[A case of constrictive pericarditis due to traumatic pericardial hematoma].

Although the cause varies widely, we recently experienced a case of constrictive pericarditis of which cause seemed to be traumatic as described below. The patient was a 62-year-old man having a history of epigastric trauma about 20 years ago. Since then, palpitation appeared and he was recently hospitalized in our department for the purpose of receiving an operation under the diagnosis of constrictive pericarditis. At operation, a hematoma was found in the pericardial region, which was considered to have been caused by trauma in the past. Less reports have so far been available concerning trauma-induced constrictive pericarditis and this case thus seemed to be of rarity as well.

[Operative indication for aortic valvuloplasty by rasping procedure from the point of histopathologic evaluation].

Rasping procedure is proposed by the author as one of the methods of aortic valvuloplasty and defined as shaving the surface of rheumato-degenerative aortic valve by using the electric rasp. Materials were the removed rheumato-degenerative aortic valves as specimen, and classified into 3 groups. The first group (type I) was valve lesion limited to valve free edge, second (type II) was mild thickening entirely, third (type III) was severe thickening with calcified degeneration. Rasping procedure was performed for the thickened portion of the valve specimen by the electric rasp. Morphologic examinations after rasping procedure were evaluated by histopathologic study. Histopathologically, there was hyaline degenerative connective tissue in superficial layer above the collagen fiber's layer in rheumato-degenerative thickened valve in type I. This hyaline degenerative connective tissue was considered to be fragile and pathologic in the tissue structure. Rasping procedure could remove this connective tissue layer. Type II, there was the similar finding to the type I from the free edge to the mid portion of the cusp. So, Rasping procedure was effective for type I and type II valve degeneration. On the contrary, the calcified lesion (type III), rasping procedure was not effective in valve coaptation and the pathological findings showed the fragmentation in the calcified layer. In the pathological comparison with the slicing procedure for type II by the surgical knife, there was a crack and cleft in the collagen fiber's layer in the case of slicing procedure. It can be concluded the results of histopathological study of the rasping procedure proved to be superior to the conventional aortic valvuloplasty (slicing method).

[The determinant factors for open heart surgery with non-blood transfusion--analysis by quantitative theory class II].

The serious complications in the field of cardiovascular surgery are the blood transfusion related problems such as post transfusion hepatitis, AIDS, GVHD and immunosuppressed conditions. These problems have not been settled so far. In our department, open heart surgery with non-blood transfusion is the final goal and extracorporeal circulation with non-blood priming has been indicated under normal conditions. However depending on the cases, blood transfusion is definitely required. Under such circumstances, we analyzed the determinant factors as to whether open heart surgery with non-blood transfusion may be indicated or not, according to the formula based on the quantitative theory (class II). Extracorporeal circulation with non-blood priming were indicated on 124 patients in our department, and they were divided into two groups; blood transfusion group (group I): 64 patients, and non-blood transfusion group (group II): 60 patients. These two groups were compared for study in terms of age, preoperative weight, the body surface area, preoperative Ht value, calculated Ht value at the start of extracorporeal circulation, the aortic cross-clamping time, the total extracorporeal circulation time and total bleeding amount. The following are described in the order of importance. 1) Calculated Ht value: more than 30%. 2) The amount of blood loss after ECC is removed: less than 500 ml. 3) Preoperative body weight: more than 50 kg. 4) Preoperative Ht value: more than 40%. 5) The total ECC time: less than 90 min. In addition, prospective factors which should be considered preoperatively are determined in the following orders. 1) Calculated Ht value. 2) Preoperative Ht value. 3) Preoperative body weight.(ABSTRACT TRUNCATED AT 250 WORDS)

[A comment on optimal shaped prosthesis for tricuspid valve using an experimental model].

The prosthesis for mitral valve has been in use instead of the prosthesis for tricuspid valve, since the latter prosthesis has not at present been available. In view of the shape of tricuspid valve, which is essentially flat in form, it is not good for replacing with the prosthesis for mitral valve which has an almost circular shape because of the difficulties in suturing, and many criticisms on this substitution have been raised. In order to obtain more suitable prosthesis as exactly benefits TVR, we have developed at first an instrument indicating the change of cardiac function occurring in the course of fixing the annulus of tricuspid valve that would undergo the difference in shape from circular to flat, using experimental models throughout, which has eventually led to the exploration of the possible exact shape of a prosthesis of the annulus for tricuspid valve. Our series of experiments proved as conclusion that the annulus of tricuspid valve is more advantageous when fixed with an ellipse of a flattened rate 1.6 compared with any circular ones tested. In view of the left ventricular stroke work, it is apparent that a prosthesis for mitral valve which is circular in shape should not be applied. We emphasize that a prosthesis for tricuspid valve which is ellipse in shape with desired flattened rate of 1.6 should be developed for our future applications.

[Clinical evaluations of surgical treatment of infective endocarditis].

This paper shows the clinical evaluations of surgical and medical treatment of infective endocarditis (IE). IE occurred in 33 cases (10.1%) among 372 cases of valve replacement. Of all the 33 patients, IE was consisted of native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE). IE was evaluated as for the microorganism, complication, operative indication and operative mortality. At first, all of NVE underwent surgical treatment, active phase endocarditis 4 and healed endocarditis 14. Microorganism was streptococcus aureus in an overwhelming majority. Operative indications was congestive heart failure in almost all cases, next to vegetation and infection resistant to medical treatment. Operative mortality was 5.6% (1 out of 18 cases), which case was in the septic shock and cerebral bleeding prior to the surgical treatment. The others was satisfactory condition postoperatively. Next of PVE, PVE happened in 15 cases, in which there were 5 cases of bioprosthetic PVE and 10 cases of mechanical valve PVE. Microorganism for PVE was staphylococcus epidermidis in the major part (60%). Mortality in PVE was 53.3% (8 out of 15), but mechanical valve PVE was worse in prognosis than bioprosthetic PVE. Cerebral complications occurred in 3 cases of mechanical valve PVE, on the other hand there was no cerebral complication in bioprosthetic PVE. As for the hemodynamic change in PVE, mechanical valve PVE had the tendency to take the prompt or sudden deterioration of hemodynamics caused by endocarditis surrounding the suture ring, especially in mitral position, on the contrary hemodynamic deterioration was gradually proceeded in bioprosthetic PVE. UCG made much of the diagnosis of PVE, especially in mechanical valve PVE, in which cases endocarditis was recognized only surrounding the suture ring. PVE takes the miserable outcome in many cases, so carefully observation is necessary in order not to lose the timing of the surgical treatment.

[Time-related degeneration of Carpentier-Edwards bioprosthesis in mitral position].

Carpentier-Edwards bioprostheses have been shown to provide a low incidence of valve-related complications, especially thromboembolism, but the durability has caused the serious concern. This report suggests that Carpentier-Edwards prostheses have been gradually degenerative, and stenotic degeneration and the year after operation are well correlative. In Osaka National Hospital, Carpentier-Edwards prostheses were implanted in 89 patients in mitral position from 1973 to 1981. Of all the patients, 50 patients were undertaken to single valve replacement in mitral position and could be followed up in our department. For a total of 50 patients, materials are 30 patients who could be detected by clinical findings, pulsed Doppler echocardiography, cardiac catheterization and soft X-ray evaluation in explanted prostheses at reoperation. Follow-up duration was ranged 4.2 to 12.1 years with a mean duration of 7.94 years. The age ranged from 32 to 71 years of age. The initial diagnosis of the time-related degeneration was the appearance of newly acoustic rumbiling murmur. Furthermore, regurgitant murmur, arrythmia (atrial fibrillation) and cardiac enlargement were followed in addition to rumbling murmur. The assess of the transmitral flow such as pressure half time and peak pressure gradient by pulsed Doppler echocardiography was the easy way to evaluated the time-related degeneration. Time-related stenotic change by pulsed Doppler was expressed as a linearized curve. At 6 years and below valve function seemed not to be impaired but stenotic dominant degeneration with the cusp tear was prominent beyond 7 years. Cardiac catheterization data could make sure of the pulsed Doppler findings by assessing mitral valve gradient and mitral valve area.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of Taussig-Bing malformation in an adult--a case report].

With the development of pediatric cardiac surgery, the surgical treatment of Taussig-Bing malformation has been common in frequency and a majority of these cases are reported. However, because the patient's condition is so critical in the early stage of life, the importance of adequate initial operation is emphasized, and this area is restricted to the operative cases of child patient. In this clinical study, the operation for 41-year-old adult patient with Taussing-Bing malformation was successfully performed using the Kawashima's procedure, and we would like to report the detailed operative procedure as well as its clinical courses. This patient was female of 41 years of age and at surgery, this case was found to be the Taussig-Bing malformation associated with pulmonic stenosis, and the operation for intracardiac repair was carried out using intracardiac conduit (5 x 4 cm) and also extracardiac conduit (5 x 3 cm). It is reported that there are many operative procedure available in child patients but we believe that Kawashima's procedure is probably the best choice of operation for adult patients because of its simplicity.

[Coronary artery stenosis following aortic valve replacement--a case report].

A case with severe left main trunk (LMT) stenosis nine months after aortic valve replacement was presented. The patient, 57-year-old female, underwent aortic valve replacement with a tilting disk valve (Omnicarbon 21 A). Her postoperative course was uneventful, but angina pectoris developed after nine months. Coronary angiography was performed and revealed 99% LMT stenosis. Operation was performed with OTCA to LMT and with a saphenous vein graft to left anterior descending artery. Coronary artery stenosis following aortic valve replacement may be dangerous and it must be treated as soon as the diagnosis is established.

[Expanding the surgical indication to the cases with high risk valve diseases].

Four hundred and fifty eight cases of valve surgery were performed at this institution over the past 7 years, during which the surgical indication has been gradually expanded to cases of three types. The first type is serious disease complicated by cardiac cachexia; in these cases, in addition to the aggressive use of IABP, we also use the intrapulmonary artery balloon pumping (IPBP) technique we developed. IVH therapy for two months before surgery has been especially effective and given good results to cases with low liver function and low respiratory function. The second type consists of cases necessitating special surgical technique, for example, cases with very narrow valvular annuli and cases complicated by acute endocarditis. Good results have been obtained in the former with a new technique that we developed, called "Coupling Valve Grafting", and in the latter with a technique of "Collared Prosthesis". The third type is elderly patients aged 70 years or more. In particular, the greatest problem now seems to lie in low liver function of which ICG (15 min) is higher than 40% and total serum bilirubin is over 3 mg/dl; in these cases, progression to MOF is frequent and the patient's life is saved in only 40% of cases.