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術中心停止となった破裂性腹部大動脈瘤の救命例を経験した.症例は4年前の冠動脈バイパス術(CABG)と7ヵ月前の胃全摘術の既往のある71歳男性で,破裂性腹部大動脈瘤に対し緊急手術を行った.開腹後心停止となり,左開胸心マッサージを開始した.胸腔内で用手的に大動脈を遮断し,腹部大動脈瘤を切開,瘤内から胸部下行大動脈へ閉塞用バルーンカテーテルを挿入し遮断後,腹部大動脈の剥離を行い,腎動脈下で遮断し直した.心停止から37分後に自己心拍が再開し,Y字人工血管で腎動脈下腹部大動脈を置換した.末梢吻合は両側とも大腿動脈で行った.下腸間膜動脈は再建しなかったが腸管に虚血所見を認めなかった.術後3日間の人工呼吸管理を必要としたが,心不全・腎不全は発症しなかった.神経学的異常は認めず,術後50日目に軽快退院された.開胸直接心マッサージ・胸腔内大動脈遮断・閉塞用バルーンカテーテルの使用が有効であった.

1981年1月から1996年12月までに, 二葉弁を用いて僧帽弁置換あるいは三尖弁置換を行った281例中10例 (僧帽弁位7例, 三尖弁位3例) に血栓弁を認めた. 血栓弁の原因は, ワーファリン内服不規則1例, 合併疾患などのため内服中止4例, 原因不明5例であった. ウロキナーゼまたは組織プラスミノゲンアクチベータ (tissue Plasminogen Activator; 以下tPA) を用いた血栓溶解療法を行い, 有効5例 (僧帽弁位4例, 三尖弁位1例), 無効5例 (僧帽弁位3例, 三尖弁位2例) であった. 僧帽弁位無効例に再僧帽弁置換術を行ったが, 2例をLOSにて失った. 三尖弁位無効例の1例に血栓除去術を行い, 残り1例は症状なく経過観察中である. 血栓弁の治療は手術が原則であるが, 二葉弁弁葉の固定位置によっては急激な循環動態の悪化を生じない場合もあり, 血栓溶解療法が有効な症例もあると考える. また, 血栓弁の早期診断にドプラー心エコー法が有効であった.

1974年から1992年8月までに教室で施行したCABG 712例中, 狭心症再発によりPTCAを34例 (4.8%), 再手術 (Re-do) を11例 (1.5%) に施行した. 不安定狭心症はPTCA群で82%と多く, 症状再発時にはPTCAが選択されることが多かった. 半数が術後1年未満の再発で吻合部狭窄等のグラフト不全が原因であり, 冠動脈病変によるものは4年以後にみられた. PTCA施行部位およびRe-doのグラフトの短期開存率はおのおの86%, 92%で有意差は認められなかった. 静脈グラフトのPTCA成功率は良好だが, 中枢側吻合部の再狭窄の発生率は高くRe-doを考慮すべきである. 両者において死亡例はなく, 急性心筋梗塞が各1例ずつみられた. PTCAは急性期における成績は良好であり第一選択とすべきであるが, Re-doによる長期生存率は高く, 再狭窄例にはPTCA後1年未満にRe-doを施行すべきである.

心筋梗塞後の合併症としての左心室瘤は一般的には真性瘤と仮性瘤とに大別され, それにより破裂の危険性, 手術適応などの判断が下される. 今回, 仮性瘤様形態を呈し, 真性瘤か仮性瘤かの判断に苦慮した2症例を経験した. 症例1は77歳男性, 心筋梗塞後左心室造影検査で後下壁に仮性瘤様の交通口の細い瘤の増大を認めた. 瘤径は40mm大で細い茎であった. 症例2は61歳男性, 心筋梗塞後 oozing rupture を来たし心タンポナーゼにてドレナージを施行, 急性期を脱したが左室造影で下壁に破裂後の瘤形成 (仮性瘤様) を認めた. 瘤径は20mm大で茎は細かった. 両者とも組織学的に真性瘤の診断を得た. 形態学的に左室後壁や下壁は支持組織の存在によって真性瘤であっても仮性瘤様の茎の細い形態をとると考えられた.

We report on an adult patient with discrete-type subaortic stenosis. A 48-year-old man who had progressed asymptomatically since childhood despite heart murmur was transferred to our hospital. The patient was diagnosed as having severe aortic stenosis with a pressure gradient of 100 mmHg across the aortic valve, associated with a grade II aortic regurgitation. A conventional aortic valve replacement was scheduled. During surgery, the aortic valve was found to be tricuspid but incompetent as a result of shrinking and thickening of the left coronary cusp. A circumferential fibromuscular ridge was observed under the cusps, which corresponded to Kelly's type II discrete subaortic stenosis. Because of the small subaortic area and deformity of the cusp, we performed aortic valve replacement after excision of all cusps and the fibromuscular ridge. Early corrective surgery is recommended for discrete subaortic stenosis to prevention regurgitation progression.

The effect of Ryanodine and CoQ10 on intracellular electrolyte alter¬ations of rabbit heart was investigated. Electrolyte concentrations in the contractile element (A band) of the myocardial cells (ventricular cells) were measured by X-ray microanalysis employing thin sections of freshly freeze-dried myocardium.

The lateral femoral circumflex artery (LFCA) is one of the branches of the deep femoral artery. In the field of plastic and reconstructive surgery, the LFCA has been used to supply composite tissue of skin and/or muscle. 1-3 The LFCA has three major branches: the ascending, transverse, and descending branches. The descending branch of the LFCA passes downward through the intermuscular space between the rectus femoris muscle and the vastus lateralis muscle and finally terminates in the vastus muscle near the knee joint, The descending branches of the LFCA have a very large diameter (2 to 3 ram) and do not taper like those of the radial arteries. 3 The descending branch of the LFCA has an attractive caliber and length. We report the first case in which a descending branch of the LFCA was used as a graft for myocardial revascularization. A 77-year-old woman had a 7-month history of increasing angina on exertion. ElectrocardiOgraphic changes were consistent with effort angina. Cardiac catheterization revealed a 99% stenosis of the proximal right coronary artery and a 75% stenosis of the middle third of the left anterior descending coronary artery. For this patient, we had planned to perform coronary artery bypass grafting (CABG): a left internal thoracic artery (LITA) in situ to the left anterior descending coronary artery and a saphenous vein graft to the right coronary artery. However, the saphenous vein had varices and was unacceptably thin. We also decided to avoid grafting the right internal thoracic artery to the right coronary artery for this elderly woman because devascularization of the sternum suggested a greater risk of sternal wound infections with the use of bilateral internal thoracic artery grafts. We concluded that the descending branch of the LFCA could be used to bypass the right coronary artery. We had evaluated the descending branches of the LFCA bilaterally by means of a femoral arteriogram 5 days before this operation. The arteriogram showed a good qUality vessel Without stenosis (Fig. 1). The descending branch of the left LFCA was harvested