Itsuro Yamagishi

Surgical Treatment of Isolated Secundum Atrial Septal Defect in Patients More Than 50 Years Old

BACKGROUND Arrhythmia-related thromboembolic accidents continue to occur in patients even after closure of secundum atrial septal defect. Older age is usually not a contraindication to the repair of an atrial septal defect. To assess the importance of the type of management in elderly patients with atrial septal defect our clinical experience is reviewed. METHODS Between 1974 and 1994, 49 patients 50 years of age or older (average, 57.4 years) underwent surgical closure of secundum atrial septal defect. All patients have been followed up for 2 to 21 years (mean, 9.7 years). RESULTS There were no operative deaths. Functional classes in most of the patients were improved after operation. There were two cerebrovascular thromboembolic accidents with one permanent neurologic dysfunction, hemiparesis, and one septal dehiscence in the early postoperative period. One patient (2%) died of renal failure 6 years after operation, late arrhythmias developed in 3 patients (6%), 3 patients had a late stroke (6%), and 1 patient was not available for follow-up. CONCLUSIONS Long-term operative results are satisfactory and beneficial to the quality of life in elderly patients. Because there is no safe and effective nonsurgical alternative to surgical closure, atrial septal defect repair in elderly patients without severe pulmonary vascular disease should not be delayed once the diagnosis had been made.

Dacron Coronary Graft Obstruction After Composite Graft Replacement of Aortic Root

Obstruction of the left 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. Intimal proliferation caused by the turbulent blood flow at this site may be the cause of the obstruction, which is considered a possible cause of late cardiac events such as sudden death and global myocardial infarction. We describe a case of tight stenosis at the left coronary ostial anastomosis in a 38-year-old woman with Marfans syndrome who had undergone a composite graft replacement that employed separate Dacron coronary grafts.

Hypoproteinemia caused by tricuspid regurgitation: Report of a case

A case of tricuspid regurgitation (TR) complicated by severe hypoproteinemia is presented herein. A 68-year-old man who had undergone coronary artery bypass grafting (CABG) for postinfarction angina suffered repeated inferior myocardial infarction due to obstruction of the proximal right coronary artery, 3 years after which he developed systemic edema. Investigations revealed TR associated with hypoproteinemia; however, treament consisting of aggressive diuretic therapy and albumin administration proved ineffective. The hypoproteinemia manifested as protein-losing enteropathy clinically, and the tricuspid valve was replaced to eliminate high venous pressure. The serum protein levels became normalized after the operation. Although TR is generally well tolerated in the absence of pulmonary hypertension, surgical management is recommended for patients with severe protein deficiency resistant to medical treatment.

Composite graft replacement of the aortic root in patients with Marfan's syndrome

Between October, 1979 and September 1994, 18 consecutive patients with Marfans syndrome underwent replacement of the ascending aorta and aortic valve with a composite graft. There were 11 men and seven women; the mean age was 38.7 years. All patients had annuloaortic ectasia with significant aortic regurgitation. Ten of the 18 patients had aortic dissection. Concomitant procedures were performed in three patients. The hospital mortality rate was 17%, and two patients with concomitant procedures died early after surgery. There were three late deaths, two of which were related to late aortic complications. The actuarial 8-year survival rates in patients with and without aortic dissection were 58.3% and 77.8%, respectively. Since aortic dilatation and its complications are progressive in patients with Marfans syndrome, improved surgical results can be obtained early in the course of the disease before cardiac disturbances and aortic dissections emerge.

Arteriosclerosis Obliterans with Huge Multiple Leg Ulcers in a Patient with X-linked Ichthyosis.

症例は有痛性多発性左下腿潰瘍を主訴とした65歳, 男性である. 四肢, 体幹に魚鱗様の紋理を認め, 同様の魚鱗癬を有する男子が家系内に6名いること, ステロイドサルファターゼが10pmol/DHEA/mg・protein/hr未満で, 本酵素の欠損と考えられたことより, 伴性遺伝性魚鱗癬と診断された. 下肢動脈造影では左腸骨動脈, 両浅大腿動脈の閉塞, 右腸骨動脈に狭窄を認めた. 以上より, 伴性遺伝性魚鱗癬に発症した閉塞性動脈硬化症による下腿潰瘍と診断した. 腹膜外アプローチにて Gelseal®人工血管 (直径8mm) による腹部大動脈-左総大腿動脈バイパス, 自家静脈による左大腿動脈-膝窩動脈バイパス術を行った. 術後経過は良好で, 前脛骨部潰瘍の治癒は遷延したが, その他の潰瘍はほぼ1か月にて治癒した. 伴性遺伝性魚鱗癬では, 皮膚潰瘍の治癒機転はほぼ正常と考えられ, 潰瘍を有する閉塞性動脈硬化症でも通常人と同様に対処してよいものと考えられた.