Hemodynamic effects of venous valves in aorto-coronary bypass grafts.

Use of the saphenous vein in aorto-coronary bypass surgery for treatment of occlusive coronary artery disease is a well-established technique. Use of the mammary artery for the same purpose has also been favorably reported. This study was undertaken to determine whether a vein graft containing a valve would have an added advantage. A comparison of the effect of competent and incompetent valves in vein grafts on the hemodynamics of coronary circulation was made. In a group of 18 dogs, a 5 cm. portion of each dog's cephalic vein containing a valve was used in a single aorto-coronary bypass graft. Flow measurements were made between the valve and the anastomosis of the graft to the left anterior descending coronary artery (LAD). The valve was made temporarily incompetent by the insertion of a spring wire basket, 3.5 mm. in diameter, through the valve via a side branch. The flow of blood through the venous graft with the competent valve was 11.0 +/- 2.6 per cent higher than with the incompetent valve. An analysis of flow patterns showed that this increased flow could be attributed to a reduction of backflow during systole and an increase in forward diastolic flow. Results suggest that postoperative myocardial perfusion is enhanced by the presence of valves in aorto-coronary bypass vein grafts.

Permanent in-series cardiac assistance with the dynamic aortic patch: Blood-prosthesis interaction in long-term canine experiments.

The blood-prosthesis interaction of the dynamic aortic patch (DAP), an in-series assist device for permanent circulatory support which is implanted in the descending thoracic aorta, was studied in 65 long-term experiments. Periods of postoperative observation with the device inactive or activated ranged from 2 weeks to 22 months. The intravascular surface of the DAP, fabricated of Dacron velour backed by bioelectric polyurethane, displayed various degrees of organization, ranging from a thin fibrin layer to a well organized pseudointima. Activation of the system did not prevent the development of an organized pseudointima. Changes in free-plasma hemoglobin were minimal; platelet count per square millimeter and state of reactivity remained within normal limits. Evidence of renal embolization, attributable to activation of the device, was found in five animals. Frequent lethal complications were aortic rupture and infections of the thoracic cavity originating at the implantation site. Further improvement of the DAP and the techniques of implantation is indicated to insure its efficacy during long-term implantation and activation.

An extravascular left ventricular assist device.

The hemodynamic efficacy and prosthesis-vessel interaction of a pneumatically activated circulatory assist device was investigated in 12 acute and 12 chronic studies in dogs. A polyurethane balloon encased in Dacron-velour cloth was fastened to the descending thoracic aorta with a spiral wrapping of Dacron graft material. Diastolic augmentation was provided by rhythmic inflation and deflation of the balloon. Hemodynamic results, based on 5 dogs with experimental myocardial ischemia, showed that left ventricular systolic peak pressure decreased by 8.2 +/- 1.9%, cardiac output increased by 13.1 +/- 2.8%, and circumflex coronary artery flow rose by 17.5 +/- 2.5%. In the chronic experiments the prosthesis was asynchronously but continuously activated from one to sixteen weeks at 74 cycles per minute. Postmortem examination of the implantation site in all 12 dogs showed that necrosis had developed but was limited to the outer half of the medial layer beneath the pumping chamber and that the aortic wall was compressed to about 70% of its original thickness. Although the method described represents a simple form of providing ventricular assistance, its applicability for long-term circulatory support remains to be evaluated.

Invasive thymoma with intracaval growth into the right atrium.

We report an unusual case of invasive thymoma with intracaval growth into the right atrium. Computed tomography and venacavography demonstrated this manner of extension of thymoma. The tumor was completely removed by means of cardiopulmonary bypass after four courses of chemotherapy. Multidisciplinary treatment for invasive thymoma with this growth pattern is thought to be useful.

Autologous arterial grafts grown on polyester molds: observations of graft growth and patency in experimental animals.

Tissue molds consisting of polyester mesh jackets covering silicone mandrils were implanted subcutaneously in dogs. When a sufficiently strong layer of connective tissue had formed around the molds they were excised and the mandrils removed. The process of tissue formation was observed and recorded. The forms were used as grafts in either the abdominal aorta or the femoral artery of the dog. Six grafts 10 mm inner diameter, six grafts 6 mm inner diameter and 26 grafts 3 mm inner diameter were implanted. After 4.5 months 80% of the 10 mm grafts, 83% of the 6 mm grafts, but only 4% of the 3 mm grafts remained patent. Histological studies at various intervals after grafting revealed gradual thickening of the neointima. The reason for graft failure was thrombus formation originating at the line of anastomosis.

Redo cardiac surgery for atrial septal defect in a patient with idiopathic thrombocytopenic purpura. Preoperative management with high-dose intravenous gamma-globulin.

A 58-year-old woman with idiopathic thrombocytopenic purpura required redo cardiac surgery of atrial septal defect closure, mitral annuloplasty, and tricuspid annuloplasty. Preoperative high-dose intravenous gamma-globulin and platelet transfusion after termination of cardiopulmonary bypass allowed successful redo cardiac surgery. Management of a patient with idiopathic thrombocytopenic purpura undergoing open heart surgery are discussed.

Aortic subannular left ventricular aneurysm in a patient of Asian ancestry.

An asymptomatic 50-year-old Japanese man was diagnosed with an aortic subannular left ventricular aneurysm during a routine physical checkup. Operative findings showed the subaortic aneurysm had developed beneath the noncoronary cusp of the aortic valve and expanded into the epicardium between the aortic root and left atrium. The operation involved patch closure of the orifice of the annular subaortic aneurysm, aortic valvuloplasty, and plication of the dilated ascending aorta.

Left atrial ball thrombus in a patient without mitral valve disease.

We experienced a large left atrial ball thrombus in a patient without mitral valve disease. By transthoracic echocardiography the mass was appeared to be free-floating and swinging randomly in the left atrium. An urgent operation was performed successfully. Operative findings revealed the mass to be a large ball thrombus loosely attached to atrial wall. We suggest that surgical removal is indicated as soon as possible, because of a very high risk of embolism or circulatory collapse.

Cardiac extension of intravenous leiomyomatosis with successful resection.

A case of intravenous leiomyomatosis spreading to the right ventricle is described. A 28-year-old woman had been previously diagnosed as having a smooth muscle tumor of borderline malignancy after hysterectomy for a large uterine tumor, because of its unusual invasive character. Based on the above diagnosis, the patient had been managed clinically as having a uterine sarcoma. One year after her hysterectomy, a local recurrence in the pelvic cavity was detected. Two years later, the tumor appeared as a cardiac tumor causing syncope. The tumor was totally resected in two surgical stages, and the correct diagnosis of an intravenous leiomyomatosis was made. The diagnostic and operative considerations are reviewed and the preferred surgical procedure is discussed.

[A case of surgical treatment for giant pseudoaneurysm of the left ventricle after myocardial infarction].

A 70-year-old male was admitted for acute postero-inferior myocardial infarction. In cardiac catheterization one month later, there was narrowing of the distal left circumflex artery and the aneurysm of the postero-inferior wall of the left ventricle. The echocardiogram strongly suggested the pseudoaneurysm of the left ventricle. At operation, a large postero-inferior aneurysm was densely adherent to the pericardium. After cardiopulmonary bypass was established, the aorta was cross-clamped and cold cardioplegia was infused, the aneurysm was opened without excision of it. There was a 4 cm by 5 cm defect in the postero-inferior wall of the left ventricle, which communicated with the cavity of the aneurysm. The defect was closed with a patch. Pseudoaneurysm of the left ventricle was diagnosed by histological examination. The postoperative course was uneventful and he discharged on 29th day after surgery.

[A case of pyoderma gangrenosum after mitral valve replacement].

A 48-year-old male with treated hypothyroidism underwent mechanical valve replacement for mitral valve regurgitation. After the operation, the patient developed progressive median chest wound ulceration. The wound did not heal with conventional therapies for mediastinitis such as administration of antibiotics, debridement of necrotic tissue or continuous irrigation. The entire surgical wound opened spontaneously. Bacterial cultures yielded negative and the wound biopsy specimen revealed non-specific inflammatory change. The anti-TSH receptor antigen level was high. Pyoderma gangrenosum based on auto-immune deficiency was diagnosed and high dose corticosteroid therapy was started. The wound healed completely in 5 months.

[A case report of ball variance of Smeloff-Cutter prosthetic valve].

A 37-year-old woman had undergone aortic valve replacement with Smeloff-Cutter prosthetic valve in 1967. She visited our hospital because of dyspnea and chest pain about 22 years after the operation. Severe aortic regurgitant murmur was audible and a chest X-ray demonstrated lung edema. A diagnosis was made of acute left heart failure due to prosthetic valve dysfunction, and emergency operation was performed. The Silastic ball was severely deformed and shrunken. Therefore, the ball was easily put off outside the cage. A St. Jude medical prosthetic valve was implanted. The postoperative course was uneventful.

[A case of pulmonary infarction secondary to subacute bacterial endocarditis with subpulmonary VSD].

A case of pulmonary infarction secondary to subacute bacterial endocarditis of pulmonary valve which is associated with subpulmonary VSD is presented. The jet stream of blood through the subpulmonary VSD made damage to the pulmonary valve, which may be one of the reasons why subacute bacterial endocarditis was associated with the subpulmonary VSD. Echocardiography of the right-sided valves will be very useful in order to detect the pulmonary valve endocarditis in congenital heart disease presenting with fever.

[A case of ruptured aortic arch aneurysm into the lung].

Successful surgical treatment of aortic arch aneurysm ruptured into the left lung was reported. The patient was a 74-year-old man suffering from recurrent hemoptysis. Computed tomography and aortic angiography demonstrated a giant aortic arch aneurysm. Emergency operation was performed. Arch reconstruction by a Dacron graft was performed with hypothermic circulatory arrest. The post operative course was uneventful and there was no evidence of cerebral complication. In the emergency operation for ruptured aortic arch aneurysm, hypothermic circulatory is very useful method for cerebral protection.

[Intrathoracic pacemaker implantation in children].

In order to minimize the complications, we introduced the intrathoracic implantation method since 1976. Until 1988, 12 children underwent this method. A pacemaker generator was exchanged in 8 patients, 12 times, because of battery exhaust. Compared with the conventional method (abdominal wall implantation), the complications such as electrode fracture, which was related to the implantation sites, were reduced. Furthermore it was very useful from the cosmetic viewpoint. Although an exchange of generator was very easily done at the first time, it was very difficult at the second time, due to rib fusion accompanying with children's growth.

[Surgical consideration of ruptured abdominal aortic aneurysms].

During the recent 18 and a half years, 30 cases of ruptured abdominal aortic aneurysm (including four cases of A-V fistula) were operated at Saiseikai Utsunomiya Hospital. In 26 cases, a conventional graft replacement was performed. In other four cases, axillo-bifemoral bypass (in the cases ruptured into the colon) or other methods were used. Overall operative mortality rate was 26.7%. However, during the last 9 years, operative results were improved (21.7%, 5 deaths out of 23 cases). Amount of intraoperative blood loss influenced the operative results greatly. Other operative risk factors included preoperative shock, preoperative severe cerebrovascular or cardiovascular complications, and postoperative thromboembolism. Factors of recent improvement in mortality included; establishment of emergency system which resulted in earlier operation after the patient's arrival at the hospital, use of occlusive balloon for bleeding control, heparin administration before the aortic clamp for preventing peripheral thromboembolism and introduction of autotransfusion system for reducing the amount of blood transfusion.