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From January 1992 through March 1997, 75 patients (DeBakey type I/II = 56/19) underwent a surgical repair of a type A acute dissection. The patients included 37 men and 38 women ranging in age from 23 to 83 years with a mean of 65 years. All patients were admitted to our hospital with a mean interval of 2.2 days from the episode of onset. The overall hospital mortality rate was 25% (19/75). There were three late deaths among the 56 patients discharged from the hospital. The actuarial survival rate for the patients surviving the operation was 87% at 5 years after repair. A subsequent aortic operation was necessary in 6 patients, while 3 other patients who had late aortic complications were put on medical therapy alone. As a result, the aortic event-free survival rate was 54% at 5 years. For a type I dissection the false lumen was completely thrombosed after repair in 34%. The descending thoracic aorta with a patent false lumen was markedly enlarged in proportion to the follow-up time. After a conservative approach to the aortic valve, all but one patient demonstrated an adequate valve function throughout this study period. This experience with a midterm follow-up showed an acceptable durability of the preserved aortic valve and a progressive enlargement of the persistent false lumen with a high rate of aortic complications. Hence, all patients with a type A dissection need a close follow-up to assess the aorta for complications of either recurrent or residual aneurysms and dissections.

We report the application of a manifold system which is attached to saphenous vein grafts after the completion of distal coronary anastomosis. This technique permits not only the direct delivery of cardioplegic solution into the distal coronary artery, but also the reperfusion of revascularized coronary arteries via saphenous vein grafts by changing the connection to the arterial circuit during proximal anastomosis under a partial occlusion of the aorta in conventional coronary artery bypass surgery.

We report the case of a 74-year-old man found to have an extensive intramural hematoma (IMH) in the infrarenal abdominal aorta during a follow-up imaging study performed after repair of a DeBakey type II aortic dissection with an aortic arch true aneurysm. Enhanced computed tomographic scan and angiography revealed an extensive IMH and multiple penetrating atherosclerotic ulcers in the abdominal aorta. The patient underwent a successful replacement of the affected abdominal aorta using a collagen-impregnated woven Dacron graft. Atheromatous ulcers are known to occur frequently in patients with advanced atherosclerosis. Hence, the elderly hypertensive patient, being at high risk of developing a variety of aortic disorders, requires careful follow-up imaging studies to assess the aorta on a regular basis.

Patients with vascular disease and coronary disease are usually treated initially by coronary artery bypass grafting (CABG), and vascular surgery is generally performed later. In this study we assessed the feasibility of combined CABG and vascular surgery in a single operation. Between 1988 and 1995, 16 patients received combined operations for vascular and cardiac lesions and the clinical results were assessed. There were no operative or hospital deaths. The mean time for operation was 421 min and the duration of the stay in the intensive care unit (ICU) was a mean of 3.6 days. In one patient with an ischemic left leg, the left internal thoracic artery (ITA) had become a collateral source of the ischemic leg, and the need for preoperative angiography of the ITA in such patients was indicated. The combined operation clearly takes longer than either vascular surgery or CABG alone, but the length of the postoperative intensive care unit stay was essentially the same as that after a single operation and the patient was still managed safely after the combined operation. In patient requiring both operations, the combined procedure therefore appears to be safe and to have a good clinical outcome.

The effect of the addition of albumin to crystalloid cardioplegic solutions was investigated in infants who underwent open heart surgery. The patients were divided into four groups according to whether or not they received a composition of crystalloid cardioplegic solutions containing albumin. Cardioplegic solution (Kurume solution) without albumin was administered to 12 patients (group 1); Kurume solution with 1% albumin to 10 patients (group 2); GIK solution without albumin to 10 patients (group 3); and GIK solution with 1% albumin to 15 patients (group 4). All patients had a ventricular septal defect and underwent closure of the defect with Dacron double velours through either the tricuspid or pulmonary valve. Our results showed that the percent oxygen extraction in group 2 was significantly greater than that in group 1, while the value in group 4 was less than that in group 3 at 5 min after reperfusion. No significant differences were seen between groups 1 and 2, or between groups 3 and 4, regarding the value for creatine kinase muscle-brain (MB) for any measurements during reperfusion. However, regarding the percent lactate and the malondialdehyde extraction values, significant differences between the groups with and without albumin were noted 5 min after reperfusion. These results did not completely support the addition of albumin to crystalloid cardioplegic solutions to help preserve myocardial aerobic metabolism in infants; however, such an addition might contribute to the preservation of myocardial lactate utilization while also helping to inhibit lipoperoxide metabolism immediately after reperfusion.

The inhibitory effect of ongoing rejection and the changes that occurred in mononuclear cell subpopulations were compared between four groups of rats treated with FK506 or steroids. Group 1 was given no immunosuppressive drugs, group 2 was given FK506 from the day of grafting, group 3 was commenced on FK506 on the 4th day after grafting, and group 4 was commenced on methylprednisolone (MP) on the 4th day after grafting. The graft survival times in groups 2 and 3 were significantly longer than those in groups 1 and 4, and there were fewer CD3+ and CD4+ T lymphocytes in the peripheral blood in the groups treated with immunosuppressive drugs than in group 1. In group 4, the levels in both the peripheral blood and thymus were significantly lower than those in the groups treated with FK506 despite the fact that graft rejection occurred soon after the discontinuation of steroid administration. Moreover, the levels of interleukin-2 receptors and macrophages in groups 2, 3, and 4 were significantly lower than that in group 1 postoperatively; however, the number of macrophages in groups 2 and 3 was significantly lower than that in group 4 on the 10th day after transplantation. The findings of this study demonstrated that FK506, even if administered after rejection has begun, might inhibit the subsequent extensive allograft rejection more specifically and effectively than steroids, and that the measurement of a marker for macrophages in the peripheral blood could be useful for the detection of rejection following allograft transplantation in rats.

We treated a man with unresectable hepatic metastases from sigmoid colon carcinoma who has since survived for more than 10 years. A sigmoidectomy with lymph node dissection was performed and a continuous hepatic arterial infusion of 5-fluorouracil (5-FU) with intermittent infusion of mitomycin C (MMC) was administered for about 3 months after this operation. The total doses of 5-FU and MMC were 16 g and 84 mg, respectively. Tegafur also was administered orally at a dose of 600 mg/day for about 8 months. The carcinoembryonic antigen (CEA) level (which had reached 4,409 ng/ml preoperatively) normalized 4 months after surgery, and still remains normal. Very few patients with unresectable hepatic metastases survive for 5 or more years. However, regional chemotherapy can be effective in some patients.

A comparison was made of the histological findings for myocardial tissue of heterotopic transplanted rat hearts administered with FK506. ACI rats were used as donors and Lewis rats as recipients. FK506 was used for 6 days except for group I (control group). Group II received 0.32 mg/kg/day of FK506 from the day of operation while group III was given the same dosage from the 4th day after transplantation. Group IV was given 1.28 mg/kg/day of the agent from the day of grafting and group V received the same dose from the 4th postoperative day. The graft survival time was longer for all groups given FK506, but was significantly longer only for groups administered with FK506 from the day of operation. Histological studies performed 10 and 20 days after transplantation showed that a moderate rejection was seen in about half of the grafts receiving FK506 from the 4th day after grafting. An ultrastructural study of these cases showed that infiltrating large lymphocytes still remained in the interstitial tissues and that the cytoplasmic organelles of the myocytes had been focally destroyed. These results suggest that, although FK506 suppressed any further rejection, the effect might be limited and the myocardial changes of the cardiac graft might persist even after administration for ongoing rejection.

During the last 10 years, complete correction of the tetralogy of Fallot (TOF) has been performed on 28 adult patients using the "separated extracorporeal circulation" (separated ECC) technique developed by us. In addition to the usual ascending aortic and dual right arterial cannulations for ECC, the separated ECC also involved femoral arterial cannulation and the insertion of a catheter with two balloons via the other femoral artery. Flow via the ascending aorta and femoral artery were maintained separately during ECC. The urine output during separated ECC was significantly better than that during ordinary ECC (P < 0.01) and the operative field for intracardiac correction was clearer as a result of blocking the collateral circulation. Thus we believe separated ECC to be a superior method for total correction of TOF in adults, which may enhance the operative outcome.