When we surgically treat cases for dissecting aortic aneurysm with an inheritable connective tissue disorder like Marfan's syndrome, we should choose the surgical procedure carefully, paying paticular attention to whether to extend the operation, because there is every possibility that the lesion might be progressive. A 41-year-old woman with Marfan's syndrome, type A chronic aortic dissection, rapidly dilating to 80mm in diameter, and with aortic valve regurgitation was operated on with a total aortic arch replacement and the modified Bentall procedure. In the procedure, the aortic root and valve were replaced with a composite graft with a prosthetic mechanical valve, and the coronary arteries were reconstructed by direct anastmosis. In this case, the infrarenal abdominal aorta had already dilated to 40mm in diameter. In many cases with Marfan's syndrome, it was reported that the lesion was progressive and the residual dissection or new aneurysm would usually dilate and eventually rupture postoperatively. Reoperation involve a high risk. With those factors in mind, we chose total aortic replacement, including the distal aortic arch, to where the dissection would not extend. The most important thing for patients with Marfan's syndrome is the development of new or reccurrent problems. We consider that the operation designed to dissect aortic aneurysm for those patients should be performed as extensively in the surgical field as possible.

Long-term follow up (10.0yrs on average) is described of 33 patients with coronary aretry fistulae (CAF) without other cardiac disorders. Of 33 patients, nine cases demonstrated some electrocardiographic ischemic changes (group I), and other twenty-four cases showed no significant electrocardiographic changes (group II) clinically. Symptomatic, hemodynamic and angiographic findings showed no significant difference statistically between both groups. Thirty patients of small to moderate left-to-right shunt ratio (<50∼60%) showed hemodynamic and angiographic stability during the 10.0 years retrograde follow-up period on average. Of 33 patients, seventeen cases have underwent surgical closure of CAF since 1973 to 1990. Seven of the seventeen patients had showed significant myocardial ischemic changes before surgical treatments, and five of the seven cases showed definitive improvement of the electrocardiographic changes seemed to be derived from occlusion of the coronary steal blood flow after surgical operations. There were no operative deaths and no appearance of new myocardial ischemia following the surgical repairs. At present since not only it is unclear whether the CAF predisposes correlate coronary arteries to some premature atherosclerosises but also there are several reports of severe late risks of surgical repair of CAF, surgical indication in the patients of CAF with small-to-moderate left-to-right shunt shou ld be limited to the cases with such as definitive myocardial ischemia or evidence of infective endocarditis.

Ionescu-Shiley pericardial xenografts implanted in the mitral position between April 1980 and October 1984 were studied. In some cases the cusp was torn in a relatively early postoperative phase, thus requiring an emergency operation. Functional disorders, such as caused by the calcification of the cusp, advance at a relatively moderate pace, and the prognosis of a second operation in cases with valve dysfunction and a chronic course was favorable. The actuarial probability of freedom from reoperation was 88.5±8.7% at 5 years and 55.7±14.5% at 10 years. The structural deterioration of the pericardial valve increased about 5 years after replacement. This tendency was the same as in other bioprostheses. At 10 years the overall actuarial survival rate was 67.2±12.1%. Freedom at 10 years from thromboembolism was 84.6±9.8%. For cases whose the course is under observation at present, the strategy is to recommend an additional operation as far as possible, while continuously observing the function of the valve.

A 19-year-old woman with thoracic aortic aneurysm complicating coarctation of the aorta was treated successfully. Aortography and 3D-CT showed the thoracic aortic aneurysm resembling a cluster of grapes. Coarctation of the aorta was seen between the aortic aneurysm and the descending aorta, and there was a 40mmHg pressure gradient between the ascending aorta and the descending aorta. At operation, the wall of the cluster-shaped saccular aortic aneurysm was very thin. We could see the blood flow through the wall, and we thought this patient was at high risk of ruptured aneurysm. The aneurysm was excised and replaced by a Hemashield tube graft, 16mm in diameter. The left subclavian artery was also constructed using a Hemashield tube graft, 8mm in diameter. Ruptured aneurysm in a patient with aortic aneurysm complicated by coarctation of the aorta has a high risk of death, so surgical intervention should be performed as soon as possible.

Fourteen patients (mean age 17.2 years, range 2 to 39 years) undergoing right ventricular outflow tract reconstruction for a Ross operation were studied between 1998 and 2000. Ten of 14 patients underwent Ross procedures and 4 received Ross-Konno procedures. Echocardiographic examination of the pulmonary homograf t was performed after surgery. The mean follow-up period was 23.1 months, ranging from 14 to 33 months. Mean peak velocity and peak gradient were 1.6±0.4m/s and 11.9±5.2mmHg, respectively. Three patients in whom echocardiography revealed a peak pulmonary gradient of 20mmHg or more were retrospectively analyzed with each catheterization data. All patients had no more than 10mmHg at the distal end of the homograft with no evidence of deformity or shrinkage. Only one patient had a trivial homograft valve regurgitation, however, no patient had more than mild pulmonary regurgitation. Patient age, donor age, and preservation period did not reveal any significant risk factor for homograft stenosis. Pulmonary homograft appears to be an excellent substitute for right ventricular outflow tract reconstruction during the mid-term postoperative period.

When homo- or isograft was used as a right ventricle-pulmonary artery bypass in the Rastellitype procedure for congenital heart disease, reoperation was mandatory due to calcification and conduit stenosis after several years. However, the survival period of intimal cells or smooth muscle cells has not been clarified, nor has the question of whether the calcification is due to an immunoreaction or not. Thus, to observe the geometrical or pathological changes of the grafts, an experimental model of homograft transplantation was established using rats' aorta, where cyclosporine A (CsA) was given after the transplantation. The rats used were 8 or 9 weeks old. Male King rats were the donors, and female Lewis rats were the recipients. The descending thoracic aorta was transplanted to the infra-renal abdominal aorta. There were 2 experimental groups; one in which CsA was not given (n=35), and the other in which CsA was given (n=44). The animals were sacrificed at 1, 2, 4, 6, 8, and 12 weeks after the transplantation, and were examined by an optical microscope after slicing longitudinally. The area of the cross-section, intima and the media of the vessel were calculated by 2 ways; manually, and by computer. These data were used to calculate and analyze the percentage of intima-media area, the ratio of the intima/media area, and the percentage of intima area and media area. The effect of suppression of the percentage of intima-media area and the percentage of the intima area were revealed to be significant at an acute stage after brief high dose CsA administration. From this result, we suggest that there is a possibility of a rejective reaction participating in the intimal hyperplasia in the acute phase after homograft transplantation.

With multiple-choice questions presenting one, two, or three of five choices (types A, K or X), the expected probability of a correct answer (P) can be obtained with a five-dimensional equation for the knowledge level (q), which is the probability of discriminating correct and incorrect items. From equations for each question type, we inversely estimated the q value (the estimated knowledge level), replacing P with the raw score rate in the actual examinations for promotion. The distribution and mean value of the raw score rate of type X differed from those for types A and K. However, distributions of estimated q values for the three question types were similar. This method can be used to estimate the actual knowledge level of students without the question type affecting the raw score but cannot be used to estimate incorrect knowledge.

In Japan, doctors inexperienced stent-graft new devices are required to secure agreement on criteria and choice of the device size in endovascular aneurysm repair (EVAR) from experienced doctors. It was hoped that strict patient selection might reduce the learning curve for initial successes in given procedures. In a leading center in Japan, a number of cases which were scheduled for operation at other institutes were evaluated anatomically. We surveyed the initial success of Zenith AAA system implantation in the remaining cases by inexperienced doctors and evaluated the results. This study aimed to verify the validity of strict patient selection in improving the success rate of inexperienced doctors. We enrolled 112 consecutive patients from 19 institutes, who were scheduled for repair between January and October in 2007. All patients were evaluated on the basis of a less-than-3mm reconstructed CT image. Mean patient age was 76±5.7 years. All cases satisfied the Zenith's anatomic prerequisites. Fifteen cases were excluded for various reasons, the major reason being insufficiency of the proximal landing zone (LZ) length, angle and contour. The second reason was difficulty to approach via the iliac artery. Ninety seven cases were included, of which 17 cases were low-risk candidates for EVAR. Medium-risk seventy two cases requiring some advice to avoid problems with device size, technique of implantation and choice of main-body side. Eight cases were high-risk, requiring the presence of an experienced surgeon. Excluded cases had significantly shorter proximal LZ, larger aortic diameters 15mm below the renal artery and tortuous access routes on preliminary measurement by inexperienced doctor. Perioperative mortality was 0%, while the major complications were injury to the iliac artery in one high-risk case and thromboembolism of the superficial femoral artery in another. Perioperative proximal type I endoleak occurred in 5 cases. In 3 of these cases, the endoleak was eliminated by implantation of a Palmatz stent. In the other 2 cases, it disappeared within a month without additional procedures. These cases had a significantly greater angle between the proximal LZ and the suprarenal aorta and significant amount of mural thromboses in the proximal LZ. Perioperative type III endoleak occurred in 3 cases. In all cases the endoleak was eliminated by additional procedure. Perioperative type II endoleak occurred 8 cases. In 3 of these cases, the endoleak disappeared within a month. In the 5 other cases, the endoleak did not disappear. Mid-term results showed iliac leg thromboembolism in one case and new type II endoleaks in 3 cases. Type II endoleak occurred in cases which had significantly greater angles between the proximal LZ and the aneurysm. The results which were evaluated in our center had excellent perioperative and mid-term outcomes. We think this evaluation system is effective for risk assessment and reduces the learning curve in EVAR. In anatomically marginal cases, it is possible for proximal type I endoleak and injury of the iliac artery to occur. It is impossible to exclude these marginal cases if treatment need for EVAR is a priority. In these cases, lessexperienced operators should be trained in troubleshooting techniques in advance.

Renal damage caused by hemolysis during cardiopulmonary bypass (CPB) was investigated, and the preventive effects of haptoglobin in regard to this condition was also evaluated. Nineteen patients who underwent open heart surgery were divided into two groups: a control group (n=11) and a haptoglobin group (n=8). In the control group, the level of plasma-free hemoglobin increased significantly after CPB (p<0.01), and this level was strongly correlated with renal tubular leaking enzymes: NAG (r=0.76) and γ-GTP (r=0.81), in the Intensive Care Unit or on the first day after surgery. On the contrary, in the haptoglobin group, in which 4, 000 units of haptoglobin was added in the priming solution of CPB, no increased level of plasma free hemoglobin was observed. Furthermore, leak age of renal tubular enzymes were statistically less (p<0.05). It was concluded that free hemoglobin was a cause of renal damage during CPB and the damage was preventable by the administration of haptoglobin.

Cor triatriatum is an uncommon congenital malformation in which the fibromuscular abnormal septum divides the atrium into two compartments. Generally it is used to mean cor triatriatum sinister in which the left atrium is divided into two lumens. In typical cor triatriatum, an abnormal fibromuscular septum divides a proximal chamber that receives the pulmonary vein from a distal chamber that communicates with the left atrial appendage and the mitral valve. Several hypothesis were proposed concerning the mechanism of the abnormal septation of the atrium, but no single hypothesis could explain all the cases convincingly. We report the successful surgical treatment of a 6-month-old male patient with the rare variant of the cor triatriatum with pulmonary hypertension. The left pulmonary vein and superior right pulmonary vein drained into an accessory chamber which opened to the right atrium through a sinus venousus type atrial septum defect. The left inferior pulmonary vein drained into the true lumen which opened to right atrium through the patent foramen ovale.