[Emergency coronary artery bypass grafting with integrated myocardial protection].

In the following retrospective study we reviewed the early postoperative results of emergency CABG; the myocardial management was achieved by utilization of integrated myocardial protection including warm cardioplegic induction, performed at our hospital. From April 1st 1994 to October 30th 1998; 63 patients underwent emergency CABG with integrated myocardial protection. All surgical procedures were performed within 6 hours from the onset of disease or admission transferred from another hospitals. Age ranged 48 to 86 years (mean 69.9 +/- 8.5; 41 male, 22 female). AMI was present in 52, UAP in 11. Preoperative PTCA was done in 20 and IABP was inserted in 53. Cardiogenic shock in 26, mechanical complications in 6, three vessel disease in 48 and LMT disease in 17 was present. Eight patients (12.7%) died in the early postoperative period. Among evaluated risk factors for early postoperative death; the occurrence of cardiogenic shock, mechanical complications of AMI, preoperatively done PTCA and prolonged CPB time were significantly increasing the mortality rate in early postoperative death.

[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.

[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.

[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.

[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.

[Aortic arch aneurysm: new modification of aortic arch reconstruction and selective cerebral perfusion].

Selective cerebral perfusion (SCP) has been widely used as the method for cerebral protection during aortic arch repair in the treatment of aortic arch aneurysms in our institution. Recently, we modified our technique of aortic arch reconstruction and SCP in order to reduce the neurological complication. Following institution of SCP into both innominate and left common carotid arteries at 22 degrees C, the distal graft anastomosis and left subclavian reconstruction were performed while the descending aorta was left opened. Then the antegrade perfusion with rewarming was started via the fourth limbs attached to the main graft instead of the femoral artery. The aortic arch was completely replaced with the graft with three limbs for arch vessels. During one-year period from December 1993 to November 1994, 30 patients were operated on for aortic arch aneurysms using this technique. The etiology of aneurysms was true aneurysms in 16 patients, and aortic dissection in 14 including 8 cases of acute dissection. The concomitant procedures included descending graft replacement in 11 patients, composite graft replacement in 5, CABG in 3, and AVR in 1. The hospital mortality was 3.3% (1 of the 30 patients). There was no neurological complication. We conclude that the present techniques are useful methods for preventing the neurological complication in the treatment of aortic arch aneurysms.

[Surgical repair of distal aortic arch aneurysm with hypothermic retrograde cerebral perfusion through standard left postero-lateral thoracotomy].

Five patients with aneurysm involving distal aortic arch underwent graft replacement of distal aortic arch and, in two patients, reconstruction of left subclavian artery through standard left postero-lateral thoracotomy with hypothermic retrograde cerebral perfusion. Retrograde cerebral perfusion with oxygen saturated venous blood could be performed by simply elevating central venous pressure to 20-23 mmHg in the Trendelenburg position and under controlling venous drainage from PA during deep hypothermic (19 degrees C) perfusion of the lower half of the body with the descending aorta occluded. Cardioplegia was induced by administration of cold blood cardioplegic solution into coronary circulation through Foley balloon catheter wedged in ascending aorta. Retrograde cerebral perfusion time was 30-77 min (mean 55 +/- 17 min), and pump time was 156-193 min (mean 168 +/- 15 min). There were no complications neurologically. In conclusion, this method rendered surgical repair of distal aortic arch aneurysm through left postero-lateral thoracotomy with both cerebral and cardiac protection able. Since any clamping of aortic arch and its branch was not necessary during above surgical procedure, cerebral emboli due to atheroma or luminal thrombus in aortic arch was prevented.

[Hemodynamic effects of Amrinone in patients following open heart surgery].

The hemodynamic effects of amrinone, a phosphodiesterase III inhibitor, were studied early after cardiac surgery in 10 patients. CI, SVI and SWI increased significantly. SAP, mPCWP, TSVR and PVR decreased significantly. DO2 and VO2 increased significantly. HR and DP were not affected. These data demonstrate that amrinone is a valuable inotropic agent with vasodilating effect for the early post-operative management of cardiac surgical patients, since it augments left ventricular performance without increase of myocardial oxygen consumption and induction of arrhythmia.

[Surgical treatment of aortitis syndrome associated with annuloaortic ectasia and the stenotic lesion of the aortic arch vessels].

A 37-year-old woman was admitted to our hospital for treatment of aortitis syndrome. Her aortogram showed critical stenosis of the innominate artery, occlusion of other arch vessels, and annuloaortic ectasia (AAE). We performed endarterectomy and patch plasty to the innominate artery using a saphenous vein graft. Graft replacement of the ascending aorta and AVR (modified Wheat's operation) were also performed at one stage. Deep hypothermic cerebral circulatory arrest was used as a method for cerebral protection. During operation, the lowest rectal temperature was 17 degrees C and the cerebral circulatory arrest time was 36 min. The postoperative course has been uneventful. In a postoperative aortogram, the innominate artery was well perfused. She has been free of complaint and been doing well for 2 years since the operation.