Severe heart failure due to subacute effusive-constrictive pericarditis in a child.

We report a 9-year-old boy with progressive heart failure due to effusive-constrictive pericarditis. The patient was successfully rescued by extensive surgical removal of the thickened pericardium. The histopathological examination revealed degenerative changes of myocardium without significant inflammation, indicating that surgical pericardiectomy should be performed for subacute effusive-constrictive pericarditis before progression to definite constrictive pericarditis.

[Double switch operation (Senning and Rastelli operation) with left atrial augumentation by in situ autologous pericardium: a case report].

A 23-month-old female infant with situs solitus, atrioventricular and ventriculoarterial discordance, pulmonary atresia, ventricular septal defect, who had received modfied right Blalock-Taussig shunt (4 mm Gore-Tex tube) at the age of 2 months, was carried out double switch operation with left atrial augumentation by in situ autologous pericardium. The spatial position of the heart was mesocardia. The systemic right ventricular end-diastolic volume was 100% of normal, and the pulmonic left ventricular end-diastolic volume was 105% of normal. Atrioventricular valvular regurgitation was not found. Postoperative course was uneventful. On the 28th postoperative day,she discharged from hospital. The disadvantage of double switch operation is difficulty of atrial switch procedure, because most patients have a small atrium due to dextrocardia or mesocardia. For the purpose of atrial augumentation without artificial materials, our modified Senning procedure is useful. But longer follow-up is necessary to determine whether this technique is indeed beneficial.

[Diversion of the inferior vena cava into the left atrium after repair of atrial septal defect with partial anomalous pulmonary venous drainage].

An 11-year-old female had operative repair of atrial septal defect associated with partial anomalous pulmonary venous drainage by direct suture at 6-year-old. Postoperatively, cyanosis and nodal bradycardia were noted by physical exercise. During 5 years thereafter, the symptoms were gradually aggravated accompanying. Cardiac catheterization revealed diversion of the inferior vena cava into the left atrium. Oxygen sampling showed right to left shunt of 22% at the atrial level. At reoperation, orifice of the inferior vena cava into the right atrium became narrow 5 mm in diameter. After enlargement of the orifice, the atrial septum was created with a Gore-Tex patch to redirect the inferior vena cava to the right atrium. Post operative course was uneventful with disappearance of the cyanosis. The patient is up and well now 9 years after reoperation.

[A case report of an infundibular ventricular septal defect with severe right ventricular outflow tract obstruction due to aneurysm of the aortic sinus of valsalva].

This paper describes the case of a 46-year-old female. Upon contacting infective endocarditis at the age of 39 years, she was diagnosed with a ventricular septal defect (VSD). Because dyspnea gradually worsened, she was later hospitalized. Cardiac catheterization was performed and angiograms were taken, revealing an infundibular VSD accompanied by severe right ventricular outflow tract obstruction (RVOTO) due to aneurysm of aortic sinus of valsalva and to mild aortic regurgitation caused by prolapsing aortic valve. The operative procedure consisted of the closure of the aortic sinus fistula by continuous suture after excision of the aneurysmal sac and patch closure of the VSD without treatment of the prolapsing aortic valve. After the operation, RVOTO improved and aortic regurgitation disappeared. The patient was discharged and has since been well.

[A case of primary tissue failure in aortic bioprosthesis due to pannus formation].

A 22-year-old man, who had received aortic valve replacement with a 21 mm of Carpentier-Edward S.A.V Bioprosthesis for aortic regurgitation at 19 years of age, was readmitted to our hospital because of a new systolic murmur and his chest roentgenogram showed remarkable cardiomegaly. Cardiac catheterization showed a 55 mmHg pressure gradient across the bioprosthesis. Under the diagnosis of primary tissue failure, reoperation was undergone. At reoperation, the sewing ring and leaflets of the prosthesis were covered with pannus, which adhered to leaflets, and the thickness of these leaflets was seen. It was thought that these changes caused aortic stenosis. Primary tissue failure due to pannus formation has been reported a little, but if bioprosthesis is implanted in the supra-annular position, pannus formation may occur because cusps of bioprosthesis are attached to the host's annulus.

[Relationship between postoperative prognosis and preoperative immunological factors in aortitis syndrome].

Valve detachment or pseudoaneurysm is a well known complication of surgical treatment for cardiovascular disease due to aortitis syndrome. Although the preoperative management of inflammation by steroid therapy is very important, occasionally, the operation in active phase might be recommended because of progressive heart failure or impending rupture of aortic aneurysm. The pathology of aortitis syndrome is related to immunological abnormality, but there has been little information concerning the immunological factors. In order to evaluate the relationship between immunological factors and surgical results in patients with aortitis syndrome, immunological examination was obtained before surgery in 12 patients. Cardiovascular lesions due to aortitis syndrome were aortic regurgitation in 6 patients, annuloaortic ectasia in 1 patient, aortic arch aneurysm in 1 patient, mitral regurgitation in 2 patients, and coronary artery disease in 2 patients. Hospital mortality including initial operative death was not found. However, 6 late death (50%) occurred at late time with the mean of 23.8 months because of severe complications such as valve detachement or pseudoaneurysm after operation. In a comparison of the preoperative immunological values between survival group and late death group, immunoglobulins such as IgG, IgA, C3 and C4 were significantly higher in late death group. According to the recurrence of inflammation, the patients were divided into three groups. Group A included 3 patients who remains in active phase after initial operation in active phase. Group B included 3 patients who changed to active phase after initial operation in inactive phase. Group C included 6 patients who remains in inactive phase after initial operation. In a comparison among 3 groups, IgG and C4 showed no significant difference. However, IgA and C3 of group C were significantly lowest among three groups. This outcome is considered to be related to existence of latent inflammation. At operation, insertion of rigid prosthesis to fragile position due to latent inflammation may stimulate immunological reactions. We conclude that the preoperative values of the immunological factors, especially IgA and C3, are reliable predictors in postoperative prognosis.

[Successful valvuloplasty for isolated tricuspid regurgitation due to traumatic ruptured papillary muscle].

A 44-year-old man suffered from an traffic accident on May 27, 1994. He was transferred to a hospital because of emergent operation for a laceration of liver, right-sided hemothorax and pneumothorax. After surgical treatment for these lesions, he was doing well. However, systolic murmur appeared from August, 1994. By echocardiography and cardiac catheterization, he was diagnosed of isolated tricuspid regurgitation due to traumatic ruptured papillary muscle. Because right heart failure was progressive, an operation was recommended. At operation, annular dilatation of tricuspid valve and ruptured papillary muscle of anterior leaflet were found. And the ruptured end of right ventricular aspect was recognized. Therefore, we performed tricuspid valvuloplasty and annuloplasty. Postoperative course was uneventful. And residual regurgitation was not detected by right ventriculography. Especially, in patients with tricuspid regurgitation due to ruptured papillary muscle, symptoms usually begin soon after trauma. Therefore, an operation should be recommended promptly in the presence of right heart failure not relieved by medical treatment. And an earlier operation could increase the feasibility of tricuspid valvuloplaty, and the possibility of maintaining sinus rhythm.

[A case of coronary artery bypass grafting using arterial grafts in a patient with Buerger's disease].

A 50-year-old male with Buerger's disease underwent coronary artery bypass grafting (CABG) using left and right internal thoracic arteries (LITA and RITA). In our case, his saphenous veins could not be used because of migrating thrombophlebitis, and we could not use right gastroepiproic artery because he had undergone gastrectomy for gastroduodenal ulcer. He underwent CABG with LITA-left anterior descending artery and free RITA-right coronary artery. Postoperative coronary angiogram showed good patency of both grafts, and his postoperative course has been uneventful for 42 months. To our knowledge, there is no report of CABG in a patient with Buerger's disease, but we think the use of arterial grafts is useful in such cases.

[Re-replacement of Starr-Edwards mitral valve (model 6320) for prosthetic valve endocarditis 22 years after replacement].

The patient was a 43-year-old woman who had undergone mitral valve replacement with Starr-Edwards ball valve (model 6320) 22 years ago. Perivalvular mitral leakage due to prosthetic valve endocarditis and tricuspid regurgitation were found. She underwent re-replacement of the mitral valve. The operative findings revealed almost intact valvular function of the ball valve. As far as we know, 22 years is the longest follow-up for the Starr-Edwards ball valve which has maintained normal function.

[Intermediate to late results of aortic or mitral valvuloplasty by rasping procedure].

We have proposed Rasping procedure as one of the methods of aortic valvuloplasty (A-Rasping) and defined as debridement of the thickened surface of the rheumato-degenerative aortic valve using an electric rasper since 1986. Furthermore, we have extended this technique to mitral valvuloplasty (M-Rasping). The purpose of this study is to evaluate intermediate to late results of valvuloplasty by Rasping procedure. From 1986 to 1994, this method was carried out on 14 patients with mild-to-moderate aortic valve disease in severe mitral valve disease or coronary artery disease, and on 6 patients with mitral stenosis. In A-Rasping group, aortic regurgitation was found in 10 patients and aortic stenosis was found in 4 patients. The degree of regurgitation, the transvalvular pressure gradient, and the pre- and postoperative cardiac function in both group were investigated chronologically by echocardiography. In this series of patients, no hospital mortally including operative death was observed. Furthermore, reoperation for repaired aortic or mital valve was not required. In A-Rasping group, 2 late deaths (14.2%) occurred at 1 year and 4 years after operation. Cause of 2 late deaths was prosthetic valve endocarditis in mitral position. In A-Rasping group, at 1 year after operation, regurgitation was reduced to degree I or less in all patients. However, at the 3rd postoperative year, regurgitation increased to degree II in 2 patients. As compared with the preoperative values, the transvalvular pressure gradient significantly decreased in 4 patients (29.5 +/- 7.6 mmHg vs 12.5 +/- 5.0 mmHg, p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

[Modified David's operation for aortic regurgitation associated with annulo-aortic ectasia].

Composite graft replacement of the ascending aorta and aortic valve has been indicated for aortic regurgitation (AR) associated with annulo aortic ectasia (AAE). 29-year-old female with AR due to AAE associated with Marfan's syndrome underwent the replacement of ascending aorta by sparing an aortic valve with good result. Under cardiopulmonary bypass, the proximal ascending aorta was dissected circumferentially down to the ventriculo-aortic junction. The aneurysmal aorta and the all three sinuses of valsalva were excised, leaving 7 mm of arterial wall attached to the aortic valve and small buttons of arterial wall around the both left and right coronary arteries. The aortic valve was reimplanted inside a 28 mm Dacron graft which was calculated by aortic valve leaflet height. The left coronary artery was reimplanted to the graft by interposing a short 10 mm Dacron graft between coronary ostia and graft and the right coronary artery was anastomosed directly to the graft (Piehler's procedure). We called these procedure "modified David's operation". The patient has survived the operative procedure without any complications. Postoperative aortogram showed a competent aortic valve and the peak systolic pressure gradient across the aortic valve was 20 mmHg. We believe this new procedure preserving the native aortic valve is useful for preventing from some complications associated with artificial heart valves.

[Successful surgical treatment of active infective endocarditis associated with perforation of aortic wall].

A 69-year-old man was transferred to our hospital because of severe progressive heart failure, eyeground hemorrhage due to embolism and uncontrollable inflammation. Emergent operation was suggested. Aortic valve replacement with a 23 mm Carpentier-Edwards bioprosthesis and patch closure of perforation using Dacron double velore was successfully performed. Vegetation was observed from the commissure between left and non coronary cusp to the aortic wall. Perforation (3 mm in diameter) and a moderate amount of bloody pericardial effusion were recognized. However periannular abscess was not detected. Postoperative course was uneventful and no recurrence of infection has been seen. We believe that surgical treatment for active infective endocarditis should be recommended when the bactericidal agents are ineffective and before the hemodynamics is suddenly deteriorated and the embolism occurs to the other organs.

[Free arterial graft for coronary bypass grafting].

Free arterial grafts were aggressively placed in 39 patients (1991 to 1993). There were 34 males and 5 females, and mean age was 59.9 year old. Of 85 arterial grafts, 41 were free grafts, and their materials included left and right internal thoracic artery (LITA, RITA) and right gastroepiploic artery (GEA). There were one free LITA-left anterior descending coronary artery (LAD), seven free RITA-LAD, three free RITA-diagonal branch (Dx), 14 free RITA-left circumflex coronary artery (LCX), 10 free RITA-right coronary artery (RCA), two sequential RITA-Dx-LCX, one free GEA-Dx, two free GEA-LCX, and one free GEA-RCA bypass. Of 41 free arterial grafts, 38 were in the aorta-coronary position, and the proximal anastomosis was constructed first under single aortic cross-clamping to get the larger anastomotic sites for both at the proximal and distal ends of the arterial graft. The proximal sites of the remaining 3 arterial grafts were placed to concomitantly utilized saphenous vein grafts in two patients and RCA in one patient because of their shortness. Perioperative complications included no exploration for bleeding, myocardial infarction in one (2.6%), intra-aortic balloon pumping in three (7.7%), and wound complications in two (5.1%). 28 cases (72%) were completely revascularized with only arterial grafts. Of 41 free arterial grafts studied within one month after operation, all grafts were patent. All patients were free from angina after a 27 months mean follow-up. We believe that the proximal anastomosis technique for free arterial graft we used could be acceptable alternative for many surgeons. These excellent results justify wider use of free arterial grafts.

[Quadruple coronary artery bypass grafting with arterial grafts--application of internal thoracic artery and right gastroepiploic artery].

Arterial graft has been widely applied for coronary artery bypass because of its excellent long-term patency. However, when more than four coronary bypass graftings should be carried out using internal thoracic arteries (ITAs) and right gastroepiploic artery (GEA), some surgical techniques must be devised. We performed quadruple coronary artery bypass grafting using three arterial grafts; bilateral ITAs and GEA, and obtained good results. We used free RITA graft for sequential grafting in one case. In another case, GEA was divided into two segments and used as two free grafts. From our experience, we believe it is possible to perform multiple coronary revascularization using only arterial grafts with one median skin incision.

[A case report of disappearance of free internal thoracic artery graft stenosis].

We have experienced an interesting case of spontaneous disappearance of stenosis of the injured free internal thoracic artery graft six months after coronary artery bypass grafting. A 61-year-old male underwent coronary bypass surgery with in situ left internal thoracic artery (LITA)-left anterior descending (LAD) and free right internal thoracic artery (RITA)-first diagonal branch (D1) bypass at our hospital. Postoperative angiogram showed the stenosis of the distal portion of the free RITA. We judged it was the injury by the electrocautery when dissecting the RITA. He was admitted to our hospital and received repeat angiography because of recurrence of angina six months after surgery. Repeat angiogram showed the good patency of LITA and complete disappearance of the stenosis of the free RITA. We consider that this case proved the free ITA can be a living graft.

[The efficacy of both antegrade and retrograde cardioplegia in coronary artery bypass surgery].

We evaluated the efficacy of the cardioplegic myocardial protection by combining antegrade cardioplegic induction via the aortic root with retrograde cardioplegia via the coronary sinus in patients who had LAD stenosis or occlusion with collateral circulation. In study I, forty-six patients were divided into two groups: antegrade group (group A; 32 cases), which were perfused by only antegrade fashion via the aortic root, and bi-directional group (group B; 14 cases), which were perfused by combining antegrade with retrograde fashion. In study II, patients were divided into four groups: 32 cases in group A were divide into three subgroups by the direction of the collateral circulation to LAD in preoperative coronary angiograms: group I (antegrade collateral circulation; 18 cases), group II (retrograde collateral circulation; 7 cases), group III (99% stenosis with delayed filling; 7 cases) and group B was as group IV. Myocardial injury was assessed with the use of enzyme indexes (total CPK, CPK-MB, %MB, peak CPK, peak CPK-MB and peak % MB) in study I and study II. There was no significant difference between the two groups in study I and the four groups in study II in terms of patients' profile, graft materials, number of grafts, aortic cross-clamping time, total cardiopulmonary bypass time and surgical results. Total CPK level in group B was significantly lower (p < 0.05) compared with group A at the point of 12 hr and 1 day after surgery and peak CPK level was also significantly lower (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)