[Left atrial myxoma combined with coronary artery bypass grafting].

We experienced 2 cases of surgical treatment for left atrial myxoma combined with coronary artery bypass grafting (CABG) using only in situ arterial grafts. A 58-year-old man who had undergone CABG [left internal thoracic artery (LITA)-right coronary artery (RCA) and saphenous vein graft (SVG)-left anterior descending artery (LAD)] 14 years before was admitted to our hospital, complaining of anterior chest pain. Coronary arteriography demonstrated total occlusion of the LAD and RCA, as well as the stenosis of high lateral branch (HL) and SVG. Left atrial myxoma was incidentally detected by echocardiography. Myxoma was resected at first, and then the right internal thoracic artery (RITA) was anastomosed to the LAD. The postoperative course was uneventful. A 69-year-old woman was admitted to another hospital, complaining of chest pain and dyspnea. Coronary arteriography revealed stenosis of LAD, left circumflex artery (LCx) and HL, as well as left main trunk (LMT). Left atrial myxoma was incidentally detected by echocardiography. Myxoma was resected at first, and then CABG [LITA-HL, gastroepiploic artery (GEA)-RCA and RITA-LAD] was carried out. The postoperative course was uneventful. The priority between CABG and the surgical treatment for cardiac myxoma remains controversial from the point of view of myocardial protection and prevention of systemic embolism of myxomal fragment.

Cardiac transplantation following a 24-h preservation using a perfusion apparatus.

BACKGROUND: We developed a new apparatus for heart preservation and have already reported successful transplantation following 12 h of preservation using this apparatus. The efficacy of coronary perfusion with an oxygenated Celsior solution was investigated through transplantation following 24 h of preservation using the apparatus. MATERIALS AND METHODS: After being harvested, grafts were preserved with a combination of immersion in a 4 degrees C Celsior solution and perfusion with an oxygenated Celsior solution using the apparatus in the coronary perfusion (CP) group and simply immersed in a 4 degrees C Celsior solution in the simple immersion(SI) group. beta-Adenosine triphosphate (beta-ATP), phosphocreatine (Pcr), and inorganic phosphate (P(i)) levels and myocardial pH (pH(i)) were measured immediately after the heart was excised and at 12 and 24 h after preservation. Following preservation, orthotopic transplantation was performed. Cardiac function was measured 2 h after weaning from cardiopulmonary bypass (CPB). RESULTS: beta-ATP/P(i), Pcr/P(i), and pH(i) levels were significantly higher in the CP group than in the SI group at 12 and 24 h after preservation. Four of six animals in the CP group and two of six in the SI group were successfully weaned from CPB. The recovery rates of cardiac function were better in the CP group than in the SI group. CONCLUSION: Twenty-four hours of heart preservation may be possible with a combination of immersion in a 4 degrees C Celsior solution and perfusion with an oxygenated Celsior solution using the perfusion apparatus.

Reconstruction of heavily calcified aorta and its visceral branches without extracorporeal circulation.

A 61-year-old Japanese female was referred to our hospital for surgical treatment of a localized heavily calcified abdominal aorta. Preoperative angiograms and computed tomograms revealed severe stenosis of the aorta, resembling a slit. Bypass grafting between the thoracic and abdominal aorta was successfully performed together with the reconstruction of the celiac artery, superior mesenteric artery, and bilateral renal arteries without extracorporeal circulation. Postoperative angiograms showed patency of the graft and branches. A localized heavily calcified abdominal aorta is relatively rare, and the cause of this entity might be Takayasu's aortitis.

[Mapping-guided focal cryoablation and endoaneurysmorrhaphy for a case of ischemic ventricular tachycardia with left ventricular aneurysm].

A 74-year-old woman admitted with exertional dyspnea. Echocardiography revealed the giant left ventricular aneurysm. In the hospital course, she fell into sustained monomorphic ventricular tachycardia. Coronary angiogram showed complete obstruction of the LAD. Left ventricular ejection fraction was 20%. The origin of tachycardia seems to be at infero-apicallateral area of LV by electrophysiology study. Because of the failure of RF energy ablation, we planned mapping-guided cryoablation, CABG and endoaneurysmorrhaphy. To prevent air embolism and myocardial ischemic damage for long aortic cross clamp, intraoperative endocardial mapping was carried out on beating heart due to continuous normothermic coronary blood perfusion (300 ml/min) from the aortic root cannula under aortic clamping. Cold crystalloid cardioplegia changed into the root cannula after EPS, focal cryoablation (-100 degrees C) was performed 3 times on cardiac arrest. Sustained VT was not inducible in the following study. CABG and endoaneurysmorrhaphy was performed on repeated cardiac arrest during single aortic clamp. Postoperative course was uneventful, and she discharged 8 weeks after the operation.

[A case report of type A dissection of the aorta presenting as a superior vena cava syndrome 10 years after aortic valve replacement].

Aortic dissection usually result in chest pain and back pain. This patient is a 58 year-old man who received aortic valve replacement for aortic regurgitation 10 years ago. In this case, the patient had superior vena cava syndrome as a result of a painless aortic dissection. The superior vena cava was compressed by the ascending aorta itself, which had become very large but had not ruptured into the mediastinum. He underwent modified Carbrol's operation under hypothermic cardiopulmonary bypass and circulation arrest on May 8, 1995. Dissecting aneurysm in the late term after aortic valve replacement is rare, and for it to result in superior vena cava syndrome is especially rare.

[Surgical treatment of malignant hemangioendothelioma originated from the right atrium: a case report].

A 32-year-old man was admitted to our hospital because a cardiac tumor had been pointed out by a physician. CT scans showed a mass lesion with irregular patterns in the right atrium. The patient had the diagnosis of a malignant cardiac or pericardial tumor and an operation was performed. The mass originated from the right atrium included massive coagulated blood, and was resected with the pericardium and the right pleura. The histological diagnosis was malignant hemangioendothelioma. We present this case because only 35 patients with cardiac malignant hemangioendothelioma were reported in Japan.

[Aortic regurgitation due to ruptured fibrous band in the noncoronary cusp: a case report].

A 67-year-old man with aortic regurgitation underwent aortic valve replacement with a 25 mm St. Jude Medical artificial valve. Intraoperative observation found several ruptured fibrous bands between the noncoronary cusp and sino-tubular ridge over the left noncoronary commissure. The same structure was observed at the left cusp, which were not ruptured. The ascending aorta was dilated to about 4 cm in diameter, so was wrapped with an artificial graft to prevent aneurysmal change. Pathological examination revealed chronic valvulitis and degenerative change at the aortic valve, and idiopathic medial degeneration at the aortic wall.

[Mediastinal schwannoma originating from the intrathoracic vagal nerve--a case report and review of the literature].

A 31-year-old woman was operated upon with the diagnosis of mediastinal tumor. The resected specimen revealed pathologically benign schwannoma originating from the right intrathoracic vagal nerve. The postoperative course was uneventful with no complication. Mediastinal schwannoma arising from the vagal nerve is rare. We discussed characteristics of this disease and reviewed the Japanese literature.

Screening for abdominal aortic aneurysm and occlusive peripheral vascular disease in Japanese residents.

To evaluate the prevalence of abdominal aortic aneurysm (AAA) and occlusive peripheral vascular disease (PVD) in Japanese residents, and to examine the correlations between these diseases and the risk factors of atherosclerosis, 348 residents of a village in central Japan aged between 60 and 79 years were screened. The screening for AAA was performed using ultrasonography (US) and that for PVD was performed by palpation and Doppler US. No AAA was found, and a right common iliac arterial aneurysm was detected in a 79-year-old man (0.3%). The mean diameter of the infrarenal abdominal aorta was 18.7 mm and an abdominal aorta of 25 mm or greater in diameter was seen in 16 participants (4.6%), all of whom need to be followed up. PVD was suspected in two patients (0.6%) with a low ankle brachial pressure index. Of a total of five patients diagnosed or suspected of having a common iliac arterial aneurysm or PVD, four (80%) had at least one risk factor for atherosclerosis. Thus, we conclude that Japanese residents with risk factors predisposing them to atherosclerosis such as hypertension, obesity, abnormal serum lipid levels, and a history of smoking should be selectively screened for AAA and PVD due to the low prevalence of these diseases and from the viewpoint of cost-effectiveness.

[A concomitant operation of coronary artery bypass grafting and thymectomy: a case report].

A 63-year-old man was successfully operated upon concomitantly for coronary artery disease and invasive thymoma. The chest roentogenogram showed a mass shadow in the anterior mediastinum, which was 6.0 x 4.0 cm in size and irregular. Coronary angiography revealed complete obstruction of the right coronary artery and 90% stenosis of the first diagonal branch (#9). Following thymectomy combined with the resection of the left phrenic nerve and the mediastinal pleura, coronary artery bypass grafting with the major saphenous vein was performed to #4 PD and #9. This is the first report of concomitant surgery for the ischemic heart disease and invasive thymoma in Japan.

[Long-term results after surgical repair for aged atrial septal defect].

Between 1980 and 1992, 84 patients over 30 years were underwent operative closure of atrial septal defect (ASD). Preoperative complaints and lower cardiac function were more frequent in the older than in the younger, but the clinical symptom of both generation improved significantly after surgery. Only a 67-year-old patient died after surgery due to low cardiac output syndrome. No long-term death occurred. The incidence of atrial fibrillation was increased postoperatively compared with preoperatively. Therefore, we recommend early surgical repair for aged ASD before thirties, if possible.

[The transverse submammary skin incision for median sternotomy].

Median sternotomy is the incision of choice to allow access to the anterior mediastinum, heart or both lungs. The vertical skin incision is cosmetically unsatisfactory for many female patients. The transverse submammary skin incision with dissection of a flap including the subcutaneous tissue and breasts allow exposure of the sternum for a median sternotomy. Seventy patients with the transverse submammary skin incision was compared with 56 patients with the vertical skin incision in the point of the cosmetic aspect and satisfaction of patients. The transverse submammary skin incision needed a longer wound size and took a longer time for cardiopulmonary bypass, but there were no difficulties in cannulating the ascending aorta for cardiopulmonary bypass. The exposure of the mediastinum and the cosmetic result were excellent. The complications associated with this incision are insignificant if close attention is paid to details.

[Surgical treatment of active infective endocarditis with aortic root abscess, left ventricular and right atrial fistulae--report of a child].

Aortic valve replacement with a 17 mm Björk-Shiley prosthetic valve, and the closure of left ventricular and right atrial fistulae which were connected with the aortic root were successfully performed in a 10-year-old boy. He was admitted because of high fever and severe heart failure, and diagnosed aortic regurgitation, and left ventricular and right atrial fistulae due to active infective endocarditis. The annular defect was repaired with annular enlargement by a pericardial patch and annulo-right atrial fistula was directly closed from the right atrium. The patient is doing well 1 year after surgery.

[Effect of extended thymectomy in myasthenia gravis of pure ocular type].

The effect of extended thymectomy in myasthenia gravis of pure ocular type was investigated in 13 patients, who were divided into the surgical group of nine and the conservative group of four. In the surgical group, the onset was at 47 +/- 20 years old. The preoperative duration of symptoms was 4 +/- 6 years. The age at the time of operation was 51 +/- 16 years old. Three patients had thymomas, including one malignant thymoma. Acetylcholine receptor antibody titer was over normal range with 34.0 +/- 49.7 nmol/l. No postoperative crisis occurred. The palliation rate of the surgical group was more higher through the whole period than that of the conservative group, and increased with progress of the course. The remission occurred in the surgical group, but did not in the conservative group. It took 7 months to improve the symptom in the surgical group, while 18 months in the conservative group. We conclude extended thymectomy is reasonable for patients with myasthenia gravis of pure ocular type.

[Surgical treatment of elderly patients with primary lung cancer].

Fourteen patients with lung cancer over the age of 70 years had the standard operation with mediastinal lymph node dissection. Their postoperative complications and prognoses were compared with those of 47 patients under the age of 70 years with the same operation. The propriety of the standard operation with mediastinal lymph node dissection for lung cancer in elderly patients was studied. A program of respiratory training was arranged preoperatively for the patients. Preoperative complications was more common in elderly than in younger patients, but postoperative complications were less frequent. The prognosis in elderly patients was also satisfactory. We conclude that the standard operation with mediastinal lymph node dissection for lung cancer can be performed as well in elderly as in younger patients.

[A case of peritonitis carcinomatosa due to advanced gastric cancer effectively treated by intraperitoneal injection of carboplatin].

The patient was a 72-year-old woman who had advanced carcinoma of the stomach. She presented massive ascites due to peritonitis carcinomatosa. The cytology of ascites was class V and the CEA level of ascites was elevated. Since renal function was low, we injected 300 mg of carboplatin intraperitoneally 2 times in 8 weeks. The amount of ascites was significantly diminished and the CEA level of ascites was decreased. The result suggested the effectiveness of intraperitoneal injection of carboplatin for the therapy of peritoneal metastasis of gastric cancer.