Aortoduodenal fistula is rare complication of nonoperative abdominal aortic aneurysm. We successfully treated a case of primary aortoenteric fistula associated with Behcet's Disease with two surgical intervention. The patient was 41 years old man. He admitted to our hospital because of severe shock due to enormous gastrointestinal hemorrhage. Emergency laparotomy revealed the inflammatory abdominalaneurysm ruptured into the duodenum. As the saccular aneurysm was densely adherent with duodenum and retoroperitoneum, graft replacement was abandoned. Primary closure of the perforated area of duodenum and the neck of aneurysm were performed. Axillofemoral bypass restored blood flow of the lower extremities. Three month after the operation, aortoduodenal fistula recurred. On the second operation, abdominal aorta was divided through retroperitoneal approach. However, primary closure of the enteric perforation with graft replacement of the aorta is considered as the first choice of the surgical treatment for aortoenteric fistula. In a case of difficult condition such as this patient with severe shock or retroperitoneal fibrosis, repair of the duodenum wall and division of the abdominal aorta with axillofemoral bypass is an alternative method of choice.

Thirty-nine years old woman had a severe renovascular hyper-tension with Takayasu's arteritis Her left renal artery stenosis was treated with percutaneous transluminal angioplasty (PTA) three times. Six months after the third PTA, the left renal artery was occluded, and left renal failure occurred. Aorto-renal bypass surgery with a prosthetic graft was performed. Blood pressure dropped to normal range, and left renal function began to recover. Although PTA is an effective method in the treatment of renovascular hypertension, an incidence of restenosis after PTA is higher in Takayasu's arteritis rather than atherosclerotic lesions. Five months after renal revascularization, hypertension recurred in this case. However the aorto-renal bypass graft was patent accompanied by no symptoms. This aorto-renal bypass surgery can be considered effective in this condition.

Causative factors for thrombi formation in left atria of 38 patients with mitral stenosis who underwent mitral valve surgery (open mitral commissurotomy or mitral valve replacement) alone or in combination with other procedures were studied. There were 9 cases of left atrial thrombosis (LAT). Left atrial diameter was increased in LAT(+) group (6.1±1.6cm) compared with LAT(-) group (4.6±0.7cm). There was significant difference in the left atrial diameter between the two groups of patients (p<0.01). Cardiac output was decreased in LAT(+) group (3.04±0.74l/min) compared with LAT(-) group (3.99±1.07l/min). Cardiac output of LAT (-) group was significantly larger than that of LAT(+) group (p<0.05). Mean transition time of blood through left atrium (MTT_LA) was calculated using left atrial volume and cardiac output. In LAT (+) group, MTT_LA was significantly increased (6.2±3.9sec) compared with LAT(-) group (2.9±1.6sec). It is considered that, in mitral stenosis, prolongation of MTT_LA is one of the risk factors for thrombi formation in the left atrium.

Fifty-five adult patients with atrial septal defect (ASD) were surgically treated. In the preoperative study, 6 patients showed high pulmonary artery systolic pressure (>50mmHg). However, there was no linear relation between PAP and age, nor between Q_p/Q_s and PAP. As for the additional surgical procedures, MVR (1), MAP (1), TAP (3), OPC (2) were carried out with ASD closure in 7 patients. Post-operative evaluation with echocardiography revealed increase in the left ventricular chamber size, decrease in the severity of tricuspid regurgitation and same grade mitral regurgitation compaired with pre-operative level. From these data, the prediction of the atrioventricular valve regurgitation after ASD closure seemed to be difficult just from the preoperative evaluation, Transesophageal echocardiography was useful for the evaluation of residual atrioventricular valve regurgitation during operation in the cases of ASD with over II grade regurgitation preoperatively.

A thirteen-day-old neonate was admitted because of systolic heart murmur, tachycardia, tachypnea and sucking weakness. The chest X-ray film demonstrated remarkable cardiomegaly and pulmonary congestion. Echocardiography detected marked thickening and stenosis of the aortic valve, and left ventricular dysfunction (EF=10%). The pressure gradient between left ventricle and ascending aorta was presumed 130mmHg with pulsed Doppler echocardiography, Since he did not respond to conservative treatment, an emergency open aortic valvular commissurotomy under cardiopulmonary bypass was performed the day after admission. We made incisions of 1mm in the left side and 0.5mm in the right side commissure of the adherent bicuspid aortic valve. After the procedure, left ventricular function improved (EF=57%), and the pressure gradient was reduced to 62mmHg. He showed good recover from the congestive heart failure. There are few reports about operative treatment of congenital aortic valve stenosis in neonates. This is considered to be the third youngest successful operative case of open aortic valvular commissurotomy in Japan.

Prostaglandin E₁ (PGE₁) was used continuously in adults from immediately after induction of anesthesia, during extracorporeal circulation, to the acute phase after open heart surgery. Using blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core as indices, the effects of afterload reduction and improvement of peripheral circulation were investigated. Subjects were 17 adults who underwent open heart surgery. PGE₁ was used in 7 patients and not used in 10. In the group using PGE₁, continuous injection of 0.015μg/kg/min of PGE₁ was started immediately after induction of anesthesia and was maintained during extracorporeal circulation until the acute phase after surgery. During extracorporeal circulation, perfusion pressure was kept at 50∼60mmHg and PGE₁ injection was controlled within the range of 0.015∼0.030μg/kg/min. At completion of extracorporeal circulation, the dose was fixed at 0.015μg/kg/min again. The degree of improvement of peripheral circulation was evaluated on the basis of hemodynamics, blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core, at induction of anesthesia (before using PGE₁) on completion of extracorporeal circulation, and in the acute phase after surgery. The value of blood flow in the toe determined by laser Doppler flowmeter was significantly higher in the PGE₁ group than in the non-PGE₁ group, from completion of extracorporeal circulation to the acute phase after surgery. Moreover, peripheral temperature was significantly higher in the PGE₁ group than in the non-PGE₁ group at completion of the extracorporeal circulation as well as immediately after surgery, and the temperature difference between periphery and core was significantly smaller. Continuous injection of PGE₁ enabled smooth control of perfusion pressure during extracorporeal circulation. Although there was no significant difference in peripheral vascular and total pulmonary resistance, the coefficients tended to be lower in the PGE₁ group. The use of PGE₁ during open heart surgery seems to be an effective method to improve peripheral circulation.