Acute occlusion of a simple aortic coarctation presenting as abdominal angina.

A 9-year-old boy whose past history was remarkable for a heart murmur was diagnosed with abdominal angina due to acute occlusion of a simple coarctation of the aorta. Using a single cross-clamp, we accomplished an end-to-end anastomosis after resection of the coarctation. Paradoxical hypertension and abdominal angina were treated successfully with a continuous intravenous infusion of lipo-PGE-1 and nicardipine. Three years after his operation, the patient's blood pressure was normal, with no stenosis at the site of the anastmosis.

[Long-term results of atriopulmonary fontan connection for complex cardiac anomalies].

To evaluate the long-term results of atriopulmonary Fontan connection, we reviewed the outcome of 20 consecutive patients (single ventricle 8, double outlet right ventricle 8, tricuspid atresia 3, mitral atresia 1; mean age, 13 +/- 11) who underwent this operation between 1981 and 1997 at our institution. Glenn shunt preceded Fontan operation in 1 patient. Four patients had a concomitant bidirectional Glenn anastomosis at the time of the Fontan operation. Follow-up was 100% complete, and total cumulative follow-up of all patients was 241 patient-years (maximum, 20 years). Three hospital deaths and 5 late deaths were observed, resulting in 58 +/- 11% of cumulative survival at 20 years after the operation. Sudden death probably due to arrhythmias was the major cause of the late death, and occurred in 3 patients. Reoperation was required in 5 patients (2%/patient-year) at 1 to 17 years postoperatively. Re-closure of an atrioventricular valve was performed for failure of the valve closure in 3 patients at 1 to 6 years postoperatively. Reconstruction of the stenotic atriopulmonary connection (APC) was concomitantly required in 2 of the 3 patients. Pacemaker implantation was required for bradycardia with atrial fibrillation in 1 patient at 17 years. One patient with atrial flutter developed intraright atrial thrombosis at 12 years after the initial Fontan operation, and this patient underwent conversion to extracardiac conduit cavopulmonary connection with right atrial maze procedure. Atrial tachyarrhythmias are most common complications, and occurred in 12 patients (5.0%/patient-year), resulting in 40 +/- 13% of the cumulative free rate at 15 years after the operation. Thus, failure of the atrioventricular valve closure and stenosis of APC were important early to intermediate complications after the atriopulmonary Fontan connection. On the other hand, atrial tachyarrhythmias were inevitable, and were most common late complications leading to intra-right atrial thrombosis, which was successfully resolved by conversion of the conventional atriopulmonary Fontan anastomosis to extracardiac conduit cavopulmonary connection.

Redo operation for thoracoaortic aneurysm after entire aortic replacement.

Resection of a saccular aneurysm that developed in a remnant of aorta in a patient with Marfan's syndrome, who previously underwent aortic aneurysmectomy, is described. The intercostal arteries were reconstructed end-to-end using small-caliber interposition grafts to the aortic prosthesis. Preoperative magnetic resonance angiography identified the artery of Adamkiewicz and facilitated its preservation.

[The validity and problems of a new staging system for lung cancer from the point of view of surgical results].

The validity and problems of the new staging system for resected lung cancer were assessed. In the new staging system for primary lung cancer, stage I is divided into two groups (A and B) on the basis of the tumor diameter. The boundary is 30 mm in maximum diameter of the tumor. On the other hand, intrapulmonary satellite nodules in the resected lung (PM1) are considered as T4. This means that a patient with PM1 is classified as stage IIIB or IV. The five-year cumulative survival rates of 191 consecutive patients of T1 or T2N0M0 who had undergone complete lung resection were calculated. The patients were divided two groups on the basis of the boundaries of the tumor diameter, such as 15, 20, 25, 30 and 40 mm (The tumor diameter in group A is the boundary and less than boundary and the diameter in group B is more than the boundary), and the cumulative survival rates of the two groups were compared. The 5-year cumulative survival rate (Kaplan-Meier survival rate) of each group and the p-value (logrank test) were 85.0%, and 0.463 in the case of the boundary of 15 mm; 84.8%, 79.9%, and 0.374 in the case of 20 mm, 82.3%, 80.0%, and 0.553 in the case of 25 mm, 79.5, 83.5, 0.524 in the case of 30 mm and 81.0%, 82.2%, and 0.783 in the case of 40 mm. In all cases, there were no significant differences between the rates in the two groups. On the other hand, 15 cases of T4N0M0 lung cancer included 12 cases of pm1, 2 cases of p3 and 1 case of d2. The five-year cumulative survival rate for T4N0M0 patients with pm1 was 71.1%, which was similar to the rate for stage I or II patients, while the two T4N0M0 patients with p3 died of recurrences of lung cancer at 10 and 13 months after the operation, and the T4N0M0 patient with d2 died of local recurrence of lung cancer 60 months postoperatively. We concluded that the sub-classification of stage I on the basis of the boundary of tumor diameter was meaningless, if the boundary was between 15 and 40 mm and that N0M0 patients with PM1 should be classified as stage II or less, or as 1 grade up of T status.

The elephant trunk technique for type A dissection.

A modified elephant trunk technique that was used to treat acute type A dissection is described. This technique prevents leaks at the distal anastomosis and facilitates surgery on the aneurysmatic downstream aorta following total arch replacement. In addition, it allows closure of the primary intimal tear in patients with DeBakey type III retrograde dissection.

Coronary ostial aneurysms after composite graft replacement.

Coronary ostial aneurysms after composite graft replacement of the ascending aorta and aortic valve is a rare complication. We report two patients with Marfan syndrome who developed coronary ostial aneurysms at the sites of the coronary anastomosis, presumably because of oversized windows made in the graft. They were successfully treated by redo composite graft replacement. To prevent this complication, it is important to consider that the hole made in the tube graft should not be larger than the diameter of the respective coronary ostium to avoid exposure of the diseased aortic wall to the circulating blood as much as possible, and that the suture used to anastomose the coronary buttons should pass through the rim of the ostium rather than through the aortic wall surrounding it.

[Removal of the left atrial myxoma combined with coronary artery bypass grafting in an elderly patient].

The case of simultaneous coronary artery bypass grafting with resection of the leat atrial myxoma is rarely reported. We surgically treated a 81-year-old woman who had been diagnosed as left atrial myxoma and unstable angina. At surgery we performed coronary artery bypass grafting prior to resection left atrial myxoma, because we thought it is the most important to protect myocardium by antegrade cardioplegia in the consequence of CABG. Postoperative course was excellent and uneventful. The patient is doing well now.

[A case report of aortic valve replacement and ascending + hemi aortic arch replacement for congenital bicuspid aortic stenosis with poststenotic dilatation of ascending aorta].

The patient of 21-year-old female, who had undergone VSD closures at the age 5 and had been pointed out to have aortic valve stenosis at that time, was admitted to our hospital with complaints of palpitation and easy fatigability. Pressure gradient of 140 mmHg between left ventricle and ascending aorta, and poststenotic dilatation of max 55 mm in diameter from ascending aorta to hemi aortic arch was recognized by cardiac catheterization and aortogram. For fear of aortic dissection in late phase caused by dilatation of ascending aorta left over, graft replacement from ascending aorta to hemi aortic arch was carried out simultaneously adding to aortic valve replacement (AVR). We are of the opinion that not only AVR but also simultaneous graft replacement should be performed actively on the case with dilatation of ascending aorta of over 55 mm in diameter in order to prevent aortic dissection.

Right parasternal minithoracotomy for repair of atrial septal defect.

Various surgical approaches for repair of atrial septal defect (ASD) have recently been introduced for superior cosmetic and less invasive results. A technique for repair of isolated ASD through a small right parasternal minithoracotomy is described. In spite of the smaller incision, there is no need to use femoral cannulation or video-assisted endoscopy. This approach is simple, less invasive, and cosmetic. We believe that right parasternal minithoracotomy is a suitable alternative to a median sternotomy for ASD closure, especially in young male patients.

[A case report of coronary artery bypass grafting in a patient with Sjögren's syndrome].

There have been very few reports on coronary artery bypass grafting (CABG) during collagen disease. This paper reports a 49-year-old female suffering angina after myocardial infarction who revealed preoperatively findings such as arthralgia, thrombocytopenia and positive anti-nuclear antibody. She underwent CABG and was definitely diagnosed as Sjögren's syndrome after the surgery. The coronary artery lesion in this case was mainly attributed to coronary arteritis due to Sjögren's syndrome because she was comparatively young and no other coronary artery risk factors such as hypertension, hyperlipidemia, thickened intima or angitis had been found by aortic pathology. Moreover, anticardiolipin antibody, which is highly related to the myocardial infarction in juveniles, was positive in this case.

Colon cancer with a high serum alpha-fetoprotein level.

We report on a patient with colon cancer and a very high serum alpha-fetoprotein level. This 75-yr-old man presented with right lower quadrant abdominal pain. An abdominal CT scan as well as ultrasonography showed a tumor in the cecum. Serum alpha-fetoprotein level was extremely high (3,070 ng/ml). At laparotomy, a large mass was found in the cecum, and a right hemicolectomy was performed. Histological examination, including immunohistochemical study, showed an adenocarcinoma of the colon producing alpha-fetoprotein.