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.

Coronary artery bypass grafting (CABG) was performed in 16 patients with impaired left ventricular function due to ischemic heart disease (IHD) and the surgical procedures and cardiac functions before and after operation were studied. Preoperative angiogram showed three vessel disease in all patients. The ejection fraction was less than 40% in all and the mean cardiac index (CI) was 1.97l/min/m². At operation arterial graft was used in 10 patients (Group-AG) and no arterial graft but saphenous vein graft was used in 6 patients (Group-SVG). The average total cardiopulmonary bypass time, aortic cross clamping time and the number of revascularized vessels in both groups showed no significant differences. However, intraaortic balloon pumping was necessitated in one of Group-SVG and the requirement of postoperative catecholamine was in higher ratio in Group-SVG than in Group-AG. Postoperative CI improved to 3.1±0.4l/min/m² and 3.3±0.3 l/min/m² in Group-AG and Group-SVG, respectively. The postoperative New York Heart Association Functional Class improved to Class I or II in all patients and there were no significant differences of the improvement between the groups. Conclusively, it seems that the arterial grafts can be used safely and extensively in CABG for impaired left ventricular function due to IHD.

Between May in 1988 and October in 1990, simultaneous coronary artery bypass grafting (CABG) and valve surgery was performed in 14 patients. Nine patients received arterial graft conduit for CABG (AG group) and only saphenous vein graft (SVG) was used in 5 patients (SVG group). In AG group, mean age was 63.3 years and the number of distal anastomosis was 2.2/patient. In valve operation, valve replacement was performed in 5 and valve plasty was in 4, and the mean aortic cross clamping time was 116min. As AG, internal thoracic artery (ITA) was used in 8 and right gastroepiploic artery (RGEA) was in 4. Among them concomitant use of ITA and RGEA was in 3, and the use of SVG was in 5. In two patients, the AG pedicle did not reach to either left anterior descending or obtuse marginal artery and the SVG was used as a graft conduit. Between AG group and SVG group, there were no significances in the age and aortic cross clamping time. However, postoperative use of cathecholamin was in three (33%) in AG group and three (60%) in SVG group and there were significant differences between them. In AG group, there were no operative deaths and the late NYHA improved to class I in 4 and class II in 5. In simultaneous CABG with AG and valve surgery, the improvement of symptom was good and stable operative result was obtained, however, the length of the pedicled graft should be carefully considered for coronary anastomosis.

Cardiac cachexia is a terminal clinical stage of valvular heart disease, and there is high incidence of postoperative mortality and morbidity. Cardiac cachexia was considered to be present when patients with mitral lesions showed all of the following criteria; 1. mitral valve disease associated with relative tricuspid regurgitation, 2. lean body below 80% of %standard weight, 3. NYHA functional class IV, 4. marked hepatomegaly and congestive liver dysfunction (ICG retention rate over 30%.) Ten patients satisfying the criteria were divided into two groups according to the interval of postoperative respiratory care. Group 1 (n=5), patients necessitating mechanical ventilation for more than 5 days after operation, Group 2 (n=5), patients requiring ventilation up to 5 days after operation. Pre- and postoperative nutrition, respiratory and circulatory states were evaluated for these two groups. In pre- and postoperative periods, intravenous hyperalimentation was administed in two groups, during the postoperative period, two patients of group 1 required tube feeding. In the pre-operative period, three patients in group 1 needed respiratory care (1 intra-tracheal intubation and 2 oxygen mask inhalation). The results were as follows; 1. The duration of illness was longer in group 1 than in group 2. 2. In the postoperative period, there was no difference in the amount of catecholamine, postoperative course and prognosis between groups 1 and 2. Surgery for valvular disease is possible even in cases of cardiac cachexia, if sufficient management of nutritional state, respiration and circulation can be maintained.

We evaluated the indications and limitations of IABP support for weaning for pump and postoperative heart failure after artificial valve replacement. Driving IABP as cardiac support in cases of acute cardiac failure during and after operation, it is most effective for transient cardiac failure-associated coronary artery spasms during and post operation, but it is not effective and is indeed limited for patients who need long term extracorporeal circulation because of operative technical failure, insufficient cardioplegia and delayed right ventricular failure after operation. The latter groups, in which IABP is insufficiently effective need additional assist devices such as V-A bypass and ventricular assist device (VAD).

A chronic traumatic thoracic aortic aneurysm, 19 years after a traffic accident was successfully treated. A 34-year-old man was admitted because of chest discomfort. An upper GI examination was performed and an esophageal submembranous tumor was suspected. However, a chest CT examination showed a thoracic descending aortic aneurysm, the maximum size of which was 7.5cm×5.5cm. The final diagnosis was chronic traumatic thoracic aortic aneurysm. Generally most cases of chronic traumatic thoracic aortic aneurysm have no symptoms for a long time after an accident. However, some have reported that the development of an aneurysm is due to not receiving treatment. We performed graft replacement using the temporary bypass method because it was an easy technique and required less heparinization. Chronic thoracic aortic aneurysms have lower risk of bleeding during the operation than acute cases. For chronic cases which have stable hemodynamics, adjunctive methods (e. g., partial extracorporeal bypass, left ventricular bypass and temporary bypass) may facilitate a safe operation.

The surgical anatomical bypass (ANA) procedures for juxtarenal aortic occlusion (JAO) have been recently developed. However, there are some critical conditions, in which we should be cautious concerning the indications of ANA. Between 1984 and 1993 in Kurume University Hospital, 17 patients with JAO were operated upon. The most common cheifcomplaint was claudication (70.6%). Acute deterioration due to ischemia was recognized in two patients (11.8%). ANA was performed in 15 patients (88.2%) and extra-anatomical bypass (EXT) in 2 with severe calcification of the aorta (11.8%). Hospital deaths occured in three patients with ANA (17.6%), whose background included two acute deterioration and one cerebral infarction with hemiplegia. As an early postoperative complication, acute renal failure occurred in one patient and subileus in two. In the presence of poor general condition, acute deterioration, or severe aortic calcification, the EXT-procedure is the choice of surgical treatment for JAO.

The results and surgical techniques were studied in 59 patients who had atherosclerotic lesions in the ascending aorta. Arterial grafting (AG) and sequential grafting for coronary artery bypass grafting (CABG) was used in as many as possible cases and the number of distal anastomoses with AG was 1.3/patient (internal thoracic artery (ITA), 56 anastomoses for 50 patients; gastroepiploic artery (GEA), 17; and inferior epigastric artery, 3). Calcification in the ascending aorta was noted in 26 patients and arterial cannulation was performed via the right axillary artery in 4 patients. Saphenous vein grafts were used for 51 patients and 30 of them required aortic reconstruction for proximal anastomosis. There were 2 hospital deaths (non-cardiac) and no neurological complications. It is difficult to perform CABG in the presence of atherosclerosis in the ascending aorta. However, the right axillary artery cannulation as the site of arterial cannulation and the use of sequential grafting, using ITA and GEA as the pedicled arterial conduits are useful to accomplish CABG in such patients. Neurological complication seems to be manufactured at a minimal level by cautious operative techniques.