A 69-year-old man had been treated with total arch replacement for acute Stanford type A aortic dissection. He had cardiac failure at 9 years after his previous operation. Computed tomography and transesophageal echocardiography showed re-dissection of the aortic root and aortic regurgitation. He was referred to our hospital for surgical treatment. In the second operation, aortic root replacement was performed. Re-dissection of the aortic root at the site of the non-coronary sinus was noted intraoperatively, and intraoperative findings suggested necrosis of the aortic wall related to the use of GRF glue. Care should be taken to ensure proper use of GRF glue. The aortic root replacement using a Freestyle valve provided good hemodynamic function and low thrombogenicity. The use of this valve in this case which had residual dissection of the descending aorta seemed useful because of the excellent hemodynamic function without anticoagulant therapy.

The early and mid-term survival after thoracic aortic surgery and the influence of age on operative mortality were examined in 93 consecutive patients from August 1994 to June 1999, together with assessment of postoperative quality of life (QOL). The mean age was 63.8±11.6 years old (range 26 to 84 years) and 65 patients were male. Aneurysms were atherosclerotic in 43 patients and aortic dissection was present in 50. Forty-eight (52%) required emergency operation. Operative procedures consisted of ascending aorta or hemiarch replacement in 23 patients, Bentall's operation was performed in 4, total arch replacement in 31, distal arch replacement in 9, descending aorta replacement in 13, replacement of the thoracoabdominal aorta in 6, and patch repair in 7. These patients were divided into two groups: the under 70 group (Y group, n=61) and the 70 or older group (O group, n=32). Current QOL of the survivors was assessed using the Asanoi method with a mailed questionnaire. There were 13 early deaths (14%). There were 10 late deaths (5.6%/P-Y (Patients-Years)). The actuarial survival rate of the Y group was significantly higher than that of the O group (p=0.0412). Perioperative stroke was seen in 11% of the Y group and 16% of the O group. These patients had a high mortality rate (Y group 43%, O group 100%) during early and long term follow-up periods. The postoperative NYHA category and exercise ability of the O group were better than those of the Y group. We obtained satisfactory answers concerning the results of operation in the majority of current survivors. Patients aged 70 years and older could undergo thoracic aortic surgery with reasonable risk. QOL following operation was satisfactory except in patients with merged perioperative stroke.

To evaluate the extension of the indications for operation and up-to-date problems in the surgical therapy of the acquired valvular disease, 581 consecutive patients of prosthetic valve replacement from January 1974 through December 1987 were analysed. The age at operation was 39.1 years (range 22 to 68) at 1974, but increased to 51.9 years (range 9 to 75) at 1987 (p<0.05). Early mortality was 3 deaths in 9 patients (33.3%) who were older than 70 years old, but its range was 0% through 7.7% in the younger patient group (p<0.05). Hospital mortality of the combined valve procedure for aortic, miral and tricuspid valvular disease was analysed. It was higher in the group of tricuspid valve replacement (30.0%) than the group of tricuspid annuloplasty (8.3%) (p<0.01). The former group was in poor preoperative state (cachexia, total bilirubin>2mg/dl, mean right atrial pressure>10mmHg and systolic pulmonary artery pressure >75mmHg), compared to the latter group. The cases of re-replacement of the prosthetic valve increased since 1985. The incidence of poor prognosis after operation, that included early death, late death and retire from society, was 47.1% in NYHA Class TV, and from 0 to 15.8% in NYHA Class I to Class III (p<0.01). 60 cases underwent valve replacement for infective endo-carditis, and 16 urgent operations were required in 23 active stage operations. Total early and late mortality was higher in active stage operation (30.0%) than in healed stage operation (2.7%) (p<0.01). In these way, the extension of the indications for operation was carried on the patients of advanced age, combined valve procedure for multiple valve disease, valve re-replacement and infective endocarditis. The operative risk was high in the patients older than 70 years old, the patients who had the risk factors of multiple organ failure after operation, valve re-replacement in NYHA Class IV, and the urgent operation at active stage of infective endocarditis.

The combined method of antegrade and retrograde administration of cardioplegic solution has been established for coronary bypass surgery. We applied this technique in patients undergoing aortic and mitral valve surgery. Between January 1989 and December 1990, 28 patients underwent both aortic and mitral valve replacements. To compare the myocardial protective effect according to the method of cardioplegic administration, they were divided into two groups; Ante group (antegrade, n=15) and Retro group (combined method of antegrade and retrograde, n=13). Aortic occlusion time and cardiopulmonary bypass time were shorter in Retro group. The mean interval of each cardioplegic administration was significantly shorter in Retro group (Ante group, 29.2±4.8min vs Retro group, 24.0±3.8min; p<0.01). These results suggest that retrograde cardioplegia method never disturbs ongoing operation during each delivery while antegrade method often does. Serum CPK-MB at 6hr of reperfusion tended to be less in Retro group (Ante group, 120±80IU/l vs Retro group, 78±50IU/l; p=0.09). The results of postoperative cardiac functions were the same in both groups. We therefore believe that this method is an optimal strategy even in patients with valvular heart disease.