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We report the use of a dilated right internal thoracic artery as a systemic-pulmonary shunt in a patient with a single ventricle who developed a systemic-pulmonary shunt stenosis following a modified Norwood's procedure. The systemic-to-pulmonary artery shunt was performed at 13 months of age, and the patient has stable oxygen saturations five years after the surgery.

Background Although repair of a supravalvular aortic stenosis (SVAS) can be performed with low mortality rates, surgery for the complex form of SVAS continues to be associated with a high incidence of residual stenosis. Case presentation The patient was referred to our hospital at 1 month of age and was diagnosed with aortic valve stenosis (AS) by using echocardiography. Cardiac catheterization revealed moderate AS, and subsequent left ventriculography revealed discrete stenosis of the sino-tubular junction and a narrowed proximal ascending aorta. We performed a reconstructive operation for such heart defects involving novel three-sinus and ascending aorta enlargement without aortic root transection in a 6-month-old boy. Conclusion Our novel three-sinus enlargement technique is suitable for treating each type of SVAS and is a useful method for a baby particularly less than 10 kg without disturbing the growth of the ascending aorta.

We report a successful Fontan completion in a 22-month-old boy with tricuspid atresia (TA) IIc with a vascular ring. The patient was referred at 1 month of age and was diagnosed with TA IIc using echocardiography. Subsequent 3-dimensional computed tomography revealed a vascular ring. We describe a reconstructive approach for such a heart defect, involving a Damus-Kaye-Stansel (DKS) anastomosis reduction plasty combined with a bidirectional cavopulmonary shunt (BCPS) created by end-to-end suturing of the right superior vena cava (SVC) to the left central pulmonary artery (PA), called the SVC translocation technique.

We report a case of pulmonary atresia with intact ventricular septum and aortic valve stenosis in a neonate. This combination is extremely rare. Cardiac catheterization was performed at 2 days of age, which confirmed the prenatal echocardiographic diagnosis and identified associated moderate aortic valve stenosis. Soon after the examination, an urgent surgical intervention was required due to uncontrollable circulatory instability. The baby underwent a successful Fontan-type repair achieved by surgical management only.

We devised an "all in one" cardiopulmonary bypass circuit for aortic surgery, and evaluated its efficacy and safety. The circuit consisted of a venous line, reservoir, single centrifugal pump, membrane oxygenator and arterial line bifurcated into two lines for systemic perfusion and selective branch perfusion. The perfusion volume was regulated by an occluder and measured by a flow sensor. A closed partial bypass was established using a shunt line bypassing the reservoir. We applied this circuit to 25 patients with aortic disease. Regulation of both the selective cerebral perfusion (SCP) and the selective branch perfusion was easily performed. There was neither stroke nor organ dysfunction postoperatively. There are some cases in which it is difficult to decide the necessity for SCP preoperatively; the use of this circuit may resolve this problem. This circuit can be easily and safely applied to any type of aortic surgery.

The regenerative capacity of viable cells remaining in cryopreserved vascular allografts is still unclear. Recently, the regenerating gene (Reg) has been documented to play an important role in various regenerating tissues. Here we show the possibility of Reg induction for the enhancement of cryopreserved vascular allograft viability. Cryopreserved rat aortae were isografted or allografted heterotopically. Fresh isografts were also tested. The transplants were retrieved 3, 6, 9, and 12 days after implantation and the intragraft Reg mRNA was measured by a real-time quantitative reverse transcriptional polymerase chain reaction method. Reg expression was not detected before implantation. Reg expression in cryopreserved isografts gradually increased after transplantation, whereas in fresh isografts or cryopreserved allografts it decreased over time after initial expression. Daily administration of 0.5 g/kg nicotinamide (an agent known to be a potent inducer of Reg) induced intragraft Reg mRNA in cryopreserved allografts (p < 0.05) accompanied by augmentation of the intragraft cell population. Daily administration of 0.5 mg/kg FK506 (an immunosuppressant) induced intragraft Reg mRNA both in cryopreserved isografts and allografts (p < 0.01). We conclude that Reg-inductive therapy shows promise as a novel strategy for enhancing the viability of vascular allografts. Moreover, FK506 may be involved in tissue regeneration as well as immunosuppression.

冠状動脈バイパス術後遠隔期に回旋枝領域の虚血が出現した3症例に対し,左開胸心拍動下冠状動脈バイパス術(lateral MIDCAB)を用いて再冠状動脈バイパス術を行い良好な結果を得たので報告する.症例1)52歳男性,初回手術後11年目に狭心症が再発した.胸部下行大動脈をinflowとして肺門下経路を通した橈骨動脈(RA)を用いて,後側壁枝(PL)と鈍縁枝(OM)にsequential bypassを行った.症例2)67歳男性,初回手術後7年目に狭心症が再発した.RAでT-composite graftを作製し,胸部下行大動脈をinflowとして肺門下経路を通してPLとOMの血行再建を行った.症例3)69歳男性,初回手術後10年目に狭心症が再発した.胸部下行大動脈に全長にわたる高度石灰化を認めたため,左腋窩動脈をinflowとして大伏在静脈(SVG)を肺門前経路を通し,開存していたSVG-PLバイパスへ端側吻合した.回旋枝領域への再冠状動脈バイパス術を行う場合に,lateral MIDCABは非常に有用であるが,graftやgraft経路,inflwの選択には工夫を要すると考えられる.

During left nephrectomy in a 35-year-old woman with a left renal cell carcinoma extending into the inferior vena cava (IVC) and right atrium, cardiac arrest occurred. Immediate transesophageal echocardiography demonstrated that the event was caused by a pulmonary tumor embolism. Emergent cardiopulmonary bypass (CPB) was established and the tumors in the pulmonary arteries were successfully removed. The left nephrectomy was completed. The patient recovered in the intensive care unit without any neurological deficit. A postoperative pulmonary perfusion scintigram showed no defect in the pulmonary circulation. Transesophageal echocardiography was useful for making a rapid diagnosis of an intraoperative pulmonary embolism originating from a tumor of the IVC or right atrium.

We report a case of heterotopic gastric mucosa of the gallbladder in a 26-year-old man. The patient was seen at another hospital because of uppr abdominal and right bach pain, and was referred to the hospital with a diagnosis of cholelithiasis. In preoperative DIC, gall bladder and cystic duct were not visualized. Helical CT revealed a filling defect in the neck of the gallbladder. Abdominal US revealed wall thickness and irregularity of the mucosa in the neck of the gallbladder that was too difficult to be differentiated from early gallbladder cancer. Then, laparoscopic cholecystectomy was performed, and the elevated lesion in the neck of the gall bladder was diagnosed as hyperplastic polyp by intraoperative frozen examination, but by postoperative permanent pathologic veiw, that was diagnosed as heterotopic gastric mucosa. Heterotopic gastric mucosa is very rare. In a review of the literature, there are 34 cases of heterotopic gastric mucosa in the gallbladder. Our case which had the elevated lesion of heterotopic gastric mucosa in the gallbladder presented difficulty in differential diagnosis from early gallbladder cancer.

We report a case of giant phyllodes tumor of the right breast invading the whole layer of the thoracic wall. A 45-year-old woman was admitted to the hospital because of a giant breast tumor 30 cm in diametter fixed on her chest wall. The tumor ulcerated and tended to bleed. It smelled bad due to sssociated infection with MRSA and Pseudomonas aeruginosa. In chest CT and MRI, invasion of the tumor into the chest wall was suspected. Extended radical mastectomy and chest wall resection associated with reconstruction by using Marlex mesh and a contralateral rectus abdominaris musculocutaneous flap were performed. Intraoperative findings showed the invasion of the tumor into the chest wall. The excised tumor was 2500 g in weight. Some distinctive gaps were revealed in specimen of the tomor. Microscopic appearance of the tumor showed malignant phyllodes tumor with low grade malignancy. Tamoxifen 20 mg was administered postoperatively to avoid recurrence. The patient was discharged from the hospital 91 days after the operation.

Dextrocardia associated with situs inversus totalis is a rare condition. A 49-year-old man with dextro-cardia and situs inversus totalis underwent off-pump quintuple coronary artery bypass grafting using bilateral internal thoracic arteries and bilateral radial arteries. The operative technique was similar to that of off-pump coronary artery bypass grafting for situs solitus. His postoperative recovery was uneventful.

A case of primary carcinoma of the duodenal bulb with pyloric stenosis is reported with some considerations of the literature in Japan. A 65-year-old woman was admitted to the hospital because of upper abdominal distension. On admission, upper gastrointestinal series revealed pyloric stenosis because the stomach was fully expanded. Endoscopic examination of the upper gastrointestinal tract revealed an elevated lesion like a Bormann's type 1 tumor in the posterior wall of the duodenal bulb, which was adenocarcinoma histopathologically by biopsy. Abdominal CT showed a wall thickening of the duodenum, but no metastatic lesions were found. From these findings, a primary duodenal cancer was strongly suspected. Distal gastrectomy, partial duodenectomy including the tumor and lymph node dissection with Billroth II reconstruction were carried out. Gross appearance of the resected specimen showed a duodenal tumor, measuring 6.0cm in diameter, in the posterior wall of the doudenal bulb which had spread to and covered the pyloric ring. Histology demonstrated well differentiated papillotubular adenocarcinoma and mucinous adenocarcinoma of the duodenal bulb. Duodenal carcinomas are uncommon. This patientpresented with symptoms due to pyloric stenosis had a rare carcinoma of the duodenal bulb. Our experience with this case would emphasize the importance that we should entertain a possible presence of duodenal carcinoma for treating pyloric stenosis, leading to early detection and improved prognosis of the disease.

This paper describes an operated case of pseudocyst of the pancreas with alcoholic chronic pan-creatitis associated with gastrointestinal and intraperitoneal bleeding. A 33-year-old man was under treatment for chronic pancreatitis at the department of medicine in this hospital on an ambulant basis for 3 years. In April, 1994, he was emergently admitted to the department because of an upper abdominal pain and hematemesis after ingestion of alcohol. Symptomatic remission was attained temporarily, but the patient fell into shock state on May 16. With retrograde pancreato-cholangiography and angiography, a diagnosis of gastrointestinal bleeding associated with intrap-suedocystic bleeding due to perforated pseudoaneurysm of the splenic artery was made. The patient underwent an operation on June 1. Intraperitoneal bleeding amounted to about 100g; and marked adhasion was observed. Excision of the pancreatic tail including the pancreatic cyst, partialgastrectomy, and side-to-side pancreatojejunostomy were carried out. Histopathologically there was a little of pancre-atic duct tissue in the cyst, and excised gastric mucosa became thin which indicated a possible communi-cation with cyst. There has been no case report of simultaneous association of gastrointestinal and intraperitoneal bleeding with a pseudocyst of the pancreas, except this case. A review of the literature is also presented here.

We report a successful one-stage biventricular repair of truncus arteriosus communis with interrupted aortic arch in a neonate. This newborn girl was diagnosed with truncus arteriosus communis type III-B (Congenital Heart Surgeons Society classification) by the echocardiography and three-dimensional computed tomography. We present a new reconstructive approach for such heart defects, involving a modified Lecompte maneuver combined with arch reconstruction, by suturing the ascending aorta to the descending aorta in end-to-end fashion called the swing-back technique.

Coronary angiography (CAG) was performed in a 77-year-old woman who presented with chest discomfort. The CAG showed two diseased vessels. For treatment, the patient underwent angioplasty and stenting. During intravascular ultrasonography (IVUS) following stent deployment, the IVUS catheter became entrapped in the left anterior descending coronary artery, causing ischemic changes in the anterolateral wall, which were apparent on the electrocardiogram. The patient underwent emergency coronary artery bypass grafting and removal of the entrapped IVUS catheter.

Background: Tourniquetting technique to fit a prosthetic valve (PV) into the annulus in valve replacement surgery has been previously reported. We modified the previously reported method and designed a simpler tying technique. Patients: We performed 11 aortic (AVR: including four cases for calcified aortic stenosis (AS) with a small annulus and one cases for infective endocarditis with intramuscular abscess cavity), eight mitral valve replacements (MVR), and one tricuspid valve replacement (TVR: for corrected transposition of the great arteries). Techniques and Results: A PV was implanted using 2-0 polyester mattress sutures with a pledget. Each of the two tourniquets held a suture at the bottom of the annulus and at the opposite position to fit a PV. The sutures between each snare were tied down from the bottom to the top. In MVR, after seating of a PV with two tourniquets, we could make sure that no native tissue of any preserved mitral apparatus disturbed PV leaflet motion. In calcific AS, a PV had a good fitting into the annulus because of tourniquets applied to unseated part during tying sutures. In AVR for infective endocarditis, mattress sutures supported by a Teflon pledget were placed to close the abscess cavity. After snaring on one of these sutures, we tied down the sutures, ensuring that they did not cut through the friable tissues. In TVR, we found that native leaflets interfered with PV motion after seating down the prosthesis and those leaflets were resected before tying down the sutures. Postoperative transesophageal echocardiography showed no paravalvular leakage in any patients and excellent PV functions.

Cryopreserved tissue allografts used for cardiovascular diseases become calcified as a late complication after transplantation, probably caused by immunological rejection. Recent attention has been focused on the inhibitory effect of matrix Gla protein (MGP) on ectopic vascular calcification, but the behavior of MGP in cryopreserved allografts is uncertain. In this study we examined the relationship between immunological rejection and MGP in cryopreserved rat aortic grafts after transplantation.Cryopreserved rat aortae were isografted or allografted intraperitoneally. Fresh isografts were also tested. The grafts were retrieved 9 days after transplantation and the intragraft MGP mRNA was measured by a real-time quantitative PCR method. The effect of daily administration of FK506 on MGP mRNA levels in cryopreserved isografts and allografts after transplantation was also evaluated.There was no significant difference in intragraft MGP mRNA levels between fresh and cryopreserved isografts 9 days after transplantation. MGP expression levels in cryopreserved allografts were significantly lower as compared to those in cryopreserved isografts (P.01). Daily administration of FK506 enhanced intragraft MGP mRNA (ninefold) in cryopreserved allografts (P.01), but not in cryopreserved isografts.Immunological rejection is likely to inhibit MGP expression in cryopreserved vascular allografts, resulting in late-onset calcification.

Background Recent reports have suggested that cryopreservation reduces the immunogenicity of donor tissue. The immunomodulation by cryopreservation might influence on the tissue durability after xenotransplantation. We investigated the in vivo morphologic changes in cryopreserved xenograft (CXG) heart valves. Material and method We transplanted a fresh (fresh xenograft; FXG) and a cryopreserved (CXG) porcine aortic root and a cryopreserved canine (cryopreserved allograft; CAG) aortic root into the abdominal aorta of a dog without any immunosuppressive agents. Explanted grafts on the 21st to 49th days after implantation were analyzed morphologically with light microscopy using some special stains, immunohistochemical analysis, and scanning electron microscopy (SEM). Result Light microscopy showed the absence of smooth muscle cells in the media of the aorta in any group after transplantation. FXG valves did not maintain any cellularity after transplantation. CXG valves contained cellular infiltration in themselves. CAG valves contained numerous fibroblasts, which showed the maintenance of tissue integrity without allowing cellular infiltration. The structure of elastic fibers was well maintained, even in the part of CXG valve with cellular infiltration. Immunohistochemical studies documented the infiltration of T lymphocytes in CXG valves that were labeled by anti-CD3 antibodies. SEM demonstrated that no endothelia were seen on the surface of the valves in any group after transplantation. Conclusion We concluded that the cryopreservation method might provide an immunomodulation of xenogeneic heart valves for transplantation.

We present a case of dilated cardiomyopathy with medically intractable congestive heart failure, which was improved by surgical intervention including mitral valve repair and biventricular pacing. This strategy is effective against dilated cardiomyopathy with interventricular dyssynchrony and mitral regurgitation.

Purpose The purpose of this study was to investigate the survival of xenogeneic embryonic stem cell (ES cell)–derived cardiomyocytes transplanted into the normal myocardium. Material and methods Undifferentiated mouse ES cells carrying the enhanced green fluorescent protein (EGFP) were cultured in hanging drops and then plated onto dishes. These cells were identified as cardiomyocytes by the expression of cardiac-specific genes, recording of action potential, and immunostaining with anti-sarcomeric myosin antibody. Donor cells were injected into the normal myocardium, with cyclosporine administered daily. One week after the transplantation, we investigated donor cell survival by examining EGFP expression, hematoxylin and eosin staining, and immunostaining with anti-sarcomeric myosin antibody. Results In vitro donor cells derived from ES cells expressed myosin light chain-2v and α-myosin heavy chain genes, had action potentials of a ventricular myocyte type, and were stained by anti-sarcomeric myosin antibody. In vivo 1 week after transplantation, EGFP-expressed cells were detected in the cell transplanted area. No lymphocytic infiltration was observed around these cells. Conclusions ES cell–derived cardiomyocytes survived in the normal myocardium after the transplantation, even in a discordant xenogeneic transplantation model. These results indicate that cell transplantation using cardiomyocytes derived from ES cells, even if xenogeneic represents an attractive strategy for treating heart disease.