Obstruction of the St. Jude Medical valve--diagnostic and therapeutic values of cineradiography.

Between 1984, and 1992, we observed 8 patients with an obstructed St. Jude Medical (SJM) valve. Of these, 1 had an obstructed SJM valve in the aortic position, 3 in the mitral position, and 4 in the tricuspid position. Diagnosis of obstruction of the SJM valve was made by cineradiography combined with echocardiography in all 8 patients. Restriction or absence of movement of the leaflet of the SJM valve was observed by cineradiography in all of the 8 patients. Normal range of leaflet mobility of the SJM valve was measured by conventional cineradiography in 70 patients with a normal SJM valve, and the results were compared with the leaflet mobility obtained from the 8 patients with an obstructed SJM valve. In this study, leaflet function in the obstructed SJM valve was strikingly abnormal, with both opening and closing angles, and leaflet motion clearly outside the normal range. Of the 8 patients, 4 underwent urgent prosthetic valve replacements after cineradiography and echocardiography were carried out. Thrombolysis using urokinase was performed in 4 patients, and this treatment was successful in 1 patient. Efficacy of thrombolytic therapy was evaluated by repeat cineradiography. Three of the 4 patients who received thrombolysis showed no significant improvement of leaflet mobility after at least 72 hours of thrombolytic therapy, and finally required surgical correction for the obstructed SJM valve. We believe that cineradiography combined with echocardiography is the optimal method for the diagnosis of obstruction of the SJM valve, and to follow the effect of thrombolytic therapy on prosthetic valve function.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation with exercise performance in twenty patients who underwent coronary artery bypass grafting with both the gastroepiploic and internal thoracic arteries.

Postoperative exercise performance was evaluated in 20 patients who underwent complete coronary revascularization with simultaneous right gastroepiploic artery and internal thoracic artery grafts for ischemic heart disease and exhibited patency of all grafts on postoperative angiograms. Three patients received only arterial grafts, and 17 simultaneously received a saphenous vein graft. Forty five right gastroepiploic artery grafts were harvested during this study, but two were not used because of foci of severe calcification. The right gastroepiploic artery was grafted to the distal right coronary artery in 17 patients and to the distal obtuse marginal branches in three patients, accompanied by an internal thoracic artery graft to the left anterior descending artery in seventeen, to the diagonal branch in three, and to the proximal right coronary artery in one patient. A postoperative exercise test with a bicycle ergonometer was administered 6 to 12 weeks after the operation, and the results are reported after conversion into metabolic units. The preoperative exercise test resulted in 3.6 +/- 1.9 metabolic units for 18 patients tested, and the postoperative metabolic units were 7.8 +/- 1.3 for 20 patients. Left ventricular wall motion was analyzed by regional ejection fraction before and after coronary artery bypass grafting in 14 patients who received an right gastroepiploic artery graft for the right coronary system. The mean regional ejection fraction of the posterobasal or diaphragmatic wall was 28.0% or 28.2% before operation and improved to 43.1% or 43.2% after coronary artery bypass graft, respectively. The flow of right gastroepiploic artery seemed to distribute adequately to the revascularized area. Long-term results have not yet been proved; the use of simultaneous right gastroepiploic artery and internal thoracic artery grafts, however, thus produced excellent results, as seen from improvements in both left ventricular wall motion and early postoperative exercise performance.

[Coronary artery bypass grafting in a patient with Kawasaki disease].

A 3-year-girl admitted because of angina at rest. She had been diagnosed as Kawasaki disease at the age of 3 months. At that time, a coronary aneurysm was detected by echocardiogram and aspirin had started to administer. At the age of 4 months, a cardiac arrest occurred after severe heart attack because of inferior myocardial infarction. At the age of 2 years and 6 months, she started to complain of a chest pain even at rest. Coronary angiography was performed, and it showed total occlusion of RCA and LAD. However, LAD was vaguely filled by collateral flow from diagonal branch, and 201Tl scintigraphy showed myocardial viability of anteroseptal area. At operation, the size of ITA was 1.2 mm in diameter. Coronary artery bypass grafting to LAD by ITA was performed. Three weeks postoperatively, graft patency was confirmed by coronary angiography. The girl discharged with good ability of exercise. The ITA seemed to be the first choice of conduit for CABG even in a small child, and to be useful for progressive surgical treatment of Kawasaki disease.

[Morphological and functional studies on implanted arterial graft].

Early morphological and functional changes in arterial graft were studied. Autologous free graft of dog femoral artery or vein was implanted in the arterial system and the changes of endothelial cell by scanning electron microscope and prostacyclin levels were observed. In arterial graft, endothelial cell detachment after the implantation was rarely observed except the site with mechanical damage around the anastomosis. The site of cell detachment regenerated by 21 days after the implantation. The prostacyclin level was 2.5 pg/mg in venous graft or 35.9 pg/mg in arterial graft. The level in venous graft decreased after the implantation and it increased according to the cell regeneration, while the level was stable in arterial graft. The prostacyclin level of internal thoracic artery or gastroepiploic artery in clinical use was 54.5 pg/mg or 50.1 pg/mg, respectively. However the level in saphenous vein (SV) was 17.3 pg/mg and there were significant differences between the levels of arterial grafts and one of SV. Conclusively the arterial graft was superior to venous graft in early morphological and functional changes after the implantation and the superiority in early period after graft implantation may be one of the factor to contribute good graft patency in long term period.

[Study on reoperation in cardiac disease].

Between January in 1988 and September in 1990, 65 patients underwent reoperation for acquired heart disease. Previous operations were closed mitral commissurotomy in 19, open mitral commissurotomy in 19, mitral valve replacement in 22, aortic valve replacement in one, and mitral repair in 4. After median sternotomy performed by hand-operated chisel and hammer, minimized dissection of the adhesive lesion was achieved. During the sternotomy, two patients required additional right thoracotomy because of marked median sternal adhesion and major cardiovascular injury occurred in three patients. Cardioplegic solution was introduced in normograde fashion except in two patients. In two patients with previous MVR by porcine prosthesis severe calcification was found in the left atrial wall and the prosthesis was not removed in one. Postoperative complications were low cardiac output syndrome requiring intra-aortic balloon pumping in two, re-thoracotomy due to hemorrhage in one, and mild air embolism without neurological damage in two. There was one early death (1.5%) but no late death. Although perioperative complication seemed to increase in reoperation, post-reoperative results was as good as those in the primary cardiac operation and reoperation on cardiac surgery should be performed before losing the indication for operation.

Complete correction of the tetralogy of Fallot in adults using separated extracorporeal circulation to block intrathoracic collateral circulation and improve perfusion of the renal vasculature.

During the last 10 years, complete correction of the tetralogy of Fallot (TOF) has been performed on 28 adult patients using the "separated extracorporeal circulation" (separated ECC) technique developed by us. In addition to the usual ascending aortic and dual right arterial cannulations for ECC, the separated ECC also involved femoral arterial cannulation and the insertion of a catheter with two balloons via the other femoral artery. Flow via the ascending aorta and femoral artery were maintained separately during ECC. The urine output during separated ECC was significantly better than that during ordinary ECC (P < 0.01) and the operative field for intracardiac correction was clearer as a result of blocking the collateral circulation. Thus we believe separated ECC to be a superior method for total correction of TOF in adults, which may enhance the operative outcome.