OBJECTIVE:The purpose of this study was to determine the relationship between the aortic atheromatous plaque echo density and the incidence of postoperative stroke or embolic events in patients undergoing on-pump coronary artery bypass grafting (CABG).PATIENTS AND METHODS:Three hundred and fourteen patients who received on-pump CABG alone were studied. Images of the aortic plaques obtained using transesophageal echocardiography were transferred to a computer. Using an image analysis program, a histogram for plaques more than 3 mm in thickness was obtained through the gray tone frequency distribution of the pixels (0-225). The gray scale median (GSM) was used as a measure of plaque echo density.RESULTS:Fifty-eight plaques in patients not associated with postoperative stroke or embolic events had GSM ranging from 58 to 241 (151.0+/-38.2), while 9 plaques in patients associated with stroke or embolic events had GSM ranging from 67 to 130 (90.6+/-21.3, p<0.001). The incidence of stroke or embolism was 58.3% when GSM of plaque was less than 100, while it was 3.6% when plaque GSM was more than 100 (p<0.001).CONCLUSION:This study indicated that computer analysis of aortic atheromatous plaque was useful for selecting patients who had a high risk of postoperative stroke or embolism when receiving on-pump CABG, and for decreasing the incidence of them.

1998年までの4年間に, 早期に上行大動脈の解離腔の閉塞を認めたA型解離21例を対象とした. 原則的に降圧療法を行ったが, 上行大動脈径が50mmを超えるかまたは再解離をきたした時点で手術を行った. Entry の部位をCT, 血管造影, 手術所見などから判定し, 症例を DeBakey 分類のI型 (n=8), II型 (n=6), III型の逆行性解離 (IIIR, n=7) に分けて検討を加えた. 急性期死亡は2例あり, 内訳はII型の上行大動脈破裂1例, IIIR型の心房細動に起因する塞栓が1例であった. 発症2週間以内の急性期に4例, 発症2カ月以内の亜急性期に6例が手術となった. 病型はI型, II型が9例で, IIIR型は1例のみであった. 遠隔死亡は2例で, 1例はI型の遠隔期手術死亡, 他の1例は脳梗塞であった. 最長4年での手術の回避率はI型25%, II型21%, IIIR型83% (p=0.07) であった. A型解離は早期血栓閉塞型でも手術を前提として治療するべきであるが, 下行大動脈に明らかに entry を認めIIIR型と判断しうる場合には降圧療法を試みる価値があると考える.

破裂性真性胸部大動脈瘤に対し, 発症より14日以内に緊急手術を行った28例の治療上の問題点について検討した。内2例は感染性吻合部動脈瘤破裂であった。28例中15例が院内死した (院内死亡率53.6%) 。7例は術中に出血のコントロールがつかず台上死した。手術遂行可能例21例の院内死亡率は38.1%で上行, 弓部, 下行, 胸腹部それぞれ50%, 33.3%, 33.3%, 50%であった。術前ボリューム負荷にもかかわらず血圧の安定が得られぬまま手術に至った重症ショック例6例は全例死亡し, 内5例は台上死であった。また感染性吻合部動脈瘤破裂2例も出血のため台上死し, かかる症例の救命は極めて困難と考えられた。一方, 手術遂行可能例の手術成績を1991年1月前後で比較すると, 近年の手術手技や各種補助手段の改善に伴い, 院内死亡率は57.1%より28.6%まで改善し (p＜0.05), 成績の向上が認められた。

Obstruction of the right coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts (Cabrol method). Occlusion at the right coronary ostial anastomosis in a 36-year-old woman with aortitis syndrome who underwent a composite graft with a Dacron coronary graft is described. She underwent a third successful operation for right coronary reconstruction by minimally invasive direct coronary artery bypass grafting technique using the right gastroepiploic artery. This approach is likely to be extremely useful in avoiding resternotomy and cardiopulmonary bypass in patients requiring coronary reoperation.

We assessed the efficacy of emergency percutaneous cardiopulmonary bypass support (PCPS) in the treatment of patients with acute myocardial infarction complicated by cardiogenic shock. Emergency PCPS was instituted in 21 consecutive patients beginning in 1991. After the stabilization of the hemodynamics, coronary reperfusion was performed by means of coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. Of the seven patients with acute myocardial infarction involving either the left main or two-vessel territories, five survived more than 1 month, but only one patient remained alive and well after 20 months. The main cause of death for this group was low output syndrome. Four of 12 patients with acute left main trunkal occlusion in the catheter laboratory survived and showed a preserved cardiac function (mean followup 28.5 months). The main cause of death for this group was brain damage. Two patients with single-vessel territory acute myocardial infarction underwent PCPS to treat refractory ventricular fibrillation. Both patients were still alive and well at a 12-month followup. Percutaneous cardiopulmonary bypass support successfully stabilized the hemodynamics, allowing time to perform revascularization for all three groups of patients with life-threatening acute myocardial infarction. Recanalization was nevertheless unable to salvage the damaged myocardium in cases of prolonged ischemic time.

近年, 大動脈解離の治療成績は向上したが, 臓器虚血をきたした症例の治療成績は未だ不十分である. われわれは Stanford B型急性大動脈解離による腸管虚血症例に対して上腸間膜動脈 (以下SMA) へのバイパス術を行い良好な結果を得たので報告する. 症例は36歳, 男性, Marfan 症候群. 突然の激しい前胸部痛を自覚し, 近医を受診. CTにて Stanford B型大動脈解離の診断を受け, 当院を紹介された. 入院時, 強い腹痛とアシドーシスを認めた. 大動脈造影にて大動脈解離に伴う腸管虚血と診断した. 初回手術は腹部大動脈にて開窓術を施行したが, 効果不十分であったため, 翌日, 大伏在静脈グラフトを用いた左総腸骨動脈-SMAバイパス術を施行し, 血行再建に成功した. 本術式は侵襲が少なく簡便で効果の大きい術式であり, 大動脈解離に伴う腸管虚血に対する第一選択術式と考えられた.

A thirty-two-year-old woman was operated on for abdominal aortic aneurysm due to vasculo-Behqet's disease. Her aortography showed an aneurysm of curious eggplant-like configuration. At operation, the aneurysm was found to be adhered to the surrounding organ with the severely thickened wall. The diseased aorta was replaced with Y-shaped Dacron graft. Three anastomosis sites were apart from the inflammation and were rolled up with the Teflon felt for reinforcement. Pathology of the diseased wall showed an infiltration of the inflammatory cells with the small-vessel vasculitis due to Behqet's disease. She has had an uneventful postoperative course with a tapering corticosteroid therapy.

The surgical treatment of nine patients with infective endocarditis (IE) complicated by annular infection and five with IE complicated by cerebral infarction is described herein. In those with annular infection, after thorough débridement of the infected tissues, valve replacement was performed at the original position in five, at the supraannular position in three, and one underwent a translocation procedure. Aortic valve replacement was able to be performed at the original position in two patients by closing the defect at the aortic annulus with a patch after thorough débridement. The five patients who underwent original valve position replacement recovered well. Of the three who underwent supraannular position replacement, two died of septicemia after a redo operation, and one received pacemaker implantation. The patient undergoing the translocation procedure died of intestinal infarction. In the five patients who suffered cerebral infarction due to embolus of the vegetation, valve replacement was performed between 40 h and 5 months after its onset. Although one patient died of the rapid progression of brain damage, the other four are alive and well, including two who developed mycotic cerebral aneurysm in the infarcted areas. In conclusion, early surgery for IE is mandatory irrespective of active infection, due to the high mortality and morbidity associated with serious sequelae such as annular abscess or cerebral infarction.

症例は67歳の男性で, Leriche 症候群に対し Cooley double velour knitted Dacron を用いた右腋窩-両側大腿動脈バイパスが施行された. 10年10か月後にグラフト瘤を指摘され今回入院したが, 手術待機中に両下肢急性動脈閉塞をきたし緊急手術を行った. 両側深大腿動脈の塞栓摘除術に引き続き, 直径8mmの ringed PTFE による左腋窩-両大腿動脈バイパス, 右大腿動脈-膝窩動脈 in situ saphenous vein bypass および右腋窩動脈パッチ形成術を行った. 術後経過は良好であった. 1981年6月以前に製造された Cooley double velour knitted Dacron には, 遠隔期にグラフト瘤をきたす例があり, 注意深い長期の follow-up が必要と思われる.

Successful repair of a distal aortic arch aneurysm without aortic cross-clamping was carried out in a 74-year-old man, using a combination of special separate cerebral perfusion and retrograde coronary perfusion, termed non-clamping selective cerebral perfusion. We believe that satisfactory results following aortic arch surgery in elderly patients can only be achieved through the prevention of emboli derived from an aortic cross-clamping site, and shortened ischemic time of the vital organs.

Twenty-four patients with cardiac myxomas consisting of 22 left and 2 right atrial myxomas were operated on. All myxomas were removed with an excision of the attachment walls using a cardiopulmonary bypass. Two myxomas required a partial cardiopulmonary bypass from the femoral vein to the artery prior to operation because they were on the verge of becoming stuck in the atrioventricular valves and potentially causing shock. For embolic complications of myxoma, the embolus of the external carotid artery was extirpated before undergoing cardiac surgery. In a patient with pulmonary infarction, the infarcted lung was resected simultaneously. Another patient with a cerebral infarction received a clipping of an aneurysm which later appeared in the infarcted area. For associated cardiac lesions, two patients underwent a coronary artery bypass graft and one mitral valve replacement with tricuspid annuloplasty. In the former two cases, the myxoma was removed prior to coronary artery bypass grafting because the use of retrograde coronary perfusion was considered to be sufficient to protect the heart. In the latter case, the removal of the myxoma first disclosed a significant mitral lesion which had been masked by the huge myxoma. All patients but one, who died of pneumonia, showed a good recovery. In this series, the problems of surgical treatment for cardiac myxoma and associated lesions are also discussed.

Peroneal Artery Bypass Grafting through a Median Approach in Two Cases of Thromboangitis Obliterans Kenji Okada, Nobuhiko Mukohara, Kyoichi Ogawa, Tatsuro Asada, Masami Nishiwaki, Tetsuya Higami, Takaki Sugimoto and Tsuyoshi Kawamura (Division of Cardiovascular Surgery, Hyogo Brain and Heart Center, Himeji, Japan) In two cases of thromboangitis obliterans (TAO) a popliteal-posterior tibial-peroneal artery sequential bypass was attempted through a median approach. The 1st case underwent the operation successfully with non-reversed saphenous vein graft. However, only popliteal-peroneal bypass was carried out in the 2nd patient because the posterior tibial artery was severely affected. In surgery of TAO patients, careful assessment of preoperative angiographic findings is important to select the site of distal anastomosis. We found that the posterior tibial artery and the peroneal artery are easily accessible through the medial route in the proximal half of the lower leg and that peroneal artery revascularization was effective for limb salvage. Jpn. J. Cardiovasc. Surg. 23: 122-124 (1994)

A true aneurysm of the deep femoral artery is very rare among peripheral aneurysms because of its anatomical position and characteristics of wall tissue. An early operation is mandatory because it has a tendency to become a large size and to rupture. During the last eight years, we experienced two cases. One ruptured case underwent only resection of aneurysm and another case received an additional reconstruction of deep femoral artery using saphenous vein graft. Both of them are doing well postoperatively. In this paper, a review of 24 cases including these two in Japanese literature was discussed.

過去3年間に遠心パンプによる左心バイパスを補助手段として18例の胸部下行大動脈瘤患者に手術を行った. うち14例に術中大量出血時の急速輸血の目的で自家血返血システム (autotransfusion system) (ATS) を使用したが今回その利点および結果を検討した. ATSには体外循環の吸引回路を応用し, 2,000mlリザーバーと熱交換器を組み込んだが, この際ヘパリンを2mg/kg投与しACTを400秒以上に保った. 14例全例が生存した. ヘパリン大量投与による合併症として術中肺出血が3例にみられたが, これが原因で死亡した例はなかった. ATS使用例では瘤切開に伴う大量出血に際し血行動態は保たれ, バイパス中の体温は0.08±0.59℃上昇した. 遠心ポンプによる左心バイパスは胸部下行大動脈瘤手術の補助手段として有用であった. また, 自家血返血システムは術中大量出血への対応が容易で, 体温低下を防止できる利点があった.