collection of autologous platelets on the day before surgery and preserving them without freezing (fresh group, 8 patients); and (iii) collection of autologous platelets intraoperatively (intraoperative group, 9 patients). Ten patients served as controls (control group). Blood pressure was not significantly affected by platelet collection in the frozen and fresh groups, but both systolic (P < 0.01) and diastolic blood pressure (P < 0.05) decreased significantly after collecting platelets in the intraoperative group. Similarly, heart rate was unaffected by platelet collection in the frozen and fresh groups, while it increased significantly in the intraoperative group (P < 0.05). Blood loss after 24 h was significantly smaller in the fresh group than in the frozen group (P < 0.05). Total blood transfusion volume was significantly smaller in the frozen and fresh groups than in the intraoperative and control groups (P < 0.05). Bleeding time 2 h postoperatively, when administration of autologous platelets had been completed, was reduced compared with immediately postoperative values in all three groups receiving autologous platelets (P < 0.05). However, only the frozen and fresh groups showed a significantly shorter bleeding time than the control group (P < 0.05). In all three groups receiving autologous platelets, the platelet count was significantly increased after administration of autologous platelets, but only the fresh group had a platelet count that was significantly greater than the control group (P < 0.05). From these results we conclude that the frozen and fresh groups received safer treatment than the intraoperative group. Although hemostasis improved after all three regimes of autologous platelet transfusion, only the frozen and fresh groups had a reduced need for allogeneic blood transfusion compared with the control group. For this reason we conclude that the frozen and fresh groups were also superior to the intraoperative group in terms of effectiveness. However, the recovery of platelets after frozen storage was low, and to obtain a good effect with the freezing method it is necessary to collect and store large volumes of platelets. In terms of simplicity, safety, and efficacy, the fresh method seems to be the preferred technique.

[Aortic and mitral valve aneurysms complicated with infective endocarditis: a case report].

A rare case of aortic and mitral valve aneurysms complicated with infective endocarditis was accurately diagnosed by transesophageal echocardiography. A 57-year-old man with severe aortic regurgitation due to infective endocarditis was admitted to our hospital. Transthoracic echocardiography showed an aortic valve aneurysm on the right coronary cusp and perforations on the other cusps. Transesophageal echocardiography demonstrated a small aneurysm on the anterior leaflet of the mitral valve which was not clearly visualized by transthoracic echocardiography. Color Doppler echocardiography revealed severe aortic regurgitation and mild mitral regurgitation without perforation of the mitral valve aneurysm. Aortic valve replacement and mitral valvuloplasty of the anterior mitral leaflet were performed. The right coronary cusp of the aortic valve showed marked thinning with infiltration of inflammatory cells. The postoperative clinical course was uneventful.

[Surgical results of emergency coronary artery bypass grafting: effect of left main trunk lesion].

Emergency coronary artery bypass grafting has higher risk than elective surgery. Furthermore, if a lesion is located at left main coronary artery, the frequency of cardiogenic shock or high risk patient would be greater, and operative results would be worse. Between January, 1989 and December, 1995, 45 patients who underwent emergency CABG were included. Age ranged 44 to 80 years (mean 67 +/- 7.6 years; 31 men, 14 women). Of 45 cases, 12 cases were patients with LMT lesion. Results were analysed by univariate analysis and multivariate logistic analysis. Of 45 emergency cases, 5 were operative death and 3 were hospital death. Mortality rate was 17.8%, which was significantly higher than the mortality of elective CABG (2.8%) during the same period (p < 0.001). A factor that influenced the mortality was acute myocardial infarction (AMI), which was confirmed by both univariate and multivariate logistic analyses. Odds ratio (relative risk) was 12.4 for AMI. Only one patient died in 12 cases with LMT (8.3%). This case was due to complication after catheter intervention possibly caused by MOF. Thus, the relative risk of LMT was not so high (p = n.s). Other factors showed no significant correlation. Although the emergency case of LMT lesion was generally severe, we could have the same result as other emergency surgeries when patients were revascularized as soon as possible.

A case of Turner's syndrome associated with partial anomalous pulmonary venous return complicated by dissecting aortic aneurysm and aortic regurgitation.

We report a successful surgical case with Turner's syndrome associated with partial anomalous pulmonary venous return (PAPVR) complicated by aortic dissection and aortic regurgitation without coarctation of the aorta. The patient, a 30-year-old woman, is of a short stature who was diagnosed with Turner's syndrome at the age of 12. She has suffered from dyspnea and edema of the legs since a year ago and was admitted to our hospital in June 1994 as echocardiography revealed rapid dilatation of ascending aorta and aortic regurgitation. A chest X-ray showed cardiothoracic ratio of 63% and transesophageal echocardiogram revealed that ascending aortic diameter was extended up to 60 mm at its maximum and that it was possible to distinguish true lumen from false lumen. The aortic arch was found to be normal. Also revealed by cardiac catheterization was drainage of the left upper pulmonary vein to the innominate vein. The L-R shunt ratio was 2.2. The surgery was performed by the Bentall method. The composite graft with a 21 mm St. Jude Medical prosthetic heart valve placed on the annulus of aortic valve. The ostiums of the coronary arteries were directly anastomosed to the composite graft with Carrel patch. After declamp of the aorta, the left pulmonary vein was directly anastomosed to the left atrial appendage without causing stenosis. The postoperative course was uneventful, and the cineangiogram after surgery demonstrated successful repair. Reports of cases of Turner's syndrome like this are sparse.

[Severe aortic regurgitation with marked thickening of the aortic annulus: a case report].

A 74-year-old woman with severe aortic regurgitation and marked thickening of the aortic annulus received aortic valve replacement. Transesophageal echocardiography demonstrated marked thickening of the aortic annulus. The maximum thickness of the aortic annulus was about 11 mm at the side of the right coronary cusp. Histological examination revealed non-specific inflammation of the aortic annulus and aortic valve chiefly composed of lymphocytes and plasma cells. Thickening of the aortic annulus associated with inflammatory aortitis was the cause of aortic regurgitation in this patient.

[Emergency coronary artery bypass grafting (CABG) in a case of coronary occlusion secondary to long segmental dissection of left anterior descending artery after percutaneous transluminal coronary angioplasty (PTCA)].

A 60-year-old man with unstable angina underwent PTCA at left anterior descending artery (LAD) #6, which had stenosis of 90%. Subsequently, a long segmental dissection formed from #6 to #7 and the patients was scheduled for CABG. On the day before the expected date of CABG, he had an angina attack and a 12 lead electrocardiogram (ECG) showed ST segment and T wave elevation in V1-3. Coronary angiograms revealed 99% stenosis in LAD #6 and immediately rePTCA was performed at the site. RePTCA improved the stenosis to 50%, but ECG showed an inverted T wave in V3,4 and emergency CABG was performed, with the saphenous vein at LAD #8 and high lateral artery. Some authors have stated that CABG is not useful for long segmental coronary dissection, but we conclude that CABG should be definitely considered in such a case, because this procedure resolves pressure gradients at before-and-after entry and the bypass grafts will be never occluded whenever anastomosis (intima-adventitia-graft) is performed.

Mechanism of inhibition of H+, K(+)-ATPase by sodium 2-[[4-(3- methoxypropoxy)-3-methylpyridin-2-yl]methylsulfinyl]-1H-benzimidazole (E3810).

Sodium 2-[[4-(3-methoxypropoxy)-3-methylpyridin-2-yl]methylsulfinyl ]- 1H-benzimidazole (E3810) and omeprazole inhibit gastric acid secretion through inhibition of the activity of H+, K(+)-ATPase present in parietal cell membrane vesicles, by chemical modification of SH groups in the enzyme molecule. In order to clarify the mechanism of the chemical modification, reaction products of E3810 and omeprazole with 2-mercaptoethanol under acidic conditions (pH 3, 4, 5, 6) were isolated by HPLC, and subjected to structural analysis by UV, 1H-NMR and mass spectrometry. E3810 and omeprazole appeared to undergo two kinds of reactions, affording disulfide-type products (type I reaction) and sulfide-type products (type II reaction). The rates of these reactions were determined by HPLC, and the stability of the products in the presence and absence of glutathione was investigated. In the case of E3810, type I reaction was found to proceed faster than type II reaction at every pH value studied. The type I reaction of E3810 was faster than that of omeprazole. The rate of type I reaction decreased at pH 5 and 6, especially for omeprazole, and the contribution of type II reaction increased as the pH of the reaction mixture was increased. The sulfide-type modification products were stable, whereas the formation of the disulfide-type modification products was reversed by the action of endogenous SH compounds such as glutathione. These results suggest that higher inhibitory activity of E3810 against gastric acid secretion and faster recovery of the enzyme activity after inhibition by E3810 can be expected, as compared with those of omeprazole.

[The effects of prostaglandin E1 infusion during cardiopulmonary bypass on cardiac and renal function in the early postoperative period].

Postoperative complications after cardiac surgery are mainly caused by the detrimental effects of cardiopulmonary bypass (CPB) on hemodynamics and humoral factors. We studied the effects of prostaglandin E1 (PGE1) infusion on CPB induced organ failure. Twenty-four patients who underwent coronary bypass surgery with normal preoperative cardiac and renal function were divided into two groups. PG group (n = 11) was given PGE1 (0.03-0.05 microgram/kg/min) during CPB while the control group (n = 13) was not. Hemodynamic studies with the Swan-Ganz catheter and renal function tests including serum creatinine (Cr), serum beta 2-microglobulin (s-BMG) and urine beta 2-microglobulin (u-BMG) measurements were performed 24 hours after surgery. After CPB, alpha-adrenergic agent requirement was higher in the PG group than in the control group. In the PG group, the mean cardiac index was slightly higher and the mean left ventricular stroke work index was lower than in the control group. Although the mean systemic vascular resistance index was lower in the PG group, the mean pulmonary vascular resistance index was higher because of the vasoconstrictive action of alpha-adrenergic agents. These differences were seen only immediately after surgery; hemodynamic parameters in both groups were at the same level 3 hour postoperatively. Immediately after surgery, creatinine in the PG group was significantly lower than in the control group. While there was no significant differences in s-BMG between the two groups, u-BMG at 6 and 12 hours postoperatively in the PG group were significantly lower than in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of physical exercise training on graft patency after aortocoronary bypass grafting].

This study evaluated the effect of physical exercise training on graft patency after aortocoronary bypass grafting (ACBG). Patients who underwent ACBG were randomized into the training (17 patients, 43 grafts) and nontraining groups (18 patients, 45 grafts). Tissue plasminogen activator (TPA) antigen, TPA activity, plasminogen activator inhibitor-1 (PAI-1) antigen and PAI-1 activity as fibrinolysis variables, and an angiographic study were performed 2 and 26 weeks after ACBG. Plasma TPA activity increased significantly in the training group, but not in the nontraining group after 24 weeks of training. Plasma PAI-1 antigen and activity decreased significantly in the training group, while PAI-1 levels remained unchanged in the nontraining group. Grafts were patent in 93% (40 of 43) of the training group and 76% (34 of 45) of the nontraining group (p < 0.05). A high plasma concentration of PAI-1 may interfere with the natural thrombolytic process. Exercise training can decrease PAI-1 levels and increase TPA activity after ACBG. Improved fibrinolysis obtained by exercise training may have beneficial effects on graft patency.

[A surgical case of atrial septal aneurysm associated with rheumatic mitral and tricuspid disease and coronary-pulmonary artery fistula].

A case of atrial septal aneurysm associated with combined valvular disease and coronary-pulmonary fistula (C-PA fistula) was presented. The patient successfully underwent mitral valve replacement, excision and closure of the aneurysm, tricuspid annuloplasty and closure of C-PA fistula. Atrial septal aneurysm is a rare anomaly and its natural course is thought to be generally good without significant clinical symptoms. However, complications such as cerebral and pulmonary embolism, or occlusion of the atrioventricular vales by the prolapsed aneurysm were reported to occur in small number of cases. In this case, diagnosis of the aneurysm was made by 2-D and Doppler echocardiography and further confirmed by cineangiography. Routine echocardiographic examinations will serve as useful noninvasive method for detection and follow up study of this anomaly.

[Dissecting aortic aneurysm of DeBakey type II diagnosed by color Doppler flow imaging and treated by a Bentall surgical procedure: a case report].

A 33-year-old man with known annuloaortic ectasia was admitted to the hospital because of chest pain. A dissecting aortic aneurysm was strongly suspected, but angiography was not performed because of his history of allergic reaction to iodine contrast material. Two-dimensional echocardiography demonstrated a markedly dilated basal aorta. The aortic wall immediately above the right sinus of Valsalva appeared to divide the aortic lumen into anterior and posterior channels. A defect in the intimal flap with a diameter of two cm was also detected six cm above the aortic ring. Color Doppler flow mapping showed blood flow passing through a probable entrance tear from the true lumen into the false lumen. Reentry could not be detected by Doppler imaging. All major aortic tributaries were presumed patent and supplied via the true lumen. The patient underwent successful emergency Bentall surgical procedure and recovered. It is emphasized that in some cases of DeBakey type I or II aortic dissection, color Doppler flow imaging is helpful for determining indications for emergency surgery.

Indication of aorto-coronary bypass graft surgery for infarction area of myocardium considered from exercise thallium-201 myocardial imagings.

To assess accurately the indication and effects of aorto-coronary bypass graft surgery (ACBG) to the myocardium infarction area, 35 patients with myocardial infarction were analyzed by using exercise thallium-201 myocardial imagings. The patients were classified into group I (18 cases) and group II (17 cases) before ACBG. Group I consisted of patients with regional hypoperfusion in the initial image who showed redistribution in the delayed image to the infarction area of myocardium. Group II consisted of those with regional hypoperfusion in the initial image without redistribution in the delayed image. Group I showed a significant improvement in myocardial perfusion (p less than 0.01), pressure rate product (p less than 0.01), global left ventricular ejection fraction (p less than 0.01), segmental wall motion abnormality (p less than 0.01), and exercise tolerance when compared with those of group II before and after ACBG. The above study showed that the pre- operative redistribution of the infarction area in the delayed image suggests myocardial viability and ACBG will be effective.

[Thallium-201 scintigraphy of the myocardium during exertion in the indication for aortocoronary bypass of an area in the myocardium, the site of an infarct]. / Apport de la scintigraphie du myocarde au thallium 201 à l'effort dans l'indication du pontage aorto-coronarien d'un territoire myocardique ayant été le siège d'un infarctus.

The purpose of this study is to precisely evaluate the indications and the results of direct revascularization surgery in a myocardial area previously infarcted. 35 cases were analyzed using thallium scintigraphy during stress. Before surgery, the patients were divided in two groups. Group I (18 cases) includes patients who presented initially a regional hypoperfusion and a reperfusion at the site of the infarction, on late scintigrams; group II (17 cases) also presented a regional hypoperfusion initially, but showed no reperfusion on late scintigrams. Concerning the results during stress, the thallium 201 scintigrams during exercise show alterations of the myocardial perfusion in the infarcted area, before and after surgery; in group I, a significant improvement (p less than 0.01) is noted in the entire group, i.e. 16 patients (88.9%), except in 2 cases where the graft was occluded, and group II shows an improvement in only 4 cases (NS) after surgery. Concerning the modifications of the product pressure X cardiac rhythm, there is a significant improvement (p less than 0.01) in group I (14 out of 18 patients (77.8%)); 2 out of 4 patients who were aggravated, presented occluded grafts after surgery. Group II shows an improvement in 10 out of 17 patients (58.8%) after surgery (NS). The left ventriculography demonstrates alterations in the global ejection fraction. Group I shows a significant improvement in 15 out of 18 patients (88.3%) (p 0.01); in group II there is improvement in 11 out of 17 patients (64.7%) (NS) after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)