[Tricuspid annuloplasty, pulmonary valve replacement, ventricular septal defect (VSD) patch closure, and right-sided maze procedure 23-years after corrective repair of tetralogy of Fallot].

Postoperative pulmonary valve regurgitation, stenosis of the right ventricular outflow tract, conduit failure, ventricular septal patch leak, secondary tricuspid valve regurgitation, and various arrhythmias are the major complications that develop after surgical repair of tetralogy of Fallot in adults. A 27-year-old male with pulmonary regurgitation, tricuspid regurgitation, residual ventricular septal defect (VSD), low left ventricular function, and chronic atrial fibrillation underwent tricuspid annuloplasty, pulmonary valve replacement with a stentless aortic valve, VSD patch closure, and right-sided maze procedure, and the postoperative course was uneventful. The cardiothoracic ratio decreased, sinus rhythm was restored, and the patient's complaints were relieved. Reoperation at the optimal time after corrective repair of tetralogy of Fallot in adults may improve the outcome.

Pulmonary embolectomy for acute massive pulmonary embolism under percutaneous cardiopulmonary support.

Portable percutaneous cardiopulmonary support (PCPS) with heparin-coated circuits and a biopump was employed in a patient who had a massive pulmonary embolism with circulatory collapse after stripping of varicosities of the leg. Emergency pulmonary embolectomy was successfully performed. The main pulmonary incision was facilitated by cross-clamping of the main pulmonary arterial root. The bypass circuit was kept closed, and used with the normothermic beating heart without converting to conventional total cardiopulmonary bypass. Blood flow from the lung was removed by pump suction, stored in the reservoir, and intermittently returned to the venous circulation. Heparin was added to the circuits to keep the activated clotting time greater than 300 sec. In massive pulmonary embolism, PCPS is useful for preoperative, intraoperative, and postoperative support.

Late leaflet fracture and embolization of a Duromedics mitral prosthesis.

A case of leaflet fracture and embolization of a mitral prosthetic valve is described. A 54-year-old man had received mitral valve replacement with an Edwards-Duromedics 29M prosthetic valve, at 10 years ago. Emergency mitral valve replacement was performed because the patient had severe congestive left heart failure with severe acute mitral regurgitation caused by a fracture in one of the mitral valve leaflets. The leaflet, which was fractured into 2 pieces, was removed from the right common iliac artery at 3 months after valve replacement. Visual inspection revealed that the leaflet contained a midline fracture. The fracture originated within a cavitary erosion pit near the major radius of the leaflet. The patient recovered from acute renal failure, requiring hemodialysis for 80 days, and is currently without complaints. We have used a Duromedics mitral valve in 11 patients, from April 1987 to April 1988. No subsequent valve failure has occurred. The diagnosis, treatment and cause of a mechanical valve fracture are discussed.

[Two cases of surgical treatment of recrudescent Stanford type A dissection after early thrombogenic closure without intimal tear].

We reported two cases of thrombosed, Stanford A type acute aortic dissection, initially without intimal tear, later operated upon because of recrudescence. They admitted to our hospital with the symptoms of aortic dissection. Early examination of computed tomography and angiography demonstrated thrombosed type A aortic dissection showing a normal aortic figure, although accompanied by pericardial effusion, that was drainaged. Under strict BP control, however, repeat CT examination revealed recrudescent dissection of ascending aorta, making dissecting aneurysms. Graft replacement of ascending aorta was performed, on the 55th and 153th day after admission, and they were discharged.

[Surgical repair of complete atrioventricular septal defect: annuloplasty by using a smaller VSD patch].

Recent policy for the intracardiac repair of complete atrioventricular septal defect (CAVSD) is demonstrated on the basis of the following theoretical background. In the normal heart, the originating portion of the ascending aorta and the crux intrude between the mitral and tricuspid orifices each from the anterior and from the posterior, separating both the orifices together with a short fibrous septal junction. In CAVSD, however, the common A-V orifice takes an elliptic form without any septal junction. It is considered beneficial, therefore, to surgically produce a short septal junction by using a smaller patch to close the ventricular portion of the AVSD. When the left lateral leaflet is larger, two leaflets valve plasty is suggested and when it is smaller, three leaflets valve plasty is suggested to reconstruct the left-sided A-V valve, although competence of the valve leaflets must be finally secured by doing repeated water injection tests. The size of the orifices of the reconstructed left-sided as well as right-sided A-V valve should also be confirmed not to be stenotic by using Hegar sizers. Since 1991, we have applied this surgical concept in 7 patients with CAVSD. Postoperatively, there was no left A-V valve regurgitation in one and slight regurgitation remained in 6 patients. The result is considered to be satisfactory. Although one patient died due to PH crisis, the cause of death was not related to valve regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

[An effective case of nitric oxide inhalation therapy in pulmonary hypertensive crisis in cardiopulmonary bypass following palliative operation for ventricular septal defect with pulmonary hypertension].

A 4-month-old female with ventricular septal defect (VSD) and severe pulmonary hypertension (PH) underwent a patch closure for VSD. She could not be weaned from cardiopulmonary bypass (CPB) after the intracardiac repair due to PH crisis. Nitric oxide inhalation therapy during partial CPB enabled her to be weaned from CPB. This therapy could be gradually taped off and quit 7 days after the operation. Nitric oxide inhaled therapy is considered to be an excellent treatment for PH crisis during CPB in congenital cardiac surgery. The causes of PH crisis were also discussed in reference to the date of endothelin-1 (ET-1) measured during the operation.

[A case report of the radical correction of a truncus arteriosus and peripheral pulmonary stenosis in association with Holt-Oram syndrome].

A one year and 6 months old female infant was admitted to our department for a radical correction of a truncus arteriosus (Collett-Edwards type II). She also had a peripheral pulmonary stenosis and Holt-Oram syndrome. Under a cardiopulmonary bypass with deep hypothermia, PFO was closed directly. First of all, the pulmonary arteries were dissected from the aorta, the defect of the aorta was closed directly and VSD was closed with Dacron fabric patch. The reconstruction of the pulmonary arteries were performed with valved conduit which consisted of Dacron graft and 14 mm Björk-Shily valve. The post-operative course was uneventful. Cardiac catheterization study, done 77 days after surgery, revealed 44 mmHg of pressure gradient between RV outflow tract and right PA. The patient was doing well and two years have passed since the surgery. She should be observed carefully at the out-patient clinic due to the mechanical valve and the presence of pressure gradient at RV outflow tract.

[Mitral valve replacement and closure of atrial septal defect in the case associated with Marfan syndrome].

This is a case report of 8-years-old boy, who was diagnosed mitral regurgitation, secundum type of atrial septal defect and annulo-aortic ectasia in association with Marfan syndrome. His diagnosis was confirmed at the age of 6 years when cardiac catheterization was carried out. Atrial septal defect was closed using PTFE patch (0.2 mm in thickness). His diseased mitral valve was replaced with CarboMedics prosthesis 27 mm in diameter. Because of intact aortic valvular function, we left the ectatic aorta alone at present time for future procedure. His postoperative course was uneventful. He is active and doing well at present and has been followed-up at the outpatient clinic routinely. He might be having to require AVR and graft implantation for ectatic ascending aorta.

[A case report of surgical management of blunt ruptured right atrium with blunt ruptured liver].

This is a case report of a 23 year old female involved in a car accident that caused blunt trauma to the patient. First of all, she was found to have cardiac tamponade when the abdomen was explored to suture and to put the gaze compression on for hemostasis of the ruptured liver. Then, she was brought to our institution by the ambulance. Upon the exploration of the heart under standby of extracorporal circulation (ECC), small multiple lacerations were found at the junction of the right atrium and superior vena cava. These were sutured directly to close without ECC. On the 2nd postoperative day, she was bought to the OR again to removal of the gaze tamponade from the ruptured liver and to complete hemostasis. The patient was discarded 35 days after admission.