A 76-year-old man who had undergone primary coronary operation through a median sternotomy 9 years previously presented with recurrent angina. Preoperative angiography revealed 90% stenosis of the circumflex coronary artery and left subclavian artery. Two saphenous vein grafts (SVG) placed in the previous operation were patent. Redo off-pump CABG was performed through a left thoracotomy approach. The proximal end of the new SVG was connected to the descending thoracic aorta using the St. Jude Medical aortic connector system. The distal anastomosis to the obtuse marginal branch was performed on a beating heart. The postoperative course was uneventful. This case suggested that, in cases requiring the proximal graft anastomosis on the descending aorta, the application of the aortic connector system can be a useful strategy, helping to facilitate the proximal anastomosis and avoid complications associated with the aortic partial-clamping on the descending aorta.

Thirty two years-old man with arthralgia in both hands was given with non-steroid anti-inflammatory drug and followed. The symptoms persisted, and hematuria and signs of infection were getting apparent. The patient was referred to our hospital with increasing dyspnea. The patient presented acute heart failure, acute renal insufficiency and respiratory failure. Echocardiography revealed vegetation and regurgitation in the aortic and mitral valve. Blood culture demonstrated α-Streptococcus. CT revealed enlargement of the aortic root. The patient was diagnosed with infectious endocarditis, and referred for surgery. At surgery, the aortic valve and mitral valve were severely destroyed. Aortic root and mitral valve replacement were performed. Pathological findings demonstrated valve destruction as a result of endocarditis due to active rheumatic fever. Clumps of bacteria were not noted around the valves. This is a rare adult case with valve destruction by acute rheumatic fever.

The purpose of this study is to clarify the effects and limitation of high-dose therapy with dopamine (DOP) and dobutamine (DOB) for the patients with severe low cardiac output syndrome (LOS) after coronary artery bypass grafting (CABG). Among the patients who underwent CABG in Sendai Tokusyukai Hospital between 1986 and 1991, two groups were selected: More than 20μg/kg/min of both DOP and DOB were administered within 48 hours after CABG in “high-dose group” patients (n=6); Less than 5μg/kg/min of DOP and DOB were administered in the same period in “low-dose group” patients (n=9). All patients in the high-dose group had episodes of acute myocardial infarction in the pre- or intra-operative period. The operative mortality rate of this group was 34% (2/6). Significant stenoses of the left main trunk were observed preoperatively in both dead cases. The postoperative changes of cardiac index, heart rate, serum CPK-MB, dose of lidocaine given, urine output, total peripheral resistance and incidence of cardiac arrhythmia within 48 hours after CABG were compared between the two groups. There were no significant differences in all parameters except cardiac index, heart rate and total dose of lidocaine. However the maximal value of the mean heart rate in high-dose group was less than 120beats/min and lidocaine was effective in all patients with premature ventricular contraction. We conclude that high-dose therapy with DOP and DOB is useful for the selected patients with severe LOS after CABG when side effects caused by these drugs are carefully managed.

A 38-year-old man underwent surgery for impending rupture of an inflammatory celiac artery aneurysm with a maximum diameter of about 50 mm. First, an extra-anatomical bypass was performed from the iliac arteries to the celiac artery, superior mesenteric artery and bilateral renal artery using ringed ePTFE grafts. Second, the celiac artery aneurysm at the distal site was directly closed and then a stent graft was placed in the abdominal aorta to cover the orifice of the celiac artery. An endovascular stent graft treatment combined with extra-anatomical bypass is useful for the treatment of inflammatory aneurysm to avoid the various surgical complications in Behçet syndrome.

A 46-year-old man was given a diagnosis of hypertension about 20 years previously. At age 41, aortitis syndrome was diagnosed, with descending thoracic aortic aneurysm and the coarctation of abdominal aorta by CT scan. He then underwent surgery to replace the descending thoracic aortic aneurysm and right axillo-bifemoral bypass. Recently, a thoraco-abdominal aortic aneurysm was pointed out at the distal site of the graft and, he was referred to our institute. We occluded the distal end of the aneurysm using an endoluminal occlusion stent graft. Today, in most cases of aortopathy associated with aortitis syndrome, surgical replacement of the aneurysms and extra-anatomical bypass is performed. An endovascular stent graft treatment combined with extra-anatomical bypass could be useful for various aortic disorders.

We report two cases of coronary artery fistulas (CAF) in children with successful surgical repair. The first case was a 14-year-old boy with a continuous heart murmur. A fistula was diagnosed between the right coronary artery (RCA) and the right atrium by echocardiography. He was asymptomatic, but the pulmonary to systemic flow ratio was shown to be high by cardiac catheterization. He underwent surgical closure of the fistula and coronary artery bypass grafting to the RCA with the right interthoracic artery. The second case was a 5-year-old boy with a continuous heart murmur and cardiomegaly on the chest X-ray film. The CAF from the left coronary artery to the right atrium was revealed by echocardiography. The pulmonary to systemic flow ratio was shown to be high by cardiac catheterization. He was asymptomatic, but he also underwent surgical closure of CAF. Surgical repair was effective and safe in these cases. Echocardiography was very useful in the diagonosis of CAF. Surgical repair in the young is recommended because CAF is much more likely to cause congestive heart failure, angina, and infective endocarditis when growing.

Videofluoroscopic examination of swallowing (VF) is widely used for evaluating swallowing function. However, pulmonary complications after VF are seldom evaluated. We checked residual barium sulfate on chest X-rays and early pulmonary complication after VF. One hundred and ninety-eight patients underwent VF and chest X-rays. Eighty-six patients who did not aspirate during VF had no residual barium on their chest X-rays. One hundred and twelve patients aspirated during VF, but only 40 of these patients showed residual barium on their chest X-rays. Ten patients had fever after VF, but no significant relationship was observed between fever and residual barium on chest X-rays or aspiration. Aspiration was not correlated with mobility or cognitive status. One case had pneumonia after VF, but VF did not seem to be the cause of the pneumonia. In conclusion, no severe early pulmonary complications after VF were observed. It is difficult to predict early pulmonary complications from chest X-rays.

We report a case of minimally invasive cardiac surgery treated by small right intercostal thoracotomy for left atrial myxoma after substernal reconstruction of the esophagus using gastric interposition. This technique could not only alleviated risk at the second median sternotomy, but was also minimally invasive. A 63-year old man was admitted to our hospital for complaints of right upper limb asthenia and slight fever. Computed tomography showed cerebral infarction. Moreover, cardiac ultrasonography showed a giant myxoma in the left atrium. We thought that it was impossible to reperform median sternotomy, because there was high risk of injury to the reconstructed esophagus using a gastric duct behind the sternum. The patient underwent excision of the myxoma by the right intercostal thoracotomy approach, and did well. He was discharged from the hospital without any complications.

During past 7 years, 43 patients less than 2 years of age underwent closure of the ventricular septal defect. Durations of postoperative use of a respirator were 3 days or less in 30 patients (short-period group) and over 3 days in remaining 13 patients (long-period group). There was no operative death. Pre-, intra- and postoperative factors affecting prolonged respiratory care were analyzed between two groups. Results were as follows: There were statistically significant differences between short- and long-period groups on age (9.7 versus 6.5 months), body weight (6.3 versus 5.2kg) at surgery, necessity of preoperative respiratory care on respirator (0/30 versus 4/13), duration of cardiopulmonary bypass (108 versus 132min.), aortic clamp time (56 versus 70min.) and respiratory index at the first postoperative day (1.1 versus 1.7). These results revealed the necessity of far earlier surgical intervention in symptomatic patients before respiratory distress develops. Furthermore, shorter cardiopulmonary bypass and aortic clamp times should always be in mind for attaining smooth postoperative course.