[Thrombectomy of subacute pulmonary thromboembolism under extracorporeal circulation: report of a case].

A 63-year-old man was admitted to a hospital for sudden loss of consciousness. Chest computed tomography (CT) revealed massive pulmonary thromboembolism. Heparin sodium and urokinase were administered, but were not effective. He was then referred to our hospital. His oxygen saturation was 88% in room air. Due to presence of severe hypoxemia and ineffectiveness of the antithrombotic therapy, thrombectomy was done under extracorporeal circulation. Postoperative course was uneventful, and he was discharged on the 24 th postoperative day. Oxygen saturation on discharge was 98% in room air. In conclusion, thrombectomy of subacute pulmonary thromboembolism was performed successfully under extracorporeal circulation.

[Bentall operation for the annuloaortic ectasia which merged liver cirrhosis and pericarditis; report of a case].

We report a case of successful aortic root replacement using a stented bioprosthetic valved conduit and pericardiectomy in a patient with liver cirrhosis and constrictive pericarditis. A 72-year-old man treated for alcoholic liver cirrhosis was referred for the aortic regurgitation and dilatation of sinus of Valsalva. He underwent Bentall operation using a stented bioprosthetic valved conduit and pericardiectomy successfully. For patients whose anticoagulation is contraindicated, aortic root replacement using valved conduit with bioprosthesis is useful option. Concomitant pericardiectomy for constrictive pericarditis may provide better long-term results.

[Dissecting aneurysm of ventricular septum following acute inferior myocardial infarction].

Dissecting aneurysm of the ventricular septum as a complication after myocardial infarction (MI) is very rare. The patient was a 70-year-old women who was diagnosed with acute inferior MI. Three months after MI, catheterization showed a left ventricular aneurysm of the inferior wall, and left-to-right ventricular shunt flow was detected in the aneurysm. Echocardiography showed that the inferior left ventricular free wall was aneurysmal and dissected from the septal wall. Nine months after MI, chronic heart failure was uncontrollable by medication. At surgery, a tear (5 mm long) in the dissecting aneurysm of the ventricular septum was found and closed directly using 2 felt patches, and aneurysmectomy was performed using felt strips. The postoperative course was uneventful and she has been free from any complication for over 1 year.

Thrombectomy and SVC reconstruction due to infective thrombus.

We report a case of thrombectomy and reconstruction of superior vena cava (SVC) in a patient presenting sepsis and SVC syndrome by infective thrombus. A 58-year-old woman presented sepsis and edema of the neck and left upper extremity during treatment of multiple organ failure. Sepsis by Serratia persisted in spite of appropriate antibiotic treatment. Computed tomography of the chest revealed thrombi that narrowed the SVC with obstruction of the left brachiocephalic vein. Removal of the infective thrombi followed by SVC reconstruction with autologous pericardial patch was performed. Postoperative period remained uneventful.

[A case report of extended thoracoabdominal graft repair for dissecting aneurysm (DeBakey Type IIIb) with visceral ischemia].

A 62-year-old man diagnosed as dissecting aneurysm (DeBakey type IIIb) with visceral is chemia was transferred to our hospital. He had suffered from abdominal pain and the absence of right femoral pulse. Emergent laparotomy revealed no evidence of visceral infarction. Right axillo-femoral bypass was performed. However, visceral ischemia gradually progressed. Enhanced CT and angiography showed that celiac artery and supramesenteric artery (SMA) were collapsed. He underwent graft replacement of thoracoabdominal aorta involving visceral arteries with femoro-femoral bypass with a centrifugal pump as an ajunct. The visceral arteries were reconstructed. Postoperative CT revealed sufficient flow of branch arteries. He recovered well without complication and then discharged.

[A re-operative case of bentall operation and aortic arch replacement using a stent graft for a Marfan syndrome, post sternum turnover and post mitral valve replacement].

A 36-year-old male with Marfan syndrome succesfully underwent Bentall operation and aortic arch replacement using a stent graft as an elephant trunk. He had received MVR with sternum turn over 14 years previously. Median sternotomy was performed. Under circulatory arrest with rertograde cerebral perfusion we performed Bentall operation and aortic arch replacement using a stent graft. The sternum was cured well. Retractive breathing was not detected. This surgical procedure was effective for cardiovascular disease with Marfan syndrome.

[Early and mid-term results of elephant trunk method using stent graft during total arch replacement].

Combined therapy of stent graft implantation and open surgery is an alternative method for aortic aneurysm. Seven patients with aortic aneurysm [annulo aortic ectasia (AAE) + Marfan syndrome (4), AAE + arch aneurysm + s/o Behçet disease (1), acute dissected aneurysm (type A) (1), thoracic aortic true aneurysm (1)] were successfully treated by means of elephant trunk method using a stent graft during total arch replacement. There was no complication related to the stent graft during the perioperative period. Postoperative computed tomographic scans were performed 1 and 6 months later. There was no endleak and no migration, and the aortic diameter around the stent graft was not changed in six patients. However, one patient showed thrombus around the stent graft, because of endleak 2 months after the operation. Such patients should therefore have careful long-term follow-up.

Coronary artery bypass grafting in 105 patients with hemodialysis-dependent renal failure.

This study was proposed to define early and long-term results of coronary artery bypass grafting (CABG) in dialysis-dependent renal failure (RF) patients, and preoperative patient characteristics. This study included 105 patients (87 males and 18 females; mean age 60.0 +/- 9.0 years, range 39-79) with RF on maintenance dialysis (hemodialysis 100, peritoneal dialysis 5) who underwent isolated CABG between August 1985 and April 2000. Postoperative follow-up was completed in 100% and averaged 3.1 years. There were 22 emergency and 2 re-CABG cases. Previous myocardial infarction (MI) was found in 55 patients (52%), and unstable angina was noted in 53 patients (50%). Diabetes mellitus was the cause of RF in 50 patients (48%; 24 patients required insulin). There was 1 case of single vessel disease, 31 cases of double vessel disease, 54 cases of triple vessel disease, and 19 cases of left main disease. Preoperative left ventriculography was performed in 92 patients (88%). Left ventricular ejection fraction (LVEF) was 48.3 +/- 15.8% (range 11-74%) and was 40% or less in 25 patients (27%). The mean number of distal anastomoses was 2.5 (range 1-5). Three patients received only vein grafts, but all were cases of emergency CABG. The remaining 102 patients (97%) received at least 1 arterial conduit. Among them, 64 patients received only arterial conduits, and 72 patients received 2 or more distal anastomoses with arterial conduits. Five patients (4.8%) died within 30 days after CABG (2 cardiac deaths and 3 noncardiac deaths), and 8 patients (7.6%) died beyond 30 days after CABG before discharge (all noncardiac deaths). The cause of 2 cardiac deaths was abrupt circulatory collapse during or after hemodialysis in patients with severe left ventricular dysfunction (LVEF; 11% and 28%) in the early postoperative period. The causes of 8 noncardiac deaths included infection in 4 and rupture of aortic aneurysm, stroke, sleep apnea syndrome, and mesenteric infarction. During the follow-up period, there were 29 late deaths (8 cardiac, 13 noncardiac, and 8 sudden death), 6 MIs, 13 percutaneous transluminal coronary angioplasty, and 1 re-CABG. The 5-year actuarial survival rate was 59.8%, the cardiac death-free rate was 83.0%, and the cardiac event-free rate was 62.4%. Although CABG in patients on hemodialysis is associated with high early and long-term mortality in terms of both cardiac and noncardiac deaths in proportion to the severity of the preoperative condition, long-term survival was still better than that of general dialysis patients. Meticulous perioperative management may be the key factor in the improvement of early results.

Re-use of left internal thoracic artery for redo operation after MIDCAB.

We report a case of recycling of left internal thoracic artery (LITA) in situ in reoperation of coronary artery bypass grafting. A 41-year-old male, who has poor-controlled hypercholesterolemia, was bypassed LITA to the left anterior descending artery (LAD) in minimally invasive direct coronary artery bypass (MIDCAB) manner at the other hospital. Four months later, he felt short of breath on effort. Coronary angiogram showed stenoses of the left main trunk and anastomosis site of the LITA. At redo operation, we skeletonised the LITA and reused it in situ to the LAD. Using the skeletonised method for re-harvesting LITA made the graft reach a more distal portion without tension. He is doing well at 18 months after surgery. In selected patients, recycling of the used arterial grafts can reserve other arterial grafts for redo operations in the future.

[Early and late results of combined valvular and coronary artery operations].

A total of 122 patients with ischemic heart disease underwent valvular surgery. Thirty-nine had combined CABG and aortic valve surgery (included Bentall method), 72 had CABG and mitral valve operations, and 8 patients had CABG and double or triple valve operations. Only 3 patients for ruptured papillary muscle due to acute myocardial infarction had isolated mitral valve replacement. Early mortality was 5.1% AV, 2.8% MV and 12.5% DTV in the combined groups and 0% in the valve only group. The grafts patency rate was 93.5%. Univariate analysis of risk factors selected in the dialysis patients and the patients age older than 65 years as the strongest predictors for early death. At the mean follow up period of 5.4 +/- 4.8 year after surgery, the 5-year all death free rates were 57.9 +/- 9.6% AV, 69.6 +/- 5.8% MV and 75.0 +/- 15.3% DTV. The 5-year cardiac death free rates were 73.8 +/- 9.0% AV, 77.5 +/- 5.4% MD and 75.0 +/- 15.3% DTV.

[Four cases of third time operation of coronary artery bypass grafting].

Reoperative coronary artery bypass operations are increasing in frequency. Consequently, an ever-increasing pool of patients now is being seen with need of coronary revascularization for repeated time. Four cases of second reoperation were retrospectively investigated. Until March 1999, 2,563 cases of isolated coronary artery bypass grafting were done at the Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan. Within those cases, 124 cases (4.8%) were reoperated. And among those 124 cases, 4 cases (3.2%) were secondly reoperated. There were one hospital death and two had a perioperative myocardial infarction. All of them needed intraaortic balloon pump support after operation. Three were discharged with relief of the symptoms. The average age at the primary operation was 51.1 years. All these cases, at the primary operation, no ITA graft was used. Two cases were incompletely revascularized, because of coronary arteries were ungraftable. Both at reoperation and at second reoperation, we are trying to make a complete revascularization by all arterial grafts. But because of limited number of arterial graft at repeated operation, all arterial complete revascularization is not done without difficulty. Therefore it is concluded that saphenous vein graft is still needed at repeated operation.

[Open heart surgery in three patients receiving dialysis for more than 20 years].

In Japan, the number of chronic hemodialysis (HD) patients is increasing, and there are 7,000 cases with a more than 20 year history of HD. At our institute, we have experienced 135 cases of open heart surgery in patients on HD, including 92 isolated CABG cases and 43 other open heart surgery cases. However, open heart surgery for patients with a more than 20 year history on HD is rare. Open heart surgery on HD patients is rather difficult, since perioperative management can be complicated and special care must be taken for prophylaxis of infection, fluid and electrolyte management and anticoagulation therapy. Many complications have been published in HD patients. At our institute, 3 cases of open heart surgery in patients with more than a 20 year history of HD have been performed. These included triple CABG, double CABG + AVR and double CABG in a post-kidney transplantation patient. They were discharged uneventfully with angiographically patent grafts. It is concluded that for CABG in patients on HD, aggressive use of arterial conduits for revascularization is recommended. For patients with a transplanted kidney, careful management against dysfunction and rejection is necessary.

[A case report of total aortic reconstruction and choice of staged operation in Marfan syndrome].

A 37-year-old man with Marfan syndrome underwent four operations for extensive cardiovascular disease. He was diagnosed as having AAE, AR and DeBakey type I aortic dissection. First, Bentall operation using Piehler procedure and total aortic arch replacement using retrograde cerebral perfusion and profound hypothermia at 18 degrees C were performed on May 11, 1994. Second, repair of leakage of the right coronary artery anastomosis and grafting for the descending thoracic aortic aneurysm were performed on December 3, 1994. Y-type grafting for the AAA was performed on December 21, 1996. Last, grafting for TAAA was performed under hypothermia at a rectal temperature of 20 degrees C on November 17, 1997. This surgical strategy of staged operation for extensive cardiovascular disease in Marfan syndrome is an effective method. Regular follow-up by CT is necessary for deciding the time and method of reoperation.

Minimally invasive cardiac surgery in the adult: surgical instruments, equipment, and techniques.

To clarify the special instruments and equipment used for minimally invasive cardiac surgery (MICS), we examined the initial experiences with MICS operations with ministernotomy or minithoracotomy at our institution. Fifty adult patients with congenital, valvular, and/or ischemic heart diseases underwent MICS operations, and all surgical procedures were completed without conversion to full sternotomy. The length of the skin incision was about 10 cm or less in all patients. Postoperative recovery was favorable, and the majority of the patients were discharged from the hospital around the end of the second postoperative week. In this series of patients, an oscillating bone saw, lifting type retractor, 2 blade spreader, cannula with a balloon, and right-angled aortic clamp among other items, were very useful for successfully performing various operations with MICS approaches and techniques. The associated results suggest that MICS with ministernotomy or minithoracotomy was feasible using special instruments and equipment and could be encouraged for adult patients with various cardiovascular diseases.

[A surgical case of angina pectoris with a severe stenosis of Lt. mid-cerebral artery: the usefulness of the monitoring of cerebral blood flow].

A 64-year-old male patient had two episodes of transient ischemic attack and a cerebral infarction. Cerebral angiography showed 50% stenosis at the junction of left internal carotid artery and 90% stenosis at left mid-cerebral artery (MCA). Coronary angiography showed two vessel disease with arteriosclerotic change and underwent coronary artery bypass grafting. To prevent intraoperative cerebral infarction, we used brain protect solution just before starting ECC, set perfusion flow around 3 l/min/m2, monitored the flow of left MCA using Transcranial Doppler (TCD) and the saturation of left internal jugular vein (SjO2) continuously. PaCO2 was controlled around 45 mmHg. TCD showed good pulsatile flow, and SjO2 was kept over 60%. The patient recovered consciousness 2 hours after operation in the intensive care unit without paresthesia. We thought the number of open-heart cases with cerebrovascular disease increased, and pulsatile low of ECC by intraaortic balloon pumping and the monitoring of SjO2 are useful for the cases.

[The effect of MS-551 on two VT/Vf patients in CABG: a case report].

Uncontrollable arrhythmia is one of the causes of operative death in CABG. We report two cases of successful treatment of recurrent VT/Vf in CABG operation by MS-551. One case was a 72-year-old male, who had unstable angina and OMI with left ventricular dysfunction (LVEF 24%). After weaning from CPB, the rhythm turned into VT/Vf suddenly. Lidocaine and verapamil were not effective. VT/Vf recurred over the over. The another case was a 52-year-old male, who had OMI and effort angina. He became myocardial infarction during operation. VT/Vf occurred after the weaning from CPB. Lidocaine and amiodarone were of no effect on his VT/Vf. In both cases, intravenous injection of MS-551 promptly stopped VT/Vf. Use of MS-551 was limited mainly on DCM patients. But other antiarrhythmic agents were ineffective on these cases. We have had to continue support circulation for a long time without MS-551. As MS-551 is being used as a trial on medically followed patients, it was unknown how effective clinically on the acute myocardial infarction. In this regard, our cases may suggest a positive answer to that.

Identification and characterization of a novel gene (neurorep 1) expressed in nerve cells and up-regulated after axotomy.

A novel gene, designated neurorep 1, was isolated by differential hybridization screening from a complementary DNA library constructed from the rat facial nucleus whose nerve had been transected seven days before sampling. In situ hybridization revealed that this gene was up-regulated in the repair stage after axotomy. The deduced protein, Neurorep 1, consists of 293 amino acid residues, and its molecular mass is approximately 34,000. Protein sequence motif search indicates that this protein has an ecto-5'-nucleotidase consensus sequence at the carboxyl terminal region. In vitro studies showed that Neurorep 1 significantly increased the activity of ecto-5'-nucleotidase, which is considered to be involved in regeneration and repair of the central nervous system. Neurorep 1 might play a significant role in the repair process of nerve tissues by its regulation of ecto-5'-nucleotidase activity.

Clinical evaluation of pulsatile flow mode of Terumo Capiox centrifugal pump.

The Terumo Capiox centrifugal pump system possesses an automatic priming function in which the motor repeatedly stops and runs intermittently to eliminate air bubbles in the circuit through the micropores of the hollow-fiber membrane oxygenator. By modifying this mechanism, we have developed a pulsatile flow mode. In this mode, maximum and minimum pump rotational speeds can be independently set every 20 rpm in the range of 0 to 3,000 rpm. The duration of the pump run at maximum and minimum speeds can also be independently set every 0.1 s in the range of 0.2 to 15 s. In a clinical trial, after obtaining the desired flow rate, 2.4 L/min/m2 in nonpulsatile flow mode, a pulsatile flow mode of 60 cycles/min (with 1 cycle being maximum speed for 0.4 s and minimum speed for 0.6 s) was obtained by adding and subtracting 500 rpm to and from the rotational speed in nonpulsatile flow mode. Pulse pressures in the femoral artery and in the circuit just proximal to the perfusion cannula (6.5 mm Sarns high flow cannula with metal tip) were measured in 5 patients who underwent pulsatile cardiopulmonary bypass (CPB) for a coronary artery bypass graft (CABG), and compared to pulse pressures obtained by intraaortic balloon pumping (IABP) in 3 patients and by the pulsatile mode of the 3M Delphin pump in 3 patients. The platelet count, free hemoglobin, and beta-thromboglobulin (beta-TG) were measured and compared with measurements from another 5 patients who underwent nonpulsatile CPB. Although the pulse pressure measured in the circuit was 180 mm Hg on average, the pressure in the femoral artery was only 15 to 40 mm Hg with a mean of 20 mm Hg. In the same patients, 60 to 80 mm Hg pulse pressure was obtained with IABP. The pulse pressure obtained with the Delphin pump was not more than that obtained with the Terumo pump. There were no significant differences in percents of preoperative levels of platelet counts (pulsatile, 87.6 +/- 15.8% and nonpulsatile, 72.4 +/- 40.6%), free hemoglobin (pulsatile, 18 +/- 8 mg/dl and nonpulsatile, 25 = 7 mg/dl), and beta-TG (pulsatile 298 +/- 28 ng/ml and nonpulsatile, 312 +/- 143 ng/ml). In conclusion, although the pulsatile mode of the Terumo centrifugal pump did not exhibit any adverse effects hematologically, the pulse pressure obtained was unsatisfactorily small, mainly because of dumping caused by the perfusion cannula.

Coronary artery bypass grafting with both internal thoracic arteries and the right gastroepiploic artery.

From July 1989 to March 1995, 83 patients (79 men, 4 women, mean age 58.3 years, range 35 to 76 years) underwent coronary artery bypass grafting with the both internal thoracic arteries (ITAs) and the right gastroepiploic artery (RGEA). Postoperative follow-up ranged from one to 69 months with a mean of 31 months. Seventy-eight patients (94%) had either triple vessel disease or left main disease. A total of 264 distal anastomoses with arterial grafts were constructed; 90 with the left ITA, 73 with the right ITA, 90 with the RGEA and 1 with the inferior epigastric artery (IEA). An additional saphenous vein graft was constructed in 13 patients including 4 sequential bypass grafting. The mean number of distal anastomoses was 3.4. Postoperative angiography was performed in 80 patients (96%) 3 to 4 weeks after the operation. There were no operative deaths or hospital deaths. No patients developed perioperative myocardial infarction. Graft patency in arterial grafts was 96% (242/253), 95% (80/84) in the left ITA, 100% (82/82) in the right ITA and IEA (1/1), and 93% (80/86) in the RGEA. Graft patency in vein grafts was 99% (84/85) and overall patency rate was 96% (326/338). Four patients (5%) died during follow-up period but all were non-cardiac deaths. Six postoperative percutaneous transluminal coronary angioplasties (PTCA) (7%) and two reoperations (re-CABG) (2%) were required, but no patients developed myocardial infarction (MI). The 5-year actuarial survival rate and cardiac event (cardiac death, MI, PTCA, and re-CABG) free rate was 90.1% and 86.6% respectively. In conclusion, the clinical outcome of the coronary artery bypass grafting with the both ITAs and RGEA was satisfactory in terms of low operative risk, high patency rate, and excellent long-term results.