The patient was an 89-year-old male who underwent transcatheter edge-to-edge repair to the mitral valve using MitraClip for severe degenerative mitral regurgitation (MR) one year earlier. Although two clips were implanted, grade III/IV MR still remained. As his heart failure progressed, he was referred to us for surgery. The patient also had aortic stenosis. He underwent mitral valve repair and aortic valve replacement. The postoperative course was uneventful. He was transferred to the referring hospital on postoperative day 14. When performing MitraClip for degenerative MR, it is important to consider carefully not only the operative risk for open surgery but also the anatomical adequacy of MitraClip. When MitraClip fails to control MR, early surgical intervention should be considered.

A 77-year-old man presenting with uremic acidosis was referred to our department for a misplaced vascular access catheter. Computed tomography revealed the catheter was passing through the subclavian artery and terminating in the ascending aorta. Under angio-fluoroscopic monitoring, a VIABAHN stent graft was deployed immediately after removing the catheter. The patient had no hemorrhagic complication although continuous hemodiafiltration was started just after surgery. His postoperative course was uneventful.

To test the hypothesis that neutrophils play a role in ischemia/reperfusion injury during heart surgery, granulocyte elastase and myeloperoxidase release from coronary circulation were measured before and after aortic cross-clamping. The production of granulocyte elastase and myeloperoxidase across the coronary circulation elevated significantly after release of aortic cross-clamp. Furthermore, the level of granulocyte elastase and myeloperoxidase released from coronary circulation demonstrated positive correlation with the duration of the aortic cross-clamp. These data indicate that neutrophils play a major role in ischemia/reperfusion injury occurring during heart surgery.

To test the hypothesis that neutrophils play a role in lung injury during cardiopulmonary bypass, granulocyte elastase and myeloperoxidase release from pulmonary circulation were measured, as well as the respiratory index, before and after cardiopulmonary bypass. The production of granulocyte elastase and myeloperoxidase in the pulmonary circulation, and the respiratory index also elevated significantly after cardiopulmonary bypass. Furthermore, the level of granulocyte elastase and myeloperoxidase released from pulmonary circulation correlated with the changes of the respiratory index and preoperative pulmonary artery pressure. These data indicate that neutrophils play a major role in pulmonary dysfunction occurring after cardiopulmonary bypass, which is accentuated in patients with pulmonary hypertension.

Six cases without aortic reconstruction for 48 hours were encountered among 22 cases of Stanford type A acute aortic dissection from April, 1990 to July, 1996. They were one man and five women, with a mean age of 60.3 years old (from 52 to 82 years old). According to Hagiwara's definition, acute thrombotic aortic dissection (ATAD) was observed in four and acute opacified aortic dissection (AOAD) in two of six cases of Stanford type A acute aortic dissection without aortic reconstruction. One of the four ATAD cases was well-controlled by medical therapy, but the others could not be controlled and underwent aortic root reconstruction within 1 month. Two AOAD patients died due to rupture within 1 month. It is said in general that the patients with acute thrombotic aortic dissection can be treated medically, but we consider that they should be treated surgically because of the frequency of late rupture.

From April 1990 to August 1995, 44 consecutive patients (25 males and 19 females; mean age, 63 years) who underwent surgery for Stanford type A aortic dissection, were studied to examine surgical results and postoperative quality of life (QOL). Ascending aortic replacement was performed in 22 patients and simultaneous replacement of the ascending aorta and the aortic arch in 22. The postoperative 30-day survival rate was 84% (37/44). Univariate analysis revealed that operation time (p<0.01), postoperative cardiac failure (p<0.02), respiratory failure (p<0.01), severe brain damage (p<0.01), and intestinal ischemia (p<0.02) were significant factors in increased operative mortality risk. Additional operative procedure was also a significant factor (p<0.05) all 3 patients with coronary artery bypass grafting died, while all 5 patients with the Bentall or Cabrol procedure lived. The factors which influenced postoperative QOL were preoperative renal damage (p<0.05), history of cerebral vascular disease (p<0.02), shock (p<0.02), postoperative renal failure (p<0.02), paraplegia (p<0.02), and residual dissection (p<0.02). The operation method, which was replacement of the ascending aorta or simultaneous replacement of the ascending aorta and the aortic arch, had no influence on postoperative QOL. Five of 22 patients receiving ascending aorta replacement had dissection only in the ascending aorta (localized type). The other 17 patients receiving ascending aorta replacement had dissections extending to the arch or descending aorta. The incidence of complications due to residual dissection was 5/17 (29%) in cases of replacement of the ascending aorta for type A aortic dissection, while it was 1/22 (5%) in cases of replacement of the ascending aorta and the aortic arch (p=0.0684). Simultaneous replacement of the ascending aorta and the aortic arch did not negatively affect the surgical results and postoperative QOL more than replacement of the ascending aorta, and there was lower incidence of postoperative complications due to residual dissection. If Stanford type A aortic dissection extends to the arch, simultaneous replacement of the ascending aorta and the aortic arch is recommended.

A chronic contained rupture of an infrarenal abdominal aortic aneurysm eroded a lumbar vertebra. A 53-year-old man complained of severe back pain for 6 months. Recently the back pain had increased. The patient looked well but a pulsatile mass in the abdomen was palpable. A CT and MRI of the abdomen and lumbar spine revealed the infrarenal abdominal aneurysm which demonstrated destruction of the third and fourth lumbar vertebra. At operation, there was a true aneurysm of the native aorta with a rupture of the posterior wall, resulting in a retroperitoneal hematoma. An orifice of the ruptured pseudoaneurysma was 2×2cm in size. An aortobiiliac graft was implanted. The patient did well postoperatively and was discharged on the 32nd postoperative day.

We investigated the quality of life (QOL) after thoracic or thoraco-abdominal aneurysmectomy in patients who had undergone the procedure within the past 15 years. We compared preoperative to postoperative performance status (PS). Defining PS in the following manner: one increase in that PS grade indicated mild worsening while an increase is by 2 or more indicated severe worsening. Maintenance was indicated by no change of PS after surgery. The QOL maintenance rate was calculated based on the following formula.
QOL maintenance(%)=No. of no change case/No. of operated cases-No. of death×100
There were a total of 74 cases in whom follow-ups could be carried out after surgery. Among them, there were ascending and aortic arch aneurysms in 19 cases, descending aortic aneurysms in 20 cases, dissecting aneurysms in 27 cases and thoraco-abdominal aortic aneurysms in 8 cases. The QOL maintenance rate in the type B dissecting aneurysms was comparatively high (85.7%). There were cases of severe worsening of PS in the ascending and aortic arch aneurysms and type A dissecting aneurysms and the QOL maintenance rate was 50% in each other. We should obtain high operative results due to improve the QOL maintenance rate, and devise the operative procedure without functional disorders of the organs after surgery.

Preoperative and operative evaluation of the arterial reconstructive tract is very important to obtain a high reconstructed graft patency rate after femoro-popliteal bypass. We analyzed the graft patency rate of 40 cases in which the graft flow was measured immediately after completion of arterial reconstruction. The mean graft flow was 122.6ml/min in patients with above-knee (AK) reconstruction and 57.4ml/min in those with below-knee (BK) reconstruction. In cases with AK reconstruction, the three-year cumulative patency rates of grafts with a blood flow of 120ml/min or more (n=12) or less than 120ml/min (n=11) were 100% and 80.8%, respectively (p<0.05). In cases with BK reconstruction, the three-year cumulative patency rates of grafts with a blood flow of 55ml/min or more (n=9) and less than 55ml/min (n=8) were 62.2% and 50.0%, respectively. All early occlusions (n=5) occurred in patients with BK reconstructions. Despite having a blood flow greater than 55ml/min, two cases became occluded in the early stage due to knee joint bending. It is considered that intraoperative measurement of the graft flow is one index to predict graft patency.

During the period between January 1975 and April 1991, 37 patients with acute arterial occulusion of the extremities were admitted to our department and were classified into 2 groups according to their causative factors, including thrombosis and embolism. Among 16 thrombosis patients with involvement of 17 limbs, 4 patients died and 6 limbs were amputated at the time of discharge. On the contrary, among 21 embolism patients with involvement of 25 limbs, 2 patients died and only one limb was amputated. Sixteen of 17 limbs with thrombosis were operated on. Arterial reconstruction was carried out initially on 5 limbs, resulting in successful limb salvage; 3 of 6 limbs which had undergone thrombectomy initially were occluded again soon after the procedure. In the end, 1 limb had to be amputated. On the other hand, 22 of 25 limbs were operated on. Three arterial reconstructions, 18 embolectomies and 1 amputation were carried out initially. All arterial reconstructions and embolectomies were successful. From these results, it was concluded that arterial reconstruction must be done initially for thrombosis patients. For the embolism patients, embolectomy is preferable.