[Aortobronchial fistula after replacement of descending thoracic aorta with ringed graft; report of a case].

A 79-year-old male patient complicated with aortobronchial fistula after replacement of descending thoracic aorta with ringed graft. He underwent replacement of the aortic arch using a four branched vascular graft and open stent grafting to replace the descending thoracic aorta after removing the ringed-graft through median sternotomy. This procedure is useful for patients as the left thoracotomy is risky and the distal anastomotic site of the descending thoracic aorta is too far to anastomose.

[Recurrent low output syndrome after the weaning from mechanical circulatory support for postcardiotomy cardiogenic shock].

We reviewed the cases of recurrent low output syndrome (LOS) after the weaning from mechanical circulatory support for postcardiotomy cardiogenic shock. Twelve patients were divide into 2 groups according to whether low output syndrome recurred or not, consisting of a recurrent low output syndrome (+) group [re-LOS (+) group, n = 6] and a recurrent low output syndrome (-) group [re-LOS (-) group, n = 6]. Between 2 groups, there was no statistical difference in preoperative left ventricular ejection fraction (LVEF), aortic closs-clamping time and cardiac index at the weaning from mechanical circulatory support. Only the LVEF at the weaning in the re-LOS (+) group was significantly less than that in the re-LOS (-) group (0.39 +/- 0.08 vs 0.62 +/- 0.19, p < 0.05). All patients in the re-LOS (-) group survived to discharge, while in the re-LOS (+) group, although 3 patients were re-supported by intra-aortic balloon pumping, 4 of 6 patients died of multiple organ failure and 2 survivors were in New York Heart Association class III. The results suggest that the key to survive to discharge after the weaning from mechanical circulatory support is whether the cardiac contraction could recover or not.

[True aneurysm of the ascending aorta and/or aortic arch; determinants of late surgical outcome].

To identify significant predictors of late mortality, multivariate analysis were applied to the clinical outcome of 150 consecutive patients with true aneurysm of the ascending aorta and/or aortic arch operated between January, 1987 and December, 2000. Mean follow-up was 53.0 months with a total of 6,682 patient-months of follow-up. Multivariate analysis revealed that operation date (before December, 1996), presence of preoperative cerebrovascular disease, rupture and postoperative phrenic nerve palsy were independent determinants of late mortality. The overall 5-year and 10-year actuarial survival rates were 66.0% and 48.2%. The 5-year and 10-year event free rate of cardiovascular and/or cerebrovascular death were 88.9% and 71.7%. Preoperative evaluation of the brain, operation prior to aneurysm rupture and phrenic nerve protection during operation is necessary to improve long-term survival rate.

Open surgical repair for a perigraft leak after endovascular stent-graft emplacement of descending thoracic aneurysm.

Although transluminal stent-graft implantation is less invasive for treating an aneurysm in the thoracic descending aorta, this technique is not always successful. Here, we report two cases of a perigraft leak identified after stent-graft deployment, and complete occlusion of the leak could not be attained by additional stent-graft deployment. Open surgical repair using a stented graft was performed through a median sternotomy without opening the left pleura. This procedure should be considered as one of the less-invasive techniques for treating a perigraft leak after endovascular stent-graft emplacement.

Commissure holder: an innovative device for aortic valve-sparing technique.

The key to obtaining maximal valve coaptation from the aortic valve-sparing procedure is in appreciating the optimal geometry of each component of the aortic root. We describe a new device called the Commissure Holder (patent pending) that aids in the selection of an appropriate graft size and in the determination of the optimal position at which each commissure should be sutured to the graft.

Concomitant replacement of the aortic root and aortic arch with or without secondary thoracoabdominal aorta replacement.

OBJECTIVES: Extensive aortic replacement, such as concomitant aortic root and arch replacement, thoracoabdominal aortic repair, and complete thoracic aorta replacement, remains controversial. We studied surgical morbidity and mortality in patients undergoing concomitant aortic root and arch replacement, and those undergoing secondary replacement of the thoracoabdominal aorta after this preceding procedure. SUBJECTS AND METHODS: Between January, 1987 and March 1999, 21 patients (mean age: 52 years) underwent concomitant aortic root and arch replacement involving 3 surgical procedures--aortic root replacement with composite graft and arch (n = 12), aortic root replacement with valve sparing and arch (n = 4), or aortic root replacement with composite graft and arch and elephant trunk (n = 5). RESULTS: Overall hospital mortality was 4.8%. Six patients (mean age: 42 years) underwent secondary thoracoabdominal aorta replacement after the concomitant root and arch procedure. The mean time until secondary surgery was 9.5 months. There was 1 hospital death. CONCLUSION: Concomitant replacement of the aortic root and arch, or secondary replacement of the thoracoabdominal aorta after concomitant root and arch replacement can be conducted with low surgical morbidity and mortality.

[Recent surgical treatment for patients with true aortic arch aneurysm].

From december 1996 to april 1999, 25 patients with true aortic arch aneurysm underwent aortic arch aneurysm repair using selective cerebral perfusion. There were 17 males and 8 females ranging in age from 62 to 79 years (mean 71 years). Orikaesi method was used in the procedure of distal anastomosis for complete aortic arch replacement with a prosthetic graft. This technique allowed us a simple approach to the lesion and the easy additional stitch. The average duration of extracorporeal circulation, aortic crossclamping, selective cerebral perfusion were 269 minutes, 140 minutes, and 122 minutes, respectively, under 19.3 degrees C of lowest esophageal temperature. There were no cases complicated with postoperative low output syndrome and cerebrovascular accident, and no hospital mortality. Replacement of the aortic arch using selective cerebral perfusion is a safe procedure with acceptable hospital mortality.

Isolation and sequencing of a cDNA clone encoding a 20-kDa protein with trypsin inhibitory activity.

The amino acid sequence of a novel trypsin inhibitor (p20) was completed by the molecular cloning of the protein in cultured soybean cells. The clone nucleotide contains an open reading frame encoding a polypeptide of 206 amino acids that shows 45-50% sequence homology to members of the Kunitz-type trypsin inhibitor family. The p20 transcript is expressed in the roots, stems and leaves of soybean seedlings. DNA gel blot analyses show that the p20 in soybean is encoded by a single gene, and that this gene may not contain an intron.

Nicorandil pretreatment and improved myocardial protection during cold blood cardioplegia.

OBJECTIVE: The present study was designed to assess whether pretreatment with nicorandil enhanced myocardial protection provided by cold (15 degrees C) high-potassium (25 mmol/l) blood cardioplegia during open heart surgery. METHODS: Subjects were 40 patients with a variety of acquired heart diseases undergoing cardiac surgery involved cardiopulmonary bypass. They were randomly divided into two groups, 25 pretreated nicorandil (0.3 mg/kg) 30 minutes before aortic cross clamping, 15 not pretreated. After aortic cross clamping, the initial dose of cardioplegic solution (10 ml/kg) was administered through the ascending aorta and supplemental doses of cardioplegia (5 ml/kg) given each 30 minutes thereafter. Preoperative and postoperative cardiac troponin-T, myosin light chain 1 and cardiac enzymes were measured and hemodynamic data recorded. RESULTS: Postoperative serum creatine kinase and myosin light chain 1 were significantly lower in the nicorandil pretreatment group than in controls. Serum glutamic oxalacetic transaminase and troponin-T were lower and cardiac output was higher after surgery in the nicorandil group, although not statistically significant. CONCLUSION: This data suggests that pretreatment with nicorandil enhances the myocardial protection achieved by cold blood cardioplegia.

[An experimental study on the occurrence of brain edema after retrograde cerebral perfusion].

To assess the safety of retrograde cerebral perfusion, the occurrence of brain edema after this procedure was investigated. Twenty-eight adult mongrel dogs were divided into three groups that underwent the following treatments: antegrade perfusion (group 1, n = 9); retrograde perfusion alone (group 2, n = 11); or tetrograde perfusion with drugs (manuitol, thiopental sodium, and methylprednisolone; group 3, n = 8). After 90 minutes of cerebral perfusion at 20 degrees C of the pharyngeal temperature, evans blue (EB) was administered to check for disruptions of the blood-brain-barrier (BBB) and brain tissue water content was measured. Intracranial pressure after cerebral perfusion was markedly higher in group 2 than in group 1 (26.4 +/- 9.4 vs. 11.2 +/- 3.6 mmHg), and brain tissue water content was also significantly higher in group 2 than in group 1 (80.7 +/- 2.0 vs. 77.8 +/- 0.9%). These data suggested that brain edema was more prominent after retrograde perfusion than after antegrade perfusion. The extent of EB to brain tissue was greater in group 2 than in group 1 (169.8 +/- 97.7 vs. 54.7 +/- 31.5 micrograms/dl). The BBB was highly disrupted in group 2 and vasogenic edema appeared after retrograde cerebral perfusion. Maximum intracranial pressure, brain tissue water content and EB concentration were significantly lower in group 3 than in group 2, and did not differ significantly between group 3 and 1. Administration of pharmacologic agents suppressed edema formation and extravasation of EB. We conclude that 90 minutes of retrograde cerebral perfusion at 20 degrees C of the pharyngeal temperature causes brain edema and disrupts the BBB in a manner different from that associated with antegrade perfusion. Mannitol, thiopental sodium, and methylprednisolone prevent these phenomena, indicating that pharmacologic intervention may improve the safety of retrograde cerebral perfusion.

[Redo operation after surgery for aortic aneurysm and dissection].

Thirteen patients who underwent redo operation after surgical treatment of aortic aneurysm and dissection were presented. In 8 patients, redo operations were performed for aortic dissection following aortic valve replacement. A-C bypass, the Koster-Collins operation and replacement of thoracic aorta. In the other 5 patients, the reasons for redo operation were aortic root enlargement after replacement of ascending aorta and aortic valve replacement, pseudoaneurysm and aneurysmal dilatation around coronary button for the Bentall operation and recurrent aneurysm after patch aortoplasty and thoracoabdominal replacement using the Crawford's maneuver. To prevent these redo operation, adequate selection of surgical procedures and meticulous operative techniques should be required in primary operation.

[Aortitis syndrome with left coronary ostial occlusion and aortic regurgitation: a case report].

A 22-year-old woman with left coronary ostial occlusion and aortic regurgitation due to aortitis syndrome was reported. The coronary artery bypass grafting, using saphenous vein and aortic valve replacement were performed. The distal anastomosis of saphenous vein was performed to left anterior descending artery (Seg. 6), just distal to the origin of circumflex artery. The postoperative course was uneventful. There was no peri-prosthetic valvular leakage and bypass graft was patent.

[Replacement of the prosthetic aortic valve within a composite graft].

In 1974, a 36-year-old man underwent composite graft replacement of the aortic valve and the ascending aorta with a Starr-Edwards prosthesis (2320). In 1993, he had hemolytic anemia due to cloth wear of the Starr-Edwards prosthesis. The prosthetic aortic valve was removed and replaced without replacement of the conduit. This technique was simple and safe, and was useful to avoid unnecessary dissection.

[Postoperative respiratory dysfunction in patients with Stanford type A aortic dissection].

Between 1986 and 1990, 24 patients with Stanford type A dissection (acute; 14, chronic; 10) underwent surgery through median sternotomy. The patients were divided into two groups by a duration of postoperative ICU stay for respiratory care. Six patients in the long-period group stayed in ICU for more than 15 days and 18 patients in the short-period group stayed for less than 15 days after surgery. Acuity of disease, age, sex, operation time, pump time, aortic clamp time, lowest esophageal temperature, amount of blood transfusion, arch manipulation for cerebral perfusion with or without arch reconstruction, occurrence of phrenic nerve palsy and other postoperative complications, postoperative cardiac, hepatic and renal functions were compared between two groups. Conclusions are as follows: 1) Arch manipulation for cerebral perfusion with or without arch reconstruction, phrenic nerve palsy, other complications (pericardial and pleural fluid accumulation, recurrent nerve palsy, postoperative bleeding and coronary spasm) and high serum creatinine level were main factors for prolonged postoperative ICU stay for respiratory care and 2) arch manipulation in the patients with chronic type A aortic dissection induced high incidence of phrenic nerve palsy.

[Result of surgical treatment of true or dissected thoracic aneurysm: determinants analysis in operative mortality and morbidity].

Between 1986 and 1990, 69 patients underwent surgery either for thoracic aneurysm (27 patients) or aortic dissection (42 patients). Sixty one patients (88%) survived and 8 patients (12%) died after surgery. Main determinants of deaths in 4 patients with true arch aneurysm were bleeding from the sites of aortic clamping or anastomosis and intraoperative severe LOS. Three patients with acute type A dissection died from bleeding due to clamp injury or myocardial ischemia. The cause of death in the patient with chronic type B dissection was associated with brain damage due to hypoxia developed during left heart bypass. Postoperative cardiac, pulmonary, hepatic and renal functions were analyzed in the operative survivors. Cardiac functions were maintained well in all patients except two patients with chronic type A dissection. Four patients, one with true arch aneurysm, 2 with chronic type A and one with chronic type B dissection, required tracheostomy. The mean of maximum total serum bilirubin exceeded 4 mg/dl in the patients with true arch aneurysm, acute and chronic type A dissection. The level of serum creatinine showed slight increase in all patients but prophylactic peritoneal dialysis was performed in one patient with chronic type A dissection. In conclusion, the cause of deaths in most patients with thoracic aneurysm was due to inappropriate operative techniques and circulatory supports during surgery. Without the complication described above, the patients could tolerate surgery well.

[The use of the bio-pump with an interposed soft reservoir in replacement of descending thoracic aortic aneurysms].

The centrifugal pump (bio-pump) as a temporary shunt during the operation of the descending thoracic aortic aneurysms was used as effective means of providing adequate circulation to the lower body. But in the acute excessive bleeding, estimates of the flow to the abdominal viscera as well as spinal cord are variable. We employed bio-pump with an interposed soft reservoir under low dose systemic heparinization in 2 cases of the descending thoracic aortic aneurysms. Both cases had been maintained adequate flow and perfusion pressure in the time of acute excessive hemorrhage, and there were no evidence of the organ failures due to microembolism. Furthermore, postoperative hemorrhage by using low dose heparin seemed to be unrisky. Compared with the previous method, bio-pump with an interposed soft reservoir provides adequate circulation to the lower body even if acute excessive bleeding occurred.

Long-term results after repair of tetralogy of Fallot.

One hundred sixty-six patients with tetralogy of Fallot including 15 pulmonary atresia repaired since 1971 were analyzed with respect to their physical activities, school or social life, hemodynamics, ECG, reoperation and late mortality. Follow-up period ranged from 1 to 19 years with an average of 9.1. There were 9 late deaths including 4 sudden deaths. Actuarial survival rates at 5 and 13 years were 96.4% and 90.5%, respectively. Eighty-five patients (72.0%) of 118 replied were in NYHA functional class I, 31 (26.3%) in class II and 2 (1.7%) in class III. Thirteen patients (7.8%) demonstrated right ventricular/left ventricular systolic pressure ratio over 0.80 because of inadequate relief of the pulmonary stenosis or obstruction, hypoplasia of the pulmonary artery or external conduit stenosis. Although the left ventricular ejection fraction was maintained at the normal range (0.65 +/- 0.09), that of the right ventricle was below the normal level (0.52 +/- 0.09). Two patients developed complete heart block postoperatively and underwent pacemaker implantations. Complete right bundle branch block was observed in 85 patients including 6 with left axis deviation. Most of the patients after correction of tetralogy of Fallot are in satisfactory conditions. However, some patients have limitations in school or social life because of residual lesions or postoperative complications. It is important to consider the proper operative procedures to avoid these problems.