[Surgical treatment for infective endocarditis].

OBJECTIVE: Surgery for infective endocarditis (IE) is technically demanding, especially the one for active IE. METHODS: Operations were performed in 21 patients with a mean age of 52.2 +/- 18.8 years. Fifteen patients were male, and 6 were female. There were 15 patients with active IE and 6 patients with healed IE. Isolated pathogens were Streptococcus in 8 cases, Staphylococcus in 3, and Enterococcus in 2. Two patients had prosthetic valve endocarditis. When the lesions affected the aortic valve, aortic valve replacement (AVR) was performed. When the lesions affected the mitral or tricuspid valves, valve repair was the treatment of choice. RESULTS: Six patients underwent AVR and 15 patients underwent a mitral valve operation (mitral valve repair in 13, replacement in 2). In 2 patients, mitral valve repair was changed to replacement, judged by intraoperative transesophageal echocardiogram. One patient underwent isolated tricuspid valve repair. Total survival and survival free of reoperation at 45 months was 95.2%. The grade of mitral regurgitation (MR) decreased from 3.7 +/- 0.1 to 0.2 +/- 0.1, and that of tricuspid valve regurgitation (TR) recovered from 3.5 +/- 0.5 to 1.0 +/- 1.0 at 21 +/- 15 months after the operation. CONCLUSIONS: Valve repair operations were useful in the mitral and tricuspid valve positions, even in the presence of active IE. Both mechanical valve and bioprosthesis showed good results after AVR for IE.

[Aortic root redissection associated with the use of gelatin-resorcin-formalin glue following surgical treatment for acute type A aortic dissection; report of a case].

A late redissection case of the aortic root after total arch replacement for acute Stanford type A aortic dissection was reported. A 55-year-old male was treated with total arch replacement for acute Stanford type A aortic dissection. The aortic valve was bicuspid valve, and the right coronary leaflet was prolapsed because of the dissection of right and non coronary cusp. Resuspension of the commissure and the fixation of the dissected aortic wall with gelatin-resorcin-formalin (GRF) glue was performed during the operation. The initial postoperative course was uneventful and the patient discharged 52 days after the operation. Redissection of aortic root was pointed out on the computed tomography (CT) 3.5 years after the operation. As the second operation, the aortic root replacement was performed. Coronary artery bypass for right coronary artery was simultaneously performed with right internal thoracic artery because the right coronary ostium was stenotic and showed ischemic change on electrocardiogram monitor during the operation. The redissection was seen on the right coronary sinus, which was fixed by the GRF glue during the first operation. The pathological study showed the migration of macrophages and the tear of the fibrous tissue. These findings was thought to be associated with the use of the GRF glue. Careful use of the GRF glue for the fixation of the dissected aorta during the surgical treatment for the Stanford type A aortic dissection was thought to be important.

[Primary pericardial malignant mesothelioma with incomplete endocardial cushion defect; report of a case].

Primary pericardial malignant mesothelioma is rare tumor and its prognosis is quite poor due to its late presentation and difficulty of complete resection. We describe a rare case of primary pericardial malignant mesothelioma in a 46-year-old female with incomplete endocardial cushion defect (ECD). Incidentally, we found 2 masses in the pericardial spaces after pericardiectomy. We have successfully removed these 2 masses en bloc and performed a total repair of incomplete ECD. Pathologically, these masses were a primary pericardial malignant mesothelioma. This patient is doing well 4 months after surgery without any evidence of recurrence despite reported poor prognosis of "primary pericardial malignant mesothelioma".

[Chronic dissecting aneurysm of the sinus of valsalva: report of a case].

The subject was a forty five year old female who was admitted to our hospital with chief complaints of cough and thoracic distress. After detailed examination, she was diagnosed as having aneurysm of the noncoronary sinus of Valsalva and aortic regurgitation. The finding during operation showed chronic aortic dissection localized to the noncoronary sinus of Valsalva. The entry of aortic dissection was just above the noncoronary annulus, which was found to be detached and leaned to the left ventricule. An operation for aortic root replacement was performed with Carrel patch method and had a good postoperative course. Only a few reports have been made on cases of aneurysm of the noncoronary sinus of Valsalva caused by chronic regional aortic dissection.

[A case of left atrial thrombus complicated with coarctation of the aorta].

The case was a sixty one year old female who was diagnosed as having acute arterial embolism of right upper arm and underwent embectomy. The detailed examination which followed revealed left atrial myxoma and coarctation of the aorta. Due to the risk of embolism, an emergency operation was performed to install a right axillofemoral bypass with an 8 mm artificial graft. Left atrial myxoma was then excised in an operation using an artificial heart-lung apparatus. Pathological examinations of excised tumor offered no trace of tumor but only of left atrial thrombus. Postoperative results were satisfactory. The pressure difference between upper and lower arms was improved to 0.8 in pressure index from preoperative 0.5 and it became possible to control the blood pressure of upper arm within the level of 130 to 150 mmHg. Axillofemoral bypass is an effective method for a case like the above where a site of coarctation of the aorta cannot be directly repaired.

[A case of coronary artery bypass grafting in a patient who has a rosary-like coronary lesion with Buerger's disease].

We report a case of coronary artery bypass grafting using left intra thoracic artery (LITA) in a 63-year-old male with Buerger's disease. His coronary angiography showed a long lesion seemed rosary in the left anterior descending (LAD). At operation, the surface of the coronary artery was dark red with white speckles. The LAD was opened distal end of disease, the intima of the coronary artery made much soft thin fold. The disease was never atheromatous. His coronary angiography showed a very rarely finding that seemed rosary.

Demonstration of double-chambered right ventricle on myocardial perfusion SPECT.

A 19-year-old man with a double-chambered right ventricle (DCRV) and an associated ventricular septal defect was admitted to the hospital for surgical correction. Preoperative study of myocardial perfusion with Tc-99m tetrofosmin SPECT depicted the two chambers of the right ventricle. There was a substantial differential in the radioactive uptake between these two chambers. The inflow and outflow chambers with different peak-pressures (94 and 18 mm Hg) showed different uptakes reflecting the pressure difference, which was intense in the inflow chamber and weak in the outflow.

[Simultaneous coronary artery bypass grafting and total arch graft replacement with dextrocardia and situs inversus].

The patient was a 79-year-old male who complained a sudden back pain. He had dextrocardia and situs inversus. An aortogram showed the dilatation of the ascending and aortic arch which reached 5.6 cm in diameter. A coronary angiogram also showed the 75 percent stenosis of segment 3 in the right coronary artery. Coronary artery bypass grafting to the right coronary artery was performed using a saphenous vein graft during cooling stage of the extracorporeal circulation. After that total arch replacement was carried out using a graft with four side branches with an aid of selective cerebral perfusion. He complicated with respiratory failure postoperatively and needed tracheostomy but recovered gradually. A postoperative computed tomogram showed good patency of three side grafts for cerebral perfusion and no abnormality of graft anastomosis.

[A case of two stage operation of thoracic and thoracoabdominal aortic aneurysm of a patient in late phase with Behçet's disease].

Patient was a 70-year-old female diagnosed as Behçet's disease 1973. She underwent descending thoracic aortic aneurysm operation 1980. She had graft replacement for a residual thoracoabdominal aortic aneurysm on April 28, 1994. She didn't accept steroid therapy although she had a slight inflammatory reaction on admission. The graft replacement of thoracoabdominal aortic aneurysm was done with an aid of Carmeda closed chest support system bypass and segmental aortic cross clamping. Reattachment of the intercostal and lumbar arteries to the graft was used with button technique or interposition technique. Visceral branches including celiac axis, superior mesenteric and right renal arteries were reconstructed to an opening made in the graft with button technique and reattachment of left renal artery was used with graft interposition during selective perfusion of visceral arteries. She started steroid therapy with 5 mg of predonine to prevent inflammatory reaction postoperatively. The thoracoabdominal aortic aneurysm accompanied with Behçet's disease was relatively rare and this is a long survival case.

[Coronary artery surgery in elderly patients].

We have experienced 351 cases of coronary artery bypass grafting in patients 70 years of age or older (107 cases: 75 years of age or older, 26 cases: octogenarians), among 1,395 cases of all coronary artery bypass grafting surgery. Estimated hospital death rate 4.8% seemed to be satisfactory.

[Epidural anesthesia reduces mortality rate in the patients after emergency abdominal surgery].

Stress response and increased sympathetic stimulation constrict gastrointestinal blood vessels. In patients after abdominal surgery, anastomotic leakage and bacterial translocation may occur as a result of gastrointestinal hypoperfusion. These patients are at risk for severe SIRS and MOF, especially after emergency surgery. Epidural anesthesia decreases sympathetic stimulation and accordingly increases gastrointestinal blood flow. The purpose of this study was to test the hypothesis that epidural anesthesia has a beneficial effect on patients after emergency abdominal surgery. Seventy-seven patients older than 50 years of age having undergone emergency abdominal surgery were studied. Thirty-nine patients received general anesthesia alone (GA) and 38 patients received epidural anesthesia (EA). The data on APACHE II score, fluid intake and output management, mortality rate, and others of the subjects were collected from patient charts. The mortality rate 3 months after surgery in group GA (35.9%) was significantly higher than that in group EA (5.3%) (P < 0.01). There was no difference in APACHE II score and age. Fluid intake was significantly larger in group EA. To reduce mortality rate, epidural anesthesia and volume expansion are recommended for patients after emergency abdominal surgery.

[Simultaneous aortic root and total arch graft replacement in a patient with aortitis syndrome].

The patient was a 45-year-old female diagnosed with aortitis syndrome and aortic regurgitation (AR). She had been taking steroid therapy since 1975. She had recently developed congestive heart failure due to AR while both the ascending aorta and aortic arch were enlarged. She had no inflammatory reaction on admission. An aortogram showed heavy dilation of both the ascending aorta and aortic arch and maximum diameters was 11 cm in the ascending aorta and 4.5 cm in the descending aorta. There was an obstruction of the left subclavian artery. Moderate AR was seen on an echocardiogram. She had a simultaneous graft replacement of aortic root and total arch. The aortic root was replaced with composite graft and coronary arteries were implanted using Carrel's patch technique, and the aortic arch was also replaced with a graft with two side branches. The postoperative course was uneventful without complication of cerebral infarction or paraplegia. The postoperative aortogram showed stenosis of the left carotid artery, but no abnormality of the coronary orifices and graft anastomosis. She returned home with disappearance of symptoms of congestive heart failure.

[Surgical treatment of mycotic coronary artery aneurysm associated with infective endocarditis: a case report].

53-year-old male was introduced our hospital for treatment of his infective endocarditis and congestive heart failure. Further evaluation revealed massive destruction of the mitral valve and aneurysm of the right coronary artery. We carried out an operation of aneurysmectomy and CABG with RGEA for coronary artery, and MVR using 29 mm SJM valve. Postoperative course was excellent. Graftgram showed good patency and perfusion of RGEA. Pathological findings were 1) macrophage infiltration into thrombi, 2) disappearance of elastic fibers of the media. 3) least atherosclerosis of the intima. We concluded that it was a mycotic coronary artery aneurysm. There have been no report of surgical treatment of such a mycotic coronary artery aneurysm upon our investigation.

[The graft replacement of the patient with aortic arch aneurysm and thrombosed aortic dissection].

The patient was male and aged 68 years and complained of dyspnea and chest pain. He was pointed out aortic arch dilatation on chest X-ray and CT demonstrated aortic arch aneurysm accompanied with acute type IIIb aortic dissection. One month later after anti-hypertensive therapy, the false lumen of aortic dissection was closed with thrombus. While we performed the graft replacement to the aortic arch aneurysm, the thrombosed false lumen was recanalized, so it needed the closure of the false lumen reinforced with teflon felt. Postoperative angiography showed no abnormality of anastomosis and complete occlusion of the false lumen.

[Aortic root replacement in twin Marfan patients].

We have performed aortic root replacement in twin Marfan patients. They were male and aged 33 years at the times of the operations. One had pneumonia but the other had no complaints. Echocardiography showed geometries typical of annuloaortic ectasia (aortic diameters of 6.4 and 6.8 cm) and a moderate degree of aortic insufficiency. Aortic roots were replaced utilizing composite valve graft and the coronary orifices were reimplanted with Carrel's patch technique. The operations were carried out at almost the same time. The patients had a satisfactory postoperative course. Because of the potential for late dissection or aneurysm in other areas of the aorta, they should have regular follow-up examinations by MRI and CT indefinitely.

[Two cases of surgically treated malignant primary tumors originated from the pulmonary artery].

Two surgically treated cases of malignant tumors which originated inside of the pulmonary artery were reported. A 62-year-old female with an undifferentiated sarcoma and a 24-year-old male with a malignant fibrous histiocytoma were successively operated on in two months for the release of their chief complaints of exertional dyspnea. In the first case the tumor was resected completely, although partially resected in the second case. Preoperatively, noninvasive examinations including the echocardiography, the computed tomography and the magnetic resonance imaging confirmed the presence of these tumors in the main pulmonary arteries in both cases and also the invasion to the vessel wall with the growth to the pericardial cavity in the second case. Both patients are doing well and has been followed up at the out-patient department 22 and 20 months after surgery, respectively.

[A case of left ventricular-right atrial communication complicated with aortic regurgitation caused by active infective endocarditis].

A 63-year-old man with cough and shortness of breath was diagnosed to have active infective endocarditis resulting in acute pulmonary edema with aortic regurgitation caused by a huge vegetation on the noncoronary cusp and left ventricular-right atrial (LV-RA) communication which were demonstrated by the echocardiogram and color doppler method. The LV-RA communication located at the atrioventricular portion of the membranous septum was closed with GoreTex patch through the right atrium combined with the aortic valve replacement with a bileaflet mechanical valve in emergency. The bacteriological studies demonstrated staphylococcus epidermidis. The postoperative course was uneventful and the patient is now on regular duty two years after surgery.

[Successful surgical treatment in a case of complete rupture of the posterior papillary muscle of the mitral valve caused by infective endocarditis].

Forty three year-old male who had cough and easy fatigability since three weeks prior to admission was diagnosed to have acute pulmonary edema with severe mitral regurgitation caused by active infective endocarditis. Transesophageal echocardiograms under the endotracheal intubation for controlled respiration suggested rupture of the posterior papillary muscle of the mitral valve and the emergency surgical treatment was performed. Intraoperatively the total rupture of the posterior papillary muscle was confirmed and mitral valve replacement was carried out with a SJM prosthetic valve. Histological examination of the ruptured papillary muscle revealed hemorrhage, muscle necrosis and small cell infiltration suggesting the presence of active inflammation with bacteria on it. Staphylococcus epidermidis was demonstrated by the bacteriological studies of the ruptured papillary muscle.

Protective effects of 2,3-dimercaptopropane-1-sulfonate on mercuric chloride-induced acute inhibition of enzymes from rat duodenal mucosa and kidney cortex.

Acute inhibitory effects of mercuric chloride on the activities of several enzymes from rat duodenal mucosa and kidney cortex and the protection provided by 2,3-dimercaptopropane-1-sulfonate (DMPS) were examined. Activities of carbonic anhydrase in homogenate, brush border and cytosol and of Mg(2+)-dependent, HCO3-stimulated ATPase in homogenate and brush border of duodenal mucosa and kidney cortex and activities of kidney microsomal Mg(2+)-dependent, Na(+)-K(+)-stimulated ATPase were all decreased following administration of HgCl2 (1-3 mg Hg/kg body weight s.c. once daily for 3 days). Decreases occurred generally in a dose-dependent manner and went back to near normal or normal levels by the combined administration of 20 and 30 mg DMPS/kg per day for 3 days. The concentration of serum urea nitrogen was increased about 8 times by the administration of 2 mg Hg/kg and restored to normal by the concomitant administration of 30 mg DMPS/kg. After the administration of 2 mg Hg/kg per day for 3 days, about half of the renal cortical proximal tubuli were necrotic. Administration of 30 mg DMPS/kg restored these changes to almost normal. The results suggest that DMPS is useful in mitigating acute Hg poisoning and that part of the protective effect of DMPS on enzyme damage induced by Hg poisoning may be due to its chelating action.

[Surgical repair of descending aortic aneurysms--experience in 100 patients under partial cardiopulmonary bypass].

Between 1975 and 1986, 100 consecutive patients with aneurysms of the descending thoracic (84 cases) or the thoracoabdominal aorta (16 cases) underwent surgical repair. Intraluminal graft inclusion procedure was employed in principle under routine circulatory support with partial cardiopulmonary bypass. In this study, overall surgical results were reviewed, and multiple factors discriminately contributing to early results were assessed using multivariate analysis (quantification theory type II) to determine if this therapeutic modality is pertinent. Fifty-five patients had non-dissecting, 42 had dissecting aneurysms and 3 had pseudoaneurysms. Seventeen patients were treated in the emergency setting. Perioperative or early deaths occurred in 14 patients. Mortality increased with advanced age (greater than 70 years) and with atherosclerotic aneurysms, especially when they involved the entire thoracic or thoracoabdominal aorta. Operative mortality during the last 5 years of the study was 9.3%: significantly lower than the figure in the first 5 years of 28% (p = 0.0198). The incidence of renal dysfunction (7.4%) or paraplegia (2.1%) was not related to aortic cross-clamp time, and both were markedly decreased to 3.8% and 0.0%, respectively, when the cases of thoracoabdominal aneurysms were excluded. There were 8 cases of exploration for postoperative hemorrhage and 6 cases of pulmonary insufficiency requiring more than 3 days of mechanical ventilation. Prolonged bypass time was a discriminative risk factor for these two complications. Cerebral vascular accidents developed in 5 patients, three of them terminated in death. In spite of partial bypass, the factors of advanced age, atherosclerosis, and cross-clamp on the aortic arch were defined responsible for brain stroke.(ABSTRACT TRUNCATED AT 250 WORDS)