Leg edema following the harvest of great saphenous vein (SV) is sometimes recognized after coronary artery bypass surgery (CABG). Maximum venous outflow (MVO) is one of the parameters of leg venous function which is measured by straingauge plethysmography. To clarify the mechanism of the development of leg edema after CABG, we measured the perioperative MVO. Six patients had leg edema afer CABG (group I), 4 patients had no edema after CABG (group II). Six patients without edema after cardiac surgery, apart from CABG, were selected as controls (group III). The MVO of both legs was measured before and after the operation. In group I, venous echo or venography of the leg, or both, were performed after the operation. The MVO of legs from which SV had been harvested in group I decreased from 35.0±13.6 (ml/min/ 100ml tissue) to 23.9±7.6 (p=0.04) after the operation, but did not differ from the MVO of the contralateral leg. The preoperative MVO of legs from which SV had been harvested in group I was slightly higher than the legs of other groups. There was no significant change of MVO in group II or III after surgery. No deep vein thrombosis was shown in group I by venous echo and venography. Left ventricular ejection fraction, blood cell count and serum chemistry indicated no changes in any of the three groups after the operation except for the hemoglobin level in group I. These results suggested that the leg which had edema had a relatively high MVO before the operation. This MVO significantly decreased to the level of leg from which SV had not been harvested after the operation, and the edema appeared. In conclusion, postoperative edema in the leg from which SV was harvested was the result of a decrease in venous function due to removal of the SV. SV which causes leg edema might play the greater part of the venous return than others and the total function of the venous return was higher than normal at the point of preoperation.

A 72-year-old man presented with chief complaints of back pain. Medical workup discovered infrarenal abdominal aortic aneurysm (AAA) with Stanford type B acute aortic dissection on CT. The dissection originated distal to the left subclavian artery and extended to the right commom iliac artery. All visceral arteries branched from the false lumen. The maximum diameter of the thoracic aneurysm was 4.8cm and that of the abdominal aneurysm was 6.5cm. Multiple renal infarcts were noted and the right kidney function was decreased. Initial surgery was performed 3 months after presentation using a graft technique. Advanced atherosclerosis and dissection were noted in the aneurysm making the arterial wall quite vulnerable. Hemorrhage was extensive and hemostasis difficult in the defective arterial wall. The patient became unstable so the aneurysm was closed and the surgical procedure was changed to right axillo-bifemoral bypass rather than the original surgical plan of anatomic reconstruction of the AAA. The patient tolerated the procedure well. We report a rare case of acute aortic dissection which extended through the AAA.

A special elective course to prepare for the United States Medical Licensing Examination for 2 hours weekly was introduced for our 3rd-and 4th-year students 3 years ago. The course consists of two parts: one part concerned basic medical knowledge taught by medical faculty with American textbooks and the other part concerned medical English taught by a native English speaker speaking at a natural speed so that students will be able to understand naturally spoken English.

Thirty-nine years old woman had a severe renovascular hyper-tension with Takayasu's arteritis Her left renal artery stenosis was treated with percutaneous transluminal angioplasty (PTA) three times. Six months after the third PTA, the left renal artery was occluded, and left renal failure occurred. Aorto-renal bypass surgery with a prosthetic graft was performed. Blood pressure dropped to normal range, and left renal function began to recover. Although PTA is an effective method in the treatment of renovascular hypertension, an incidence of restenosis after PTA is higher in Takayasu's arteritis rather than atherosclerotic lesions. Five months after renal revascularization, hypertension recurred in this case. However the aorto-renal bypass graft was patent accompanied by no symptoms. This aorto-renal bypass surgery can be considered effective in this condition.

A 6-year-old boy underwent one stage operation for atrial septal defect (ASD) and funnel chest. The procedure began with removal of cost-sterno complex (plastron) following median skin incision. Plastron was kept in cold saline with antibiotics during ASD closure, and sterno-costal elevation method was performed. Simultaneous operation for heart disease and funnel chest is profitable in preventing postoperative circulatory or respiratory complications, in avoiding problems of two stage operation such as adhesion and mental stress of the patients. In addition, wide exposure and easy approach to the heart is available with this one stage procedure. Although current refinement both of cardiac and thoracic surgery has encouraged the possibility of simultaneous corrections for heart disease and funnel chest, much precautions against bleeding and infection are necessary for the satisfactory surgical result.

Causative factors for thrombi formation in left atria of 38 patients with mitral stenosis who underwent mitral valve surgery (open mitral commissurotomy or mitral valve replacement) alone or in combination with other procedures were studied. There were 9 cases of left atrial thrombosis (LAT). Left atrial diameter was increased in LAT(+) group (6.1±1.6cm) compared with LAT(-) group (4.6±0.7cm). There was significant difference in the left atrial diameter between the two groups of patients (p<0.01). Cardiac output was decreased in LAT(+) group (3.04±0.74l/min) compared with LAT(-) group (3.99±1.07l/min). Cardiac output of LAT (-) group was significantly larger than that of LAT(+) group (p<0.05). Mean transition time of blood through left atrium (MTT_LA) was calculated using left atrial volume and cardiac output. In LAT (+) group, MTT_LA was significantly increased (6.2±3.9sec) compared with LAT(-) group (2.9±1.6sec). It is considered that, in mitral stenosis, prolongation of MTT_LA is one of the risk factors for thrombi formation in the left atrium.

This is a case report of a 57-year-old woman with high aortic occlusion (HAO) who had acute symptoms of severe ischemia of the lower extremities and the intrapelvic organs. Generally, HAO is a chronic ischemic disease of the lower extremities and the intrapelvic organs; therefore, acute HAO is relatively rare. Acute thrombotic occlusion of a major collateral artery might be the cause of acute HAO. Laser Doppler flowmetry of the sigmoid colon was useful to evaluate the ischemia of intrapelvic organs. Thrombectomy of the juxtarenal portion with the suprarenal aortic cross clamp was performed within four minutes, then the clamp was moved to the infrarenal portion. The remaining occluded aorta was replaced with a Y-shaped knitted Dacron graft. She had no symptoms after the surgery except renovascular hypertension. Seventy five percent stenosis of the right renal artery was exacerbated to 99%. Vascular clamping of the right renal artery might have been the cause of severe stenosis. Percutaneous transluminal renal angioplasty was successfully performed after the surgery. Aggressive renal artery reconstruction during surgery is recommended in cases with moderate or severe renal artery stenosis.

We performed surgical treatment for 21 patients of airway obstructions associated with congenital heart disease from December 1986 to March 1993. In all patients perioperative bronchoscopy demonstrated the cause and site of airway obstructions. Seven patients with corrective cardiac surgery (7/7), 7 with palliative cardiac surgery (7/10) and 2 with surgery for airway diseases (2/4) could be weaned from respirators following surgical treatment. Five patients died postoperatively. A respirator was required in 16 patients (76%) preoperatively. The suspension of pulmonary artery with intraoperative bronchoscopy was carried out in 6 patients. Five (5/6) were successfully extubated earlier postoperative day (mean 8.4 days), whereas only five in 10 patients without that procedure could be weaned from the respirator at a mean of 2 months. Identification of potential airway obstruction and early extubation is needed to reduce the mortality and morbidity caused by airway obstruction associated with congenital heart disease. Preoperative bronchoscopy is useful for diagnosis of airway obstructions and essential for decision making concerning surgical treatment. To early extubation in patients with marked airway obstructions, we recommend appropriate choice of the surgical procedure combined the suspension of pulmonary artery.

Seven patients with congenital heart defects suffered from multiple major hemorrhages from the lung after surgery and 5 of them died at 8 to 54 postoperative days because of respiratory insufficiency. In a patient with tetralogy of Fallot associated with pulmonary atresia, bleeding occured after the second shunt operation, presumably from rupture of bronchial collateral vessels. The clinical diagnoses of the other 6 patients were coarctation of the aorta (CoA) with common atrioventricular canal (CAVC) in 1, triple shunt in 1, persistent truncus arteriosus in 2, total anomalous pulmonary venous connection in 1 and CAVC in 1. Subclavian flap aortoplasty was performed without pulmonary artery banding in the patient with CoA and CAVC, whereas complete repair was performed in the other 5 patients. As these patients were associated with severe pulmonary hypertension preoperatively and 4 of them encountered pulmonary hypertensive crisis, the hemorrhage from the lung may be related to pre and postoperative high pressure of the pulmonary artery. Dilatation and rupture of the pulmonary capillary net was demonstrated in the patient with CoA and CAVC. These findings suggest the hypothesis that bleeding occurred due to rupture of the capillary net as a result of transmission of high pressure. Major bleeding from the lung is a rare but catastrophic complication after repair of congenital heart defects. As the treatment is difficult, early surgical intervention and treatment of postoperative pulmonary hypertension are important in complex lesions with severe pulmonary hypertension.

The incidence of ventricular subepicardial aneurysm following myocardial infarction is quite low. We report a case of subepicardial aneurysm that was diagnosed on postoperative pathohistologic examination. A 69-year-old man was admitted to our hospital because of left ventricular aneurysm following myocardial infarction. The patient had left main trunk disease, triple-vessel coronary artery desease and low output syndrome. Under cardiopulmonary bypass with the heart arrested, the aneurysm was resected and the defect was closed. The suture line was reinforced using Teflon felt and GRF glue. A saphenous vein graft was anastmosed to the left anterior descending artery. On pathohistologic examination, the wall of the aneurysm was found to be composed of fibrotic tissue, myocardial fibers, medium-sized pericardial arteries, epicardium and fibrin thrombi. We diagnosed this as subepicardial aneurysm.