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.

Coronary artery bypass grafting (CABG) was performed in 16 patients with impaired left ventricular function due to ischemic heart disease (IHD) and the surgical procedures and cardiac functions before and after operation were studied. Preoperative angiogram showed three vessel disease in all patients. The ejection fraction was less than 40% in all and the mean cardiac index (CI) was 1.97l/min/m². At operation arterial graft was used in 10 patients (Group-AG) and no arterial graft but saphenous vein graft was used in 6 patients (Group-SVG). The average total cardiopulmonary bypass time, aortic cross clamping time and the number of revascularized vessels in both groups showed no significant differences. However, intraaortic balloon pumping was necessitated in one of Group-SVG and the requirement of postoperative catecholamine was in higher ratio in Group-SVG than in Group-AG. Postoperative CI improved to 3.1±0.4l/min/m² and 3.3±0.3 l/min/m² in Group-AG and Group-SVG, respectively. The postoperative New York Heart Association Functional Class improved to Class I or II in all patients and there were no significant differences of the improvement between the groups. Conclusively, it seems that the arterial grafts can be used safely and extensively in CABG for impaired left ventricular function due to IHD.

Between May in 1988 and October in 1990, simultaneous coronary artery bypass grafting (CABG) and valve surgery was performed in 14 patients. Nine patients received arterial graft conduit for CABG (AG group) and only saphenous vein graft (SVG) was used in 5 patients (SVG group). In AG group, mean age was 63.3 years and the number of distal anastomosis was 2.2/patient. In valve operation, valve replacement was performed in 5 and valve plasty was in 4, and the mean aortic cross clamping time was 116min. As AG, internal thoracic artery (ITA) was used in 8 and right gastroepiploic artery (RGEA) was in 4. Among them concomitant use of ITA and RGEA was in 3, and the use of SVG was in 5. In two patients, the AG pedicle did not reach to either left anterior descending or obtuse marginal artery and the SVG was used as a graft conduit. Between AG group and SVG group, there were no significances in the age and aortic cross clamping time. However, postoperative use of cathecholamin was in three (33%) in AG group and three (60%) in SVG group and there were significant differences between them. In AG group, there were no operative deaths and the late NYHA improved to class I in 4 and class II in 5. In simultaneous CABG with AG and valve surgery, the improvement of symptom was good and stable operative result was obtained, however, the length of the pedicled graft should be carefully considered for coronary anastomosis.

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).

The operative results in case of aortic coarctation (CoA) were studied. Between June 1980 and June 1995, 37 children with CoA underwent surgical intervention during their first year of life in our institute. The aortic lesion was repaired by the subclavian flap (SCF) method in 27, direct anastomosis (DA) method in 7, grafting or other methods in 3 children, respectively. The mean follow up period was 7.4±5.3 years (6 months-13 years). Rate of re-stenosis of the aorta was 10% (2 in 20 children) after SCF method, 0% (0 in 7 children) after DA method. The stenotic lesion was successfully dilated by the percutaneous balloon reconstruction in one child. Perioperative mortality was 25% (1/4) in one-stage repair, while one-stage repair was successfully performed in the last three cases and 16.6% (3/18) in two-stage repair for CoA associated with ventricular septal defect (VSD). The mortality was 60% (6/10) of CoA associated with other complex anomalies. In conclusion, one-stage repair seems to be recommendable for the operation of CoA with VSD, and two-stage repair seems to be safe for CoA with complex anomalies.

Postoperative cardiac function, changes of LV wall motion and exercise tolerance test were studied in 49 patients who received coronary artery bypass grafting (CABG) using antegrade intermittent warm blood cardioplegia (IWBC) and had postoperative left ventriculography (LVG). The mean aortic cross clamp (ACC) time was 68.2±22.8 minutes, and the coronary perfusion time during ACC was 12.6±6.9 minutes (18.2±7.1% of total ACC time). Spontaneous return of normal sinus rhythm was seen in 45 patients (92%). Perioperative myocardial infarction occurred in only one patient and one patient required inotropic support>5μg/kg/min after operation. The mean cardiac index measured by Swan-Ganz catheter improved postoperatively, and the postoperative LVG revealed improvement of the LV wall motion in comparison with that of preoperative LVG, and no local asynergy due to inadequate distribution of IWBC was seen in the early postoperative period. The mean postoperative exercise tolerance performed in 24 patients was 6.6 METS (metabolic equivalents), and no patient revealed myocardial ischemia at exercise. In conclusion, the IWBC is considered to be an easy and safe technique for distal anastomoses of CABG with no influence upon the postoperative cardiac function and LV wall motion.

Thirty six patients with post-infarction complications underwent operation, and the postoperative and late follow-up results were analyzed. There were post-infarction ventricular septal perforation (VSP) in 9 patients and left ventricular aneurysm formation in 27 patients. The operative indications were poor physical work capacity in 13, cardiogenic shock or severe congestive heart failure in 10, left ventricular thrombus in 7, severe ventricular arrhythmia in 6, and repeated angina in 6. Left ventricular aneurysmectomy was performed in 14 patients and VSP closure was in 8. Coronary arteries were simultaneously bypassed in 14 patients. Three patients were died of sudden postoperative arrhythmia 10 days, 55 days and four years after operation. All survivors except two patients with preoperative massive cerebral infarction or prolonged heart failure were in New York Heart Association Class I or II in their late postoperative periods. However, five patients in whom the significant coronary lesion had not been bypassed or the bypassed grafts had occluded complained of mild angina after operation. Postoperative arrhythmia was one of major factors in the late results and simultaneous coronary artery bypass grafting was important to improve the symptoms in the late postoperative periods.

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.