[Surgical treatment of aortic root disease].

We reviewed aortic root disease and operative procedures. Between January 1982 and December 2008, aortic root operation was performed for 58 patients with various aortic root disease. We chose Bentall type operations in extensive root destructive cases and urgent or reoperative cases. Overall in-hospital mortality was 8.6% (5/58). Four patients (7.5% of survivors) died during the period of followup. Actuarial survival at 15 years was 92%. Freedom from cardiovascular event at 10 and 15 years was 81% and 27%, respectively. Of 5 reoperations in 5 patients, only 1 was required due to complications of the initial Bentall type operation. The Bentall type operations resulted in a durable result. Although, in Marfan syndrome, freedom from cardiovascular event was lower than that in non-Marfan syndrome, actuarial survival rate was equal with non-Marfan syndrome. Close observation is necessary for detecting cardiovascular event, especially in Marfan syndrome.

[Improved cardiac function after inhalation of nitric oxide and tricuspid annuloplasty in dilated cardiomyopathy patient on left ventricular assist system].

A 17-year-old man with severe cardiac failure due to dilated cardiomyopathy was treated by medication. As he did not improve, he had indication for transplantation of the heart and was put on a ventricular assist system as a bridge until he could be transplanted. He also had severe tricuspid regurgitation and tricuspid annuloplasty was performed. Inhalation of nitric oxide was used to decrease pulmonary vascular resistance. Although cerebral infarction was present postoperatively, he is waiting for transplant without paralysis. The ventricular assist system proved to be useful therapy for serious cardiac failure due to terminal dilated cardiomyopathy.

[Interrupted aortic arch type B survived after single stage repair and continuous hemodiafiltration; report of a case].

A 14-day-old, 2,042 g neonate with interrupted aortic arch (IAA) type B was admitted to our hospital because of respiratory failure. Although alprostadil and alprostadil alfadex were used to keep the ductus arteriosus open, her congestive heart failure became worse and anuria and metabolic acidosis started to appear. We performed single-stage repair for her at 14 days old. Continuous hemodiafiltration (CHDF) was initiated immediately after the operation and peritoneal dialysis was started after paralytic ileus improved. CHDF improved her renal function and she was discharged at postoperative day 84. We conclude that CHDF is effective for neonates with acute renal failure although circulation management is rather difficult.

[Palliative right ventricular outflow reconstruction in tetralogy of Fallot with pulmonary atresia and aberrant right subclavian artery; report of a case].

A 1-month-old girl weighting 3.1 kg was diagnosed as tetralogy of Fallot (TOF) with pulmonary artery atresia (PA) and aberrant right subclavian artery. Before the operation, pulmonary blood flow from a ducus arteriosus was maintained by lipo prostaglandin E1 (PGE1). The patient underwent palliative right ventricular outflow tract reconstruction (pRVOTR) because the proximal aberrant right subclavian artery was stenotic and the ductus arteriosus and branch of the left pulmonary artery were so close. Postoperative course was uneventful and pulmonary artery showed good growth. The pRVOTR as 1st procedure is a useful method for hypoplastic pulmonary artery to get equal and good growth. Although there are controversies about the size of right ventricular outflow tract (RVOT), 5 or 6 mm diameter of RVOT is recommended for the operative repair of hypoplastic left heart syndrome. We concluded that the pRVOTR should be one of the options as 1st palliative procedure for TOF with PA and diminutive pulmonary artery.

[Left ventricular-right atrial communication resulting from infective endocarditis].

We report a rare case of acquired left ventricular-right atrial communication resulting from infective endocarditis. A 57-year-old male with aortic regurgitation due to infective endocarditis was referred to our hospital because of severe congestive heart failure. Preoperative transthoracic echocardiography showed aortic, mitral and tricuspid severe regurgitations. Intraoperative transesophageal echocardiography revealed left ventricular-right atrial shunt. The fistula was located at the atrioventricular membranous septum. The communication site from the left view was below the commissure between the right coronary cusp and non-coronary cusp, and from the right view was just above the tricuspid annulus of the septal leaflet. The fistula was closed directly with mattress suture and aortic valve replacement and both mitral and tricuspid ring annuloplasty were carried out simultaneously. The postoperative course was uneventful. It is important to inspect shunts carefully in echocardiography of infective endocarditis with massive regurgitations.

[Emergency small-sized stent placement following aortic true lumen obliteration of Stanford type B acute aortic dissection].

Acute aortic obstruction induced by acute aortic dissection frequently causes life-threatening organ ischemia. Although early reperfusion of lower extremities, renal and mesenteric artery is necessary, surgical treatment such as graft replacement is invasive and may result in myonephropathic-metabolic syndrome (MNMS), which leads to loss of limb and life. We herein report a case of stent placement as a less invasive treatment for true lumen obliteration associated with Stanford type B aortic dissection in a patient with chronic renal failure on hemodialysis. Ten mm metallic stents were placed in the obliterated true lumen of the descending aorta in order to perfuse peripheral organs within 5 hours after occurrence. It relieved symptoms of visceral organ and leg ischemia. On the postoperative day 14, abdominal discomfort after meal, hypertension in the upper extremity and headache appeared. Chest and abdominal computed tomography (CT) revealed stenosis of the true lumen proximal to the stents. On the other hand, the diameter of the true lumen was inversely dilated distal to the stents. Bilateral axillo-femoral artery bypass was performed with relief of upper extremity hypertension and visceral organ ischemia. The patient otherwise had an uneventful course and was discharged on the postoperative day 37. Our experience suggests that emergency stent placement can provide an option that is less invasive, more effective and prompt treatment for patients with visceral organ and leg ischemia resulting from acute aortic dissection.

[Ruptured thoracic aortic aneurysm presenting as massive epistaxis; report of a case].

An 80-year-old woman was transported to the emergency room at our hospital by the ambulance, suffering from massive epistaxis. As the patient was hemodynamically stable, otolaryngologist attempted to perform tamponade using nasal packing. However, the patient's condition deteriorated, with the development of dyspnea and a reduction in oxygen saturation to 90%. A chest X-ray performed at this point revealed left lung consolidation and pleural effusion while chest computed tomography (CT) demonstrated that rupture of a descending aortic aneurysm with periaortic hematoma and extension of hemorrhage into the left lower lobe of the lung. Emergency surgery was performed under partial extracorporeal circulation, established by cannulation of the right femoral artery and vein. In addition to the replacement of the descending aorta with a prosthetic conduit, left lower lobectomy was necessary because of severe adhesion to the descending aorta. The postoperative course was largely uncomplicated apart from development of chylothorax, which resolved with a short period of total parenteral nutrition and she was discharged 50 days after surgery.

[Effectiveness and advisability of using a graft in off-pump coronary artery bypass grafting].

In off-pump coronary artery bypass grafting (off-pump CABG: OPCAB) procedures involving multiple vessels, the Aorta No-Touch technique is increasingly being adopted to avoid cerebral infarction, while gastro-epiploic artery (GEA)-left anterior descending coronary artery branch (LAD) anastomosis or composite T-grafting is performed to supply blood to multiple coronary arteries through the left internal thoracic artery (LITA) as an inflow conduit. The objective of the present study is to investigate the effectiveness and advisability of grafting in patients who undergo OPCAB involving multiple vessels, including those who undergo standard CABG. CONCLUSIONS 1: Composite T-grafts of the LITA in OPCAB involving multiple vessels can present certain problems with patency, patient survival, and need for subsequent revision procedures. In the event of a graft failure, serious symptoms resembling left main coronary trunk (LMT) may develop. 2: The incidence of cardiac events with GEA-LAD is high, and patency in the distal phase is poor. 3: Ideally, LITA-LAD should be performed alone. 4: Among patients who have been screened before the procedure, satisfactory results are obtained for OPCAB in which the ascending aorta serves as an inflow conduit; this procedure should be considered as a viable option.

[Modified bentall operation using composite graft without resection of aortic valve].

A 27-year-old male whose diagnoses were aortic dissection (Stanford A), aortic regurgitation, annulo-aortic ectasia, and Marfan syndrome underwent modified Bentall operation using composite graft and total arch replacement. Modification of proximal suture without resection of aortic valve like intravalvular implantation might have resulted in good recovery without blood transfusion. Another 63-year-old male who suffered from spontaneous aortic rupture with aortic regurgitation also underwent modified Bentall operation in the similar manner as the first case with good result. Spontaneous aortic rupture reported here is a rare case, and operation is thought to be prerequisite for the patient who suffers from this disease to survive.

[A report of three surgical cases in a family of Marfan syndrome].

A family of 3 patients with Marfan syndrome was reported. All of them had surgical interventions in cardiovascular disorders such as DeBakey type I, III aortic dissection and thoracoabdominal aortic aneurysm. In 2 patients, multiple surgical treatments were performed for aneurysmal dilatation of the distal false lumen or another lesions of the treated aorta. Since cardiovascular lesions of Marfan syndrome are systemic and progressive, the postoperative long term follow-up, including systemic evaluation of the arterial system, is essential to detect the latent cardiovascular complications. Careful examining the family with Marfan syndrome is necessary to discover any cardiovascular abnormalities in these people early.

[An adult case of Bochdalek hernia without an obvious cause; report of a case].

A 72-year-old female was transported by ambulance to our department to undergo transthoracic surgery. She had previously undergone transabdominal surgery under a diagnosis of adult Bochdalek hernia, but the restoration was believed to have been incomplete. During the transthoracic procedure, a dorsolateral defect of the diaphragm was detected and reinforcement with a Gore-Tex patch was performed. The patient's postoperative course was uneventful. Adult Bochdalek hernia is rare, but it requires immediate surgical intervention. Although transabdominal surgery is generally considered the first line treatment approach to restore Bochdalek hernia, restoration of the diaphragm is occasionally difficult. On the other hand, a transthoracic approach is thought to be effective as it allows for observation of the lung and diaphragm, and easy closure of the diaphragmatic defect. As complete restoration through early surgical intervention is important, a transthoracic approach in conjunction with transabdominal surgery should be considered whenever necessary.

Myocardial protection of the pressure overload hypertrophied heart in human cardiac surgery by acceleration of anaerobic glycolysis.

BACKGROUND: Because of the decreased tolerance to ischemia and increased reperfusion injury in hypertrophied myocardium, myocardial hypertrophy is a well known risk factor for cardiac surgery. We have previously demonstrated in a left ventricular hypertrophy (LVH) model that a highly buffered cardioplegic solution (HBS) that provided glucose as a substrate and promoted anaerobic glycolysis during ischemia afforded superior myocardial protection when compared to standard formulations. And we reported the superiority of this cardioplegia in human cardiac surgery. METHODS: In this study, 16 patients with aortic stenosis (AS) and LVH receiving HBS were reviewed and compared to another patient group with AS and LVH who received either cold blood cardioplegia (CBC; n=5) or glucose insulin potassium (GIK; n=6). RESULTS: Postoperative cardiac index was better in the HBS group than the other two groups with similar or lower catecholamine. CK-MB was lower in HBS group than GIK group, but this was not significant. Only one DC cardioversion was required in the HBS group, whereas 2 DC in the CBC group and total 7 DC in the GIK group. CONCLUSIONS: We found that histidine buffered cardioplegic solution provided comparable or better pump performance after surgery with relatively lower inotropic requirement, less DC cardioversion and homologous blood requirements for left ventricular hypertrophied heart associated with aortic stenosis.

Rapid growth and difficulty of early detection of scirrhous carcinoma of the stomach.

We report six cases of scirrhous carcinoma of the stomach in which we were able to observe the natural history of serial radiographs. All the patients developed scirrhous carcinoma of the stomach in an observation periods ranging from 2 to 15 months (mean: 5.8 months). No abnormalities or obvious findings indicative of a carcinoma were detectable, on the prior radiographs, even when they were reviewed. Endoscopy was also performed in two patients during the observation period, and no lesions were detected. At the time of diagnosis, two patients were inoperable because of metastases and died of the disease 2 and 5 months later. Three patients died of the disease 5, 8, and 26 months after gastrectomy, respectively. Only one patient is free of disease 16 months after gastrectomy. Our findings suggest that the difficulty of detection and the rapid growth of this tumor may explain why it is seldom detected at an early stage and has a very poor prognosis.