[A reconstruction of the left ventricle for post infarction left ventricular aneurysm complicated by ventricular septal perforation--a case report].

A 68-year-old male with post myocardial infarction left ventricular aneurysm (LVA) complicated by ventricular septal perforation (VSP) was treated surgically. At first, he was admitted with acute myocardial infarction by a physician. Coronary angiography (CAG) revealed a total occlusion of the left anterior descending coronary artery. It was improved to 99% of stenosis by PTCR. Echo cardiography revealed the VSP. However, the patient was approached conservatively because of complications of severe pneuminitis and acute hepatitis. Cardiac catheterization was performed three months after admission. The data on the catheterization are as follows: Left ventricular (LV) wall dyskinesis is presented at segment 1-5. Global ejection fraction (EF) = 26%, Corrected EF = 40%, LVEDP = 36 mmHg, Qp/Qs = 1.8. Elective surgery was then performed with IABP, LVA was resected 90 x 50 mm in size under ventricular fibrillation. VSP, which was 9 mm in size, was closed directly with Teflon felt strips. LV plication was then made with 3.0 polypropylene under cardiac arrest. Reconstruction of the LV was then performed with a double patch, of which a cow pericardium was laid on top of a Gore-Tex patch. Post operative cardiac function was improved remarkably. We consider this procedure excellent because of the avoidance of thrombus and the maintenance of the LV form.

[A correlation between atrial natriuretic peptide, brain natriuretic peptide, and perioperative cardiac and renal functions in open heart surgery].

Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) are homeostatic hormones secreted from the human heart which protect both cardiac and the renal function. It is well known that these hormones increase in patients along with increases in the severity of congestive heart failure or acute myocardial infarction. However, as yet there are no reports in the literature on changes of the secreted level of ANP or BNP in surgical patients undergoing cardiopulmonary bypass (CPB). We evaluated the relationship between ANP, BNP, and perioperative cardiac and renal functions in patients with heart failure caused by CPB. We selected 45 patients of elective open heart surgery. We measured plasma level of ANP in all 45 cases, and BNP in 18 cases at preoperation, postoperation, and postoperatively three days after, respectively. At the same time, the cardiac index (CI) was measured. These cases were divided into the following groups. Group A1 (n = 23): cases in which the preoperative ANP was less than 40 pg/ ml. Group A2 (n = 22): cases in which the preoperative ANP was more than 40. Group B1 (n = 8): cases in which the preoperative BNP is increased to the level of 5 times as mach as the normal level. Group B2 (n = 8): cases in which the preoperative BNP is increased to the level of 5 times as much as the normal level. Group B2 (n = 10): cases in which the preoperative BNP was more than that of 10 times as mach as normal level. We then carried out a comparative study of the perioperative cardiac and renal functions in group A1 and A2, and group B1 and B2, respectively. In the terms of preoperative cardiac and renal function, there were no significant differences between groups A1 and A2, and there were no significant differences in urinary volume during CPB or post operative CI. However, the urinary volume during CPB of group B1 was significantly more than that of B2. Furthermore, the incidence of postoperative CI in group B1. Furthermore, the incidence of postoperative CI in group B1 was significantly higher than in B2. The preoperative and post operative third day BNP level had significant negative correlations with postoperative CI and postoperative third day CI, respectively (r = -0.641, -0.514, p = 0.008, 0.012). The postoperative ANP and BNP levels tend to a mean level roughly similar to one another because of the easing of cardiac stress by surgery and postoperative management. According to these results and several instances in the literature, a preoperative high BNP is considered to suggest a potential perioperative risk for cardiac and renal function. We conclude that determination of the plasma BNP level can be helpful for decisions related to CPB flow and measures taken to enhance cardiac and renal protection during surgery, and therefore is a useful reference for perioperative management.

Bilateral common iliac artery aneurysms secondary to fibromuscular dysplasia accompanied with a coronary aneurysm. A case report.

Fibromuscular dysplasia (FMD) is found in various arteries but the common iliac arteries and the coronary arteries are seldom involved. A 49-year-old woman was referred to our hospital with a pulsatile mass in her right lower quadrant. She had subdural hemorrhage in a postpartum state at the age of 27. After admission angiography diagnosed the bilateral iliac artery aneurysms and coronary angiography revealed a coronary artery aneurysm, the size of which was 12 mm x 19 mm in the region of the left main trunk. The bilateral iliac artery aneurysms were resected and Y-shaped vascular prosthesis was replaced. Microscopic sections of the aneurysm showed remarkable decrease of elastic fibers and thinning of the media, but no increase occurred in the smooth muscle. Histopathological diagnosis was FMD (periarterial fibroplasia). To our knowledge, no patient with a iliac arterial aneurysm caused by FMD has been reported and only a few cases with coronary arterial FMD have been described. This is the first report of iliac arterial aneurysm due to FMD. Since this case has multiple aneurysms, a long-term follow-up is definitely required, especially focusing on the coronary aneurysm.

A family with hereditary high serum thyroxine-binding globulin.

A family with hereditary high serum thyroxine-binding globulin was studied. All the subjects studied were clinically euthyroid without goiter. The propositus (female), her mother and sister had high TBG, total T4 and total T3 with normal free T4, free T3 and TSH. Her father's thyroid function was within the normal range. Possible etiologic factors causing secondary hyper-TBG-nemia were ruled out in all the affected subjects. Isoelectric focusing demonstrated qualitatively normal microheterogeneity, ruling out possible TBG variations caused by liver diseases, estrogen therapy or pregnancy. Although the mechanism involved in the TBG increase awaits further investigation, it could be an abnormality in the gene controlling the synthesis of TBG.

[Successful resection of a pseudoaneurysm and reconstruction of the left ventricle following myocardial infarction].

A 56-year-old male experienced an anterolateral myocardial infarction and was readmitted to our department at the age of 57 for treatment of his effortive back pain. A chest X-ray disclosed that his cardiac silhouette was slightly enlarged and he was diagnosed by angiography as having a pseudoaneurysm of the left ventricle. He underwent surgery using ventricular fibrillation. We resected his pseudoaneurysm of the left ventricle, and then we reconstructed his left ventricle with double EPTFE (Gore-Tex patch) supported by his own pericardium. He has received a normal post-operative course and is making satisfactory progress. We believe that left ventricular reconstruction could be recommended for treatment of some left ventricular aneurysm.

[Management of the severe calcified ascending aorta during coronary bypass surgery].

The best management of the calcified ascending aorta during coronary surgery has not established. Clamping of the calcified aorta causes cerebral embolism, aortic rupture and laceration as a lethal complication. Recently we had two successful cases of surgical treatment and these were treated by "Non-touch aortic technique". The femoral cannulation and ventricular fibrillation with moderate hypothermia or circulatory arrest will reduce the risk of coronary bypass surgery in the calcified aorta.

[A successful report of emergency CABG for severe calcified thoracic aorta--the porcelain aorta].

The best management for patients requiring CABG with severe calcification of the thoracic aorta has not be established. To clamp ascending aorta in such cases produce cerebral embolization, aortic dissection or mural laceration. We reported a 60-year-old male for unstable angina with LMT lesion. Emergency CABG using IABP was performed with femoral cannulation, moderate hypothermia and induced ventricular fibrillation. His postoperative course was uneventful and coronary arteriography revealed a satisfactory patent graft of the RITA to the LAD system.

[Successful report of total aortic root replacement by a new technique].

We employed a new procedure of the total aortic replacement in 2 cases which is made of composite graft and reimplantation of the coronary arteries by direct suture technique. These patients took good clinical course and were discharged after operation. We believe that this procedure is a very useful for annuloaortic ectasia or dissecting aortic aneurysm involved coronary artery with aortic regurgitation.

[Surgical treatment of bilateral spontaneous pneumothorax].

88 cases of bacterial spontaneous pneumothorax, 20 cases, occurred same time and 68 cases, occurred different time, were treated in our Department of Thoracic Surgery from 1975 to July 1987, and represented 16.6% of all cases of spontaneous pneumothorax. The characteristics of bilateral spontaneous pneumothorax, occurred same time, were as follows; 1) frequent in teens, 2) often occurred with history of unilateral spontaneous pneumothorax, 3) slightly collapsed. For the treatment of bilateral spontaneous pneumothorax, occurred same time, bilateral thoracotomy was necessary. The characteristics of bilateral spontaneous pneumothorax, occurred different time, were as follows; 1) frequent in the twenties, 2) often occurred the other side after unilateral thoracotomy within a year. For the treatment of bilateral spontaneous pneumothorax, occurred different time, if the patient is under 20 thoracotomy must be carried out, but if the patient is over 20 at the side of pneumothorax must be operated.