In 5 cases of profound left ventricular failure, simultaneous application of a percutaneous cardiopulmonary support system (PCPS) in which the entire circuit was coated with heparin, and intra-aortic balloon pumping (IABP) were performed. No case responded to therapy consisting of large amounts of inotropic agents, followed by IABP. With the assistance of the PCPS (mean flow rate 2.3l/min) combined with moderate doses of inotropic agents and IABP, the hemodynamics of all 5 patients were stabilized. Using low amounts of heparin, the activated coagulation time during PCPS was maintained between 150 and 200 seconds. No complications directly related to this procedure such as thromboembolism and bleeding were observed. Four cases have been successfully weaned from the PCPS. Of the four, two cases are long-term survivors and are currently functioning normally in society. At present, the indications, optimum parameters for PCPS flow rate, and when to start weaning from the PCPS have not been established. However, we conclude that simultaneous use of PCPS and IABP is useful to maintain adequate systemic circulation in cases not responding to medication and IABP.

A 61-year-old male had received aortic valve replacement due to AR in 1987 and the operative findings showed the enlargement of the ascending aorta and maximum diameters of 4cm in the ascending aorta. He had been doing well until 1992 when he sufferred cerebral infarction and aortic root dilatation reached a maximum diameter of 7.5cm demonstrated by CT. Cabrol's operation using the previously replaced aortic valve was carried out because the prosthetic valvular function was normal and the type of coronary arteries was balanced. Postoperative angiography showed good patency at anastomosis of bilateral coronary arterial orifices and he had a satisfactory postoperative course. The dilatation of the ascending aorta over 4cm accompanied with AR may need not only AVR but also aortic root replacement.

Anastomotic aneurysm was diagnosed in a 77-year-old man following graft replacement of the distal aortic arch aneurysm using the inclusion method in 1991, Enhanced CT demonstrated the aneurysm of the distal anastomotic site with a maximum diameter of 5cm between the graft and the aneurysmal wall. On left thoracotomy the aneurysm was found to severely adhere to the lung, so it was difficult to dissect its adhesion and clamp the proximal aorta. The rectal temperature was cooled to 18°C with the aid of femoro-femoral bypass. We anastomosed the previous graft-end to the new graft with one side branch during simple hypothermic retrograde cerebral circulation (RCC). RCC time was 16min and the distal end was anastomosed to the descending thoracic aorta. Though it took a long time to undertake systemic cooling and rewarming, intraoperative bleeding was small and the postoperative course was satisfactory without cerebral complication.

Pulmonary artery (PA) aneurysm is rare, but its true incidence is unclear, because most cases remain asymptomatic. The need for surgical treatment is controversial. We report two cases of surgical treatment of PA aneurysm associated with pulmonary valve (PV) disease in adults. Case1: A 54-year-old woman. She underwent pulmonary valvotomy for pulmonary stenosis (PS) at age 22. She had suffered from palpitations and dyspnea on effort recently. Then progressive changes of pulmonary stenosis-regurgitation (PSR) occurred. After further examinations, she was diagnosed as having PA aneurysm and right ventricular dysfunction with PSR, tricuspid regurgitation and paroxysmal atrial fibrillation. We performed PV replacement, PA aneurysmo-plasty, tricuspid annuloplasty, cryo-MAZE procedure. Case2: A 70-year-old man sufferd recently from dyspnea on effort. The dilatation of the pulmonary artery was pointed out on chest X-ray. PA aneurysm and PS with ventricular arrhythmia were diagnosed. We performed PV commissurotomy and PA aneurysmo-plasty. There were no significant findings of high PA pressure in either case. PA with pulmonary valve disease in the presence of low pulmonary pressure have low risk of rupture and dissection. Surgical treatments are recommended when right ventricular dysfunction or ventricular arrhythmia secondary to pulmonary valve disease is present.

Fifty-three patients who had received aortic valve replacement (AVR) using tilting disc valve prostheses (Lillehei-Kaster valve, Omniscience valve, Omnicarbon valve), underwent replacement of their aortic valve prostheses over the past 13 years. The indications for reoperation were non-structural opening failure in 35 patients, thrombosed valves, including 2 stuck valves in 8, prosthetic valve endocarditis (PVE) in 7 and perivalvular leakage (PVL) in 3. The interval periods until reoperation for opening failure and thrombosed valve were 112 and 118 months respectively, and for PVE and PVL were 21 and 25 months. There were 7 hospital deaths (13.2%). Surgical results in cases of active PVE with root abscess and stuck valve required emergency operation were significantly worse than these for nonstructural opening failure. Opening failures, which accounted for two-thirds of the indications for reoperation was found to be due to subvalvular pannus formation on minor orifices which hindered the disc from opening properly. It was suggested that reoperation for these types of prosthetic valve should be done before they develop into emergency cases, taking account of these valve-related complications.

We report a case of successful graft replacement of the total aortic arch using selective cerebral perfusion for recurrent distal aortic arch aneurysm (DAAA). A 72-year-old man who had a history of patch aortoplasty for saccular DAAA was admitted to our hospital. Computed tomography and digital subtraction angiography showed recurrent saccular DAAA and coronary angiography revealed 90% stenosis of the first diagonal branch, resulting in a diagnosis of recurrent DAAA with coronary artery stenosis. A graft replacement of the total aortic arch with the aid of selective cerebral perfusion and coronary artery bypass grafting to the first diagonal branch was carried out. Postoperatively, he had no cerebral complications. One year after the operation, he had an operation for an abdominal aortic aneurysm. The patient is now leading a normal life.

We conducted a clinical study on a newly developed large diameter vascular graft (Triplex^®, Terumo Corporation, Tokyo, Japan) with a non-biodegradable material used as sealing material, to evaluate its effectiveness and safety. Triplex^® grafts were implanted in 170 patients with either aneurysmal or occlusive arterial disease in either the thoracic artery, abdominal artery or iliac arteries, between October 2001 and March 2003. The patients consisted of 141 men and 29 women with an average age of 69.0±10.0 years old (mean±SD). In 82 patients, Triplex^® was implanted for the thoracic artery area, in 88, for the abdominal artery area. The cumulative graft patency rate 12 months after implantation was 100.0% in each area, there was no any abnormality such as occlusion or rupture from the trunk of Triplex^®. The distension ratio, which is the index of the dilatation resistance, was 1.03±0.06 as a whole (n=139), 1.03±0.06 in the thoracic artery area (n=73), 1.03±0.06 in the abdominal artery area (n=66). In other words the dilatation of Triplex^® was hardly observed. As manipulability during the operation, the following characteristics were evaluated; anastomosis, resistance to fraying, hemorrhage, conformability with the host vessel. Triplex^® was evaluated as “good” in 75% of all items accounted for 75% or more. A transitory rise thought to be due to the surgical stress immediately after the operation because of the change of temperature and laboratory findings (CRP, WBC) between implantation and discharge was observed, but then recovered to the normal levels of each patients at discharge and the re-elevation was not recognized. In 90 patients, 277 adverse events occurred. Although in 33 adverse events in 21 patients a causal relation with Triplex^® could not be excluded, most of them were already known events as complications which could occur after operation on the aorta. Therefore, it was confirmed that Triplex^® has certain advantages: 1) good manipulability, 2) good patency and dilatation resistance, 3) no inflammatory reaction related to Triplex^®, as a graft for the aorta.

Between March 1985 and May 1988 we performed valve replacement to 86 cases using 92 Duromedics prosthetic valves in the atrioventricular position. Long term results were obtained, we examined the problem (especially thrombosed valve). The cumulative follow-up was 313.6 patients-year (p-y). The 6-year actuarial survival rate including early mortality was 83.4±4.1%. The valve-related complications were as follows; peripheral embolism 3 cases (1.0%/p-y), thrombosed valve 7 cases (2.2%/p-y), hemorrhage and paravalvular leakage each 1 case (0.3%/p-y). All valve-related complications were 12 cases (3.8%/p-y). Reoperation for valve-related complications were 5 cases (1.6%/p-y), it was all to thrombosed prosthetic valve. Thrombosed valve were seen 7 cases (4 cases in mitral, 3 cases in tricuspid position). The event free rate of thrombosed valve was 89.1±4.0%. It was high incidence in tricuspid position. We concluded that it was necessary to be done early reoperation the time of fixed with one leaflet alone.