Recently we reported that tumor necrosis factor-α (TNF-α) mRNA expression and the development of postoperative intimal hyperplasia (IH) is different in rat epigastric vein interposition graft, compared to femoral artery re-anastomosis. We evaluated whether a TNF-α suppressive agent, FR-167653 (Fujisawa Pharm. Co., Ltd., Osaka) could suppress IH or not. Eleven Lewis male rats (480±8g) were studied. The epigastric vein graft was interposed into the common femoral artery. They were divided into two groups: group FR (n=5) with 2.0μg/g of FR-167653, and group C (n=6) with same dose of saline instead of FR-167653. The intimal areas of vein grafts were measured at 4 weeks postoperatively. The mean intimal area in group FR was significantly decreased, compared with group C (0.160±0.057mm² vs. 0.434±0.045mm², p<0.01). These results suggest that the TNF-α suppressive agent FR-167653 may suppress the postoperative intimal hyperplasia that occurs on the interposition vein graft in rats.

Recently we reported that the inhibitor of p38 mitogen-activated protein kinase, FR-167653 (Fujisawa Pharm. Co., Ltd., Osaka) may suppress postoperative intimal hyperplasia. In this study we evaluated the best dosage and phase for administration of FR-167653, in order to clarify its mechanism in the postoperative treatment of intimal hyperplasia. Twenty-one Lewis male rats (484±5g) were studied. The epigastric vein graft was interposed into the common femoral artery. The rats were divided into four groups according to the dosage and phase of administration of FR-167653: group I (n=5) with 2.0μg/g of FR-167653 immediately before bypass, group T (n=5) with 2.0μg/g immediately before bypass and 2 weeks after bypass, group D (n=5) with 4.0μg/g immediately before bypass, and the control group (n=6) with the same dose of saline. The intimal areas of vein grafts were measured at 4 weeks postoperatively. The mean intimal areas in group I, T and D were significantly decreased compared with the control group, especially in group D (0.05±0.02mm² vs. 0.43±0.05mm², p<0.001). These results suggest that FR-167653 can suppress the postoperative intimal hyperplasia that occurs with interposition of vein grafts in rats.

A 16-year-old female who complained of hoarseness and left back pain. An abnormal shadow in the left superior mediastinum was observed in chest X-ray films. Thoracic aortogram revealed elongations of the aortic arch and two sacculated aneurysms located in the minor curvature of the arch. She was operated by median sternotomy and left collar incision. The left vagal nerve laid between the two aneurysms. The proximal aneurysmal wall seemed to be of normal thickness, but the distal aneurysmal wall was so thin that the intraluminal blood stream was visible. Aneurysmectomy and insertion of a Dacron patch were successfully performed under cardio-pulmonary bypass with selective cereberal perfusion. The postoperative course was uneventful.

We evaluated 13 patients (4 men & 9 women, mean age: 61 years-old) who required steroid treatment for more than 1 month before open heart surgery. The subjects included 3 patients with collagen diseases, 3 with dermatopathy, 2 with bronchial asthma, one each with Takayasu's disease, autoimmune hemolytic anemia, paroxysmal nocturnal hemoglobinuria, brain tumor and post-renal transplantation. Surgical procedures were performed with an AC bypass in 9 cases, one each with AVR, MVR, reMVR and ASD patch closure. The steroid treatment before open heart surgery had been continued for a mean of 4 years and 11 months at a mean dose of 9.4mg/day equivalent of prednisolone. We evaluated the adrenocortical function on the rapid ACTH test and found hypoadrenalism in 5 of 8 cases (63%). In these cases we gave either 100mg of hydrocortisone or 1, 000mg of methylprednisolone before open heart surgery. The total perioperative dosage of steroid was a mean of 2, 488mg equivalent of prednisolone, including 4mg/kg of betamethasone during the extra corporeal circulation. Postoperatively we lost one case due to ventricular rupture after MVR. Other major complications were seen in one case each, cardiac tamponade, temporary clamp, wound infection and lumbar vertebral fracture. For steroid treated patients, it is important to select the patient who really need steroid by the rapid ACTH test, and to use the minimum dosage of steroids in open heart surgery.

A 72-year-old woman underwent simultaneous combined surgical treatment for descending aortic aneurysm, coronary artery disease and left common iliac artery stenoses. The operation was performed through the left posterolateral thoracotomy via the 6th intercostal space and a left retroperitoneal approach. At first, 10mm woven Dacron graft was anastomosed to the abdominal aorta as an inlet of the cardiopulmonary bypass and the left femoral vein was used for venous drainage. A saphenous vein graft was anastomosed to the left anterior descending artery during partial cardiopulmonary bypass with the heart beating. Secondly, the aneurysm was replaced with 24mm woven Dacron graft. Thirdly, the proximal end of the vein graft was anastomosed to the Dacron graft of the descending aorta. Finally after cardiopulmonary bypass was terminated, the distal end of the woven Dacron graft for arterial perfusion was anastomosed to the left external iliac artery in end-to-side fashion. The postoperative course was uneventful. We conclude that simultaneous operation for descending aortic aneurysm and coronary artery bypass grafting through left thoracotomy with the heart beating is useful in these combined diseases.

A 65-year-old woman underwent abdominal aortic replacement using a woven Dacron tube graft for abdominal aortic aneurysm on April 2nd, 1996. She had pyrexia on the 6th postoperative day and abdominal enhanced CT scan showed periprosthetic bubble formations. She underwent relaparotomy 14 days after the initial procedure due to large retroperitoneal abcess bacterial culture of which revealed methicillin resistant staphylococcus aureus. She underwent debridement and local irrigation by an electrolyzed strong acid solution. Her pyrexia diminished immediately after relaparotomy and bacterial culture of the drain of the left retroperitoneal space became negative 82 days later. She was discharged and has had no active inflammatory signs for 3 years. She is doing well at present.

Several substitutes have been utilized for pericardial closure after open heart surgery. A 55-year-old man was admitted to our hospital with a diagnosis of constrictive pericarditis 13 years after open mitral commissurotomy. At reoperation, the thickened pericardium was peeled off and the epicardium was covered with 0.1mm expanded polytetrafluoroethylene surgical membrane (Gore-tex^®, sheet thickness 0.1mm). At the 7th postoperative day, he complained of fatigue and dyspnea. Physical examination revealed jugular venous distension, hepatomegaly, ascites and peripheral edema. Cardiac catheterization suggested the suspicion of pericardial or epicardial constriction. On the 3rd-operation, the Gore-tex^® sheet was removed and multiple longitudinal and transverse incisions were made in the thickened epicardium, that is the waffle procedure, while protecting the myocardium and the coronary arteries. Perioperative hemodynamics improved remarkably. His cardiac index increased from 3.0 to 4.5l/min/m². The postoperative course was uneventful.

Of 225 patients who underwent surgery for abdominal aortic aneurysm from April 1995 to June 2002, 8 patients. or 3.6%, aged 90 years or more (mean age 90.8±1.4. range 90 to 94, 7 men and 1 woman) were the subjects of this study. Four of these patients (50%) underwent emergency surgery. Of these 4 patients, preoperative shock was found in 1 patient. Preoperative complications were hypertension in 4 (50%), ischemic heart disease in 1 (13%), disseminated intravascular coagulation syndrome in 1 (13%), and pleuritis in 1 (13%). The maximum diameter of AAA was 69.5±16.6mm (range 48 to 100mm). The surgical procedure was median laparotomy. Long-term follow-up by the attending physician, or questionnaire by phone was completed for all patients and range to 6.3 years (median, 2.4 years). There were no hospital deaths. Postoperative complications were delirium in 2 (25%), atelectasis in 1 (13%), and ileus in 1 (13%). There were 5 (63%) late deaths. The causes of death were pneumonia in 2, senescence in 1, cardiac failure in 1, and rupture of a pseudoaneurysm at the anastmotic site in 1. Long-term survivals at 1 year, 2 years, and 3 years were 88±12%, 63±17%, and 20±18%, respectively, whereas expected survivals at 1, 2, and 3 years were 82%, 65%, and 51%, respectively. Longterm survivals were not good, but no significant difference was found between long-term and expected survivals. Therefore, this surgical and long-term treatment can achieve satisfactory results. This result led us to recommend performing the operation for patients aged 90 years or more, except if they were bedridden, had severe dementia, or were at the end stage of a malignant disease.

We evaluated 30 patients who required hemodialysis (HD) before open heart surgery between January 1990 and September 2003. The patients were divided into 2 groups according to surgical procedure: 20 patients underwent coronary artery bypass grafting (CABG group: 14 men and 6 women, mean age, 63 years), and 10 patients underwent valve replacement (VR group: 6 men and 4 women, mean age, 56 years). The mean duration of HD in the CABG group was significantly shorter than that in the VR group (67 months: 121 months, p=0.02). The actual survival rate was calculated by Kaplan-Meier's method. No patient was lost to follow-up. There were 3 hospital deaths in the CABG group (cerebral infarction, arrhythmia, and mediastinitis), and 2 hospital deaths in the VR group (gangrenous cholecystitis and sepsis). There were also 5 late deaths in the CABG group (acute subdural hematoma, pneumonia, AMI, heart failure and gastric cancer) and 4 deaths in the VR group (uterus cancer, 2 intracerebral hemorrhages and PVE). All cardiac event deaths in the CABG group had undergone CABG only with vein grafts. The 4-year actuarial survival rates were 56% (n=5) in the CABG group with a mean follow-up period of 29 months (max 156 months), and 47% (n=3) in the VR group with a mean follow-up period of 35 months (max 131 months). There are 3 points to improve the prognosis of open heart surgery in hemodialysis patients: control of postoperative infection in both groups, prevention of cardiac events in the CABG group and careful anticoagulation therapy in the VR group.

A 65-year-old woman was admitted with a diagnosis of unstable angina after PTCA. She was diagnosed with acromegaly 8 years ago. She underwent an emergency coronary artery bypass grafting (LITA-LAD, SVG-HL-Cx). Serum growth hormone (GH) levels were 65.5ng/ml (normal limit<5ng/ml) before the operation. During a cardiopulmonary bypass GH levels elevated to 92.7ng/ml, but decreased to 15.9ng/ml after the operation. After 3 postoperative days GH levels increased gradually again and blood sugar levels became unstable. Finally it was necessary to increase the dose of bromocriptine. To our knowledge, there are only a few patients who have undergone coronary artery bypass grafting associated with acromegaly. This case suggests it is important to control GH levels at the operation and during the postoperative period.