Nine patients underwent surgical repair of ventricular septal defect (VSP) following acute myocardial infarction in our hospital during the past 5 years. Sites of perforation were apex ventricular septum (A-VSP) in five, high anterior ventricular septum (H-VSP) in one and posterior ventricular septum (P-VSP) in three. A-VSPs were closed by single patch on the left ventricular side of the septum. H-VSP was closed by double patch and ventriculotomy was closed directly. For P-VSPs, three different operative procedures were performed. Patch closure of VSP and reconstruction of free ventricular wall was done in one, while in other two VSP was closed by single patch on the left or right side of the septum. There were two operative deaths, one A-VSP and one P-VSP. We think that patch closure through right ventriculotomy is useful in cases of small P-VSP.

When performing surgery of the thoracic aorta, several supporting methods must be easily available to facilitate various grafting procedures which are selected as the most suitable method for each case. We report on a practical cardiopulmonary bypass (CPB) circuit which can be used in the surgical treatment of any thoracic aortic disease: aortic dissection, true aneurysm involving the aortic arch, descending aortic aneurysm or thoraco-abdominal aortic aneurysm. The circuit design is based on a percutaneous cardiopulmonary support system. We added some modifications to the system for managing CPB simply. The improved bypass circuit was applied in operations on 26 patients and yielded excellent clinical results. The advantages of the circuit are listed as follows: 1) If massive bleeding occurs during closed-circuit CPB, the blood can be sucked into a built-in hard shell reservoir on the venous side of the bypass, and can immediately be returned back into the bypass circuit. 2) Using clamping forceps it is possible to easily switch between closed-circuit CPB and conventional CPB using gravitational venous return. 3) Selective cerebral or other organ perfusion can be done by a built-in roller pump distal to the oxygenator. The perfusion line using the roller pump diverges from the main line using the centrifugal pump kept in a spinning state. If the hypothermic method is used, the lower body is perfused via a femoral arterial cannulation by the centrifugal pump, and the upper body by the roller pump with right subclavian arterial cannulation. When the cardiac rhythm changes to ventricular fibrillation in cooling the patient, the flow ratio of the lower body to the upper body must be 1:1, since retrograde perfusion from the femoral artery may cause cerebral infarction due to embolism of dislodged debris or thrombi from the aneurysm.

There were 10 patients of left ventricular free wall rupture accompanied with acute myocardial infarction in our coronary care unit from Jan. 1987 to Jan. 1991, while 872 AMI patients in the same period. Five of 10 ruptured patients died. All these 5 patients were acute type of rupture. Elder patient, female, 1st attack of infarction and PTCA were considered to be risk factors of rupture. We managed 5 subacute and chronic type ruptured patients successfully at emergent operation with using fibringlue-oxycellulose. Fibringlue-oxycellulose method was useful especially for woozing from infarcted myocardium. The management for acute type rupture is difficult because of its clinical time course, it is considered that prevention of rupture for high risk patient is most important to reduce the mortality of AMI patients in the coronary care unit.

A 39-year-old woman was referred for assessment of abnormality of on a CT scan with a vascular anomaly of the aortic arch. This patient was completely asymptomatic with no concomitant pathologies and no reported prior trauma. Laboratory data for syphilitic or other microbial infections were negative. The diagnosis was confirmed by angiographic computed tomographic scan with 3-dimensional reconstruction. This technique documented the presence of the aneurysm and the left subclavian artery arising from the unique form of aneurysm. Early surgery was preferred because of the young age of the patient and the morphology and the size of the aneurysm (50 mm). Surgery was performed by a left postero-lateral thoracotomy through the forth intercostal space. Femoro-femoral partial cardiopulmonary bypass was used for distal perfusion. An aortic clamp was placed just distal to the left carotid artery, and a second clamp was placed in the descending thoracic aorta. The aortic isthmus was replaced with a 20-mm Dacron graft, and the left subclavian artery was reimplanted to the prosthesis with an 8-mm Dacron graft interposition. This aneurysm was the result of abnormal organogenesis of a primitive aortic arch and the remnant of the dorsal aorta, in other words, Kommerell's diverticulum. Microscopic examination demonstrated severe medial layer atrophy. In the light of the high risk of rupture, which was proved to be present by the very thin aneurysm wall at the time of surgery, we suggest early surgical treatment of idiopathic isthmus aneurysms in young patients regardless of aneurysm diameter.

Cardiovascular reoperations involve high-risk because of adhesions. We examined the strategies and clinical outcomes of the reoperations in our institute. From January 2003 to December 2008, 52 patients underwent reoperations, accounting for 4.5% of all adult patients. The duration from the previous surgery was 10.1±9.3 years. Reoperations were performed due to infection (n=10), after valve surgery (n=16), after coronary surgery (n=9), due to Marfan syndrome (n=3), after aortic surgery (n=7), after congenital surgery (n=4), and for other reasons. In the reoperations, the same surgical site was exposed in 65%, the femoral vessels were exposed before re-sternotomy in 77%, the inflow was on the ascending aorta in 35%, and cardiopulmonary bypass was initiated before re-sternotomy in 37%. Systemic cooling was needed in 4 patients and some maneuvers for patent internal thoracic artery grafts in 6 patients. The operation time of 9.6±2.5 h and the cardiopulmonary bypass time of 295±111 min, respectively. We experienced intraoperative injuries in 16 patients (31%). Platelet transfusion was needed in 90% and a second CPB in 15%. Postoperative complications included hemorrhage (14%), infection (13%), stroke (4%), respiratory failure (44%), and renal failure (1%). The hospital mortality was 7.7% (4/52) due to uncontrolled infection, liver failure, pulmonary hemorrhage, and left ventricular rapture. The 2-year survival rate was 83.1% with the mean follow-up of 24±18 months. In conclusion, although the risk of injuries at re-sternotomy was not high, limited surgical field due to adhesions resulted in fatal injuries and in the cardiac reoperations we experienced. We need to improve our strategies for further reduction in mortality and morbidities in reoperations.

A 60-year-old man with type 2 diabetes mellitus and severe obesity (height 170 cm, weight 160 kg, BMI 55) was admitted to our hospital because of acute inferior wall myocardial infarction due to acute thromboembolism of the right coronary artery (RCA). Because of three-vessel coronary diseases, we planned coronary artery bypass grafting after the medical therapy. The patient was intubated, then suffered congestive heart failure and pneumonia, and had a tracheotomy because of obesity hypoventilation syndrome. When his general condition improved after 14 months of medical therapy, we performed the operation. At that time, his weight had decreased to 107.5 kg, and BMI decreased to 37.2. We decided that tracheotomy was necessary to avoid respiratory complications. We chose a thoracoabdominal spiral incision for 2 reasons. Firstly we needed to avoid wound contamination by the tracheotomy stoma. Secondly we decided that the left internal thoracic artery (LITA) and the right gastroepiploic artery (RGEA) were sufficient for bypass grafts to the left anterior descending artery (LAD), the diagonal branches (D1), the posterolateral artery (PL) and the posterior descending artery (PD). Before the operation, epidural anesthesia was performed for postoperative analgesia to prevent respiratory dysfunction. In the right semi-lateral position at 30°, a 4th intercostal space thoracotomy was performed, and the LITA was harvested. The skin incision was extended to the midline of the abdomen and the RGEA was harvested. The end of the LITA was anastomosed with the free RGEA as I composite and the composite was anastomosed to the LAD, the D1, the 14 PL and the 4 PL without cardiopulmonary bypass. Without any perioperative blood transfusion, the patient was discharged with no perioperative complication, including mediastinitis. With this incision, we achieved secure prevention of wound contamination by the tracheotomy stoma, harvesting of a sufficient length of the LITA and RGEA and good visualization of the anastomotic sites with less cardiac displacement than median sternotomy.

Purpose: The purpose of this study was to evaluate the cone-beam computed tomographic (CBCT) imaging and histopathological characteristics of osteoradionecrosis (ORN) and medication-related osteonecrosis of the jaw (MRONJ). Materials and Methods: Ten surgical specimens from segmental mandibulectomy (3 ORN and 7 MRONJ) were analyzed using CBCT. The CBCT parameters were as follows: high-resolution mode (tube voltage, 90.0 kV; tube current, 4.00 mA; rotation time, 16.8 s; field of view, 56 mm×56 mm; thickness, 0.099 mm). Histopathological characteristics were evaluated using histological slides of the surgical specimens. The Pearson chi-square test was used to compare ORN and MRONJ in terms of CBCT findings (internal texture, sequestrum, periosteal reaction and cortical perforation) and histopathological characteristics (necrotic bone, inflammatory cells, reactive bone formation, bacteria, Actinomyces, and osteoclasts). A P value less than 0.05 was considered to indicate statistical significance. Results: MRONJ showed periosteal reaction on CBCT more frequently than ORN (7 of 7 [100%] vs. 0 of 3 [0%], P<0.05). Regarding histopathological characteristics, MRONJ showed osteoclasts more frequently than ORN (6 of 7 [85.7%] vs. 0 of 3 [0%], P<0.05). Conclusion This study evaluated the CBCT imaging and histopathological characteristics of ORN and MRONJ, and the findings suggest that CBCT could be useful for the evaluation of ORN and MRONJ.