A 61-year-old woman developed shock during transportation to our hospital in an ambulance under a diagnosis of acute myocardial infarction, Emergency coronary angiography showed left anterior interventricular descending branch #6 to be completely occluded. At the same time, ultrasonic cardiography showed pericardial effusion. Therefore we diagnosed left ventricular free wall rupture, and performed emergency surgery to repair the rupture site. After pericardiotomy massive hemorrhage occurred and we diagnosed blow-out type left ventricular free wall rupture. We immediately established extracorporeal circulation via the femoral artery and vein, and cross clamped the ascending aorta, then achieved cardiac arrest. Because the area of myocardial infarction was extensive, we applied the David-Komeda method to avoid bleeding due to left ventricular systolic pressure, left ventricular aneurysm or ventricular septal rupture. The postoperative course was good; the patient was weaned from PCPS on the 3rd day postoperatively, IABP on the 5th day postoperatively and from the respirator on the 8th day postoperatively. She was discharged on postoperative day 40. Currently she has no cardiac complains, no left ventricular aneurysm and no neurological problems. Left ventricular free wall rupture can remain a fatal complication after acute myocardial infarction. We consider the David-Komeda method useful for repairing left ventricular free wall rupture (blow-out type) after acute myocardial infarction as well as ventricular septal rupture without a risk of left ventricular aneurysm, bleeding or ventricular septal wall rupture.

A 22-year-old woman without any serious distincted symptoms was found to have hypertension on a health examination. On further examinations, involving echocardiography and chest enhanced CT, showed dilatation of the ascending aorta, aortic coarctation, well-developed intercostal arteries and other collateral arteries. She was only 137 cm tall and weighed 52 kg. Besides, she had not had menstruation for the past two years. Chromosomal studies revealed Turner syndrome. Left lateral thoracotomy was thought to have the risk of heavy bleeding from collateral arteries, therefore we chose ascending-to-descending aorta bypass grafting through median sternotomy. She had an uncomplicated postoperative course. Here we report about operation in a adult case of coarctation of the aorta and discuss the usefulness of extraanatomical bypass grafting.

We describe the case of a 60-year-old woman with severe aortic stenosis and severe calcification of the thoracic aorta, who underwent an apico-aortic conduit bypass using an aortic valved graft. Because of stenosis of the annulus of the aortic valve and severe calcification of the thoracic aorta (porcelain aorta), we did not perform ordinary aortic valve replacement. Instead, apico-aortic conduit bypass surgery was performed using a St. Jude Medical Aortic Valved Graft (19-20 mm : St. Jude Medical, St. Paul, MN, USA) and cardiopulmonary bypass (CPB) surgery was performed using descending aortic perfusion and left pulmonary artery drainage, while the subject was in the right decubitus position. The descending aorta was clamped and a 20-mm graft (Hemashield Platinum ; Boston Scientific/Medi-tech, Natick, MA, USA) was sutured to it. Under ventricular fibrillation, the left ventricular apex was circularly resected using a puncher with a diameter identical to that of the 20-mm graft, in order to create a new outflow for the conduit bypass. The graft was sutured to the outflow, and a torus-shaped equine pericardial sheet was used to reinforce the suture line. After recovery of the heartbeat, the aortic valved graft was first sutured to the graft at the outflow and then to the graft at the descending aorta. The CPB time was 285 min and ventricular fibrillation time was 36 min. Therefore, the benefits of using an aortic valved conduit for apico-aortic conduit bypass are reduced operation time, since there is no need to prepare a handmade valve conduit, and easy management of the grafts which are made of the same material.

To identify the factors affecting the high mortality rates associated with ruptured abdominal aortic aneurysm (rAAA), a review was made of the records of 35 consecutive patients (33 males, 2 females, mean age 69.9yr.) treated surgically between 1988 and 1997. Preoperatively profound shock (systolic pressure less than 70mmHg) was seen in 19 patients and loss of consciousness in 9. Maximum diameter of the AAA was 79±20mm and the preoperative hemoglobin level was 9.1±2.4g/dl. Proximal aortic clamp was performed at the intrathoracic aorta in 3 cases, the suprarenal aorta in 6, balloon occlusion in 4, and the infrarenal aorta in 22. Since 1994, diltiazem and nitroglycerin have been routinely given for latent myocardial ischemia and early induction of continuous hemodialysis for renal failure was attempted postoperatively. The overall hospital mortality rate was 20%. Multisystem failure was the most frequent cause of hospital death (57.1%), followed by pneumonia with sepsis in 28.6%, and intraoperative cardiac arrest (14.3%). By univariate analysis of various factors associated with the mortality rate, loss of consciousness, abnormality on electrocarciogram (ECG) and duration of shock for more than five hours were statistically significant. Multivariate analysis with stepwise logistic regression demonstrated that an ECG abnormality and duration of shock more than five hours were associated with high mortality, but not at statistically significant levels. These findings suggest that factors that are predictive of death (loss of consciousness and ECG abnormality) may be a reflection of shock in this patient population.

The use of the radial artery (RA) for coronary artery bypass grafting (CABG) is increasing. This study describes mid-term results of the use of RA for CABG. Between March 1996 and March 1999, we performed 134 CABGs using RA or saphenous vein graft (SVG) for the left circumflex branch area or diagonal branch area. The mean age was 62.6±9.6 years in the RA group and 65.0±7.8 years in the SVG group. The average number of anastomoses was 2.7per patient. RA was anastomosed with the postero-lateral branch (PL) in 69 cases, with the obtuse marginal branch (OM) in 29 cases and with the diagonal branch (DB) in 10 cases. SVG was anastomosed with PL in 26 cases, with OM in 14 cases and with DB in 2 cases. The proximal anastomosis was made with the ascending aorta in all cases. No sequential bypass anastomosis was used in any case. The early patency rate of the grafts was 97.9% (93/95) in RA and 91.7% (33/36) in SVG. The clinically negative rate in the treadmill test (TMT) performed later was 99.0% (102/103) in RA and 90.9% (30/33) in SVG. The late patency rate of the grafts was 92.9% (13/14) in RA and 50.0% (3/6) in SVG. Perioperative death occurred in 5 cases. Late cardiac death occurred in 2 cases (0.02%) of the RA group and 1 case (0.03%) of the SVG group. The 3 year-survival rate free of cardiac events was 92.8% in the RA group and 80.9% in the SVG group. The use of RA for CABGs is not only effective for myocardial revascularization, but also can be expected to bring about good patency as a late result.