[Postoperative chylothorax treated with fibrin glue and absorbent mesh: a case report].

A 66-year-old man was treated by graft replacement for a thoracic aortic aneurysm. Chylothorax occurred on postoperative day 2. In spite of cessation of oral intake and IVH management, chest tube drainage did not decrease, the patient became malnourished. A chest X-ray and CT scan revealed the massive pleural effusion. Reoperation assisted with a thoracoscopy was carried out for chylothorax on postoperative day 27. Because we were unable to find the thoracic duct and the leakage point, the fibrin glue and absorbent mesh was applied to parietal and mediastinal pleura. Four days after reoperation, the chest tube was removed. This method is useful for this type of a chylothorax and lymphorrhea.

[Atraumatic local interruption technique for coronary circulation in MIDCAB].

Various methods have been employed for "local" interruption of the coronary blood flow before anastomosis during MIDCAB. However, coronary artery injury caused by a snare and coronary artery stenosis at the snare site resulting in late complications have been reported. We utilize a technique that minimizes the risk of injury to the coronary artery. At about 1 cm proximal to the coronary artery incision, expanded polytetrafluoroethylene (ePTFE) suture (GORE-TEX Suture CV-3 with an 18 mm needle that is tightly curved) is placed around the coronary artery, picking up a large chunk of myocardium with the curve of the needle. A Teflon felt is then attached, and threaded through a tourniquet. The tourniquet is tightened with the minimum strength needed for hemostasis. In order to avoid damage to the distal side of the coronary artery incision, a snare is not placed. Instead, an intraluminal occluder is used to block the blood flow. Anastomosis can easily be obtained with the use of a stabilizer. Hemorrhage from passage of suture is negligible, even during administration of 1.5 mg/kg heparin, because there is no difference between the diameter of the needle and that of the thread (diameter: 0.422 mm). The thread stretches minimally along the major axis but is flexible along the minor axis and thus produces less vascular wall trauma than does polypropylene thread. Furthermore, when the coronary artery is tightened through the cushiony myocardium and the Teflon felt by the flexible GORE-TEX thread, the injury to the coronary wall is minimized.

[Size estimation method for patch used in reconstruction of LV cavity].

The reconstruction of LV cavity is accomplished by suturing a patch to the viable myocardium to exclude the infarcted area from the high LV pressures. However, there is no clear guideline to estimate the size of patch used for LV reconstruction. We have designed a new method to determine the correct patch size, and applied it in 5 cases. The suture line of the patch is at the junction of contractile (functional) and infarcted portions of LV. The patch size is determined by the length of AB, termed "a", as the base, where "point A" represents the junction on the LV anterior wall side, and "point B" the junction of the LV posterior wall side, from RAO 30 degrees projection of the left ventriculogram obtained by cardiac catheterization. In LV aneurysm, we designed the patch in the range of a/2 < l < or = pi a/2, where patch length on RAO 30 degrees is considered "l". An effort was made to reconstruct to normalize LV volume and contour by designing the patch size to be a/2 < l < a, particularly when the contractile portion was enlarged by aneurysm. On the other hand, in post AMI VSD, LV contractile portion is not enlarged in early stage. Therefore, the patch was designed in the range of a < l < or = pi a/2 to maintain LV volume. Postoperative LV volume can be calculated prior to surgery, by using the lengths of the designed patch. Postoperative analysis indicated that the actual LV volume and contour were almost identical to our estimation. This method is very useful in planning the patch size for LV reconstruction.

[A clinical experience of agranulocytosis just after open heart surgery].

A 63-year-old woman who underwent aortic and mitral valve replacement developed agranulocytosis just after operation. It was considered that agranulocytosis was caused by bone marrow suppression by antiarrhythmic agent and extracorporeal circulation. Her white blood cell counts decreased to 300/mm3 on the third postoperative day, but increased surprisingly 5 days after administration of G-CSF. Fortunately she did not suffered from severe infection, and thereafter postoperative course was uneventful. Although agranulocytosis just after open heart surgery has not been reported, it appears that G-CSF might be useful.

[A successful surgical treatment of postinfarction posterior ventricular septal defect through a right ventricular approach].

A 72-year-old man with acute postinfarction ventricular septal defect located posteriorly underwent successful operation through a right ventricular approach. Following cardiac catheterization revealed posterior ventricular septal defect with 82% left to right shunt ratio and coronary angiography showed three vessel disease, emergency operation was performed. The defect was exposed through anterior right ventriculotomy and closed by a teflon patch sutured right side of the interventricular septum, with added bypass grafting to left anterior descending artery. Postoperative course was uneventful and postoperative cardiac catheterization showed no residual shunt with patent bypass graft. He was discharged from our hospital about 2 months after operation.