An unusual case of a 71-year-old man with massive sinuses of Valsalva presenting with coronary insufficiency was reported. Primarily, he had undergone aortic valve replacement (AVR) with a diagnosis of severe aortic regurgitation (AR) and annulo-aortic ectasia (AAE). Four years after the primary operation, he came to our hospital as an emergency admission complaining of chest pain. Electrocardiography showed sinus rhythm with ST wave elevation in limb leads of II, III and aVF and a diagnosis of acute myocardial infarction was made. Coronary angiography revealed right coronary insufficiency and aortography showed massive sinuses of Valsalva (diameter 8.5cm) with minimal functional AR. At the second operation, the right coronary artery was severely stretched and attenuated over the surface of the right coronary sinus. The ostium was found to be free of atherosclerosis. A composite reconstruction of the aortic root with a new valved conduit and reimplantation of coronary arteries were performed. The postoperative course was uneventful. Aneurysmal change of the sinus of Valsalva is rare, and it is reported that the mean maximal diameter is 5.4cm in this type of AAE. In our case, the unusual dilation of the sinuses of Valsalva resulted in right coronary insufficiency. This case reminded us that aortic root replacement must be applied in patients with AAE as the initial treatment of choice.

A 23-year-old woman with mitral valve infective endocarditis complicated by embolism of the right common iliac artery underwent transfemoral embolectomy by a Fogarty catheter and mitral valve replacement. She developed occlusion of the right internal iliac artery, that was revealed by computed tomography on the 9th postoperative day. The occlusion was considered to result from migration of a part of the emboli from the right common iliac artery into the right internal iliac artery during the procedure of embolectomy. On the 16th postoperative day, she underwent repeat mitral valve replacement because of perivalvular leakage. Furthermore, after 2 weeks from the diagnosis of embolism of the right internal iliac artery, the embolic site showed aneurysmal formation finally requiring aneurysmectomy. Her recovery was uneventful. Our case is considered to be rare in that serial observations on computed tomography indicated the development of mycotic aneurysm at the site of septic embolism. In addition, care must be taken to prevent migration of emboli into branched arteries during the procedure of embolectomy for peripheral arterial septic embolism caused by infective endocarditis.

We report two cases of extended sandwich patch technique through right ventriculotomy for ventricular septal perforation (VSP). One was an 82-year-old woman. Preoperative coronary angiography showed occlusion of the left anterior descending artery proximal to the first major septal branch. Operative inspection revealed relatively extensive infarction of the anterior wall, a part of which had the appearance of free wall rupture. In the other case of an 85-year-old woman, the culprit lesion was occlusion of the left anterior descending artery distal to several septal branches and to the first diagonal branch. Despite their old age and emergency surgery in cardiogenic shock status, their postoperative recovery was uneventful. In the former case, however, echocardiography at the early postoperative phase revealed significant expansion and thinning of the infarcted anterior wall. Furthermore, serial observations showed deterioration of the left ventricular systolic function and mitral regurgitation due to leaflet tethering. In addition to secure VSP closure by transmural stitches, extended sandwich patch technique can offer geometric and functional preservation of postinfarction left ventricle. Although this can eliminate the risk of postoperative low output syndrome even if anterior infarction is extensive, late follow-up will be required because this technique can also allow postinfarction left ventricular remodeling.

A rare case of secundum type atrial septal defect associated with cleft of the anterior mitral leaflet in 63-year-old man is reported. The electrocardiogram showed right bandle branch block and indeterminate QRS axis. Preoperative cardiac catheterization revealed left to right shunt at the atrial level and moderate mitral regurgitation due to a cleft in the anterior mitral leaflet. Marked tricuspid regurgitation due to a dilated annulus concomitantly existed. The valve deficiencies were repaired and the atrial septal defect was closed at operation. Forty cases of secundum type atrial septal defect associated with cleft mitral valve were discussed about their electrocardiograms and operative indications.

Between January, 1975 and June, 1990, 67 patients underwent surgical treatment for infective endocarditis at our hospital. Of 67 patients, 27 patients showed active endocarditis at the time of operation. In these 27 patients, 20 had active endocarditis of the native valve (NVE), and the seven had active prosthetic valve endocarditis (PVE). The interval between onset of infective endocarditis and operation ranged from 7 to 252 days (mean, 36 days). In the operative results, 3 of 20 patients (15%) with NVE and 2 of 5 patients (40.0%) with PVE died before discharge from the hospital. According to analysis of preoperative hemodynamic state and bacteriological data, the determinant factors of operative mortality and morbidity were preoperative NYHA functional classification, the interval between onset of infection and operation, and annular destruction (annular abscess). Patient's age, preoperative renal function, positive blood culture, the site of infection, and positive culture or stain of the surgically excised valve did not play an important role to determine operative mortality and morbidity. It is our conclusion that all patients with infective endocarditis who develop progressive congestive heart failure and echocardigraphical extravalvular infection despite medical treatment, should have prompt valve replacement.

The operative results in case of aortic coarctation (CoA) were studied. Between June 1980 and June 1995, 37 children with CoA underwent surgical intervention during their first year of life in our institute. The aortic lesion was repaired by the subclavian flap (SCF) method in 27, direct anastomosis (DA) method in 7, grafting or other methods in 3 children, respectively. The mean follow up period was 7.4±5.3 years (6 months-13 years). Rate of re-stenosis of the aorta was 10% (2 in 20 children) after SCF method, 0% (0 in 7 children) after DA method. The stenotic lesion was successfully dilated by the percutaneous balloon reconstruction in one child. Perioperative mortality was 25% (1/4) in one-stage repair, while one-stage repair was successfully performed in the last three cases and 16.6% (3/18) in two-stage repair for CoA associated with ventricular septal defect (VSD). The mortality was 60% (6/10) of CoA associated with other complex anomalies. In conclusion, one-stage repair seems to be recommendable for the operation of CoA with VSD, and two-stage repair seems to be safe for CoA with complex anomalies.

Among 95 infants aged less than one year who underwent intracardiac repair for congenital heart disease at Kurume University Hospital between August 1990 and June 1995, a patients (3.9%) received primary elective open sternal (PEOS) and delayed sternal closure (DSC) after operation. 1) The mean interval for DSC was 4.3±0.9 (2-8) days, and DSC interval significantly correlated with the extracorporeal circulation (ECC) time. 2) Before DSC, patients became hemodynamically stable and requirements for inotropes and FiO₂ for mechanical ventilation decreased. 3) It was important to carefully manage fluid balance before DSC, and the balance after operation should be 0. 4) There was only one patient with mediastinal infection. Of the three patients who died in hospital the cause of death was pulmonary infection due to prolonged mechanical ventilation. 5) Both PEOS and DSC required careful postoperative management, but, the treatment seemed to improve postoperative results in cases in which postoperative hemodynamic status was unstable due to prolonged ECC.

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.

We studied the effects of intermittent tepid blood cardioplegia on patients with prolonged aortic cross-clamping. Forty patients undergoing coronary artery bypass grafting with cross-clamp time of greater than 120 minutes were studied. The patients were divided into two groups according to the cardioplegic solutions, cold (4°C) crystalloid cardioplegia (Cold) and tepid (30°C) blood cardioplegia (Tepid). Cardiac function, myocardial enzyme and clinical outcomes were compared between the groups. Mean aortic cross-clamp time were 150±10 minutes in the Cold group and 149±4 minutes in the Tepid group. Recovery rate of spontaneous rhythm after cross-clamp removal and postoperative left ventricular stroke work index were significantly greater in the Tepid group than those in the Cold group. Duration of ventilation and ICU stay were significantly shorter and total release of CK-MB, requirements of dopamine during 48 hours after the operation and the incidence of low-output syndrome were significantly less in the Tepid group. There were no early deaths in the Tepid group versus three early deaths in the Cold group. In conclusion, intermittent tepid blood cardioplegia provided superior postoperative cardiac function and clinical results to conventional cold crystalloid cardioplegia, thus the technique appears to be safe for patients requiring prolonged aortic cross-clamping.

Perioperative changes in thyroid function and hemodynamic state were studied in 6 hypothyroid patients and 15 euthyroid patients who underwent coronary artery bypass grafting. Serum free T₃ and total T₃ concentrations declined significantly in hypothyroid patients after the surgery. Serum total T₃ concentration decreased significantly also in euthyroid patients, indicating the occurrence of“euthyroid sick syndrome”in this group. Hypothyroid patients resulted in significantly lower left ventricular stroke work index despite greater central venous pressure and pulmonary capillary wedge pressure, and greater requirements of dopamine and dobutamine compared with those in euthyroid patients. The results indicated poorer postoperative cardiac performance in hypothyroid patients. Serum free T₃ concentration after cardiopulmonary bypass demonstrated a significant positive correlation with left ventricular stroke work index measured simultaneously. Preoperative serum free T₃ concentration showed a significant negative correlation with the postoperative dopamine and dobutamine requirements. Therefore, the results suggest that free T₃ has inotropic effects and the concentration of this hormone can be a predictor for a incidence of postoperative low cardiac output. In conclusion, since hypothyroid patients undergoing coronary artery bypass grafting are prone to have low cardiac output status, careful perioperative management, including hormone replacement therapy, is required for the patients.