[Coronary artery aneurysm with various clinical course].

Case 1: A 77-year-old woman had effort angina pectoris. Coronary angiography (CAG) revealed a coronary artery aneurysm on the left descending artery. Coronary artery bypass grafting (CABG) and patch angioplasty for the aneurysm were performed. Case 2 : A 69-year-old woman had effort dyspnea CAG showed dilation of the left main trunk and beaded aneurysms (maximum 6 cm in diameter) behind the ascending aorta with a fistula to the right atrium. We closed the fistula and performed CABG to the circumflex branch. Case 3 : A 78-year-old woman had had general fatigue for 2 weeks. Previous CAG had revealed coronary artery aneurysms and current chest computered tomography revealed pericardial effusion. She was, therefore, diagnosed with the rupture of the coronary artery aneurysm. We closed the coronary artery aneurysm and performed CABG. Case 4: A 55-year-old man had been diagnosed with acute myocardial infarction and had undergone percutaneous coronary intervention 3 years before. CAG revealed a coronary artery aneurysm on the right coronary artery. We resected the aneurysm and interposed with saphenous vein graft. Although coronary artery aneurysm often has no symptoms, in the cases of angina, myocardial infarction, rupture or large aneurysm more than 3 times larger than the normal diameter, surgical repair should be considered.

[Preservation of aortic root with severe destruction in Stanford type A acute aortic dissection].

From November 1999 to December 2008, 197 patients with Stanford type A acute aortic dissection underwent the surgical treatment on an emergency basis. In 19 cases, we preserved the severely destroyed aortic root using gelatin-resorcin-formalin (GRF) glue avoiding aortic root replacement. We examined the indication and limitation of repair of the destroyed aortic root. The 19 patients were classified into 3 groups (A, B and C). Group A consisted of 7 patients who had no aortic regurgitation (AR). Group B consisted of 6 patients who had moderate to severe AR. Group C consisted of 6 patients who had coronary involvement. We preserved the broken aortic root in group A and group B. But it seemed to be rather difficult to repair the destroyed aortic root in some cases of group C.

Increased isoprostane content in coronary plaques obtained from vulnerable patients.

8-Iso-prostaglandin F(2)(alpha) (8-iso-PGF(2)(alpha)), a representative isoprostane, is a reliable biomarker for enhanced oxidant stress in vivo. Its urinary excretion has been proposed as a risk marker in patients with coronary heart disease. Isoprostane content has not yet been well elucidated so far in human coronary plaques. The aim of this study was to evaluate content of immunoreactive 8-iso-PGF(2)(alpha) in directional coronary atherectomy (DCA) specimens from patients with coronary heart diseases. Twenty-seven patients with stable angina pectoris (SAP) and 8 vulnerable patients (5 patients with unstable angina pectoris and 3 with recent myocardial infarction) were subjected to DCA. The specimens from SAP consisted of 14 de novo and 13 restenotic lesions, whereas those from the vulnerable patients were all de novo lesions. Total 8-iso-PGF(2)(alpha) content in the DCA specimens from the vulnerable patients was significantly greater than that from patients with SAP (5.48 (2.70-10.43) versus 2.38 (1.19-4.32)ng/g tissue, median (interquartile range), P<0.05). There was no significant difference in total 8-iso-PGF(2)(alpha) content between de novo and restenotic lesions from patients with SAP (3.25 (1.48-5.05) versus 1.57 (0.62-2.47)ng/g tissue, respectively, P=0.895). Total 8-iso-PGF(2)(alpha) content in apparently normal peripheral artery specimens was only 0.34 (0.26-0.46)ng/g tissue. In conclusion, 8-iso-PGF(2)(alpha) was enriched in the DCA specimens from vulnerable patients, suggesting a crucial role of free radicals in formation of vulnerable plaques and a putative benefit of anti-oxidant therapy on these patients.

[Surgical treatment for acute type A aortic dissection; for better postoperative quality of life].

From November 1999 to December in 2005, 114 patients with acute type A aortic dissection underwent surgical treatment on an emergency basis. The overall in-hospital mortality was 7.9% (9 patients). Four were rupture cases before cardiopulmonary bypass. De novo postoperative stroke rate was 3.5% (4 patients). But all of them were discharged on foot. There were 6 rupture cases before operation. Unfortunately only 2 patients survived. Preoperative stroke due to malperfusion occurred in 19 cases (16.7%). Among them, those with clear consciousness had tendency to better social rehabilitation than those with drowsiness. We had experienced 2 vegetable states in the group of drowsiness after the operations. For better outcome, we must avoid rupture before operation and reconsider the timing of operation in the case of brain ischemia.

Catalytic Enantioselective Addition of Nitro Compounds to Imines-A Simple Approach for the Synthesis of Optically Active ß-Nitro-α-Amino Esters.

The catalytic and asymmetric nitro-Mannich reaction of nitro compounds to α-imino esters catalyzed by chiral bisoxazoline-copper complexes [Eq. (1); Pg = protecting group] gave ß-nitro-α-amino esters with excellent diastereo- and enantioselectivities. The reactions can be performed under ambient conditions.

[A successful case report of a patient who had severe aortic stenosis with cardiac arrest: bridge use of percutaneous cardiopulmonary support system (PCPS)].

A 62-year-old female with chronic renal failure was transferred to our unit for the purpose of surgical treatment. During hemodialysis, cardiac arrest occurred suddenly. Cardiac resuscitation was not effective, necessitating PCPS. She successfully underwent an emergent aortic valve replacement. She had no brain damage and was discharged on foot on the 45th postoperative day.

[A successful surgical case of giant arch aneurysm with severe pulmonary dysfunction and angina pectoris].

A 70-year-old female was admitted to our unit with chief complaints of dyspnea on effort and angina pectoris. She had suffered from chronic bronchitis. Chest CT scan demonstrated a giant arch aneurysm which strongly attached to the left anterior chest wall. Coronary angiogram showed two vessels disease. She successfully underwent coronary artery bypass grafting and total arch replacement under selective cerebral perfusion. She needed long respiratory care because of her pulmonary dysfunction. But she could wean from the ventilator under intensive respiratory care on 46th postoperative days and was discharged on foot.

[Surgical treatment of acute massive pulmonary embolism: report of two cases].

We experienced two cases of acute massive pulmonary embolism. Both of the patients required emergent surgical procedures under cardiopulmonary bypass after cardiopulmonary resuscitation. Postoperative courses of them were uneventful. In severe cases with acute massive pulmonary thrombosis, there is no time to choose medical treatment alternative to pulmonary embolectomy. The diagnosis should be made promptly, and immediate decision of operation is very important.

[Surgical treatment of the Palmaz-Schatz stent trapped in the left coronary ostium].

A 72-year-old male with failed delivery of the Palmaz-Schatz stent to the coronary dissection following percutaneous transluminal coronary angioplasty (PTCA) was admitted to our hospital. He was very sick and required an emergent surgical procedures. We successfully carried out the bypass grafting to the LAD and removed the stent through the aortotomy. Besides his respiratory care, postoperative course was uneventful.

[An emergent surgical treatment of recurrent Stanford type A thrombosed aortic dissection].

A 71-year-old male was admitted to our hospital with a chief complaint of back pain. Chest CT scan showed so-called Stanford type A thrombosed aortic dissection. Aortography revealed no ulcer like projection. At first, conservative treatment was carried out. But about two hours later, he had another back pain. Repeat chest CT scan demonstrated an enlarged dissecting lumen, necessitating emergent graft replacement. Postoperative course was uneventful and he was discharged on the 33rd postoperative days.

[An emergent coronary artery bypass grafting to total occlusion of all three coronary arteries in a patient with severe hyperbilirubinemia].

A 69-year-old man was transferred to our hospital because of chest pain and dyspnea. He had been very ill due to acute hepatitis and hyperbilirubinemia. Coronary angiography showed total occlusion of all three coronary arteries. An emergent coronary artery bypass grafting was successfully performed after insertion of IABP. Even though total bilirubin levels rose to 20.5 mg/dl, it gradually decreased without plasmapheresis. He had no hepatic failure and was discharged on foot on the 24th postoperative days.

[Clinical experiences of minimally invasive direct coronary artery bypass (MIDCAB)].

From Jan. to Oct. in 1997, we performed 18 minimally invasive direct coronary artery bypass (MIDCAB), aged from 45 to 86 years (the mean age of 69 years). They had single LAD disease post PTCA failure in 2 patients, and multiple vessel disease in 16 patients including left main stenosis in 2 patients. Sixteen patients had associated risk factors for using cardiopulmonary bypass, such as cerebrovascular disease in 9 patients, calcification of ascending aorta in 5 patients, renal failure in 2 patients, old age over 80 years in 4 patients and cancer in one patient. Single bypass grafting of left internal thoracic artery (LITA) to left anterior descending artery (LAD) underwent through left anterior small thoracotomy in 9 patients, double bypass grafting of gastroepiploic artery or right ITA to right coronary artery with LITA to LAD in 9 patients through subxiphoid small incision or right anterior small thoracotomy. The mean number of distal anastomosis was 1.5/patient. All patients are alive and asymptomatic, and postoperative angiography demonstrated the patency rate of 96.2% (26/27). MIDCAB is considered as a justified and safe technique for the patients who are ineligible for standard coronary artery bypass grafting.

[Total aortic arch graft replacement: strategy for shortening the duration of cardiac ischemic arrest].

Between August 1991 and November 1993, five patients underwent total aortic arch graft replacement in a manner which placed emphasis on myocardial protection. All operations were performed with the use of extracorporeal circulation and selective cerebral perfusion. Oxygenated warm blood was infused at a flow rate of 300 ml/min. via a catheter inserted proximal to the site of occlusion of the ascending aorta or replaced graft of the ascending aorta. After the beating of the heart was resumed under left venting, aortic arch was replaced using a prosthetic graft with three branches. Concomitant operations were reconstructions of the aortic root with composite graft (Bentall's technique) in two patients of Marfan's syndrome and type A aortic dissection. All patients were easily taken off cardiopulmonary bypass and postoperative course was uneventful. We believe that shortening of the duration of ischemic cardiac arrest is important if surgical results of total aortic arch replacement are to be further improved, above all in patients at high risk for surgery, such as elderly subjects whose organ function is often compromised.

[Successful repair of acute traumatic rupture of the thoracic aorta].

We report four male patients (from 18 to 36 years in age) with acute traumatic rupture of the aortic isthmus due to blunt chest trauma caused by motor vehicle accident in three patients and a full in one patient. Of these patients, 3 underwent segmental replacements of the descending thoracic aorta with vascular prosthesis using cardiopulmonary bypass, and an additional patient underwent the same procedure using left heart bypass. All patients survived without the development of any serious complications. Since traumatic rupture of the thoracic aorta due to blunt trauma frequently occurs in the relatively young, some form of assisted circulation is necessary to prevent the ischemic spinal cord injury from cross clamping of the aorta during repair of the rupture. We prefer cardiopulmonary bypass as a most appropriate support in emergency situations, because extensive mediastinal hematoma or sudden hemorrhage could make dissection extremely hazardous without it. However, cardiopulmonary bypass requires systemic heparinization, which predisposes the patients with associated multiple injuries to a tendency of bleeding. Thus, a thorough investigation of the preoperative status, including the severity of multiple injuries, should be undertaken, and appropriate therapeutic measures instituted before the start of cardiopulmonary bypass. The determination of the timing of operation is crucial to success in the treatment of acute traumatic ruptures of the thoracic aorta.

[Congenital isolated tricuspid insufficiency in an elderly woman].

Isolated congenital tricuspid insufficiency due to primary malformation of the tricuspid valve is rare. The patient was a 70-years-old woman complaining of exertional dyspnea. Cardiac echo-sonography and catheterization showed severe TR with no other cardiac abnormality. At surgery, the anterior leaflet of the tricuspid valve was hypoplastic and attached to the right ventricle with shortened chorda. Tricuspid valve replacement was successfully performed with a 31 mm Carpentier-Edwards pericardial valve. The postoperative clinical course was smooth. This is the oldest known reported case of a successful operation for congenital tricuspid insufficiency.

[A case report of cavitary bronchial carcinoma with intracavitary aspergillosis].

A 64-year-old male with cavitary bronchial carcinoma underwent right middle and lower lobectomy. The presence of a mural nodule in the cavity suggested that the cancer originated from the bulla wall. Histologically, adenocarcinoma was found to invade the entire cavity wall, and aspergillus was detected in the intracavitary space. Of 6 patients with cavitary bronchiolar carcinoma with intracavitary aspergillosis reported in Japan including this case, 3 were treated for aspergillus before operation because X-ray had revealed fungus ball shadow. Although the mechanism by which aspergillus infects patients with cavitary bronchial carcinoma is not precisely known, it is suggested that this type of carcinoma originates from the bulla wall and that there is considerable time for infection with aspergillus to develop.

[A case report of translocation method for active infective aortic valve endocarditis with aortic root abscesses].

We experienced a case of 51-year-old woman who underwent emergency aortic valve replacement by translocation method for active infective aortic valve endocarditis with aortic root abscesses. Postoperative course was complicated as the following. Three days later, the perforation of noncoronary sinus of Valsalva into the right atrium was noted and she developed progressive heart failure due to the massive left-to-right shunt. The second operation was performed immediately for the patch closure of the perforation through the right atriotomy. Two months later, unstable angina appeared because of the stenosis of the vein graft to the left coronary artery, leading to the emergency third operation in which LITA was placed to the left anterior descending artery. In spite of these complications she recovered gradually and she was discharged 6 months after the first operation. She is now doing well in NYHA class 2. Translocation method is quite useful for such a case of the aortic valve endocarditis with periannular abscesses in whom conventional valve replacement is supposed to be impossible, but the long durability of this type of the repair is unknown. Careful follow-up of the patient is mandatory.