[How to protect the surgeons' faces against spurting blood from the ascending aorta].

The blood spurting from the ascending aorta is uncomfortable for cardiac surgeons. To protect the surgeons' faces from this spurting blood, we use a longitudinal half of a plastic bottle, which is semi see-through. While the assistant is holding this device above the ascending aorta, the surgeons can proceed the operation with good surgical view.

[Pacemaker implantation in a patient with sick sinus syndrome, complicated with persistent left superior vena cava and absent right superior vena cava; report of a case].

A 78-year-old man was referred to our hospital with syncope and palpitation. A Holter electrocardiography (ECG) revealed sick sinus syndrome (SSS), and an enhanced chest computed tomography (CT) scan showed persistent left superior vena cava (PLSVC) and absent right superior vena cava. Myocardial leads and a pacemaker implantation were peformed through left anterior thoracotomy approach. There were only 10 reports of pacemaker implantation in a patient with SSS complicated with PLSVC and absent right superior vena cava in Japan. Open thoracotomy approach was thought to be usuful for these patients.

[Papillary fibroelastoma which occurred from the posterior leaflet of the mitral valve; report of a case].

Papillary fibroelastoma is a rare benign tumor arising from the cardiac endothelium. In this report, we describe the surgical treatment for mitral valve papillary fibroelastoma with hypothyroidism. A 69-year-old woman was admitted to our hospital for the treatment of cardiac tamponade. Echocardiography revealed massive pericardial effusion and a small tumor attached to the posterior mitral leaflet. We drainaged the pericardial effusion, and found that the cause of pericardial effusion was hypothyroidism. After controling the thyroid function, open heart surgery was performed. We excised the tumor including a part of the posterior mitral leaflet, and mitral valve plasty was done. Both the surgical and histological findings showed papillary fibroelastoma, and the postoperative course was uneventful. To avoid embolic complications, early surgical intervention is recommended.

[Postinfarction ventricular septal perforation; tips of patch closure].

There are several techniques, such as patch closure and David procedures, for surgical repair of postinfarction ventricular septal perforation (VSP). In any operation, postoperarive low output syndrome (LOS) and residual shunt are serious problems. We prefer to use patch closure method and we have some tips to prevent LOS and residual shunt. (1) Minimal part of the ventricular septum is resected. 4-0 SH-1 polypropylene mattress sutures reinforced with Teflon pledget are placed away from the edge of VSP. Stunned myocardium around VSP might recover after operation. (2) Sutures are placed about 2 cm inner of a large xeno-pericardial patch. Even if myocardial cutting and left-right shunt flow occurs, an excessive xeno-pericardium, like a skirt, should be caught by the left ventricular pressure. This might cover and close the 'residual shunt'. We applied this technique to 6 VSP patients, and the results were good.

[One-stage coronary artery bypass and extra-anatomical bypass operation in a patient with ischemic heart disease and Leriche syndrome; report of a case].

With the overall increase in ischemic heart disease (IHD), cases combining arteriosus sclerosis obliterans (ASO) of the lower extremity and IHD are on the rise. Each case is unique and requires the use of various criteria to select between methods of operating. This case involves IHD with low cardiac function, conbined with ASO of the collateral circulation fed to the legs through the internal thoracic artery and a calcified abdominal aorta refractory to anatomical reconstruction. We selected a one-stage operation of axillo-bifemoral bypass grafting and coronary artery bypass grafting. The postoperative course was uneventful, and the patient was discharged on the 23rd day after operation.

[The analysis of renal function in off-pump coronary artery bypass grafting].

OPCAB (off-pump coronary artery bypass grafting) is useful for preventing post-operative neurologic complications. On the other hand, the effect of OPCAB on post-operative renal function is still unclear. We analyzed the post-operative renal function in 39 patients. Thirty-two patients had normal pre-operative renal function (CRE < or = 1.4 mg/dl). Thirty-one patients were doing well in terms of post-operative renal function. Only 1 patient needed hemodialysis (HD) because of systemic infection in early post-operative period. Another 7 patients had pre-operative renal dysfunction (CRE > or = 1.5 mg/dl). Three cases with high-grade pre-operative renal dysfunction (CRE > 3.0 mg/dl and CCR < 20 ml/min) needed temporary HD or continuous hemo-diafiltration (CHDF) in early post-operative period, and then they needed maintenance HD for the treatment of chronic renal failure within 3 weeks after OPCAB. Three of 4 cases with low-grade pre-operative renal dysfunction (CRE: 1.9-2.7 mg/dl and CCR: 22-42 ml/min) needed temporary HD or CHDF in early post-operative period. These 3 patients were relieved of the early post-operative renal failure, but required maintenance HD in the late periods. In summary, OPCAB could not prevent the development of acute renal failure in the patients with pre-operative renal dysfunction.

[Analysis of continuous hemodiafiltration after open heart surgery].

The development of renal failure after open heart surgery is associated with a high mortality. Thirteen patients were treated with continuous hemodiafiltration (CHDF) for renal failure following open heart surgery since April 1999 to December 2001. The indication of CHDF was blood purification in 8 patients and water balance control in 5 patients. Two patients with hemodialysis (HD) before operation returned to usual HD early after operation, and discharged. One patient died of severe heart failure, and another patient died of sepsis and multi organ failure. In these 2 patients, CHDF could not withdrawn. Seven patients weaned from CHDF 1 to 19 days after operation. Five of 7 patients discharged, but 2 patients died of cerebral infarction 4 month after operation. The remaining 2 patients could not wean from CHDF, and were introduced HD. Only 1 of 13 patients had bleeding tendency (cardiac tamponade). CHDF did not influence the hemodynamic state and was very effective for the treatment of renal failure in many patients.

The safety and usefulness of cool head-warm body perfusion in aortic surgery.

OBJECTIVE: To determine the safety and usefulness of antegrade hypothermic cerebral perfusion in conjunction with mild hypothermic (tepid) visceral perfusion (so-called cool head-warm body perfusion; CHWB) in aortic surgery; the clinical outcomes and perioperative data on this new technique were retrospectively analyzed. METHODS: From January 1990 to March 1999, 59 patients underwent ascending aorta or aortic arch surgery using antegrade selective cerebral perfusion (SCP). Three perfusion techniques, differentiated by perfusion temperature, were used, those being deep hypothermia (DH; nasopharyngeal temperature of 20 degrees C, n=14), moderate hypothermia (MH; nasopharyngeal temperature of 28 degrees C, n=17) and CHWB (nasopharyngeal temperature of 25 degrees C and bladder temperature of 32 degrees C, n=28). Selection of the technique largely followed a chronological pattern, in this order: DH, MH and, more recently, CHWB. The three groups were retrospectively compared in terms of operative outcome, duration of cardiopulmonary bypass (CPB) and operation, and intraoperative blood loss. RESULTS: The early (within 30 days after surgery) mortality/hospital mortality (including operative mortality) was 7.1/21.4, 5.9/11.8 and 3.6/7.1% in the DH, MH and CHWB groups, respectively. The rate of stroke was 7.1, 6.3 and 3.6% in the DH, MH and CHWB groups, respectively. No statistical difference was found in early or hospital mortality, or in the rate of stroke among the three groups. The CPB time, especially the time for rewarming, was significantly shorter in the CHWB than in the DH group. Likewise, the operation time, especially the time after CPB, was significantly shorter in the CHWB than in the DH and MH groups. Blood loss was significantly less in the CHWB than in the DH group. CONCLUSION: Our data suggest that CHWB perfusion in aortic surgery is a safe and useful technique in shortening the operation time and reducing blood loss, but further prospective study is necessary.

[A case report of total removal of infected pacemaker leads with cardiopulmonary bypass through right thoracotomy].

A 61-year-old man with septicemia had four infected pacemaker leads, which were impossible to remove using simple traction method. He received CABG previously, and SVG anastomosed to LAD was patent. Redo median sternotomy had a possibility to make damage to SVG. Total removal of infected pacemaker was performed successfully with cardiopulmonary bypass through right thoracotomy.

[Successful treatment of an infected pseudoaneurysm of the ascending aorta with omental transfer--a case report].

The formation of pseudoaneurysm is an uncommon complication of after coronary artery bypass grafting (CABG). We report a 66-year-old man in whom an anastomotic pseudoaneurysm of the ascending aorta derived from mediastinitis after repeat CABG. At operation, the pseudoaneurysm was revealed to be involved in the proximal anastomotic site of a saphenous vein graft to the RCA. The aneurysm was resected and the defect was repaired with woven dacron patch under deep hypothermic circulatory arrest. In addition, omental transposition was performed to treat mediastinitis radically. Debris of the pseudoaneurysm grew methicillin-resistant Staphylococcus aureus (MRSA), so vancomycin was administered intravenously for 8 weeks. The postoperative course was uneventful. We considered that omental transfer can be very effective in the management of severe mediastinitis, especially that due to an infected pseudoaneurysm or widespread mediastinitis caused by MRSA.

[A case of infective mitral endocarditis after percutaneous transvenous mitral commissurotomy].

We encountered a case of infective mitral endocarditis (IE) due to Methicillin resistant staphylococcus aureus (MRSA) after percutaneous transvenous mitral commissurotomy (PTMC). A 65-year-old woman underwent PTMC for mitral stenosis. Two days later, she incurred a fever of more than 40 degrees C, and MRSA was detected in her blood culture. Inflammation and renal function deteriorated despite transvenous administration of antibiotics. Transesophageal echocardiogram revealed vegetation at the mitral valve. Mitral valve replacement was performed after diagnosis of IE, and MRSA was identified from the vegetation. The patient improved with the transvenous application of antibiotics including vancomycin hydrochloride. The blood culture became negative and inflammation was suppressed. In view of this case, we consider that IE is a possible complication following PTMC.

[Surgical treatment of recurrent thymic carcinoid--a case report].

Reoperation for recurrent thymic carcinoid was performed in a 77-year-old man, who had undergone extirpation of an anterior mediastinal tumor in September 1986. The pathological diagnosis was thymic carcinoid after the first operation. An abnormal lesion was found on the chest X-ray film in November 1992. Chest CT and supraclavicular lymph node biopsy revealed that the thymic carcinoid had recurred with lymph node metastasis, so reoperation was performed in February 1993. The patient is alive with residual tumor at 11 months after reoperation. Radiotherapy or chemotherapy are not so effective for thymic carcinoid. However this type of tumor often reocurrs, it grows slowly. Accordingly, total thymectomy including tumor should be carried out for thymic carcinoid, and surgical resection is the best choice for the treatment of tumor recurrence.

[A case report of patch angioplasty of the left main coronary artery for isolated left main coronary artery disease].

A 49-year-old woman was admitted to our hospital because of palpitation and right shoulder pain. Examinations showed isolated left main coronary artery disease. Surgical angioplasty of left main coronary artery was considered. The left main stem was approached anteriorly. Pericardium was chosen for patch material and the left main coronary artery was enlarged from 1.5 to 4.0 mm in diameter. Postoperative course was very stable, and postoperative angiography revealed an excellent result.

[A case report of type A acute aortic dissection, which arose from true aneurysm in aortic arch].

A 69-year-old woman was admitted to our hospital because of back pain. Examinations showed type A acute aortic dissection, which arose from true aneurysm in aortic arch, and emergency operation was considered. Deep hypothermic selective cerebral perfusion was carried out for brain protection. Ascending to aortic arch was replaced with 24 mm woven Dacron graft. There was no postoperative neurological complication.

[A case report of congenitally bicuspid aortic valve and ascending aortic aneurysm treated by wheat operation].

A 59-year-old man who complained of palpitation was diagnosed as having a congenitally bicuspid aortic valve, severe aortic regurgitation, and an ascending aortic aneurysm. He underwent aortic valve replacement and conduit replacement by the modified Wheat technique. Since this technique requires no coronary artery anastomosis, it causes no problems associated with reconstruction of the coronary artery. Postoperative angiogram revealed no aneurysm formation of the aortic root or paravalvular leakage. This case suggest that aneurysm of the ascending aorta with aortic regurgitation is more effectively treated by the modified Wheat technique if cephalad displacement of the coronary ostium is not extensive.

[Coronary artery bypass grafting in six patients with familial hypercholesterolemia].

UNLABELLED: From June 1989 through November 1991, six patients with familial hypercholesterolemia underwent surgical treatments. The surgical procedures were coronary artery bypass grafting (CABG) alone 4, ligation of coronary aneurysm + CABG 1, and CABG + femoro-femoral bypass 1. There were no operative or hospital deaths. Early post operative patency rate of the grafts was 100%. CASE PRESENTATION: A 44-year-old man whose anginal pain recurred 11 years after CABG. Coronary angiogram revealed stenosis and a large aneurysm in the circumflex coronary artery. Previous grafts to the left anterior descending coronary artery and diagonal branch were patent. Ligation of the aneurysm and internal mammary artery bypass grafting were performed. Postoperatively, the patient has remained asymptomatic. Our data indicate that CABG for FH patients is effective in the early postoperative period.

Serial changes in myocardial beta-adrenergic receptor after experimental brain death in dogs.

Early donor heart failure is one of the serious problems in heart transplantation. This heart failure may be related to myocardial change during brain death before implantation of the heart. Actually, a gradual increment in catecholamine requirement to maintain hemodynamics is not infrequently seen in patients with brain death. This may presumably be related to alterations in the myocardial beta-adrenergic receptor system. In this experimental study, we investigated the changes in myocardial beta-adrenergic receptors after brain death induced by intracranial hypertension in dogs. To maintain the mean arterial pressure higher than 60 mm Hg after brain death, massive crystalloid infusion (group A) or 0.4 to 1.3 micrograms/kg/min of adrenaline infusion (group B) was applied. Blood adrenaline levels and myocardial beta-adrenergic receptor (receptor number and affinity with [125I]iodocyanopindolol binding) were measured at 3 hours (group A-3H or group B-3H, n = 5, respectively) and 6 hours (group A-6H or group B-6H, n = 5, respectively) after brain death. Blood adrenaline levels reduced in group A-6H and elevated in group B-3H and group B-6H. Beta-adrenergic receptor affinity was not different among each group. Beta-adrenergic receptor number decreased in group B-6H. Myocardial beta-adrenergic receptor density decreased in the adrenaline group during 6 hours of hemodynamic maintenance after brain death, whereas myocardial beta-adrenergic receptors did not change in the crystalloid group. Our data suggest that the large doses of catecholamines used to maintain hemodynamics in donors with brain death may depress myocardial beta-adrenergic receptors.

[Phrenic nerve palsy after open heart surgery--problems in post-operative respiratory management].

We clarified the problems in respiratory management in patients with phrenic nerve palsy (PNP) after open heart surgery. From December 1988 to March 1991, 248 adult patients underwent open heart surgery with topical myocardial cooling. In these patients PNP was diagnosed in 17 patients (6.9%). Age of these patients at operation ranged from 25 to 76 years with a mean age of 57 years. 9 patients were valvular heart disease (7 were reoperation), 7 were coronary artery disease, and one patient was aortic aneurysm. PNP was diagnosed by chest roentgenogram or percutaneous phrenic nerve stimulation test (PNST). Frequency of long-term intubation (> 14 days) was higher in complete PNP patients than incomplete PNP patients. 2 patients, who were observed effort dyspnea at the time of respiratory weaning, were extubated followed by respiratory and circulatory deterioration, and were reintubated. PNP were confirmed after reintubation by PNST. These patients died of pneumonia. Another 2 patients were observed effort dyspnea during respiratory weaning, and were doubted of PNP. PNP were confirmed by PNST before extubation. After hemodynamic stabilization and respiratory physiotherapy, these patients were extubated without any trouble. One patient, who required repeated intubation, was diagnosed PNP by PNST. This patient was extubated after confirmation of improvement of PNP by follow-up PNST. The incidence of PNP was higher in patients with previous open heart surgery than without previous operation. We supposed that the dissection around the heart might be one of major cause of postoperative PNP. So, in recent 4 cases of mitral reoperation, we attempted to reach mitral valve through atrial septum with minimum dissection.(ABSTRACT TRUNCATED AT 250 WORDS)

Alterations in the beta-adrenergic receptor system after hypothermic ischemia in hearts with preischemic beta-receptor desensitization.

Although hypothermic cardioplegic arrest is a basic method of myocardial protection in cardiac surgery, the beta-adrenergic receptor (BAR) system has been little investigated in the heart subjected to hypothermic ischemia. Additionally, although the hypothermic arrest is often induced in hearts with preischemic desensitization of the BAR system by preceding congestive heart failure, the functional state of the BAR system after ischemia has not been studied in these hearts. We investigated alterations in the BAR system after hypothermic ischemia in normal rat hearts and in those with preischemic desensitization of the BAR system produced with isoproterenol (ISP: 400 micrograms/kg/hr for 24 hr). Both normal and BAR-desensitized hearts were isolated and subjected either to 40 min of hypothermic (10 degrees C) global ischemia followed by 40 min of reperfusion or subjected to time-matched aerobic perfusion with modified Krebs-Henseleit solution. At the end of perfusion (1) BAR binding properties with [3H]CGP-12177 and adenylate cyclase activity were measured in crude membrane fraction and (2) the inotropic response to ISP (delta LV + dP/dtmax) was evaluated in an isovolumetric contracting heart preparation. Following reperfusion, normal hearts without desensitized BAR showed a higher Bmax value than those of nonischemic time-matched hearts (41.8 +/- 3.1 vs 35.4 +/- 2.4 fmole/mg protein, P less than 0.05), whereas the Kd value was in a similar range in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)