A 44-year-old man presented with syncope and complete A-V block on electrocardiogram. Echocardiography revealed vegetation attached to the aortic, mitral and tricuspid valves. He underwent surgical repair because of uncontrollable congestive heart failure. The vegetation was attached to the noncoronary cusp entirely and had developed to the anterior mitral leaflet. The noncoronary sinus of Valsalva formed a giant mycotic aneurysm toward the right atrium and the aneurysm involved the tricuspid valve. The vegetation was resected together with the aortic valve and the aneurysm. Debridement was performed extensively on the right atrial wall and the aortic root. After closure of the orifice of the aneurysm with a bovine pericardium, aortic valve replacement was performed concomitantly with aortic annular reconstruction using a Hemashield^® graft. Valvuloplasty was performed on the mitral and tricuspid valves. The technique described above enabled us to resect the infectious focus and successfully repair the defective tissues.

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.

A 59-year-old man was admitted for treatment of Stanford type B acute dissecting aneurysm with acute renal failure. He had begun hemodialysis one month after onset, because digital subtraction angiography (DSA) revealed that the truelumen was narrowed by a dilated false channel just above the renal artery. Initially axillo-femoral bypass was performed to treat renal failure, and the patients was easily weaned from hemodialysis. Eight months after the first operation, descending thoracic aorta replacement was performed. The patient is doing well one year after operation. In conclusion, axillo-femoral bypass yielded good results because our patient recovered from renal failure and could undergo radical operation safely. Axillo-femoral bypass allowed evaluation of the hemodynamic study before radical operation.

The effects of milrinone, a phosphodiesterase III inhibitor, were studied in patients with heart failure following coronary artery bypass grafting. Twenty patients with heart failure (either a cardiac index of less than 2.0l/min/m² or a pulmonary capillary wedge pressure of greater than 12mmHg) were divided into two groups according to whether or not they received postoperative milrinone administration. The control group (n=10) received no milrinone treatment and the milrinone group (n=10) received intravenous milrinone infusion at a speed of 0.5μg/kg/min postoperatively. The hemodynamic measurements were made perioperatively and clinical results were accessed perioperatively. Within-group comparison revealed a marked (p<0.05) decrease in pulmonary capillary wedge pressure and systemic vascular resistance in the milrinone group. Cardiac indices were significantly (p<0.05) greater in the milrinone group than those in the control group and within-group comparison revealed a significant (p<0.05) increase in left ventricular stroke work index in the milrinone group. There was no significant difference in rate pressure product in between- and within-group comparison. The milrinone group had a significantly (p<0.05) lower temperature difference between the rectum and the sole, and significantly (p<0.05) less catecholamine requirements postoperatively. Milrinone was not associated with a significant increase in the prevalence of adverse effects. The results suggest that milrinone possesses positive inotropic and vasodilatory effects in patients with heart failure following coronary artery bypass grafting. In addition to catecholamines and vasodilators, milrinone may become a useful agent in the treatment of patients with postoperative heart failure.

Ventricular Septal Defect (VSD) is the most frequent cardiovascular anomaly. VSD causes pulmonary hypertension through stenotic changes in the pulmonary vasculature, and this progress depends on the size of defect and associated cardiovascular anomalies. Since surgical repair has been performed in childhood for patients without a tendency toward spontaneous closure of VSD, operations in elderly patients, especially those aged over 40, are rare. We report an elderly patient with VSD complicated with severe pulmonary hypertension who underwent surgical repair. A 66-year-old man was admitted to our hospital because of general fatigue, chest oppression and palpitations. The pulmonary to systemic pressure ratio was 0.66. The oxygen saturation stepped up at the right ventricle level. The pulmonary to systemic blood flow ratio was 2.9, shunt ratio was 71% and resistance ratio was 0.12. The VSD was 18mm in diameter at the perimembranous trabecula and was closed with a Dacron patch through a right atrium incision. The lung biopsy specimen revealed little occlusive pulmonary vascular disease, Grade I according to the Heath-Edwards criteria. The patient had an uneventful recovery.

A 71-year-old woman with Lutembacher syndrome was admitted for severe congestive heart failure and cardiac cachexia. The preoperative cardiac catheterization showed a huge secundum atrial septal defect (Qp/Qs=3.08) with mitral valve stenosis, tricuspid valve regurgitation, atrial fibrillation and severe pulmonary hypertension. Patch closure of atrial septal defect, mitral valve replacement (SJM 25mm) and tricuspid annuloplasty (Key's method) were performed. However, she suffered prolonged respiratory failure postoperatively. Enforced alimentation for cardiac cachexia and careful administration for sustained heart failure resuscitated her severe postoperative status. The postoperative cardiac catheterization showed sufficient decrease of pulmonary pressure. Reports of successful surgical correction for Lutembacher syndrome in elderly are extremely rare. This is the oldest case of successful correction for Lutembacher syndrome in Japan. From our experience, the surgical treatment for Lutembacher syndrome should be considered even in elderly patients.