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当院で腹部大動脈瘤(AAA)に対しハンドメイドのステントグラフトを用いて血管内治療を行った90症例のうち,動脈瘤の拡大あるいは破裂のため開腹手術による腹部大動脈瘤人工血管置換術を施行した症例を2例経験した.症例1は77歳,男性.平成17年10月,最大径68mmのAAAに対しステントグラフト内挿術を施行した.術後よりendoleak(Type I)を認めていたが,外来で経過観察していた.今年になってAAA最大径75mmと拡大してきたために,平成18年4月開腹手術による人工血管置換術を施行した.大動脈遮断は左上腕動脈より挿入したocclusion balloonより腹腔動脈上で一時的に行い,ステントグラフト除去後に腎動脈下に遮断鉗子をかけなおした.術後経過は良好であった.症例2は86歳,女性.平成17年4月,AAAに対してステントグラフト内挿術を施行した.術後の検査ではendoleakを認めず他院でfollowされていた.平成18年5月,AAA破裂によるショックのため当院救命センターに搬送され,同日緊急で開腹手術による人工血管置換術を施行した.大動脈遮断は腎動脈上に一時的に遮断鉗子をかけ,ステントグラフト除去後速やかに腎動脈末梢側にかけなおした.術後経過は良好であった.

End-stage heart failure is associated with high rates of mortality. Obviously, heart transplantation is the ultimate surgical intervention for its treatment. However, this surgical option is severely limited by immunosuppressive drug morbidity and inadequate donor organ availability. Partial left ventriculectomy, the so called Batista procedure, has been proposed for the treatment of dilated cardiomyopathy and other end-stage heart failure. Although initial reports lacked significant information on the safety and efficacy of this procedure, overall clinical impression from the reports is that the operation may serve as a relatively inexpensive bridge to transplantation especially in the patients with idiopathic dilated cardiomyopathy. In order to select an exact procedure to resect appropriate amount of scar tissue, dobutamine echocardiographic study, intraoperative volume reduction test using cardiopulmonary bypass, positron emission tomography, or magnetic resonance imaging scans can be used. To avoid the late deterioration related to the development of significant mitral valve regurgitation, definitive mitral valve repair or replacement at the time of the partial left ventriculectomy may be advised. Further study is required to determine the procedure's exact role in the treatment of congestive heart failure. This would have to be a multicenter, randomized, and long-term follow-up study.

We present herein a review of 95 patients who underwent valve replacement with the CarboMedics (CM) valve prosthesis between April 1990 and December 1992. The operative mortality for the entire group was 4.2%: 0% following aortic valve replacement (AVR), 2.7% following mitral valve replacement (MVR), and 12.5% following double valve replacement (DVR). All patients were prescribed warfarin and bucolome for anticoagulation, and were followed up for a mean period of 29.9 months. Late mortality was 8.4%: 3.1% following AVR, 10.8% following MVR, and 12.5% following DVR. There were no cases of mechanical prosthetic valve failure, significant hemolysis, infective prosthetic valve endocarditis, or bleeding complications. After 44 months of follow-up, the actuarial freedom from complications was calculated as: thromboembolism, 97.8±1.6%; valve thrombosis, 97.8±1.1%; paravalvular leak, 96.7±1.9%; and reoperation, 98.9±1.1%. The overall survival rate was 84.3±6.3% and all survivors showed a significant improvement in NYHA functional class, from 81% in classes III and IV preoperatively to 99% in classes I and II postoperatively. The CM valve exhibited no significant differences in hemolytic parameters or hemodynamic performance after isolated AVR or MVR compared with the similar type of St. Jude Medical bileaflet valve. The evidence provided by the present study therefore suggests that the CM valve prosthesis can achieve excellent mid-term clinical results and hemodynamic performance with a low incidence of thromboembolism and valve thrombosis.

Background . The insertion of bioprosthetic valves into the pulmonic position is not performed commonly because of uncertainty concerning the necessity and durability of such valves. Methods . We reviewed the long-term outcome of 10 patients who underwent pulmonary valve replacement with bioprostheses between March 1985 and March 1997. A Carpentier-Edwards supraannular bioprosthesis was used in 7 patients, a Hancock II bioprosthesis was used in 2 patients, and a Carpentier-Edwards pericardial bioprosthesis was used in 1 patient. The mean patient age at the time of pulmonary valve replacement was 38.9 ± 16.3 years (range, 15 to 63 years). The diagnoses were pulmonary valvular regurgitation after corrective surgery for tetralogy of Fallot in 7 patients, right ventricular outflow tract stenosis and absent right pulmonary artery combined with a double-outlet right ventricle in 1 patient, pulmonary valvular regurgitation with pulmonary artery dilatation in 1 patient, and aortic valve stenosis treated with our modification of the Ross procedure using a pulmonary bioprosthesis in 1 patient. Survivors were followed up for a mean of 5 years and 5 months. Results . One patient underwent reoperation because of infective endocarditis of the bioprosthesis. No bioprosthetic valve dysfunction has been observed on Doppler echocardiography during a maximum follow-up period of 12.2 years, except in the patient who underwent replacement at 15 years of age. Conclusions . Bioprostheses in the pulmonic position are durable in adult patients because they face a minimal hemodynamic load, but they may undergo early leaflet degeneration in younger patients.