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大動脈四尖弁は大動脈二尖弁と同様に大動脈弁機能不全の原因疾患となる先天性弁膜症である. 発生頻度は大動脈二尖弁より少なく稀な疾患である. 今回, 超音波検査により術前に大動脈弁四尖弁と診断し得た2症例を経験したので報告する. 症例1 : 63歳, 男性, ペースメーカー植込み術を受けている. 労作時呼吸困難を自覚するようになり入院した. 心エコー検査の結果, 重度の大動脈弁逆流を認め, 左冠尖と無冠尖の間に副尖を有する大動脈四尖弁であった. 手術で四尖が確認され大動脈弁置換術 (SJM 23 mm) を施行した. 組織像では軽度の線維増生と粘液変性が認められた. 症例2 : 58歳, 女性, 高血圧と気管支喘息のため近医で加療を受けていた. 労作時呼吸困難を自覚するようになり入院した. 心エコー検査の結果, 重度の大動脈弁逆流と大動脈弁狭窄の所見を認めたが, 大動脈弁形態は不明であった. 経食道心エコー検査を施行し, 左冠尖と右冠尖の間に副尖を有する大動脈四尖弁と判明した. 手術で四尖が確認され大動脈弁置換術 (SJM 17 mm) を施行した. 組織像では高度の線維増生と石灰化が認められた. 心エコー検査で大動脈弁膜症の原因を検索する際には大動脈四尖弁の可能性も考慮に入れ慎重に観察する必要がある.

To evaluate the stabilizing effects of an antilipemic agent, bezafibrate, on coronary plaques, we carried out a prospective angioscopic and angiographic open trial. From April 1997 to December 1998, 24 patients underwent coronary angioscopy of plaques in non-targeted vessels during coronary interventions and then again 6 months later. The patients were divided into control (10 patients, 14 plaques) and bezafibrate (14 patients, 21 plaques) groups. Oral administration of bezafibrate (400 mg/day) was started immediately after the intervention and was continued for 6 months. The vulnerability score was determined based on the angioscopic characteristics of plaques and compared before and 6 months later. Six months later, the vulnerability score was reduced (from 1.6 to 0.8; P

Mechanical complications of acute myocardial infarction (AMI), such as free wall rupture, ventricular septal perforation (VSP), and mitral regurgitation due to papillary muscle rupture, are associated with high mortality rates. These complications result in extreme deterioration and increased risk of death in patients who do not receive timely resuscitation and surgical treatment. We studied the effectiveness of percutaneous extracorporeal life support (ECLS) for fatal mechanical AMI complications. Nine patients (7 men and 2 women, mean age 69 +/- 6 years) who suffered circulatory collapse refractory to conventional resuscitation were treated with ECLS. Circulatory collapse was caused by free wall rupture in 4 patients, VSP in 4, and mitral regurgitation due to papillary muscle rupture in 1. All patients were successfully resuscitated by ECLS and underwent surgical repair with conventional cardiopulmonary bypass. Eight patients required ECLS after surgery. Four of the 9 patients (2 with free wall rupture, 1 with VSP, and 1 with papillary muscle rupture) were successfully weaned from ECLS and were discharged. Three of the 4 survivors had no major complications, but the remaining survivor suffered neurological deficit. Four patients died while on devices. The duration of ECLS was from 13 to 167 h (mean 76 +/- 57 h) with a maximum bypass flow of 2.0 to 3.9 L/min (mean 2.9 +/- 0.6 L/min). There were no device-related complications during the support period. Total weaning rate was 56% (5/9), and survival was 44% (4/9). We conclude that ECLS can provide appropriate circulatory support during resuscitation and subsequent postoperative circulatory support for cardiovascular collapse associated with AMI complications.

During November 1986 and May 1997, 19 patients with total anomalous pulmonary venous connection (TAPVC) underwent repair surgery. 20 operations including two reoperations were performed. 8 of 19 patients were classified as Darling type Ia, 5 as type IIa, 4 as type III and 2 patients were type IV. Two patients were operated under emergency circumstances within 24 hours after admission, 7 patients were after a short term stabilization of 4.4 days, and the other 11 patients received surgical treatment after a mean of 8.8 days as scheduled cases. For the anostomosis, the common pulmonary venous chamber or the vertical vein was connected with the left atrium in type Ia and III cases; in type IIa and IV cases the cut-back method was performed. Persistent pulmonary hypertension and post-operative pulmonary venous obstruction (PVO) affected the post-operative clinical course. Persistent pulmonary hypertension caused the death of one patient with type IIa and III each, just after operation. One type IV patient died 50 days after operation. The autopsy revealed post-operative obstructions of the remote parts of the pulmonary veins on the anostomosis site. Two patients (type IIa, III) successfully underwent reoperation due to PVO. Post-operative cardiac catheterization was performed after 12 month in 12 cases. Persistent pulmonary hypertension was found in 4 patients, and a type III patient was reoperated because of stenosis of the anostomosis site. The other three patients had persistent pulmonary hypertension without any demonstrable PVO. Persistent pulmonary hypertension and PVO are combined as TAPVC complex. The difficulty to reoperated patients with persistent pulmonary hypertension caused by PVO is one major problem. So preoperative prevention of PVO by normalization the morphologic changes of the pulmonary veins by using drugs could be a different view point in TAPVC therapy after the initial operation.

A case of tricuspid valve regurgitation due to a non-penetrating chest trauma was presented. This case involves a 20-year-old man, who was admitted to a nearby hospital because of rib fracture, mandibular fracture, and hemorrhage of the left hemopneumothorax, caused by a traffic accident. Palpitation and chest discomfort were observed at admission time, but there was no follow-up. Tricuspid regurgitation was pointed out during surgery for the mandibular fracture, and he continued follow up treatment at an outpatient clinic. However his palpitation and chest discomfort worsened, and he was admitted to our department 8 month after injury. During surgery to repair the tricuspid valve, a papillary muscle rupture, valve cusp laceration, and anulus dilatation were found. We performed a papillary muscle repair (chorda tendineae reconstruction), valve cusp suture, and annuloplasty. Absence of the left pericardium was observed during the operation. We reported valve repair of traumatic tricuspid regurgitation which with papillary muscle rupture. Due to its rarity and the fact that there has been no reported cases of papillary muscle repair for traumatic tricuspid regurgitation in Japan, we used researched information on the subject.

A 52-year-old man with Leriche syndrome with a high aortic occlusion, in which the abdominal aorta proximal to the origin of the renal artery was thrombosed, is reported. The patient was admitted to the hospital because of intermittent claudication and sexual impotence. On aortogram the abdominal aorta just from the infrarenal portion to bilateral common iliac arteries occluded completely and the orifice of right renal artery was slightly stenotic. Operation was performed under hypothermia at 30°C of rectal temperature, and a wide operative field was secured through a modified spiral skin incision and extraperitoneal approach (by Stoney et al., 1973). Through a longitudinal aortotomy, thrombus was found locating from the proximal to the renal arteries to bilateral common iliac arteries. The orifice of the right renal artery was thrombosed, too. The long segmental thrombus was removed carefully. Aorta was reconstructed with Y-shaped Dacron graft from the infrarenal portion to bilateral common iliac arteries. The postoperative course was uneventful without renal dysfunction. On postoperative aortogram blood flow was sufficient along the prosthetic graft. In conclusion the spiral skin incision with extraperitoneal approach under systemic hypothermia is a preferable and appropriate procedure for this disease.

To identify the relationship of risk factors for atherosclerosis with venous thromboembolism (VTE) and the utility of transthoracic echocardiography in acute pulmonary thromboembolism (APTE).In 75 patients with VTE (VTE group), 101 patients with suspected VTE (N group), and 50 control subjects (control group), the frequency of atherosclerosis risk factors such as hyperlipidemia, obesity, hypertension, smoking, and diabetes mellitus and the number of risk factors were evaluated. Transthoracic echocardiographic findings such as tricuspid regurgitation, right ventricular dilation, pulmonary hypertension, and right ventricular dysfunction were evaluated in 15 patients with APTE (APTE group) and 38 patients in the N group (NC group).The incidence of hyperlipidemia in the VTE group was statistically higher than that in the control group (odds ratio 2.16, 95% confidence interval 1.43-3.08). Additionally, the incidence of obesity was higher in the VTE and N groups than in the control group (odds ratio was 2.76, 95% confidence interval 1.67-4.37). Risk factors other than obesity and hyperlipidemia and the number of risk factors were not significant. The incidence of tricuspid regurgitation, right ventricular dilation, and pulmonary hypertension in APTE was statistically greater than that in NC group. Right ventricular dilation and right ventricular dilation + tricuspid regurgitation are reliable findings in echocardiography. However, even combining with tricuspid regurgitation, right ventricular dilation is insufficient to identify or screen patients with APTE.Hyperlipidemia and obesity may be risk factors for VTE. However, obese patients can manifest similar findings to VTE. Although transthoracic echocardiograpghy is not recommended as a diagnostic or screening test in APTE, it should be used as an ancillary test.

The preventive effect of pemirolast against restenosis after coronary stent placement was evaluated.Eighty-four patients with 89 de novo lesions who underwent successful coronary stenting were assigned to the pemirolast group(40 patients, 45 lesions) and the control group(44 patients, 44 lesions). Administration of pemirolast(20 mg/day) was initiated from the next morning after stenting and continued for 6 months of follow-up. Quantitative coronary angiography was performed immediately after stenting and at follow-up. Angiographic restenosis was defined as diameter stenosisor = 50% at follow-up. Intravascular ultrasound study conducted at follow-up angiography was used to measure vessel cross-sectional area(CSA), stent CSA, lumen CSA, neointima CSA(stent CSA--lumen CSA), and percentage neointima CSA(neointima CSA/stent CSA x 100%) at the minimal lumen site.There were no significant differences in baseline characteristics between the two groups. Restenosis rate was significantly lower in the pemirolast group than in the control group(15.0% vs 34.1% of patients, 13.3% vs 34.1% of lesions, p0.05, respectively). The intravascular ultrasound study at follow-up(36 lesions in the pemirolast group, 33 in the control group) found no significant differences in vessel CSA and stent CSA between the two groups(17.3 +/- 2.2 vs 16.8 +/- 2.4 mm2, 8.6 +/- 1.9 vs 8.4 +/- 1.7 mm2, respectively). However, lumen CSA was significantly larger in the pemirolast group than in the control group(5.5 +/- 1.3 vs 4.4 +/- 1.1 mm2, p0.05). Moreover, neointima CSA and percentage neointima CSA were significantly smaller in the pemirolast group(3.1 +/- 1.1 vs 4.0 +/- 1.2 mm2, p0.05 and 36.2 +/- 15.9% vs 47.4 +/- 15.6%, p0.01).Pemirolast has a preventive effect against restenosis after stent placement, possibly by inhibiting neointimal hyperplasia.

We attempted combined use of angioscopy and intravascular ultrasonography (IVUS) to localize the coronary ostia and determine the aortic segment to be replaced in patients with annuloaortic ectasia, because these preoperative informations are important for selection of an appropriate technique for reconstructing the coronary artery, to prevent complications, and also to postoperative follow-up. Two cases with annuloaortic ectasia underwent angioscopy and IVUS both pre- and post-operatively. Structure of aortic cusps, position of coronary ostia, the extent of ectasia with very thin wall were clearly observed by IVUS. Angioscopy showed milky white luminal surface of the ectasic segment. After Cabrol’s operation, the sutured portion of native aorta and graft was clearly identified by IVUS and mural thrombus and naked surface of graft were observed by angioscopy. Complications were observed in none. The results indicate feasibility of combined use of angioscopy and IVUS for determination of surgical approach and follow-up in patients with AAE.