[Intermittent opening of a mechanical mitral valve prosthesis due to pannus formation; report of a case].

A 76-year-old woman with a history of severe mitral valve stenosis had undergone mitral valve replacement with a 27 mm St. Jude Medical (SJM) valve in 1991. Follow-up transthoracic echocardiography revealed an increase in the pressure gradient across the mitral prosthesis 16 years after the surgery. Prosthetic valve dysfunction was suspected, but transesophageal echocardiography and cineradiography failed to show mechanical valve dysfunction. Two years later, she presented with dyspnea on exertion and leg edema. Cineradiography revealed intermittent restriction of the opening of the mechanical valve leaflet approximately every 10 beats. Thus, we diagnosed intermittent prosthetic valve dysfunction and performed a reoperation. On inspection of the prosthesis, we observed semicircular pannus formation around the posterior leaflet in the ventricular side. It was considered that the pannus tissue had interfered with 1 leaflet opening of the mitral valve prosthesis, resulting in intermittent valve dysfunction. We replaced the prosthesis with a new 25 mm SJM valve. The patient was discharged after confirmation of normal prosthetic function.

[Graft harvesting in coronary artery bypass grafting].

The technique of graft harvesting during coronary artery bypass grafting (CABG) consists of 2 main components: the vessel exposure at an adequate layer and the division of branches. Recently, the ultrasonic scalpel has been used for skeletonization of arterial grafts. A hook-type tip is used for the internal thoracic artery and the radial artery graft, while a shear type tip is used for the right gastroepiploic artery graft. The ultrasonic scalpel is useful both for graft vessel exposure and for the division of branches. The cavitation phenomenon is useful for the vessel exposure, while ultrasonic protein coagulation is useful for the division of branches. In endoscopic saphenous vein graft harvesting, electrocautery scissors are used for the division of branches. Avoiding thermal damage to the graft vessel is important in the use of either device. In any graft harvesting, direct contact with the main trunk should be avoided as much as possible to prevent damage. A thorough knowledge of the anatomy of the graft vessel and the surrounding organs is necessary for graft harvesting and to avoid complications. Furthermore, an understanding of characteristics of the harvesting devices is also important.

[Long-term evaluation of aortic root replacement using Svensson technique with multislice computed tomography].

The Svensson technique of aortic root composite valve graft replacement, which involves reimplantation of the left coronary ostium with a long interposed graft wrapping behind the composite graft, is technically simple and advantageous. However, surgeons must be concerned about complications regarding the long interposed graft in the long-term follow-up. In 32 cases with the Svensson technique, we evaluated their replaced aortic roots by multislice computed tomography (MDCT) at 4.5 +/- 3.6 years (maximum, 14.9 years) postoperatively. The mean age was 54.5 +/- 14.1 years and 22 patients were male. No patients have experienced any complications regarding the technique at the follow-up of 6.9 +/- 4.9 years (maximum, 16.4 years). No structural complications were detected by MDCT of all patients. In conclusions, the Svensson technique was demonstrated to be favorable with no technical problems in the long-term evaluations with MDCT. The Svensson technique can be considered as a justifiable technique in any aortic root replacements including complicated or redo aortic roots.

[New proximal anastomotic system in coronary artery bypass grafting].

The Heartstring proximal anastomotic system is a device designed to facilitate the creation of a clampless hand-sewn proximal anastomosis. Thirty-four patients who underwent coronary artery revascularization had 40 proximal anastomoses using the Heartstring device. There were 26 men and 8 women, with the mean age of 70 +/- 8.9 years. Thirty-one patients underwent coronary artery bypass grafting through off-pump procedures and 3 patients on-pump beating procedures. In all patients, saphenous vein grafts were anastomosed to the aorta using the Heartstring device, the median number of distal anastomoses being 2.4 +/- 0.7. Either emergent or urgent surgery was required in 14 patients (41%). Diseased aorta was found in 11 patients (32%). One patient (2.9%) died postoperatively due to ischemic necrosis of the small intestine and the colon. There was no occurrence of postoperative stroke. Of 40 saphenous vein grafts anastomosed with the Heartstring system, 39 (97.5%) were patent. The occluded saphenous vein was not considered to be device related. Our clinical experience demonstrated that the Heartstring system allow us to create clampless and reproductive hand-sewn proximal anastomosis and to decrease the incidence of neurological complication.

[Aortic root replacement in Marfan syndrome with hemophilia A].

A 34-year-old man with Marfan syndrome was admitted to our hospital for surgical treatment of aortic regurgitation due to annuloaortic ectasia. He had no history of bleeding complications. Preoperative investigation revealed a slight prolongation of an activated partial thromboplastin time, which went unnoticed. He underwent aortic root replacement with a composite valve graft. During the operation, he had excessive bleeding due to coagulopathy after the termination of cardiopulmonary bypass, and needed a large amount of blood transfusion to obtain hemostasis. Before his discharge from our hospital, he was diagnosed as mild hemophilia A because of the decline in his factor VII level. To our knowledge, there has been no published case of cardiac operations in Marfan syndrome with hemophilia A.

[Successful off-pump coronary artery bypass for a patient with aplastic anemia].

We report a 61-year-old man with aplastic anemia who underwent successful off-pump coronary artery bypass (OPCAB) after being admitted for angina pectoris. Coronary angiography showed severe stenosis of the left main coronary artery. Preoperative WBC was 2,200/microl, neutrophil 704/microl, Hb 8.1g/dl, and PLT 16,000/microl. We conducted OPCAB on double vessels using left internal thoracic and radial artery grafts. Thirty units of platelets were transfused intraoperatively with little perioperaive hemorrhage. Because of high grade fever, we injected 150 microg granulocyte colony-stimulating factor (G-CSF) every 3 days postoperatively to prevent major infection. The combination of appropriate perioperative management and OPCAB yielded an effective result for a patient with severe hematological disorders causing pancytopenia.

[Bronchial artery embolization for treatment of mediastinal hemorrhage after pulmonary resection: report of a case].

We report a rare case of mediastinal hemorrhage after pulmonary resection. A 64-year-old woman with hypersensitivity pneumonitis was diagnosed as adenocarcinoma of the lung by bronchoscopical examination. Left lower lobectomy and mediastinal lymph node dissection were performed. Sudden chest pain and dry cough developed 14 days after the operation. Her diastolic pressure rose transiently but electrocardiogram remained normal. Chest X-ray showed widening of the mediastinum and enhanced chest computed tomography (CT) showed extravasation of the contrast media just under the bifurcation of the trachea. Multi projection volume reconstruction revealed mediastinal hemorrhage from the bronchial artery. The chest pain disappeared after a successful bronchial artery embolization and the patient discharged 21 days later. Hemorrhage after pulmonary resection is a common complication, but no previous report has described mediastinal hemorrhage occurring 2 weeks after the operation. In a similar case, bronchial artery embolization is a reliable and minimally invasive therapy for mediastinal hemorrhage.

FK778 controls acute rejection after rat liver allotransplantation showing positive interaction with FK506.

This study including prevention and rescue experiments was performed to examine the efficacy of FK778 and its interactions with FK506. In the prevention experiment, Brown-Norway rats transplanted with a 7 Lewis livers received day-course of FK778 or a combination of FK778 and FK506 treatment. For the rescue experiment, the recipients were additionally treated with FK778 from days 7 to 13. Blood chemistry and histopathological findings were used to examine the host and the graft condition. Donor-specific IgM was measured using enzyme-linked immunosorbent assays. The serum trough level of FK778 was examined by high-performance liquid chromatography. FK778 suppressed acute rejection in a dose-dependent manner. The optimal FK778 dosage was 20 mg/kg body weight (BW) d. FK778 treatment from days 7 to 13 rescued liver grafts from ongoing rejection. The combination of FK506 (0.125 mg/kg BW/d) and FK778 (20 mg/kg BW/d) maintained better graft condition than FK778 (20 mg/kg BW/d) monotherapy. In conclusion, FK778 prevents acute rejection in and rescues transplant recipients from ongoing rejection after rat liver transplantation. The optimal monotherapy dosage of FK778 was 20 mg/kg BW/d. Combination therapy with FK506 was more beneficial than FK778 monotherapy.

Mitochondrial K(ATP) channel opener prevents ischemia-reperfusion injury in rat liver.

Ischemia-reperfusion injury is responsible for the morbidity associated with liver surgery under total vascular exclusion or after liver transplantation. Recently, it has been reported that mitochondrial K(ATP) channel openers have an effect on myocardial protection via a pharmacological preconditioning action. However, it remains unclear as to whether K(ATP) channel openers can reduce ischemia-reperfusion injury in the liver. The aim of this study was to determine the effects of the mitochondrial K(ATP) channel opener, nicorandil, on ischemia-reperfusion injury in the rat liver. Male Wistar rats were subjected to 73% ischemia for 45 minutes followed by 120 minutes of reperfusion. Nicorandil (3 mg/kg) was orally administered 60 minutes before hepatic ischemia. Nicorandil significantly decreased plasma levels of alanine aminotransferase and lactate dehydrogenase by about 50% and inhibited the remarkably increased TUNEL-positive hepatocytes after reperfusion. Some mediators associated with apoptosis were analyzed by Western blotting. Cytochrome-c and caspase-3 levels in the cytosol increased after reperfusion; nicorandil inhibited the release of cytochrome-c and activation of caspase-3. The expression of Bax and Bcl-2 was significantly increased after reperfusion, being slightly inhibited by the administration of nicorandil. These results suggest that the protective effects of nicorandil against hepatic ischemia-reperfusion injury correlate with the inhibition of mitochondrial cytochrome-c release and caspase-3 activation. These findings demonstrate that nicorandil may become a therapeutic drug for ischemia reperfusion-related liver injury.

Bilateral video-assisted thoracoscopic surgery in the supine position for primary spontaneous pneumothorax.

On the basis of the bilateral nature of bullous lesions of the lung, the authors have performed single-stage bilateral video-assisted thoracoscopic surgery (VATS) in the supine position for primary spontaneous pneumothorax in five patients since October 1999. All five patients were males with a mean age of 23 years (range 19 to 29 years). The presenting pneumothorax was ipsilateral (right-sided) in four patients and simultaneous bilateral in the one remaining patient. Apart from the one case of simultaneous bilateral spontaneous pneumothorax (SBSP), all patients had a history of at least one pneumothorax episode requiring tube thoracotomy. Bilateral bullae were confirmed in all patients on preoperative chest computed tomography (CT). Bilateral bullectomy was performed by endo-stapler with no difficulties. Mean operating time was 111 minutes (range 85 to 140 minutes). All patients were returned to the surgical ward in good condition from the operating room immediately after extubation. No complications were observed, and duration of postoperative hospital stay was two to four days. All patients were alive without recurrence of pneumothorax after a mean follow-up period of 25 months (range, 9 to 43 months). Single-stage bilateral VATS in the supine position has shown itself to be an excellent approach for the treatment of bilateral bullous lesions, combining both efficacy and low morbidity.

Placement of the Dumon stent using a flexible bronchofiberscope via tracheostomy.

In this paper, we report on a new technique of Dumon stent placement using a flexible bronchofiberscope. This procedure was used to insert Dumon stents in two bronchial obstruction and two bronchofistula cases. The stenting technique described here can be used through either a tracheostoma or the oral cavity; it presents a very straightforward and safe procedure that does not require the use of a rigid bronchoscope.

[Redo coronary artery bypass operation under beating heart via the left thoracotomy reusing patent grafts].

We report three cases of successful redo coronary artery bypass grafting (CABG) under beating heart via left thoracotomy with recycling of patent grafts previously implanted. Case 1 and 2: Anginal attack relapsed due to occlusion of the proximal portions of saphenous vein grafts (SVG) that had been sequentially anastomosed to the left coronary artery branches. In each case, the distal portion of the SVG was patent and functioned as coronary-coronary bypass. The left internal thoracic artery graft (ITAG) anastomosed to the left anterior descending coronary artery (LAD) was patent. Each patient underwent off-pump CABG through a left posterolateral thoracotomy. CABG was performed with the radial artery to the circumflex coronary artery (case 1) or the circumflex coronary artery and previous SVG (case 2). The proximal ends of radial artery grafts were anastomosed to the descending aorta. Case 3: Simultaneous reoperative CABG and the operation for the pseudoaneurysm that developed after the abdominal aortic graft replacement were performed. Bypass grafting between ITAG and LAD was performed with SVG via a left anterolateral thoracotomy because of severe anastomotic stricture of ITAG-LAD. The postoperative courses was uneventful for all patients.

[In situ graft replacement for the thoracoabdominal aortic aneurysm with abscess around the aorta; report of a case].

A 58-year-old woman who complained of epigastralgia, back pain and pyrexia was admitted for further examination. A computed tomography (CT) scan revealed an abnormal mass between the descending aorta and esophagus. Exploratory thoracotomy was performed and brown purulent fluid was drained from the mass. Postoperatively, the white blood cell count normalized and the patient become afebrile. Eleven days postoperatively, circa 500 ml of blood discharged from a chest drain tube. A CT scan demonstrated enlargement of the thoracoabdominal aorta, necessitating an emergency operation. A pseudoaneurysm was found in the thoracoabdominal aorta, with inflammation in the aortic wall. On opening the aneurysmal sac, the intima of the aorta was found to have a partial defect. In situ graft replacement of the thoracoabdominal aorta and reconstruction of the intercostal artery were performed. Finally, a pedicled omental flap was used to cover the artificial graft. Two years postoperatively, the patient is doing well with no recurrence of infection.

Gallium-67 scintigraphy in the diagnosis and management of chronic sarcoid myopathy.

The authors describe a patient with chronic sarcoid myopathy. Except for the presence of left posterior synechia, no other organ involvement was observed. Gallium-67 ((67)Ga) scintigraphy showed many intense nodular uptake areas in both the upper and lower extremities. Treatment with oral prednisolone 30 mg/day resulted in a marked improvement on (67)Ga scintigraphy. This case suggests that (67)Ga scintigraphy is useful for the differential diagnosis of systemic myopathies and also for monitoring the effect of glucocorticoid treatment.

[Aortic root replacement using cryopreserved allograft for an infected aorta patient associated with mediastinitis].

We herein report a case of aortic root replacement using cryopreserved allograft. A 52-year-old man received aortic valve replacement using a mechanical prosthesis for aortic stenosis. He was complicated by postoperative methicillin-resistant staphylococcus aureus mediastinitis involving the ascending aorta. Surgical therapy including debridement, omental transposition, patch closure using pericardium had not achieved satisfied result. Aortic root replacement using cryopreserved allograft was mandatory for refractory aortic infection. He had an uneventful postoperative course. The cryopreserved allograft was effective for a patient with refractory aortic root infection due to postoperative mediastinitis.

[Long-term results of aortic arch replacement using combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion; comparison of result for atherosclerotic aneurysm and aortic dissection].

Between 1992 and 2001, 73 patients with aortic arch lesion underwent surgical treatment. The aneurysm was characterized by atherosclerosis in 54 patients (TAA) and by aortic dissection in 19 patients (DAA). All patients received graft replacement under combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion. The hospital mortality rate for all patients was 15.6%. The follow-up period of 61 survival patients ranged from 2 to 90 months (mean 33.2 months). The actuarial survival rate was 93.2%, 83.5%, and 79.7% at 1, 3, and 5 years, respectively. No significant difference was noted between TAA and DAA in the actuarial survival rate. The freedom from vascular complication was 97.9%, 95.8%, and 95.8% at 1, 3, and 5 years, respectively. The rate was significant higher in the patients of DAA than in those of TAA (TAA: 100%, 100%, and 100%, DAA: 90.9%, 81.8%, and 81.8%). The freedom from cardiac complication was 96.4%, 89.7%, and 84.1% at 1, 3, and 5 years, respectively. There was no significant difference between TAA and DAA. The freedom from cerebrovascular complication was 100%, 97.6%, and 83.4% at 1, 3, and 5 years, respectively. No significant difference was noted between TAA and DAA. The late result of surgical treatment for the aortic arch using combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion was satisfied. The long-term survival rate was higher in TAA patient than in DAA one. The possibility remained that fatal vascular complication affected the long-term survival rate.

Metastatic synovial sarcoma of the left ventricle.

A metastatic synovial sarcoma of the left ventricle is described. A 26-year-old Japanese woman underwent resection of a synovial sarcoma of the right thigh 8 years prior to admission, which was followed by multiple surgical procedures for pulmonary metastasectomy. Echocardiography demonstrated obstruction of the outflow tract of the left ventricle caused by a metastatic tumor, which was surgically resected on the day of admission. The histologic characteristics of the cardiac tumor were identical to those of the pulmonary metastases. Additional cardiac metastasectomy was performed 9 months later. She complained of dyspnea on exertion 8 months after the second cardiac metastasectomy due to recurrence in the heart. Radiotherapy with LINAC (a total dose: 50 Gy) diminished the size of the tumor temporarily. The patient died 20 months after the initial cardiac metastasectomy.

Slow induction of milrinone after coronary artery bypass grafting.

The aim of this study was to evaluate the hemodynamic effects of a slow induction of milrinone after open heart surgery. Twenty patients who underwent elective coronary artery bypass grafting were randomized into two groups, with 10 patients receiving a continuous infusion of milrinone (5 microg/kg/min) (group M), and 10 patients undergoing treatment without milrinone (group C). This is a preliminary study for evaluating the efficacy of a slow induction of milrinone, so patients in low cardiac output state were excluded. A continuous infusion without an initial loading dose was initiated in the intensive care unit. Hemodynamic parameters and the concentration of milrinone were measured 90 minutes and 3 hours after initiation of the milrinone infusion. A significant decrease in arterial pressure occurred at 3 hours in group M, and both the systemic vascular resistant indices decreased significantly (p<0.05) at 90 minutes. No significant changes occurred in group C. Cardiac index and heart rate increased significantly (p<0.05) in group M, but were unchanged in group C. No significant change in double product was observed in either group. Hypotension (systolic blood pressure less than 100 mmHg) or arrhythmia did not occur in group M. The concentration of milrinone at 90 minutes and 3 hours was 97+/-22 and 124+/-27 ng/ml, respectively. A slow induction of milrinone is safe and effective in patients following cardiac surgery.

Aortic valve replacement in a patient with factor XII deficiency: case report.

Congenital factor XII deficiency is a rare condition. We report a case of aortic valve replacement (AVR) in a 63-year-old man with factor XII deficiency. On admission, the patient's activated partial thromboplastin time (aPTT) was prolonged (271 s), and activated clotting time was 500 s. His factor XII level was <3%. The Sonoclot signature showed an abnormal pattern. AVR with a prosthetic valve (St. Jude Medical) was performed safely after the normalization of aPTT and the Sonoclot signature by frozen plasma transfusion. The perioperative management in patients with factor XII deficiency is discussed.