Efficacy of protocol-based pharmacotherapy management on anticoagulation with warfarin for patients with cardiovascular surgery.

WHAT IS KNOWN AND OBJECTIVE: Anticoagulation therapy with warfarin requires periodic monitoring of prothrombin time-international normalized ratio (PT-INR) and adequate dose adjustments based on the data to minimize the risk of bleeding and thromboembolic events. In our hospital, we have developed protocol-based pharmaceutical care, which we called protocol-based pharmacotherapy management (PBPM), for warfarin therapy. The protocol requires pharmacists to manage timing of blood sampling for measuring PT-INR and warfarin dosage determination based on an algorithm. This study evaluated the efficacy of PBPM in warfarin therapy by comparing to conventional pharmaceutical care. METHODS: From October 2013 to June 2015, a total of 134 hospitalized patients who underwent cardiovascular surgeries received post-operative warfarin therapy. The early series of patients received warfarin therapy as the conventional care (control group, n=77), whereas the latter received warfarin therapy based on the PBPM (PBPM group, n=68). These patients formed the cohort of the present study and were retrospectively analysed. RESULTS: The indications for warfarin included aortic valve replacement (n=56), mitral valve replacement (n=4), mitral valve plasty (n=22) and atrial fibrillation (n=29). There were no differences in patients' characteristics between both groups. The percentage time in therapeutic range in the first 10 days was significantly higher in the PBPM group (47.1%) than that in the control group (34.4%, P<.005). The average time to reach the steady state was significantly (P<.005) shorter in the PBPM group compared to the control group (7.3 vs 8.6 days). WHAT IS NEW AND CONCLUSION: Warfarin therapy based on our novel PBPM was clinically safe and resulted in significantly better anticoagulation control compared to conventional care.

Evaluation of automated 2D-3D image overlay system utilizing subtraction of bone marrow image for EVAR: feasibility study.

OBJECTIVE: To evaluate the automated 2D-3D image overlay system ("3D Roadmap") for use during endovascular aneurysm repair (EVAR) in the hybrid operating theater. METHODS: Datasets of preoperative CT images were modified to subtract dense bone marrow to improve the visualization of vasculature on the overlaid image, and allow for accurate navigation of the endovascular devices. The 3D-CT overlay image was registered on the 2D fluoroscopy image to mark the iliac crest and lumbar vertebrae on both images as landmarks. RESULTS: Arteriography was performed only twice to confirm the precision of the position of renal artery and the final evaluation. Twenty patients underwent EVAR with Medtronic Endurant, Gore Excluder, or COOK Zenith using "3D Roadmap". The origin of the renal artery and iliac bifurcation were registered with complete accuracy in 10 patients (50%). The lower renal artery deviated toward the cranial side less than 3 mm in six patients. In all cases, EVAR was successful, and completed with the volume of contrast material limited to 43.8 ± 3.1 mL. CONCLUSION: "3D Roadmap" was confirmed to be valuable for visualization of vessel origin in a fused image and for reduction of contrast material during EVAR.

Spinal cord injury is not negligible after TEVAR for lower descending aorta.

OBJECTIVES: To clarify the incidence of spinal cord injury (SCI) after thoracic endovascular aneurysm repair (TEVAR), we investigate the intercostal/lumbar arteries that supply the Adamkiewicz artery (ICA-AKA). PATIENTS: Among 81 patients subjected to TEVAR, we retrospectively reviewed the clinical records of 50 patients (range: 57-86 (median age: 77) years, 41 males) who underwent TEVAR for part of or the whole distal descending aorta (T7 to L2) after identification of ICA-AKA by magnetic resonance angiography (MRA) or computed tomography angiography (CTA). RESULTS: The 50 patients were classified into group A: 17 patients whose patent ICA-AKA was not covered, group B: 24 patients whose ICA-AKA was covered and group C: nine patients in whom no patent ICA-AKA was identified. Only three patients in group B suffered paraplegia and of them two recovered full ambulation. The estimated incidence of permanent and transient paraplegia was 3.7% in all TEVAR patients, 6.0% when part of or the entire distal aorta was covered and 12.5% when the patent ICA-AKA was covered. The length of aortic coverage in patients with paraplegia was >300 mm. CONCLUSIONS: Paraplegia after TEVAR occurred in one of eight patients in whom the stent graft covered ICA-AKA. Long coverage of the aorta including the ICA-AKA was critical. To prevent this serious complication, identification of the ICA-AKA is crucial.

[Long-term outcome of aortic valve sparing procedures in connective tissue disorders].

OBJECTIVES: The aim of this study is to determine the long-term outcome of aortic valve sparing procedures for patients having connective tissue disorder. METHODS: Between 1993 and 2008, the aortic valve sparing surgery was performed in 94 patients having aortic root dilatation. Eighty patients of them (37.2 +/- 13.4 years, 50 male) had cystic medial necrosis in the aortic wall, which was confirmed the pathological examination. We reviewed these patients. Sixty percent (48/80) had Marfan syndrome, 5% (4/80) had Loeyz-Dietz syndrome, 2% (2/80) had bicuspid aortic valve, and 11% (9/80) had aortic dissection. Our reimplantation procedure has been refined as followed: with a tube graft in 41, a tube graft with creation of neo-sinuses in 11, and a Valsalva graft in 14. Fourteen patients underwent the remodeling procedure. The follow-up rate was 100% with the duration of 3.7+/- 3.4 years. RESULTS: There were no operative death but six late deaths. Seventeen (21.3%) patients required aortic valve replacement, for recurrent aortic insufficiency in 13 and infection in 4. Freedom from reoperation was 80%, 43%, and freedom from moderate or severe aortic insufficiency was 80%, 54%, at 5 and 10 years, respectively. Pathological findings of the aortic valve obtained in the reoperations showed elongation and prolapse of the aortic valve due to myxomatous degeneration and fibrous thickening caused by aortic insufficiency. CONCLUSIONS: Even in connective tissue disorders, aortic valve sparing operation is associated with acceptable long-term durability, although cusp degeneration resulting in recurrent aortic insufficiency might be progressive.

Ten-year experience of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair.

BACKGROUND: Mitral valve repair is the procedure of choice to correct mitral regurgitation (MR). Although chordal replacement with expanded polytetrafluoroethylene (ePTFE) has been widely accepted to repair anterior mitral prolapse and other difficult situations, the long-term results of the repair and the fate of ePTFE have not been delineated. METHODS AND RESULTS: From July 1988 to April 1999, 74 patients (49 males, 25 females) aged 17 to 77 years (mean age 55. 3+/-14.8 years) underwent mitral valve repair with chordal replacement with ePTFE. The follow-up period was from 6 months to 11. 3 years (mean 4.6+/-3.2 years). The causes of MR were degenerative in 65 patients (88%) and infective in 9 (12%). Three patients had active infective endocarditis. Valve lesions were anterior in 35 patients, posterior in 10, and both anterior and posterior in 29. Various procedures for plasty of leaflets were necessary in 37 patients (50%). Atrial fibrillation was associated in 38 patients (51%), and the maze procedure has been performed in a selected group of 30 patients (41%) since July 1992. There was 1 in-hospital death (1.4%) and 3 late cardiac deaths (4.1%). More than moderate MR developed in 12 patients (17%) during the follow-up period. Three of these patients required early reoperation within 1 year due to hemolysis. Two patients underwent mitral valve replacement at 6 and 8 years after repair, respectively. The actuarial reoperation-free rates at 5 and 10 years were 94.3+/-2.8% and 81.7+/-9.1%, respectively. Sinus rhythm was restored in 21 patients (70%) with the maze procedure. There was only 1 thromboembolic episode (0. 3%/patient-y) in a patient with atrial fibrillation who did not undergo the maze procedure. Event-free survival rates as assessed by the freedom from cardiac death, thromboembolism, reoperation, and anticoagulation-related hemorrhage at 5 and 10 years were 91.3+/-3. 4% and 71.6+/-9.7%, respectively. There was no relationship between recurrent MR and the change of ePTFE. Structural analysis of the ePTFE resected during reoperation revealed no calcification and showed remaining flexibility and pliability. Protein infiltration was observed in the ePTFE, and collagenous proliferation was recognized at the site of fixation to the valve leaflet and the papillary muscle. The surface of the ePTFE was completely endothelialized, which may induce antithrombogenicity. CONCLUSIONS: The long-term durability and biological adaptation of ePTFE as artificial chordae for mitral valve repair of MR were proved for >10 years.

A morphologic study of Carpentier-Edwards pericardial xenografts in the mitral position exhibiting primary tissue failure in adults in comparison with Ionescu-Shiley pericardial xenografts.

OBJECTIVE: We sought to investigate the durability and mechanism of the Carpentier-Edwards pericardial xenograft in the mitral position in comparison with that of the Ionescu-Shiley pericardial xenograft. METHODS: A total of 284 patients who received the Ionescu-Shiley pericardial xenograft in the mitral position between 1980 and 1984 and 84 patients who received the Carpentier-Edwards pericardial xenograft in the mitral position between 1984 and 1999 were included in the study. The freedom from reoperation rates for both graft types were determined. For morphologic study, the pathologic findings of 23 valves of 123 explanted Ionescu-Shiley pericardial xenografts with structural valve deterioration, nonstructural valve deterioration, or both were determined and compared with those of 20 explanted Carpentier-Edwards pericardial xenografts with structural valve deterioration, nonstructural valve deterioration, or both. Each pathologic finding was graded and assigned a score. Both types were matched for age at reoperation (50-75 years) and duration of valve function (8-11 years). RESULTS: Freedom from reoperation caused by structural valve deterioration, nonstructural valve deterioration, or both was significantly better for Carpentier-Edwards pericardial xenografts than for Ionescu-Shiley pericardial xenografts at 8 years after the operation (Carpentier-Edwards pericardial xenografts: 91.3% vs Ionescu-Shiley pericardial xenografts: 71.9%, P =.0061), but it was similar for both types at 12 years (Carpentier-Edwards pericardial xenografts: 43.6% vs Ionescu-Shiley pericardial xenografts: 43.6%, P =.2865). No severe leaflet tears were seen among Carpentier-Edwards pericardial xenografts. The mean area percentage of tissue overgrowth was 15.3% in Carpentier-Edwards pericardial xenografts and 3.4% in Ionescu-Shiley pericardial xenografts (P =.0001). The mean calcification area percentage was 13.6% in Carpentier-Edwards pericardial xenografts and 31.5% in Ionescu-Shiley pericardial xenografts (P =.0001). CONCLUSIONS: Tissue overgrowth on the atrial surface, ventricular surface, or both was the cause of structural valve deterioration, nonstructural valve deterioration, or both of Carpentier-Edwards pericardial xenografts in adults. This was different from Ionescu-Shiley pericardial xenograft failure, which resulted from severe calcification and leaflet tears. Organized thrombi on cusps, in addition to valve design, may have contributed to such tissue overgrowth on Carpentier-Edwards pericardial xenografts.

Cardiac papillary fibroelastomas: rationale for excision.

We experienced a case of papillary fibroelastoma of the left ventricular outflow tract in a patient with severe valvular heart disease that was detected only by transesophageal echocardiography. Preoperative detection of this lesion altered the surgical procedure to include resection of the mass through the aortic valve annulus along with repair/replacement of the valves. The literature documents sufficient morbidity/mortality to support excision of these lesions regardless of symptoms or location.

Calcified ball thrombus in the left atrium.

We experienced a case of calcified ball thrombus that was fixed to the atrial septum in the left atrium. This patient had no symptoms and no cardiac dysfunction. the thrombus was detected during preoperative work-up of a retroperitoneal tumor. The process of fixation to the atrial septum and calcification is unclear.

Predictive factors for mortality and cerebral complications in arteriosclerotic aneurysm of the aortic arch.

BACKGROUND: The incidence of cerebral complications is high in patients with aortic arch aneurysm. METHODS: Between December 1977 and December 1995, 246 patients with arteriosclerotic arch aneurysm underwent operation. Thirty-nine patients had an aneurysm involving the entire arch, 193 had only distal arch aneurysm, and 14 had arch aneurysm extending to the descending aorta. Eighty-seven patients underwent replacement of the total arch, 85 had replacement of only the distal arch, 14 had simultaneous replacement of the descending aorta, 45 had patch repair, and 15 had thromboexclusion. Selective cerebral perfusion was used in 112 patients and partial bypass in 58 in the earlier series of patients, but deep hypothermic circulatory arrest with retrograde cerebral perfusion technique was exclusively applied in the most recent 76 patients. RESULTS: There were 50 (20%) early deaths and 37 (19%) late deaths. Postoperative stroke was found in 26 (11%) patients of which 13 (50%) died. Mutual predictive factors for postoperative mortality and stroke were earlier series, preoperative chronic renal failure, ruptured aneurysm, arch clamping during procedure, and using partial cardiopulmonary bypass. Among 129 patients operated on during the most recent 5 years, early mortality and incidence of stroke decreased to 14.7% and 6.9%, respectively. CONCLUSIONS: Results of operations for arteriosclerotic aneurysms of the transverse aortic arch in 246 patients during a period of 17 years have been improving but are still not satisfactory.

Pericardiectomy for constrictive pericarditis using the harmonic scalpel.

A 35-year-old man with constrictive pericarditis underwent pericardiectomy. The pericardium was dissected with a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH). This new device has many advantages including no muscular stimulation, low heat, a smokeless field, and easy hemostasis. The Harmonic Scalpel is beneficial for dissection of thickened pericardium.

Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion.

BACKGROUND: The purpose of this study was to compare the results of total aortic arch replacement using two different methods of brain protection, particularly with respect to neurologic outcome. METHODS: From June 1997, 60 consecutive patients who underwent total arch replacement through a midsternotomy were alternately allocated to one of two methods of brain protection: deep hypothermic circulatory arrest with retrograde cerebral perfusion (RCP: 30 patients) or with selective antegrade cerebral perfusion (SCP: 30 patients). Preoperative and postoperative (3 weeks) brain CT scan, neurological examination, and cognitive function tests were performed. Serum 100b protein was assayed before and after the cardiopulmonary bypass, as well as 24 hours and 48 hours after the operation. RESULTS: Hospital mortality occurred in 2 patients in the RCP group (6.6%) and 2 in the SCP group (6.6%). New strokes occurred in 1 (3.3%) of the RCP group and in 2 (6.6%) of the SCP group (p = 0.6). The incidence of transient brain dysfunction was significantly higher in the RCP group than in the SCP group (10, 33.3% vs 4, 13.3%, p = 0.05). Except in patients with strokes, S-100b values showed no significant differences in the two groups (RCP: SCP, prebypass 0.01+/-0.04: 0.05+/-0.16, postbypass 2.17+/-0.94: 1.97+/-1.00, 24 hours 0.61+/-0.36: 0.60+/-0.37, 48 hours 0.36+/-0.45: 0.46+/-0.40 microg/L, p = 0.7). There were no intergroup differences in the scores of memory decline (RCP 0.74+/-0.99; SCP 0.55+/-1.19, p = 0.6), orientation (RCP 1.11+/-1.29; SCP 0.50+/-0.76, p = 0.08), or intellectual function (RCP 1.21+/-1.27; SCP 1.05+/-1.15, p = 0.7). CONCLUSIONS: Both methods of brain protection for patients undergoing total arch replacement resulted in acceptable levels of mortality and morbidity. However, the prevalence of transient brain dysfunction was significantly higher in patients with the RCP.

Intermittent antegrade warm blood cardioplegia for CABG: extended interval of cardioplegia.

BACKGROUND: Intermittent delivery of warm cardioplegia provides a bloodless surgical field, but it is clinically important to evaluate the periods of normothermic ischemia. The aims of this study are to compare intermittent antegrade warm blood cardioplegia (IAWBC) with intermittent antegrade cold blood cardioplegia (IACBC) groups in terms of myocardial protection, and also to evaluate whether the length of ischemic time in the IAWBC group has an effect on myocardial dysfunction. METHODS: This study is based on a retrospective review of patients who underwent elective coronary artery bypass surgery: 162 consecutive patients with IAWBC and 107 consecutive patients with IACBC. RESULTS: The creatinine kinase peak was smaller in the IAWBC group compared with the IACBC group (p<0.0001). The cardiac index after cardiopulmonary bypass was higher in the IAWBC group (p<0.02), and the amount of inotropic support required to wean from cardiopulmonary bypass was less in the IAWBC group compared with the IACBC group (p<0.0001). CONCLUSIONS: IAWBC with 30 minutes of ischemia provides to be clinically acceptable myocardial protection for coronary bypass surgery.

Is distal anastomosis only to the true channel in chronic type B aortic dissection justified?

BACKGROUND: We investigated long-term outcomes of the distal false lumen of the aorta and aortic branches after distal anastomosis of the graft only to the true lumen in chronic type B aortic dissection. METHODS: From November 1979 until June 1998, we treated 98 patients without Marfan syndrome who had chronic type B aortic dissection and underwent replacement of the descending aorta, 79 of whom had distal anastomosis to the true lumen only. The celiac artery originated from the false lumen in 11 patients, superior mesenteric artery in 5, right renal artery in 19, and left renal artery in 16. RESULTS: There were 12 (15.1%) early deaths. Spinal cord ischemia was detected in 5 patients. Postoperative follow-up was achieved in 67 patients, and 13 patients died. Postoperative survival at 10 years was 67.6% +/- 7.1%. Eight patients had complete occlusion of the distal false lumen, 54 patients had occlusion of the false lumen down to the celiac artery, and 5 patients had a patent false lumen. Four patients required further replacement of the thoracoabdominal aorta. CONCLUSIONS: In non-Marfan patients with chronic type B aortic dissection, the false lumen distal to the graft anastomosis was likely to be thrombosed when the graft was anastomosed to the true lumen only. Postoperative visceral circulation was not compromised, but spinal cord ischemia is a problem that remains to be solved.

Transmural necrosis of the esophagus secondary to acute aortic dissection.

A case of transmural ischemic necrosis of the esophagus secondary to aortic dissection is presented. A 66-year-old woman with acute type A aortic dissection underwent total arch replacement with a technique of deep hypothermic arrest and retrograde cerebral perfusion. Postoperatively she had hematemesis, and endoscopic examination revealed circumferential mucosal necrosis and desquamation of the lower esophagus. She died of multiple organ failure on postoperative day 74. Autopsy demonstrated transmural necrosis of the esophagus secondary to ischemia. Ischemia of the esophagus secondary to aortic dissection is extremely rare.

Pathologic aspects of polytetrafluoroethylene sutures in human heart.

BACKGROUND: Polytetrafluoroethylene (PTFE) sutures have been widely used as a mitral chord substitute. We present the cases of 4 patients who underwent mitral valve repair with chordal replacement by PTFE sutures and these required another operation. This gave us the chance to examine the PTFE sutures. METHODS: Structural analysis of the PTFE sutures was performed 26 to 378 days postoperatively. The specimens were examined grossly, microscopically, and by scanning or transmission electron microscopy or both. RESULTS: The PTFE suture in 1 patient was found to be completely covered with endothelial cells 154 days postoperatively. There was no calcification, and the flexibility and pliability of the PTFE sutures was preserved. Even though the PTFE sutures seemed uncovered on visual inspection, there was a thin lining of collagen and fibrin on the surface. Endothelial cells were seen in areas that looked clear in one specimen 26 days postoperatively. CONCLUSIONS: We think that the new layer of collagen could be promising in terms of durability and that the endothelial layer wil resemble normal tissue in its anticoagulant properties.

Long-term pathological changes of expanded polytetrafluoroethylene (ePTFE) suture in the human heart.

Expanded PTFE (ePTFE) sutures have been used widely as a mitral chordal substitute. We present a structural analysis of ePTFE sutures implanted as artificial chordae for 7.5 years and 8.6 years in patients with mitral regurgitation. No calcification was found either macroscopically or microscopically, and the ePTFE suture retained its normal flexibility. The suture was totally encapsulated with host tissues composed of dense fibrous tissue covered with endothelial cells.

Early and long-term results of surgery for aneurysms of the thoracic aorta in septuagenarians and octogenarians.

OBJECTIVE: The purpose of this study was to demonstrate early and long-term results of surgery for thoracic aortic aneurysm in patients over 70 years of age compared with those of patients under 70 years and to clarify the clinical problems peculiar to this subset of patients. PATIENTS AND METHODS: Of 1157 patients who underwent surgery for thoracic aortic aneurysm from 1978 to December 1997, 261 who were 70 years or older were selected for analysis. Mean age at the time of surgery was 74.4 +/- 3.5 years. Aneurysms were atherosclerotic in 177 patients and aortic dissection in 84. Acute aortic dissection was found in 25 patients and ruptured aneurysm in 44. The control group consisted of 896 patients under 70 years. Preoperative complications such as AAA, peripheral arterial disease, emphysema, and old cerebral infraction were more common in the older group. Operative procedures consisted of replacement of the ascending aorta or hemiarch in 51 patients, total arch replacement in 75, distal arch replacement in 35, descending aorta replacement in 75, replacement of the thoracoabdominal aorta in 28, and extra-anatomical repair and others in 15. The technique of extracorporeal circulation was selective cerebral perfusion in 69 patients, deep hypothermic circulatory arrest in 90, femoro-femoral bypass in 39, left heart bypass in 12, and temporary aorto-arterial bypass in 30, and others in 21. RESULT: Early mortality was 21% (54 patients), which was greater than that of the control group (113 patients, 13%, P < 0.01). The incidence of postoperative stroke, transient brain dysfunction, and respiratory problems was higher in the study group (P < 0.01 in all). Mean duration in ICU among survivors was 9.3 +/- 20.2 days and that of the control group was 5.9 +/- 2.8 days (P < 0.01). In a recent series (from 1991 to 1997) postoperative mortality improved to 15.6% (30/192 patients) in the study group however this result was still inferior to that of the control group (8.6%, 39/452, P = 0.03) however mortality of emergency surgery during the same periods was still high (31%, 11/35 patients). Logistic regression analysis revealed that significant risk factors for postoperative hospital death were surgery before 1991, age over 70 years, preoperative cardiac problems, aneurysm rupture, postoperative stroke, low output syndrome, bleeding, and acute renal failure. Postoperative follow-up was obtained in 408 patients/year and the longest period was 10.2 years. Late deaths were documented in 31 patients. Five-year and 10-year survival were 61.2 +/- 5.7% and 31.3 +/- 16.4%, respectively. In the control group the 5-year and 10-year survival were 78.0 +/- 2.1% and 62.5 +/- 4.0%, respectively (P = 0.03). However, survival of the early survivors in the study group was similar with that of the age-matched normal population. Aortic reoperation was performed in 13 patients. Freedom from aortic reoperation was 86.7 +/- 4.2% at 5 years and 80.5 +/- 7.1% at 10 years in the study group and 83.4 +/- 1.8% at 5 years and 64.1 +/- 13.3% at 10 years in the control group (P = 0.27). CONCLUSION: Although recent advances have been achieved, early and long-term results of surgery for thoracic aortic aneurysm in patients older than 70 years were less satisfactory compared with those of patients under 70 years of age, especially in patients who required emergency surgery. Preoperative disorder of the vital organ systems was considered to be the main causative factor for high mortality, however, pertinent surgical strategies are necessary to improve the outcome of elderly patients.

Preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography in patients with descending or thoracoabdominal aortic aneurysms.

OBJECTIVE: Investigating the possibility of magnetic resonance angiography (MRA) to visualize the Adamkiewicz artery of as a preoperative study of thoracic aortic aneurysms. METHODS: From February 1998 to March 1999, 26 consecutive patients who had aneurysms of the thoracoabdominal or descending aorta underwent preoperative MRA to visualize the Adamkiewicz artery. Mean age was 60.5+/-11.5 years. Fifteen patients had non-dissecting aneurysm and 11 had aortic dissections. Nineteen patients underwent replacement of the aneurysms, four patients underwent endovascular stent-graft repair, and three patients were discharged without treatment of aneurysm. MRA was performed on a 1.5-T system (Magnetom, Siemens) and data acquisition was repeated two times following injection of gadolinium-DTPA. Source images were reconstructed with multiplanar reconstruction and maximum intensity projection. Criteria for the Adamkiewicz artery of were that the artery ascends from the dorsal branch of the intercostal or lumbar artery to the anterior mid-sagital surface of the spinal cord in the early phase. RESULTS: The Adamkiewicz arteries were demonstrated in 18 patients (69%). These arteries were originated from the left intercostal or lumbar arteries in 13 (72.2%) patients and from the right in 5 (27.8%) and from the Th8 branch in three, Th9 in seven, Th10 in two, Th11 in four, and L1 in two. All patients had graft replacement of the aorta using a partial bypass. All intercostal or lumber arteries, which were visualized as the origin of the Adamkiewicz artery, were reattached to the grafts. No spinal cord injury occurred. CONCLUSION: Preoperative detection the Adamkiewicz artery was possible by MRA and was very useful to reduce the incidence of ischemic injury of the spinal cord during surgery of the thoracoabdominal or descending aorta.

Mitral valve plasty in systemic lupus erythematosus in the setting of antiphospholipid syndrome.

The first case was of a 27-year-old female, who was diagnosed as having mitral valve stenosis with regurgitation, systemic lupus erythematosus and antiphospholipid syndrome at her previous pregnancy. We performed mitral valve plasty, which included open mitral commissurotomy and Kay's annulo plasty. The second case was of a 53-year-old female, who was diagnosed as old myocardial infarction, mitral regurgitation, systemic lupus erythematosus and antiphospholipid syndrome. She underwent mitral valve plasty and coronary artery bypass grafting. Both cases were treated by administration of methylpredonisolone and heparin perioperatively to avoid thrombosis and aggravation of systemic lupus erythematosus. Both patients showed good postoperative outcome without complications. We consider that it is important to perform the plasty as far as possible, and to administer effective anticoagulation treatment to prevent complications for patients in the setting of systemic lupus erythematosus and antiphospholipid syndrome.

[Late results of extended Stanford type A acute aortic dissection].

From 1978 to July 1997, 140 patients with extended Stanford type A aortic dissection underwent surgical treatment. There were 77 acute and 63 chronic aortic dissections. The follow-up period of the 61 surviving patients in acute aortic dissection ranged from 2 to 164 months (mean, 56 months). During follow-up periods, 6 patients died of no dissection-related causes. The actuarial survival ratios in 77 patients were 77.2% at 3 years, 72.2% at 5 years and 62.6% at 10 years, respectively. There was no significant difference between acute aortic dissection and chronic aortic dissection in actuarial survival ratio. The ratio of the clotted false lumen in the distal aorta was lower and subsequent surgery was more frequent in patients with Marfan syndrome than those with non-Marfan syndrome. In extended type A aortic dissection, the observation of the residual false lumen using body CT scan was very important after surgery, especially in Marfan syndrome. If the false lumen is dilated, a subsequent surgery is needed to get good late results.