[Open stent-grafting for the distal arch aneurysm using a new delivery system].

Recently, open stent-grafting has been employed for distal arch aneurysm. However, several complications have been reported. We have used a new delivery system (CLATE) in 8 patients who underwent open stent-grafting. The advantage of CLATE is that it is flexible, and can freely change its shape. Using this delivery system, stent graft is hard to dislocate, and can be delivered at the target site accurately. Therefore, CLATE is considerd to be able to prevent aortic wall injury, peripheral embolic complication and paraplegia.

[Aortic dissection and annulo-aortic ectasia complicating systemic lupus erythematousus; report of a case].

A 31-year-old man with systemic lupus erythematosus had received long term steroid therapy. He had no compliant, but magnetic resonance imaging showed aortic dissection and annulo-aortic ectasia. Echocardiogram showed severe aortic regurgitation. Therefore aortic root replacement was performed. A histological study of the aortic wall demonstrated myxomatous degeneration in the media. He recovered uneventfully, except for receiving continious hemodia filtration during 4 days after the operation

[Infective endocarditis with the fistula from sinus Valsalva to right atrium and ventricle; report of a case].

A 77-year-old man complained general fatigue and fever. Preoperative echocardiography revealed vegetation of aortic valve, abnormal shunt flow from the sinus of Valsalva was detected in the right atrium and ventricle without perivalvular abscess cavity or aneurysm of the sinus of Valsalva. He diagnosed aortic valve endocarditis with aorto-right atrium and ventricle fistula. He received aortic valve replacement and patch closure at the sinus of Valsalva using the pericardium. Residural aortic-right atrium and ventricle shunt was not detected after the operation, the post operative course was uneventful without congestive heart failure nor signs of infection.

[Large coronary aneurysm after coronary intervention for acute myocardial infarction; report of a case].

A 59-year-old man was admitted to our hospital because of angina pectoris and a large right coronary aneurysm. Two years previously, he underwent percutaneous coronary balloon angioplasty for a stenotic lesion in right coronary artery (RCA) #3. Angiography and computed tomography showed a large right coronary aneurysm. On-pump coronary artery bypass grafting (CABG), ligation of RCA proximal and distal to the aneurysm, resection of the aneurysm was performed successfully. Postoperative course was uneventful with satisfactory angiographic results.

[Perforation due to new myocardial infarction long time; report of a case].

A 65-year-old man was admitted to the hospital because of effort chest pain, 8 years after he received coronary artery bypass grafting [CABG: left internal thoracic artery (LITA) to left anterior descending artery (LAD), saphenous vein graft (SVG) to first diagonal branch (D1) and SVG to postero-lateral branch (PL)]. Emergent coronary angiography revealed right coronary artery occlusion with well patent bypass grafts. Percutaneus coronary intervention (PCI) was performed successfully, but 9 hours later, ventricular septal perforation (VSP) was occurred. Swan-Ganz catheter revealed that pulmonary to systemic blood flow ratio (Qp/Qs) was 2.6. In spite of intensive medical care, his hemodynamics was gradually exacerbated. Subsequent intracavitary repair with equine pericardial patch, sutured using interrupted mattress sutures with felt pledgets, was performed. He had an uneventful recovery thereafter, extubated and weaned from an intra-aortic balloon pumping at the 1st day. He was discharged from hospital on the 27th postoperative day.

[Endovascular stent-grafting for mycotic thoracic aortic aneurysm].

We report 3 cases of endovascular stent-grafting (ESG) for mycotic thoracic aortic aneurysm. The case 1 was a rupture of pseudoaneurysm of the descending aorta caused by mediastinitis due to perforation of esophageal ulcer. The patient underwent emergent ESG for temporary control of the rupture. He underwent esophagus reconstruction 5 month after ESG. The case 2 was admitted due to inflammatory reaction. She was diagnosed with mycotic descending aortic aneurysm and underwent elective ESG because of her old age. Her postoperative course was uneventful and no infection recurred. The case 3 underwent ESG for a ruptured mycotic descending aortic aneurysm. But 113 days after ESG, he underwent ESG again for a ruptured endoleak of the stentgraft. His blood culture demonstrated methillin-resistant Staphylococcus aureus (MRSA). He died of rupture to bronchus and esophagus at 18th day after ESG. We believe that ESG is useful in high risk patients for temporary management of the rupture.

[Successful consecutive seven time's surgical repair of Marfan syndrome].

We report a patient with Marfan syndrome who received successful 7 consecutive operations during 11 years. She underwent descending aortic replacement for chronic type B dissection at the age of 24. Mitral valve replacement (MVR) was performed for mitral regurgitation (MR) at the age of 30, and abdominal aortic replacement was done for persistent dissection at the age of 31, aortic root and arch replacement was done at the age of 34. The 9 months later, she received re-MVR for dysfunction of bioprosthesis and tricuspid valve anuloplasty (TAP) for tricuspid regurgitation (TR). But severe paravalvuler leakage of mitral valve necessitated direct closure of detachment. Thoracoabdominal replacement was performed for rupture of persistent dissection at the age of 35. She was discharged on the 54th day after the 7th surgery.

[Management of quadruple valves for severe infective endocarditis; report of a case].

A 74-year-old man had pustulant bilateral arthritis complicated with sepsis and disseminated intravascular coagulation (DIC). Microbiologic study of blood sample showed Streptococcus and methicillin resistant Staphylococcus aureus (MRSA). He was complicated with postulant diskitis since then. Medical treatment for DIC and administration of antibiotics were performed. Preoperative echocardiography revealed massive aortic regurgitation and vegetation of aortic valve, moderate pulmonary regurgitation and vegetation of pulmonary valve, massive mitral regurgitation, massive tricuspid regurgitation. He was diagnosed as infective quadruple valve endocarditis. He received aortic valve replacement, pulmonary valve replacement, mitral valve repair and tricuspid valve repair. Postoperative echocardiography showed satisfactory function of bioprosthesis. Postoperative course was uneventful.

[Left atrial myxoma combined with coronary artery bypass grafting].

We experienced 2 cases of surgical treatment for left atrial myxoma combined with coronary artery bypass grafting (CABG) using only in situ arterial grafts. A 58-year-old man who had undergone CABG [left internal thoracic artery (LITA)-right coronary artery (RCA) and saphenous vein graft (SVG)-left anterior descending artery (LAD)] 14 years before was admitted to our hospital, complaining of anterior chest pain. Coronary arteriography demonstrated total occlusion of the LAD and RCA, as well as the stenosis of high lateral branch (HL) and SVG. Left atrial myxoma was incidentally detected by echocardiography. Myxoma was resected at first, and then the right internal thoracic artery (RITA) was anastomosed to the LAD. The postoperative course was uneventful. A 69-year-old woman was admitted to another hospital, complaining of chest pain and dyspnea. Coronary arteriography revealed stenosis of LAD, left circumflex artery (LCx) and HL, as well as left main trunk (LMT). Left atrial myxoma was incidentally detected by echocardiography. Myxoma was resected at first, and then CABG [LITA-HL, gastroepiploic artery (GEA)-RCA and RITA-LAD] was carried out. The postoperative course was uneventful. The priority between CABG and the surgical treatment for cardiac myxoma remains controversial from the point of view of myocardial protection and prevention of systemic embolism of myxomal fragment.

Use of tactile stiffness to detect fatigue in the latissimus dorsi muscle.

In clinical settings, no method has been established to examine the fatigue of a latissimus dorsi muscle (LDM) preconditioned for cardiomyoplasty. We examined the feasibility of measuring muscle stiffness (tactile stiffness) to evaluate muscle fatigue in situ using our tactile sensor. We stimulated canine LDM with burst pacing and monitored both stiffness and tension to determine their relationship. In both dissected LDM and LDM in situ, the decrements of these parameters during burst pacing were compared between preconditioned and unconditioned LDM. In measurement in situ, the sensor probe was placed on the LDM through a small incision. Strong statistical correlation was shown between stiffness and tension (r = 0.935). In decrements of stiffness in situ, there were statistically significant differences between preconditioned and unconditioned LDM. Our tactile sensor system can provide an efficient method for evaluating fatigue of muscles in situ without measuring muscle tension.

Metastatic hepatocellular carcinoma obstructing the right ventricular outflow tract.

A 49-year-old female with a past history of liver resection due to hepatocellular carcinoma was referred to our Department for treatment of a metastatic cardiac tumor obstructing the right ventricular outflow tract. She underwent operation twice with cardiopulmonary bypass, and symptoms were relieved. Metastasis from hepatocellular carcinoma to the heart is very rare, but should be taken into consideration during follow-up after treatment for a primary liver tumor.

Swinging motion of intimal flap through the aortic valve in acute aortic dissection.

The purpose of this article is to present a very rare case of Stanford type A acute aortic dissection featuring a swinging motion of the cylinder-shaped intimal flap through the aortic valve. The patient was a 62-year-old male suffering from severe cardiogenic shock. A transthoracic echocardiogram revealed aortic dissection and severe aortic regurgitation. A transesophageal echocardiogram demonstrated that the aortic dissection in the ascending aorta was circumferential and the proximal portion of the intimal flap was swinging through the aortic valve, ie., falling into the left ventricle during the diastolic phase and being ejected back into the ascending aorta during the systolic phase. An emergency graft replacement of the ascending aorta was performed. During ventricular fibrillation under total cardiopulmonary bypass, we performed cardiac massage to prevent myocardial ischemia, because blood flow from a heart lung machine inverted the intimal flap, which might have disturbed the coronary circulation. The patient's postoperative course was uneventful, and his postoperative echocardiogram revealed only a trace of regurgitant flow through the aortic valve. Back-and-forth movement of the cylinder-shaped intima requires coexistence of the following three conditions: severe aortic regurgitation, circumferential dissection, and complete transection of the intimal flap. We conclude that this movement of the intimal flap should be regarded as one of the most serious complications leading rapidly to cardiogenic shock. From a surgical point of view, it is most important to prevent myocardial ischemia during cardiopulmonary bypass especially in cases in which ventricular fibrillation has occurred. We describe the ways to prevent myocardial ischemia in this rare situation.

Minimal damage during endoscopic latissimus dorsi muscle mobilization with the harmonic scalpel.

BACKGROUND: To reduce wound-related complications, a video-assisted surgical technique has been adopted for the mobilization of the latissimus dorsi muscle. We postulated that thermal damage to the muscle might be minimized by using a Harmonic Scalpel instead of electrocautery during this procedure. METHODS: Canine latissimus dorsi muscles were mobilized through a small incision, assisted by a videoscope. In 6 dogs, dissection with electrocautery was used to mobilize the latissimus dorsi muscle. In 6 other dogs, the Harmonic Scalpel was used. We compared operation times, wound infection rates, histologic changes in the muscles, and ease of handling between these groups. RESULTS: The operation time was significantly shorter in the Harmonic Scalpel group than in the electrocautery group (61.5 versus 106.5 minutes, p = 0.00014). The Harmonic Scalpel caused less histologic damage to the mobilized muscles and produced less vision-obscuring smoke. CONCLUSIONS: The Harmonic Scalpel shortens the operation, minimizes muscle damage, and facilitates the performance of video-assisted latissimus dorsi muscle mobilization.

[Open heart surgery in patients with a tracheostoma].

From April 1992 to May 1997 six patients underwent open heart surgery, who had tracheostoma at the time of operation. The sternum was divided completely in three patients whose tracheostoma lay highly on the neck, and it was cut transversely on the manubrium at the level of the first intercostal space, below which it was split longitudinally in two patients (partial median sternotomy). In one patient right anterolateral thoracotomy was used. There were no operative death and no complication related to infection. A left internal thoracic artery (LITA) was used successfully for a bypass conduit in two patients who underwent partial median sternotomy. Dissection of the proximal portion of the LITA through the second intercostal space prior to the sternotomy made the graft procurement feasible in this particular situation. In conclusion, full-length sternotomy is performable safely when the tracheostoma lies highly on the neck, and the partial sternotomy up to the midmanubrium is applicable, including LITA harvesting, even if it is just at the sternal angle.

Repair of ruptured anastomotic aneurysm: elephant trunk technique after endovascular covered stents.

Endovascular covered stents were successfully applied to temporarily halt hemoptysis and postpone surgical intervention in a 69-year-old man with a ruptured anastomotic false aneurysm of the distal aortic arch. Surgical graft implantation was performed successfully by the elephant trunk technique 14 days after the endovascular stent-grafting, at which time aspiration pneumonia had subsided.

Thoracoscopic cardiomyoplasty: a canine feasibility study.

BACKGROUND: Thoracoscopy may be effective in reducing the surgical stress of cardiomyoplasty. The feasibility of thoracoscopy in cardiomyoplasty was investigated. METHODS: Cardiomyoplasty by thoracoscopy and by the open method through a thoracotomy was performed in dogs. After 8 to 10 weeks of preconditioning, the hemodynamic effect of burst stimulation was measured. RESULTS: Cardiomyoplasty by thoracoscopy took 90 +/- 21 minutes (mean +/- standard deviation), whereas cardiomyoplasty by the open method took 67 +/- 10 minutes (p < 0.05). As a result of burst stimulation, aortic pressure, descending aortic flow, and left atrial pressure increased by 15.1% +/- 6.5%, 8.6% +/- 6.3%, and 3.8% +/- 4.6%, respectively, in the dogs that received the cardiomyoplasty by thoracoscopy, whereas those indices increased by 16.5% +/- 6.9%, 9.8% +/- 5.9%, and 4.8% +/- 4.2%, respectively, in dogs that received cardiomyoplasty by the open method. No significant difference between the two groups was shown in any index. CONCLUSIONS: Cardiomyoplasty by thoracoscopy was technically practical, and its hemodynamic effect was similar to that of the open method. The feasibility of cardiomyoplasty by thoracoscopy was thereby suggested.

[Cardiomyoplasty effectiveness: review of the mechanism].

The effectiveness of cardiomyoplasty on cardiac function is discussed, and the four mechanisms proposed to explain cardiomyoplasty effectiveness are reviewed. The first such mechanism, termed the squeezing effect, suggests that skeletal muscle wrapped around the heart squeezes the heart in the same way as cardiac massage, resulting in direct improvement in cardiac function. Hemodynamic improvement is rarely detectable, but significant subjective improvement is commonly seen clinically. The second mechanism, termed the sparing effect, suggests that even if cardiac performance remains unchanged after cardiomyoplasty, contraction of the wrapped lattisimus dorsi muscle causes an increase in the slope of the end-systolic pressure-volume relationship, and a reduction in left ventricular wall stress. Myocardial oxygen consumption is thereby reduced. The third mechanism, called the girdling effect, suggests that cardiomyoplasty may act like an elastic girdle around the heart to prevent enlargement of the failing heart. The fourth mechanism, called the collateral effect, suggests that, when applied to the ischemic heart, cardiomyoplasty increases collateral blood flow to the myocardium, thereby benefiting cardiac function. However, the existence of unknown mechanisms is suggested by two phenomena that cannot be explained by these four mechanisms alone. Cardiomyoplasty was introduced as a method of direct cardiac assistance. However, it now appears that the relatively passive role of cardiomyoplasty in oxygen consumption saving and ventricular enlargement prevention may be of great importance.

[Surgical intervention to tuberculous pericarditis: a case report].

A 32-year-old man was hospitalized because of cardiac tamponade with the thickened visceral and parietal pericardial layers. Marked high level of adenosine deaminase activity (ADA) in pericardial fluid strongly suggested the diagnosis of tuberculous pericarditis, which was later assured by positive smear and culture of the pericardial fluid for Mycobacterium tuberculosis. Before rigid adhesion of the pericardial space was established, pericardiectomy was easily performed with satisfactory improvement of the hemodynamic status and physical symptoms of the patient. The present case suggests the efficacy of early surgical intervention to tuberculous pericarditis when it shows a sign of rapid progression to constrictive pericarditis. Furthermore, high ADA in pericardial fluid might be an useful diagnostic modality for tuberculous pericarditis.

[A case of left main coronary artery stenosis: additional insertion of saphenous vein graft to discontinue cardiopulmonary bypass].

A 62-year-old man with the lesions of the left main coronary artery and all the three vessels underwent a complete revascularization, in which the left internal mammary artery (IMA) was anastomosed to the large LAD. Although the operation proceeded uneventfully, the patient could not be weaned from the cardiopulmonary bypass (CPB). Another saphenous vein graft insertion into the LAD just distal to the IMA made it possible to discontinue the CPB. Postoperative angiogram revealed the patency of all grafts. But the IMA graft showed flow competition and string sign. We assume that failure to wean the patient from the CPB might be caused by hypoperfusion of the IMA graft, and in such a case, insertion of a saphenous vein graft is effective.

[Hypothermic cardiopulmonary bypass with circulatory arrest of the lower half of the body and selective perfusion of the upper and lower half of the body for thoracic aortic aneurysm operation].

A 62-year-old man with thoracoabdominal aortic aneurysm of Crawford type IA and a 61-year-old woman with triple descending thoracic aortic aneurysms were operated on under total cardiopulmonary bypass with hypothermic circulatory arrest of the lower half of the body (rectal temperature of 17-19 C) and low flow selective perfusion of the upper and lower half of the body. Low porosity woven Dacron UBE grafts without preclotting were used for the replacement of the aorta. Postoperative courses were uneventful without paraplegia and angiographic examination revealed excellent hemodynamic results.