Objective : To investigate the efficacy of aortic valve replacement with annular enlargement for congenital aortic valve stenosis. Methods : Eleven patients underwent aortic valve replacement with annular enlargement for congenital aortic valve stenosis in our institute between January 2002 and July 2012. The clinical status of these patients, including preoperative and postoperative echocardiography, was evaluated in this study. Results : The median age of the patients was 15.5 years (range : 9-38 years). The patients had a mean body surface area of 1.48±0.3 m² (range : 1.00-1.92 m²). Mechanical prostheses were used in all patients and the techniques of aortic annular enlargement were the Nick procedure in 4 patients, Manouguian procedure in 3 (modified Manouguian in 2), Yamaguchi procedure in 2, and Konno procedure in 2. The average follow-up period was 32.1 months (range : 1-117 months). There was neither operative death nor late death. The peak/mean pressure gradient of aortic valve improved from 77.9±31.7/46.6±18.0 mmHg preoperatively to 27.9±7.7/14.8±4.7 mmHg postoperatively and to 28.3±11.1/14.1±7.0 mmHg at intermediate-term follow-up. The estimated left ventricular mass also improved from 206.8±93.4 g preoperatively to 179.7±61.1 g postoperatively and to 100.4±76.3 g at intermediate-term follow-up, respectively. Conclusions : Our series shows the efficacy and safety of aortic valve replacement with annular enlargement for congenital aortic valve stenosis.

We report a relatively rare case of syphilitic aortic aneurysm that was treated by reconstruction with interposition of a prosthesis. The patient was a 72-year-old woman who presented with an abnormal shadow on chest radiograph and an abdominal pulsatile tumor. Aortography revealed double aneurysms in the descending thoracic and infrarenal abdominal regions, combined with a left common iliac artery aneurysm. Microscopic examination revealed an inflammatory infiltrate within the adventitia and destruction of the elastic fibers in the media, classical features of syphilitic aortitis. The incidence of double aortic aneurysm is expected to increase in the future, and one of the many problems involved in the management of this disorder is the correct timing for safe surgery. We prefer simultaneous surgery to secondary surgery, since this rules out the possibility of rupture of the remaining aneurysm. In order to perform this operation safely, it is necessary to treat the patient's general condition with regard to the surgical procedure and possible adjevant therapy.

We studied the effects of granulocytic elastase (GEL) and fibronectin (FN) on the coagulation and fibrinolytic system when using cardiopulmonary bypass (CPB). Blood sampling was performed before CPB (Pre), just after CPB (Post) the 1st postoperative day (PD1) and the second postoperative day (PD2). Laboratory parameters were GEL, FN, fibrinogen (Fib), prothrombin time (PT), fibrin degradation products (FDP), D dimer (D-D), α2 plasmin inhibitor plasmin complex (PIC) and antithrombin III (AT III). The level of GEL was highest and that of FN was lowest at Post. The levels of Fib, PT and AT III were lowest and that of PIC was highest just after CPB. The levels of FDP and D-D were highest on PD1. The levels of GEL and D-D correlated just after CPB and on PD1 and PD2. The level of GEL correlated with that of PIC on PD1. These results demonstrated that the level of FN decreased with CPB. And it was expected that CPB time affected the level of GEL. The levels of GEL affects D-D and PIC which are fibrinolysic factors particularly related to secondary fibrinolysis.

Although insulin resistance in peripheral tissue has been demonstrated in patients with cardiac disease, expression of glucose transporter (GLUT) isoform mRNA in the cardiac muscle is not known. We analyzed GLUT isoform mRNA in the cardiac muscle of 10 patients by RT-PCR. GLUT 4 mRNA was semi-quantitated by kinetic analysis, altering the cycles of PCR, and insulin resistance was examined by euglycemic hyperinsulinemic glucose clamp with an artificial pancreas. In addition to GLUT 2, 3, and 4 mRNA, all of which were constantly demonstrated in the skeletal muscle of normal volunteers, GLUT 1 was documented in all the cardiac samples examined. The quantity of GLUT4 mRNA was not related to the degree of insulin resistance or M values. These results may suggest that glucose uptake in the cardiac muscle is maintained by 4 different glucose transporters and that the response of GLUT 4 mRNA to insulin resistance is different in the cardiac muscle and in the skeletal muscle.

Fourteen patients with 22 solitary aneurysms of the iliac artery were operated in a 16-year period (1983 to 1999). Patients were divided into two groups. The non-ruptured group consisted of 6 patients who underwent surgical intervention before aneurysm rupture, and their mean age was 78.5 years. The ruptured group consisted of 8 patients who underwent surgical intervention for aneurysm rupture, with a mean age of 68.5 years. Although seven patients underwent emergency surgery for aneurysm rupture, less than half of them were operated upon within 24hr after the onset of aneurysm rupture. The average size of aneurysms was similar in the two groups (common iliac artery aneurysms: non-ruptured 47mm vs. ruptured 44mm in diameter, internal iliac artery aneurysms: non-ruptured 55mm vs. ruptured 55mm). Two patients died in the ruptured group, in which the operative mortality rate was 25%. Six patients (75%) of the ruptured group had hypovolemic shock, and two of them died during surgical repair. Of the patients with shock, two patients had intestinal ischemia after operation. Intestinal ischemia was one of the serious complications of ruptured iliac aneurysms. These results suggest that in patients with shock from ruptured iliac artery aneurysms, strategy for treatment is an important determinant of the outcome.

A 61-year-old man admitted to another hospital because of cerebral infarction had fever (about 39°C). Computed tomographic scanning revealed a pseudoaneurysm of the brachiocephalic artery, accompanied by pericardial fluid. The patient was transferred to our hospital. Culture studies of a sample of pericardial fluid revealed Staphylococcus aureus. A mycotic pseudoaneu-rysm of the brachiocephalic artery was diagnosed. Antibiotics were given for about 2 weeks after transfer to our hospital. Surgery was performed after the inflammation subsided. The pseudoaneurysm was incised during circulatory arrest. A hole measuring 2cm in diameter was found at the origin of the brachiocephalic artery. The hole was sealed with an autologous arterial patch, made from a 3-cm section of the right axillary artery. The axillary artery was reconstructed by end-to-end anastomosis. After surgery, infection was controlled by means of systemic antibiotics and closed mediastinal lavage. The patient was discharged from the hospital in good condition 160 days after surgery. To date, there has been no flare-up of infection.

This report documents a case of three-channeled aortic dissection. The diagnosis of dissecting aneurysm was made by chest X-P and CT to 70-year-old man, with a chief complaint of back pain. Aortogram showed aortic aneurysm (DeBakey type IIIb), which had an entry at distal of the beginning of the left subclavian artery. Though we had given a pressure control therapy, the patient died on the 5th day of the admission. At autopsy, a new dissection was found in the chronic dissecting outer wall, forming three channeled dissection and rupture was there. Three-channeled dissection is very rare, only 8 cases including ours have been reported so far. From this case, we learned it very difficult to diagnose and treat it.

A Case of abdominal aortic occlusion caused by acute aortic dissection (DeBakey's type III b) is reported. A 59-year-old woman was admitted with sudden onset back pain and sensory disturbance of bilateral lower extremities. The pulsations of bilateral femoral arteries were absent. CT and aortogram revealed dissection of the thoracic descending aorta and infrarenal aortic occlusion. Since ischemic change had progressed, bilateral axillofemoral bypass was performed for limb salvage, and the symptoms improved rapidly. Axillofemoral bypass is an easy and safe procedure even in the acute phase of aortic dissection. It provides fast reperfusion, and so is considered to be useful to preventing myonephrotic metabolic syndrome MNMS.

A 49-year-old man who had no history of cardiac disease or intravenous drug abuse was referred to our hospital complaining of fever despite antibiotic chemotherapy. Blood culture was positive for Streptococcus agalactiae, and transesophageal echocardiography revealed vegetation attached to the tricuspid valve and moderate tricuspid regurgitation. Two-thirds of the anterior leaflet and a part of the posterior leaflet of the tricuspid valve were excised with the vegetation, and the remaining anterior leaflet was sutured to the posterior leaflet after annular plication. DeVega's annuloplasty was added to a diameter of two fingers. Following this procedure tricuspid regurgitation was minimal.

A 51-year-old man underwent arch replacement for a thoracic aortic succular aneurysm in December 1996. The pathological examination indicated aortitis to be the cause of the aneurysm. At that time we did not surgically treat the abdominal aortic aneurysm (AAA) which was only 32mm in diameter. Sixteen months after the first operation, he complained of a pulsatile tumor in his left leg. Angiography revealed an aneurysm of the left superficial femoral artery. The artery distal to the aneurysm was occluded, and the left popliteal artery received collateral blood flow from the deep femoral artery. The size of the AAA increased to 48mm, an indication of repair. Aneurysmectomy of the left superficial femoral artery and replacement of the abdominal aorta were performed simultaneously. The operative findings showed that the aneurysm of the left superficial femoral artery had been ruptured and formed a pseudoaneurysm. The pathological findings demonstrated both aneurysm aortitis. After the second operation, he was given steroid therapy to control the inflammatory reaction and he has been well for one year.