[Results and problems of open heart surgery in patients seventy years of age and older].

The purpose of this study was to assess the influence of aging on the surgical results. The subjects which were 70-year or older included 13 cases of acute myocardial infarction with mechanical failure (AMI), 36 of elective aortocoronary bypass (CABG) and 33 of valvular heart disease (VHD). The control group younger than 70 included 32 cases of CABG and 32 of VHD. The complication rate of hypertension or diabetes mellitus in the older group was not significantly higher than in younger group. The characteristics of the preoperative status in the older group, however, seemed to be renal and hepatic hypofunction and anemia. The amount of intraoperative bleeding in older group was larger than in younger group. The periods of ICU stay, respiratory assist and postoperative hospitalization in older group were significantly longer than in younger group. The operative mortality rate of AMI was 61.5%, of CABG 8.3% and of VHD 12.1%. The operative mortality rate of emergent or urgent operation was 47.6% and of elective one 8.2%. The 4-year survival rate of CABG was 82% and the 6-year survival rate of VHD was 85%. Sixty four survivors (95.5%) improved to I-II of NYHA classification and of only 3 survivors (4.5%) remained in NYHA III class. The operative and long term results of elective surgery in older patients were comparable to those in younger ones. Therefore aging, itself, should not be a limiting factor in 70-year or older patients with good mental activity.

[Congenital kinking of the aortic arch associated with aortic arch aneurysm: a case report].

A surgical case of congenital kinking of the aortic arch associated with aortic arch aneurysm, which had been observed as the mediastinal tumor for 15 years, was reported. Twenty-two surgical cases of the aortic lesion, which were diagnosed pseudocoarctation or congenital kinking, have been reported in the literature. This paper focused on the pathogenesis, surgical treatment and terminology of this anomaly.

[Long-term results of operation in patients with annuloaortic ectasia].

From 1974 to 1990, 24 patients were operated on for annuloaortic ectasia. We chose Bentall's technique for 17 patients with great displacement of coronary ostium, but Cabrol's one for 6 patients since coronary displacement was not great. The hospital mortality was 8.3% (2 deaths). The late mortality has been 5/22 (22.7%). Nevertheless, all the patients employed Cabrol's technique have been free from death, events and reoperation. These results were remarkably better than those of primary isolated AVR. It is considered that poor results were caused not by the operating mode using a composite graft but by the connective tissue disorder as primary pathology of annuloaortic ectasia. We conclude that the patient with annuloaortic ectasia must be observed for a long-term after operation.

Recovery of end-stage organ dysfunction by circulatory assist.

To clarify the effectiveness of left ventricular assist on recovery of critical organ dysfunction, 18 patients with ventricular septal rupture or free wall rupture after acute myocardial infarction were retrospectively studied. Fifteen patients were managed with an intraaortic balloon pump (IABP group), and three with a left ventricular assist device (LVAD group) after surgery. In the IABP group, nine patients survived and six died. There were no significant differences between survivors and nonsurvivors with respect to age, cardiopulmonary bypass time, or preoperative renal function. In addition, there were no significant differences in the early postoperative changes in cardiac index. Larger doses of catecholamines were required in nonsurvivors than in survivors, however; blood urea nitrogen and creatinine levels were significantly higher in nonsurvivors than in survivors, and the nonsurvivors' creatinine clearance values stayed under 20 ml/min during the postoperative course, so that all nonsurvivors required renal assist. All in the LVAD group were weaned. Two patients were lost, however, because of cardiac arrythmia and massive gas embolism. Cardiac index in the LVAD was maintained at over 2.1 L/min/m2 with a minimum dose of catecholamines, regardless of poor left ventricular function, and creatinine clearance recovered to over 20 ml/min during circulatory assist. From these data, high doses of catecholamines depressed renal function after surgery. Therefore, it has been concluded that the major role of circulatory assist is to maintain more of the physiologic circulation with minimum doses of drugs.

Annulo-aortic ectasia with DeBakey type II dissecting aneurysm in Gaucher's disease.

Annulo-aortic ectasia is an extremely rare complication of Gaucher's disease. We report successful surgery in a patient with Gaucher's disease complicated by annulo-aortic ectasia and aortic dissection. Cabrol's operation was accomplished without bleeding or sternal adaptation problems.

Transesophageal echocardiographic findings of intracardiac events during cardiac assist.

Transesophageal echocardiography (TEE) is an easy, noninvasive and reproducible method for evaluation of left ventricular function, coronary flow patterns, and intracardiac blood flow patterns during cardial assist. TEE facilitated better management of the patients with LVAD and gave us the various information: (a) Observing the drawing catheter tip by TEE, it could be settled just above the mitral orifice to obtain the maximum bypass flow; in addition, dislocation of the catheter tip could be easily diagnosed. (b) The intracardiac thrombus could be clearly detected by TEE; it was removed without complications, weaning from left ventricular assist device (LVAD). (c) The left ventricular wall motion was periodically observed. The end systolic LV diameter (Ds) was decreasing and fractional shortening (%FS) was increasing as the natural heart recovery. Additionally, the preejection period (PEP) and the ejection time (ET) were measured. The ratio of PEP/ET was decreasing gradually. Ds did not alter with preload change during on-off testing unlike the other parameters. Ds seems to be the most reliable parameter for the natural heart recovery within certain amounts of bypass flow. (d) The flow velocity in the left anterior descending coronary artery could be measured by transesophageal Doppler method; it was clinically shown that counterpulsation produced a larger amount of coronary blood flow than copulsation.

[The clinical criteria for Carpentier-Edwards bioprosthesis in the mitral position].

This is a comparative study of late results of mitral valve replacement between Carpentier-Edwards (C-E) and Björk-Shiley (B-S) valve prosthesis. The purpose of this study is to clarify the clinical criteria for C-E valve. C-E valve was implanted in 202 patients. The mean follow up period was 5.8 years and the longest one was 11 years. For B-S valve, it was 132 patients, 5.3 years and 17 years, respectively. With respect to the incidence of thromboembolic episodes, in spite of no anticoagulant therapy in the C-E group, there was no statistical difference between the C-E and the B-S groups. The incidence of valve related complication in the C-E group was significantly lower than that in the B-S group 5 years postoperatively. But that in the B-S group was significantly low 10 years postoperatively. Since the over 60 years old patients in the C-E group had low incidence of primary tissue failure, over ten years durability might be secured. In conclusion, the present clinical criteria for C-E valve should be as follows: 1) the patient older than 65 years, 2) the patient with contraindication for anticoagulant therapy, 3) the woman who desires pregnancy and 4) the patient with hemorrhagic diathesis caused by cardiac cachexia, liver cirrhosis and so on.

[Late results after heart valve surgery in the elderly].

Heart valve surgery was performed in 133 patients over the age of 60 between 1976 and 1981. There were 54 men and 79 women. Their ages ranged from 60 to 74 years (mean age 64.3 years). In this study, 54 valve prostheses (15 porcine and 39 mechanical) in the aortic position, 79 prostheses (69 porcine and 10 mechanical) in the mitral position and 3 prostheses (3 porcine) in the tricuspid position were implanted in 121 patients. Fifteen patients (11.3%) died in the hospital. The hospital mortality was high in the cases of MVR (14.6%), MVR + TAP (12.5%) and emergency (50%). The mean follow-up was 37.2 months (range 4 to 129 months, total 367.3 patient-years). There were 10 late deaths (8.5%). Actuarial survival for hospital survivors at 5 years was 89.2 per cent. At follow-up, 95.8% of the surviving patients were in New York Heart Association functional class I or II. Valve-related complications were thromboembolism (2.0% pt/year), periprosthetic leak (1.7% pt/year), primary tissue failure (0.5% pt/year) and thrombosed valve (0.3% pt/year). Anticoagulant-related hemorrhage necessitating hospitalization occurred in 2 patients (1.0% pt/year). The freedom from all events at 5 years was 72.8 per cent. This study suggests that heart valve surgery in the elderly can be performed with an acceptable mortality. Advanced age alone should not be a contraindication to surgical management.