[Mycotic descending thoracic aortic aneurysm complicated by pyothorax postoperatively: report of a case].

We experienced with a case of mycotic descending thoracic aortic aneurysm (MTAA) complicated by pyothorax postoperatively. The graft replacement accompanied with wrapping by omental pedicle flap (OPF) was performed in this case. We considered that causative organism for MTAA was Salmonella species, and discussed effectiveness of the application of OPF to MTAA.

[Determinants of long-term outcome for operative survivors of acute aortic dissection].

Predictability of aorta-related complications and survival was examined in 79 operative survivors of acute aortic dissection. Follow-up was 94.9% complete and totaled 458 patient-years. Actuarial survival was 93 +/- 3% (+/- S.E.) (n = 43) at 5 years, and 74 +/- 8% (n = 13) at 10 years. Survival was significantly lower in patients having neurological complication. Freedom from aorta-related complications was 82 +/- 5% (n = 37) at 5 years, and 67 +/- 8% (n = 11) at 10 years. Multivariate Cox regression analysis identified residual entry and leak on anastomotic site as independent predictors of aorta-related complications. We conclude that in the treatment of acute aortic dissections, reducing the incidence of residual entry and leak on anastomotic site improves long-term outcome.

Induction chemoradiotherapy for advanced stage III non-small cell lung cancer: long-term follow-up in 42 patients.

This multi-institutional phase II study was designed to assess the feasibility, efficacy, toxicity, and long-term survival of induction chemoradiotherapy followed by surgery in previously untreated patients with advanced stage III non-small cell lung cancer. Chemotherapy regimen included cisplatin 20 mg/m2 on days 1-5 and 29-33, and VP-16 40 mg/m2 on days 1-5 and 29-33. Radiotherapy (50 Gy in 25 fractions) began on day 1. Clinically downstaged patients underwent thoracotomy 3-5 weeks after the completion of radiotherapy. Forty-two eligible patients (ten stage IIIA and 32 IIIB) were followed for a median period of 64 months. The response rate was 81%, and 20 patients had a clinically good response. Twenty-one patients underwent thoracotomy. Nineteen patients had complete resections and there were seven pathologic complete responses. There were four treatment related deaths (all stage IIIBs). There were significant survival differences between stage IIIA versus IIIB patients (P = 0.028; median survivals, 24.9 vs. 11.1 months; 5-year survival rates, 20% vs. 8.3%), and patients that achieved pathologic complete response (CR) versus those that did not (P = 0.045; median survivals 30.1 vs. 11.1 months; 5-year survival rates, 28.6% vs. 8.3%). Although the induction chemoradiotherapy employed in this study was not appropriate for stage IIIB patients, it proved feasible in stage IIIA patients in whom it resulted in good 5-year survival rates. It also provided good survival rates in patients achieving pathologic CR.

[The case of left atrial myxoma originating from posterior leaflet of mitral valve].

We experienced the case of left atrial myxoma originating from posterior leaflet mitral valve. Mitral valve repair was performed in that case, because of the presence mitral leaflet defect due to removal of the myxoma. Transesophageal echocardiography was a useful tool for perioperative evaluation of the mitral valve and precise localization of the origin of the myxoma.

[A case of contralateral pneumothorax after right pneumonectomy].

A 46-year old man, who had a history of right pneumonectomy for pulmonary tuberculosis 28 years ago, was referred to our hospital for surgical treatment of contralateral pneumothorax. The patient underwent multiple excisions of bullae and parietal pleurectomy through the median sternotomy in order to save pulmonary function. The postoperative course was satisfactory as he could maintain preoperative pulmonary function. He returned to his work soon. We consider that the median sternotomy would be the most useful approach to save pulmonary function of patients who plan to undergo surgical treatment of contralateral pneumothorax after pneumonectomy.

[Thoracic duct cyst--a case report].

The patient was a 59-year-old man with a 5-month history of cough, difficulty breathing, and palpitations while working. Initial examination at the internal medicine department of our hospital in August 1992 revealed a mass in the left side of the neck, and he was admitted for further examination and treatment. Preoperative investigations revealed a cystic lesion extending from the left neck area to the mediastinum. The mass was resected on August 13, 1992. Based on the intraoperative findings and postoperative histological examination, a diagnosis of thoracic duct cyst was made. The postoperative course was good and the patient was discharged after two weeks. This is extremely rare case, and the Trap door surgical approach proved useful for resection.

[A case of cardiac herniation following intrapericardial pneumonectomy after induction chemoradiotherapy].

A case of cardiac herniation following left intrapericardial pneumonectomy after induction chemoradiotherapy has been presented. Curative resection after induction chemoradiotherapy for central bronchogenic cancer may require intrapericardial pneumonectomy. Cardiac herniation through the pericardial defect is a fatal complication after a pneumonectomy unless pericardial repair should be done immediately. Closure of the pericardial defect with prosthetic patch, regardless of defect size, is always necessary for the prevention of the cardiac herniation following intrapericardial pneumonectomy after induction chemoradiotherapy.

[Treatment of aneurysm of aortic arch using selective cerebral perfusion].

The objective of this study is to evaluate safety and efficacy of the selective cerebral perfusion (SCP) for an adjunct to perform operation of aortic arch aneurysms. From November 1982 to June 1993, surgical treatment of aneurysm of aortic arch using SCP was performed in 22 patients. The hospital death was accounted in 5 cases (23%), the intraoperative stroke was observed in 3 cases (14%) and these patients died. The cause of intraoperative stroke was cerebral hypoperfusion due to multiple sclerosis of intracranial arteries or insufficient SCP. Variables of an increased operative risk seemed to be older age (over 70 y.o.) and rupture. SCP time more than 120 minutes did not promote the operative risk. Cerebral hypoperfusion was directly responsible for not only intraoperative stroke, but also operative death. Therefore, SCP seems effective and safe if hypoperfusion is prevented.

Postoperative flow characteristics of left internal thoracic artery grafts.

Twenty patients whose left internal thoracic artery (LITA) was anastomosed to the left anterior descending artery (LAD) underwent postoperative coronary angiography and Doppler ultrasound velocimetry. During angiography, the diameter of the LITA conduit was measured at three points: proximal, mid, and distal. The degree of left anterior descending artery stenosis proximal to the anastomotic site was evaluated by densitometry. The LITA flow velocity pattern was obtained at the three points to calculate the total, systolic, and diastolic flow volume. There were significant differences in the total LITA flow among the three points (proximal, 36.0 +/- 17.2 mL/min; mid, 29.9 +/- 15.2 mL/min; distal, 27.2 +/- 14.0 mL/min; p < 0.001 between the proximal and the mid or distal portions). The degree of left anterior descending artery stenosis affected the distal LITA flow and diameter (r = 0.823 and 0.811, respectively). There were significant differences in the systolic LITA flow among the three points (proximal, 13.2 +/- 6.5 mL/min; mid, 8.1 +/- 4.7 mL/min; distal, 5.6 +/- 3.4 mL/min; p < 0.001 between the proximal and the mid or distal portions). However, there was no statistically significant difference in the diastolic LITA flow among the three points (proximal, 22.9 +/- 11.0 mL/min; mid, 21.7 +/- 10.8 mL/min; distal, 21.6 +/- 10.8 mL/min). We conclude that a lower degree of LAD stenosis significantly reduces the LITA flow, inducing the string phenomenon. Additionally, during the diastolic phase, the LITA graft transports the blood primarily to the coronary artery but not to the side branches. Therefore, the steal phenomenon might not apply in the setting of an LITA graft.

Non-invasive Doppler technique for detection of flow velocity in left internal mammary artery grafts.

The capability of Doppler to detect patency of left internal mammary artery grafts through the supraclavicular approach was evaluated. A total of 37 patients with a left internal mammary artery graft to the left anterior descending artery were divided into three groups, according to postoperative coronary angiographic studies. Group 1 comprised 20 patients with no significant stenosis of the left internal mammary artery and subtotal or total obstruction in the left anterior descending coronary artery proximal to the anastomotic site. There were ten patients with no significant stenosis of the left internal mammary artery and 75% stenosis of the left anterior descending coronary artery in group 2. Seven patients with significant stenosis of the left internal mammary artery formed group 3. Analysis of the flow velocity pattern in the left internal mammary artery graft included: (1) systolic peak velocity (SPV), (2) diastolic peak velocity (DPV), (3) systolic time velocity integral (SI), (4) diastolic time velocity integral (DI), (5) diastolic peak velocity/systolic peak velocity and (6) diastolic time velocity integral/diastolic time velocity integral+systolic time velocity integral. There were no significant differences in systolic peak velocity and systolic time velocity integral between the three groups. The diastolic peak velocity and diastolic time velocity integral were greater in group 1 than in groups 2 (P < 0.05, P < 0.01) and 3 (P < 0.05). The diastolic peak velocity/systolic peak velocity and diastolic time velocity integral/diastolic time velocity integral+systolic time velocity integral ratios in group 3 were significantly smaller than in groups 1 and 2 (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[An operative case of aortic regurgitation due to quadricuspid valve].

A case of quadricuspid aortic valve is described. A 43-year-old man admitted because of chest oppression on exercise. He had a ejection systolic murmur and decrescendo diastolic murmur. Electrocardiogram revealed severe left ventricular hypertrophy. Echocardiogram showed dilated left ventricle and supernumerary cusp between the right and left coronary cusp. Aortogram revealed quadricuspid aortic valve with grade 4 aortic regurgitation. At operation, quadricuspid aortic valve in which supernumerary cusp between right and left coronary cusp was smaller was found. Four cusps were excised and replaced with 23 mm Medronic-Hall prosthesis. His postoperative course was uneventful. Quadricuspid aortic valve has been extremely rare. Twenty operative cases has been reported. The clinical feature was presented.

[A case report of surgical repair of aneurysm involving the distal arch and the descending aorta through median sternotomy].

A 46-year-old male patient with aneurysm involving the distal arch and the descending aorta was operated on successfully. Graft replacement of aneurysm with inclusion method was performed through median sternotomy with left pleurotomy. One month after operation, CT scan showed thrombus occupied between the graft and the aneurysm, and two years postoperatively, the aneurysm shrunk almost to normal size of the aorta. Therefore, our surgical procedure was considered to be proper.

[Results and problems of open heart surgery in patients seventy years of age and older].

The purpose of this study was to assess the influence of aging on the surgical results. The subjects which were 70-year or older included 13 cases of acute myocardial infarction with mechanical failure (AMI), 36 of elective aortocoronary bypass (CABG) and 33 of valvular heart disease (VHD). The control group younger than 70 included 32 cases of CABG and 32 of VHD. The complication rate of hypertension or diabetes mellitus in the older group was not significantly higher than in younger group. The characteristics of the preoperative status in the older group, however, seemed to be renal and hepatic hypofunction and anemia. The amount of intraoperative bleeding in older group was larger than in younger group. The periods of ICU stay, respiratory assist and postoperative hospitalization in older group were significantly longer than in younger group. The operative mortality rate of AMI was 61.5%, of CABG 8.3% and of VHD 12.1%. The operative mortality rate of emergent or urgent operation was 47.6% and of elective one 8.2%. The 4-year survival rate of CABG was 82% and the 6-year survival rate of VHD was 85%. Sixty four survivors (95.5%) improved to I-II of NYHA classification and of only 3 survivors (4.5%) remained in NYHA III class. The operative and long term results of elective surgery in older patients were comparable to those in younger ones. Therefore aging, itself, should not be a limiting factor in 70-year or older patients with good mental activity.

[Congenital kinking of the aortic arch associated with aortic arch aneurysm: a case report].

A surgical case of congenital kinking of the aortic arch associated with aortic arch aneurysm, which had been observed as the mediastinal tumor for 15 years, was reported. Twenty-two surgical cases of the aortic lesion, which were diagnosed pseudocoarctation or congenital kinking, have been reported in the literature. This paper focused on the pathogenesis, surgical treatment and terminology of this anomaly.

[Long-term results of operation in patients with annuloaortic ectasia].

From 1974 to 1990, 24 patients were operated on for annuloaortic ectasia. We chose Bentall's technique for 17 patients with great displacement of coronary ostium, but Cabrol's one for 6 patients since coronary displacement was not great. The hospital mortality was 8.3% (2 deaths). The late mortality has been 5/22 (22.7%). Nevertheless, all the patients employed Cabrol's technique have been free from death, events and reoperation. These results were remarkably better than those of primary isolated AVR. It is considered that poor results were caused not by the operating mode using a composite graft but by the connective tissue disorder as primary pathology of annuloaortic ectasia. We conclude that the patient with annuloaortic ectasia must be observed for a long-term after operation.

Recovery of end-stage organ dysfunction by circulatory assist.

To clarify the effectiveness of left ventricular assist on recovery of critical organ dysfunction, 18 patients with ventricular septal rupture or free wall rupture after acute myocardial infarction were retrospectively studied. Fifteen patients were managed with an intraaortic balloon pump (IABP group), and three with a left ventricular assist device (LVAD group) after surgery. In the IABP group, nine patients survived and six died. There were no significant differences between survivors and nonsurvivors with respect to age, cardiopulmonary bypass time, or preoperative renal function. In addition, there were no significant differences in the early postoperative changes in cardiac index. Larger doses of catecholamines were required in nonsurvivors than in survivors, however; blood urea nitrogen and creatinine levels were significantly higher in nonsurvivors than in survivors, and the nonsurvivors' creatinine clearance values stayed under 20 ml/min during the postoperative course, so that all nonsurvivors required renal assist. All in the LVAD group were weaned. Two patients were lost, however, because of cardiac arrythmia and massive gas embolism. Cardiac index in the LVAD was maintained at over 2.1 L/min/m2 with a minimum dose of catecholamines, regardless of poor left ventricular function, and creatinine clearance recovered to over 20 ml/min during circulatory assist. From these data, high doses of catecholamines depressed renal function after surgery. Therefore, it has been concluded that the major role of circulatory assist is to maintain more of the physiologic circulation with minimum doses of drugs.

Annulo-aortic ectasia with DeBakey type II dissecting aneurysm in Gaucher's disease.

Annulo-aortic ectasia is an extremely rare complication of Gaucher's disease. We report successful surgery in a patient with Gaucher's disease complicated by annulo-aortic ectasia and aortic dissection. Cabrol's operation was accomplished without bleeding or sternal adaptation problems.

Transesophageal echocardiographic findings of intracardiac events during cardiac assist.

Transesophageal echocardiography (TEE) is an easy, noninvasive and reproducible method for evaluation of left ventricular function, coronary flow patterns, and intracardiac blood flow patterns during cardial assist. TEE facilitated better management of the patients with LVAD and gave us the various information: (a) Observing the drawing catheter tip by TEE, it could be settled just above the mitral orifice to obtain the maximum bypass flow; in addition, dislocation of the catheter tip could be easily diagnosed. (b) The intracardiac thrombus could be clearly detected by TEE; it was removed without complications, weaning from left ventricular assist device (LVAD). (c) The left ventricular wall motion was periodically observed. The end systolic LV diameter (Ds) was decreasing and fractional shortening (%FS) was increasing as the natural heart recovery. Additionally, the preejection period (PEP) and the ejection time (ET) were measured. The ratio of PEP/ET was decreasing gradually. Ds did not alter with preload change during on-off testing unlike the other parameters. Ds seems to be the most reliable parameter for the natural heart recovery within certain amounts of bypass flow. (d) The flow velocity in the left anterior descending coronary artery could be measured by transesophageal Doppler method; it was clinically shown that counterpulsation produced a larger amount of coronary blood flow than copulsation.

Long-term echocardiographic follow-up of patients with a tricuspid bioprosthesis.

To clarify the long-term results of bioprosthetic valve function in the tricuspid position, 29 consecutive patients who underwent tricuspid valve replacement (TVR) were evaluated. There were 20 girls/women and 9 boys/men, with ages ranging from 6 to 61 years (mean 41.4 years). The bioprosthetic valves included Hancock in 2, and Carpentier-Edwards in 27. The follow-up period ranged from 32 to 145 months (mean 89 months). Regurgitant flow of the tricuspid bioprosthesis was studied by color Doppler echocardiography. Peak velocity (Vp) and pressure half time (PHT) were measured by continuous wave Doppler echocardiography. Operative mortality was 13.7% (4/29), with the actuarial survival rate, including operative deaths, 75% at 10 years. Valve thrombosis developed in one patient 4 years after TVR. Color Doppler showed regurgitation in 7 of the 20 patients who were completely followed up, but they were all asymptomatic and required no special intervention. Cusp tear or calcification requiring reoperation was not observed in this study, including 8 patients younger than 35 years of age. The Vp was significantly slower, and PHT was significantly prolonged, in the tricuspid rather than the mitral position. These data demonstrate that bioprosthetic valves in the tricuspid position can be used safely. Doppler examination should be performed taking these different flow dynamics into account.

[The clinical criteria for Carpentier-Edwards bioprosthesis in the mitral position].

This is a comparative study of late results of mitral valve replacement between Carpentier-Edwards (C-E) and Björk-Shiley (B-S) valve prosthesis. The purpose of this study is to clarify the clinical criteria for C-E valve. C-E valve was implanted in 202 patients. The mean follow up period was 5.8 years and the longest one was 11 years. For B-S valve, it was 132 patients, 5.3 years and 17 years, respectively. With respect to the incidence of thromboembolic episodes, in spite of no anticoagulant therapy in the C-E group, there was no statistical difference between the C-E and the B-S groups. The incidence of valve related complication in the C-E group was significantly lower than that in the B-S group 5 years postoperatively. But that in the B-S group was significantly low 10 years postoperatively. Since the over 60 years old patients in the C-E group had low incidence of primary tissue failure, over ten years durability might be secured. In conclusion, the present clinical criteria for C-E valve should be as follows: 1) the patient older than 65 years, 2) the patient with contraindication for anticoagulant therapy, 3) the woman who desires pregnancy and 4) the patient with hemorrhagic diathesis caused by cardiac cachexia, liver cirrhosis and so on.