[Long-term survival of malignant fibrous histiocytoma of the chest wall by multidisciplinary treatment].

We report a case of malignant fibrous histiocytoma (MFH) of the chest wall. A 70-year-old man admitted for recurrent chest wall tumor diagnosed for MFH histologically and resected 7 months and 13 months before admission. Chest computed tomography (CT) revealed a tumor located at right posterior chest wall. In May 1997, resection of the tumor was done (the 3rd operation), but metastasis to the ribs (the 4th operation), subcutaneous tissue (the 5th operation), and local recurrence (the 6th operation) was found within 4 years postoperatively. Resection was done for each metastasis, and postoperative radiotherapy (66 Gy) and chemotherapy (CYVADIC) were done. The patient is doing well without apparent recurrence 57 months after last surgery, and survives 113 months after initial surgery. Multidisciplinary treatment may provide longer survival for patients with MFH of the chest wall.

Clinical experience with temporary vena cava filters.

An experience with temporary filter placement, which seems to be safe and effective for temporarily preventing pulmonary embolism, is reported. Since October 1997, six patients had temporary filters. There were two men and four women, with a mean age of 37 years. Three filters were placed at the infrarenal inferior vena cava, two at the suprarenal inferior vena cava, and one at the superior vena cava. All filters were placed before various surgical interventions. During filter placement, anticoagulation therapy was routinely performed. There were no complications at and during filter placement. No pulmonary emboli occurred during surgical intervention. All filters were successfully removed, two of which were exchanged for permanent filters. All patients are alive and well without recurrent deep vein thrombosis and/or pulmonary emboli during a follow-up period of 11 to 25 months. Although this experience is small, temporary filter placement is safe and effective for short-term prevention of pulmonary emboli even in older patients or those with malignant disease. Veins of the upper part of the body may be more favorable than the femoral vein for insertion of a temporary filter. Temporary filters can be safely placed not only at the infrarenal inferior vena cava, but also at the suprarenal inferior vena cava or superior vena cava.

[A case of giant cell tumor originating from the rib].

We have experienced a case of giant cell tumor originating from the rib. A 45-year-old male was admitted to our hospital because of a mass in the left chest wall. A tumor shadow was observed in the left side of chest X ray. Chest CT, bone scintigram showed tumor originating from the left 4th rib. The tumor was suspected giant cell tumor of bone by needle biopsy examination. The tumor was completely resected with chest wall surrounding the tumor. The defect of chest wall was reconstructed with Marlex mesh and the Latissimus dorsi muscle flap. The pathological diagnosis was a giant cell tumor of bone. The patient has been well for two years and one month since surgery, with no signs of recurrence.

Acute type A aortic dissection following intramural hematoma of the aorta. A case report.

A seventy-three-year-old woman had symptoms of aortic dissection. Initial computed tomographic (CT) scan and angiography showed an extensive intramural hematoma (IMH) of the aortic segment from the ascending aorta to the bulk of the descending aorta without intimal tear or false lumen. Two weeks later the patient's symptoms recurred. A repeat CT demonstrated a classic type A aortic dissection with a false lumen and an intimal defect. The patient underwent a successful hemiarch repair with use of selective cerebral perfusion under profound hypothermic circulatory arrest. This case suggests extensive IMH as an important underlying pathology of the aortic dissection.

[Abdominal aortic aneurysm and annuloaortic ectasia in siblings with Marfan syndrome].

A combination of annuloaortic ectasia (AAE) and abdominal aortic aneurysm (AAA) appeared in siblings with Marfan syndrome is presented. The patients were a 53-year-old female and her younger brother. The brother died of arrhythmia twenty years before while waiting for surgical repair of AAE. His AAA and Marfan syndrome were ascertained at autopsy. The female patient received surgical repair for AAA and AAE subsequently. Pathologic study of the resected aneurysm revealed cystic medial necrosis. A combination of AAE and AAA developed in two members of a family with Marfan syndrome is extremely rare.

The management of patients with dissection of the descending thoracic aorta: a comparison between closing and nonclosing dissections.

This study was designed to clarify and compare the clinical characteristics and prognoses of patients with closing and nonclosing dissection of the descending thoracic aorta. Between January 1991 and December 1994, 19 patients with closing dissection (Group A) and 20 with nonclosing dissection (Group B) underwent surgical repair or medical treatment at our institution. There were 29 men and 10 women, aged between 37 and 74 years, with a mean age of 62 years. There was a significant difference in age between the two groups, being 67 +/- 7 and 58 +/- 12 years for Groups A and B, respectively (P = 0.009). The presence of a concurrent abdominal aortic aneurysm was confirmed in 32% and 10% of Groups A and B, respectively (P = 0.095). A total of 15 patients experienced a variety of complications related to the dissection, but there were no significant differences in the morbidity rate between the two groups. Visceral ischemic disorders such as renal failure, leg ischemia, and ileus were the most common complications. The overall survival rate 4 years after the development of dissection was 80%, with no significant difference between the two groups. These findings led to the establishment of our policy to place all patients with dissection of the descending thoracic aorta on careful antihypertensive therapy and frequent follow-up imaging studies to assess the aorta, regardless of the condition of the false lumen.

A new experimental model for simultaneous evaluation of aortic and pulmonary allograft performance in a composite graft.

A model was developed in pigs for simultaneous evaluation of aortic and pulmonary allograft performance in a composite graft. The composite graft consisted of vascular prosthesis and aortic and pulmonary allografts. Following antibiotic preservation, it was anastomosed to the recipient's thoracic descending aorta by an extrapleural approach without using cardiopulmonary bypass. Aortic blood flow was completely diverted into the composite graft. All 12 recipient pigs recovered well, 4 of which were assigned for the initial study to design the suitable experimental schedule. Calcification readily occurred in the aortic allografts and aneurysmal dilatation without calcification developed in the pulmonary allografts. These morphological findings were consistent with those of previous reports. This model has several benefits. First, aortic and pulmonary allograft conduits can be implanted and evaluated simultaneously under the same conditions by making a composite graft. Second, the magnitude of the operation is minimum, and postoperative circulatory and respiratory management is uncomplicated. Third, wound infection rarely occurs, because the skin incision is made on the back. These preliminary studies suggest that this model will allow future study concerning aortic and pulmonary allograft conduits under different conditions.

[Open heart surgery in patients with chronic dialysis].

From January, 1986 to May, 1995, twelve patients with dialysis (11 hemodialysis; HD, and one continuous ambulatory peritoneal dialysis; CAPD) received open heart surgery. They consist of 10 males and two females aged between 35 and 66 with a mean of 58.8. The duration of dialysis was 6.8 years in a mean (the shortest for 2 months and the longest for 16 years). They classified into an equal number of four in NYHA class II, III and IV. Two of them had isolated coronary artery bypass grafting, four had aortic valve replacement (AVR) and two had mitral valve replacement (MVR). Others were each one of AVR and MVR, AVR plus MVR with tricuspid annuloplasty (TAP), AVR plus TAP, and removal of left atrial myxoma. All patients except for one of CAPD were dialysed daily 2 or 3 days before operation. Three patients were managed postoperatively with HD, one with PD, six with continuous hemodiafiltration, and two with continuous hemofiltration. The operative mortality was 25% (3/12). The causes of death were left ventricular rupture, bronchospasm, and respiratory failure. All patients who died were in class in III and IV. For the improvement of the results we emphasize the necessity of early operation that should be scheduled in class II period.

Successful application of hypothermia combined with intra-aortic balloon pump support to low-cardiac-output state after open heart surgery.

The authors report a successful application of hypothermia, along with intra-aortic balloon pump (IABP) support, to postcardiotomy ventricular failure. Surface-cooling hypothermia was applied in 8 patients after open heart surgery. The original cardiac procedure consisted of 3 aortocoronary bypass graftings (ACBGs), 2 aortic valve replacements (AVRs), 1 repair for left ventricular (LV) rupture after mitral valve replacement (MVR), 1 MVR + ACBG, and 1 MVR + AVR + tricuspid valve annuloplasty (TAP). Their ages ranged from fifty-two to sixty-eight years with a mean of sixty-one years. Hemodynamic criteria for induction of hypothermia included cardiac index (CI) less than 2.0 L/min/m2 with left atrial pressure greater than 18 mmHg despite the use of IABP and maximum pharmacologic support. Blood temperature was maintained at around 33 degrees C. By six hours after induction of hypothermia the tissue oxygen consumption decreased significantly with no hemodynamic deterioration as compared with that before cooling. The duration of hypothermia ranged from thirty-six to one hundred fifty-nine hours with a mean of seventy-eight hours. All 8 patients finally discontinued IABP support with a mean driving time of one hundred thirty-two hours. Five of them were ultimately discharged from the hospital and returned to their previous life-style. The authors believe that, from the perspective of monetary and personal resources, the use of hypothermia with IABP support could be a therapeutic option for patients with postcardiotomy ventricular failure.

[Coronary arterial bypass grafting for angina pectoris suspected with aortitis syndrome: a case report].

We report herein the case of a 56-year-old man with angina pectoris suspected to be accompanied with aortitis syndrome who underwent coronary artery bypass grafting (CABG). His cerebral blood flow consisted of only that of the right vertebralartery, and the marked collaterals of the bronchial artery anastomosing to the coronary artery. CABG was performed under combined with electrical fibrillation and systemic deep hypothermia, for fear of a bad influence on the cerebral tissue by the influx of high potassium cardioplegic solution. The postoperative course was uneventful and the coronary angiography revealed that the all graft were patent.

[A case of ASD with SLE treated with Carmeda BioActive surface circuit in cardiopulmonary bypass system].

A 61-year-old woman of ASD complicated with SLE was operated on. We used a heparin coating Carmeda BioActive Surface (CBS) in cardiopulmonary bypass circuit for the purpose to prevent the postoperative complications due to the reduced complement activation by SLE. This system could prevent the decline of the reduced complement activation during cardiopulmonary bypass and after operation. The management of steroid therapy for SLE patient, usefulness of heparin coating CBS system for hypocomplement disease were discussed.

[Surgical results of valve replacement with porcine bioprostheses].

We evaluated the 80 cases of porcine valve replacement, accomplished between April 1975 and December 1980. There were 48 males and 32 females aged between 16 and 60 years old with a mean of 37.4 +/- 11.4. Ten patients underwent aortic valve replacement (AVR), 63 mitral valve (MVR), and 7 AVR plus MVR. Twenty-seven Hancock valves (H) were implanted in aortic (3) and mitral (24) position and 61 Carpentier-Edwards valves (CE) were used in aortic (14), mitral (46), and tricuspid (1) position. The mean duration of follow-up was 9.3 years (0.2-19.2 years) and cumulative follow-up was 747.2 patient years (py). The late mortality was 3.3%/py (25 patients). Actuarial survival rates for all patients at 10 and 15 years were 67%, and 49% respectively. The linearized rates (LR) of structural valve deterioration (SVD) was 7.0%/py. The freedom from SVD for all patients at 10, and 15 years were 47.1%, and 12.4% respectively. There were no differences of free rates of SVD between H and CE. between valve sites implated, and among age at operation. The incidence of occurrence of SVD was gradually increased 6 years after operation. The LR of thromboembolism (TE), anticoagulant-related hemorrhage (ACH), prosthetic valve endocarditis (PVE), nonfunctional valve dysfunction (NVD), and reoperation (RO) were 0.7%/py, 0.1%/py, 0.3%/py, 0.1%/py and 7.4%/py, respectively. The freedom from TE, ACH, PVE, NVD, and RO for all patients at 15 years were 91.3%, 98.1%, 95.6%, 80%, and 6.5%, respectively. The surgical results of glutaraldehyde-preserved porcine bioprostheses was excellent during the first 5 years after operation. A high incidence of SVD has been occurred thereafter. According the indication for valve replacement with bioprotheses is now strictly limited for elderly, child bearing female case, contraindition for therapy of anticoagulants, and some social condition.

[Surgical results of valve replacement with the Björk-Shiley tilting disc valves].

We evaluated the Björk-Shiley tilting-disc (BS) valve replacement up to the longest duration for about 12 years. The study was started in November 1982 and ended in September 1991. There were total number of 206 with 117 males and 89 females aged between 18 and 71 with a mean of 51.6. Eighty three patients had isolated aortic valve replacement (AVR), 92 had isolated mitral valve replacement (MVR), and 31 had AVR plus MVR. One hundred and fourteen spherical-disc valves were replaced in the aortic, 112 spherical and 11 monostrut in the mitral position. The mean duration of follow up was 6.5 years for a total of 1330.6 patient years (PY). Forty-one patients (3.8%/PY) died later, and 14 out of 41 died of valve-related complications. Actuarial survival rates for all, AVR, MVR and DVR at 10 years after operation were 71.2%, 73.5%, 73.9% and 55.4%, respectively. The linearized rates of thromboembolism (TE), thrombosed valve (TV), anticoagulant-related hemorrhage (ACH), prosthetic valve endocarditis (PVE), hemolysis (H), and reoperation (RO) were 1.2%/PY, 0.2%/PY, 0.7%/PY, 0.2%/PY, 0.1%/PY, and 0.2%/PY, respectively. The rates of freedom from TE, TV, ACH, PVE, H, and RO and 10 years after operation were 83.5%, 98.5%, 94.0%, 98.4%, 99.0% and 95.6%, respectively. The major causes of postoperative mortality and morbidity were TE, TV, and ACH. One hundred and fifty-six out of 161 patients showed an improvement in NYHA functional class post operatively. The surgical results of valve replacement with the BS valve was excellent and acceptable one. Intensive management with a special reference of anticoagulant therapy is necessary for a long-term management of the patients with mechanical valve replacement.

Massive endobronchial hemorrhage after pulmonary embolectomy.

Massive endobronchial hemorrhage is a lethal complication in pulmonary embolectomy. We report a case of massive endobronchial hemorrhage occurring after successful restoration of pulmonary blood flow using cardiopulmonary bypass in a patient with pulmonary embolism. Two possible causative factors of this complication are described.

[Management of patients with closing aortic dissection].

Acute aortic dissection is a catastrophic event requiring immediate diagnosis and definitive treatment, while the clinical characteristics of closing aortic dissection are not well known. From Jan. 1991 through Dec. 1994 a total of 24 patients with closing aortic dissection (CAD) was managed at our institution. There were 19 men and 5 women, ranging in age from 49 to 74 years with a mean of 65 years. All patients presented with a sudden onset of severe chest and back pain. Twenty patients had a history of hypertension with a wide mediastinal silhouette on chest X-ray. The diagnosis of CAD was established by contrast computed tomographic (CT) scans in all patients with no evidence of patent false lumen. The descending thoracic aorta was involved in 17 patients and the ascending in 5. Conservative medical management was initially attempted for all. Seven patients (Stanford type A/B: 2/5) ultimately required surgical intervention, and 2 patients died. The follow-up was 100% complete with a mean term of 14.6 months. The overall survival rate was 74% at 3 years after the initial presentation. Based on our clinical experience, all patients with CAD need careful antihypertensive therapy and frequent follow-up studies to assess the aorta.

Acute aortic dissection in a patient with osteogenesis imperfecta.

A case of osteogenesis imperfecta complicated with acute type A aortic dissection is presented. Emergency graft replacement of the ascending aorta was performed successfully despite the anticipated difficulties with tissue friability. Therefore, such an operation is suggested to be worthy of consideration and feasible in patients with osteogenesis imperfecta.

[Double valve replacement with mechanical prostheses--an operative results].

From January 1980 to December 1993, sixty eight patients underwent double valve replacement with mechanical prostheses. There were forty males and twenty-eight females with a mean age of 49.6 years (ranging from 30 to 68 years). They were classified 10 of NYHA class IV, 28 of class III. Twelve patients had previous cardiac operation. TR was identified in 20 patients. DVR was performed in 53 patients, DVR + TVR in one, DVR + TAP in 13. Twenty-two had St. Jude Medical (SJM) prostheses and 46 had Björk-Shiley (BS) prostheses. Early death before 30 postoperative days occurred in 6 patients (8.8%). MOF was the most frequent cause for early death. The risk factors for early death were the NYHA class IV, infective endocarditis, longer duration of cardiopulmonary bypass, necessity of postoperative IABP support. Other factors such as emergency operation, previous operation, tricuspid valve surgery, duration of aortic cross clamp time were not the predictors for early death. Cumulative follow-up was 284.0 patient years (PY). The rate of late survival was 74.1% (40 patients). Linearized rates of thromboembolism (TE), prosthetic valve endocarditis (PVE), hemolysis (H), reoperation (RO) were 2.8%/PY, 0.7%/PY, 0.4%/PY, 1.1/PY respectively. The free rates from TE, PVE, H, RO at nine years were 75.6%, 96.2%, 93.1%, and 89.8%, respectively. The cumulative survival rates at 14 years were 53.2% in over-all patients, and 64.3% in hospital survivors. We conclude that the early surgery is recommended for the patients with multiple valvular heart disease. The late outcomes of DVR with SJM or BS mechanical prosthesis is an acceptable one.

[Significance of combined use of anticoagulants and antiplatelet agents in the early stage after prosthetic valve replacement].

Patients who had undergone prosthetic valve replacement were treated with warfarin (anticoagulant) alone or in combination of ticlopidine (200 mg/day) or aspirin (81 mg/day) (anti-platelet agents). The study of blood coagulation factors and platelet aggregation were carried out with these cases. 1) The patients (n = 24) receiving warfarin for 21 days after prosthetic valve replacement revealed marked increases in PIVKA-II and vitamin K1-epoxide. The protein C activity was significantly lower than that before the operation. High levels of more than 5 ng/ml of TAT were found before operation and after warfarin administration for 21 days. 2) Warfarin did not affect platelet aggregation, whereas ticlopidine inhibited ADP-induced platelet aggregation and aspirin inhibited both collagen-induced and arachidonic acid-induced aggregation. In conclusion, combined use of anticoagulants and antiplatelet agents after prosthetic valve replacement will suppress not only the blood coagulation but also the platelet aggregation systems.

[Isolated aortic valve regurgitation due to degeneration of the valve leaflet--a clinical study].

From 1989 through 1993 thirty-eight patients underwent aortic valve replacement at our institution for isolated aortic regurgitation (AR) caused by idiopathic degeneration of the valve. There were 32 male and 6 female patients aged between 33 and 74 years with a mean of 59 years. Preoperative New York Heart Association functional class, cardiothoracic ratio, cardiac index, and left ventricular end-diastolic pressure were 2.6, 57%, 3.1 L/min/m2, and 18 mmHg, respectively. Cross-sectional echocardiography clarified aortic valve prolapse in seven patients. Excised valvular cusps were thin, redundant and translucent in association with cuspal fenestration in 9 cases and idiopathic commissural disruption in 2 cases. Histological study revealed significant disruption of the fibrosa and cystic degeneration of the spongiosa layer filled with mucopolysaccharide. Actuarial survival rate, including 3 operative deaths, was 89% at 3 years after AVR with no apparent valve related complications. Idiopathic degeneration of the aortic valve is a common cause of AR, occurring in half of the surgically treated patients. We emphasize the importance of this lesion as a cause of AR.