Search

Right ventricular failure after repair of tetralogy of Fallot (TOF) is associated with late mortality and morbidity. We report a case of tricuspid and mitral regurgitation with severe pulmonary regurgitation (PR) diagnosed 31 years after repair of TOF. The patient, a 48-year-old woman, presented with severe ventricular arrhythmia and exercise intolerance. She was treated successfully with triple valve replacement, following which her symptoms improved dramatically. She has remained well for 2 years postoperatively.

2000年1月から2003年12月までの4年間に当院で施行した80歳以上の大動脈弁置換術(AVR)症例29例を高齢者群とし,その手術成績ならびに中期成績について検討した.使用した弁は,全例,生体弁(Carpentier-Edwards PERIMOUNT)であった.また,同時期に施行された75歳以下の生体弁によるAVR症例36例を対照群として,2群間で比較検討を行った.平均年齢は高齢者群で82.9歳,対照群で71.6歳であり,病変は高齢者群では大動脈弁狭窄(AS)症例が79%と対照群の53%に比較して有意に多く,ASの程度も高度であった.術前合併症としては,高齢者群では糖尿病と腎機能障害(Cr≧1.5)の頻度が有意に高く,緊急手術例も高齢者群24%,対照群6%と高齢者群で緊急手術の頻度が有意に高かった.術後合併症は,48時間以上の長期の人工呼吸器管理を要した症例と一時的にCHDFを必要とするような腎機能障害をきたした症例の頻度が高齢者群で有意に高かったが,病院死亡は高齢者群6.9%,対照群5.6%と差はなく,3年生存率も高齢者群89%,対照群78%と差は認めなかった.80歳以上の超高齢者に対するAVR症例では術前の重症度が高かったが,その手術成績ならびに遠隔成績は良好であり,外科的治療を積極的に考慮すべきであると考えられた.

We report a case of thoracoabdominal aortic aneurysm (TAAA) Crawford type I with high-risk factors. A 74-year-old woman, who had a history of myocardial infarction with severe left ventricular dysfunction, asthma, and hypothyroidism, underwent endovascular stent-graft replacement for TAAA and simultaneous surgical reconstruction of the visceral arteries to avoid thoracotomy and extracorporeal circulation. Postoperatively she suffered from weakness of the left leg, with suspected paraparesis, but recovered muscular strength to some extent and was discharged in a wheelchair on postoperative day 74.

Objectives: Coronary artery disease (CAD) and abdominal aortic aneurysms (AAA) commonly coexist. However, each disease treatment complicates the management of the other. In this study, we evaluate whether a simultaneous operation of AAA repair and off pump coronary artery bypass (OPCAB) would be safe and acceptable, compared with either procedure alone. Subjects and Methods: We retrospectively reviewed all patients who underwent simultaneous AAA repair and OPCAB (AAA/OPCAB, n=18), compared AAA repair alone (AAA, n=239) and OPCAB alone (OPCAB, n=137) from June 1999 to December 2003. There were no significant differences with regard to age or gender, but the AAA/OPCAB group had significantly larger aneurysms (60.6 vs. 53.2 mm) and significantly lower ejection fractions (EF) (54.9 vs. 60.3%). Results: The patients in the AAA/OPCAB group underwent a significantly longer operative time than AAA, OPCAB (403 vs. 360,296 minutes, respectively), there was significantly greater blood loss (726 vs. 426, 462 ml), and more transfusion required (8.13 vs. 1.69, 2.8 units). The number of bypass grafts in AAA/OPCAB group (1–5 per patients) was significantly smaller (1.78 vs. 2.93). The AAA/OPCAB patients had a significantly longer hospital stay than the AAA (38 vs. 22 days), but was not significantly longer than the OPCAB. There were no significant differences with regard to the morbidity and mortality rate among the three groups. Conclusion: This study suggests that the simultaneous operation of AAA and OPCAB can be done with the same morbidity and mortality as independent surgical procedures. Key words: coronary artery bypass grafting, abdominal aortic aneurysm, off pump coronary artery bypass, simultaneous operation

症例は45歳,男性.A型大動脈解離に対して全弓部置換術を行った.術中の経過は安定していたが,術後7時間目ころから洞性頻脈となり,続いてPaCO2が上昇,PaO2が低下し,代謝性アシドーシスが進行した.その後39.7℃までの急激な体温上昇とともに血圧が低下した.全身冷却にて体温は低下傾向となったが,意識障害,無尿と低酸素血症は持続した.悪性高熱と診断しダントロレンを投与したが,多臓器不全が進行し術後7日目に死亡した.血中CPKは最高12,446IU/lまで上昇,血中ミオグロビンは術後2日目で36,500ng/mlと非常に高値であった.開心術後に悪性高熱を発症することはきわめてまれであるが,原因不明の急激な体温上昇を認めたときには念頭におかなければならない.

症例は74歳,男性.遠位弓部大動脈瘤を伴ったStanford B型の慢性大動脈解離を認め,瘤径が60mmと拡大してきたため,2004年4月26日左開胸にて手術を行ったが,遠位弓部大動脈から下行大動脈にかけて偽腔の高度石灰化が認められ,大動脈遮断ならびに吻合が困難であり,大動脈壁の石灰化部分を切除して吻合することも考慮されたが,吻合部から出血した場合の修復も難しいと判断された.また,切開創を腹部にまで延長し,石灰化の軽度な吻合可能部位を探すことは,慢性肺気腫による低肺機能を有することから過大侵襲と判断し手術を断念した.本症例では解離は横隔膜レベルで終了しさらに偽腔は完全に血栓閉鎖しており,胸骨正中切開による経大動脈アプローチでステント付き人工血管を瘤末梢側の真腔内に留置することによって瘤の完全な血栓化が図れると判断し,6月14日に再手術を施行した.循環停止下脳分離体外循環法を補助手段として経大動脈的にステント付き人工血管内挿術を行った.術後はエンドリークを認めず順調に経過した.本症例のようなhigh risk症例の慢性大動脈解離で偽腔の高度石灰化を有し末梢側吻合が困難な遠位弓部大動脈瘤あるいは大動脈壁の高度石灰化を認めるいわゆるporcelain aortaを伴った真性胸部大動脈瘤に対する治療法として本術式は侵襲が少なく重篤な合併症を回避できる有用な手技であると考えられた.

症例は65歳,男性,他院にて肝膿瘍のドレナージと抗生剤の投与を受けていたが,心不全ならびに菌血症に伴うショックとなり,その経過中に心エコー検査にて感染性心内膜炎(以下,IE)による僧帽弁閉鎖不全症と診断され,本院に救急搬送され緊急手術を行った.僧帽弁の弁尖ならびに弁輪部には感染所見は認められず腱索に疣贅が存在し,疣贅から離れた前乳頭筋,後乳頭筋および周囲の心筋内に多発性の心筋内膿瘍を形成していた.手術は,前尖を腱索ならびに乳頭筋とともに一塊として切除し,そのほかの心筋内膿瘍は可及的に切開排膿したのちに僧帽弁置換術を施行した.疣贅と心筋内膿瘍の細菌培養では,肺炎桿菌が検出された.乳頭筋ならびに周囲の心筋内に膿瘍を合併したIEは非常に希であり,本症例では弁や弁輪部とは離れた部位に多発性に膿瘍が認められたことや膿瘍部の心内膜が保たれていたことから,IEから菌血症となり血行性に心筋内へ感染が波及したものと考えられた.

症例は70歳,女性.遠位弓部大動脈瘤に対して,脳分離体外循環下に弓部大動脈人工血管置換術を行ったが,閉胸時に突然,肺動脈主幹部からの出血でショックとなった.出血部を用手的に圧迫しつつただちに体外循環を再開し,心停止下に肺動脈を検したところ,肺動脈主幹部から左主肺動脈近位部の頭側の後壁よりの肺動脈壁が長さ3cmにわたって縦に裂開していた.裂開部は自己心膜にて修復した.本症例は,術前のCT検査所見で径88mmの巨大な遠位弓部大動脈瘤が肺動脈を著明に圧迫していたことから,弓部大動脈人工血管置換後に動脈瘤による圧迫が解除され,壁在血栓によって閉塞されていた大動脈瘤肺動脈穿通部から出血したものと考えられた.術前に左右シャント血流がなく壁在血栓によって閉塞していた大動脈瘤肺動脈穿通部から,術中に肺動脈破裂をきたしたきわめてまれな合併症を経験したので報告する.

腸腰筋膿瘍を合併した感染性腸骨動脈瘤に対して自家浅大腿静脈グラフトを用いたin situ血行再建術を施行し良好な結果が得られたので報告する.症例は73歳,男性.発熱と左下腹部痛を主訴に他院入院となり,入院後の腹部CT検査にて左腸骨動脈瘤の破裂が疑われたため当科緊急入院となった.入院時の血液検査にて高度の炎症所見が認められたことと造影CT所見より,腸腰筋膿瘍を合併した感染性腸骨動脈瘤と診断された.人工血管による血行再建術はグラフト感染の危険性が高いことから,自家静脈である右浅大腿静脈を採取し,血行再建術を行うこととした.手術は,瘤切除ならびに腸腰筋内の膿瘍腔をdebridementしたのちに,浅大腿静脈グラフトを使用してin situにて左腸骨動脈の血行再建術を行った.現在,術後1年6ヵ月が経過しているが再感染の徴候もなく順調に経過している.

Objectives: The safety and reliability of a method of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, CVG, Cincinnati, Ohio) were evaluated. Methods: The mural branches of the internal thoracic artery were cut by means of 3 methods, differentiated by distance from the site of application of the Harmonic Scalpel blade to the internal thoracic artery. A total of 15 branches were cut from the internal thoracic artery at (0 mm) the origin (group I) or at 1 mm (group II) or 2 mm (group III) distal to the origin. Tissue preparations were examined for successful vessel closure and severity of tissue damage. The length of stump (L) and the length of tissue damage from the stump (D) were determined by a computer image analysis system, and pressure testing was performed to evaluate the physical strength of vessel closure. Results: In group I, 8 of the 15 branches exhibited discontinuity of the vascular wall structure, probably because of insufficient sealing of the divided section, and 12 of the 15 branches exhibited tissue denaturation on the internal thoracic artery wall adjacent to areas of origin, which was probably caused by the heat transferred from the branches during the process of coagulation. In groups II and III, continuity of wall structure of stumps suggestive of stable closure of branches was confirmed. The lengths of tissue damage from the stump (D) were 0.96, 0.58, and 0.63 mm in groups I, II, and III, respectively, and the lengths of intact area (L – D) in the corresponding groups were –0.78, 0.61, and 1.51 mm. The negative figure in group I indicates the presence of tissue damage in the internal thoracic artery itself. By contrast, in groups II and III the internal thoracic arteries were intact, with a safety margin of greater than 0.5 mm. On physiologic evaluation of vessel closure, 2 of the 24 (8.3%) branches burst under a pressure lower than 350 mm Hg because of insufficient vessel coagulation, but the remaining 22 branches (91.7%) remained intact under pressures up to 350 mm Hg. Conclusion: The internal thoracic artery skeletonization method with an ultrasonic scalpel (Harmonic Scalpel: output level 2) appears to be a safe and reliable method of skeletonized internal thoracic artery harvesting when branches are sectioned at least 1 mm distal to their origin at a sufficiently slow speed. (J Thorac Cardiovasc Surg 2000;120:1142-7)

We report the case of an 85-year-old man with a recurrent thoracoabdominal aortic aneurysm who underwent two-staged combined endovascular and surgical procedure. First, two retrograde bypasses using saphenous vein grafts were implanted from the right common iliac artery to the celiac artery and superior mesenteric artery. Two weeks later the aneurysm was successfully excluded with a stent-graft. The postoperative course was uneventful. This two-staged combined endovascular and surgical approach may be a safe and effective alternative to open surgical repair of thoracoabdominal aortic aneurysm in high-risk patients.

A 26-year-old man who underwent aortic valve replacement for aortic regurgitation due to Takayasu's arteritis 2 years earlier experienced left amaurosis persisting for some minutes. Computed tomography showed aneurysmal dilation of the ascending aorta to a diameter of 60 mm and occlusion of the left carotid artery. Cardiac echography showed perivalvular leakage. Following administration of a calcium antagonist, the patient's amaurosis subsided and brain bloodstream scintigraphy showed no abnormalities. We resected the aneurysm instead of using Bentall's operation. Following an uncomplicated postoperative course, the patient was discharged 21 days after surgery and echocardiography has shown no perivalvular leakage to date.

両側多発性肺炎症性偽腫瘍の1例を経験したので報告する.症例は49歳, 男性で健康診断にて胸部異常陰影を指摘された.胸部陰影は両側に計7ヵ所認め, 転移性肺腫瘍を疑ったが, 原発巣は不明であり, 左側肺の病巣 (8ヵ所) を摘除した.病理組織像は, 膿瘍中心と炎症性細胞 (リンパ球, 形質細胞, マクロファージ) の浸潤像が主体であった.対側の陰影は術後3ヵ月後に消失していた.炎症性偽腫瘍は多くは孤立性に発生して, 摘出を受けるためその予後は不明であるが, 本症例の経過より自然寛解の可能性が示唆された.

We present a case report on a 54-year-old woman with extraskeletal osteosarcoma of the left atrium featuring severe congestive heart failure. We resected the tumor, which occupied the left atrium and had widely infiltrated the atrial wall, but the patients died of the tumor 9 months after surgery. This is to our knowledge the 32nd case of cardiac osteosarcoma ever reported.

僧帽弁位の Carpentier-Edwards Pericardial Bioprosthesis の使用後に一過性の逆流と溶血を生じた症例を経験したので報告する. 症例は, 69歳女性で手術後より収縮期雑音を認め, 心エコー検査にて生体弁中央からの逆流が認められた. 同時に溶血 (LDHの上昇と貧血の進行) を来し, 再弁置換を考慮したが, 術後12日目に逆流は消失した. 弁縫着時のステントディストーション (stent distortion) によるものと思われるが, 詳細についての報告は少なく, 生体弁置換後の逆流においては鑑別すべき病態と考えられた.

抗薬剤抗体陽性のため他家血輸血が不可能な狭心症例に対し, 自己血輸血を行うことにより冠動脈バイパスを安全に行えたので報告する. 症例は62歳, 女性で, 狭心症のため当院に入院した. 精査の結果3枝病変と診断されたが, 術前の不規則抗体スクリーニングにて抗薬剤抗体および抗P1抗体 (冷式抗体) 陽性となり, 予約血すべてとの交差適合試験で不適合と判定された. 貧血があったため手術を延期し, エリスロポエチンを併用しながら自己血を800ml採血後手術を行った. 手術は左冠動脈前下行枝および回旋枝へ大伏在静脈を用いて2枝バイパスとした. 総出血量は580gであった. 術後ヘモグロビンは7～10g/dlで経過し, 溶血性貧血等の重篤な合併症もなく無輸血で順調に経過した.

We used the common hepatic artery (CHA) as an inflow site for a saphenous vein graft bypass to the right coronary system during off-pump coronary artery bypass grafting. The CHA is a suitable inflow vessel to provide sufficient blood flow and a short-distance bypass in case both the ascending aorta and the gastroepiploic artery are considered inadequate.

Recent studies have reported that apoptosis may be induced by reperfusion injury following ischemia in cardiomyocytes. We present a case with evidence of apoptosis induced by myocardial ischemia without reperfusion. DNA fragmentation was demonstrated in the nuclei of the myocardial cells surrounding the ventricular septal rupture following acute myocardial infarction without reperfusion in the infarct-related left anterior descending coronary artery. This finding suggests that ischemia without reperfusion may induce apoptosis in myocardial cells.

The intracardiac growth and extension of liposarcoma was observed in a 60-year-old woman. The epicardial tumor was identified to originate from the anterior wall of the right ventricle. She initially showed symptoms associated with cardiac tamponade. A surgical operation was performed but it resulted in incomplete resection due to massive invasion and dissemination. The recurrence of the tumors led to congestive heart failure. Finally, she died of heart failure and liver dysfunction as a result of tumor metastasis and invasion. An autopsy detected the primary cardiac liposarcoma. Only a few cases of cardiogenic liposarcoma have so far been reported. A further elucidation of cardiac liposarcoma could reveal mechanisms of the disease, and thus contribute to development of complementary therapies after surgical intervention.

Inflammatory aortic aneurysms are found most commonly in the infrarenal abdominal aorta. We report the case of a 78-year-old man with an inflammatory aortic aneurysm of the ascending aorta, which is extremely unusual. Surgery revealed that the ascending aorta was adherent to the superior vena cava and pulmonary artery, but a dissection membrane was not found. The wall of the ascending aorta was up to 20 mm thick with perianeurysmal fibrosis. Pathologic examination revealed an inflammatory aneurysm with adventitia remarkably thickened by fibrotic tissue and infiltrated by lymphocytes and plasma cells. Our search of the literature found only seven other cases of an inflammatory ascending aortic aneurysm. Preoperative diagnosis was very difficult in most of these cases; however, improved scanning techniques using multidetector row computed tomography may allow the differential diagnosis of this clinical entity.

Postoperative chylothorax in patients with a thoracic aneurysm is generally infrequent. We report a mode of surgery to reduce the incidence of paraplegia. We review our experience with chylothorax after resection of an aneurysm to find its cause and to evaluate the success of management.For descending thoracic aneurysms, intercostal arteries in the aneurysm were exposed before incising the aneurysm and, they were only sacrificed no change in motor-evoked potentials (MEPs) occurred after temporary occlusion. Between January 2001 and December 2003, out of a total of 147 aneurysms including thoracic and thoracoabdominal, 4 consecutive patients (2.7%) with chylothorax were reviewed.The chylothorax was diagnosed 1.5 days after operation (range 1 to 2 days). All patients were initially treated by the cessation of oral intake. This treatment was successful for 2 patients and the remaining 2 required surgical intervention to control the fistula. Chylothorax was cured in all patients.We postulate that chylothorax is caused by injury of the thoracic duct or its branch during the exposing the intercostal arteries. In the management of chylothorax, early intervention is recommended when the volume of chylous fluid is not decreased by conservative treatment.

Pulmonary thromboendarterectomy was performed on a patient with chronic pulmonary thromboembolism showing thrombophilia. The patient was a 56-year-old female with the above condition complicated by congenital protein C deficiency. She was admitted to our hospital with severe dyspnea accompanied by right ventricular failure. A pulmonary arteriogram showed occlusion and stenosis from lobar to segmental arteries. Cardiac catheterization showed marked pulmonary hypertension. A lung perfusion scintigram revealed multiple defects in the right and left lungs. After the insertion of an inferior vena cava filter, she was operated on. Following a median sternotomy, thromboendarterectomy of the bilateral pulmonary arteries was performed using deep hypothermia and intermittent circulatory arrest. Circulatory arrest was employed in three periods totaling up to 36 minutes. After surgery, she had improvements in pulmonary hypertension and pulmonary vascular resistance. She maintained improved lung functions, and remained in the New York Heart Association functional class I for more than two years and eight months after surgery.

The purpose of this study was to determine the relationship between the aortic atheromatous plaque echo density and the incidence of postoperative stroke or embolic events in patients undergoing on-pump coronary artery bypass grafting (CABG).Three hundred and fourteen patients who received on-pump CABG alone were studied. Images of the aortic plaques obtained using transesophageal echocardiography were transferred to a computer. Using an image analysis program, a histogram for plaques more than 3 mm in thickness was obtained through the gray tone frequency distribution of the pixels (0-225). The gray scale median (GSM) was used as a measure of plaque echo density.Fifty-eight plaques in patients not associated with postoperative stroke or embolic events had GSM ranging from 58 to 241 (151.0+/-38.2), while 9 plaques in patients associated with stroke or embolic events had GSM ranging from 67 to 130 (90.6+/-21.3, p0.001). The incidence of stroke or embolism was 58.3% when GSM of plaque was less than 100, while it was 3.6% when plaque GSM was more than 100 (p0.001).This study indicated that computer analysis of aortic atheromatous plaque was useful for selecting patients who had a high risk of postoperative stroke or embolism when receiving on-pump CABG, and for decreasing the incidence of them.

Objectives: Papillary muscle rupture following acute myocardial infarction (AMI), which rarely occurs, leads to catastrophic outcomes. We reviewed 6 patients who were diagnosed as having papillary muscle rupture. Subjects and Methods: Between February 1986 and September 2002, 6 consecutive patients underwent mitral valve replacement (MVR) for acute mitral regurgitation due to postinfarction papillary muscle rupture (4 men and 2 women, mean age 67 years). Preoperatively, all were in New York Heart Association (NYHA) class IV. All patients had intraaortic balloon pumping, and one needed additional percutaneous cardiopulmonary support. Operations were performed within 1 to 19 days (mean 6.8) after the onset of AMI, and within 24 hours after papillary muscle rupture. Complete ruptures were found in 5 of 6 patients. Four patients had posterior papillary rupture and 2 patients anterior. All patients underwent MVR to preserve the posterior mitral leaflet. Concomitant coronary artery bypass grafting was performed in 5 of 6 patients (mean 1.6 grafts per person) and pulmonary venous isolation for atrial fibrillation in one patient. Results: The cardiopulmonary bypass time ranged from 178 to 325 minutes (mean 236), and the aortic cross clamp time from 123 to 196 minutes (mean 155). Two patients died of low cardiac output syndrome. Of 4 operative survivors, 3 patients were in NYHA class I and one in class II. The mean follow-up term was 21 months. One patient with the pulmonary venous isolation has been in sinus rhythm. All survivors have been doing well without any valve related complications. Conclusion: Six patients underwent MVR for the papillary muscle rupture following AMI and the perioperative mortality rate was 33%. All survivors have been well with no cardiac events. We propose that in papillary muscle rupture following AMI emergent surgery should be undertaken as soon as possible, and that concomitant surgery should be performed as thoroughly as possible.

We presented a case of left anterior descending coronary artery aneurysm that was developed after percutaneous coronary intervention (PCI) with stent implantation. The aneurysm was plicated after removal of the stent device, and the left descending coronary artery was bypassed with the left internal thoracic artery. Few have reported surgical treatments for the coronary aneurysm including PCI stent. In this report, a patient requiring PCI stent explantation was described and technical considerations for this patient were discussed.

We present an unusual case of acute type A dissection complicated with severe aortic valve insufficiency caused by prolapse of the tubular intimal flap into the left ventricular outflow tract, which was shown legibly by transesophageal echocardiography in the diastolic phase and by intraoperative macroscopic findings. The dissected ascending aorta was excised completely and replaced without any repairing of the aortic valve, resulting in a favorable outcome for the patient. Prolapse of an intimal flap from the aorta into the left ventricle represented a rare pathophysiology of aortic regurgitation in patients with aortic dissection.

We report an unusual case of subepicardial aneurysm (SEA) of the left ventricle. An 82-year-old man had undergone patch closure of a ventricular septal rupture due to anterior acute myocardial infarction. A postoperative left ventriculogram showed the presence of contrast medium outside the left ventricle, and urgent surgery was performed. The lesion was diagnosed as SEA, and was repaired before rupture.

A 46-year-old female with alcoholic liver dysfunction was admitted for mitral regurgitation due to infective endocarditis. She underwent mitral valvuloplasty and resection of the vegetation without complication. After removal of the chest tube, late cardiac tamponade occurred and subsequently recurred. On the 64th day after mitral valvuloplasty, we performed redo median sternotomy with small laparotomy trying to reveal and repair injured lymphatic vessels in the pericardial space and successfully cured the leakage of lymph. The post reoperative course was uneventful and the patient was discharged 20 days after reoperation. We review a rare complication of recurrent cardiac tamponade of lymphatic leakage associated with liver dysfunction.

We describe a case of ruptured sinus of Valsalva aneurysm (RSVA) with moderate aortic regurgitation (AR), which developed on the second day after admission. The AR was caused by a hemodynamic effect solely, in which the shunt blood flow through ruptured site pulled the right aortic cusp away from closure. The pathological mechanism of the AR was clearly visualized by intraoperative transesophageal echocardiography (TEE) and the AR was successfully resolved after simple closure of the RSVA without any additional procedure to the aortic valve.

65歳男性の両側性孤立性内腸骨動脈瘤を経験した. 通常, 内腸骨動脈瘤の手術は内腸骨動脈の血行再建を行わずに内腸骨動脈起始部の血流遮断とか内腸骨動脈瘤縫縮術が行われている. この症例は両側性であり, 両側の動脈結紮により結腸虚血または殿筋虚血を生じる可能性があったため, 一側内腸骨動脈の血行再建を行った. 症例を呈示するとともに内腸骨動脈血行再建術の問題点につき述べる.

A 67-year-old man who had undergone coronary artery bypass grafting 3 years previously suffered from severe mitral regurgitation associated with Streptococcal infective endocarditis. He was placed in New York Heart Association functional class III. Preoperative angiography demonstrated good opacification of all 3 conduits implanted in the previous operation. We replaced the mitral valve through an anterolateral right thoracotomy, approaching the mitral valve as an alternative to redoing sternotomy to minimize potential injury to patent grafts. His postoperative course was uneventful. After a 1-month course of antibiotics, the patient was discharged as New York Heart Association class II and at present, 3 months after discharge, is doing well. This approach is an effective alternative to redoing sternotomy for mitral valve operation, especially in patients undergoing a previous coronary arterial bypass grafting via median sternotomy.

Background. We have developed an ultrasonic complete skeletonization technique for obtaining internal thoracic artery (ITA) grafts and have used this method clinically since January 1998. In this report, we discuss the early results of bilateral ITA grafts obtained with our method. Methods. We studied 200 consecutive patients who underwent coronary artery bypass grafting using ITAs obtained by this technique. Angiography of the grafts was performed in 188 patients (94%) within 1 month after coronary artery bypass grafting. Results. The ITA grafts were about 4 cm longer than pedicled ITA grafts. The free flow through the grafts was at least 30% higher than through pedicled ITAs. The early patency rate determined by postoperative angiography of the grafts was 99.7% for left ITAs and 100% for right ITAs. No patient required postoperative intervention or repeated surgery. Conclusions. Ultrasonic complete skeletonization increases the effective length of ITA bypasses, improves free flow through the bypasses, and it is less invasive than conventional pedicled harvesting. These excellent early results indicate that this technique is a straightforward, safe, less invasive, and optimal method for obtaining ITA bypass grafts.

We report herein the case of a patient with chronic renal failure in whom mitral valve stenosis with extensive mitral anular calcification involving the entire anulus and leaflets was successfully treated surgically. Excision of both leaflets and partial resection of the anular calcification enabled the insertion of a 23-mm St. Jude Medical prosthetic valve. The technical difficulties involved with inserting the appropriate-sized prosthetic valve in a narrowed mitral anulus with heavy calcification are discussed following this case report.

From 1984 to 1996, four patients with transvenous intracardiac tumor extension underwent operations in the Kobe University Hospital. The primary tumors of two were intravenous leiomyomatoses originating from the uterus; a third patient had invasive thymoma, and the fourth patient had clear cell sarcoma of the kidney. In 1985, one patient had a curative, staged resection. One-stage operations were carried out in three patients, and all intracardiac tumors were successfully resected en bloc with the primary tumors under conditions of electrical ventricular fibrillation and mild hypothermia. Combined venous reconstructions were necessary for en bloc resection in three cases. Two patients with malignancy received postoperative chemoradiotherapy, and all four patients were discharged uneventfully from our hospital. We consider radical resection with curative intent only for patients with tumors extending into the heart. In these cases, a one-stage operation is preferable, and electrical ventricular fibrillation with mild hypothermia is a recommended method of circulatory assist because of its simplicity. (J Vasc Surg 1998;27:740-4.)

A simple and inexpensive new graft-holding method is described. This method requires only a cotton bandage to hold the skeletonized graft in off-pump coronary artery bypass. A wet cotton bandage hung between the blades of a retractor can hold grafts in an atraumatic fashion at the center of the operating field and facilitate anastomosis during off-pump coronary artery bypass.

A new method to skeletonize and harvest the internal thoracic artery using an ultrasonic scalpel is presented. The technique is simple, safe, and minimally invasive. It is possible to obtain sufficient vessel length for anastomosis to most coronary arteries for bypass grafting.

During last five years, four patients out of fifty-five patients who were operated on abdominal aotic aneurysms developed acute renal failure and had been undertaken hemodialysis.The nature of acute renal failure were nonoligulic in three, and oligulic in one. In all patients, disturbance of consciousness were found before hemodialysis. Respiratory failure or hemorrhagic tendency were also found in two patients, respectively.Hemodialysis were performed in generalized heparinization in two, local heparinization in one and use of gabexate mesilate in one.Three patients could be come off from hemodialysis and the other developed into chronic renal failure with permanent hemodialysis.Though there are still some technical difficulty for usage of hemodialysis in early postoperative period, hemodialysis could be performed with great and precise care in patients following abdominal aortic aneurysm surgery.

Five octogenarians who survived resection of abdominal aortic aneurysms are reported. All of these patients were men and their ages ranged from 80 to 85 years (mean 82). Four patients had elective operations for nonruptured abdominal aortic aneurysms and the other patient had an emergency operation for a ruptured abdominal arotic aneurysm. There were no early deaths. Severe diarrhea was the sole major postoperative complication. All patients are doing well 6 months to one and one-half years postoperatively. It is concluded that operations for large aneurysms or for symptomatic aneurysms in octogenarians should be performed unless the patients have a complicaing serious disease.

During the past eight years, 46 of the 106 patients who underwent mitral valve replacement were associated with tricuspid insufficiency. No surgical correction was performed (14 cases) in cases of slight tricuspid insufficiency. Tricuspid annuloplasty (11 cases) or valve replacement (21 cases) was employed according to the severity of insufficiency. In the non-repair group, the mortality rate was fairly low (21 per cent), but the postoperative status was the least satisfactory by the NYHA classification. Tricuspid insufficiency was significantly reduced only in two of these 14 cases after the mitral valve replacement. In the tricuspid annuloplasty group, although the technique of tricuspid annuloplasty did not always correct insufficiency completely, only one patient died of residual insufficiency. The cardiac output measured with Minnesota Impedance Cardiograph increased postoperatively in proportion to stress in this group. In the tricuspid valve replacement group, cardiac catheterization studies revealed hemodynamic improvement at rest in all, but cardiac output during exercise remained unchanged or decreased in some cases. Now we consider that tricuspid insufficiency with advanced mitral valve disease, even of a slight degree, should be surgically treated and that annuloplasty has more obvious hemodynamic benefits than valve replacement.