[Combined operation for ischemic heart diseases and valvular heart diseases].

We performed combined operation for patients who have both ischemic heart disease and valvular heart disease in 21 cases from January 1991 to October 1999. This operation was 3.1% of 682 cases of coronary artery bypass grafting and 5.0% of 416 cases of operation for valvular heart disease during that period. The mean age of these patients was 67.9 +/- 9.1 years. The average number of grafts in the coronary artery bypass grafting was 1.5 +/- 0.6. Aortic valve replacement was performed in 6 cases, mitral valve replacement in 10 cases and mitral valve plasty in 5 cases. Together with this combined operation, ascending aorta and aortic arch replacement was done in 1 case and abdominal aortic replacement in 2 cases. Three patients died due to postoperative aortic rupture, cerebral infarction or excessive surgical intervention in ascending aorta and aortic arch replacement. Combined operation for ischemic heart diseases and valvular heart diseases can safely performed, but it appears necessary to pay attention to arteriosclerotic lesions.

[Risk factors for pulmonary hypertensive crisis (PHC) following VSD repair in infants].

We examined 100 patients who had undergone VSD repair from 1988 to 1991 to determine the risk factors to induce PHC postoperatively. We analyzed age, weight, preoperative Pp/Ps, Rp/Rs, Qp/Qs, and postoperative Pp/Ps using discriminant analysis. We had 34 cases of pulmonary hypertension (PH: Pp/Ps > 0.7) preoperatively. Among 100 cases, PHC developed in 6 patients and 2 of them died postoperatively. Incidence of PHC in all patients was 6%, and that in patients with PH was 18%. PHC fatality rate was 33%. The analysis revealed that the occurrence of PHC was significantly higher among those whose ages were below 2.1 years, and with weight of under 9.85 kg, preoperative Pp/Ps > 0.73, Rp/Rs < 0.34, and postoperative Pp/Ps > 0.43. In those with preoperative PH, the risk for PHC increased significantly when their postoperative Pp/Ps exceeded 0.44.

[A case-report of pacemaker malfunction caused by dry pocket after replacement of pulse generator].

Pacemaker malfunction was attributed to the increasing in impedance to current flow caused by a pocket of air separating the anodal contact plate of a unipolar generator from the overlying connective tissue (so-called dry pocket). Lack of capture was noted just after replacement of pulse generator. The malfunction was permanently corrected by bediside infusion of saline to pacemaker pocket.

[A case report of aneurysm of the diverticulum of the ductus arteriosus in the elderly].

A 82-year-old female was admitted to our department with complaint of hoarseness. Retrograde aortogram revealed an aneurysm arising from distal aortic arch. The aorta including the aneurysm was resected and replaced with woven Dacron graft under partial cardiopulmonary bypass. An Aneurysm of the diverticulum of the ductus arteriosus is rare in adult and because of its high fatality it should be resected.

[A case of aortic regurgitation combined with obstruction of the left coronary ostium caused by adhesion of left coronary cusp].

A case, 31-year-old female with aortic regurgitation and ostial obstruction of left coronary artery, was reported. Her chief complaint was effort angina. The coronary angiography showed obstruction of left coronary ostium with intact main stem and its branches, perfused from right coronary artery and the aortogram revealed aortic regurgitation of grade 3-4. Left Valsalva sinus was obstructed by adhesion of left coronary cusp. Each coronary cusps were resected, and aortic valve replacement with 23 mm SJM valve and coronary arterial bypass by means of in-situ graft of left internal thoracic artery underwent successfully. The pathological findings of aortic cusps were healed valvulitis without specific inflammation as syphilis or aortitis syndrome.

[A case of open heart surgery associated with liver cirrhosis and pancytopenia].

A 58-year-old female was diagnosed as mitral regurgitation and tricuspid regurgitation, combined with liver cirrhosis (T. Bil 2.3 mg/dl, ICG-R 37%) and pancytopenia (Hb 9.4 g/dl, WBC 3,000, Plt 56,000). She underwent mitral and tricuspid annular plications. After extracorporeal circulation, the postoperative platelet count was maintained higher than preoperative one by transfusion of platelet-rich plasma. Administration of FOY was begun during operation. Levels of T. Bil. and BUN were highest at 15th postoperative day and decreased gradually. Postoperative pleural effusion was treated by administration of 25% albumin solution keeping the level of Alb. up 3.5 mg/dl.

[Reoperation cases long after Rastelli operation: right ventricular outflow tract reconstruction by means of a xenograft non-valved patch].

Two cases who underwent the new procedure of treatment for extracardiac conduit stenosis after Rastelli operation are reported. They had undergone Rastelli operation 11 and 12 years ago. Because of stenotic Hancock valve of the conduit, they were reoperated. A longitudinal incision was made anteriorly over the conduit and the conduit was dissected free. The sides and posterior half of the conduit bed were preserved. The roof of the new right ventricular outflow tract was formed using a xenograft pericardium patch. Their postoperative courses were smooth.

[Long-term survival with Hufnagel ball valve--a case report].

Authors report a 61-year-old female with an aortic aneurysm at the distal end of the Hufnagel ball valve which was implanted surgically for the treatment of aortic insufficiency 23 years previously. The Hufnagel ball valve has been working well for the past 23 years, but the aneurysm was found enlarging in size, therefore the replacement of aneurysm with a 20 mm dacron graft was performed following removal of the well-working Hufnagel ball valve. There were 151 cases with Hufnagel ball valve implantation in the literature and at least 7 cases of them were reported in Japan. Among them, the majority survived only several years after surgery and the cases with long-term survival were very few in number. Our case is unique, because the valve in this case has worked well for 23 years.

[A case report of atypical coarctation of the aortic arch with thoracic aortic aneurysm].

A 30-year-old woman was admitted to our hospital because of the abnormal shadow on chest X ray film and paralysis of right fingers. The preoperative aortogram and DSA showed atypical coarctation of the aortic arch with thoracic aortic aneurysm. We successfully performed extra-anatomical bypass with a 14 mm Cooley low porosity Ducron graft between ascending aorta and discending aorta. Her postoperative course was uneventful and discharged one month after the operation.

Consturction of new right ventricle on the epicardium: a possible correction for underdevelopment of the right ventricle.

By covering almost the entire right ventricular free wall and the anterior wall of the left ventricle with a Teflon cloth, we constructed a new chamber on the epicardium of a canine heart. An aortic homograft with the aortic valve was anastomosed to the right atrium as an inlet of this chamber. Another aortic homograft was sutured to the main pulmonary artery as an outlet. Pressure produced in this chamber ranged 25 to 55 mm. Hg and its first derivative was 450 to 1,870 mm. Hg per second. Thus this chamber had an excellent capability of epicardium will yield more physiological benefits to patients with an agenetic or hypoplastic right ventricle than do the current surgical procedures, in which a conduit is interposed between the right atrium and the main pulmonary artery. The procedures proposed could pressurize the pulmonary circulation and produce a pulsatile flow.