An unusual case of a 71-year-old man with massive sinuses of Valsalva presenting with coronary insufficiency was reported. Primarily, he had undergone aortic valve replacement (AVR) with a diagnosis of severe aortic regurgitation (AR) and annulo-aortic ectasia (AAE). Four years after the primary operation, he came to our hospital as an emergency admission complaining of chest pain. Electrocardiography showed sinus rhythm with ST wave elevation in limb leads of II, III and aVF and a diagnosis of acute myocardial infarction was made. Coronary angiography revealed right coronary insufficiency and aortography showed massive sinuses of Valsalva (diameter 8.5cm) with minimal functional AR. At the second operation, the right coronary artery was severely stretched and attenuated over the surface of the right coronary sinus. The ostium was found to be free of atherosclerosis. A composite reconstruction of the aortic root with a new valved conduit and reimplantation of coronary arteries were performed. The postoperative course was uneventful. Aneurysmal change of the sinus of Valsalva is rare, and it is reported that the mean maximal diameter is 5.4cm in this type of AAE. In our case, the unusual dilation of the sinuses of Valsalva resulted in right coronary insufficiency. This case reminded us that aortic root replacement must be applied in patients with AAE as the initial treatment of choice.

Between January, 1975 and June, 1990, 67 patients underwent surgical treatment for infective endocarditis at our hospital. Of 67 patients, 27 patients showed active endocarditis at the time of operation. In these 27 patients, 20 had active endocarditis of the native valve (NVE), and the seven had active prosthetic valve endocarditis (PVE). The interval between onset of infective endocarditis and operation ranged from 7 to 252 days (mean, 36 days). In the operative results, 3 of 20 patients (15%) with NVE and 2 of 5 patients (40.0%) with PVE died before discharge from the hospital. According to analysis of preoperative hemodynamic state and bacteriological data, the determinant factors of operative mortality and morbidity were preoperative NYHA functional classification, the interval between onset of infection and operation, and annular destruction (annular abscess). Patient's age, preoperative renal function, positive blood culture, the site of infection, and positive culture or stain of the surgically excised valve did not play an important role to determine operative mortality and morbidity. It is our conclusion that all patients with infective endocarditis who develop progressive congestive heart failure and echocardigraphical extravalvular infection despite medical treatment, should have prompt valve replacement.

Cardiac cachexia is a terminal clinical stage of valvular heart disease, and there is high incidence of postoperative mortality and morbidity. Cardiac cachexia was considered to be present when patients with mitral lesions showed all of the following criteria; 1. mitral valve disease associated with relative tricuspid regurgitation, 2. lean body below 80% of %standard weight, 3. NYHA functional class IV, 4. marked hepatomegaly and congestive liver dysfunction (ICG retention rate over 30%.) Ten patients satisfying the criteria were divided into two groups according to the interval of postoperative respiratory care. Group 1 (n=5), patients necessitating mechanical ventilation for more than 5 days after operation, Group 2 (n=5), patients requiring ventilation up to 5 days after operation. Pre- and postoperative nutrition, respiratory and circulatory states were evaluated for these two groups. In pre- and postoperative periods, intravenous hyperalimentation was administed in two groups, during the postoperative period, two patients of group 1 required tube feeding. In the pre-operative period, three patients in group 1 needed respiratory care (1 intra-tracheal intubation and 2 oxygen mask inhalation). The results were as follows; 1. The duration of illness was longer in group 1 than in group 2. 2. In the postoperative period, there was no difference in the amount of catecholamine, postoperative course and prognosis between groups 1 and 2. Surgery for valvular disease is possible even in cases of cardiac cachexia, if sufficient management of nutritional state, respiration and circulation can be maintained.

We evaluated the indications and limitations of IABP support for weaning for pump and postoperative heart failure after artificial valve replacement. Driving IABP as cardiac support in cases of acute cardiac failure during and after operation, it is most effective for transient cardiac failure-associated coronary artery spasms during and post operation, but it is not effective and is indeed limited for patients who need long term extracorporeal circulation because of operative technical failure, insufficient cardioplegia and delayed right ventricular failure after operation. The latter groups, in which IABP is insufficiently effective need additional assist devices such as V-A bypass and ventricular assist device (VAD).

Cardiac papillary fibroelastomas are rare but are still the second most common benign cardiac tumor ; after myxoma. While cardiac papillary fibroelastomas are benign, there is the potential for severe complications related to embolism. Consequently, a surgical treatment approach is generally recommended. Nevertheless, from the risk of the recurrence of tumor and the valve insufficiency, the excision range is still controversial, particularly with tumors arising from the valve. We report the case of a 66-year-old woman who underwent resection of cardiac papillary fibroelastomas arising from three leaflets of the aortic valves. We performed simple excision without valve surgery and obtained an uneventful prognosis. At 18 months after surgery, no recurrence of tumors was recognized. We consider that it is possible to resect cardiac papillary fibroelastomas without performing valve repair or replacement if they are removed carefully even if the tumors arise from three leaflets of an aortic valve.

We studied possible factors to cause left ventricular rupture after mitral valve replacement and the prevention in eight patients of 1, 046 receiving mitral valve replacement between September, 1965 and August, 1991. The age at operation ranged from 43 to 67 years old (average 58 years old), and there were one man and seven women. According to the Treasure and Miller's classification, the type of rupture was type I in 5, type II in 2, and type III in 3. The onset time of rupture was immediately after cardiopulmonary bypass in 3 and at the time of chest closure in one. In four patients it occurred 11 hours, 14 hours, 18 hours and 25 hours after operation, respectively. In 8 patients, repair was performed with external closure under heart beating and in five patients with both internal and external closure during cardiac arrest under cardiopulmonary bypass. Two patients under cardiopulmonary bypass were successful for hemostasis, however, they died with low cardiac output syndrome, following to multiple organ failure 2 or 44 days after operation, respectively. The repair was not successful in 6 patients. In four patients the left ventricular rupture occurred immediately after hypertension and pathological findings showed severe myocardial degeneration of left ventricular muscle in all of them. These findings may suggest that hypertension after the operation is one of major factors to cause left ventricular rupture and thus the careful management of the systemic blood pressure after mitral valve replacement is effective to prevent the left ventricular rupture.

The surgical anatomical bypass (ANA) procedures for juxtarenal aortic occlusion (JAO) have been recently developed. However, there are some critical conditions, in which we should be cautious concerning the indications of ANA. Between 1984 and 1993 in Kurume University Hospital, 17 patients with JAO were operated upon. The most common cheifcomplaint was claudication (70.6%). Acute deterioration due to ischemia was recognized in two patients (11.8%). ANA was performed in 15 patients (88.2%) and extra-anatomical bypass (EXT) in 2 with severe calcification of the aorta (11.8%). Hospital deaths occured in three patients with ANA (17.6%), whose background included two acute deterioration and one cerebral infarction with hemiplegia. As an early postoperative complication, acute renal failure occurred in one patient and subileus in two. In the presence of poor general condition, acute deterioration, or severe aortic calcification, the EXT-procedure is the choice of surgical treatment for JAO.

Between 1961 and 1994, 121 patients our hospital were treated by conservative and surgical therapy for acute (67 patients) and chronic (54 patients) type B aortic dissection. Among the acute type B aortic dissections, two patients died before operation and 4 patients underwent surgical treatment in the acute phase. The false channel was occluded due to thrombosis in 30 patients. 9 in 31 patients with patent false channels required surgical therapy in the chronic phase. 46 of 54 patients with chronic type B aortic dissection underwent surgical treatment and 9 other patients were not operated on because of the false channel was not enlarged, nearly thrombosed type and refusal to operate. The long-term survival rate appeared to be better in cases acute closing aortic dissection than in cases of aortic dissection with patent false channels. Among the 54 patients who required surgical treatment in the chronic phase, there were eight early deaths (13.3%). Among chronic phase surgical cases, the long term survival rate appeared to be similar to that in type B aortic dissections treated by conservative therapy. Therefore, we consider that type B aortic dissections with acutely thrombotic false channels should be treated by medical therapy, while type B aortic dissection with patent false channel should be treated surgical treatment in the subacute phase or early chronic phase.

The results and surgical techniques were studied in 59 patients who had atherosclerotic lesions in the ascending aorta. Arterial grafting (AG) and sequential grafting for coronary artery bypass grafting (CABG) was used in as many as possible cases and the number of distal anastomoses with AG was 1.3/patient (internal thoracic artery (ITA), 56 anastomoses for 50 patients; gastroepiploic artery (GEA), 17; and inferior epigastric artery, 3). Calcification in the ascending aorta was noted in 26 patients and arterial cannulation was performed via the right axillary artery in 4 patients. Saphenous vein grafts were used for 51 patients and 30 of them required aortic reconstruction for proximal anastomosis. There were 2 hospital deaths (non-cardiac) and no neurological complications. It is difficult to perform CABG in the presence of atherosclerosis in the ascending aorta. However, the right axillary artery cannulation as the site of arterial cannulation and the use of sequential grafting, using ITA and GEA as the pedicled arterial conduits are useful to accomplish CABG in such patients. Neurological complication seems to be manufactured at a minimal level by cautious operative techniques.

A 59-year-old man was admitted for treatment of Stanford type B acute dissecting aneurysm with acute renal failure. He had begun hemodialysis one month after onset, because digital subtraction angiography (DSA) revealed that the truelumen was narrowed by a dilated false channel just above the renal artery. Initially axillo-femoral bypass was performed to treat renal failure, and the patients was easily weaned from hemodialysis. Eight months after the first operation, descending thoracic aorta replacement was performed. The patient is doing well one year after operation. In conclusion, axillo-femoral bypass yielded good results because our patient recovered from renal failure and could undergo radical operation safely. Axillo-femoral bypass allowed evaluation of the hemodynamic study before radical operation.