Renal function, hemolysis and hematologic parameters after transfusion using a cell-separation (CS) device were retrospectively evaluated during abdominal aortic aneurysm repair. Fifty-eight patients were divided into two groups, that is, the CS group (n=39) who received autologous retransfusion using the CS device and the non-CS group (n=19) who were operated before 1989, when we started to use CS device in our operating theater. Hematologic parameters and levels of GOT, GPT, LDH, BUN and creatinine were assessed before and 1, 2, 3, 4 and 7 days after the operation. Mean transfused homologous blood was 1.3±1.8 units in the CS groups and 4.9±3.1 units in the non-CS group (p<0.05). Peak levels of LDH and GPT were significantly higher in the CS group than the non-CS group (p<0.05) after the operation (GOT, CS group: 60.4±29.1IU/l vs non-CS group: 34.8±12.3IU/l, LDH, CS group: 643±324IU/l vs non-CS group: 446±108IU/l). There was no significant difference in the levels of BUN and creatinine levels between the two groups. Hemoglobin levels decreased gradually after the operation in CS group patients who did not receive a homologous blood transfusion. These data suggested that mild hemolysis occurred after retransfusion of autologous blood, but that the hemolysis due to the CS device had no effect on the renal function of the patients.

A 79-year-old man underwent aortic valve replacement by xenografts for active infective endocarditis with aortic regurgitation. Two months later, he developed congestive heart failure and uncontrolled infective endocarditis. The second operation was performed 3 months later, with an aortic valve translocation procedure because of aortic regurgitation due to aortic root abscess and prosthetic valve endocarditis. Six months after the second operation, the saphenous vein graft (SVG) to the left coronary artery (LAD) revealed a severe stenotic lesion at the proximal site. The stenotic vein graft fed almost the entire left coronary circulation. The third operation was performed via left thoracotomy, under hypothermic circulatory arrest with cardiopulmonary bypass. A new radial artery (RA) graft was anastomosed between the descending thoracic artery and the old SVG for LAD. The patient recovered without any major complications and postoperative angiography showed that the new RA graft was patent.

A 30-year-old man with a fever, cough, and dyspnea, was admitted to our hospital. A ruptured aneurysm of the Valsalva sinus (Konno classification, type I) was diagnosed associated with infective endocarditis of the aortic valve accompanied by aortic regurgitation (AR, grade II), and a ventricular septal defect (VSD, subarterial type). The operation was performed as follows: the removal of the aortic and pulmonary valves involved with endocarditis, the resection of the right aneurysm of the Valsalva sinus, and the myectomy of the fragile tissue of the right ventricle around the VSD. As a result, the large deficit region with the VSD and the resected right Valsalva sinus was patched with double sheets of equine pericardium. Aortic valve replacement (a prosthetic valve, ATS 18 AP) was anastomozed to the closed patch with the aid of the sheet as a part of the aortic valvular ring, and pulmonary valve replacement (a prosthetic valve, ATS 23 A) was done to the native pulmonary valvular site. During the 13 months after the surgery, under strict control of warfarin administration, the patient's clinical outcome has been favorable without infection and congestive heart failure. This case had AR accompanied with the subarterial type VSD, and aneurysmal formation of the Valsalva sinus and its rupture, and also revealed progressive infective endocarditis of the aortic and pulmonary valves, which resulted in severe cardiac failure. Early and appropriate surgical treatment for the ruptured aneurysm of the Valsalva sinus is required for a better prognosis prior to prevent exacerbation leading to infective endocarditis and critical heart failure.

The total arch replacement protocol using the open-style stent-graft placement is frequently performed for type A aortic dissection to obtain complete closure of entry sites. However the open-style stent-graft placement must be carefully planned when the entry site is in the descending aorta and extends beyond the level of the tracheal bifurcation, because spinal cord ischemia can be caused due to occlusion of lower thoracic intercostal arteries. We report an alternative to total arch replacement for type A aortic dissection with entry in the ascending aorta and aneurysmal re-entry in the descending aorta, beyond the level of the tracheal bifurcation. We inserted a guide-wire from the dissected area of the aortic arch towards the normal region beyond the re-entry in the descending aorta, with confirmation by direct ultrasonography and already incised half, introduced a graft into the descending aorta using the wire as a guide and performed anastomosis at the level of the transverse aortotomy in the inclusion method. This operation has the advantage of preventing spinal cord ischemia because the re-entry site in the descending aorta is confirmed by direct ultrasonography and the distal anastomosis does not reach the lower thoracic intercostal arteries. In this method, by which the prosthesis is introduced through the descending aorta and anastomosed in the inclusion method, is not needed troublesome treatment in the descending aorta and less invasive than conventional single-stage total arch replacement and applicable with the great safe for aortic dissection that had shown difficulty in application of open-style stent-graft placement.

A 63-year-old woman was admitted to our hospital for combined valvular disease with tricuspid valve stenosis. Aortic and mitral valves were replaced with artificial valves and tricuspid valve were replaced with a biological valve. We chose artificial valves for the aortic and mitral valves because the patient was younger than 70, while a biological valve was used for the tricuspid valve to avoid possible thromboembolism. The postoperative course was excellent. We propose that it is better to use a biological valve for the tricuspid valve, even if artificial valves are used in other sites.

Infectious endocarditis associated with Streptococcus bovis, which is rare in Japan, is a frequently reported complication of gastrointestinal tumors, especially in colon cancer. We report a patient who was successfully treated for the S. bovis-induced infectious endocarditis complication in colon cancer. A 60-year-old man was admitted to our hospital for detailed examination of high fever of unknown origin, that had lasted for 2 months. S. bovis was identified in the venous blood culture. An echocardiogram showed severe aortic valve regurgitation of the third degree and vegetation on the aortic valve. We therefore diagnosed infectious endocarditis. Colonoscopy revealed sigmoid colon cancer. After endoscopic mucosal resection of the lesion, the aortic valve was replaced. The postoperative course was uneventful and he was discharged from the hospital 36 days post operatively.

We report a case of tricuspid infective endocarditis with peripheral pulmonary artery aneurysm. A 31-year-old man with a history of intravenous drug abuse was admitted to our institution. Echocardiography showed severe tricuspid valve insufficiency and large vegetation (10 mm) attached to the tricuspid valve. Computed tomography (CT) revealed a right peripheral pulmonary artery aneurysm. We operated because of the large amount of vegetation. Before the operation, we performed coil embolization for peripheral pulmonary aneurysm. During the operation, we removed the posterior leaflet with vegetation, and performed tricuspid valve repair. The postoperative course was uneventful. Postoperative echocardiography did not show any tricuspid valve insufficiency or vegetation.

DeBakey IIIb aortic dissection associated with thoracic aneurysm was successfully operated upon in a 59-year-old man. The patient had sudden onset of severe back pain and pain in the left lower extremity and dissection associated with thoracic aneurysm was diagnosed. During the operation, we used partial cardiopulmonary bypass support with cannulation of the pulmonary and femoral artery. The entry of the dissection was in a true aneurysm of the descending aorta, and it was replaced with a 22mm Hemashield prosthetic graft. Aortic dissection, with entry in the true aneurysm is rare and is of high risk for rupture.

There are few reports on the long term efficacy of surgery for endocardial cushion defect (ECD) in elderly patients. We report a case with a successful course after ECD operation. A 70-year-old man was admitted with incomplete ECD, grade III mitral and tricuspid regurgitation, pulmonary hypertension and atrial fibrillation. The operative procedures included direct closure of the mitral cleft, pericardial patch closure for the ostium primum defect, direct closure of the tricuspid cleft and tricuspid annuloplasty. Pulmonary hypertension was improved after the operation, and he was discharged on the 41st day after the operation. Now, 3 years and 6 months after the operation, he has maintained an improved quality of life (QOL) with an uneventful postoperative course. The present report may suggest one solution for the long term effective treatment by operation for elderly patients who suffer from ECD, especially to achieve better QOL.

A 52-year-old woman who had been treated for miliary pulmonary tuber culosis complained of left flank pain. Abdominal aortic angiography revealed a saccular type aneurysm in the supra-renal abdominal aorta. We resected the aneurysm and reconstructed the aorta by arificial graft patch under partial extracorporeal circulation. The left renal artery was reconstructed by an artificial graft. During the operation, the superior mesenteric artery and the bilateral renal arteries were perfused by blood from the extracorporeal circuit. On pathological examination, it was shown that the aneurysm was caused by tuberculosis.