Blood transfusion is usually required to perform open cardiac surgical repair in small infants, but the use of blood might be rejected by parents on religious grounds. We operated on a 1.4 years old boy with ventricular septal defect (VSD) and severe (grade 3/4) mitral regurgitation (MR) due to elongated anterior chordae, whose mother was a “Jehovah's witness” sympathizer, initially rejecting any blood transfusion. In view of the deteriorating condition of the infant, and the inadequacy of the pulmonary artery banding alone as therapeutic modality, the mother was persuaded to ultimately consent to controlled cross-circulation between her and the child. The arterial blood was pumped with a roller pump from the mother's femoral artery to the infant's ascending aorta; caval venous return of the infant was drained by gravity into a reservoir and then pumped into the femoral vein of the mother by a second roller pump. A large membranous ventricular septal defect and the mitral regurgitation were repaired (patch closure of the VSD, and shortening of the elongated anterior papillary muscle chordae in conjunction with Kay's type mitral annuloplasty for the MR) during a cross-circulation time of 212min. 2.2 years after the operation, both, the infant and the mother, enjoy good health.

To evaluate the efficacy of the retroperitoneal approach (RP) when compared with the transperitoneal approach (TP) in elective aortoiliac reconstruction, 41 cases were reviewed. From February 1987 through October 1991, 16 patients underwent aortoiliac reconstruction through the TP approach and 25 patients underwent operation through the RP approach for abdominal aortic aneurysms (AAA). The TP approach was associated with larger intraoperative blood loss (648.6±416.5ml) when compared with the RP approach (357.7±208.9ml) (p<0.01). The TP approach was associated with greater intraoperative blood transfusion (2093.8±1179.0ml) when compared with the RP approach (1010.4±905.3ml) (p<0.01). Both groups had similar operative times. Postoperative initiation of oral water intake was prolonged in the TP group (50.2±27.4hr) when compared with the RP group (22.3±8.9hr) (p<0.01). Postoperative initiation of walking training was prolonged in the TP group (88.7±37.1hr) when compared with the RP group (60.1±23.2) (p<0.01). This experience demonstrates that the RP approach is a preferable alternative to the TP approach in elective aortoiliac reconstruction.

From May 1975 to August 1991, 90 patients (56 males and 34 females) underwent Bentall's operations or its modified technique. In our modified technique the coronary ostium is cut out like a button and anastomosed to the aortic graft and aortic grafts are not wrapped by the aortic wall. Preoperative diagnoses were AAE (25 patients, 28%), Stanford type A dissection (19, 21%), Marfan's syndrome (16, 18%), aortitis syndrome (12, 13%), AR+ascending aortic aneurysm (6, 7%), syphilitic aortitis (5, 6%), AS+ascending aortic aneurysm (3, 3%), Valsalva's sinus aneurysm (2, 2%) and other diseases (2, 2%). The hospital mortality rate was 17% (15/90) for all cases. The hospital mortality for aortic dissection (37% (7/19)) and reoperation cases (75% (3/4)) were very high. There were 10 cases of late death and the 10 year actuarial survival rate was 66.3%. Among 11 cardiovascular events which occured in the late phase, 5 were dissection at other aortic sites in the type A dissection and Marfan syndrome cases, and 3 were pseudoaneurysm formation at the site of coronary or the aortic anastomosis in the aortitis syndrome cases, and a detachment of the composite graft in the Marfan's syndrome cases. The 10-year event-free rate was 92.0% for non-specific AAE, 68.8% for aortitis syndrome, 61.9% for Marfan's syndrome and 47.3% for Stanford type A dissection. Non-specific AAE had excellent long-term results, but Marfan's syndrome and dissection had poor results. The button technique for coronary reconstruction is effective for all cases and its long term results are good, but, even with this technique, coronary pseudo-aneurysm occured in cases of aortitis syndrome.

The new St. Jude Medical aortic valve graft prosthesis was evaluated for composite graft replacement of the aortic root in 32 patients at three institutions. This study was performed in conformity with the Japanese Drugs, Cosmetics and Medical Instruments Act. The grafts were preclotted with blood of serum albumin: coronary artery reconstruction was performed employing the classical Bentall procedure (4 cases), Cabrol's procedure (14 cases), the interposition graft technique (8 cases) or the button technique (6 cases); concomitantly the aortic arch was replaced in one patient, and the mitral valve was replaced in two patients. One early death (3%) occurred as the result of shock sustained prior to establishing cardiopulmonary bypass. Postoperative complications included perivalvular leakage (one case), perioperative myocardial infarction (two cases), hepatitis (one case). There were no late deaths and no complications related to the SJM valve graft prosthesis. The SJM valve graft prosthesis is a safe and reliable prosthesis for use as a composite graft replacement of the aortic root.