Frequency and operative correction of aortic insufficiency associated with ventricular septal defect.

Frequency and surgical results of aortic cusp prolapse and aortic regurgitation (AR) associated with ventricular septal defect (VSD) were studied. One hundred thirty-six consecutive patients with type I and II VSD according to Kirklin and associates' classification were divided into two groups; group A included 50 patients with type Ia VSD without the conal muscular rim, and group B included 86 patients with type Ib VSD with the conal muscular rim, or with type II VSD. Aortic cusp prolapse was detected in 74% of group A patients and 29% of group B patients. The aortic cusp prolapse correlated negatively with preoperative left-to-right shunt ratio, mean pulmonary artery pressure, and pulmonary-to-systemic pressure ratio in both groups. In group B patients, the smaller the VSD, the higher the frequency of aortic cusp prolapse, especially when less than 4 mm. Aortic regurgitation was observed in 44% of group A patients and 24% of group B patients. All 20 patients with first grade AR underwent VSD closure, 11 with second or third grade AR underwent VSD closure plus valvuloplasty, and 1 with third grade AR underwent aortic valve replacement. Postoperative persistent AR occurred in 8 out of 32 patients, and correlated positively (p < 0.01) with the preoperative grade of AR and the number of plication stitches in both groups.

The effects of the hypothermic management of brain dead dogs on preserving graft viability in heart transplantation.

The effect of hypothermic management for brain dead dogs on preserving graft viability was evaluated through preservation and transplantation. After the occurrence of brain death, 43 dogs were divided into two groups; the normothermic group (37.2+/-0.3 degrees C) and the hypothermic group (31.8+/-0.3 degrees C) according to the esophageal temperature. After the 6-hour management of brain dead donors, the heart beat was arrested using a cardioplegic solution followed by coronary vascular bed washout. The donor heart was then harvested and preserved for 12 hours with simple immersion into the University of Wisconsin solution. Following preservation, orthotopic transplantation was performed in six grafts randomly selected from each group. During the 6-hour management of brain dead dogs; 1) heart rates, rate-pressure products, and the total amount of catecholamine were significantly (p<0.05) lower in the hypothermic group than in the normothermic group, and 2) lactate contents collected from the coronary sinus blood and O2-extraction rates of the heart tended to be lower in the hypothermic group than in the normothermic group. During 12 hours of preservation, intracellular pH and creatine phosphate contents were higher in the hypothermic group than in the normothermic group. Following orthotopic transplantation, the animals in the hypothermic group showed a significantly (p<0.05) higher recovery rate of left ventricular (LV) pressure and the maximum rate of the rise of LV pressure compared with normothermic group animals. We conclude that the hypothermic management of brain dead dogs may be effective in preserving graft viability and may provide a clinical application for heart transplantation with acceptable outcomes.

Induction of acute-phase reactive substances during open-heart surgery and efficacy of ulinastatin. Inhibiting cytokines and postoperative organ injury.

OBJECTIVE: A systemic inflammatory response after open-heart surgery using cardiopulmonary bypass may be responsible for postoperative organ dysfunction. Ulinastatin, a protease inhibitor, plays an important role in host defense under periods of stress. METHODS: We studied the efficacy of ulinastatin on changes in acute-phase reactive substances during and after open-heart surgery. Patients undergoing open-heart surgery were divided into an ulinastatin group (Group U) and a control group (Group C). In Group U, we introduced 600,000 units of ulinastatin into a priming solution for cardiopulmonary bypass, 300,000 units into a cardiopulmonary bypass circuit at the removal of aortic cross-clamping, and 300,000 units a day for 5 days following surgery. RESULTS: Immediately after cardiopulmonary bypass, alpha 1-antitrypsin levels decreased significantly in both groups, and increased significantly on the second day after surgery. Ulinastatin levels decreased after cardiopulmonary bypass in Group C. Significantly high levels of ulinastatin were obtained in Group U. Interleukin-6, interleukin-8, and polymorphonuclear elastase were markedly induced, and high levels of plasma concentration continued for several days after surgery. At all sample points, these concentrations in Group U tended to be lower than those in Group C. A significantly positive correlation was seen between the maximum levels of interleukin-8 and polymorphonuclear elastase, but these cytokine and polymorphonuclear elastase levels did not correlate with parameters such as the duration of anesthesia, surgery, cardiopulmonary bypass, or aortic cross-clamping. CONCLUSIONS: Our study suggests that high-dose ulinastatin administration to maintain a sufficient concentration of circulating protease inhibitors may suppress overinduction of cytokines and polymorphonuclear elastase in open-heart surgery.

[Postoperative infections related to pacing wires, pulmonary arterial catheters, and drainage tubes temporarily inserted during open-heart surgery].

Bacterial examinations of temporary pacing wires (P-wires), pulmonary arterial (P-A) catheters, and drainage tubes temporarily inserted during open-heart surgery were performed in 213 patients. Bacteria were detected in 19 (2.8%) of 672 specimens gathered from the subject patients, with coagulase-negative Staphylococcus (CNS) being most frequently observed. P-wires accounted for 17 out of 19 of the culture-positive specimens, and 7 of the P-wires remained in place for more than two weeks. The frequency of infection with the P-wires was significantly higher than with the P-A catheters or drainage tubes. The period of time that the P-wire was left in place significantly longer than for P-A catheter or drainage tube. There was, however, no statistically significant difference between the culture-positive and negative groups in respect to age, detention periods, operation times, CPB times, or length of ICU stay. As a result of these findings, we have concluded that P-wires should be removed as soon as possible following surgery, and in any case, a meticulous care should be taken to prevent transcutaneous infection.

[Duodenal metastasis from squamous cell carcinoma of the lung; report of a case].

Metastatic carcinoma from primary lung cancer is usually recognized in the brain, adrenal glands, and bone. It is uncommon in the digestive system, particularly in the duodenum. We report a 63-year-old man who had undergone a left lower lobectomy for lung cancer. Anemia (Hb 6.9 g/dl) had been observed 2 months after surgery for primary lung cancer. Gastroduodenoscopy showed duodenal metastasis, and further examination demonstrated adrenal metastasis. Palliative treatment was selected and the patient died 5 months after surgery.

[Secondary abnormal development of the bronchial artery: report of a case].

A 65-year-old man was admitted to our hospital because of massive hemoptysis. The patient had suffered from pneumonia since 1999, but he had refused to undertake further examinations. In 2002, the patient was transferred to our emergency room because of massive hemoptysis. Following endotracheal intubation, the patient underwent bronchial artery embolization. The X-ray and computed tomography (CT) films on admission revealed localized bronchiectasis in the left upper lung. Bronchoscopic findings revealed massive bleeding from the left upper bronchus. Bronchial arteriography of the left bronchial artery showed peripherally hypervascular finding in the left upper lobe. A segmentectomy of the left upper division was performed as a radical therapy for localized lesions with massive hemoptysis. The pathological diagnosis was secondary abnormal development of the bronchial artery. We speculated that massive hemoptysis had occurred probably due to infection in the focus.

[Congenital bronchial atresia treated with video-assisted thoracoscopic surgery; report of a case].

We report an adult case of congenital lobar emphysema due to bronchial atresia. A 24-year-old man was referred to our department because of cough and fever. A chest roentgenogram on admission showed multiple cystic shadows in the left lower lung field. Chest computed tomography (CT) demonstrated multiple cysts with neveau and scattered infiltration in the left lingual segment and lower lobe. Surgical treatment was scheduled because of no improvement of the chest lesions. The interlobar fissure was not found between the upper and the lower lobes, but between the upper and the lingual divisions. Additionally, the lingual bronchus was not bifurcated from the upper bronchus, but from the lower bronchus. As inflammatory changes were extended to the lingual division and the lower lobe, a left lingual segmentectomy and a lower lobectomy with video-assisted thoracoscopic surgery were performed. His postoperative course was uneventful and he was discharged at the seventh day after surgery.

[Lung cancer with an extrapericardial single trunk as the left pulmonary vein; report of a case].

A left lower lobectomy was successfully performed in a lung cancer patient with anatomical variation in which the left superior and inferior pulmonary veins were connected to the left atrium after forming an extrapericardial single trunk. This variation is surgically important because ligation and division of the left inferior pulmonary vein may result in blockage of upper lobe vein drainage at the time of a left lower lobectomy. The ligation of the pulmonary vein leads to severe lung edema, which may cause infection, respiratory distress, or postoperative complications that could be life-threatening. Surgeons must always pay attention to this variation when performing a left lower lobectomy.

[A long-term surviving case with invasive thymoma undergone 4 times operations for tumor recurrences].

We reported a long-term survivor with invasive thymoma associated with myasthenia gravis. The patient underwent operations 4 times for these 13 years. At the third and fourth operation, the tumor was resected after preoperative neo-adjuvant chemotherapy with cisplatin and adriamycin, and postoperative radiotherapy was added. Her postoperative course was uneventful, and she has been alive. Our strategy for invasive thymoma is that tumors which include both primary and recurrent lesions are removed as completely as possible, and that postoperative radiotherapy is added for stage II, III and IV in Masaoka's classification, and preoperative neo-adjuvant chemotherapy for stage III and IV. We believe that these multidisciplinary treatments and long term follow-up lead good results without harm to quality of life.

[Surgical treatments of emphysematous giant bullae accompanied with severe bronchial asthma].

Two operative cases of emphysematous giant bullae of the lung accompanied with bronchial asthma were reported. Case 1: A 41-year-old man suffering from dyspnea and fever-up was diagnosed as emphysematous giant bullae of the right lung accompanied with severe bronchial asthma. Preoperative examination revealed severe hypoxemia (PO2 46 mmHg) and mixed type ventilatory disorder; VC 1.68 t (41%), FEV1.0 0.59 l (35%). On the first anesthesia, operation was postponed by the severe asthmatic attack and circulatory collapse. After the complete prevention of the attack by giving corticosteroid (25 mg/day) for two weeks, resection of giant bullae could be performed safely. Case 2: A 31-year-old man complaining wheeze was diagnosed as emphysematous giant bullae of bilateral upper lobes of lung accompanied with bronchial asthma. Preoperative and intraoperative states were uneventful, though, on the day after the operation, asthmatic attack occurred due to the difficulty in expectation of sputa. It took 12 hours and many kinds of drugs to improve the respiratory state. In the patients of bronchial asthma, preoperative sufficient suppression of hyperreactivity of airway tracts and postoperative careful treatment to avoid asthmatic attack seem to be indispensable.

[Coronary artery bypass grafting for a patient with left ventricular ejection fraction of 16%: a case report and review of the Japanese literature].

A 65-year-old man with left ventricular ejection fraction (LVEF) of 16% successfully underwent coronary artery bypass grafting (CABG). CABG used to be contraindicative for patients with LVEF below 20%. However, such patients are recently involved to indication of CABG if viability of the myocardium is proved. We consider CABG is indicated for a patient who keeps a sufficient cardiac output despite a low level of LVEF. Intraaortic balloon pumping which was started immediately after the induction of anesthesia was effective. Only eight patients with LVEF below 20% have undergone CABG in Japan. Thus, we reported our patient with some discussion on operative indication and perioperative management.

[Methicillin-cephem-resistant Staphylococcus aureus (MRSA) mediastinitis following open heart surgery].

Mediastinitis following cardiac surgery occurs frequently in association with high mortality and morbidity. Patient was a 6-year-old boy suffering from Sotos syndrome with secundum type of ASD. He was operated upon to repair ASD. Following the surgery, he suffered from MRSA mediastinitis and osteomyelitis of the sternum. Routine method of closed irrigation after reopening of the sternal wound was ineffective. Patient recovered following aggressive debridement repeatedly, open drainage and topical irrigation with vancomycin. This appears to be a useful method to treat MRSA mediastinitis of the sternum.

[Effects of dopamine and dobutamine on systemic hemodynamics and myocardial metabolism in children after open heart surgery].

The purpose of this study is to know the effects of Dopamine (DOA) and Dobutamine (DOB) on the systemic hemodynamics and myocardial metabolism in the acute phase after open heart surgery in children. Thirty patients with congenital heart disease were divided into following two groups. The first 14 cases were administered 5 and 10 micrograms/kg/min (gamma) of DOA, and the systemic hemodynamic and metabolic data were taken before and after the administration of the drug. The second 12 cases were given the same doses of DOB instead of DOA. DOA: The blood pressure was elevated by 10 gamma of DOA, and cardiac index (CI) and stroke volume index (SVI) rose up at both doses of DOA. On the other hand, systemic vascular resistance (SVR) and left atrial pressure (LAP) were decreased at both dosage levels. DOB: At the same dose of DOA, DOB increased HR and SVI, so CI rose up markedly. The systolic and mean blood pressure also rose up at both doses. CVP and LAP were depressed at either dosage level. SVR did not show an appreciable change. Myocardial metabolism: The two drugs tested did not exhibit the progress of anaerobic myocardial metabolism. The myocardial oxygen uptake rate increased with DOA, but decreased with DOB. This phenomena probably suggests that DOB dilates coronary vascular bed. From the above data, the following effects are expected by the use of each drug after open heart surgery in children: 1) an increase of cardiac output due to inotropic action by DOA, 2) powerful inotropic and chronotropic action by DOB.

[Left ventricular rupture following aortic and mitral valve replacement in a patient with osteogenesis imperfecta: a case report].

Intraoperative left ventricular rupture (type I) occurred following aortic and mitral valve replacement in 62-year-old man with osteogenesis imperfecta. Re-replacement of the mitral valve and the repair of left ventricular rupture were successfully performed. However, the patient died suddenly 3 days after the operation. Retroperitoneal bleeding due to the insertion of a continuous hemofiltration catheter via the femoral vein was detected at autopsy. Seven patients who underwent double valve replacements for aortic and mitral disease with osteogenesis imperfecta were reported with poor surgical results. We report our patient and discuss the relationship between osteogenesis imperfecta and left ventricular rupture.

[Effects of dobutamine and isoproterenol on systemic hemodynamics and myocardial metabolism in children after open heart surgery].

The purpose of this study is to know the effects of Dobutamine (DOB) and Isoproterenol (ISP) on the systemic hemodynamics and myocardial metabolism in the acute phase after open heart surgery in children. Twelve patients with congenital heart disease were administered 5 and 10 micrograms/kg/min (gamma) of DOB, then 0.005 and 0.01 gamma of ISP, and the systemic hemodynamic and metabolic data were taken before and after the administration of the drugs. DOB: DOB increased HR and SVI, so CI rose up markedly. The systolic, diastolic and mean blood pressure also rose up after both doses. CVP and PCWP were depressed at both dosage levels. SVRI and PVRI did not show an appreciable change. ISP: ISP increased HR, CI and systolic blood pressures significantly. On the other hand, SVRI, PVRI and PCWP were decreased at both dosage levels. Myocardial metabolism: The two drugs tested did not exhibit any effect on the progress of anaerobic myocardial metabolism. The myocardial oxygen uptake rate was decreased with DOB and ISP. These phenomena probably suggest that DOB and ISP dilate the coronary vascular bed. From the above data, the following effects can be expected by the use of each drug after open heart surgery in children; 1) powerful inotropic and chronotropic action by DOB, and 2) chronotropic action and after-load reduction by ISP.

[Surgical treatment of active infective endocarditis with aortic root abscess, left ventricular and right atrial fistulae--report of a child].

Aortic valve replacement with a 17 mm Björk-Shiley prosthetic valve, and the closure of left ventricular and right atrial fistulae which were connected with the aortic root were successfully performed in a 10-year-old boy. He was admitted because of high fever and severe heart failure, and diagnosed aortic regurgitation, and left ventricular and right atrial fistulae due to active infective endocarditis. The annular defect was repaired with annular enlargement by a pericardial patch and annulo-right atrial fistula was directly closed from the right atrium. The patient is doing well 1 year after surgery.

[Surgical treatment of traumatic rupture of the bicuspid aortic valve: case report].

A 64-year-old female was admitted to our hospital with the complaints of chest oppression and dyspnea, 3 months after the traffic accident. She was operated on with the diagnosis of aortic regurgitation and bicuspid aortic valve. The tear of aortic valve was detected in the anterior cusp, and the size of the tear was 12 mm. The aortic valve replacement was performed and her postoperative course was uneventful. In the pathological study of the cusps, the tear was originated from trauma without inflammatory changes. This is the first report of traumatic rupture of the bicuspid aortic valve in Japan.