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This is a report of 2 cases, in which preoperative 3-dimentional demonstration of the spinal cord artery with 64-row computed tomography was feasible, less invasive, less time-consuming, and helpful in making an interventional strategy for complex aortic disease, resulting in no postoperative paraplegia One was a 63-year-old man, who underwent total arch replacement and a long elephant trunk method for arch and descending aortic aneurysms. The length of the long elephant trunk was so determined that it ended between the descending aortic aneurysm and the origin of the spinal cord artery. The second case was a 59-year-old man, who underwent descending thoracic aorta replacement for type B aortic dissection. During the distal anastomosis, the dissection septa were trimmed in order to perfuse the blood into the true and 2 false channels, one of which was connected to the spinal cord artery. In this report, we are not suggesting that preservation of the demonstrated spinal cord artery is enough for spinal cord protection, because it is still controversial. Further study is needed to confirm the reliability and reproducibility of our methods.

In this report, aortic arch replacement was performed successfully in 2 cases with our modified method placing priority on the cardiac and cerebral reperfusion, resulting in no postoperative cardiac or neurological complication. One was a 63-year-old man with old cerebral infarction and ischemic heart disease, and the other was a 72-year-old man with severe stenosis of the left common carotid arteries. Our method is similar to so-called "arch first technique". First, the ascending aorta is clamped and proximal anastomosis is accomplished during core cooling, followed by reconstruction of the brachiocephalic arteries under deep hypothermic circulatory arrest. Then perfusion of the heart and brain is restarted, while distal anastomosis is performed. It was proved that the method had several possible advantages such as minimized duration of brain ischemia and deep hypothermia, and elimination of direct cannulation to the branches of the aortic arch and a separate perfusion circuit for the brain.

Although type A acute aortic dissection is considered a surgical emergency, the optimal treatment of patients with preoperative cerebral malperfusion remains controversial. From September 1994 to December 2005, 68 consecutive patients with type A aortic dissection underwent emergent surgical treatment. Eight patients showed preoperative newly-developed neurological deficits. The hospital mortality rate was 25% (2 of the 8 patients). Of the 8 patients, 1 with preoperative coma died due to severe brain injury. Another with acute myocardial infarction and left hemiparesis died due to low output syndrome in the immediate postoperative period. Three of the others had persistent left hemiplegia. One of these patients showed new paraplegia early postoperatively. The preoperative neurological deficit of the remaining 3 patients had improved in some degree. The optimal strategy should be taken individually under the accurate and prompt evaluations of hemodynamic and neurological state in such patients.

A 47-year old woman, who was diagnosed as Stanford type A acute aortic dissection, underwent an emergent operation. Because of obesity and bleeding, it was impossible to find the right axillary artery. Only we could have for inflow line was the femoral line. After starting cardiopulmonary bypass (CPB) and crossclamping the ascending aorta, mean blood pressure of the right radial artery dropped to 15 mmHg, suggesting the occurrence of malperfusion. The ascending aorta was immediately transected, and the CPB was ceased. Inflow cannula was directly inserted into the true rumen of the ascending aorta, and resumed the CPB. The mean blood pressure rose up to 80 mmHg. Such procedure took about 10 minutes. Abnormal neurological findings were not apparent except for the transient postoperative delirium. The patient was discharged on the 48th day after operation. It is suggested that this method was useful and safe to have the new inflow line when emergently necessary.

The early and mid-term survival after cardiac or thoracic aortic surgery and influence of age to the operative mortality were examined in 168 consecutive patients aged 70 years and older from August 1994 to December 1998, together with assessment of postoperative quality of life (QOL). The mean age was 74.1 +/- 3.7 years old (70 to 86 years). 80 patients had IHD, 59 had VHD, 28 had TAA. Preoperative risk score was classified in 5 groups (good, fair, poor, high, extremely high) based on Parsonnet method. Current QOL of the survivors was assessed using Asanoi method with questionnaire by a letter. There were 9 early deaths (5.4%). Following the Parsonnet model observed mortality was absolutely lower than predicted mortality. When age score was excluded in the Parsonnet model, the observed mortality became almost equal with the predicted mortality. There were 22 late deaths (6.9%/P-Y). The actuarial survival rate of age 70 to 74 group was significantly higher than the age 75 years and older group (p = 0.0021). The actuarial survival rate of TAA group was significantly lower than the VHD or IHD group (p < 0.02). Postoperative NYHA and activity score of TAA group were better than VHD or IHD group. We got satisfactory answers for operation in 95% current survivors. Patients aged 70 years and older will be undergone cardiac or thoracic aortic surgery at a reasonable risk and well satisfaction.

Complement activation and leukosequestration to the lung was studied during cardiopulmonary bypass in eleven patients undergoing cardiac operation without blood transfusion. Six patients (group I) received methylprednisolone before and after the bypass, and the other five (group II) received cepharanthine (biscoclaurin alkaloid) before the bypass associated with methylprednisolone therapy. Leukosequestration to the lung was observed at the time of reperfusion of the lung only in group I, although complement activation estimated by the increase of C 4 a and C 3 a was quite similar in both group. Cepharanthine prevented the sequestration of the leukocyte to the lung may be by its membrane stabilizing effect.

Postoperative complications of Bentall operation for the annuloaortic ectasia have frequently occurred, although the mortality has been reduced. To reduce complications after Bentall operation we have taken three major treatments since 1987. The first was reimplantation technique of coronary ostia in replacing the ascending aorta and the aortic valve with a tube graft. The second was the infusion technique of cardioplegic solution such as retrograde cardioplegia infusion. The third method was to save blood and reduce the blood transfusion by preserving autoblood preoperatively and using cell saving machine. The purpose of this study was to analyse 20 patients who underwent the Bentall procedure and to investigate the effect of our treatments in Bentall operation on the operative results. We divided our patients into two groups. Fourteen patients in the group 1 were operated before 1987, when our principles were not performed. Six patients in group II were operated under the principles mentioned above. There were no differences in cardiopulmonary bypass time and ischemic time between group I and II. Transfused blood volume in group II was remarkably less than that of group I. Postoperative complications occurred in all patients in group I (100%), while three patients in group II (50%) had complications (p less than 0.05). We, hence, conclude that our method could be useful for reducing postoperative complication rate in Bentall operation.

Progress in infant open-heart surgery last 10 years was reviewed mainly based on the surgical experiences in Fukuoka Children's Hospital. Recent advances and present problems in patient's care, cardiopulmonary bypass methods and cardioplegia were discussed. Low surgical mortality of 4.8% in 245 infant open-heart repairs between 1988 and 1990 in Fukuoka is highly suggestive of early primary repair for most of congenital heart diseases.

From 1974 to March 1991, 34 patients were operated on for ascending aortic aneurysm with aortic regurgitation caused by annuloaortic ectasia (18), dissecting aneurysm (11) and so on. Twenty-one patients underwent composite valve graft replacement, 7 separate valve graft replacement, 5 aortic resuspension and graft replacement, and one aortorrhaphy and aortic valve replacement. Four of these patients required ascending aorta and arch reconstruction. Another two patients who had previous separate valve graft replacement for annulaortic ectasia and required reoperation underwent Bentall operation successfully. The 30-day survival rate was 94%. Recently, we adopted open-unwrapping and aortic button technique. As a result we achieved no homologous blood transfusion by using "Cell Saver" and autologous blood preoperative storage program in four out of five patients of Bentall operation. Late survival rate including operative death were 78% and 63% at 5 and 10 years after operation, respectively.

Recently, it has been recognized in Japan that informed consent is indispensable to make decisions for medical treatment, although it had been already confirmed in western countries for several decades of years. However, there may be some differences in the content of informed consent between Japan and western countries. We discussed the problems of informed consent in Japan concerning the choice of prosthetic valve, mechanical prosthesis or bioprosthesis, in patients to be undergone valve replacement. We conclude that informed consent should be the humane relationship between therapists and a patient.

The patient was a 67-year-old female, complaining of cyanosis, clubbed finger and anoxic spell-like symptom. She was diagnosed as pulmonary arteriovenous fistula combined with mitral regurgitation. The fistula was giant and multiple, and was located in the right middle-lower lobe. Right to left shunt ratio was 27%, SO2 was 58.2%, %VC was 60%, mean pulmonary arterial pressure was 19 mmHg. Mitral regurgitation was mild (II). Ligation of the middle-lower branch of right pulmonary artery and the right lower pulmonary vein was performed through a median sternotomy. All of her symptom improved.