Yoshiki Shibata

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.

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.

Inhibitory effect of photooxidation on intimal and medial thickening of saphenous vein

BACKGROUND The inhibitory effect of short-term photooxidation on medial and neointimal proliferation of human saphenous vein was investigated. METHODS Culture medium-filled surgically prepared saphenous vein segments were photooxidized in 0.01% methylene blue solution for 5 minutes. Photooxidized and nonphotooxidized saphenous veins were checked for viability of endothelial cells by culturing vein segments for 21 days followed by histologic and immunohistochemical studies. RESULTS Endothelial cells of saphenous vein segments remained unaffected after photooxidation. Both the intima and media of nonphotooxidized veins became highly cellular and thickened because of the proliferation and migration of smooth muscle cells. Like precultured fresh saphenous vein, intimal (0.031+/-0.017 mm; p=0.0067) and medial thicknesses (0.702+/-0.123 mm; p < 0.0001) and proliferating cell nuclear antigen-positive cell count (14+/-8/mm2; p=0.0005) of cultured photooxidized veins were significantly less than those of cultured nonphotooxidized veins (intimal thickness, 0.059+/-0.041 mm; medial thickness, 0.997+/-0.228 mm; proliferating cell nuclear antigen positive cell count, 34+/-16/mm2. CONCLUSIONS Methylene blue-induced short-term photooxidation is effective in inhibition of intimal and medial thickening of saphenous vein.

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.

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.

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.