Background and aim of the study: Treatment for hypertrophic obstructive cardiomyopathy (HOCM) has been reported; however, there has been no report on the characteristics of medication-responsive and -refractory hypertrophic obstructive cardiomyopathy (HOCM). Using the classification of systolic anterior movement (SAM) which has been previously reported, we tried to identify the characteristics and use them to treat HOCM appropriately. Methods: The clinical, echocardiographic, catheterization, and surgical data of 29 hospitalized patients with HOCM during 1980 to 1999 were analyzed retrospectively. We classified SAM in all patients by echocardiography. Ninteen patients improved with medical treatment (medical group), and 10 patients underwent surgical treatment because of ineffectiveness of medication (surgical group). We studied the relation between types of SAM and medical/surgical groups, and examined the relation between types of SAM and the surgical methods. Results: Type I SAM was significantly more frequent in the medical group, while type II SAM was more frequent in the surgical group (p = 0.047). Patients in the surgical group underwent mitral valve replacement (MVR), myectomy, or a combination of MVR and myectomy. Left ventricular outflow gradient (LVOG) of over 100 mmHg was recognized in almost all patients with type II SAM. Conclusions: It was suggested that patients with medication-responsive HOCM tended to have type I SAM and those with refractory HOCM tended to have type II SAM. We consider that in type I SAM, if the position of the papillary muscles changed with medication or myectomy, shift of the chordae and type I SAM were reduced or disappeared. However, in type II SAM, even if the position of the papillary muscles changed, SAM did not disappear because lifting of the mitral leaflets remained. It is therefore suggested that patients with type II SAM should undergo at least MVR.

OBJECTIVE The aim of this study was to evaluate the late results of left ventricular (LV) aneurysm repair. METHODS From July 1968 to 1999, 86 consecutive patients (74 male, 12 female, mean age 56.0 +/- 9.3) underwent LV aneurysm repair at our institute. The surgical methods were as follows; linear repair in 71 patients, endoaneurysmorrhaphy in 5, endoventricular circular plasty in 4, Jatene method in 1 and plication of aneurysm in 5. Thirty-nine patients underwent concomitant myocardial revascularization. Major arrhythmias occurred in 38 patients. The results were retrospectively reviewed and follow-up was achieved in 95.3%. RESULTS There were 6 operative deaths and 4 hospital deaths. Actuarial survival rate including the 10 deaths was 72.7% at 5 years and 46.3% at 10 years. In patients with coronary artery bypass grafting (CABG), survival rate was 82.2% at 5 years and 56.3% at 10 years, and was significantly higher than that in those without revascularization (p = 0.01). In patients without arrhythmias, survival rate was 79.2% at 5 years and 55.0% at 10 years, and was significantly higher than that in patients with arrhythmias. CONCLUSIONS The patients were not homologous and the techniques were not the same; however, in spite of these study limitations, patients who underwent revascularization, and were without major arrhythmias preoperatively, had better long-term survival.

A 57-year-old man suspected of having angina pectoris underwent coronary angiography and comprehensive examination, which revealed a right-side aortic arch accompanying Kommerell diverticulum and a aberrant left subclavian artery. Esophagography indicated that the esophagus was compressed on its right posterior side and the computed tomography (CT) revealed that the posterior side of the tracheal was compressed, however, the patient experienced no difficulty in breathing, hoarseness of voice or dysphasia. The size of the aortic diverticulum was less than 5 cm and the patient showed no symptom, however, if it was left untreated, there was a risk of rupture in the future. Also the esophagus and tracheal may develop complications due to prolonged compression. Therefore, we decided that the case required surgical operation. Total arch replacement was performed through mediastinotomy and right posterolateral in the 4th intercostal. The postoperative condition was good, and the patient was discharged without any complications.

The aim of this study was the evaluation of the thrombogenicity and the biocompatibility of the SunMedical EVAHEART left ventricular assist system (LVAS) coated with 2-methacryloyloxyethyl phosphorylcholine (MPC) polymer compared to a diamond-like carbon (DLC) coating. Four calves were implanted with the MPC polymer-coated LVAS. Eight calves were implanted with DLC coated LVAS. The thrombogenicity and biocompatibility of the pumps were evaluated. At explant, 60.0 +/- 37.2% (5-85%) of the pump surface area was still coated with MPC polymer after the duration of 45.0 +/- 32.0 days. In 1 out of 4 MPC and 2 out of 8 DLC coated pumps, there was a very small amount of thrombus around the seal ring; otherwise the blood contacting surfaces were free of thrombus. Major organs were normal except for a few lesions in kidneys from both groups. The MPC polymer coated EVAHEART LVAS seems to have low thrombogenicity and high biocompatibility similar to the DLC coated system. The current study demonstrated that the MPC polymer coating shows great promise for being used as an antithrombogenic substrate for the LVAS due to its ease of application, significant cost benefit, and reduction in anticoagulation therapy in acute postoperative period.

AIMA review of past and current operative procedures for the treatment of aneurysms of the distal aortic arch is presented in conjunction with a series of 43 patients. In this study, distal aortic arch aneurysm refers to an aneurysm involving at least the origin of the left subclavian artery, but not extending beyond the left common carotid artery. We excluded dissection aneurysm and extended aneurysm to the descending thoracic aorta from this study.METHODSBetween January, 1985, and March, 2000, 43 consecutive patients (37 males, 6 females; mean age 67.5 years) underwent repair of aneurysms of the distal aortic arch. The approach to the aneurysm was through a left thoracotomy in 4 patients and a median sternotomy in 39 patients, including an additional left thoracotomy continued to a median sternotomy in 2 patients. The supportive methods during surgery were left heart bypass using a centrifugal pump in 4 patients (LHB group), cardiopulmonary bypass with selective cerebral perfusion in 11 patients (SCP group), and cardiopulmonary bypass with continuous retrograde cerebral perfusion in 28 patients (RCP group). In the RCP group, the "aortic no-touch technique" was applied in 21 patients. The operative methods were patch closure in 4 patients, graft replacement of the distal arch using the inclusion technique in 14 patients, and total arch replacement using the exclusion technique in 25 patients.RESULTSThere were 5 hospital deaths: 1 patient in the LHB group, intractable bleeding; 1 patient in the SCP group, rupture of the distal anastomosis; 3 patients in the RCP group, stroke, rupture of the dissection arising from the distal anastomosis, and perioperative myocardial infarction. Stroke occurred in 1 patient (25%) with LHB, 3 patients (27.2%) with SCP, and 1 patient (3.6%) with RCP. Among the postoperative survivors, a new onset of left recurrent nerve palsy occurred in 2 patients (66.7%) with LHB, 1 patient (10%) with SCP, and in 1 patient (4%) with RCP. No neurological injury or left recurrent nerve palsy occurred in the patients who underwent the "aortic no-touch technique".CONCLUSIONTotal arch replacement with the graft exclusion technique under profound hypothermic circulatory arrest using RCP through the median sternotomy is a promising surgical treatment for atherosclerotic distal aortic arch aneurysm. The "aortic no-touch technique" further improved the surgical results of the distal aortic arch aneurysm.

From March 1996 to May 2000, 41 patients [age 39-78 (mean 63.5 +/- 8.8) years, 90.2% male] underwent all arterial multiple coronary artery bypass grafting (CABG) using bilateral internal thoracic (BiITA) and radial (RA) arterial conduits. The reason for using RA was that the right gastroepiploic artery (RGEA) was small or occluded on preoperative angiography, a history of upper abdominal surgery or disease, or the right coronary arterial lesion was proximal and mild. The BiITA were used as in situ grafts and the proximal anastomosis of RA was to the ascending aorta in all cases. All patients underwent conventional elective CABG with median sternotomy using cardiopulmonary bypass. The mean number of anastomoses was 3.3 +/- 0.5 branches and complete revascularization rate was 80.5%. Postoperative follow-up averaged 20 months and the longest was 50 months. There was no early death, and overall graft patency 2-3 weeks after surgery was 96.2% (LITA 94.0%, RITA 97.6%, RA 97.6%). Four-year actuarial survival rate was 96.4 +/- 3.5% (1 patient: 9 months, no cardiac death), and cardiac event-free rate after surgery was 89.7 +/- 4.9% [4 patients: percutaneous transluminal coronary angioplasty (PTCA)]. However, once patients were discharged from hospital, cardiac event-free rate was 100%. These excellent results suggest that all arterial graft CABG was satisfactory, and RA can be used as a third suitable arterial bypass conduit, if RGEA cannot be used or is unsuitable for use.

Background Although some surgeons prefer to use artificial valve rings for tricuspid valve annuloplasty, we have mainly performed De Vega's tricuspid annuloplasty for functional tricuspid regurgitation, because it is a simple and effective technique for reducing tricuspid regurgitation due to annular dilatation. We evaluated long-term results of the De Vega's tricuspid annuloplasty up to 19 postoperative years.Methods. Between January 1980 and June 1999, 408 patients underwent De Vega's tricuspid annuloplasty. Long-term results after De Vega's tricuspid annuloplasty were analyzed.Results. There were 14 (3.4%) early deaths within 30 postoperative days. There were 63 (15.4%) late deaths during the follow-up period. The actuarial survival rate at 15 years after operation was 74.0%, the 15-year freedom from re-operation was 91.6%, and the 15-year freedom from all events was 58.7%, respectively.Conclusions. These results suggest that De Vega's tricuspid annuloplasty was an effective and reliable procedure of choice for secondary tricuspid regurgitation with annular dilatation.

Dissecting aneurysm of the ventricular septum as a complication after myocardial infarction (MI) is very rare. The patient was a 70-year-old women who was diagnosed with acute inferior MI. Three months after MI, catheterization showed a left ventricular aneurysm of the inferior wall, and left-to-right ventricular shunt flow was detected in the aneurysm. Echocardiography showed that the inferior left ventricular free wall was aneurysmal and dissected from the septal wall. Nine months after MI, chronic heart failure was uncontrollable by medication. At surgery, a tear (5 mm long) in the dissecting aneurysm of the ventricular septum was found and closed directly using 2 felt patches, and aneurysmectomy was performed using felt strips. The postoperative course was uneventful and she has been free from any complication for over 1 year.

BACKGROUND:In the present study we analyzed the in vivo performance of the 19-mm St. Jude Medical Hemodynamic Plus aortic prosthesis (19HP), evaluated the midterm performance of 19HP in the aortic position, and compared the implantability and hemodynamic characteristics of this valve with those of the 21-mm standard St. Jude Medical valve (21SD) in adult patients with aortic stenosis and a narrowed aortic annulus.METHODS:From February 1994 to December 1999, 60 patients who underwent isolated aortic valve replacement with either the 19HP (n = 31) or the 21SD (n = 29) were studied. Comparison between the two models included analysis of early and late mortality and morbidity. Pre- and postoperative echocardiography was performed in all patients to evaluate and compare the hemodynamic performance of both prosthetic valves. The postoperative serum lactic dehydrogenase activity was measured in both groups of patients as an indicator of hemolysis.RESULTS:The mean body surface area was 1.46 +/- 0.16 m2 in the 19HP group and 1.49 +/- 0.13 m2 in the 21SD group (p = 0.1577). Other than female dominance in the 19HP group, there was no statistically significant difference between the two groups in terms of preoperative variables (age, preoperative pressure gradients, and New York Heart Association functional class). The average postoperative peak pressure gradient was 23.3 +/- 10.5 mm Hg in the 19HP group and 27.9 +/- 9.9 mm Hg in the 21SD group (p = 0.0666). There was no hospital death in either group. Six-year follow-up was completed in both groups of patients. Late death occurred in 1 patient in the 19HP group (1.09% per patient-year). Actuarial survival at 6 years was 92.3% +/- 7.4% in the 19HP group, and 100% in the 21SD group (p = 0.33). The linearized complication rate was 1.09% per patient-year and 1.02% per patient-year for thromboembolism, and 1.09% per patient-year and 1.02% per patient-year for anticoagulant-related hemorrhage in the 19HP group and the 21SD group, respectively. Freedom from all complications at 6 years did not show any significant difference between the two groups (p = 0.54). Although left ventricular mass indices decreased significantly after aortic valve replacement in both groups (19HP group, p = 0.0002; 21SD group, p = 0.0006), there were no significant differences in the two indices between the groups after aortic valve replacement (p = 0.999). There was no significant difference in the lactic dehydrogenase level between the two groups (p = 0.4915).CONCLUSIONS:In vivo hemodynamic performance of the 19HP valve as well as the early and intermediate clinical outcome up to 6 years was satisfactory and corresponded closely to that of the 21SD valve in adult patients. The 19-mm Hemodynamic Plus model can be recommended in patients with a measured 19-mm annulus and this valve will minimize the need for the aortic annular enlargement procedure.

We experienced two cases of rupture of an abdominal aortic aneurysm during the early postoperative period of coronary artery bypass grafting (CABG). A 71-year-old man on hemodialysis (HD) was diagnosed with ischemic heart disease (IHD) and abdominal aortic aneurysm (AAA) of 70 mm in size. After CABG, he developed symptoms of acute pancreatitis and died of rupture of AAA on the 12th postoperative day. A 74-year-old man with early gastric cancer was diagnosed with IHD and AAA of 70 mm. After CABG and gastrectomy, he died of rupture of AAA due to anticoagulant therapy on the 3rd postoperative day. One-stage operation should be performed in patients with IHD, AAA more than 60 mm in size and other organ disease. It is important to control blood pressure and anticoagulant therapy appropriately during the early postoperative period when graft replacement for AAA is not performed simultaneously. Careful observation is required to establish the differential diagnosis of acute pancreatitis and impending rupture of AAA in patients on HD.

Objectives; The aim of this study is evaluation of thromboembolism and histology of major organs under long-term heart assist with continuous flow left ventricular assist system (LVAS). Methods; Continuous flow LVAS were implanted in 10 calves. There were two groups. Group S: Short-term assist <1 month and group L: Long-term assist >4 months. At the end of each study, histopathology was performed on major organs to evaluate thromboembolism and effects of continuous flow VAD support. Results; Mean assist duration was 17.6(15–21) days in group S (n=3) and 167.3(141–223) days in group L (n=7). There was no difference between these two groups in pump flow rate and pulsatility index ((systolic blood pressure-diastolic blood pressure) /mean blood pressure). With the exception of renal infarcts, no thromboembolism was found in either group. There was no pathological changes in major organs in group S, but all of group L calves had chronic interstitial nephritis and two of them had marked hypertrophy of smooth muscle cell in small renal arteries. Two of group L had myocardial atrophy. Liver, spleen, gastrointestinal tract were all normal in both groups. Conclusion; Our results suggest the possibility of hypertrophy of small arterial structure in long-term assist with continuous flow LVAS. However, since it is not clear whether these changes are primary or compensatory due to atrophy with diminished pulsatility, further research will need to be done.

A 36-year-old male with Marfan syndrome succesfully underwent Bentall operation and aortic arch replacement using a stent graft as an elephant trunk. He had received MVR with sternum turn over 14 years previously. Median sternotomy was performed. Under circulatory arrest with rertograde cerebral perfusion we performed Bentall operation and aortic arch replacement using a stent graft. The sternum was cured well. Retractive breathing was not detected. This surgical procedure was effective for cardiovascular disease with Marfan syndrome.

Cardiac hemangiomas in the left ventricle are extremely rare. A 34-year-old woman, without symptoms, with a diagnosis of cardiac tumor at the apex of the left ventricle was referred to us. The tumor was surgically resected, and the diagnosis was hemangioma. The Jatene technique, originally introduced for left ventricular aneurysmectomy was excellent for repair after resection of a cardiac tumor at the apex.

Coronary ostial stenosis between an interposition graft and coronary artery is rare and fatal. A 46-year-old woman who had reconstruction of both coronary arteries using interposition grafts for type A acute dissecting aneurysm presented with acute chest pain. Emergent coronary artery bypass grafting was done with saphenous vein grafts. Inappropriate use of gelatin-resorcinol-formaldehyde glue can be associated with ostial stenosis in the long term. Transesophageal echocardiography is useful to diagnose ostial stenosis of the coronary arteries.

A 62-year-old man diagnosed as dissecting aneurysm (DeBakey type IIIb) with visceral is chemia was transferred to our hospital. He had suffered from abdominal pain and the absence of right femoral pulse. Emergent laparotomy revealed no evidence of visceral infarction. Right axillo-femoral bypass was performed. However, visceral ischemia gradually progressed. Enhanced CT and angiography showed that celiac artery and supramesenteric artery (SMA) were collapsed. He underwent graft replacement of thoracoabdominal aorta involving visceral arteries with femoro-femoral bypass with a centrifugal pump as an ajunct. The visceral arteries were reconstructed. Postoperative CT revealed sufficient flow of branch arteries. He recovered well without complication and then discharged.

A 30-year-old man was diagnosed to have an anomalous origin of the right coronary from the pulmonary artery. Through a mini-sternotomy, without extracorporeal circulation, reimplantation of the anomalous origin of the right coronary artery from the pulmonary artery to the aorta was successfully performed. This is a successful case of off-pump cardiac correction of this type of isolated anomaly, using a minimally invasive approach.

This study was proposed to define early and long-term results of coronary artery bypass grafting (CABG) in dialysis-dependent renal failure (RF) patients, and preoperative patient characteristics. This study included 105 patients (87 males and 18 females; mean age 60.0 +/- 9.0 years, range 39-79) with RF on maintenance dialysis (hemodialysis 100, peritoneal dialysis 5) who underwent isolated CABG between August 1985 and April 2000. Postoperative follow-up was completed in 100% and averaged 3.1 years. There were 22 emergency and 2 re-CABG cases. Previous myocardial infarction (MI) was found in 55 patients (52%), and unstable angina was noted in 53 patients (50%). Diabetes mellitus was the cause of RF in 50 patients (48%; 24 patients required insulin). There was 1 case of single vessel disease, 31 cases of double vessel disease, 54 cases of triple vessel disease, and 19 cases of left main disease. Preoperative left ventriculography was performed in 92 patients (88%). Left ventricular ejection fraction (LVEF) was 48.3 +/- 15.8% (range 11-74%) and was 40% or less in 25 patients (27%). The mean number of distal anastomoses was 2.5 (range 1-5). Three patients received only vein grafts, but all were cases of emergency CABG. The remaining 102 patients (97%) received at least 1 arterial conduit. Among them, 64 patients received only arterial conduits, and 72 patients received 2 or more distal anastomoses with arterial conduits. Five patients (4.8%) died within 30 days after CABG (2 cardiac deaths and 3 noncardiac deaths), and 8 patients (7.6%) died beyond 30 days after CABG before discharge (all noncardiac deaths). The cause of 2 cardiac deaths was abrupt circulatory collapse during or after hemodialysis in patients with severe left ventricular dysfunction (LVEF; 11% and 28%) in the early postoperative period. The causes of 8 noncardiac deaths included infection in 4 and rupture of aortic aneurysm, stroke, sleep apnea syndrome, and mesenteric infarction. During the follow-up period, there were 29 late deaths (8 cardiac, 13 noncardiac, and 8 sudden death), 6 MIs, 13 percutaneous transluminal coronary angioplasty, and 1 re-CABG. The 5-year actuarial survival rate was 59.8%, the cardiac death-free rate was 83.0%, and the cardiac event-free rate was 62.4%. Although CABG in patients on hemodialysis is associated with high early and long-term mortality in terms of both cardiac and noncardiac deaths in proportion to the severity of the preoperative condition, long-term survival was still better than that of general dialysis patients. Meticulous perioperative management may be the key factor in the improvement of early results.

We have converted the current bulky open-circuit “on-the-floor” type cardiopulmonary bypass (CPB) into a compact (priming volume; 700 ml) closed-circuit “on-the-table” type CPB using centrifugal pump (CP). For volume adjustment, we incorporated a shunt circuit equipped with a soft reservoir with two legs, between the drainage and perfusion lines. Usually these two legs are closed and when we want to return volume to the patient, the leg connected to the drainage line is opened. The blood in the reservoir enters the main circuit under the negative pressure created by CP. On the contrary, when we want to withdraw volume from the patient, the leg connected to the perfusion line is opened and the volume will enter the soft reservoir from the main circuit. To remove air bubbles sucked into the drainage circuit effectively, we added one more bubble trap into the drainage line in addition to the arterial filter. The small roller pump is rotated when air bubbles are sucked into the drainage line. The effectiveness of this system was evaluated in a canine model at a flow rate of 3 L/min. Following bolus injection of air into the drainage circuit, the ultrasound microbubble detector (CMD-20, Hatteland, Norway) did not detect air bubbles of larger than 20 micrometer size even when 60 ml of air was Injected. However, microbubbles up to 80 micrometer were detected when microbubbles created by shaking mixture of 20ml air and 20 ml blood was injected although no macroscopically recognizable air was noted. In conclusion, although the development of effective microbubble remover is desirable, this new system will open new horizons for CPB because of its compactness, less contact with foreign surfaces and ease of handling.

Colforsin daropate hydrochloride (COL) is a novel drug for the treatment of acute heart failure. COL stimulates adenylate cyclase directly and produces positive inotropic and vasodilator effects accompanied by the increase in cellular cAMP. We investigated its cardiovascular effects for 9 patients who showed low cardiac index (< 3.0 l/min/m2) after open-heart surgery in ICU. After 2 or 3 hours from administration of COL, heart rate and cardiac index increased, and pulmonary artery pressure and central venous pressure decreased significantly, but blood pressure and systemic venous oxygen saturation did not show significant change. In conclusion, COL improved hemodynamics through positive inotropic and vasodilator effects without hypotension. We should investigate more proper usage of this drug to avoid such side effects as tachycardia and arrhythmia, which occurred in some cases.