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Angiosarcoma has been reported as a rare case, having high potential of hematogeneous lung metastasis and then developing to pneumothorax with ease. The patient was a 74-year-old man afflicted with a malignant hemangio endothelioma (MHE) of the scalp. His MHE of the scalp was resected and skin grafting was made, then, he was administered docetaxel hydrate intravenously as adjuvant setting. Three years after, he complainted left chest pain and dyspnea, so his chest Xp was checked up and showed left pneumothorax. Chest computed tomography revealed multiple thin walled cavities of right and left lung and bullae with slightly thick walled cavity at apex legion of the left lung. We resected bullae with tumor of the left apex legion under video assisted thoracic surgery. After operation, He was administerd ricombinant interleukin-2 intravenously in order to control lung metastasis of the scalp, but his condition deteriorated and 6 months after pneumothorax he died. The average survival time from the 1st pneumothorax episode was only 4.7 months. He kept a good activities of daily living without reccurrence of pneumothorax by operation, so we thought that the operaion for pneumothorax with MHE was one option for therapy.

Pulmonary artery banding remains a useful procedure for special conditions. A 3-month-old girl diagnosed as Down syndrome with atrioventricular septal defect underwent pulmonary artery banding. We used polyester tape smeared with Bone Wax for this pulmonary artery banding. After 7 months period, the tape was easily dissected from surrounding tissue and removed at radical operation. Microscopic appearance showed that the tape was intact and no evidence of inflammation or mineralization. We believe Bone Wax smeared polyester tape accomplishes well as silicone impregnated one.

Despite an extensive experience with Fontan operation, there is a paucity of information to guide the indication of the procedure in patients with Down syndrome. Of 79 patients who had undergone a Fontan operation in our hospital between 1995 and 2003, 3 had Down syndrome. All 3 patients had complete atrioventricular septal defect with single ventricular physiology. Two patients survived, and 1 died of chylothorax and respiratory infection. The 2 survivors have done well in the short-term without complications. We consider that in appropriately selected patients with Down syndrome in whom biventricular repair is precluded, the Fontan operation is the choice of the procedures.

A 67-year-old male was diagnosed to have a right atrial tumor by echocardiography incidentally. Computed tomography (CT) indicated a mass which showed very low radiodensity and magnetic resonance imaging (MRI) [T1-weighted] showed the high signal intensity of tumor. We could predict the mass as lipoma. Tumor removal was performed under cardio-pulmonary bypass and under ventricular fibrillation because of the calcification in ascending aorta. Microscopically the tumor was consisted of mature adipose tissue. The postoperative course was uneventful. Cardiac lipomas are rare tumors. CT and MRI are better investigations for preoperative diagnosis. After surgical excision the prognosis is excellent.

We report the repair of tetralogy of Fallot in a 51-year-old man. He underwent a left classical Blalock-Taussig (B-T) shunt when he was ten years old. Preoperative angiography showed a patent B-T shunt. Total corrective surgery was performed. Postoperatively, he suffered from left ventricular failure. Re-intubation was required three times. Postoperative catheterization showed excellent correction of the right ventricular system, however, descending aortography revealed a great many aorto-pulmonary collateral arteries, which caused the left ventricular failure. Coil embolization of these 13 collateral arteries was performed and he recovered from the left ventricular failure. We conclude that even in an elderly patient with tetralogy of Fallot, total correction should be performed, since the surgical risk is acceptable and the procedure improves the capacity for physical activity and quality of life. Preoperative examination of collateral arteries is important, especially in elderly patients, and coil embolization should be considered.

We measured levels of bisphenol-A (BPA) in a priming solution and blood of a cardiopulmonary bypass (CPB) circuit. Eight circuits were used in the study of a priming solution. Blood samples were obtained from 6 patients who underwent open heart surgery after the commencement of CPB and at the termination of CPB. Another 3 samples were collected directly from the saline in a polyethylene container as a control. Then the concentrations of BPA in them were determined by means of gas chromatography. No detectable BPA was found in controls. However, a small amount was detected in the saline from the circuits (0.9 +/- 1.1 micrograms/l). A very small amount was also detected in the blood after the commencement and at the termination of CPB (0.3 +/- 0.2 microgram/l, and 0.4 +/- 0.3 microgram/l, respectively). BPA was considered to be leached from the circuit to the priming solution and the blood because the parts of the reservoir and the oxygenator were made of polycarbonate containing BPA. We suppose the BPA concentration is probably at a safe level. However, the data on the endocrinologically toxic level of blood BPA are insufficient. Therefore, the use of plastic in a circuit may require closer scrutiny to determine whether BPA contributes to exposure to xenoestrogens.

We experienced 4 cases of coronary artery-pulmonary artery fistula with coronary aneurysm, three patients had symptoms of chest pain, and 1 patient had cardiac murmur. Coronary arteriography showed that three patients had fistulas from the left coronary artery to the pulmonary artery; and that 1 patient had a fistula from both the right and left coronary arteries to the pulmonary artery. Moreover, 1 patient had 90% diameter stenosis of segment 7. The maximum diameter of the coronary aneurysm ranged from 12 to 20 mm (average: 15.3 mm). One patient underwent closure of the opening of the fistula, 2 patients underwent multiple ligatures of fistulas, and 1 patient underwent multiple ligatures of fistulas with coronary artery bypass grafting. The postoperative course of every patient was uneventful. There have been 42 reports on this abnormality in Japan. We should treat the fistula as early as possible to prevent cardiac complications such as myocardial ischemia and rupture of coronary aneurysm.

Recent studies suggest that early tracheal extubation after coronary artery bypass grafting (CABG) may reduce intensive care unit use and cost. During recent two years, 96 patients were underwent CABG under cardiopulmonary bypass by low-dose fentanyl and isoflurane anesthesia. We compared two groups of patients for evaluation of factors associated to early tracheal extubation. 47 cases (Group A) were extubated within six hours (average 4.4 hrs) following operation, and 26 cases (Group B) were extubated later than twelve hours (average 57.5 hrs). It is suggested that emergency cases, female, elderly patients, dysfunction of kidney and long operation time associated to late extubation. But early extubation after CABG does not increase perioperative morbidity except for the cases that fell in low cardiac output syndrome or postoperative respiratory complications.

Between February 1993 and July 2000, 18 patients with a mean age of 7.9 years underwent re-operation for critical stenosis of the right ventricular outflow tract. Their diagnoses of these patients included tetralogy of Fallot (n = 7), transposition of the great arteries (n = 6), truncus arteriosus communis (n = 3), and double outlet right ventricle with pulmonary stenosis (n = 2). The first operations were extracardiac conduit operations (n = 9), arterial switch operations (n = 6) and patch reconstruction of the right ventricular outflow tract (n = 3). At re-operation, the right ventricular outflow tract obstruction was released completely and reconstructed using a monocusp ventricular outflow patch (n = 14), valved pericardial roll (n = 2), or bovine pericardial patch sparing the native pulmonary valve annulus (n = 2). There were no early deaths, although one patient died of arrhythmia 2.6 years after re-operation. The pressure gradient across the right ventricular outflow tract, right ventricular systolic pressure, and right ventricle to systemic systolic pressure ratio were satisfactorily relieved (84.3 +/- 19.0 vs. 16.7 +/- 19.7 mmHg, 109.2 +/- 20.5 vs. 48.7 +/- 16.7 mmHg, 0.92 +/- 0.25 vs. 0.43 +/- 0.16; p < 0.001, p < 0.001, p < 0.001, respectively). The right ventricular end-diastolic volume index and right ventricular ejection fraction were also improved (166.3 +/- 85.2 vs. 105.6 +/- 28.8% of normal, 38.3 +/- 12.6 vs. 50.9 +/- 8.8%; p < 0.05, p < 0.005, respectively). Re-operation should be done before the development of marked right ventricular dysfunction, while it can still be performed at a low risk with satisfactory results.

We measured levels of di-2-ethylhexyl phthalate (DEHP) in a priming solution of a cardiopulmonary bypass circuit. The circuit consisted of a venous reservoir, an oxygenator, and polyvinyl chloride (PVC) tubes. Eight circuits were used in this study. In 4 circuits a heparin-coating PVC tube was used and, in the others, a non-coating PVC tube. After they were primed with 1,500 ml of saline, the saline was circulated for 30 minutes at a rate of 6 l/min at 42 degrees C. Another four samples were collected directly from the saline in a polyethylene container as a control. Then the concentrations of DEHP in them were determined by means of gas chromatography. No detectable DEHP was found in controls. But, a small amount was detected in the saline from the circuits (2.75 +/- 4.27 ppb, and 3.75 +/- 4.99 ppb, respectively). DEHP was considered to be leached from the circuit to the priming solution because the tubes were made of PVC containing DEHP as a plasticizer. We suppose the DEHP concentration is probably at a safe level. However, the data on the endocrinologically toxic level of blood DEHP are insufficient. Therefore, the use of plastic in a circuit may require closer scrutiny to determine whether DEHP leached from PVC contributes to exposure to xenoestrogens.

A one-year-old infant underwent repair of atrioventricular septal defect with common orifice. About 2 years later, echocardiography revealed a left ventricular outflow tract obstruction for the first time. Because of progression of the obstructive lesion, a modified Konno procedure through a transaortic transpulmonary approach was later performed at 8 years old, and the postoperative course was uneventful. This is a useful procedure for left ventricular outflow tract obstruction with normal aortic valve and aortic annulus, because it can both preserve a native aortic valve and dose not necessitate right ventriculotomy in resection of hypertrophied muscle and patch enlargement of interventricular septum.

To evaluate the differences in patch-materials used to reconstruct the pulmonary artery in arterial switch operation for transposition of the great arteries, we compared mid-term results in 50 consecutive survivors who underwent arterial switch operation. In 35 patients (XP-group), the pulmonary artery was reconstructed using a glutaraldehyde-treated heterologous pericardial patch, while in 15 patients (AP-group) it was reconstructed using a fresh autologous pericardial patch. A W-shaped patch was used in 14 patients of the XP-group. In 21 patients of the XP-group and all those of the AP-group, a square patch was used. The mean length of follow-up has been 94.1 +/- 38.1 months after surgery in XP-group, and 16.7 +/- 11.8 months in AP-group, respectively. Four patients in XP-group required balloon angioplasty for pulmonary stenosis and 5 patients in XP-group underwent reoperation, but no patients in AP-group required balloon angioplasty or reoperation for pulmonary stenosis. The risk factors influencing postoperative pulmonary stenosis (sex, age at surgery, preliminary pulmonary artery banding, patch shape and material) were analyzed by multiple regression analysis. The patch material (heterologous patch) was the only identifiable risk factor for pulmonary stenosis. These data suggest that pulmonary artery reconstruction with an autologous pericardial patch may be effective to prevent postoperative pulmonary stenosis, although the long-term prognosis remains unknown.

Placement of stents for the tracheal or carinal stenosis have a meaning of maintaining the airway. Failure of the stenting causes death. In cases of severe airway stenosis and low pulmonary function, the pulmonary support method should be performed instead of intubation and mechanical ventilation. Generally, PCPS (percutaneous cardio-pulmonary support system) is used as a pulmonary support. This method was very useful to place stents for airway stenosis. We concluded that PCPS was useful in emergency cases, and in cases of severe fixed type airway stenosis and low pulmonary function it had be on stand-by.

We reviewed the records of 9 pediatric patients with muscular trabecular ventricular septal defects undergoing repair between April 1994 and June 1998 (mean age 2.6 +/- 3.1 years, mean weight 9.0 +/- 5.2 kg). The prevalence rate for muscular trabecular defects in the patients undergoing open-heart surgery for congenital heart disease was 2.0%. Although only 6 of the 9 patients were diagnosed as having muscular trabecular defects preoperatively, 60 degrees left anterior oblique and 30 cranially tilted projections of left ventricular cineangiocardiogram were useful to detect these defects. The technique of filling the left heart with blood by stopping to vent the left heart and inflating the lungs during the last one or two ligatures in closure of the defects was also useful to detect these defects intraoperatively. In closure of muscular trabecular defects, division of some trabeculations including a moderator band enabled complete repair through a right atriotomy. The nearer the inferior border of the ventricular septal defects were to the heart apex, the more postoperative residual shunts were left. We consider that apical left ventriculotomy may be needed in apical defects, although the right atrial approach is satisfactory for most muscular trabecular defects.

A 1-month-old male infant with respiratory distress was referred to our hospital for operation of the ventricular septal defect. A chest roentgenogram demonstrated pulmonary emphysema especially in the right upper and middle lobes. At 3 months, a perimembranous ventricular septal defect was closed. But the infant could not be weaned from the ventilator. On the 21st postoperative day, a right upper and middle bilobectomy was performed. Three days later, he was weaned from the ventilator and the postoperative course was uneventful. The pathologic diagnosis revealed no bronchial cartilagenous abnormality. Infantile lobar emphysema of the right upper lobe with congenital heart disease is rather rare. We emphasize the need for lobectomy simultaneous with, secondary to, cardiac surgery in these cases.

In this report, 15 cases using straight staple (group A) and 35 cases using barbed staple (group B) were compared for the purpose of investigating efficacy for median sternal closure. The staples were placed by a Stapilizer powered metaphyseal staple system following partial transsternal fixation with two wires. As a means of assessing the status of back out, which is a major cause of poor fixation, the back out rate (BOR) was measured on lateral sternal radiographies. The average BOR was found to be 33.8% in group A and 21.2% in group B (p < 0.001). Barbed staples seemed to be more useful for sternal fixation than straight staples. This method of applying barbed staples had the advantages of speed, ease of insertion and noninvasion of the retrosternal region. It should be recommended in cases with severe adhesion of the retrosternal region after coronary operation.

We have experienced a case of bilateral partial anomalous pulmonary venous return without atrial septal defect. Right upper pulmonary vein returned to the superior vena cava and left upper pulmonary vein returned to the left brachiocephalic vein. This type of bilateral partial anomalous pulmonary venous return was extremely rare, and only 4 such cases have been reported in the Japanese literature. The patient, aged 3 years and 11 months, was successfully operated on, using a direct anastomosis between the right atrial appendage and the superior vena cava. This procedure is considered to be advantageous because both this right atriotomy line and suture line avoid injury of the sinus node and the sinuatrial node artery and no foreign material is used. A decrease in postoperative arrhythmia can also be expected from this procedure.

The incidence of catheter fragment induced by iatrogenic accident has been increasing because of frequent use of intravenous catheters and catheterization in daily practice. Migrated intravascular fragments from broken catheters were retrieved transcutaneously in four cases. All fragments were removed safely using biotome, multipurpose grasping forceps and basket catheter. But in a case which the fragment was lodged in the pulmonary artery, retrieval was not easy and it took many times. Fragments lodged in the right ventricle and in the pulmonary artery cause many complications including deaths. So broken fragments should be removed as soon as possible, before it migrated to there.

A 70-year-old woman underwent aortic valve replacement and coronary artery bypass surgery with a saphenous vein graft for aortic regurgitation and 99% stenosis in the right coronary artery. During the period of weaning from the cardiopulmonary bypass enlargement of the ascending aorta and bleeding from the suture line were observed. The intraoperative diagnosis of ascending aortic dissection (DeBakey type I) was made with transesophageal and transthoracic echocardiography. Cardiopulmonary bypass was reinstituted and the patients was cooled to 20 degrees C. Under circulatory arrest and continuous retrograde cerebral perfusion through the superior vena cava the intimal tear at the point of infusion cannula was removed and the ascending aorta was reconstructed by direct suture bolstered with Teflon felt strips. Following completion of the repair no further dissection was seen, and the patient was successfully weaned from cardiopulmonary bypass. There were no signs of neurologic complications. Although intraoperative aortic dissection is uncommon, it can be a fatal iatrogenic complication of cardiac operations. Prompt recognition and surgical repair of the injuries are essential to achieve a successful outcome. The combination of transesophageal echocardiography and transthoracic echocardiography permits the immediate diagnosis of aortic dissection. And it is suggested that continuous retrograde cerebral perfusion through the superior vena cava protects the brain for 52 minutes of cerebral circulatory arrest at the lowest nasopharyngeal temperature of 18.7 degrees C. This technique is simple, and required neither special preoperative preparation or special equipment, so that it is suitable especially for intraoperative aortic dissection such as this case.

We report a successful case of external conduit operation in a 7.2 kg male infant. A 17-month-old boy was admitted because of increasing cyanosis and polycythemia. He had undergone classical Blalock-Taussig shunt at the age of 51 days with the diagnosis of tetralogy of Fallot with pulmonary atresia. Cardiac catheterization showed stenosis of the right pulmonary artery related to the site of the shunt. We chose external conduit operation and correction of the right pulmonary artery stenosis instead of additional shunt and correction of the stenosis with cardiopulmonary bypass. He is in a good postoperative condition. It is preferable that external conduit operation is applied to similar infant cases from the standpoint of exercise ability, myocardial degeneration and postoperative arrhythmia.

The efficacy of cimetidine administration after the open heart surgery was studied using the cimetidine concentration examination in the twenty five consecutive cases. Cimetidine was administered intravenously. The cases were divided into five groups for the infusion period. There was no case which developed the gastro-duodenal bleeding after the surgery. The concentration of cimetidine has showed more than 0.5 microgram/ml in each group. It was concluded that the administration of 800 mg cimetidine infused more than three hours, repeated every twelve hours was the possible treatment for the prevention of the gastro-duodenal bleeding after the open heart surgery.

Hypothermia has many valuable merits compared with under cardiopulmonary bypass using pump oxygenator, as known. But, on the contrary, it has some weak points, such as, long time required for cooling and rewarming. We have developed the device for rapid cooling and rewarming by using jet water blows. It appeared that the key point in hypothermia was control of ether inhalation and timing of rewarming. We demonstrated that mongrel dog could survive for at least 72 hours after transplantation of heart-lung under simple deep hypothermia with ether anesthesia. The dog was breathing 50-100 percent oxygen gas under control through respiratory ventilator. Postoperative arterial blood gases were maintained between pH 7.3-7.5 and PO2 80-200mmHg on the other hand, PCO2 was unstable from 14 to 63mmHg. It seemed that the anesthesia in canine heart-lung transplants using profound surface hypothermia with either anesthesia was useful methods.

A case of Behçet disease associated with aortic valve regurgitation treated with aortic valve replacement is reported. The patient was treated successfully with special surgical techniques for prevention of post operative paravalvular leakage and occurrence of pseudo aneurysm because the patient was under long-term steroid therapy for Behçet disease.

Tracheobroncho plasty is currently carried out by a number of surgical techniques. Extraordinal plastic modes require special techniques. We prefer to anastomose the posterior site by tying sutures respectively, but at the anterior site by tying sutures after placing them. However, this procedure is difficult to apply in extraordinal plastic modes. Our preference in such cases is to place all anastomotic sutures clipped to field drapes, and then tie them down from front to back of the anastomotic site. This anastomotic technique was carried out in cases of 1) extreme tension in approximation of both anastomotic stumps, 2) subaortic arch anastomosis, and 3) end to side anastomosis. This technique prevents cutting with a suture through cartilage rings with a suture and enables anastomosis to be carried out even in the deep and narrow operative field. The usefulness of this technique was discussed.

A total of ten patients have undergone sequential bypass grafting of the internal mammary artery (IMA) to the coronary arteries at Osaka Medical College. Operative procedures included left IMA bypass to the left anterior descending (LAD) artery and its major diagonal branch in six patients; to the obtuse marginal branch and diagonal branch in three patients; and to the first and the second diagonal branches in one patient. The right internal mammary artery was concomitantly utilized in 4 patients and saphenous vein graft was also utilized in 6 patients. Postoperative angiographic studies were performed in nine patients within 6 months after operation and in all 18 sites of IMA anastomoses, the IMA sequential grafts were patent. Since sequential IMA-coronary bypass technique means the increase of arterial graft, we believe that this technique should be used for multivessel coronary revascularization especially in younger patients.

Rupture of the left ventricular wall after mitral valve replacement (MVR) is a rare but lethal complication, particularly in delayed type. We have encountered five cases of this complication, and the last case who was suffered 6 hours after MVR was successfully repaired. This case is a 56-year-old woman with MS. She underwent MVR with a Duromedics 25 M. She was transferred to the ICU and the postoperative course was uneventful until 6 hours after the operation, then bleeding from chest drainage tubes increased suddenly. She was promptly brought to the operating room, and the cardiopulmonary bypass was restarted. A tear and hematoma at the posterior wall of the left ventricle (Type II perforation) were found. The rupture was closed with three interrupture mattress sutures with a teflon felt strip. Bleeding was decreased, but oppression with sponge was applied to small but continuous bleeding. At present, she is in a good condition without occurrence of pseudoaneurysm of the left ventricle. We investigated our own five cases and sixty cases reported in Japan, and etiology, surgical repair and prevention of this complication were discussed.