Pulmonary vein isolation procedure was performed for atrial fibrillation associated with mitral valve disease in twelve patients. This simple procedure consisted of only isolation of the four pulmonary veins. Combined mitral valve surgery consisted of mitral valve plasty, mitral valve replacement with or without aortic valve replacement and tricuspid annuloplasty. Ten patients returned to a sinus rhythm. Two patients required DDD pacemaker implant for sick sinus syndrome. Left atrial contraction was detected in eight cases by trans-esophageal echography. Compared with the maze procedure, this operation was less invasive and preserved atrial appendage, helping to maintain normal secretion of atrial natriuretic peptide. This study suggests that the pulmonary vein isolation procedure may be an effective and simple maneuver for atrial fibrillation associated with mitral valvular disease.

In dialysis cases complicated with ischemic heart disease, there are many problems, such as poor preoperative general condition, calcified aorta, water-electrolyte control, and the necessity for other simultaneous operations. Off-pump coronary artery bypass grafting (OPCAB) was considered very useful in coping with these problems. OPCAB, employed in five cases, was compared with conventional coronary artery bypass grafting with extracorporeal circulation (ECC group, 9 cases). Regarding preoperative coexisting diseases, collagen diseases, porcelain aorta, cerebral infarction, and others were recognized in the OPCAB group in 3 of 5 cases. Emergency operations were performed in 5 of 9 cases in the ECC group, and in 2 of 5 cases in the OPCAB group. The bypass number (3.2 vs. 2.0) and complete revascularization rate (7 of 9 vs. 2 of 5), tended to be higher in the ECC group. The OPCAP group was significantly superior in blood transfusion (6.7 vs. 3.0u), postoperative CK-MB (63 vs. 33u), and the postoperative usual hemodialysis commencing time (4.2 vs. 1.0 day). Concerning use of postoperative IABP (3 of 9 vs. 0 of 5), and postoperative ventilator weaning time (2.7 vs. 1.0 day), a good tendency was shown in the OPCAB group. Although a high mortality rate (2 of 5) was recognized in OPCAB group compared with ECC group (1 of 9), those were urgent cases who had a very poor preoperative condition, and both cases suffered non-cardiac deaths. Excluding special cases, such as an unstable hemodynamic state requiring assisted circulation, and poor coronary run off, OPCAB seems useful for the treatment of coronary artery disease in dialysis patients.

Coronary artery disease (CAD) was evaluated by noninvasive examination in abdominal aortic aneurysm (AAA) patients. A simultaneous operation or a 2-staged operation was performed depending on the seriousness of the condition when both diseases were combined. A total of 36 patients underwent elective repair of AAA between 1996 and 2001. Coronary angiography (CAG) was performed only in patients with suspected CAD by dipyridamole myocardial scintigraphy. Significant CAD was found in 8 patients. Simultaneous operation was performed in 4 patients, and off-pump coronary artery bypass grafting (OPCAB) was performed in all cases of simultaneous operation. In 4 patients receiving 2-staged operations, 1 standard coronary artery bypass grafting (CABG), 1 OPCAB and 2 percutaneous transluminal coronary angioplasties (PTCA) were performed prior to AAA surgery. Twenty-eight patients underwent only AAA operation. Though there were no incidents of perioperative myocardial infarction or cardiac related deaths in this group, 2 patients died due to other causes (hemorrhage and duodenal perforation). In the 8 patients associated with CAD, 1 patient died of MNMS after simultaneous operation. The other 7 patients revived their social function soon of the discharge. Dipyridamole cardiac scintigraphy was considered to be an effective examination for evaluation of CAD in AAA patients. There was no need to perform CAG in all AAA patients. The policy of choosing simultaneous operation or 2-staged operation according to the seriousness of the 2 diseases seemed to be appropriate.

A 72-year-old man suffering from congestive heart failure, swelling of the lower limbs and hematuria was transferred from another hospital with a diagnosis of large aneurysms of the abdominal aorta and the left common iliac artery. Iliac arteriovenous fistula (AVF) was definitively diagnosed preoperatively by contrast-enhanced CT and angiogaphy. At operation, an infrarenal abdominal aortic aneurysm of 8cm and left iliac arterial aneurysm of 12cm were identified. After proximal and distal aortic clamping, the aneurysm was entered and an AVF orifice of 1cm communicating with the left common iliac vein was disclosed at the right posterior wall of the left common iliac artery. Venous blood reflux was controlled by inserting an occlusive balloon catheter to the fistula and intraoperative shed blood was aspirated and returned by an autotransfusion system. The AVF was closed from inside the iliac aneurysm by three interrupted 3-0 monofilament mattress sutures with pledgets. The aneurysms were resected and replaced with a bifurcated Dacron prosthetic graft. The patient had an uncomplicated postoperative recovery; the lower limb edema subsided and heart failure improved rapidly. Preoperative identification of the location of the AVF is mandatory to make surgery safe. Moreover, easy availability or routine use of the devices for controlling undue blood loss such as an autotransfusion system and an occlusive balloon catheter are other important supplementary means to obtain good results of surgical treatment.

A gelatin-sealed knitted Dacron graft which has zero-porosity at implantation and does not require preclotting preparation has been developed. Gelatin-sealed aortic grafts were implanted into 39 patients and vascular surgery reconstruction was performed for thoracic aortic aneurysm (TAA) in 10, abdominal aortic aneurysm (AAA) in 19, and arteriosclerosis obliterans (ASO) and other conditions in 10. A total of 39 bifurcated or straight grafts were inserted. The Gelseal Dacron graft had superior handling characteristics and biocompatibility in comparison to conventional graft. There was no measurable blood loss from the body of the sealed graft at the time of implantation. The gelatin-sealed Dacron graft (n=10) was compared with an Intervascular Micron^® graft (n=10) implanted into the abdominal aorta. No problems were evident with regard to intraoperative bleeding, allogenic and autologous transfusion volume and blood parameters between the two groups. These results suggested that the Gelseal Dacron graft sealed with gelatin was a safe, zero-porosity implantable prosthesis for clinical use.