[Off-pump coronary artery bypass for old myocardial infarction associated with jejunotomy for obstructive ileus due to gall bladder stone; report of a case].

In non-cardiac operative cases with inflammatory digestive organ disease, bacterial translocation (BT) often results from non-enteral nutrition postoperatively. If coronary artery bypass grafting (CABG) is performed in the case having old myocardial infarction (OMI) and inflammatory digestive organ disease at first before non-cardiac operation, he seems vulnerable to have severe complications such as multiple organ failure due to systemic inflammatory response syndrome (SIRS) and preexisting BT postoperatively. We performed a off-pump CABG (OPCAB) for OMI associated with jejunotomy for obstructive ileus due to gall bladder stone. No complication was found in the postoperative course. We conclude that combined operation, non-cardiac surgery after OPCAB is worth considering in those cases. And we think OPCAB is better than conventional CABG in such cases, because cardiopulmonary bypass is known to ponder comparable damages to immune system, coagulation system and others.

Surgically treated Swyer-James syndrome.

Because patients with Swyer-James syndrome have almost always been treated conservatively, few reports exist of pathological findings of the lung in this syndrome. We report a case of this rare disease treated surgically and discuss pathological findings. A 36-year-old woman repeatedly contracted bronchitis and pneumothorax since adolescence, until April 26, 1997, when she reported chest pain and dyspnea. Chest X-ray on admission showed left pulmonary collapse with a slight deviation of the mediastinum toward the right. Chest computed tomography showed an apical bulla and emphysematous change in the left upper lobe. Pulmonary arteriography at age 17 showed hypoplasia of left pulmonary artery branches in the left upper lobe. Based on a diagnosis of Swyer-James syndrome, we conducted left upper lobectomy on May 2, 1997. Pathological examination of the resected left upper lobe showed marked emphysematous change, including an emphysematous bulla with destruction of alveolar structure and peribronchiolar fibrosis. No vascular abnormality was recognized in histology. Emphysematous change secondary to repeated bronchiolitis is believed to have led to her repeated pneumothorax.

Traumatic cardiac rupture with acute ascites.

A rare accumulation of serous ascites following traumatic cardiac rupture is reported for a 21-year-old man transferred to the emergency center of our hospital from a community hospital suffering from severe shock due to a motorcycle accident. Computed tomography scan showed moderate pericardial and intrapelvic fluid accumulation strongly suggesting cardiac and visceral injuries. An emergency sternotomy disclosed a rupture of the right atrial appendage, successfully closed with primary sutures. A laparotomy was done to aspirate moderate serous fluid, which was clear and not bloody. Edema of the retroperitoneal space and hepatic congestion were noted with no accompanying organ injury. Ascites pathogenesis is unknown but appeared to be related to portal venous congestion induced by cardiac tamponade combined with massive intravenous fluid infusion done to correct the patient's deteriorating hemodynamics.

Structural study of PLGA [copoly (DL-lactic/glycolic acid)], a biodegradable polymer for parenteral sustained release preparations, by tandem mass spectrometry.

A copoly (DL-lactic/glycolic acid) (PLGA), with a weight-average molecular weight of about 8400, has been characterized using fast atom bombardment (FAB)-tandem mass spectrometry in order to determine the sequence. Because of the large molecular size, PLGA was partially hydrolyzed and the terminal hydroxyl groups in the resulting oligomer mixture acetylated as the indicator. The FAB spectrum of this sample showed a complex ion signal pattern containing monomer to octamer. Diagnostic product ions containing useful information for sequence determination were observed in collision-induced dissociation-MS/MS and MS/MS/MS of these oligomer ions. The results of analysis for dimers through pentamers showed that they have random sequences of lactic and glycolic acid, suggesting that the whole structure of PLGA also has a random sequence.

Argatroban, an attractive anticoagulant, for left heart bypass with centrifugal pump for repair of traumatic aortic rupture.

Systemic heparinization often increases the risk of fatal bleeding from other injured organs in surgical repair of the aorta using extracorporeal circulation in patients with traumatic aortic rupture associated with multisystem injuries. We used an antithrombin agent, argatroban, as an alternative anticoagulant in left heart bypass with the Bio-Medicus centrifugal pump in 7 of 9 recent patients who underwent aortic repair using left heart bypass. All these patients survived without obvious evidence of systemic thromboembolization. Surgical treatments for other organ injuries were carried out in 3 patients concomitantly or immediately after aortic repairs without undue blood loss. Argatroban may have a complementary effect for preventing thrombus formation without aggravating bleeding tendency because of its monotarget specificity to thrombin. We believe intravenous administration (0.5 to 2 micrograms/kg/min) of argatroban is a safe anticoagulant for left heart bypass in repairs of traumatic aortic rupture associated with multiple organ injuries.

[A case of progressive saccular aneurysm caused by localized dissection of descending aorta].

A fifty-three-year-old man was admitted because of chest pain. CT scan showed the localized dissection of the descending aorta which was partially thrombosed. The patient was followed by controlling of essential hypertension. He, however, complained of the second attack of chest pain after a year and 5 months. CT scan showed the increased dilatation of the false lumen as compared to that of previous examination. MR angiogram showed a saccular aneurysm localized in the middle portion of the descending aorta. An operation was performed through posterolateral thoracotomy in the 4th intercostal space with the aid of normothermic femoro-femoral bypass circulation. The aneurysm was located at the level of 5th thoracic vertebra with the size of 70 mm in length and 45 mm in diameter. Entry was observed in the posterior wall of the aorta, and the terminal end of the false lumen was occluded with the organized thrombus. The aneurysm was successfully replaced with a prosthetic graft. To the extent of our knowledge, only limited surgical cases of saccular aneurysm caused by localized dissection of the middle portion of the descending aorta have been reported.

[Coronary artery bypass grafting with arterial graft alone: radial artery and inferior epigastric artery used in combination].

UNLABELLED: We experienced 8 cases in which Coronary Artery Bypass Grafting (CABG) was performed by the arterial graft alone with radial artery (RA) and inferior epigastric artery (IEA) used in addition to internal thoracic artery (ITA) and right gastroepiploic artery (RGEA). All the patients were male ranging in age from 50 to 66 years (mean 57.5 year). The number of anastomosis was 3 to 5 branches (mean 3.6 branches). IEA was anastomosed with LITA and used as a composite graft in all cases. As for the proximal anastomosis of RA it was anastomosesd with ascending aorta. On postoperative radiography of graft, LITA, RITA, IEA and RA were all patent and RGEA was occluded only in one anastomosis where it was sequentially used (96.6%). All the patients followed a satisfactory postoperative course, and no case developed any major complications. CONCLUSION: The use of IEA and RA made it possible to perform CABG using only the artery with excellent postoperative results and early patency rate of the graft.

[Radial artery for coronary artery bypass graft].

Early postoperative results were studied in 50 cases of coronary artery bypass graft (CABG) using a radial artery (RA). The patients ranged in age from 37 to 81 years, with the mean age of 61 years. Of them, 49 were male. An average of RA was 17.6 cm at completion of detachment and 15.6 cm when the graft was cut for use. The internal diameter before anastomosis an average of 3.7 mm on the proximal side and an average of 2.8 mm on the distal side. RA was anastomosed with ascending aorta in 47 cases, with the left internal thoracic artery in 2 cases and with the right internal thoracic artery in one case on the proximal side. RA was anastomosed with the left anterior descending branch area in 6 cases, with the left circumflex branch area in 40 cases and with the right coronary artery area in 4 cases on the distal side. There was no case of operative death, but one patient died while in hospital. The cumulative patency rate of the RA grafts was 95% (n = 40). Early postoperative results of the RA graft were satisfactory, therefore the RA graft were satisfactory, therefore the RA graft was an excellent alternative conduit for myocardial revascularization.

[Surgical treatment of aortic valve endocarditis associated with aortic root aneurysm and abscess].

Between Jan. 1979 and Mar. 1996, aortic root abscess and aneurysm were encountered in 10 (34.5%) of the 29 patients who underwent surgical treatment for the aortic valve endocarditis ; native valve endocarditis (NVE) in 8 and prosthetic valve endocarditis (PVE) in 2. Noncoronary sinus was involved in 8 (80%) of 10 patients, left coronary sinus destructed in one, and more than one sinus were involved in one. All patients underwent aortic valve replacement after repair of abscess or aneurysm with suture closure in 5, and patch closure in 3, and its resection in one. Aortic root reconstruction using a valved conduit was required for the repair of aortico-ventricular discontinuity followed debridement of the abscess cavity of almost entire annulus in one PVE patient who consequentry died of LOS and sepsis. There was no operative or postoperative death in the other patients, however, one female patient suddenly died 24 months after surgery. She underwent direct suture closure of left coronary sinus aneurysm and aortic valve replacement with a small-sized prosthetic valve. Suture dehiscence of the orifice of the aneurysm developed immediately after surgery. It is concluded that patch closure of aortic root aneurysm or abscess is recommended so as to avoid narrowing of left ventricular outflow tract and recurrence of aneurysm formation even if its orifice proved to be small.

[Traumatic thoracic aortic rupture--diagnosis and surgical repair].

Fifteen cases of traumatic thoracic aortic rupture (TAR) were treated at St. Marianna University Hospital from December 1980 to July 1995. Causes of TAR were due to vehicle accidents in 14 patients and fall in one patient. On diagnosis, contrast-enhanced CT scan was routinely performed in the patients with blunt chest trauma associated with superior mediastinal widening, loss of the aortic knob or right shift of the trachea on the initial roentgenogram. When CT scan demonstrated specific signs for TAR, pseudoaneurysm formation and/or extravasation of the contrast dye, aortography was eliminated before operation. As a role, operation was performed on an emergency basis as soon as the diagnosis was confirmed. Four cases died due to intrapleural rupture before or immediately after thoracotomy. Nine (82%) of the 11 patients in whom operation was completed survived and are doing well. In one of the 4 patients who underwent operation with simple aortic cross-clamping; paraplegia developed after 30 minutes of spinal ischemia. Left heart bypass with the Bio-Pump without heparin or with an antithrombin agent, argatroban, was used in recent 6 patients. Use of left heart bypass with the Bio-Pump without anticoagulant or with argatroban appears to be promising as a safe adjunct in the repair of TAR, preventing fatal bleeding of other injured organs.

[The usefulness of combined measurements of transcranial Doppler sonogram and somatosensory evoked potentials during hypothermic cardiopulmonary bypass].

Serial and simultaneous measurements of the blood flow velocity of the middle cerebral artery (MCA-V) by transcranial Doppler sonography (TCD) and somatosensory evoked potentials (SEP) were performed in 7 adult patients during hypothermic cardiopulmonary bypass (CPB). CPB was instituted by alpha-stat blood gas management until the rectal temperature stabilized at 24 to 28 degrees C and gas management was converted from alpha to pH-stat by adding 4-7% of CO2 gas into the oxygenator for 10 minutes. MCA-V during hypothermic CPB by alpha-stat management was identical with normothermic prebypass MCA-V. However it significantly increased after pH-stat conversion, suggesting that CO2 reactivity was preserved even in the hypothermic situation above 24 degrees C of body temperature. Latency of all wave components of SEP and central conduction time (CCT) prolonged and wave voltages decreased as the body temperature dropped and SEP waves almost completely recovered following the temperature resumed to the prebypass temperature. There were no significant changes developed in latency and wave forms of SEP by conversion of the blood gas management from alpha-stat to pH-stat. The combined technique of TCD and SEP for detecting the real time changes of cerebral blood flow and brain function is considered to be useful to minimize the brain damage during open heart surgery.