[Long-term result of arterial switch operation for corrected transposition of the great arteries or double inlet left ventricle].

The purpose of this study is to analyze the operative maneuver and long term outcome of the arterial switch operation (ASO) for congenitally corrected transposition of the great arteries (c-TGA) or double inlet left ventricle (DILV). Since October 1977, 221 patients had undergone ASO in National Cardiovascular Center, Japan. Of these, 8 patients underwent ASO as a part of double switch operation (DSO) for c-TGA, and 1 patient underwent ASO and ventricular septation for the DILV with a rudimentary right ventricle simultaneously. We retrospectively reviewed these 9 patients. Six patients had a past history of the pulmonary artery banding. Age at the time of ASO ranged from 6 months to 5 years (median 3 year). As a reconstruction of the pulmonary artery at the time of ASO, Lecompte maneuver was performed in 7 patients, and original Jatene procedure was performed in 2. Coronary transfer was done as usual in all patients. There was no early death, and 1 patient died 1 year after the operation due to chronic heart failure. Late complication related to the ASO was pulmonary artery stenosis (1 patient after DSO) and aortic regurgitation (1 patient after ventricular septation).

[A case report of ross operation and ventricular septal defect closure following correction of type A interruption by modified Blalock-Park, pulmonary artery banding and patent ductus arteriosus division].

A 2-year-old boy who had undergone a correction of a type A interruption using a modified Blalock-Park operation, pulmonary artery banding and the division of a patent ductus arteriosus, underwent a Ross operation and closure of ventricular septal defect (VSD). Although a pre-operative echo cardiogram revealed a bicuspid aortic valve, and a Doppler echocardiogram showed only 10 mmHg of pressure gradient across the aortic valve, Ross procedure was performed as a procedure accompanying the closure of a total conus VSD. The total conus VSD was closed with a Dacron patch using pledget mattress sutures. In addition, a running suture was applied over the denuded aortic root and the cranial margin to achieve water tight closure. An aortic root replacement procedure was our first choice for the Ross operation. After both coronary buttons were re-implanted into pulmonary sinuses, a pulmonary artery autograft was wrapped around by the remaining aortic wall for reinforcement to prevent future dilatation. The main pulmonary artery was reconstructed using a bicuspid pericardial valve conduit with a diameter of 24 mm. A post-operative echocardiogram showed no neoaortic valve regurgitation, good coaptation of tri-leaflets, mild regurgitation of pericardial valve and good cardiac performance.

[A modified Fontan operation in the presence of a supracardiac total anomalous pulmonary venous connection].

We report a case of 2-year-old girl with asplenia syndrome who successfully underwent modified Fontan procedure and concomitant repair of supracardiac total anomalous pulmonary venous connection (TAPVC). The preoperative diagnosis included a common atrioventricular canal (type C), a double outlet right ventricle, a common atrium, common atrioventricular valve regurgitation, pulmonary stenosis, and a bilateral superior vena cava (SVC). Cardiac catheterization revealed a Qp/Qs of 1.3, mean PA pressure of 16 mmHg and an Rp of 1.3. The TAPVC drained to left SVC (LSVC) at a position proximal to the hemiazygos vein with an ostium of 5 mm in diameter. The LSVC was divided distal to its connection to the common pulmonary vein (CPV). The TAPVC ostium was cut back into the CPV, then it was anastmosed with posterior aspect of the atrial wall in an effort to provide a wide anastomosis. The postoperative course was uneventful and the patient was discharged from hospital on the 35th postoperative day.

Complete resection of cardiac leiomyosarcoma extending into the pulmonary trunk and right pulmonary artery.

A cardiac leimyosarcoma is an extremely rare tumor. We report a case of complete resection of a cardiac leiomyosarcoma extending into the pulmonary trunk and the right pulmonary artery using the Freestyle bioprosthesis (Medtronic, Inc, Minneapolis, MN) and Xenomedica graft (Baxter Healthcare Corp, Horw, Switzerland). Extensive resection and reconstructive surgery with the addition of radiotherapy prolonged the patient's life.

[A surgical case of papillary muscle reconstruction and double-CABGs for mitral regurgitation due to ruptured papillary muscle after myocardial infarction].

A 76-year-old female patient underwent papillary muscle reconstruction, and d-CABGs a month after the onset of myocardial infarction. Posterior papillary muscle (PPM) was recognized to be ruptured partially, its stump was sewn to original PPM. An ePTFE suture (CV 5) was placed from anterior mitral leaflet to anterior papillary muscle in attempt to reinforce PPM-repair. Carpentier-Edwards ring was inserted and d-CABGs (LITA to LAD and GEA to RCA) were performed, simultaneously. Postoperative examination revealed no regurgitation and no stenosis of bypass grafts during follow-up period of 5 months after the procedure. Papillary muscle reconstruction was effective procedure for MR due to the ruptured papillary muscle.

[Early experience with the freestyle stentless xenograft].

We performed aortic valve replacement with the Freestyle stentless xenograft in 9 patients. There were 6 men and 2 women, whose ages ranged from 44 to 76 years. The modified subcoronary implantation was used in 6 patients and the completely subcoronary implantation was used in 2 patients. The full root replacement was used in 1 patient with bicuspid aortic valve. In a patient who underwent root replacement, postoperative cineangiogram revealed just proximal right coronary artery stenosis. The patient underwent coronary artery bypass grafting to right coronary artery by use of the right internal mammary artery. One in-hospital death occurred on the 46th postoperative day in a patient with severe aortic stenosis and renal failure. 5 patients were investigated by doppler echocardiography at 2 weeks, 3, 6, and 12 months after operation. Peak pressure gradient 1 year after implantation was 11.7 +/- 3.9 mmHg for all valves. No patient had postoperative significant aortic regurgitation.

[A successful case of simultaneous operation of aortic arch aneurysm and left lung cancer].

We report a simultaneous operated case of a 73-year-old man with aortic arch aneurysm and squamous cell carcinoma of the lung. Via median sternotomy, aneurysmectomy and graft replacement was performed under hypothermic circulatory arrest and selective brain perfusion. After changing the position, left upper lobectomy with lymph node dissection was performed via left posterolateral thoracotomy. In spite of using cardiopulmonary bypass, hemostasis was easy, and there was no complication through intra-operative to post-operative course. The cases of simultaneous operation of thoracic aortic aneurysm and lung cancer are rare, and only 3 cases have been reported in Japan. Under careful selection of the patients, simultaneous operations can be performed safely.

[A case of supravalvular mitral ring].

A two-year-old girl with supravalvular mitral ring successfully underwent the excision of the ring. The preoperative echocardiogram showed supravalvular mitral ring and almost normal mitral leaflets. We paid attention not to injury mitral valve at the excision of the ring because supravalvular mitral ring adhered to the mitral valve.

[A case of Bentall's operation for an 11-year-old patient with Marfan syndrome].

An 11-year-old girl who was diagnosed to have Marfan syndrome in her infancy, visited us with complaints of easy fatigability and chest discomfort. She was pointed out to have acute development of annuloaortic ectasia with severe aortic regurgitation and mild mitral regurgitation. She underwent replacement of the ascending aorta and aortic valve using composite graft with prosthetic valve (Bentall's operation) and circular annuloplasty of the mitral valve. Bentall's operation for infants and children is remarkably rare because in this generation, acute development of aortic dilatation leading rupture and dissection is quite infrequent while main death is caused by mitral regurgitation.

[A case of mediastinal teratoma discovered availing of pneumonia].

A 42-year-old woman was admitted to our hospital with hemosputum and an abnormal shadow on chest X-ray. Although her hemosputum disappeared after the treatment of pneumonia, the abnormal shadow was not improved. Chest CT showed a mediastinal mass. She underwent thoracotomy and the tumor, measuring 6 x 5 x 5 cm in size, was resected. Pathological diagnosis was a mature type teratoma with direct invasion to the lung. We have to take mediastinal teratoma into consideration as one of the causes of pneumonia.

[Surgical relief of airway obstruction from a double aortic arch associated with corrected transposition of the great arteries, pulmonary atresia and bilateral patent ductus arteriosus in a neonate].

A rare 20-day-old male with double aortic arch, corrected transposition of the great arteries (cTGA), pulmonary atresia and bilateral patent ductus arteriosus (PDA) was transported to our institute because of severe respiratory dysfunction and cyanosis. The patient had been already intubated and ventilated on respirator. A echocardiography and cine-angiography demonstrated that the both sides aortic arch had almost identical sizes, originating common carotid arteries and subclavian arteries and PDAs respectively, and the descending aorta located on the left side of the mid-line. At the first surgery, the distal of the right aortic arch was divided just proximal to the descending aorta after complete tissue dissection around the arch. The divided right sided aortic arch was mobilized from posterior to anterior aspect of the bronchus. Then the right subclavian artery was divided and an original Blalock-Taussig shunt was employed. The right sided PDA was ligated. After the first surgery, respiratory dysfunction lasted for weeks mainly because of the PGE1 dependent left sided PDA. At the second surgery, left sided modified Blalock-Taussig shunt was constructed and the left sided PDA was divided. These procedures resulted in stable respiratory status and oxygen saturation. The patient was extubated three days later and now in satisfactory clinical condition.

[A successful repair of ventricular septal defect and patient ductus arteriosus associated with pulmonary hypertension in an infant with left lung agenesis].

We report the first case of successful repair of ventricular septal defect (VSD) and patent ductus arteriosus (PDA) associated with pulmonary hypertension in an infant with left lung agenesis. A 70-days-old infant was referred to our hospital with the diagnosis of congenital heart disease and abnormalities of the left lung. Two-dimensional echocardiogram showed ventricular septal defect and patent ductus arteriosus associated with pulmonary hypertension. Computed tomogram of the chest and bronchogram confirmed agenesis of the left lung. The operation was performed at age 114 days with the body weight 4333 g. VSD was closed with the patch and PDA was ligated under cardiopulmonary bypass. Postoperative course was uneventful. Cardiac catheterization, 50 days after operation, revealed normal pulmonary arterial pressure and good cardiac function. Agenesis of the lung is a rare condition and often associated with congenital abnormalities of the skeletal, gastrointestinal, genitourinary and cardiovascular system. As the prognosis is poor especially in those with congenital heart disease, the cardiac surgery is mandatory for the patient to survive.

[Relation between surgical outcome and preoperative end-systolic volume of the left ventricle in patients with regurgitant valvular heart disease].

The relation between the end-systolic volume index of the left ventricle (ESVI (ml/m2)) and the early and late results after valve replacement were reviewed in 249 patients with pure aortic regurgitation (AR) and 189 patients with pure mitral regurgitation (MR). The patients with AR were classified into 4 groups (A1-A4) and those with MR were classified into 3 groups (M1-M3) according to the ESVI. The ESVI, the number of patients (No of P), early mortality rate (EM) and the actuarial survival rate at 12 years after valve replacement (AS at 12 yr) in each group are shown in the following Table. [table: see text] The actuarial survival rate at 12 years after operation in A1 and A2 were significantly lower than that in A3 and A4. In 57% of the late deaths in A1 and A2 patients, the cause of the death was thought to be rhythm disturbance. In contrast, there were no differences in late survival among the three groups with MR (M1, M2 and M3). The minor axis of the left ventricle at end-diastole and at end-systole (Dd and Ds) and shortening fraction of the left minor axis (FS), evaluated by echocardiography, were normalized early after the operation in A1 patients only. The Dd, Ds and FS in A2 and A3 returned to normal late after the operation. However, in A4, these parameters still remained abnormal. Thus, patients with a deteriorated left ventricle can survive the operation. However, the long-term results in patients with AR with ESVI more than 150 ml/m2 were unsatisfactory.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pulmonary hypertension in aortic valve disease].

144 surgical patients with isolated aortic valve disease were reviewed to determine the incidence and the mechanism of pulmonary hypertension (PH). The hemodynamic data revealed PH (pulmonary artery systolic pressure of 40 mmHg or more) in 18 patients (12.6%). There was a positive correlation between left ventricular end-diastolic pressure (LVEDP) and pulmonary artery pressure. After operation the pulmonary artery pressure normalized in all cases but 2 patients in early post-operative period. In patients with aortic stenosis with PH, LVEDP/LVEDVI ratio was higher than that of patients without PH, which showed left ventricular diastolic dysfunction. In patients with aortic regurgitation with PH, the cause of elevated LVEDP was not only severe long-standing regurgitation with ventricular dysfunction, but also the imbalancement of compensation by dilated ventricle with preserved left ventricular function.

[Functional evaluation of skeletal muscle ventricles for circulatory assist].

Skeletal muscle has a potential power for cardiac assist. Two approaches have been used to harvest this power: dynamic cardiomyoplasty, which involves the application of muscle directly to the heart to support cardiac contractile function; and the construction of skeletal muscle pouches or ventricles, which are used as separate pumps working either in parallel or in series with the heart. In this study, we evaluated the function of the skeletal muscle ventricles (SMVs) for circulatory assist. In six dogs (18.5 +/- 2.3 kg, mean +/- S.E.M.), SMVs were constructed from the right latissimus dorsi muscle, and placed in the right hemithorax. After a 3-week vascular delay period, the SMVs were preconditioned electrically by 2 Hz continuous stimulation for six weeks. Nine weeks later, SMVs were connected to a mock circulation device for functional evaluation. As right-sided pumps, at a preload of 10 mmHg, SMVs generated stroke work of 0.63 +/- 0.04 x 10(6) ergs with 25 Hz and 0.80 +/- 0.06 x 10(6) ergs with 85 Hz, which exceeded that of the native right ventricle. As left sided pumps, also at a preload of 10 mmHg, SMV stroke work was 0.49 +/- 0.13 x 10(6) with 25 Hz 0.90 +/- 0.09 x 10(6) ergs, which was roughly half that of the left ventricle. These results demonstrate that SMVs have the potential to function as left or right heart assist devices.

[A case of acute A type aortic dissection with lower extremity ischemia--percutaneous fenestration of the aortic septum followed by ascending aortic graft replacement by open distal anastomosis and retrograde cerebral perfusion].

A 56-year-old woman with severe back pain and a cold, pulseless right extremity was admitted to our hospital. Angiogram revealed a type A aortic dissection extending from ascending aorta to the aortic bifurcation with no definite re-entry point. The false lumen gave origin to the right renal artery and the right external iliac artery was occluded. Therefore, a catheter was manipulated into the true lumen through a percutaneous right femoral artery approach, and was advanced into the false lumen through the right posterolateral wall of the dissecting aortic septum. Fenestration was then performed with fully dilated angioplasty balloon across the septum. Immediately after the procedure, the patient's symptoms improved. The day after the fenestration, replacement of the ascending aorta with 24 mm woven Dacron graft was followed under the deep hypothermia and the retrograde cerebral perfusion. The patient followed a satisfactory postoperative course and postoperative angiogram showed a complete closure of the entry at the ascending aorta and adequate revascularization of the right renal and external iliac arteries.

[Combined operation for left atrial myxoma, mitral regurgitation, coronary artery stenosis and abdominal aortic aneurysm].

A 68-year-old male patient with a left atrial myxoma, mitral regurgitation, ischemic heart disease and abdominal aortic aneurysm underwent resection of the myxoma, mitral valve replacement, 4 coronary artery bypass grafting and replacement of the aneurysm simultaneously. The aneurysm was replaced under partial cardiopulmonary bypass. Combined cardiac and abdominal aortic operation is useful in selected patients who require IABP support postoperatively or whose cardiac function is poor.

[Successful emergency operation of a right atrial rupture due to a traffic accident].

A case of right atrial rupture with cardiac tamponade due to a traffic accident is reported. By thoracic CT, we diagnosed this condition and successfully repaired the ruptured site five hours after injury. Early diagnosis of cardiac rupture is always very difficult, but at any time in nonpenetrating injury, we must treat patient under suspicion of this disease.

["Wrapping" method of the graft in repair of acute aortic dissection].

A simple method to wrap the graft in repair of acute aortic dissection was described. The diseased ascending aorta was excised and both ends of the aorta were trimmed with application of a Teflon felt inside and a preserved equine pericardium outside. The graft was anastomosed to the trimmed ends and the equine pericardiums were turned and sutured around the graft. Two additional sutures were tied around the equine pericardium to reinforce oppression. This simple technique is very useful to control oozing from the suture lines.