Minimally invasive cardiac surgery (MICS) has been developed to offer patients the benefits of open heart operations with limited skin incision, but this procedure tends to be more difficult than conventional methods. We tried to evaluate whether MICS would be reasonable as a standard operation for congenital heart defects. From August 1997 to March 2000, 42 patients with atrial septal defects (ASD) and 47 patients with ventricular septal defects (VSD) underwent total repair by the minimal skin incision and lower partial median sternotomy. Fifteen ASD patients and 6 VSD patients were enrolled by residents (resident group). Twenty-seven ASD patients and 41 VSD patients were treated by leading surgeons (staff group). We compared the clinical course of the patients between resident and staff groups. Operative time, bypass time and cardiac arrest time (VSD) of the staff group were clearly shorter than those of the resident group (p<0.05). Other clinical course parameters of the two groups showed no significant difference. The results of this study indicate that MICS for ASD and VSD is reasonable as a standard operation because there was no significant difference of postoperative clinical course except the time required for the operation.

A 31-day-old infant with total anomalous pulmonary venous drainage (type I-A) suffered from severs left-sided heart failure unable to be weaned from cardiopulmonary bypass (CPB) after total repair. By reopening the vertical vein, the CPB was successfully terminated and the sternum was closed primarily. Percutaneous delayed closure of the vertical vein by lifting up the string which had been encircled the vertical vein at the time of repair was performed 3 days after repair. Systemic arterial pressure and left atrial pressure were unchanged after closure of the vertical vein. Postoperative cardiac study revealed satisfactory result and no left-to-right shunt through the vertical vein.

We evaluated 13 patients (4 men & 9 women, mean age: 61 years-old) who required steroid treatment for more than 1 month before open heart surgery. The subjects included 3 patients with collagen diseases, 3 with dermatopathy, 2 with bronchial asthma, one each with Takayasu's disease, autoimmune hemolytic anemia, paroxysmal nocturnal hemoglobinuria, brain tumor and post-renal transplantation. Surgical procedures were performed with an AC bypass in 9 cases, one each with AVR, MVR, reMVR and ASD patch closure. The steroid treatment before open heart surgery had been continued for a mean of 4 years and 11 months at a mean dose of 9.4mg/day equivalent of prednisolone. We evaluated the adrenocortical function on the rapid ACTH test and found hypoadrenalism in 5 of 8 cases (63%). In these cases we gave either 100mg of hydrocortisone or 1, 000mg of methylprednisolone before open heart surgery. The total perioperative dosage of steroid was a mean of 2, 488mg equivalent of prednisolone, including 4mg/kg of betamethasone during the extra corporeal circulation. Postoperatively we lost one case due to ventricular rupture after MVR. Other major complications were seen in one case each, cardiac tamponade, temporary clamp, wound infection and lumbar vertebral fracture. For steroid treated patients, it is important to select the patient who really need steroid by the rapid ACTH test, and to use the minimum dosage of steroids in open heart surgery.

A 65-year-old woman underwent abdominal aortic replacement using a woven Dacron tube graft for abdominal aortic aneurysm on April 2nd, 1996. She had pyrexia on the 6th postoperative day and abdominal enhanced CT scan showed periprosthetic bubble formations. She underwent relaparotomy 14 days after the initial procedure due to large retroperitoneal abcess bacterial culture of which revealed methicillin resistant staphylococcus aureus. She underwent debridement and local irrigation by an electrolyzed strong acid solution. Her pyrexia diminished immediately after relaparotomy and bacterial culture of the drain of the left retroperitoneal space became negative 82 days later. She was discharged and has had no active inflammatory signs for 3 years. She is doing well at present.

Several substitutes have been utilized for pericardial closure after open heart surgery. A 55-year-old man was admitted to our hospital with a diagnosis of constrictive pericarditis 13 years after open mitral commissurotomy. At reoperation, the thickened pericardium was peeled off and the epicardium was covered with 0.1mm expanded polytetrafluoroethylene surgical membrane (Gore-tex^®, sheet thickness 0.1mm). At the 7th postoperative day, he complained of fatigue and dyspnea. Physical examination revealed jugular venous distension, hepatomegaly, ascites and peripheral edema. Cardiac catheterization suggested the suspicion of pericardial or epicardial constriction. On the 3rd-operation, the Gore-tex^® sheet was removed and multiple longitudinal and transverse incisions were made in the thickened epicardium, that is the waffle procedure, while protecting the myocardium and the coronary arteries. Perioperative hemodynamics improved remarkably. His cardiac index increased from 3.0 to 4.5l/min/m². The postoperative course was uneventful.

The patient was a 61-year-old male, who underwent thoracoabdominal aortic aneurysm repair with Gelseal Triaxial prosthetic graft 2 years previously. False-aneurysm due to prosthetic graft dilatation was diagnosed. The direct closure of the ostium of the disruption of the anastomosis was successfully performed by an emergency operation. The postoperative course was uneventful. This case suggests that prosthetic graft dilatation may cause false-aneurysm at the site of end-to-side anastomosis.

A 65-year-old woman was admitted with a diagnosis of unstable angina after PTCA. She was diagnosed with acromegaly 8 years ago. She underwent an emergency coronary artery bypass grafting (LITA-LAD, SVG-HL-Cx). Serum growth hormone (GH) levels were 65.5ng/ml (normal limit<5ng/ml) before the operation. During a cardiopulmonary bypass GH levels elevated to 92.7ng/ml, but decreased to 15.9ng/ml after the operation. After 3 postoperative days GH levels increased gradually again and blood sugar levels became unstable. Finally it was necessary to increase the dose of bromocriptine. To our knowledge, there are only a few patients who have undergone coronary artery bypass grafting associated with acromegaly. This case suggests it is important to control GH levels at the operation and during the postoperative period.

A 71-year-old woman underwent mitral valve replacement with Carpentier-Edwards Pericardial Xenograft for mitral regurgitation on January 8, 1987. She had nocturnal hematuria and paroxysmal nocturnal hemoglobinuria was diagnosed in November, 1992. She had congestive heart failure in February, 1993. Cineradiographical analysis revealed a fracture of the wireform in three locations of the Xenograft and the stent was distorted inward. A second mitral valve replacement was successfully performed on March 16, 1993. She was discharged 45 days after operation after an uneventful course.

Between March 1976 and February 1996, 17 patients underwent surgical treatment for cardiac myxomas. There were 5 men and 12 women with a mean age of 55 years (range: 22 to 78 years). The location was the left atrium in 13, right atrium in 2, right ventricle in 1 and multiple locations in 1. Since 1978 the standard operative method to treat left atrial myxoma has been a biatrial approach with complete removal of cardiac myxoma and partial resection of the atrial septum. There were no perioperative deaths, but 1 patient had a permanent pace-maker implantation, 2 had transient atrial fibrillation during the early postoperative period, and 1 had acute pulmonary edema after resection of a right ventricular myxoma. There were two late deaths, not related to cardiac event and one recurrence with multiple myxomas. Overall with long term follow-up, the actual survival rate at 10 years was 75% (n=6), with a mean follow-up of 7.1 years, with a 100% follow-up ratio (17 patients). We conclude that the biatrial approach with complete removal of the left atrial myxomas and partial resection of the atrial septum is one of the best procedures for surgical treatment.