[An unconscious patients with ascending aortic aneurysm accompanied by aortic regurgitation successfully treated by emergency operation after cardiopulmonary resuscitation].

A-37-year-old woman in shock condition was transferred to our hospital after cardiopulmonary resuscitation for ventricular fibrillation. She was unconscious and suspected of suffering ischemic brain damage, with pathologic reflexes and weak brain stem reflexes. Brain CT scan showed cerebral edema without hemorrhage or infarction and an electroencephalograph revealed slow alpha-theta waves. Chest CT scan and echocardiogram showed ascending aortic aneurysm with sever aortic regurgitation. An emergent operation was performed for progression of heart failure. There were no distortion or dilatation of the sinus of Valsalva and annuloaortic ectasia and aortic valve leaflets were almost normal. We considered that the aortic valve dysfunction was cause by dilatation of the sinotubular junction. Ascending aortic and aortic valve replacement were carried out to shorten cardiopulmonary bypass time and to prevent the progression of brain damage. Mild hypothermia was employed as a neuroprotective procedure for three days after surgery. The patient's neurological symptoms, which were right hemiparesis, facial apraxia and motor aphasia, improved and she was discharged from the hospital on foot without any neurological complications on the 47th postoperative day and returned to work after two months.

Thrombus on the intraluminal felt strip. A possible cause of postoperative stroke.

We report a case of a 60-year-old woman who received an operation for acute aortic dissection and who had a postoperative complication of multiple cerebral infarction. Through aggressive investigation using transesophageal echocardiography, a mobile thrombus on the intraluminal felt strip used for the enforcement of the dissecting aortic wall was detected as the possible source of the cerebral thromboembolism. After anticoagulation therapy was started, the mobile thrombus growing on the intraluminal felt strip disappeared, and no new lesions of cerebral thromboembolism occurred.

Interleukin-2-dependent but not independent T-cell lines infected with human T-cell leukemia virus type 1 selectively express CD45RO, a marker for persistent infection in vivo.

Human T-cell leukemia virus type 1 (HTLV-1) is an etiologic agent of adult T-cell leukemia. HTLV-1 is exclusively detected in CD45RO+ T-cells in infected individuals, but CD45RO is weakly expressed in HTLV-1-transformed T-cell lines in vitro. The aim of this study was to investigate the role of CD45RO in the persistent HTLV-1 infection in vivo. Flow cytometry showed that only two out of eight interleukin(IL)-2-independent HTLV-1-transformed T-cell lines expressed CD45RO, whereas all five IL-2-dependent ones expressed CD45RO, and the level of expression was higher in IL-2-dependent than in IL-2-independent cells. The high CD45RO expression in IL-2-dependent cell lines was not due to IL-2, since IL-2 had little effect on the expression of CD45RO in T-cell lines. Using western blotting, we showed that IL-2-dependent HTLV-1-transformed T-cell lines expressed a lower level of expression of the viral transcriptional regulatory protein Tax than IL-2-independent ones, and that the level of expression correlated inversely with that of CD45RO. However, the expression of Tax in one HTLV-1-negative T-cell line little affected the expression of CD45RO, suggesting that Tax at least alone does not suppress the expression of CD45RO in HTLV-1-infected T-cell lines, and that other viral or cellular factor(s) are probably involved in such suppression. Our results suggest that CD45RO+ Tax-low IL-2-dependent T-cell lines in vitro correspond to the persistent HTLV-1-infected cells in vivo, and HTLV-1-infected cells in vivo are immortalized in IL-2-dependent manner.

Successful reconstruction in a patient with chronic and multisegmental venous obstruction: report of a case.

We describe herein our technique of performing complex venous reconstruction for a patient with chronic, multiple, and long segmental venous obstruction from the left iliac vein to the infrapopliteal deep veins. To improve venous outflow and prevent venous gangrene caused by graft failure, we preserved the ipsilateral saphenous vein without dissection and performed complex venous reconstruction in the form of iliofemoral crossover bypass using a prosthetic graft, femoropopliteal bypass using the contralateral saphenous vein, both thromboembolectomy and venous repair of the infrapopliteal veins, and the creation of a distal arteriovenous fistula. The successful outcome of this surgery may provide some insight into the treatment of extended chronic venous obstruction.

Special cerebral perfusion in surgery for the ruptured thoracic aortic aneurysm.

BACKGROUND: For surgical treatment of the ruptured thoracic aortic aneurysm (TAA), it is important to control bleeding and to protect the brain, spinal cord, and myocardium. We have developed and performed a new procedure on 6 patients with a ruptured TAA, a true aneurysm in 3 patients and a type A dissection in the other 3. METHOD: Cardiopulmonary bypass is installed with cannulations to the iliac artery and vein and to the common carotid arteries on both sides of the neck before the sternum is divided. For control of bleeding, venous drainage is accelerated, whereas cerebral perfusion is maintained via the carotid arteries. After insertion of the occlusion catheters into the descending aorta and the left subclavian artery following the aortotomy, the bypass flow to the iliac artery is increased. RESULTS: The arch replacement was performed in 4 patients and hemiarch replacement in two. Five patients are alive without neurologic deficits; one patient died of multi-organ failure on the 24th postoperative day. CONCLUSIONS: We conclude that our procedure may be advantageous for patients with a ruptured TAA, a large retrosternal aneurysm, or reoperation of the thoracic aorta.

Percutaneous management of renal calculi: experience with percutaneous nephrolithotomy in 60 children.

PURPOSE: We report our experience with percutaneous nephrolithotomy in a pediatric population in which primary as well as recurrent stone episodes are frequent and the need for less invasive procedures is imperative. MATERIALS AND METHODS: Percutaneous nephrolithotomy was performed in 60 children 3 to 13 years old (average age 6), including 44 boys (73.3%) and 16 girls (26.7%). There was a single obstructing renal calculus in 43 patients, while 17 had multiple calculi. The procedure was performed in 1 stage in 49 patients, and it was staged with preliminary nephrostomy in 11 who presented with calculous anuria and elevated serum creatinine. Normal saline was used as an irrigant and perioperatively serum electrolytes were measured to monitor fluid absorption in 18 patients. Stones were extracted intact from 40 patients (66.6%) and ultrasonic lithotripsy was performed in 20 (33.3%). RESULTS: Of the 60 patients 50 (83.3%) were rendered stone-free at 1 session. Incomplete stone clearance at 1 session was due to intraoperative bleeding requiring blood transfusion, extravasation, multiple stones that were inaccessible via 1 tract, displacement of stone fragments into an inaccessible calix and insignificant residual fragments less than 3 mm. in 2 cases each. During followup of 3 months to 6 years (average 1 year) no late complications were noted. CONCLUSIONS: Percutaneous nephrolithotomy is a safe and relatively efficacious mode of managing pediatric renal calculi. Although higher success rates are achieved in adults, caution should be exercised in children, in whom diligent attempts at stone clearance in 1 session may be made at the expense of safety.

Abdominal aortic aneurysmectomy with left-sided inferior vena cava and transplanted kidney.

Aortic aneurysmectomy was performed in a 43-year-old man with left-sided inferior vena cava (It-IVC) after renal transplantation 10 years before. In the admission examination chronic rejection was found histopathologically. For renal protection, a temporary heparin-coated shunt tube was used to maintain continuous blood flow to the transplanted kidney. The shunt was placed between the left brachial artery and the right external iliac artery, because there was no segment healthy enough for cannulation of the shunt tube and the It-IVC crossed over the aorta above the aneurysm. Aortic aneurysmectomy was performed without complications and perioperative renal function was satisfactorily maintained without progression of the chronic rejection.

Biocompatibility of a silicone-coated polypropylene hollow fiber oxygenator in an in vitro model.

BACKGROUND: A silicone-coated microporous hollow-fiber membrane oxygenator has been developed to prevent plasma leakage during long-term use. The objective of this study was to evaluate the biocompatibility of the oxygenator. METHODS: A silicone-coated oxygenator was compared with an uncoated oxygenator in an in vitro model of cardiopulmonary bypass. Simulated circulation was maintained for 6 h at 37 degrees C. RESULTS: Platelet counts decreased significantly (p < 0.05) and leukocyte counts tended to decline; however, the differences between groups were not significant. Concentrations of C3a increased significantly in both groups (p < 0.05), but levels were significantly less in the silicone-coated oxygenator (p = 0.008). In contrast, concentrations of C4a, beta-thromboglobulin, and granulocyte elastase increased significantly (p < 0.05), but the differences between groups were not significant. CONCLUSIONS: Silicone coating over a microporous hollow-fiber membrane may improve biocompatibility by reducing C3a activation.

Surgical management of cardiovascular lesions caused by systemic inflammatory diseases.

BACKGROUND: The surgical treatment of cardiovascular disorders caused by inflammatory diseases presents many difficulties, including suture detachment and progression of vascular lesions. We here report the various surgical procedures used to treat these disorders and their long-term outcomes. METHODS: We operated on 14 patients: eight with Takayasu's disease, three with systemic lupus erythematosus, two with rheumatoid arthritis, and one with Behçet's disease. Patients were divided into three groups as follows; patients (n=7) requiring aortic valve replacement; patients (n = 4) requiring reconstruction of the coronary artery; and patients (n = 3) requiring aortic aneurysm repair. RESULTS: There were no early or late deaths in the postoperative follow-up period of 70 +/- 40 months, but there was one operative death. Three patients received postoperative steroids due to progression of the inflammation. However, there were no major complications such as valve detachment, pseudoaneurysmal formation, or occlusion of the bypass conduit. CONCLUSIONS: We conclude that it is crucial to reduce inflammation pre- and postoperatively, to reinforce the suture line, and to carefully select the operative procedures when treating cardiovascular disorders caused by inflammatory diseases.

The effect of fibrin glue on inhibition of pericardial adhesions.

The effect of fibrin glue on inhibition of pericardial adhesions was tested using 26 beagle dogs. Dacron patches were sutured to the heart and tincture of iodine was applied to promote adhesions. Fibrin glue (3 ml) was sprayed over the patches in 15 dogs (test group), and was not separated in the remaining 11 dogs (control group). All animals in the test group had minimal adhesions between the pericardium and the epicardium or patched region, and an accumulation of gelatinous material was found in the subpericardial space. Marked fibrosis and a poor demarcation of the subpericardial space were found in the control group. The adhesion score and the visibility of coronary anatomy in the test group were significantly better than in the control group. The tension strength in the test group was significantly less than in the control group. We concluded, therefore, that fibrin glue may also be useful as an adhesion inhibitor.

Development of an endocardioscope for repair of an atrial septal defect in the beating heart.

The purpose of this study was to evaluate the possibility of surgical treatment of an atrial septal defect in the beating heart without cardiopulmonary bypass. The first step was to develop an endocardioscope that permitted observation of the inside of the beating heart. To visualize the inside of the beating heart, the tip of the endoscope was covered with a glass adapter. The endocardioscope was inserted through the right atrial appendage in eight beagles. The atrial septum, foramen ovale, coronary sinus, tricuspid valve, and chordae tendineae were identified without hemodynamic derangement. The second step was to attempt to close the foramen ovale with clips or staplers. We were able to close the foramen ovale with these devices, but a safer, easier device is needed. The endocardioscope we developed should prove to be a useful tool for minimally invasive surgical treatment of heart diseases, such as atrial septal defect.

Respiratory insufficiency caused by an aneurysm with multiple vascular lesions.

A 71-year-old woman, who presented tracheobronchial obstruction caused by a thoracic aortic aneurysm, was admitted to our institution. Although she had multiple cerebral infarctions, old myocardial infarction, bilateral iliofemoral atherosclerotic lesions with abdominal aortic aneurysm, and superior vena cava syndrome, aneurysmectomy was undertaken in order to rescue her from respiratory insufficiency. The operation successfully relieved her of exertional dyspnea and dysphagia.

Left atrial ball thrombi without mitral valve disease treated by surgical removal.

We describe two patients with free-floating left atrial ball thrombi with no evidence of cardiac disease except atrial fibrillation. One patient had experienced an embolic stroke, and the second patient had a history of stroke and peripheral thromboembolism. In each patient, the thrombi, which were not visible on transthoracic echocardiography, were detected by transesophageal echocardiography. Each patient underwent successful surgical removal using cardiopulmonary bypass.

Successful surgery for an acute type A aortic dissection following repair of a descending thoracic aortic aneurysm.

Acute type A aortic dissection in the presence of a previously repaired atherosclerotic descending thoracic aortic aneurysm is rarely reported. We experienced a patient who underwent an ascending aortic replacement with reconstruction of the aortic arch 16 months after repair of a descending thoracic aortic aneurysm. We succeeded in the redo operation with comprehensive techniques involving selective cerebral perfusion, deep hypothermia, early antegrade systemic circulation for cerebral protection, and femoro-femoral bypass with occlusion of the descending aorta for lower systemic perfusion as well as renal perfusion. The patient recovered and is doing well one year after the redo operation.

Complete intercostal artery reimplantation using a method of aneurysmoplasty.

We report the case of a 58-year-old woman who underwent repair of a chronic dissecting thoracoabdominal aortic aneurysm. Using a method of aneurysmoplasty under normothermic cardiopulmonary bypass, all intercostal arteries were quickly reperfused, and the spinal cord ischemic time was minimized. No neurological deficits developed in our patient using this method.

Surgery for giant popliteal artery aneurysm with a modified Sims' position.

A 73-year-old man with a giant popliteal artery aneurysm extending from the mid-thigh to the popliteal fossa underwent exclusion, bypass, and obliterative endoaneurysmorrhaphy while in a modified Sims' position. The use of this position allowed for exposure of the saphenous vein and the entire popliteal artery in the same operative field. No muscle division was required. Moreover, this position provided easy access to the superficial femoral and distal below-knee popliteal arteries.