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The goal of this study was to evaluate perioperative and mid-term results of coronary artery bypass grafting (CABG) in patients with end-stage renal disease (ESRD).Thirty-five consecutive dialysis patients who required CABG over a 5-year period were investigated retrospectively.Mean patient age was 62.5+/-11.5 years. The mean number of diseased vessels was 2.3W0.8. Off-pump CABG (OPCAB) was performed in 12 patients. The mean number of anastomoses per patient was 2.5+/-1.1. The perioperative mortality was 5.7%, and the average duration of hospitalization was 25.3+/-13.4 days. Overall 5-year survival rates were 63.7%. The cardiac-related 5-year survival rate was 89.3%, and the cardiac event-free rate was 51.7%. Multivariate analysis failed to identify any significant prognosticators for perioperative or long-term outcomes. The morbidity rate was significantly lower in patients undergoing OPCAB than in patients undergoing conventional CABG (8.3 vs. 47.8%; p=0.03). Perioperative mortality in the OPCAB group was 0%, and the average duration of hospitalization was shorter in the OPCAB group than in the conventional CABG group (19.7 days vs. 28.5 days; p=0.1).In the context of coronary artery bypass surgery, OPCAB produced better outcomes than conventional CABG procedure in patients undergoing chronic dialysis. Further-more, OPCAB procedure seems to offer a greater benefit to dialysis patients than non-dialysis patients.

Therapeutic strategy for ischemic heart disease has been changing in this decade. We attempted to improve the conventional extracorporeal circulation with the aim of less invasive coronary artery revascularization. Our extracorporeal circulation has been used since 2002, and called the 'mini-pump system' or 'MECC (minimized extracorporeal circulation) system'. The mini-pump system has a centrifugal pump, a membrane oxygenator, a soft reservoir and the characteristics of low prime volume completely closed circuit and low volume cardioplegia. We investigated the degree of invasiveness of the mini-pump system by examining the clinical outcomes (minimum hematocrit, the amount of transfusion and so on), thrombin-antithrombin III complex (TAT), complement factor (C3a) and interleukin (IL)-10 levels. The mini-pump system demonstrated better value than the conventional extracorporeal circulation (TAT; 19.5 : 66.1 ng/ml, C3a; 1,349 : 1,895 mg/dl, IL-10; 105 : 486 pg/ml, respectively) and proved to be less invasive. The incidence of postoperative atrial fibrillation using the mini-pump system was less than that of the conventional extracorporeal circulation. In this issue we presented the vista of the mini-pump system by showing how it decreased invasiveness.

BACKGROUND The goal of the present study was to investigate the feasibility of mitral valvle repair in patients with infective endocarditis (IE). METHODS AND RESULTS Twenty-one patients who had undergone mitral valve surgery for IE were reviewed. Valve repair was performed in 8 patients with active and in 6 patients with healed endocarditis: 6 of these 14 patients were New York Heart Association (NYHA) functional class III or IV preoperatively. Valve replacement was performed in 5 patients with active endocarditis and in 2 with healed endocarditis: 6 of these 7 patients were NYHA functional class III or IV preoperatively. Repair techniques included annuloplasty (n=13), resection-suture (n=13), chordal transfer (n=2), and closure of the perforation (n=3). In the valve replacement group, 6 patients required concomitant aortic valve replacement. In the valve repair group, 1 patient died and 1 patient required reoperation for recurrent mitral regurgitation. Postoperative echocardiography demonstrated no (n=8) or mild (n=4) mitral regurgitation at the last follow-up examination. In the valve replacement group, 1 patient died and 1 patient required reoperation because of a paravalvular leak. No cases of recurrent infection occurred in either group. CONCLUSIONS Mitral valve repair in patients with IE is feasible and has low morbidity.

The application of the pulmonary autograft (Ross) procedure in the treatment of dilated aortic annulus is still controversial, because technical errors of implantation are more likely to occur as the host annular diameter increases. The Ross procedure was successfully employed in a 28-year-old woman with a dilated aortic annulus after simple annular plication. The annulus was plicated beneath the three commissures where the pulmonary autograft was subsequently attached. The diameter of the annulus was reduced from 32 to 26 mm. This technique may provide a number of advantages compared with aortic valve replacement, especially for women of child-bearing age.

It is reported that cardiac afferent information is transmitted through at least three different pathways to the CNS: sympathetic, parasympathetic, and somatic; however, there are few studies concerning the role of afferent fibers of vagus nerves for eliciting cardiac sensation including pain. Especially, receptive field properties innervated by single vagal nerve fiber and mechanical threshold of nociceptors on the cardiac surface are not yet quantitatively studied. Therefore, in this study, we systematically investigated characteristics of vagal units innervating cardiac nociceptors in rats. Using anesthetized and artificially ventilated rats, 37 single unit recordings were made from fine nerve filaments of the left vagal nerve. For quantitative mechanical stimulation, the cardiac surface was stimulated by a von Frey type device. In addition, bradykinin was used for checking the chemical sensitivity of the nociceptor. Electrical stimulation was used to estimate the conduction velocity of the recorded nerve fiber. All units recorded from the vagal nerve were either Adelta- or C-polymodal nociceptors. About 70% of the afferents had conduction velocities in the C-fiber range. In 60% of the units, the peripheral receptive field covered spot-like areas, but we also found larger and continuous receptive fields. Our results show that a majority of nociceptors innervated by vagal afferents are the C-polymodal type with spot-like receptive fields. We consider it to relate to the ambiguous and dull pain of angina pectoris.

Endovascular treatment is now an alternative to surgery for the treatment of iliac artery aneurysms (IAAs). A variety of minimally invasive therapeutic options are available (eg, coil embolization, stent-graft placement), and choosing an appropriate option is essential for achieving excellent long-term results and reducing potential complications. Preprocedural imaging with multi-detector row computed tomography or magnetic resonance imaging is necessary for evaluating patient eligibility and planning the interventional procedure. An imaging classification system for IAAs that is based on anatomic features and endovascular treatment options has been developed and may help determine therapeutic strategies for affected patients. Early experience indicates that endovascular treatment is safe and effective in treating IAAs, and it is expected that various devices that will make endovascular treatment easier to perform will soon become commercially available. However, large, long-term follow-up studies will be needed to determine whether this approach is a practical alternative to open surgery.

Background Posterior autologous pericardial annuloplasty is an option in mitral valve repair. However, the durability of posterior pericardial annuloplasty remains controversial. Methods From June 1999 to July 2004, 49 patients (18 male and 31 female; mean age, 64 ± 12 years) with isolated posterior leaflet prolapse received posterior autologous pericardial annuloplasty. Transthoracic echocardiographic examination before the operation, at the time of discharge, and then annually was performed and analyzed. Results There was no incidence of in-hospital or late death. Only 1 patient (2.1%) required reoperation. In terms of recurrent mitral regurgitation, 31 patients (64.6%) exhibited grade 0 mitral regurgitation, 7 patients (14.6%) exhibited grade 1, and 9 patients (18.8%) exhibited grade 2, whereas only 1 patient (2.0%) exhibited more than grade 3. In terms of predicting postoperative recurrence of significant mitral regurgitation (≥grade 2), multivariate Cox analysis demonstrated that marked left atrial dilatation and high fractional shortening were independent risk factors. In 8 of 10 patients significant mitral regurgitation recurred after discharge. In terms of left atrial dimension, no significant reduction was observed in the postdischarge recurrent group, and there was a significant difference of left atrial dimension between the postdischarge recurrent group and the nonrecurrent group at the time of discharge. Conclusions The merits of mitral valve repair using posterior autologous pericardial annuloplasty are attractive. However, its use should be limited in selected patients with isolated posterior leaflet disease, nonenlarged atria, and non-high fractional shortening to maintain the durability of the mitral valve repair.

Cardiac transplantation is an established treatment for end-stage heart failure, but its use is very limited. Partial left ventriculectomy has been reported as an alternative treatment for end-stage dilated cardiomyopathy. However, it has been well recognized that emergency partial left ventriculectomy for intractable decompensation is associated with poor survival. We report a case of a 68-year-old man with a left ventricular end-diastolic diameter of 108 mm, who underwent emergency extended partial left ventriculectomy, without papillary muscle resection, and mitral valve replacement with chordae preservation to deal with ongoing cardiogenic shock caused by end-stage dilated cardiomyopathy. The patient's cardiac status and general condition improved after the operation, and he survived the crisis. This operation should be considered as an alternative strategy for patients with septal motion and very large left ventricle. Thus, we report a successful extended partial left ventriculectomy and mitral valve replacement for end-stage dilated cardiomyopathy with very large left ventricular end-diastolic diameter.

Objective: Mitral valve repair is frequently performed now because it produces a favorable postoperative quality of life, as well as improved cardiac function. For the treatment of posterior leaflet prolapse, we perform a posterior mitral annuloplasty using an autologous pericardium. The present study assessed the efficacy of this operation. Methods: From April 1999 to October 2003, 42 patients underwent a posterior mitral annuloplasty using autologous pericardium for the treatment of posterior leaflet prolapse. There were 15 men and 27 women with an average age of 63.9 ±11.8 years. The length of the autologous pericardium matched the length of the posterior leaflet annulus as measured with Carpentier-Edwards ring sizer that was chosen based on the area of the anterior leaflet. Results: The average size of the Carpentier-Edwards ring sizer that was used to determine the length of the autologous pericardium was 27.7±1.3 mm, and the absolute length of the pericardium was 50.9±1.8 mm, and the average intra-operative jet area, as assessed by transesophageal echocardiography, was 0.36±0.47 cm2. The five-year freedom from reoperation was 97.1%, while the freedom from significant residual mitral regurgitation (≥3+/4+) was 92.0%. Two patients (4.8%) developed systolic anterior motion, and one patient (2.4%) had a cerebral infarction. None of the patients died after surgery, and no patients developed complications such as hemolysis or ring detachment. Conclusions: Posterior mitral annuloplasty using an autologous pericardium was shown to be a superior technique because it allows a sufficient annular repair with no complications such as hemolysis or ring detachment.

Papillary muscle rupture (PMR) is a rare, but catastrophic mechanical complication of acute myocardial infarction (AMI). Patients with PMR present in acute pulmonary edema and commonly in cardiogenic shock. The absence of new heart murmur after AMI dose not exclude the diagnosis. To diagnose PMR accurately, transesophageal echocardiography is the most useful and essential, coronary angiography is also necessary for appropriate surgical treatment. Based on these results of diagnostic procedure, combined myocardial revascularization and mitral operation should be performed without delay. Although mitral valve repair has the effects of improving left ventricular function, repairing could be undertaken successfully in limited cases, such as ruptured muscle tissue is not friable. If repair is technically more challenging, mitral valve replacement should not be hesitated. Postoperative early and late survival may relate to surgical correction of coronary artery revascularization, especially in multivessel disease, concomitant coronary artery bypass grafting is benefit theoretically and should be performed.

This study was conducted to evaluate and demonstrate the efficacy of low prime volume completely closed cardiopulmonary bypass (LPVP) in arrested coronary artery bypass grafting (CABG). We improved the percutaneous cardiopulmonary support (PCPS) circuit to reduce the deleterious effects of cardiopulmonary bypass (CPB).Between April 1999 and May 2003, among 228 isolated CABG procedures, 47 procedures using LPVP (group L) and 86 procedures using standard prime volume open CPB (group S) were compared. The LPVP priming volume was 590 mL; the circuit was completely closed with a soft reservoir. Cardiac arrest was obtained by warm blood cardioplegia.The following average values were obtained: packed red blood cell transfusions, 0.88 +/- 1.4 U (group L) vs. 2.1 +/- 2.5 U (group S); intraoperative lowest hematocrit value, 28.7 +/- 4.6% (group L) vs. 22.4 +/- 3.3% (group S); blood loss over first 24 hours, 439 +/- 242 mL (group L) vs. 599 +/- 409 mL (group S); ventilation time, 5.1 +/- 3.1 hours (group L) vs. 10.4 +/- 14.9 hours (group S).Compared to standard prime volume open CPB, LPVP resulted in fewer deleterious operative effects. Less blood loss, fewer blood transfusions, and earlier patient recovery was noted with LPVP. Thus, LPVP is a very efficient form of CPB.

Prosthetic valve endocarditis (PVE) caused by Candida species is associated with high morbidity and mortality. A combination of surgical resection and antifungal drug therapy is the golden standard for treatment, yet surgical intervention is not possible in all cases of Candida PVE. We report a case of PVE due to Candida albicans cured by medical treatment alone. This case suggests that, in some instances, Candida PVE can be managed medically with antifungal therapy. Such a conservative approach should be applied with caution and necessitates very close follow-up on a long-term basis.

Off-pump coronary artery bypass grafting (OPCAB) may reduce the inflammatory response associated with cardiopulmonary bypass (CPB) and contribute to minimizing postoperative complications. Heparin-coated circuits and poly2methoxyethylacrylate (PMEA)-coated circuits were developed to reduce such complications. We compared the postoperative inflammatory response with or without CPB.Eighteen consecutive patients undergoing isolated coronary artery bypass grafting (CABG) were divided into three groups: OPCAB group (n=6), heparin-coated circuits group (n=6), PMEA-coated circuits group (n=6). The plasma concentrations of the following inflammatory markers were measured: cytokines [interleukin (IL-10)], polymorphonuclear elastase (PMNE), coagulofibrinolytic factor [thrombin-antithrombin III complex (TAT)], complement factor (C3a).At the end of CPB, IL-10 and TAT concentrations were significantly different among the three groups (OPCAB groupPMEA-coated groupheparin-coated group). The PMNE concentration was significantly lower in the OPCAB group and the heparin-coated group as compared to the PMEA-coated group both at the end of CPB and 4 hours after CPB. C3a concentration was significantly lower in the OPCAB group than in the CPB groups at the end of CPB. Clinical variables did not differ significantly among the three groups.Off-pump CABG is associated with a reduction in the inflammatory response when compared with on-pump CABG, using either PMEA-coated or heparin-coated circuits.

Purpose: To report endovascular repair of a chronic aortic dissection complicated by disseminated intravascular coagulation (DIC). Case Report: A 61-year-old man developed DIC associated with a chronic Stanford type B aortic dissection that occurred during cardiac catheterization 12 years earlier. At the current admission, computed tomography showed a partially thrombosed false lumen extending from the aortic arch to the left common iliac artery. On angiography, entry and re-entry tears were identified at the right subclavian and left common iliac arteries, respectively. After stent-graft implantation at the entry and re-entry sites, not only was the false lumen completely thrombosed but the DIC also resolved. The patient is doing well with no complication at 16 months after treatment. Conclusions: Endovascular stent-grafting is an acceptable alternative to surgical repair for aortic dissection accompanied by DIC.

Objective: The aim of this study was to assess the adequacy of our treatment strategy for patients with post-sternotomy mediastinitis. Methods: Between May 1997 and December 2000, 1,045 consecutive adult cardiac operations were performed at our center. Mediastinitis occurred in 8 patients (0.77%) and as treatment, they underwent (1) aggressive debridement, (2) closed irrigation and drainage, and (3) transvenous administration of antibiotics. We irrigated the mediastinum with 0.1–1.0% povidone-iodine solution, alternating with electrolyzed strong acid aqueous solution. We subsequently reviewed the outcome after the closed irrigation treatment for patients with post-sternotomy mediastinitis. Results: In four of the 8 patients, the culture specimen grew Methicillin-resistant Staphylococcus aureus. In the others, Serratia marcescens, Staphylococcus epidermidis, Pseudomonas aeruginosa and Gram-negative rods were cultured. The mean period between primary surgery and the diagnosis of mediastinitis was 16.3 (8–57) days. The mean period between diagnosis of mediastinitis and the start of the irrigation treatment was 0.8 (0–3) days. The mean irrigation period was 30.0 (14–17) days. The irrigation complications were mild hepatic dysfunction in 2 patients, hyponatremia in 2 and protracted wound infection in 1. The hospital mortality was 1/8 (12.5%). Seven survivors are free from recurrent mediastinitis. Conclusions: Our experience of closed irrigation and drainage suggests that it can yield satisfactory results after poststernotomy mediastinitis, comparable to other reported results with or without muscle flaps.

High origin of the radial artery is the most common variation in the arterial network of the upper extremities in humans. A 36-year-old Japanese woman undergoing chronic hemodialysis presented with a pseudoaneurysm originating from the brachial portion of the radial artery and associated with a high radial artery origin. Recognition of variants of the arterial network in the upper extremities is crucial for clinicians because their superficial position at the elbow joint may make these vessels vulnerable to injury.

A 52-year-old male with a history of repair of aortic coarctation by prosthetic tube graft replacement 35-years ago developed anterior spinal artery syndrome caused by acute functional occlusion of the aorta at the repair site where pseudoaneurysm formation was observed. The patient was rescued by an emergency axillofemoral bypass, and residual hypertension in upper limbs was improved by elective ascending aorta-descending aorta bypass grafting.

The systemic inflammatory response to cardiopulmonary bypass (CPB) may contribute to the development of postoperative complications. Heparin-coated circuits and poly2methoxyethylacrylate (PMEA)-coated circuits have been developed to reduce the risk of such complications. We compared the biocompatibility of these circuits. Twelve patients scheduled to undergo elective coronary artery bypass grafting (CABG) with CPB were assigned to CPB with a PMEA-coated circuit (PMEA-coated group, n=6) or a heparin-coated circuit (heparin-coated group, n=6). The plasma concentrations of the following inflammatory markers were measured before CPB and just after, 4 hours after, and 24 hours after the termination of CPB: cytokines (interleukin [IL]-6, IL-8, IL-10), complement factor (C3a), polymorphonuclear elastase (PMNE), and coagulofibrinolytic factors (thrombin-antithrombin III complex [TAT], D-dimer). Postoperative clinical response was evaluated on the basis of respiratory index, blood loss, and the postoperative and preoperative body-weight percent ratio. There were no significant differences between the groups in the plasma concentrations of IL-6, IL-10, C3a, PMNE, TAT, or D-dimer. Plasma IL-8 concentrations were below the assay detection limits at all time points in both groups. Clinical variables did not differ significantly between the groups. In conclusion, PMEA-coated CPB circuits are as biocompatible as heparin-coated CPB circuits and prevent postoperative organ dysfunction in patients undergoing elective CABG with CPB.

Between September 1999 and January 2001 we performed thrombus removal with the use of a temporary vena caval filter in 11 patients who had acute iliofemoral venous thrombosis. To facilitate thrombus removal, 5 patients initially received catheter-directed thrombolytic therapy (thrombolysis group), and the other 6 received surgical thrombectomy (thrombectomy group). Residual thrombus was confirmed after initial catheter-directed thrombolysis in all patients in the thrombolysis group, and thrombolysis was continued in the ward. Bleeding complications subsequently occurred in 2 patients. In the thrombectomy group, 1 patient had residual thrombus just below the temporary filter, and a permanent vena caval filter was deployed for removal. Another patient had a residual thrombus in the superficial femoral vein, and rethrombectomy was performed. One patient in the thrombectomy group died of pneumonia. All other patients were discharged. There were no deaths from pulmonary thromboembolism in this series. Post-thrombotic syndrome occurred in 2 of the 5 patients in the thrombolysis group (40%) and in 3 of the 6 patients (50%) in the thrombectomy group. We conclude that a temporary vena caval filter is useful for the management of acute proximal deep vein thrombosis, especially when aggressive treatment is required.

A 73-year-old woman underwent both mitral and aortic valve replacements with porcine heart valve prostheses because of severe mitral regurgitation and severe aortic regurgitation. Ten months after surgery, maximal flow velocity of the aortic valve reached 4.6 m/sec and moderate mitral regurgitation was detected. Repeated mitral and aortic valve replacements with mechanical heart valves were performed. The excised mitral valve showed thinning of the 3 cusps, and 2 of them were perforated. There was pannus overgrowth on the flow surface of the porcine aortic valve. Histologic examination of the excised mitral valve revealed marked inflammatory changes with macrophages.

The management of the chronically ischemic leg with ulcer formation that is not suitable for either surgical or interventional treatment is still a matter of controversy. We describe three cases of ischemic ulcer treated with basic fibroblast growth factor spray. Ulcer healing was accelerated and complete epithelialization was achieved in all cases. Basic fibroblast growth factor spray is useful in the treatment of the ischemic ulcer in patients with arteriosclerosis obliterans, especially in high-risk surgical patients.

Objective: Sinus rhythm gained after the Cox/maze procedure concomitant with mitral valve operation has demonstrated long-term attrition during the follow-up, no information exists on whether the type of mitral valve operation—(repair vs. replacement)—affects this sinus rhythm maintenance rate. We retrospectively studied patients undergoing concomitant mitral valve operation and Cox/maze procedure to answer this question.Methods: Between April 1993 and August 1995, 87 consecutive patients—35 men and 52 women (mean age: 59.3 years)—with chronic atrial fibrillation and mitral valve disease underwent the modified Cox/maze procedure and concomitant mitral valve operation, with 56 having mitral valve repair (repair group) and 31 mitral valve replacement (replacement group). Patients were followed up and changes in rhythm studied retrospectively.Results: Follow-up for a mean 51.3±11.6 months was completed in 82 of 83 long-term survivors (99%). Repair group surgery survival was 98.1±1.9% at 1 year and 94.2±3.2% at 5 based on the Kaplan-Meier method. Replacement group surgery survival was 85.7±5.9% at 1 year and 82.9 ±6.4% at 5. Probability in sinus rhythm maintenance for the repair group at 1 year was 88.6±5.4% and at 5 years was 67.6±9.1%. Probability in sinus rhythm maintenance for the replacement group at 1 year was 95.7±4.3% and at 5 years was 65.0±11.1%.Conclusions: Medium-term results after the Cox/maze III procedure concomitant with mitral valve operation are good. The attrition of sinus rhythm maintenance appears similar by the completion of 5-year follw-up.

A semi-flexible annuloplasty ring (Physio-ring) was clinically used in 30 cases of mitral valve insufficiency. The Physio-ring has the characteristics in which the anterior section is rigid and has a saddle-shaped curve, while the posterior section is flexible to allow for changes in size and shape of the anulus during ventricular contraction. The patients were aged from 23 to 73 years (mean 53.8 +/- 12.5). The cause of mitral valve insufficiency was degenerative (in 24 patients), rheumatic (2), ischemic (1), endocarditis (1), congenital + degenerative (1), and traumatic (1). On the 6-month post-implant echocardiogram, 96.6% had grade 0 or +1 regurgitation. The effective valve orifice area was 2.61 +/- 0.82 cm2 (n = 19). There was no late death. However, there was 1 (3.3%) hospital death after the patient had received a simultaneous coronary artery bypass grafting, and then developed low output syndrome after surgery. Although there was no device-related complication, hemolysis of undetermined cause was observed in 1 (3.3%) patient. The findings from this study indicated a low incidence of device-related complication, while excellent valvular function was maintained.

There have been published not a few reports concerning the early recovery from heart surgery. But most of them were restricted in CABG cases. We report our efforts and its results about the early recovery from valvular heart surgery. To make a contribution to the early recovery we have made some efforts since 1995, including normothermic perfusion, low-dose fentanyl and introduction of terminal warm blood cardioplegia. As the results, the tracheal intubation period was shortened from 12.6 +/- 5.3 (hour) to 6.7 +/- 4.1. The number of the cases who had tracheal extubation in the operative day increased from 27% to 84%. The postoperative cardiac function was satisfactory and there were no abdominal or neurologic disturbances among the patients those who were entered into the early recovery protocol. We obtained satisfied early recovery in safe after valvular heart surgery.

Background: Doppler echocardiography is a valuable noninvasive method for evaluating of the occurrence and degree of either prosthetic valve stenosis or regurgitation. By using serial Doppler echocardiographic examination, we evaluated the incidence and the mode of the Carpentier-Edwards pericardial valve (CEPX) dysfunction compared with that of the Ionescu-Shiley valve (IS). Methods and Results: After aortic and/or mitral valve replacement, 80 patients with CEPX and 111 with IS underwent Doppler echocardiography at intervals of at least 2 years after surgery. The average durations of follow-up were 6.1 ± 2.9 years for patients with CEPX and 7.2 ± 3.0 years for those with IS. Bioprosthetic valve stenosis was defined as reduced excursion of the bioprosthetic valve leaflets and peak gradient ≥60 mm Hg after aortic valve replacement and mean gradient ≥7 mm Hg after mitral valve replacement. Bioprosthetic valve regurgitation caused by bioprosthetic valve dysfunction was defined as grade ≥3 transvalvular regurgitation. In the aortic position, although there was no significant difference in the actuarial rate of freedom from bioprosthetic valve stenosis between patients with IS and those with CEPX (10 years after surgery, 88% ± 7% vs 90%, NS), bioprosthetic regurgitation caused by bioprosthetic valve dysfunction occurred less frequently in patients with CEPX than in those with IS (10 years after surgery, 86% vs 54% ± 9%, p < 0.05). In the mitral position, bioprosthetic valve stenosis occurred more frequently in patients with CEPX than in those with IS (10 years after surgery, 54% ± 11% vs 72% ± 8%, p < 0.01). Although grade ≥3 transvalvular bioprosthetic regurgitation occurred later in patients with CEPX than in those with IS, there was no significant difference in the actuarial rate of freedom from that regurgitation between patients with CEPX and those with IS (10 years after surgery, 63% ± 10% vs 54% ± 7%, NS). Conclusions: For aortic valve replacement, CEPX has good long-term durability because of the low incidence of bioprosthetic regurgitation. For mitral valve replacement, long-term durability of CEPX is poor, although medium-term durability is satisfactory. (Am Heart J 1998;135:1086-92.)

It is unclear how long-term support with a left ventricular assist system (LVAS) affects the severely failing left ventricle (LV). From 1994, we applied our LVAS to seven patients with profound heart failure. Of those, six patients were supported for more than 3 weeks. The etiologies of heart failure were valvular heart disease (VHD) in one, ischemic heart disease (IHD) in two, dilated phase hypertrophic cardiomyopathy (DHCM) in one, and dilated cardiomyopathy (DCM) in two. In one patient, biventricular assist was performed because of coexisting severe right heart failure. Each LVAS was installed between the left atrium and the ascending aorta and the pump was positioned paracorporeally. After stabilization of general condition, exercise was started. The natural heart size was examined and systolic heart function was evaluated by the systolic time interval (STI) under LVAS pumping by using echocardiography. This STI was calculated from the equation: ejection time divided by pre-ejection period measured from aortic valve movement. At the beginning of assistance, the STI was low ( 1 and their LVDd decreased to

Background . Behcet's aortitis is one of the most severe manifestations of Behcet's disease. However, there have been few reports of this rare entity. This article we describe our experience with surgical treatment of Behcet's aortitis in 8 patients. Methods . From May 1978 to February 1995, we operated on 8 patients with Behcet's aortitis. All patients were followed up for a total of 54.4 patient-years (mean, 6.8 years). Results . There were no operative deaths, but 1 patient died in the hospital of ventricular fibrillation. Another death occurred as a result of pseudoaneurysm rupture 10 months after operation. Fourteen operations were performed on eight patients: a second operation was performed on four patients, and a third operation was performed on two patients. The translocated Bentall procedure, a modified Bentall procedure, was performed six times. One patient required a second operation for graft detachment, but the others have done well without further surgical intervention. Aortic valve replacement was performed six times, and three reoperations were needed after aortic valve replacement. Conclusions . The translocated Bentall procedure may be effective for Behcet's aortitis, but further investigation is necessary.

From the Division of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan. Received for publication June 25, 1996; accepted for publication Sept. 24, 1996. Address for reprints: Kiyoyuki Eishi, MD, Division of Cardiovascular surgery, National Cardiovascular Center of Japan, 5-7-1 Fujishiro-dai, Suita, Osaka, 565 Japan. J Thorac Cardiovasc Surg 1997;113:609-11 Copyright © 1997 by Mosby-Year Book, Inc. 0022-5223/97 $5.00 + 0 12/54/78176 is commonly used for ease of exposure of the LMT itself. However, kinking of an onlay patch at the junction of the LMT and the left posterolateral aortic wall may result in serious flow disturbances. ~ An onlay patch placed by means of the posterior approach would rest flat from the LMT onto the right posterolateral aortic wall. However, exposure of the LMT from this angle is limited. To expose the whole LMT and avoid kinking of the patch, we developed a new approach using the cadaver heart. This "superior approach" was then successfully used clinically. A 74-year-old man had angina pectoris for approximately 1 year. Coronary cineangiography revealed a 75% stenosis of the left coronary artery (LCA) at its origin. The remainder of the coronary arteries appeared normal. The LMT was long and had a large diameter, making angioplasty a viable treatment alternative (Fig. 1).

A 54-year-old male who experienced a syncopal episode underwent aortic valve replacement for aortic stenosis and regurgitation. The aortic valve was incompetent as a result of thickening of the left coronary cusp and noncoronary cusp. In addition a saccular aneurysm was indicated on the left coronary cusp. A shelf of tissue protruding at right angles from the ventricular septum was particularly prominent below the right coronary cusp, resulting in subvalvular stenosis. The cause of the saccular aneurysm was most likely caused by the long-term effects of the jet stream instigated by discrete subaortic stenosis.

We reviewed the cases of 66 patients who underwent 67 tricuspid valve replacements with Carpentier-Edwards pericardial xenografts between April 1985 and January 1994. Average patient age at time of operation was 52 years (range 8 to 71 years). Concomitant mitral or aortic valve replacements were performed in 46 patients. There were 10 operative deaths and 6 late deaths. Actuarial survival at 9 years was 75.4% ± 5.7%. Prosthetic valve endocarditis occurred twice in one patient. Reoperations for tricuspid regurgitation and for concomitant procedures (maze operation and repair for leak of the mitral prosthesis) were performed in two patients. In both cases, examination of the explanted prostheses showed that the tricuspid regurgitation was the result of nonstructural dysfunction caused by fibrous pannus formation on the cusps of the ventricular side. Among the survivors, 47 patients (92%) were in functional class I or II. Prosthetic valve function was studied by color Doppler echocardiography. Among 38 patients, tricuspid regurgitation more than grade 3/4 or transprosthetic gradient more than 5 mm Hg was found in 11. One patient had right heart failure and the others had no symptoms. In 10 years of experience with the Carpentier-Edwards pericardial xenograft, mortality and morbidity after tricuspid valve replacement were satisfactory. Echocardiographic examination revealed subclinical prosthetic dysfunction in 35% of patients who were followed up for longer than 5 years, however, and we believe that these patients should receive careful follow-up. (J Thorac C ardiovasc S urg 1996;111:605-12)

Background. While the maze procedure does not always eliminate atrial fibrillation (AF) secondary to organic cardiac lesions, concomitant performance of the procedure is associated with increased surgical complexity and potential risks. Methods. To stratify the surgical approach for patients with AF secondary to underlying cardiac lesions, we analyzed 24 preoperative and perioperative variables in 115 consecutive patients with AF undergoing a modified maze procedure combined with valvular intervention (101), repair of congenital anomalies (13) and coronary revascularization (1). Results. Patients who remained in AF (18) compared to patients with restored atrial rhythm (97), had a higher incidence of giant left atrium(56% vs 10%, P

Background Persistent atrial fibrillation (AF) leaves patients symptomatic and at increased risk of thromboembolism even after otherwise successful cardiac surgery. Methods and Results To treat AF secondary to cardiac lesions requiring surgery, we combined a modified maze procedure in 101 patients simultaneously undergoing valvular procedures (87), repair of congenital anomalies (12), and other procedures (2), including 24 repeat operations. Duration of AF varied from 0.1 to 30 years (average±SD, 8.8±7.0 years); the f-wave voltage ranged from 0 to 0.45 mV (0.15±0.09 mV); and cardiothoracic ratio varied from 40% to 99% (63±9%). Aortic cross-clamp time varied from 75 to 229 minutes (138±31 minutes), with bypass time ranging from 119 to 326 minutes (217±42 minutes). There were two early deaths (2%), no late deaths, and one episode of transient neurological ischemic attack in follow-up ranging from 1.0 to 3.1 years, for a total of 190 patient-years. Postoperative rhythms were sinus in 83 patients (82%), junctional in 4 (4%), and persistent AF in 14 (14%), each of whom had mitral valve disease. Patients with other underlying pathology had complete recovery of atrial rhythm. A normal-sized A wave was detected in 88% for transtricuspid flow and in 73% for transmitral flow, suggesting concomitant recovery of atrial contraction. Among 36 patients without mechanical valves, 30 (83%) with atrial rhythm and contraction have been taken off anticoagulation therapy, including 10 who are free of all medication. Conclusions The results suggest that the combined approach is safe, effective, and indicated in patients who are judged capable of tolerating the procedure and likely to regain atrial rhythm.

We report a case of systolic anterior motion of the mitral valve after mitral reconstruction without a semirigid mitral annular ring. A 56-year-old man with mitral regurgitation due to ruptured chordae tendineae underwent mitral valve reconstruction by replacement of chordae tendineae, leaflet excision, and suture annuloplasty without an annular ring. Postoperatively, left ventricular outflow tract obstruction developed and echocardiography revealed systolic anterior motion of the mitral valve. These findings disappeared after medication with a beta-blocking drug.

Right ventricular (RV) failure after the implantation of a left ventricular assist device (LVAD) limits the use of univentricular support for patients awaiting heart transplantation. An understanding of the mechanism responsible for RV failure after LVAD implantation is essential for determining patient selection for univentricular assist devices versus the total artificial heart as a bridge to transplantation. To examine the effect of LVAD implantation on the RV, we explored the relations among RV end-systolic elastance (Ees), effective pulmonary arterial elastance (Ea), and the energy transfer from the pressure-volume area (PVA) to external mechanical work (EW). Eight patients were studied intraoperatively before and after Novacor LVAD implantation, using a trans-esophageal echocardiogram and catheter tip micromanometer to construct a RV pressure-cross-sectional area loop, thereby measuring Ees, Ea, PVA, and EW. The Ees was obtained by transiently occluding the inferior vena cava. After the implantation, Ea/Ees was reduced from 10.4 ± 6.9 to 3.7 ± 2.5 and EW/PVA improved from 0.32 ± 0.51 to 0.51 ± 0.20. Ea/Ees was negatively correlated with EW/PVA (r = -0.75). Those who required mechanical RV assistance showed both an increase in Ea/Ees and a worsening of the mechanical efficiency of the right ventricle. The implantation of a LVAD brought about RV afterload reduction, which optimized ventricular/arterial coupling, thereby improving the mechanical efficiency of the RV.

In Bentall-type procedures, the bleeding and dehiscence occurring around the coronary ostial anastomosis still remain major complications. To reinforce the coronary anastomosis and shorten the time required for hemostasis, a Carrel patch and inclusion technique was employed without any subsequent complications in 13 patients. We excised the coronary ostium with a collar of the aortic wall while leaving epicardium on the aortic wall, anastomosed it to the composite graft, and then included the graft with the aortic wall.

To evaluate the applicability of single lung transplantation as a treatment of pulmonary hypertension, we investigated the relationships between the pulmonary blood flow and resistance in allografts 10 days after single lung transplantation in dogs. In eight surviving recipients and five healthy dogs (control group), pulmonary flow-resistance relationships were investigated at flows in the range of 0.3 to 2.0 L/min at 0.1 L/min increments. Resistance decreased from 2585 to 746 dyne.sec.cm-5 in the successful group (five allografts receiving complete studies) and 2400 to 891 in the control group with an increase of flow. Lung water content of the successful group was 2.0 times that of the control group (successful group, 95.6 +/- 16.7 gm; control group, 47.8 +/- 7.5 gm), and water content of the other allografts (unsuccessful group), including allografts of dogs that died before investigations, was 2.2 times that of the successful group (unsuccessful group, 211.0 +/- 89.6 gm). The chest roentgenograms of the successful group showed mild or moderate consolidations, whereas those of the unsuccessful group showed severe consolidations, but no difference was found in pulmonary flow-resistance relationships between the successful and the control groups. These results show that the allografts, which have about twice the water content of normal lung, maintain adequate pulmonary vascular function. We concluded that single lung transplantation could be an effective treatment for pulmonary hypertension.

Purpose: In this report we review our experience of operations on mitral regurgitation associated with abnormal papillary muscles/chordae tendineae of the mitral valves and discussed the clinical characteristics, operative findings, and treatment strategies. Methods: Undifferentiated papillary muscle was defined as a hypoplastic chordae tendineae with anomalous formation of papillary muscles attached to the mitral valves directly. Consecutive 87 patients undergoing surgery for mitral regurgitation at our institution were reviewed and 6 of them had undifferentiated papillary muscle. Results: The underlying mechanism of regurgitation was prolapse at the center of the anterior leaflet in 3 cases and tethering, a wide area of myxomatous degeneration, and annular dilatation in one case, respectively. Five patients underwent mitral valve plasty and 1 patient received replacement. Anomalous formation of chordae tendineae was corrected by resection and suture with transplantation at the tip of the leaflet to which abnormal chordae were attached in 2 cases, while resection and suture with chordal shortening was performed in 1 case, and chordal reconstruction using artificial chordae was employed in 2 cases. There was no operative death, and postoperative echocardiography showed no residual regurgitation in any of the cases. Conclusions: Mitral regurgitation associated with undifferentiated papillary muscle resulted from prolapse or tethering and impaired flexibility of leaflets. It was possible to successfully treat the patients by mitral valve plasty unless complex congenital cardiac malformation coexisted. Detailed examinations of attached papillary muscle by echocardiography and intraoperative inspection are necessary and surgical techniques should be selected appropriately in each case., General Thoracic and Cardiovascular Surgery, 60(7), pp.406-410; 2012