Keiji Seki

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.

Long-term results of primary closure for ventricular septal defects in the first year of life

The long-term results of primary closure for large ventricular septal defects (VSDs) in infants under 1 year of age with severe symptoms were studied over a period of more than 10 years. Between January, 1971 and March, 1982, 49 infants underwent primary closure of a VSD through a right ventriculotomy using complete cardiopulmonary bypass with mild hypothermia. There were four hospital deaths but no late deaths. Two of four infants with residual shunts had a left ventricular-right atrial shunt which necessitated reoperation. Surgical heart. block occurred in two infants who recovered sinus rhythm in the late period. The cardiothoracic ratio decreased from 60.5% preoperatively to 50.6% in the late postoperative period. Examination by cardiac catheterization revealed that the pulmonary-to-systemic pressure ratio (Pp/Ps) of 23 patients with a Pp/Ps of over 0.75 fell from 0.89 ± 0.09 preoperatively to 0.42 ± 0.12 by 1 month postoperatively, then to 0.27 ± 0.05 in the late postoperative period. The latest values for the cardiac index and left ventricular ejection fraction were 3.41 /min per m2 and 64.4%, respectively. More than 10 years after their operation, all the survivors were growing normally and maintaining a good quality of life, which supports our recommendation that primary repair should be performed in the first year of life for infants with large VSDs.

Inhibitory effect of methylene blue-induced photooxidation on intimal thickening of vein graft.

BACKGROUND We have previously speculated that methylene blue-induced photooxidation of adventitial surface for 5 minutes can completely inhibit the intimal and medial growth of surgically prepared saphenous vein in vitro. In this study, inhibitory effect of methylene blue-induced photooxidation on intimal thickening of vein graft in vivo was investigated. METHODS Jugular vein grafts were photooxidized in 0.01% methylene blue solution for 5 minutes, and interposed into arterial circulation for 4 weeks in rabbits. Vein grafts were studied by morphometry and immunohistochemistry. RESULTS The intimal thickening of photooxidized vein grafts were suppressed significantly compared with those in the nonphotooxidized group. Proliferated cell nuclear antigen (PCNA) index (total PCNA-positive cells/total cell count x 100%) of vein graft was significantly higher in the nonphotooxidized group than those in the photooxidized group. CONCLUSIONS Methylene blue-induced photooxidation is effective in the inhibition of intimal thickening of vein graft interposed in the arterial circulation for 4 weeks in vivo.

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.

Ligation-and-bypass technique through the posterior approach for bilateral popliteal aneurysms.

A 56-year-old man with a painful, progressively enlarging pulsatile mass in the bilateral popliteal fossae was diagnosed with a bilateral popliteal artery aneurysm (PAA) and referred to our hospital to undergo surgical therapy. Computed tomographic scanning demonstrated a large, middle-type PAA with a rich mural thrombus in the bilateral popliteal arteries. Following aneurysm exclusion posteriorly, the patient underwent bypass surgery using a ringed polytetrafluoroethylene graft bilaterally. This procedure was chosen to prevent nerve injury caused by mobilization of the adherent nerves and aneurysmal resection. The patient had a satisfactory postoperative course. This procedure may be recommended for large, middle-type PAAs because (1) the adherent tibial nerve trunk and its branch nerves can be protected by aneurysm exclusion with arterial branch ligation and (2) frequently occurring postexclusion expansion of the aneurysm caused by insufficient branch ligation using the medial approach can be avoided.

Surgical Treatment of Double Aortic Arch and Associated Problems of Tracheomalacia, and Intracardiac Anomalies.

乳幼児期に呼吸器症状にて発症した重複大動脈弓3症例に対し, 大動脈弓離断術を施行した. 2例が気管軟化症を, 全例に心内奇形を合併していた. これが原因で3例ともに術後の長期呼吸管理を要した. 1例は残存するVSD+PHによる心不全, 呼吸不全のために第49病日にVSD閉鎖を必要とした. われわれの経験した気管軟化症合併例はいずれも保存的治療にて抜管可能であった. 気管軟化症に対する外科治療としては Aortopexy, Splinting, ステントなどが試みられているが, 決定的な術式はないのが現実であり, われわれは積極的に同時手術を行ってはいない. しかし, 血管輪解除術後にも呼吸器症状が改善しない症例では症状の主たる原因が何に起因するのかを見極め, 適切な治療方針をたてる必要がある.

Surgical Treatment of Acute Aortic Dissection: Efficacy of Retrograde Cardioplegia for Myocardial Protection

The operative morbidity and mortality of patients with Stanford type A acute aortic dissection undergoing urgent operation using retrograde cadioplegia for myocardial protection were evaluated to assess the efficacy of such surgery. A total of 18 patients (12 men and six women. 19–71 years of age) were operated on 9–137 h after onset of dissection using cardiopulmonary bypass with deep hypothermia and retrograde cardioplegia. Graft replacement was performed in ten patients, primary anastomosis in three, and Cabrol and Bentall operations in five. All patients were weaned from cardiopulmonary bypass, but four died in hospital (mortality rate 22%). Thirteen patients were in good health at follow-up ranging from 3 to 98 months, and the remaining patient died from rectal cancer 5 months after surgery. It is concluded that urgent operation of patients with Stanford type A acute aortic dissection can be performed with reasonable operative and excellent follow-up results. Retrograde cardioplegia is an easy and reliable method of myocardial protection to repair the fragile aortic wall.

Clinical Study on Peripheral and Visceral Aneurysms.

1975年から1990年までに外科治療を行った四肢および腹部臓器の末梢動脈瘤症例は34例であった. 動脈瘤の発生部位は, ほぼ全身にわたっていたが, 下肢が最も多かった. その成因としては動脈硬化が半数以上を占め, 次いで医原性が24%のほか, 外傷, Behcet 病, aortitis などがあった. 動脈硬化性のものは左右両側に発生する多発例が多かった. 全体の破裂の頻度が26%と高率であるのと, 体表から深い位置にある腹部臓器動脈瘤や内腸骨動脈瘤などが激しい突発症状で発症するのが診断上の問題であった. 末梢動脈瘤の手術成績は良好であるが, 遠隔期に心血管系の続発症が多いので, 術後も注意深い経過観察が必要である.