[Long-term results of aortic arch replacement using combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion; comparison of result for atherosclerotic aneurysm and aortic dissection].

Between 1992 and 2001, 73 patients with aortic arch lesion underwent surgical treatment. The aneurysm was characterized by atherosclerosis in 54 patients (TAA) and by aortic dissection in 19 patients (DAA). All patients received graft replacement under combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion. The hospital mortality rate for all patients was 15.6%. The follow-up period of 61 survival patients ranged from 2 to 90 months (mean 33.2 months). The actuarial survival rate was 93.2%, 83.5%, and 79.7% at 1, 3, and 5 years, respectively. No significant difference was noted between TAA and DAA in the actuarial survival rate. The freedom from vascular complication was 97.9%, 95.8%, and 95.8% at 1, 3, and 5 years, respectively. The rate was significant higher in the patients of DAA than in those of TAA (TAA: 100%, 100%, and 100%, DAA: 90.9%, 81.8%, and 81.8%). The freedom from cardiac complication was 96.4%, 89.7%, and 84.1% at 1, 3, and 5 years, respectively. There was no significant difference between TAA and DAA. The freedom from cerebrovascular complication was 100%, 97.6%, and 83.4% at 1, 3, and 5 years, respectively. No significant difference was noted between TAA and DAA. The late result of surgical treatment for the aortic arch using combination of deep hypothermic circulatory arrest and retrograde cerebral perfusion was satisfied. The long-term survival rate was higher in TAA patient than in DAA one. The possibility remained that fatal vascular complication affected the long-term survival rate.

Ultrasonic evaluation of congestive liver after tricuspid annuloplasty.

To assess the effect of tricuspid annuloplasty (TAP), the authors measured the size of the liver by using echography in the patients undergoing tricuspid annuloplasty. From April 1989 to August 1996, 18 patients underwent TAP. The authors measured preoperatively and postoperatively the hepatic index (HI) by echography, defined as follows: HI=L x D/BSA (L: the top-to-bottom length of the left hepatic lobe; D: the front-to-back length of the left hepatic lobe; BSA: body surface area). They also calculated the reducing rate (RR) of HI. The mean HI decreased after TAP; preoperative HI: 39.7+/-11.8 vs postoperative HI: 33.8+/-10.5 (p=0.0069). The RR of the patients with postoperatively residual tricuspid regurgitation (TR) over 2 degrees (n=4) was significantly lower than that of the other patients (n=14): -11.0+/-6.0% vs 20.2+/-3.2% (p=0.0003). They conclude that the use of echography to measure the HI is a good method of assessing congestion after TAP.

Influence of preoperative nutritional state on inflammatory response after surgery.

To investigate whether the preoperative nutritional state influences the postoperative inflammatory reaction and immunity, we grouped patients whose postoperative nutritional support was performed by total parenteral nutrition into the good nutritional state group (group I) and the latent protein-calorie malnutrition suggested group (group II) based on the preoperative rapid turnover protein (RTP). Nutritional markers markedly decreased after surgery and recovered almost to preoperative levels on postoperative day (POD-) 7 in groups I and II. Nutritional markers on POD-7 in group II were significantly lower than those in group I (RTP, P < 0.001; albumin, P < 0.05). After surgery, levels of interleukin-6 (IL-6), C-reactive protein (CRP), and polymorphonuclear (PMN-) elastase were higher in group II than in group I (P < 0.01). In groups I and II, IL-6 and interleukin-8 (IL-8) rose before the remarkable elevation of CRP and PMN-elastase. In group I, all the nutritional markers showed a negative correlation with CRP and PMN-elastase. Further, a positive correlation was observed between IL-6 and CRP and between IL-8 and PMN-elastase. In conclusion, evaluation of the preoperative nutritional state appears to be very important for the prediction of postoperative complication.

Inhibitory effects of H2-receptor antagonists on platelet function in vitro.

To evaluate in vitro inhibitory effects of four types of histamine H2-receptor antagonist (H2-receptor antagonists), famotidine, roxatidine, cimetidine and ranitidine, on platelet function, we examined aggregating potency and P-selectin levels with agonist-induced aggregation. Ranitidine and cimetidine inhibited, in concentration of 0.35 mM, the secondary aggregation induced by 5 microM adenosine diphosphate (ADP), the aggregation induced by 1 microg/mL collagen and 3 microM arachidonic acid. All of H2-receptor antagonists inhibited, in concentration of 1.4 mM, the aggregation induced by ADP, collagen and arachidonic acid. Ranitidine and cimetidine reduced markedly, in same concentration, P-selectin levels after induction of aggregation by 5 microm ADP, 1 microg/mL collagen and 3 microM arachidonic acid. When classified by the strength of inhibitory action, ranitidine and cimetidine were strong, followed by famotidine and roxatidine. It is considered that inhibitory effects of H2-receptor antagonists on platelet function are weaker than those of acetylsalicylic acid (ASA), since ASA inhibited platelet aggregation in concentration of 100 microM. No relationship was observed between inhibitory effects of H2-receptor antagonists on platelet aggregation induced by above agonists and the presence or absence of imidazole ring in the chemical structure.

Myxoma of mitral valve associated with infective endocarditis.

A 20-year-old man was hospitalized for persistent fever, embolism, and syncopal attack. Echocardiography demonstrated a tumor on the mitral posterior leaflet. It was removed under extracorporeal circulation following extirpation of thrombus in the right common like artery. The tumor consisted of myxoma and vegetation with bacterial colony. Myxoma and/or vegetation had destroyed the mitral posterior leaflet. Accordingly, it was necessary to perform mitral valve replacement. The postoperative course was uneventful. This is the 14th surgical case of mitral valve myxoma, and the first case of that associated with infective endocarditis.

Repair of an acute type A dissection: fate of the remnant false lumen and preserved aortic valve.

From January 1992 through March 1997, 75 patients (DeBakey type I/II = 56/19) underwent a surgical repair of a type A acute dissection. The patients included 37 men and 38 women ranging in age from 23 to 83 years with a mean of 65 years. All patients were admitted to our hospital with a mean interval of 2.2 days from the episode of onset. The overall hospital mortality rate was 25% (19/75). There were three late deaths among the 56 patients discharged from the hospital. The actuarial survival rate for the patients surviving the operation was 87% at 5 years after repair. A subsequent aortic operation was necessary in 6 patients, while 3 other patients who had late aortic complications were put on medical therapy alone. As a result, the aortic event-free survival rate was 54% at 5 years. For a type I dissection the false lumen was completely thrombosed after repair in 34%. The descending thoracic aorta with a patent false lumen was markedly enlarged in proportion to the follow-up time. After a conservative approach to the aortic valve, all but one patient demonstrated an adequate valve function throughout this study period. This experience with a midterm follow-up showed an acceptable durability of the preserved aortic valve and a progressive enlargement of the persistent false lumen with a high rate of aortic complications. Hence, all patients with a type A dissection need a close follow-up to assess the aorta for complications of either recurrent or residual aneurysms and dissections.

Clinical experience of 473 patients with the omnicarbon prosthetic heart valve.

BACKGROUND AND AIM OF THE STUDY: The long-term clinical experience of patients receiving Omnicarbon heart valve prostheses between January 1985 and December 1996 was investigated. METHODS: In total, 473 patients (255 males, 218 females; mean age 57.5 +/- 10.1 years (range: 20n-73 years) received 523 prostheses. These included 253 mitral (MVR), 170 atrial (AVR) and 50 double (DVR) valve replacements. RESULTS: The 30-day mortality rate was 4.7% (n = 22); in addition eight patients died more than 30 days after surgery, but during the same hospital stay. Mean follow up was 3.9 years (maximum 11 years and 7 months). Cumulative follow up was 1,750.1 patient-years (pt-yr); follow up was 97.5% complete. Among 39 late deaths, 20 were valve-related (seven cerebral infarction, seven cerebral bleeding, six endocarditis) and four cardiac-related. The overall five-year cumulative survival rate (excluding early mortality) was 90.2 +/- 11.7% (MVR 88.0 +/- 2.5%, AVR 93.1 +/- 2.3%, DVR 93.7 +/- 4.8%). At 10 years, the overall survival rate was 76.4 +/- 7.7%. Valve-related complications included thromboembolism (n = 13, 0.7%/pt-yr), anticoagulation-related hemorrhage (n = 12, 0.7%/pt-yr) and endocarditis (n = 7, 0.4%/pt-yr). Neither mechanical failure nor clinical hemolysis was observed. The overall valve-related event-free rate after five years was 89.3 +/- 2.0% (MVR 89.8 +/- 2.4%, AVR 93.5 +/- 2.6%, DVR 89.4 +/- 5.7%) and after 10 years it was 87.6 +/- 2.6% (MVR 85.4 +/- 3.7%, AVR 93.5 +/- 2.6%, DVR 82.5 +/-10.1%). CONCLUSIONS: These long-term results with the Omnicarbon valve are excellent; especially satisfactory results were achieved in terms of the low rate of thromboembolic complication.

Effects of sarpogrelate hydrochloride on platelet aggregation, and its relation to the release of serotonin and P-selectin.

Inhibitory effects of sarpogrelate hydrochloride (sarpogrelate), a 5-HT2 receptor antagonist, on platelet aggregation was examined as well as the relationship to serotonin and P-selectin, a platelet alpha-granule membrane glycoprotein. Platelet aggregation was induced by simultaneous addition of collagen (0.06-0.12 microg/ml), which did not induce aggregation alone, and serotonin (0.88 micromol/1) to platelet-rich plasma (PRP). The PRP was obtained from healthy volunteers and percentage maximum aggregation (MA) was measured. Serotonin levels and P-selectin levels in the supernatant of PRP after aggregation were determined. When vehicle-treated PRP was stimulated in the aforementioned manner, platelet aggregation dependent on collagen concentration was induced. Serotonin levels and P-selectin levels were also dependent on collagen concentration. Sarpogrelate (10(-6) to 10(-4) mol/l) inhibited such aggregation dose-dependently, and decreased serotonin levels and P-selectin levels in a dose-dependent manner. There were close correlations between MA and serotonin levels, MA and P-selectin levels, as well as serotonin and P-selectin levels. These results suggest that extracellular release of serotonin and P-selectin from platelets was caused by induction of aggregation, and these responses were suppressed by sarpogrelate.

Congenital bicuspid aortic valve: analysis of 63 surgical cases.

BACKGROUND AND AIMS OF THE STUDY: This study reports the clinicopathologic characteristics of congenital bicuspid aortic valves necessitating surgical intervention. METHODS: Among 374 aortic valve procedures during the past 15 years, 63 cases of bicuspid aortic valve were encountered. Patients included 45 males and 18 females; mean age was 53 years (range: 14 to 76 years). RESULTS: Thirty-two patients demonstrated aortic stenosis (AS), 27 aortic regurgitation (AR), and four had both conditions. Patients with AR were significantly younger than those with AS (45 +/- 13 versus 60 +/- 11 years; p < 0.01). Histologic study of the excised valve disclosed severe myxoid degeneration in 16 of 27 patients with AR. These patients underwent surgery at a younger age than the other 11 with calcification and endocarditis (40 +/- 13 versus 52 +/- 10 years; p = 0.01). Based on the macroscopic appearance, the lesions were divided into those with (n = 38) and without (n = 25) raphe. Twenty-one patients (55%) in the former group demonstrated AR, whereas 19 (76%) in the latter group demonstrated AS. Patients with raphe were significantly younger at the time of surgery than those without raphe (50 +/- 15 versus 57 +/- 11 years; p = 0.02). As a complication, ascending aortic aneurysm was observed in six patients. CONCLUSIONS: In a bicuspid aortic valve, calcification with stenosis commonly occurs in most older patients. However, in some young adult patients with raphe, AR may result from myxoid degeneration. The presence of raphe in the bicuspid valve appears to have a significant influence on valve hemodynamics.

[Late results of emergency operation in acute type A dissection].

77 cases of acute type A dissection underwent emergency operation during 5 years were studied. There were 37 men and 40 women, and 58 cases in type I, 19 cases in type II on DeBakey type. The grafting for the aorta including the tear was basically performed under selective brain perfusion and deep hypothermic circulatory arrest. The overall hospital mortality rate was 24.7%. However, it was 14% after using GRF glue. The overall actuarial survival rate for 58 patients who survived operation was 87% at 5 years after surgery. Late remnant false lumen-related complications were recognized in four patients (6.9%). For two of them, subsequent operations were performed. Another two patients died of rupture of remnant false lumen during observation. Aortic valve regurgitation was recognized preoperatively in 13 patients. None of them required subsequent operation in late phase. Results and countermeasure for late remnant false lumen-related and aortic valve-related complications were investigated.

Pedicle transposition of the greater omentum for sternal osteomyelitis and mediastinitis after cardiac operation.

Three patients underwent pedicle transposition of the greater omentum for sternal osteomyelitis and mediastinitis after cardiac operation. These patients were previously operated on with coronary artery bypass grafting, aortic valve replacement and redo Fontan operation in each. This procedure was carried out on 4, 6, 8, and 14th postoperative day. The complications cured within about one month after the procedure in all cases. It is suggested that this maneuver is effective for obtaining healing osteomyelitis and mediastinitis following cardiac operation.

Intramural hematoma of the thoracic aorta.

OBJECTIVE: This study was designed to clarify the optimal treatment mode of patients with intramural hematoma (IMH) of the thoracic aorta. METHODS: From 1992 through 1997, 51 patients underwent surgical repair or medical treatment of IMH of the thoracic aorta. There were 36 male and 15 female patients, aged between 49 and 79 years with a mean of 67 years. The ascending aorta and/or aortic arch was involved in 18 patients (group I), whereas the descending thoracic aorta was affected in 33 (group II). The presence of intimal disruption in IMH was confirmed in 10 of group I and 13 of group II patients. RESULTS: For group I patients 13 required aortic arch repairs and the remaining 5 underwent conservative therapy including anti-hypertensive medication. Primary indications for immediate surgery were: cardiac tamponade in 5 patients, aortic dissection superimposed on IMH in 2, and persistent pain with an aortic arch aneurysm in 1, respectively. Early elective operations were done for enlarged ulcer in 3 patients and aneurysmal dilatation in 2 of which 1 had a coexisting aortic arch aneurysm. The 2-year survival rate after diagnosis was 94% with an operation-free rate of 25%. Nine of the group II patients experienced surgical intervention of which 8 had intimal disruption, 4 patients received urgent replacement of the descending thoracic aorta for massive pleural effusion and 1 had the aortic arch replaced for a coexisting aneurysm with persistent pain. All other patients underwent conservative treatment and 4 of them had to be shifted to early surgery during the initial hospitalization because of an enlarged ulcer. The 5-year survival rate in group II patients was 63% with an operation-free survival rate of 66%. CONCLUSIONS: On the basis of our experience early operation is recommended for almost all patients with ascending aortic IMH, and medical therapy for those with descending aortic involvement unless complication developed. However, the presence of intimal disruption may require early surgical treatment even in the patients with descending thoracic IMH.

[Preoperative autologous donation of blood in cardiac surgery--age related factors].

We have studied influence of the age related factors on preoperative autologous donation (PAD) of blood in cardic surgery. PAD was undertaken in 246 cases of elective cardiac surgery by means of simple or leap-frog method, starting at approximately 4.5 weeks before operation. It provided 1726 ml of autologous blood storage on the average. Sorting the patients into three groups with age, leading surgical procedures were as follows: closure of the atrial septal defect (ASD) in teen 30s (group L, n = 51), aortic valve replacement (AVR) or mitral valve replacement (MVR) in 40s-50s (group M, n = 83) and 60s and over (group H, n = 112). Coronary artery bypass grafting (CABG) was more common in group H. Percent-freedom from allogeneic blood transfusion was 82.3% in group L, 80.7% in group M and 61.6% in group H, respectively (p < 0.05; L, M vs. H), donated blood volume in group H was significantly less than that of group M (p < 0.05, M: 1987 +/- 63, H: 1610 +/- 60 ml), because blood volume and hemoglobin level before donation tended to be less in group H. Each group did not differ in blood loss during and after operation, which showed a significant positive correlation with operation time and cardiopulmonary bypass (CPB) time. Comparing factors in ASD, CPB time was relatively long, and postoperative blood loss was significantly larger in group H (p < 0.05; L: 432 +/- 71 ml, M: 369 +/- 34 ml, H: 754 +/- 124 ml). This finding suggests that the secondary lesions in age ASD cases adversely affected hemostasis. As to AVR, MVR and CABG, there were no differences in these factors but donated blood volume among three groups. We conclude that elderly patient (60s and over) tends to necessitate allogeneic blood transfusion in cardiac surgery because of the insufficient PAD. Earlier commencement of PAD or concomitant application of erythropoietin will improve this situation.

Infected atherosclerotic ulcer of the abdominal aorta as a cause of mycotic aneurysm treated by in-situ prosthetic graft reconstruction: report of a case.

A 68-year-old man with an infrarenal mycotic aneurysm underwent successful in-situ graft reconstruction using a woven Dacron graft. A tissue culture taken from the excised aortic wall revealed Staphylococcus epidermidis, and histological study subsequently showed penetrating atherosclerotic ulcers (PAU) involving all layers of the aortic wall and marked neutrophilic infiltration with abscess formation inside the ulcer. Atherosclerotic aortic lesions such as PAU are considered susceptible to bacterial infection, which may lead to the formation of an aneurysm after destruction of the vessel wall. Hence, elderly hypertensive patients, being at high risk for such aortic pathology, require careful studies performed to assess the aorta. The usefulness of computed tomographic (CT) scans to determine the presence of PAU or surrounding inflammation should be borne in mind even when a small mycotic aneurysm exists.

Penetrating atherosclerotic ulcers in an abdominal aortic aneurysm: report of a case.

We report the case of a 74-year-old man found to have an extensive intramural hematoma (IMH) in the infrarenal abdominal aorta during a follow-up imaging study performed after repair of a DeBakey type II aortic dissection with an aortic arch true aneurysm. Enhanced computed tomographic scan and angiography revealed an extensive IMH and multiple penetrating atherosclerotic ulcers in the abdominal aorta. The patient underwent a successful replacement of the affected abdominal aorta using a collagen-impregnated woven Dacron graft. Atheromatous ulcers are known to occur frequently in patients with advanced atherosclerosis. Hence, the elderly hypertensive patient, being at high risk of developing a variety of aortic disorders, requires careful follow-up imaging studies to assess the aorta on a regular basis.

[Two cases of mitral restenosis occurring eight years after percutaneous balloon mitral commissurotomy (PTMC)].

A 63-year-old man and a 49-year-old man who underwent PTMC eight years before were admitted in our hospital because of regurgitation and restenosis of the mitral valve. Both of them had ulcer like lesion on the anterior leaflet near the commissure of the mitral valve. These changes were made by PTMC and likely caused thrombosis. Long-term follow up data of PTMC is essential to chose the correct operative method for treating mitral stenosis.

[Composite valve graft replacement in patients with type A aortic dissection--a modified cabrol procedure].

Composite valve graft replacement of the ascending aorta and aortic valve is indicated for a variety of conditions affecting the aortic root. However, a major drawback in this operation is bleeding from the proximal suture line and coronary anastomosis especially in patient with friable root tissue involved by aortic dissection. We describe here a modified technique to take advantage of the aortic button and cabrol techniques to reattach the coronary artery ostia. We have experienced seven patients with the aortic root replacements for type A dissection using the described technique over the past two years. In view of our favorable experience, we recommend this technique especially for patient with acute dissection involving nondilated aortic annulus, in addition to the patients with Marfan syndrome or annulo-aortic ectasia.

Retrohepatic cavoatrial shunt with a ringed polytetrafluoroethylene graft for the Budd-Chiari syndrome. A case report.

This report describes a patient with Budd-Chiari syndrome who was operated on successfully by means of shunt formation with polytetrafluoroethylene graft between the inferior vena cava (IVC) and right atrium. The patient is a sixty-two-year-old woman suffering from persistent edema of the lower limbs for four years. The examination disclosed complete obstruction of the IVC at the level of the diaphragm with a patent right inferior hepatic vein. Following the operation, edema of the limbs disappeared, hypersplenism improved, and the serum ammonium concentration decreased to the normal range. In conclusion, a retrohepatic cavoatrial shunt is feasible and useful in treating a patient with the Budd-Chiari syndrome who has patent major hepatic veins.