[Tricuspid annuloplasty, pulmonary valve replacement, ventricular septal defect (VSD) patch closure, and right-sided maze procedure 23-years after corrective repair of tetralogy of Fallot].

Postoperative pulmonary valve regurgitation, stenosis of the right ventricular outflow tract, conduit failure, ventricular septal patch leak, secondary tricuspid valve regurgitation, and various arrhythmias are the major complications that develop after surgical repair of tetralogy of Fallot in adults. A 27-year-old male with pulmonary regurgitation, tricuspid regurgitation, residual ventricular septal defect (VSD), low left ventricular function, and chronic atrial fibrillation underwent tricuspid annuloplasty, pulmonary valve replacement with a stentless aortic valve, VSD patch closure, and right-sided maze procedure, and the postoperative course was uneventful. The cardiothoracic ratio decreased, sinus rhythm was restored, and the patient's complaints were relieved. Reoperation at the optimal time after corrective repair of tetralogy of Fallot in adults may improve the outcome.

Characterization of ginseng saponin ginsenoside-Rg(3) inhibition of catecholamine secretion in bovine adrenal chromaffin cells.

Since ginsenoside-Rg(3), one of the panaxadiol saponins isolated from the ginseng root, significantly inhibited the secretion of catecholamines from bovine adrenal chromaffin cells stimulated by acetylcholine (ACh), the properties of ginsenoside-Rg(3) inhibition were investigated. Although ginsenoside-Rg(3) inhibited the secretion evoked by ACh in a concentration-dependent manner, it affected the secretion stimulated by high K(+) or veratridine, an activator of the voltage-sensitive Ca(2+) or Na(+) channels, only slightly. The ACh-induced Na(+) and Ca(2+) influxes into the cells were also reduced by ginsenoside-Rg(3). The inhibitory effect of this saponin on the secretion of catecholamines was not altered by increasing the external concentration of ACh or Ca(2+). The ACh-evoked secretion of catecholamines was completely restored in cells that were preincubated with 10 microM ginsenoside-Rg(3) and then incubated without the saponin, whereas secretion was not completely restored in cells that were preincubated with 30 microM of this compound. Above 30 microM ginsenoside-Rg(3) increased the fluorescence anisotropy of diphenylhexatriene in the cells. Furthermore, the inhibitory effect of ginsenoside-Rg(3) at 30 microM on the ACh-evoked secretion of catecholamines was dependent upon the preincubation time, but this was not the case at 10 microM. These results strongly suggest that ginsenoside-Rg(3) blocks the nicotinic ACh receptor-operated cation channels, inhibits Na(+) influx through the channels, and consequently reduces both Ca(2+) influx and catecholamine secretion in bovine adrenal chromaffin cells. In addition to this action, the ginsenoside at higher concentrations modulates the fluidity of the plasma membrane, which probably contributes to the observed reduction in the secretion of catecholamines.

Late leaflet fracture and embolization of a Duromedics mitral prosthesis.

A case of leaflet fracture and embolization of a mitral prosthetic valve is described. A 54-year-old man had received mitral valve replacement with an Edwards-Duromedics 29M prosthetic valve, at 10 years ago. Emergency mitral valve replacement was performed because the patient had severe congestive left heart failure with severe acute mitral regurgitation caused by a fracture in one of the mitral valve leaflets. The leaflet, which was fractured into 2 pieces, was removed from the right common iliac artery at 3 months after valve replacement. Visual inspection revealed that the leaflet contained a midline fracture. The fracture originated within a cavitary erosion pit near the major radius of the leaflet. The patient recovered from acute renal failure, requiring hemodialysis for 80 days, and is currently without complaints. We have used a Duromedics mitral valve in 11 patients, from April 1987 to April 1988. No subsequent valve failure has occurred. The diagnosis, treatment and cause of a mechanical valve fracture are discussed.

Grossly punched-out lesions in the aorto-iliac region can be histologically classified as false, pseudo-false, or disguised aneurysm.

Aneurysms are morphologically classified as true or false based on the nature of their walls. True aneurysms are composed of all or parts of layers of the vessel. False aneurysms are the result of rupture and their walls have only fibrous tissues. The orifice of false aneurysms is narrow relative to the aneurysmal diameter and thus they are grossly or angiographically referred to as punched-out lesions. Hence false aneurysms present with punched-out lesions, but in reverse, are all of punched-out lesions false aneurysms? We experienced some cases of punched-out lesions which histologically contained traces of elastin, and the purpose of this report was to histologically investigate grossly punched-out lesions. We examined 671 elderly autopsy cases, and a total of 21 grossly punched-out lesions in the aorto-iliac region were selected. They were histologically classified as false, "pseudo-false", or "disguised" aneurysm. False aneurysms were found in 3 patients (0.45%), and were histologically mycotic. A total of 5 "pseudo-false" aneurysms were found in 3 patients (0.45%). They histologically contained traces of elastin, and thus they were categorised in true aneurysms. A total of 13 "disguised" aneurysms were found in 6 patients (0.89%). They were true fusiform aneurysms with an eccentric thrombus, on which a fibrin-cap formed a narrow orifice. Partial sections are insufficient for diagnosis; cross-sections are necessary. To the best of our knowledge, there have been no reports of "pseudo-false" or "disguised" aneurysms in the aorto-iliac region.

Spontaneous perforation of a non-aneurysmal atherosclerotic abdominal aorta or femoral artery.

The spontaneous perforation of a non-aneurysmal atherosclerotic abdominal aorta or femoral artery is reported. Over the past 14 years, four perforations have been found in the abdominal aorta and one in the femoral artery; the incidence of each was 1.1% and 5.9%, respectively. Computed tomography scanning was useful for diagnosing pseudoaneurysms in all cases, since it revealed haematoma outside the arterial wall. One of these cases presented with an aortoduodenal fistula. The arteries were severely atherosclerotic with calcification. All of the patients underwent a graft replacement. Operative findings confirmed pseudoaneurysm. One patient died from pneumonia 4 months after the operation, and the other four have remained well during the follow-up period ranging from 2-9 years.

A clinicopathological study of familial abdominal aortic aneurysms.

The purpose of this report is to document what we have observed in patients with familial abdominal aortic aneurysms (FAAAs) between 1987 and 1993. Patients with FAAAs were reviewed and compared with those without familial clustering with regard to age, sex, past history, laboratory data, smoking habits, and type of implanted graft. We identified 7 families among which a total of 15 members had AAAs. The incidence of familial clustering reached 5.4%. The mean age of the FAAA group was significantly younger than that of the non-FAAA group (mean age: 65.8 +/- 10.3 versus 71.0 +/- 7.3 years). In the FAAA group, furthermore, patients in the second generation were significantly younger than those in the first generation (mean age: 55.3 +/- 10.5 versus 69.6 +/- 7.4 years). FAAA was significantly more often complicated by ischemic cardiac diseases. There were no significant differences in other risk factors. Interestingly, however, we observed a morphological similarity in the shape of the aneurysms within each family. Histological examinations showed moderate or severe lymphocytic infiltration into the aortic adventitia in 6 out of 9 cases. FAAA is clinically important, because it can represent a high-risk group that may benefit from a screening program for early detection and elective management of AAA. Studies of FAAAs will be useful for elucidating the pathogenesis of AAAs.

Computer-aided 3-dimensional visualization of abdominal aortic aneurysms from CT images.

A new method for elucidating the process of abdominal aortic aneurysm enlargement is presented herein. First, 3-dimensional (3-D) reconstructed images were used to precisely evaluate the size of an aneurysm, after which reconstruction and a volume analysis of images were performed with a personal computer system using serial computed tomographic films. The evolution of an aneurysm was examined by the detailed reconstruction, and an estimation of size was achieved by accurately measuring the figure reconstructed from the angle perpendicular to the axis of the contour. In quantifying the enlargement of an aneurysm, an exact evaluation of volume changes and morphological changes can be performed using the 3-D reconstruction method from the film series obtained at follow-up studies. The volume analysis proved especially useful for evaluating the axial expansion of aneurysms with stable maximum diameters.

Nonanastomotic aneurysm formation in a Dacron arterial graft: report of a case.

Dacron prostheses are the most widely used grafts in replacement procedures for abdominal aortic aneurysms, having been proven as the most reliable substitute for arterial replacement. However, we present herein the rare case of an 82-year-old woman in whom nonanastomotic aneurysm formation occurred in the graft as a complication associated with a Dacron prosthesis. The patient presented with a pulsatile mass in the right inguinal region. She had undergone surgery 13 years earlier for an abdominal aortic aneurysm, at which time an aortobifemoral graft reconstruction had been performed with a double-velour knitted Dacron prosthesis. The pulsatile mass was found to be a nonanastomotic aneurysm of the right limb of the bifurcated graft with an intact distal anastomosis. In this case, the development of the graft aneurysm seemed to result from deterioration of the Dacron prosthesis itself due to mechanical fatigue caused by the inguinal band.

Inferior mesenteric and hypogastric artery reconstruction to prevent colonic ischaemia following abdominal aortic aneurysmectomy.

In 179 patients receiving prosthetic grafts for abdominal aortic aneurysmectomy, an attempt was made to preserve or restore continuity of at least two vessels, including the patent inferior mesenteric artery (IMA) and bilateral hypogastric arteries (HGAs), so as to prevent colorectal ischaemia. Adjunctive reconstruction of the IMA and/or HGAs was performed in 60 patients; a total of 40 HGAs and 31 IMAs were reconstructed. The hospital mortality rates of patients with elective and ruptured aneurysm repair were 3.9 and 22% respectively. There were no deaths related to colorectal ischaemia. The mean(s.d.) IMA stump blood pressure was 66(18) mmHg and the mean(s.d.) IMA stump pressure index (the ratio of mean peak systolic IMA pressure to mean systolic systemic pressure) was 0.58(0.15). The IMA was revascularized in all patients whose stump pressure was < 40 mmHg and whose index was < 0.4. Postoperative angiography revealed a 94% patency rate for the IMA and 92% for the HGAs. Colorectal ischaemia did not develop in any patient in whom aneurysmectomy was performed electively or in any who had colonoscopy because of watery diarrhoea after surgery. These results indicate the significance of adjunctive reconstruction of the IMA and HGA during abdominal aortic aneurysmectomy.