Ankylosing spondylitis is chronic, progressive, inflammatory disease involving the spine, peripheral joints, and periarticular structures. Cardiac abnormalities associated with ankylosing spondylitis are well recognized, but a case with DDD pacemaker implantation for complete atrioventricular block and aortic valve replacement for aortic regurgitation has not been previously reported. We report a case of a 66-year-old man with ankylosing spondylitis who was successfully treated by DDD pacemaker implantation for complete atrioventricular block and aortic valve replacement for severe aortic regurgitation.

Bicuspid aortic valve (BAV) is one of the more common congenital anomalies. It is well known that the ascending aorta and aortic root sometimes dilate in patients with BAV, even when the valve function is normal. We examined the morphological type and histological features of the dilated ascending aorta in patients with BAV. Of 276 patients who underwent aortic valve replacement (including coronary artery bypass grafting) from 2004 onwards, 60 (21.5%) with BAV were included in this study. The type of BAV was defined according to the Sievers classification. Type 1 BAV was the most common, and enlargement of the ascending aorta (≥45 mm) was the most common in the L/R type of BAV (48%). The morphology of the dilated ascending aortic wall was evaluated using three-dimensional CT angiography. The majority of dilations were asymmetric, but dilation was symmetric in the patient with dilation of the aortic root. Histological examination graded cystic medial necrosis of the ascending aortic walls using the aortic wall score. All patients with BAV had degeneration of the aortic wall, even when there was no dilation. The aortic walls of patients with dilated aortic roots showed advanced degeneration compared with the aortic walls of other patients. Therefore, aggressive root replacement may be appropriate, when the root is mildly dilated in patient with BAV.

This study aimed to clarify whether continuous hemodiafiltration (CHDF) or hemodialysis (HD) was more effective after open heart surgery in dialysis patients. We evaluated 48 consecutive hemodialysis patients (28 men and 20 women, mean age : 68±10 years) who underwent coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) between January 2003 and December 2008. The patients were divided into 2 groups according to their postoperative dialysis treatment either continuous hemodiafiltration (CHDF) (CHDF group, n=36) or hemodialysis (HD) (HD group, n=12). Surgery in the CHDF group included 13 concomitant operations, 16 CABGs and 7 AVRs. There was only 1 concomitant surgery in the HD group, and there were 6 CABGs and 5 AVRs. There was no difference between the 2 groups regarding operation time, aortic clamp time, cardiopulmonary bypass time or intraoperative volume balance. CHDF was started significantly earlier than HD (8.0±5.8 vs. 21.0±1.0 h, p <0.01), which resulted in the removal of a greater volume of body fluid, during the first postoperative 24 h in the CHDF group (1,200±110 vs. 550±50 ml, p <0.01). However, there was no difference between the 2 groups regarding the amount of postoperative chest drainage. There were 6 hospital deaths in the CHDF group (17% ; 3 heart failures, and 1 each of pneumonia, arrhythmia and massive intestinal necrosis). There was also 1 hospital death in the HD group (8.3% ; heart failure). Most of the hospital deaths occurred after concomitant operations (6/7, 86%). It is beneficial to start CHDF soon after open heart surgery in hemodialysis patients.

We successfully performed aortic root replacement in an asymptomatic 52 year-old man with dilatation of the Valsalva sinuses (75 mm). The patient had previously undergone a radical operation for the tetralogy of Fallot at 13 years of age and AVR at 46 years of age. Massive bleeding occurred in the lungs after weaning from CPB. Emergency bronchoscopy revealed that the bleeding came from the right middle and lower lobes. The bleeding was stopped conservatively on POD 3 ; however, V-V ECMO was started on POD 5 because of severe hypoxia. ECMO was successfully weaned on POD 11 and he discharged on POD 59. The presence of developed bronchial collaterals and barotrauma during the operation were speculated the causes of the bleeding from the right lung.

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.

Coronary artery bypass grafting (CABG) in elderly patients has been increasing in recent years. Between June 1981, and February 2004, 32 patients aged 80 years or older (mean 81.8) underwent CABG in our hospital. Twenty one patients (67%) were in New York Heart Association class III or IV. Incidence of emergency surgery in the elderly (17 of 32, 53%) was significantly (p<0.0001) higher than that in younger patients (131 of 969, 13.5%). Total hospital deaths were 19% (6 of 32, emergency procedures 5, elective 1). The hospital deaths in patients with an ejection fraction (EF) of 45% or more (5 of 12, 42%) were significantly (p<0.05) higher than those in patients with an EF of more than 45% (1 of 20, 5%). The main features of CABG in octogenarians was the high rate of emergency surgery and high mortality. Thus CABG in octogenarians should be performed early, before the cardiac function deteriorates, in order that treatment not be denied because of age alone.

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.

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.

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.

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.