[On-pump coronary artery bypass grafting is still useful for the complete revascularization of low risk patients].

Many clinical studies demonstrate that complete revascularization with total arterial grafts leads to the best late surgical results. Though off-pump coronary artery bypass grafting (CABG) is superior to on-pump CABG (ONCABG) in morbidity and mortality, some coronary surgeons feel it difficult to revascularise multi-vessel disease completely without cardiopulmonary bypass (CPB). Acute conversion from off-pump to on-pump results in increased major complications and high mortality. For the patients with high risk for CPB, coronary revascularization should be performed without CPB even if completeness is failed. It seems to be reasonable to adopt ONCABG for low risk patients who need many anastomoses in the posterior wall of the heart.

[Ultrasound carotid artery plaque morphology and perioperative stroke risk in patients undergoing coronary artery bypass grafting].

OBJECTIVE: To determine the influence of carotid artery plaque (CAP) morphology on perioperative stroke in coronary artery bypass grafting (CABG). PATIENTS AND METHODS: Ninety-three patient undergoing CABG were studied. CAPs and other lesions including intima-media thickness (IMT) and stenosis were examined by using ultrasound imaging. CAPs were morphologically classified as either homogeneous (HmP) or heterogeneous (HtP). RESULTS: Mean and max IMT were 1.26 +/- 0.15 and 2.44 +/- 0.76 mm. Mean total plaque score was 15.75 +/- 6.82. HmP and HtP were seen in 80 (86.0%) and 54 (58.1%) patients. Stenosis greater than 50% was found in 22 (23.7%) patients. HtP was significantly associated with age (p<0.05), diabetes and severity of coronary artery disease (p<0.01) and stenosis was associated with diabetes and history of cerebrovascular events (p <0.05). Late postoperative stroke occurred in 3 (3.2%) patients during hospitalization. One of them had 90% stenosis in the carotid artery. The others had no carotid stenosis. In all of the 3, the predominant plaques were heterogeneous. CONCLUSION: CAP morphology in patients undergoing CABG was detailed. As well as stenotic lesion, plaque heterogeneity may be a risk factor for perioperative stroke. Diabetes is associated with severity of both plaque heterogeneity and stenosis.

[Off-pump versus conventional coronary artery bypass grafting in octogenarians].

Coronary artery bypass grafting (CABG) in elderly patients is becoming increasingly common. From January 1996 to February 2002, 836 patients underwent CABG in our hospital, of whom 33 patients (3.9%) were aged 80 years or older. We evaluated the clinical and short-term results of 7 cases of off-pump CABG (OPCAB) and 26 cases of conventional CABG (C-CABG). Mean patient age and preoperative risk factors were similar in both groups. The OPCAB group had significantly decreased operation time (218 versus 281 minutes, p<0.05), and the number of distal anastomoses was significantly fewer in the OPCAB group than in the C-CABG group (1.9 versus 3.8, p<0.05). The frequency of complete revascularization in C-CABG was significantly higher than that of the OPCAB group (84.6% versus 42.9%, p<0.05), and there were no differences in the incidence of major postoperative complications between the groups. There was no hospital death in either group. Cumulative cardiac event free rates were 75% at 1 year and 75% at 3 years in the OPCAB group and 100% at 1 year and 84.6% at 3 years in the C-CABG group (p<0.05). In conclusion, CABG is safe and effective for myocardial revascularization in octogenarians. Except for high-risk cases, complete revascularization with OPCAB or C-CABG should be performed, because favorable outcomes can be expected even in the elderly patients.

[Surgical treatment of pulmonary metastases from colon and rectal cancer].

We retrospectively studied the surgical treatment for pulmonary metastases from colon and rectal cancer. A total of 24 patients (9 males and 15 females; mean age 61 years) underwent 29 thoracotomies for metastatic colon carcinoma, while 22 patients (16 males and 6 females; mean age 63 years) underwent 29 thoracotomies for metastatic rectal cancer. The median interval between the primary procedure and lung resection for metastases was 26 months in the patients with colon carcinoma and 32 months in the patients with rectal cancer. In the patients with colon carcinoma, 16 underwent wedge resection or segmentectomy (including 4 video-assisted procedures) and 13 (54%) underwent lobectomy or pneumonectomy. In the patients with rectal cancer, 15 underwent wedge or segmentectomy (including 1 video-assisted procedure), 13 (59%) underwent lobectomy or pneumonectomy, and 1 underwent exploratory thoracotomy. All procedures except exploratory thoracotomy were curative operations. There was no mortality. Overall 5-year survival was 56% (n=46). Five-year survival was 65% for patients with colon metastases (n=24) and 45% for patients with rectal metastases (n=22), and there was no significant difference. Recurrent sites were 4 lungs (36%), 4 livers (36%), 1 bone, 1 uterus, and 1 peritoneum in patients with colon carcimoma, and 10 lungs (43%), 5 brains (22%), 3 livers (13%), 1 bone, and 1 vagina in patients with rectal cancer. Pulmonary resection for metastases from colon carcinoma may have better prognosis than that from rectal cancer. However, further investigation may be required to obtain convincing conclusions.

T-cell clonality to Porphyromonas gingivalis and human heat shock protein 60s in patients with atherosclerosis and periodontitis.

Individuals with periodontitis have been reported to have a significantly increased risk of developing coronary heart disease. Several studies have demonstrated that the immune response to heat shock protein 60 (HSP60) may be involved in the pathogenesis of both atherosclerosis and chronic periodontitis. To investigate this possible link between these diseases, cellular and humoral immune responses to HSP60 in atherosclerosis patients were compared with those in periodontitis patients and healthy subjects using human and Porphyromonas gingivalis HSP60 (GroEL) as antigens. Antibody levels to both human and P. gingivalis HSP60s were the highest in atherosclerosis patients, followed by periodontitis patients and healthy subjects. Clonal analysis of the T cells clearly demonstrated the presence of not only human HSP60- but also P. gingivalis GroEL-reactive T-cell populations in the peripheral circulation of atherosclerosis patients. Furthermore, these HSP60-reactive T cells seemed to be present in atherosclerotic lesions in some patients. These results suggest that T-cell clones with the same specificity may be involved in the pathogenesis of the different diseases.

[Elucidation of one-lobe intrapulmonary metastasis route of primary lung cancer by means of long-term results].

OBJECTIVE: We hypothesized that the cause of one-lobe intrapulmonary metastasis of primary lung cancer is mainly lymphatic, and investigated by means of the long-term outcome. METHODS: From 1988 to 2000, 860 patients underwent complete resection of primary lung cancer patients in our hospital without neoadjuvant therapy. Patients were classified into 4 groups: group A (n 0 pm 0, n = 573), group B (n 0 pm 1, n = 37), group C (n 1 pm 0-1, n = 122), and group D (n 2 pm 0-1, n = 128). RESULTS: No significant difference was seen between groups in median age, sex ratio, histological cell type, or pathological tumor-size and p-factor. The rates of bi-lobectomy and pneumonectomy were higher in groups C and D than in groups A and B. The 5-year survival rate was 73% for group A, 57% for group B, 43% for group C, and 28% for group D. The 10-year survival rate was 57% for group A, 45% for group B, 20% for group C, and 16% for group D. There was a significant difference (p < 0.0001) between 4 groups in the 5- and 10-year survival rate. CONCLUSION: The hypothesis that the cause of one-lobe intrapulmonary metastasis may be lymphatic was not incompatible with the long-term results.

[Pneumothorax due to pulmonary metastasis of gingival carcinoma: report of a case].

A 72-year-old woman developed left pneumothorax 14 months after the first operation of a gingival carcinoma. The chest X-ray films and computed tomographic scans on admission revealed left pneumothorax and 2 lesions with a thin-walled cavity in the upper lung field. They seemed to be pulmonary metastasis from a carcinoma of gingiva and one of them ruptured into the pleural cavity. As airleak continued after tube thoracostomy, wedge resections of 2 lesions were performed through thoracotomy. Postoperative histological examination revealed that both of the lesions were moderately differentiated squamous cell carcinoma and they were the same histological findings as the gingival carcinoma excised previously. Pulmonary metastasis from a carcinoma of gingiva is rare, while it may be thought 1% of metastatic lung tumors. And also pulmonary metastasis is unusual cause of pneumothorax, especially without chemotherapy for it. We reported the very rare case of pneumothorax due to pulmonary metastasis from a carcinoma of gingiva.

[Prosthetic valve endocarditis complicated with cardiogenic shock and disseminated intravascular coagulation; report of a case].

A 67-year-old man, who had been performed aortic and mitral valve replacement 3 years before, was admitted because of appetite loss, general fatigue and anemia. Although transthoracic echocadiogram showed no evidence of prosthetic valves failure, the patient fell in profound shock. He needed endotracheal intubation and inotropic support. Transesophageal echocadiogram revealed vegetation formation on the prosthetic mitral valve and massive periprosthetic valve leakage. The diagnosis of prosthetic valve endocarditis was established. Blood examination showed severe disseminated intravascular coagulation (DIC). The patient underwent re-mitral valve replacement and recovered well from shock and DIC.

Subtotal thoracic aortic replacement as reoperation for ruptured aortic dissection: report of a case.

We report successful repair of a ruptured chronic aortic dissection in a 63-year-old female who had undergone end-to-end anastomosis for acute type A dissection 8 years before. The patient had hypotension with back pain and cough. A computed tomogram revealed a large chronic aortic dissection (Stanford type A) and complete atelectasis of the left lung due to hemothorax. The brachiocephalic artery was also dissected and aneurysmal. Emergency surgery was performed. Subtotal thoracic aortic replacement with reconstruction of 4 cervical vessels was carried out using hypothermic circulatory arrest with selective cerebral perfusion via a redo-sternotomy and a left anterolateral thoracotomy. The patient was discharged from the hospital without any sequelae.

Aortic valve replacement for aortic stenosis with a small aortic annulus in a patient having Werner's syndrome and liver cirrhosis.

Werner's syndrome is a rare genetic disease characterized by premature aging and scleroderma-like involvement of the skin. We report a case of aortic valve replacement for severely calcified aortic valve stenosis with a small annulus in a patient suffering from Werner's syndrome and liver cirrhosis

Simultaneous mitral valve replacement and bypass grafting for mycotic aneurysm of the femoral artery during the active phase of infective endocarditis: a case report.

A 52-year-old woman with a 3-week history of fever and cough was diagnosed as having bacterial endocarditis with vegetation and severe mitral valve insufficiency by echocardiography. Blood culture revealed Streptococcus mitis. After antibiotic treatment for 3 weeks, the patient noticed swelling with pain in her left groin. Computed tomography revealed an occluded aneurysm in the left common femoral artery. Simultaneous surgical treatments of mitral valve replacement and bypass grafting using a saphenous vein following resection of the mycotic femoral arterial aneurysm were performed. Pathohistological examination of surgical specimens revealed acute inflammatory findings, but no microorganisms were found, probably because of the preoperative antibiotic therapy. Her postoperative course was uneventful, and there was no recurrence of mycotic aneurysms in a period of 10 months after the operation. Prompt recognition and urgent simultaneous surgical treatments for mycotic aneurysms complicated with infective endocarditis were effective.

[Surgical treatment of a ruptured saccular aneurysm associated with bilateral coronary arteries-pulmonary artery fistulas: a case report].

We reported a successful operative case of ruptured coronary artery saccular aneurysm associated with bilateral coronary arteries-pulmonary artery fistulas. A 57-year-old woman, had been treated with hemodialysis due to chronic renal failure, suffered from acute heart failure with chest pain suddenly. Echocardiograph showed moderate pericardial effusion. A saccular coronary artery aneurysm with bilateral coronary arteries-pulmonary artery fistulas revealed by coronary angiogram. Ligation of coronary artery fistula, closure of orifice of draining artery to pulmonary artery and aneurysmorrhaphy were performed emergently. Post operative angiogram revealed complete disappearance of the fistulas.

[Surgical results of emergent coronary artery bypass grafting].

During a period of past five years, 57 patients underwent emergent coronary artery bypass grafting at our hospital. The reason for performing emergent CABG were unstable angina pectoris in 38 patients and acute myocardial infarction in 19 patients. Five patients died postoperatively. Mortality rate was higher in the patients with AMI (15.8%) than in the patients with UAP (5.3%). Among 19 patients after AMI, 7 patients were in cardiogenic shock preoperatively, and two of them died after operation. Though the surgical results for AMI with cardio-genic shock is discouraging, complete revascularization can be performed safely for the patients with UAP and uncomplicated AMI. It appears that optimal timing of the patients with left main shock syndrome should be guided by the relative presence of an element of ischemia or necrosis.

[Syphilitic thoracic aortic aneurysm with destruction of vertebral body, producing numbness of lower extremities and paraplegia].

Numbness and paraplegia are uncommon complaints in patient with thoracic aortic aneurysm (TAA). The patient was a 64-year-old man. He suffered numbness and gait disturbance (paraplegia). The blood examination showed no positive findings except a Wassermann was positive. Roentgen examination of the chest showed two abnormal shadows like tumors. The CT and MRI revealed destruction of the vertebral bodies and TAAs adjacent to the spinal cord. After the graft replacement was performed, numbness and paraplegia disappeared. This suggests that in our patient the TAAs destruct the vertebral body and produce pressure on the spinal cord, causing numbness and paraplegia. We experienced a rare case of the syphilitic TAA producing bone destruction, numbness and paraplegia.

Combined warfarin and antiplatelet therapy after St. Jude Medical valve replacement for mitral valve disease.

OBJECTIVES: The clinical effect of combined warfarin and antiplatelet therapy on the incidence of stroke and postoperative complications after mitral (plus aortic) valve replacement was studied and compared with that observed with warfarin therapy alone. BACKGROUND: It has been reported that combined warfarin and antiplatelet therapy may be effective but may be associated with an increased hemorrhagic risk. Therefore, definite benefits of the treatment in patients with an implanted prosthetic valve have not been clearly documented. METHODS: Between January 1980 and December 1992, 195 patients with a St. Jude Medical valve at the mitral (plus aortic) position were assigned to receive treatment with either warfarin alone (125 patients) or warfarin plus antiplatelet agents (70 patients), such as dipyridamole (150 or 300 mg daily, 14 patients) or ticlopidine (200 or 400 mg daily, 56 patients). A minimal dose of aspirin (10 to 40 mg) was added (29 patients) if the maximal platelet aggregation rate by collagen was not reduced. The target thrombotest level was 10% to 20%. RESULTS: The two treatment groups were similar with regard to gender and age distribution. The number of patients with atrial fibrillation, left atrial thrombus, history of previous stroke, simultaneous aortic valve operation and previously performed valve procedures were comparable in the two groups. Actuarial survival rate at 10 years was 98.3 +/- 1.7% (mean +/- SD) in the warfarin plus antiplatelet group and 90.3 +/- 3.2% in the warfarin group (p < 0.05 at 1 and 9 to 12 years). The actuarial stroke-free rate at 10 years was 95.3 +/- 3.4% and 84.3 +/- 3.8%, respectively (p < 0.05 by the generalized Wilcoxon test). The actuarial complication-free rate at 10 years was 89.4 +/- 4.3% and 67.9 +/- 4.8%, respectively (p < 0.05 by the generalized Wilcoxon test). No hemorrhagic complications were seen in the warfarin plus antiplatelet group. CONCLUSIONS: The results strongly indicate the effectiveness and safety of combined warfarin plus antiplatelet treatment after St. Jude Medical valve replacement for mitral (plus aortic) valve disease.

Surgical excision of a broad-based left atrial myxoma: report of a case.

We report herein the case of a 72-year-old woman who underwent successful resection of an unusual type of broad-based left atrial myxoma. The tumor, which was attached to the fossa ovalis and anterior wall of the left atrium posterior to the aorta, was resected en bloc with the interatrial septum and the affected free wall of the left atrium. The defect in the left atrium and atrial septum was then reconstructed with an equine pericardial patch. To our knowledge, this type of cardiac myxoma, with a base extending from the septum to the atrial wall, has not been previously reported.

[A case report of pulmonary metastasis of malignant fibrous histiocytoma (MFH) accompanied by mediastinal lymph node metastasis].

Mediastinal lymph node metastasis associated with pulmonary metastasis is rarely seen in soft tissue sarcoma. A case is presented in which investigation of primary lung cancer (cT2N2M0) in a 78-year-old woman with a history of MFH of the left thigh revealed pulmonary metastasis of MFH accompanied by paratracheal (#2) and anterior mediastinal (#3a) lymph node metastases.

Direct thrombolytic revascularization of the occluded basilar artery.

Successful direct revascularization in a 54-year-old man with embolism of the basilar artery following St Jude Medical valve replacement for mitral regurgitation 6 years earlier is reported. He arrived at the hospital in a deep coma. Computed tomography showed no new lesions, but subsequent angiography revealed occlusion of the basilar tip, bilateral posterior cerebral arteries and right superior cerebellar artery. Direct thrombolytic therapy was performed using 420,000 units urokinase through an infusion catheter placed in the basilar artery. The patient immediately regained consciousness, with only slight diplopia. Direct thrombolytic therapy is considered to be an effective treatment for thromboembolism following prosthetic valve replacement in certain selected cases.

[Flow characteristics and responses to vasoactive drugs in canine gastroepiploic artery].

We studied flow characteristics and response to norepinephrine, Chlorpromazine and gastrin in 22 canine gastroepiploic artery (GEA) recirculation model. The GEA flow was obtained by a drip for a minute, opening the end of pedicle GEA. Furthermore, aortic flow and celiac arterial flow were measured by magnetic flow probe. The administration of chlorpromazine, vagostigumine, and gastrin induced a increase in both celiac arterial flow and pedicle GEA graft flow. Especially, the administration of gastrin induced significant increase in GEA flow and celiac arterial flow. Furthermore, adding norepinephrine step-wisely, the GEA flow increased remarkably, in spite of decrease of celiac arterial flow. This response was caused from difference in vascular resistance among celiac arterial branches. Therefore, the pedicle GEA graft has homogenous response as same as intact GEA that perfuses stomach, because its flow was affected by adrenergic and parasympathetic agent, alpha-blocker and gastric hormone.

[Late postoperative outcome of plastic operation versus valve replacement for mitral regurgitation].

Between January 1980 and August 1991, 99 patients underwent operation for mitral valve regurgitation (MR). The ages of the patients ranged from 12 to 67 years, (49.4 +/- 11.9 years), and there were 39 males and 60 females. Pathological cause of regurgitation, which was determined by intraoperative inspection and histological findings of excised leaflets, was rheumatic in 46, degenerative in 38, infective endocarditis in 9, ischemic in 4 and unknown in 2 patients. Cardiac rhythm was atrial fibrillation in 73, normal sinus rhythm in 24 and junctional rhythm in 2 patients. Our principles for valve repair were (1) excision of responsible segment and repair for prolapsed leaflet due to torn chordae, (2) shortening of elongated chordae, (3) annuloplasty, and (4) repair of perforated leaflet. Finally, 19 patients endured plastic operation, and 80 patients underwent prosthetic valve replacement. The rate of plastic procedure was 62.5% (10/16) in degenerative MR with mural chordal lesions, 42.9% (3/7) in rheumatic MR without stenosis, 22.2% (2/9) in infective endocarditis and 100% (2/2) in MR with unknown etiology. Mitral valve repair was failed both in rheumatic MR associated with stenosis (39 patients) and in ischemic MR (4 patients). A ten-year survival rate after operation was 92.2 +/- 3.1% in patients with valve replacement and 83.6 +/- 10.0% with valve repair (N.S.), and a proportion of event-free survival in patients with valve replacement was similar to valve. Late postoperative cardiac catheterization revealed decreased left ventricular volume indices and increased left ventricular end-systolic stress/volume ratio in both groups compared to preoperative values, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)