[Aortic dissection after aortic valve replacement with an aorto-left atrial fistula; report of a case].

Aortocameral fistula is a rare complication of aortic dissection. We herein report a case of aortic dissection after aortic valve replacement (AVR) complicated with a fistula to the left atrium. A 76-year-old man who had undergone AVR 1 year previously, was admitted to our hospital because of facial edema and chest discomfort. On auscultation, a continuous murmur was heard at the left lower sternal border. Computed tomography revealed dissecting aneurysm of the ascending aorta and a fistula to the left atrium was suspected. Transesophageal echocardiography showed the fistula between the false lumen of the aneurysm and the left atrium. Ascending aorta replacement and closure of the fistula was performed. There was dense adhesion between the aortic root and the roof of the left atrium. It seems that postoperative adhesion plays an important role in formation of aortocameral fistula.

[Giant cardiac metastasis of myxoid liposarcoma causing cardiac tamponade; report of a case].

We report a very rare case of cardiac metastasis of myxoid liposarcoma. A 55-year-old man presented with dyspnea. Two and a half years ago, he underwent resection of myxoid liposarcoma in the left thigh. Magnetic resonance imaging (MRI) revealed a giant tumor occupying the pericardiac cavity and pressing the heart and consequently causing cardiac tamponade. The patient underwent surgery through a left thoracotomy approach. The pericardiac cavity was filled with a giant tumor with a stalk from the right ventricle and 2 small nodules on the main pulmonary artery. He was relieved from the symptom: however, he had a recurrence of the tumor at the same site 5 months after the operation. He underwent surgery for the removal of the second tumor; however, he died 49 days after the operation. Although cardiac metastasis is a very rare condition, its awareness is essential for careful long-term follow-up for the early detection of a metastatic cardiac liposarcoma after the resection of the primary tumor.

[Surgical technique of aortic valve replacement for small aortic annulus in elderly patients].

Recent reports have shown that aortic valve replacement in elderly patients over 65 years with atherosclerotic aortic stenosis and a small aortic annulus is possible by using a small sized bioprosthesis (Carpentier-Edwards pericardial valve). Here we present out surgical technique. Firstly, the native calcified aortic valve was removed completely to gain total exposure of the surrounding aortic root and sinus of Valsalva like Bentall procedure. Secondly, a small sized bioprosthesis was implanted with intermittent noneverting mattress 2-0 sutures with spaghetti and small polytetrafluoroethylene (PTFE) felt. Aortic annulus is the dilated by inserting Hegar dilator sizing from 25 to 27 mm. Therefore, aortic valve replacement for small aortic annulus in intra- or supra-annular position should be easily accomplished. Good surgical results and hemodynamic state were achieved in 25 consecutive cases using this technique.

Equivalence of the acute cytokine surge and myocardial injury after coronary artery bypass grafting with and without a novel extracorporeal circulation system.

Cardiopulmonary bypass (CPB) contributes to a morbidity-inducing systemic inflammatory response after cardiac surgery. We compared this response in patients receiving coronary artery bypass grafting (CABG) with (CPB group; n = 7) or without (off-pump group; n = 8) the Minimal Extracorporeal Circulation (MECC) system. Serum concentrations of tumour necrosis factor (TNF)-alpha, soluble TNF receptors, pro- and anti-inflammatory interleukins (ILs) and other myocardial injury markers were measured after anaesthetic induction, at 1 h, 4 h and 24 h after completing all anastomoses or serially. Soluble TNF receptor type I (sTNFRI) and IL-8 peaked early after CABG in both groups and did not decline. Serum sTNFRI was significantly higher in the CPB compared with the off-pump group at 1 h, whereas IL-8 was significantly lower in the CPB group throughout. The MECC system, therefore, produces an equivalent acute cytokine response and degree of myocardial injury to off-pump CABG, and may be useful when CABG cannot be performed without CPB.

beta2-adrenergic receptor stimulation-induced immunosuppressive effects possibly through down-regulation of co-stimulatory molecules, ICAM-1, CD40 and CD14 on monocytes.

We examined the effects of beta2-adrenergic receptor (beta2-AR) agonists on the expression of co-stimulatory molecules on lipopolysaccharide (LPS)-stimulated human peripheral blood mononuclear cells. The study found that beta2-AR agonists inhibited the expression of intercellular adhesion molecule-1 (ICAM-1), CD40 and CD14 on monocytes, and that AR agonist activity was antagonized by the selective beta2-AR antagonist, butoxamine. The selective beta2-AR agonists salbutamol and terbutaline induced a similar co-stimulatory molecule expression pattern. The LPS-induced production of tumour necrosis factor-alpha was inhibited by AR agonists, and this was also antagonized by butoxamine, and mimicked by salbutamol and terbutaline. The AR agonists also inhibited T-cell proliferation through beta2-AR stimulation. This study clearly demonstrated that endogenous catecholamines elicited immunosuppressive effects through beta2-AR stimulation, possibly due to down-regulation of the expression of ICAM-1, CD40 and CD14 on monocytes. These results suggested that the sympathetic nervous system might regulate the T-helper cell balance via the peripheral end-effectors of the stress system.

[Cardiac surgery for chronic dialysis patients].

Chronic dialysis patients who received open heart surgery were examined, and main concern was perioperative management. There were 12 chronic dialysis patients and open heart surgeries were performed between October 1990 and June 2000. The patients were comprised of 7 men and 5 women with the average age being 64 with plus or minus 7.9. The operative procedure of 6 coronary artery bypass grafting (CABG) [on-pump], 1 CABG + mitral valve replacement (MVR), 3 aortic valve replacement (AVR), 1 mitral valvuloplasty (MVP) and 1 ascending aorta replacement were performed. All patients were discharged from the hospital with good conditions 27.1 days after operation. There were no hospital deaths. One postoperative complication of mediastinitis of the sternum has been found. A conventional dialysis was performed the day before the operation and an intra-operative hemodialysis (HD) was performed, placing a dialyzer into a cardiopulmonary system during the operation. For the perioperative management, HD was started the day or 2 days after the operation with no immediate postoperative hemocatharsis and returned to the normal HD 7 days after the operation. The result of the perioperative management has been good.

[An elderly case of ruptured aortic arch aneurysm 3 years after coronary artery bypass grafting].

We reported a case of trans-aortic endovascular stent grafting (open stent method) for ruptured true aneurysm of the aortic arch. A 83-year-old female, who had suddenly complained back pain and been diagnosed as the ruptured aortic arch aneurysm by computer tomography, was admitted for an emergent surgery. We performed emergent trans-aortic endovascular stent grafting (open stent method). Postoperatively she had no complication and recovered uneventfully.

Calcineurin antagonists inhibit interferon-gamma production by downregulation of interleukin-18 in human mixed lymphocyte reactions.

Tacrolimus (FK-506) and cyclosporin A (CsA) are calcineurin antagonists used widely as T-cell immunosuppressants; however, their relative efficacy on the production of interleukin-18 (IL-18) remains undefined. We have examined the effects of FK-506 and CsA on the cytokine generation of human peripheral blood mononuclear cells (PBMCs) in mixed lymphocyte reaction (MLR) with lipopolysaccharide (LPS). We studied the levels of interleukin-18 (IL-18), IL-12, IL-10, IL-6, IL-2 and interferon-gamma (IFN-gamma) in the supernatant in allo-MLR by ELISA assay. Supernatant levels of IFN-gamma, IL-2, IL-6, IL-10 and IL-12 were detected 12 h after MLR and markedly increased thereafter. In contrast, production of IL-18 was detected at 12 h, reached a near maximum level at 24 h and decreased at 72 h. These results suggested that IFN-gamma production depended on IL-18, IL-12 and IL-2 in the early phase of MLR and depended mainly on IL-12 and IL-2 in the late phase. Both calcineurin antagonists inhibit the generation of IL-18, which plays a large role in allogeneic cell interactions, in macrophages and they also promote an equivalent down-regulation of T helper 1 (Th1) and Th2 responses in a concentration-dependent manner. About 90% of IFN-gamma production induced by MLR was inhibited by an anti-IL-18 antibody, showing that IL-18 can trigger IFN-gamma production in MLR. These results suggest that dual signaling consisting of antigen-driven nuclear factor of activated T cells (NFAT) activation and LPS-mediated NF-kappaB activation is crucial for IL-18 production in macrophages, and that IL-18 can trigger IFN-gamma production in T-cells by MLR.

Aortic and mitral valve replacement in an 83-year-old female. 3 years follow-up of 16 mm bileaflet valve at the aortic position.

An 83-year-old female with aortic and mitral stenosis showed orthopnea. The aortic valve pressure gradient was 139 mmHg. The mitral valve orifice was 0.92-1.05 cm2 and the right ventricular pressure was 70 mmHg. The body surface area of the patient was 1.23 m2. Double valve replacement was performed with 16 mm CarboMedics pediatric bileaflet valve for the aortic position and 25 mm CarboMedics mitral valve for the mitral position. The patient leads a normal daily life with NYHA class II three years after surgery.

[A case of primary cardiac malignant fibrous histiocytoma].

In this article, we report a case of primary cardiac malignant fibrous histiocytoma. The patient, 74-year-old female, had been treated medically for heart failure with minimal improvement and was referred to our hospital. Echocardiogram revealed two cardiac tumors in the left atrium, one of which was obstructing the inflow of the mitral valve. Emergent surgical resection was performed successfully with shortterm ICU stay, but the patient died of DIC on the 24th day after surgery. The pathological examination revealed malignant fibrous histiocytoma and this report is the 40th case report of this kind of primary cardiac tumor.

[Surgical treatment for a 16-year-old girl with anomalous origin of the right pulmonary artery from ascending aorta].

Anomalous origin of the right pulmonary artery is a rare congenital malformation and is usually fatal without early surgical correction. A 16-year-old patient, who had received no previous treatment, demonstrated abnormal findings on ECG. On cardiac catheterization, the pressure in the normally arising left pulmonary artery was found to be greater than the systemic level. Bidirectional shunting across a patent ductus was identified and aortography revealed that the right pulmonary artery arose from the posterior wall of the proximal ascending aorta. The presence of severe pulmonary vascular obstructive disease was anticipated and right lung biopsy was performed. The index of pulmonary vascular disease rating was 2.8 and the Heath-Edwards classification was grade 3. Consequently, we considered that corrective right pulmonary circulation could be maintained after correction, and total correction was performed. The postoperative course was uneventful and the pulmonary artery pressure reduced significantly. Discussion focuses on the surgical indications for such infrequent older cases and we conclude that preoperative lung biopsy is useful in identifying severe pulmonary vascular disease and evaluating indications for surgery.

[A case of chronic traumatic dissecting aneurysm of the thoracic aorta].

A case of chronic traumatic dissecting aneurysm was reported. A 61-year-old man was admitted to our hospital for multiple trauma caused in traffic accident. MRI, performed for evaluation of the spinal injury, revealed dissection of the thoracic descending aorta by chance, seven months after injury. Retrospectively CT, just after admission, showed bleeding around the thoracic descending aorta. Replacement of thoracic aorta was performed after 33 months from the traffic accident, for enlargement of dissecting lumen accompanied with hoarseness. The postoperative course was uneventful and the patient returned to his daily life successfully.

[Improved sternotomy closure with polyester tapes and conventional wires].

In the purpose of reducing the occurrence of postoperative sternal dehiscence, improved technique of closure with supplemental use of polyester tapes was performed. To add to the conventional closure with wires, two polyester tapes were used around the body of sternum through the intercostal spaces just before approximation of sternum. The sternum was firmly fixed at the body and the tapes will prevent cut sternum by the wires and disruption of the wires themselves. In our series of recent 155 cases with this technique of closure, no sternal dehiscence occurred.

[Partial resection of superior vena cava using two stage venous return catheter for a new application].

A case of invasive lung cancer was reported, in which operation partial resection and reconstruction of the invaded superior vena cava (SVC) was performed. During procedure in SVC, a two stage venous return catheter, which is ordinary used in cardiac operations, was used as a temporary SVC-right atrial internal bypass. This new application of the catheter was convenient and effective for resection and reconstruction of SVC.

[Predonation of autologous blood for up to 6 weeks in MAP solution prior to elective cardiac surgery].

Predonation of autologous blood was performed by means of MAP solution prior to elective cardiac surgery. MAP solution made it possible to store in the fashion of fluid for 6 weeks. In twenty-three patients, total 39 times, predonation of autologous blood was performed prior to the elective cardiac surgeries. The mean volume of predonated blood was 583 ml (400-1200 ml)/case with MAP solution and 165 ml (0-400 ml)/case with conventional CPD solution, and the mean volume of total predonated blood was 748 ml (400-1600 ml)/case. The mean of the maximum duration of MAP predonate blood storage in individual cases was 25 days. Homologous blood transfusion was required in three cases. Two of the three cases had total aortic arch replacement under selective cerebral perfusion and the remainder was 76 year-old-man with unstable angina. In twenty cases (87%), any homologous blood transfusion was not performed throughout their clinical course. Twenty (95%) cases of 21 conventional cardiopulmonary bypass operation cases, except two selective cerebral perfusion cases, could successfully avoid homologous blood transfusion. To conclude, by using MAP solution, it became possible to take the longer period for predonation prior to elective surgery up to 6 weeks, compared with that in conventional way of storage by means of CPD solution. It seems worth-while to use MAP solution in order to take more predonated blood for avoiding homologous blood transfusion in elective cardiac surgery as far as possible.

[Complications of femoral artery cannulation in aortic arch related operations].

Two cases of complications of femoral artery cannulation in aortic arch related operations were reported. In the first case of them, we encountered massive cerebral infarction after concurrent CABG and aortic arch aneurysm operation. The patient also had untreated abdominal aortic aneurysm with mural thrombus. It was strongly suspected that retrograde perfusion from femoral artery cannulation made the mural thrombus free and the cerebral embolism subsequently occurred. The second case was acute aortic dissection with massive aortic valve regurgitation. Ascending and arch aorta replacement with resuspension of aortic valve was performed under selective cerebral perfusion. After the operation, myonephropathic metabolic syndrome appeared maybe for occlusion of femoral artery during cardiopulmonary bypass. The patient needed to receive hemodialysis therapy for three weeks after the operation. Through these two cases of complications of femoral artery cannulation, the potential of trouble in retrograde perfusion from femoral artery was noted. After these experiences, we planed to avoid retrograde perfusion from femoral artery as far as possible, especially in cases with mural thrombus or possibly detachable atheroma in ether descending or abdominal aorta. In cases, in which femoral artery cannulation can not be avoided, the duration of femoral artery occlusion should be made as short as possible. In order to shorten the duration, we usually make one supplemental branch in aortic prosthetic graft. After completion of aortic reconstruction, the perfusion in the rewarming period is made through the supplemental branch and the femoral artery can be perfused earlier. This supplemental branch is useful in preventing myonephropathic metabolic syndrome after surgery, especially in cases of prolonged cardiopulmonary bypass time.

[Mechanical valve thrombosis in the tricuspid position--reoperative management of 2 cases].

Because valve thrombosis occurred after the tricuspid valve replacement with the mechanical valve, we performed replacement of the mechanical valve with the bovine pericardial valve in two cases. Case 1: The patient, at 13 years old, received open-heart surgery to correct infundibular stenosis. At 23 years of age, decortication and tricuspid valve replacement (TVR) with a phi 31 mm Björk-Shiley valve were performed due to constrictive pericarditis and tricuspid regurgitation developed after the initial operation. Thrombosis of the mechanical valve occurred after the TVR. Treatment with urokinase for the thrombolytic therapy failed to improve the valve opening. Finally 12 years after the TVR, replacement of the mechanical valve with a phi 27 mm Carpentier-Edwards bovine pericardial valve was performed. Case 2: The patient, at 21 years old, received open-heart surgery to close an atrial septal defect. At 40 years of age, mitral and tricuspid valve replacements were performed because regurgitation developed in both valves. The mitral and tricuspid valves were replaced with phi 27 mm and 31 mm St. Jude Medical valves, respectively. Thrombosis of the mechanical valve used for the TVR occurred 2 months after the replacement. The mechanical valve was replaced with a phi 27 mm Carpentier-Edwards bovine pericardial valve. In both cases, subjective symptoms improved and prosthetic valve complications did not occur after re-replacement with the bovine pericardial valve. These cases suggested that for TVR a bovine pericardial valve of sufficient size would be better to select than a mechanical valve.

[Frozen blood from one closely related donor reduced complications of blood transfusion without adverse effects in the open-heart surgery].

We used frozen blood from one closely related donor in 24 patients (group I) who underwent open heart surgery for congenital heart disease, in order to reduce of complications from a large quantity of blood transfusion. Blood of 600-2200 ml was collected from the single donor and was kept frozen until the operation. Two conditions of the patients were instituted, (1) body weight less than or equal to 40 kg (2) the single donor is father or mother or a close relative. The group of these patients was compared with patients using frozen autologous blood (group II) and patients using banked blood (group III). In group I patients two times of decline of red blood cell counts (RBC), hematocrit (Ht), hemoglobin (Hb) and total protein (TP) were noticed. The first was the period during the cardio-pulmonary bypass. The second was the time about one week after the transfusion of frozen red cells. But degree of the decline was uneventful clinically. The increment of complications induced from the use of frozen red cells was not noticed, and there was no case of serum hepatitis in group I patients. We concluded that the open-heart surgery using frozen blood cells (single donor), if the application was appropriate, could be undergone safely and would be effective on reducing infection and reaction induced from blood transfusion.

[Post-operative evaluation of a 17 mm diameter Björk-Shiley Monostrut prosthesis for aortic valve replacement--pressure gradient and effective valve area].

A 17 mm diameter Björk-Shiley Monostrut prosthesis was implanted in a 64-year-old female for aortic valve replacement in a semi-emergency. This valve was one of the smallest valves which were available in Japan. The patient was admitted because of severe hemolytic anemia and heart failure. Echocardiography showed regurgitation and calcification of Ionescu-Shiley tissue valve which was implanted 5 years ago. The patient's body surface area was 1.2 m2. Because of narrow aortic annulus, we could barely implant a 17 mm diameter Björk-Shiley Monostrut prosthesis. The valve function was examined by Brockenbrough method. During catheterization, the heart rate was 85 b/min and cardiac index was 3.00 l/min/m2. In these hemodynamic conditions, simultaneous measurements of aortic and left ventricular pressures revealed only 9 mmHg mean systolic pressure gradient. Similarly, 20 mmHg of pressure gradient across the implanted valve was obtained by Gorlin's formula. We could calculate that the effective orifice area of a 17 mm diameter Björk-Shiley Monostrut prosthesis was 1.0 cm2. Postoperative echocardiography demonstrated 42 mmHg systolic pressure gradient across this prosthesis by Doppler techniques, and left ventricular wall thickness was not decreased. To best our knowledges, this was the first case in which post-operative evaluation such a small prosthesis was measured.