[Natural evolution of coronary artery ectasia after coronary artery bypass grafting].

Coronary artery aneurysm and ectasia, unusual angiographic findings, are considered as variant of atherosclerotic coronary artery disease. A 49-year-old man whose right coronary artery ectasia had progressed to large aneurysm, accompanied by advanced obstructive coronary artery disease, 6 years after the initial coronary artery bypass grafting. It was treated with ligation of aneurysm and distal bypass grafting under cardiopulmonary bypass. Fragile fresh clot was formed within the aneurysm irrespective of coumadin therapy as a standard regimen for the coronary artery ectasias. We will discuss the surgical management for the dilated coronary artery with significant coronary stenosis.

Washing of the residual solution of cardiopulmonary bypass circuit after coronary artery bypass grafting in idiopathic thrombocytopenic purpura.

A 76-year-old female with chronic idiopathic thrombocytopenic purpura required coronary bypass grafting. Preoperative treatment with high-dose intravenous immunoglobulin at a dose of 0.4 g/kg/day raised the platelet count from 57,000 to 110,000/microL. After termination of cardiopulmonary bypass (CPB) the residual blood in the CPB circuit was washed to reduce total immunoglobulin G (IgG) level, including platelet-associated immunoglobulin G (PA-IgG), and returned to the patient. Intraoperative platelet transfusion was used due to a drop in platelet count to the pretreatment level. The postoperative level of IgG and PA-IgG remained significantly lower than preoperatively. The postoperative course was uneventful and without bleeding complications. Perioperative management of a patient with idiopathic thrombocytopenic purpura undergoing open-heart surgery is discussed.

[Surgical treatment of chronic pulmonary thromboembolism caused by a cavernous hemangioma at the lower limb].

A 48-years old man complained of dyspnea and was admitted to the hospital. Chest enhanced CT confirmed the presence of the thrombus in the pulmonary artery. Cardiac catheterization showed severe pulmonary hypertension (mean PAP 75 mmHg). ATIII level, protein C and S antigen were within normal range. Anticardiolipin antibody and lupus anti-coagulant determination were negative. He was diagnosed as chronic pulmonary thromboembolism, and underwent pulmonary thromboendarterectomy via median sternotomy under deep hypothermic intermittent circulatory arrest. At the same time IVC filter was inserted. The origin of the thrombus was not detected before operation, but after surgery, MR angiography of total body showed a cavernous hemangioma at left lower limb. We speculated this lesion was the origin of pulmonary embolism.

Mediastinal irrigation with superoxidized water after open-heart surgery: the safety and pitfalls of cardiovascular surgical application.

Postoperative mediastinal infection after open-heart surgery via median sternotomy is a devastating complication. In this paper, we describe a simple method of irrigating the mediastinum using superoxidized water to prevent perioperative contamination. After mediastinal hemostasis was done, warm superoxidized water of more than 21 was uninterruptedly irrigated for 5 min immediately prior to sternal closure. We have used this method in 25 patients undergoing cardiac surgery, and noted significant perioperative electrocardiographic changes, including ST elevation, without hemodynamic compromise in 15 of these patients.

[Pulmonary hyalinizing granuloma diagnosed by thoracoscopy].

A 36-year-old woman was examined by our hospital for pulmonary coin shadows in both lungs, as disclosed on chest X-ray films. She had no subjective complaints other than allergic rhinitis, but exhibited hypergam-maglobulinemia, particularly in IgE. Inhalative allergen tests were positive for three types of allergens, but no autoimmune disease was detected. Although transbronchial and percutaneous fine needle biopsies failed to obtain enough specimens because of the wandering shadow a thoracoscopic biopsy was effective because of the subpleural location of the target lesions. The histologic findings were consistent with pulmonary hyalinizing granuloma, with extensive, hyalinized lamellar collagen bundles arranged haphazardly in the central area. Infiltration by lymphocytes and plasma cells, together with the destruction of bronchiolar and vessel walls, were observed in the marginal areas. No amyloid deposits or lymphocytic monoclonality were observed in the lesion. Twenty-five months after the biopsy, the patient's clinical and radiographic data had not changed.

[Sasumata(U+I) shape skin incision for the surgery through median sternotomy].

Since April, 1994 we have tried median sternotomy in a new skin incision which resembles to "Sasumata", a Japanese historical weapon of police, for the surgery of eleven patients with thymic disease or lung cancer for cosmetic reasons. An U-shaped skin incision in the upper half portion of the breast and a vertical incision from the bottom of "U" to xyphoid process were made. A comparison was made in eight patients with former conventional method, a linear incision on the sternum. The new incision was useful not only for cosmetic reasons but also for the following reasons; enough operation area, good lymph node dissection from lower neck to upper mediastinum without additional collar incision, and good healing of the skin. There were no differences between the two incision groups on operation time, bleeding volume and hospital stay after surgery. In a postoperative research almost all patients have been satisfied with the new incision.

Plasma lipids and apolipoproteins as discriminators for presence and severity of angiographically defined coronary artery disease.

The relationship of coronary artery disease to with plasma lipids and apolipoproteins was examined in 100 male patients aged 32-69 years undergoing coronary angiography for suspected myocardial infarction. Patients with angiographically defined coronary artery disease had significantly lower plasma levels of high density lipoprotein (HDL) cholesterol, apolipoproteins A-I and A-II, and significantly higher values of low density lipoprotein (LDL) cholesterol and apolipoprotein B than those in patients without coronary artery disease. The ratios derived from the measurements as LDL cholesterol/HDL cholesterol, apo B/apo A-I and apo B/apo A-II were highly significantly increased in the patients with coronary artery disease. Coronary score values, by which the severity of coronary artery disease was quantified, were not related to plasma levels of the HDL components, while they were positively correlated with those of the LDL components. These results suggest that, in single measurements, plasma levels of the HDL components, HDL-cholesterol and apo A-I, contribute strongly to the discrimination between patients with coronary artery disease and those without this disease, whereas the LDL components, LDL-cholesterol and apo B are more suitable parameters for the severity of the disease than are the HDL components. The ratios of LDL cholesterol/HDL cholesterol, apo B/apo A-I and apo B/apo A-II were powerful discriminators for either presence or severity of coronary artery disease.