From 1982 to March 1999, 276 St. Jude Medical prostheses were implanted in aortic position. Of the 276 patients, 6 (2.2%) required redo aortic valve replacement due to aortic stenosis. The peak velocity measured by continuous-wave Doppler echocardiography ranged from 3.5 to 5.4m/sec with mean of 4.55m/sec. Aortic stenosis was attributable to pannus formation in 3 patients, valve thrombosis in 1 patient, and prosthesis-patient mismatch in 2 patients. The prostheses of patients with pannus formation were implanted in valve orientation parallel to the septum. It is therefore considered that the St. Jude Medical prosthesis should be implanted perpendicular to the septum in the aortic position and that careful follow-up observation of the patients should be made, particularly with echocardiography.

Ischemic colitis is a serious complication of abdominal aortic surgery. Patients with bilateral internal iliac aneurysm have a high risk of ischemic colitis after operation. A 72-year-old man had infrarenal abdominal aneurysm, bilateral common and internal iliac aneurysm and an occluded right internal iliac artery. We examined the flow of the superior rectal artery during operation by transanal Doppler, and intramucosal pH of the sigmoid colon by a tonometer after operation. The flow of the superior rectal artery did not change after clamping of the left common iliac artery, clamp of the infrarenal aorta. He underwent uneventful abdominal aortic aneurysmectomy, Y-grafting and exclusion of bilateral internal iliac aneurysms. The intramucosal pH of the sigmoid colon returned to the normal range 25h after surgery. He had no complications after surgery. Transanal Doppler examination was essential for the successful prevention of postoperative colonic ischemia, and intestinal intramural pH by tonometry was an early reliable marker of the absence of ischemic colitis.

From 1983 to 1999, 12 St. Jude Medical prostheses were implanted in the tricuspid position. Mean patient age at the time of operation was 40±19 (6 to 62) years. Seven patients were female and five were male. There were no hospital deaths but three late deaths. The cumulative survival rate was 100% at 5 years, 80% at 10 years and 60% at 15 years. Four patients required redo tricuspid valve replacement because of a thrombosed valve. The reoperation-free rate was 100% at 5 years, 78% at 10 years and 29% at 15 years. The data illustrated that patients who underwent tricuspid valve replacement with the St. Jude Medical valve should receive strict anticoagulation therapy.

Papillary fibroelastoma is a relatively rare cardiac tumor. A report is presented on a 64-year-old man who was admitted to our institute with dyspnea. Distal arch aneurysm was detected by chest computed tomography and aortography. Preoperative transesophageal echocardiography revealed a tumor 9×5mm in size in the ventricular septum of the left ventricular outflow tract. Total arch replacement and tumor resection were performed. The pathohistological diagnosis of the tumor was papillary fibroelastoma. The postoperative course was uneventful and echocardiography conducted one year postoperatively revealed no recurrence.

Primary cardiac angiosarcoma is very rare and its prognosis was reported to be very poor (average survival period 7 months). A 46-year-old woman with angiosarcoma was admitted for recurrent symptoms of cardiac tamponade. Surgical excision of the tumor was performed 5 months after initial presentation and irradiation therapy was added. Thereafter, immunotherapy, and transcatheter arterial embolization were performed for liver metastasis. Despite this multidisciplinary therapy, she passed away 355 days after surgery. In our report, we described our multidisciplinary approach to this highly malignant tumor and the treatment strategy was discussed.

During a period of 5 years from January 1991 to December 1995, one-stage operation was performed on 10 cases with ischemic heart and occlusive peripheral vascular disease, excluding cases combined with AAA (abdominal aortic aneurysm). They were composed of 7 men and 3 women whose mean age at time of surgery was 65.8 years. The mean number of coronary artery bypass grafts made was 2.2. The procedures employed for occlusive peripheral vascular disease were TEA (thromboendarterectomy) of the internal carotid artery in 2 cases, aorta-subclavian bypass in 2 cases, aorta-bilateral common iliac artery bypass in 1 case, interposition of the common iliac artery in 1 case, aorta-external iliac artery bypass in 1 case, F-P (femolo-popliteal) bypass in 3 cases (4 bypasses), and F-T (femolo-tibial) bypass in 1 case. Mean operation time was 428 minutes, mean extracorporeal circulation time was 121 minutes, and mean aortic cross-clamp time was 61 minutes. Blood transfusion was not made in 4 cases. There was one operative death in a case of MNMS (myonephropatic metabolic syndrome) with emergency IABP (intraaortic balloon pumping) insertion following complication of PMI (perioperative myocardial infarction). A comparative study was made with 183 non-emergency cases of CABG (coronary artery bypass graft) conducted during the same period. Operation time was longer in cases of one-stage operation, but no significant difference was observed in operative mortality rate, rate of cases not requiring blood transfusion, days of intubation, and postoperative hospitalization duration. The surgical procedure was relatively safe.

Between January 1991 and December 1998, we performed two successful procedures to repair abdominal aortic aneurysm with primary aortoenteric fistula. We had 197 surgical repair proceduers of aortic aneurysm during the same period. Incidence of primary aortoenteric fistula in abdominal aortic aneurysm was 1% in our institute. We performed primary closure of the fistula and removal of the possibily infected aneurysmal wall followed by anatomical grafting. We utilized omental wrapping for prophylaxis of potential graft infection. We achieved excellent surgical results in both patients by this approach.

Right-sided infective endocarditis (IE) accounts for 5% to 10% of all IE. Compared with left-sided IE, antibiotic treatment is effective in about 70% of cases. The timing of surgical treatment for right-sided IE is therefor controversial. A 26-year-old woman had suffered from tricuspid valve endocarditis with DIC. There was no evidence of any previous cardiac event or dental treatment. Echocardiography showed a large vegetation attached to the anterior leaflet of tricuspid valve with moderate tricuspid regurgitation. We removed the vegetation with a part of the anterior leaflet and performed tricuspid valvuloplasty and annuloplasty. The patient had an uneventful postoperative course and received intravenous antibiotic treatment for a further 4 weeks.

A 27-year-old woman was given a diagnosis of infectious endocarditis with severe tricuspid regurgitation. Despite adequate antibiotics therapy, her general condition did not improve, and moreover multiple pulmonary abscesses were detected by computed tomography. Therefore surgery was indicated. Surgery consisted of removal of vegetation and tricuspid valve plasty with autologous pericardial patch augmentation of the anterior leaflet. Tricuspid valve plasty was carried out without prosthetic materials. Her postoperative course was uneventful with only mild tricuspid regurgitation. One year after surgery, neither recurrence of infection nor worsening of tricuspid regurgitation was noted. This method could be a useful technique for young patients with severe infection.

We described a patient with free wall rupture followed by papillary muscle rupture due to acute myocardial infarction. A 69-year-old man was transferred complaining of transient unconsciousness. His clinical history, electrocardiogram, and chest CT showed myocardial infarction with free wall rupture indicated that several days had passed since the onset. Coronary angiography showed occlusion of the right coronary artery and severe stenosis of the left anterior descending artery. Since cardiac rupture was at inferior wall and hemorrhage wasn't active, repair of the rupture using fibrin glue and fibrin sheet and coronary artery bypass grafting to the left anterior descending artery was performed without cardiopulmonary bypass. On the 10th postoperative day, his arterial oxygen saturation suddenly deteriorated. Transesophageal echocardiography revealed papillary muscle rupture and severe mitral regurgitation. Emergency mitral valve replacement was performed. After two emergency operations, he gradually recovered and were discharged to home. In three months after discharge, he was admitted again due to congestive heart failure with left ventricular aneurysm at inferior wall and recovered in response of conservative treatment. Surgical experience of double rupture is rare. Based on this case, it may be necessary to perform reperfusion therapy toward even this case of recent myocardial infarction, to prevent papillary muscle rupture. It also may be better to use a patch on free wall rupture to prevent cardiac aneurysm.