A total of 35 patients who underwent mitral valve replacement were followed up for more than 5 years. Their hemodynamics and valve function were analyzed using transthoracic and esophageal Doppler ultrasound echocardiography and cineangiography. They were classified and evaluated according to valve function. The tilting disk valve replacement group (group I) consisted of 24 cases, the bileaflet valve replacement group (group II) consisted of 11 cases. There were 4 mechanical valve dysfunction cases in group I. The function of group II tended to be superior to group I, even excluding those with valve dysfunction. However, the hemodynamic recovery of the latter was as good as that of group II. The left cardiac function parameters of LVEF, %FS and CI were comparable in both groups, but in valve dysfunction cases LVEDVI decreased because of prosthetic stenosis and there was some right ventricular overload with severe tricuspid regurgitation.

A 65-year-old patient underwent successful transluminally placed endoluminal prosthetic grafts (TPEGs) of a descending thoracic aortic aneurysm (dTAA). Two hours after TPEGs, the patient suddenly complained of chest, back pain and right leg pain. Angiography and computed tomography showed acute type B aortic dissection. Re-TPEGs was immediately performed, and the entry was successfully closed. This case suggests that TPEGs for the treatment of acute aortic dissection may be useful for selected patients.

A 51-year-old woman suffered from a sudden onset of anterior chest pain and was referred to our hospital on the suspicion of an anginal attack. The exercise ECG showed findings of an anterior lesion and ischemia. Coronary angiography also revealed left anterior descending branch fistula and circumflex branch fistula connecting to the main pulmonary artery trunk. Direct closure was performed for both intra-pulmonary openings under cardiopulmonary bypass. The postoperative course was uneventful and the patient did not show any precordial pain. Coronary angiography showed no coronary organic narrowing, but contrast medium remained in the fistulae although there was no left to right shunt. Ligation of the fistulae had to be performed simultaneously to confirm complete obstruction of the coronary-pulmonary arterial fistulae. The antiplatlet agent is administered to the patient to prevent occurring myocardial infarction caused by thrombus which might be formed in fistulae.

Preoperative hemodynamics in the lower limbs in 174 limbs of 103 patients were measured and investigated and the surgical results were evaluated. The subjects were divided into the C_4-6-group, which included 51 limbs with skin changes, and the C_{2, 3}-group, which consisted of 123 limbs without skin changes. Plethysmography showed that the maximum venous outflow was significantly higher, and the refilling time was shorter in the C_4-6-group compared to the C_{2, 3}-group. All C_4-6-group patients had reflux of the long saphenous vein, and the reflux velocity and volume was significantly greater than in the C_{2, 3}-group. Limbs with deep vein reflux accounted for 45% of the C_4-6-group. We performed angioscopic deep vein external valvuloplasty in 23 of those limbs. There was no case of reccurence of skin changes at a mean follow-up of 22 months. However chronic venous insufficiency often was associated with multisegmental reflux lesions and in such cases it might be necessary to perform multiple surgical procedures to eliminate the reflux.

We studied 90 consecutive cases undergoing open heart surgery with preoperative collection of autologous blood and ultrafiltration during extracorporeal circulation. Among the 58 out of 90 patients (64.4%), open heart surgeries were achieved without homologous blood. We evaluated 13 factors (age, height, weight, body surface area, cardiopulmonary bypass time, aortic cross clamping time, dilutional rate, Hct before predonation, lowest Hct during cardiopulmonary bypass, amount of predonated autologous blood, term of autologous blood predonation, amount of bleeding during surgery, amount of bleeding after surgery) in connection with open heart surgery without homologous blood. Among these factors, age, body surface area, cardiopulmonary bypass time, aortic cross clamping time, lowest Hct during cardiopulmonary bypass, amount of predonated autologous blood, amount of bleeding during surgery and amount of bleeding after surgery demonstrated differed significantly between the only autologous blood transfusion group and the homologous blood transfusion group. According to the evaluation by multivariate regression analysis of these factors, the amount of bleeding after surgery was the most contributor to open heart surgery without homologous blood, followed by amount of bleeding during surgery and body surface area. We concluded that open heart surgery without homologous blood may be achieved in more patients by understanding these factors. Autologous blood predonation by the “leapfrog” method, control of the dilution rate by ultrafiltration during extracorporeal circulation and fresh autologous blood transfusion after extracorporeal circulation were effective to achieve open heart surgery without homologous blood.

This paper describes a very rare case of both ventricular septal defect (VSD) and atrial septal defect (ASD) associated with pulmonary hypertension (PH) successfully repaired via a right thoracotomy in infant with right lung aplasia. A 4-month old infant was admitted to our hospital because of congenital heart disease and right lung abnormalities. Roentogenograms revealed complete opacity of the right hemithorax, with a shift of the mediastinum and the heart to the right. Computed tomography of the chest showed the absence of the right lung and a right bronchus remnant. Therefore, a dignosis of aplasia of the right lung was made at this point. Echocardiogram confirmed VSD and ASD, both of which were 5-mm in diameter, and associated with PH. At the age of 1 year and 7 months, cardiac catheterization was performed, showing pulmonary hypertension with a systolic pulmonary-to-systemic pressure ratio (P_p/P_s) of 0.66. Tolazoline hydrochloride decreased pulmonary vascular resistance (R_p) from 6.92 units·m² to 3.11 units·m². The operation, under cardiopulmonary bypass, was performed via a right thoracotomy approach, because of severe counterclockwise rotation of the heart. VSD and ASD were closed by primary suturing. This approach offered excellent exposure of the intracardiac anatomy in our case. An intraoperative pressure study showed normal pulmonary arterial pressure, the P_p/P_s decreased to 0.33. The postoperative course was uneventful.

Infra-renal abdominal aortic aneurysms were electively treated by bifurcated endovascular stent grafts (Power Web^TM system, Endologix Co., USA) at 5 Japanese centers. The stent grafting (SG) was applied for candidates nominated by the selection committee after informed consent was obtained according to the IRB in each center. The delivery success rate of 60 patients (53 males) was 96.7%. There were 2 patients with type I endoleaks, resulting in a technical success rate of 93.3%. The operation time of 193±55min and blood loss of 440±240g were significantly shorter and less, respectively in the SG group when compared with 303±88min and 1, 496±2, 025g in 97 patients (83 males) treated by conventional open surgery. Endoleaks were detected in 4 patients (type I: 3, type II: 1) by CT scan taken at the time of discharge or 1 month after SG procedure. Type I endoleak was observed in patients with short and severely angulated SG landing zones. Renal artery obstruction, and temporary buttock pain caused by internal iliac artery occlusion occurred, but there was no hospital death. In 56 patients excluding an SG-unrelated death and a dropout from surveillance, there was no secondary endoleak or marked adverse events at all except 1 SG limb occlusion during a 6-month follow up period. The aneurysm size shrank in 26 patients and remained unchanged in 30 patients. No aneurysm enlargement was observed. The Power Web^TM system is appropriate for minimally invasive surgery for abdominal aortic aneurysms. Long-term follow-up studies will follow.

A cervical aortic arch is a very rare congenital malformation of aortic arch. A case is reported of a 42-year-old woman with an extensive circular aneurysm of a left-sided cervical aortic arch. The arch aneurysm was successfully removed surgically and replaced with woven Dacron graft. Histologic examination of the aneurysm revealed atherosclerosis and intimal defect.

In a consecutive series of 160 surgically treated abdominal aortic aneurysm, four patients with acute aortic thrombotic occlusion of an abdominal aortic or iliac aneurysm were encountered. Three of four aneurysms were 7cm in diameter or smaller. Also, 3 of 4 patients had chronic occlusive disease of legs. Our mortality rate was 75%. The recommendation is made that all abdominal aortic aneurysms be resected if there is substantial associated distal occlusive disease.

A 44-year-old woman with over 20 years history of rheumatic heart disease developed progressive heart failure from aortic stenosis and mitral restenosis after open mitral commissurotomy. In December, 1986, she underwent aortic and mitral valve replacements with Medtronic Hall prosthesis (aortic: 21mm, mitral: 27mm). Following an eventful recovery, she was discharged from the hospital and continued on a regimen of Coumadin. In February, 1991, the patient developed chest and back pain, which necessitated her emergency admission to our clinic. During the coronary examination, the aortic prosthetic occluder was not moving, fixed in the opening position, lasting from one to several minutes. She underwent emergency operation for replacement of the defective valve. At operation, we noted the pannus formation into the valve orifice on the inflow side of aortic prosthesis. She made a satisfactory recovery and has enjoyed good health since that time.