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P37 The management of dissecting aneurysm for DeBakey type III
23rd World congress of the International
Society for Cardiovascular
D. KIKUGA WA, Y FUJUHIRO, A. TABUCHI, I. MORITA and A. ISHIDA, Kurashiki, Japan Of the 3.57patients who underwent isolated coronary bypass grafting, 26 patients (7.3%) underwent a second operation. Mean interval between operations was 85.6 months ranging from 8 to 173 months. The ages at the second operation ranged from 44 to 74 years (mean:63). The angiography at the first operation showed 1 vesseldisease in 6, 2 vessel in 7, 3 vessel or left main in 13 patients. Saphenous vein grafts were used in all patients and arterial grafts in 3. At the second operation, the angiography disclosed stenotic vein graft to the LAD in 20 patients, new lesions in 3 (LAD in 2 and RCA in 11, occluded vein grafts to the RCA and CX in 1 and coronary stenosis following PTCA in 2 (RCA in 1 and CX in 1). In 22 patients, coronary bypass grafting for the LAD was performed using 17 arterial grafts and 5 vein grafts. 26 patients received 46 bypass grafts including 23 arterial grafts. Follow-up was conducted on 26 patients. There were 4 deaths at reoperation and 2 late cardiac deaths. The acturial survival rate was 73.4% at 18 years and that after the second operation was 72.7% at 8 years. The survivors were in NYHA class I or II in 19 patients and class III in 1. During the past 8 years, 17 patients underwent PTCA following CABG. The ages ranged from 44 to 75 years (mean: 60). The angiography disclosed 1 vessel disease in 2, 2 vessel in 4, 3 vessel in 10 and left main in 1. Eight patients had LAD or LAD graft stenosis (Group 1) and 9 had intact LAD or LAD graft (Group 2). Group 1 consisted of PTCA of LAD in 3, LAD graft in 3, RCA graft in 1, and CX graft and RCA in 1. PTCA was successful in 5 and failed in 3. Among the 3 patients with PTCA failure, there were 2 late deaths. Group 2 consisted of PTCA of RCA graft in 3, CX graft in 2, RCA in 1, CX in 2 and D in 1. PTCA was sucessful in 7 and failed in 2. These 2 unsuccessful cases underwent CABG. In a majority of cases,the indication for a second operation was a stenotic vein graft to the LAD or a new lesion in the LAD. Therefore, it is preferable to use an arterial graft to the LAD at the primary operation and also at the second operation. PTCA after CABG is an alternative therapy for the patient with recurrent angina but prognoses of the patients with failed PTCA of LAD or LAD graft were poor.
P37 The Management Type III
of Dissecting Aneurysm for DeBakey
0. SHIGEMITSU, T. HADAM4, Y MORI, S. MIXAMOTO, H. SAKO, H. ANAI, T. SOEDA, H. YOSHIMATSU, X RHI, Y UCHIDA, Oita, Japan We experienced 99 cases of DeBakey type III dissection aneurysm from October 1982 to November 1996. Stanford type (St.) B was 89 cases,St. A was 10 cases.In the cases of St. B, 54 case were treated conservatively. 35 case were operated. The reasons of conservative therapy were mainly early thombosed cases, small chronic cases, and the cases refusing operation. In operative cases of St. B, 25 cases s20
Surgery
were performed graft replacement for descending aorta, 3 caseswere closed the entry portion, 3 caseswere plastid by reducing the pseudolumen, and 3 cases were performed extra-anatomical bypass. The operative reasons in acute period for St. B were rupture (2 cases), impending rupture (4 cases), and visceral ischemia (3 cases). The operative reasons in chronic period for St. B were dilatation of entry portion (7 cases) or pseudolumen (17 cases),and rupture (1 case). In the cases of St. A, 2 caseswere not operated due to early thrombosis in the pseudolumen of ascending aorta, 8 cases were operated. 5 cases were performed graft replacement of ascending aorta or arch to add to that, 3 cases were performed graft replacement of descending aorta. 2 casesout of that 3 cases occurred postoperatively redissection of ascending aorta. The operative death of St. A was 2 cases(20%), that of St. B in acute period was 4 cases(44%), and that for St. B in chronic period was 3 cases(13%). The outcome of the patients needs operation in acute period was poor. The operation for St. B was easier in early chronic period (within 2 month) than after that because of rare adhesion to lung and short length of dilatation of aorta. In the case of St. A and DeBakey type III, the graft replacement from ascending aorta to descending aorta at the same time is ideal, but the operative damage may be too much. We think it better that firstly ascending aorta or involving arch is replaced, secondly descending aorta is replaced as occasion demands.
P38 Thoracic Aortic Aneurysm Associated with Congenital Bicuspid Aortic Valve M. ANDO, Y OKITA, T. MOROTA S. TAKXMOTO, Osaka, Japan
and
Congenital bicuspid aortic valve is a relatively rare malformation. It is reported that the presence of this anomaly predisposes the patient to development of true aortic aneurysms or dissecting aortic aneurysms. Between 1978 and October 1996,23 patients with aneurysm of the thoracic aorta associated with congenital bicuspid aortic valve underwent surgical treatment at our institution. There were 19 males and 4 females. The age of patients ranged from 27 to 74 years (mean 53 years). There were 16 patients with true ascending aortic aneurysm (of which 7 presented with annulo-aortic estasia) and 7 with dissecting aortic aneurysm (4 with DeBakey type I dissection, 2 with type II, and 1 with type III b). These 23 patients constituted 2.6% (23/899) of all casesof surgical operations for aneurysm of the thoracic aorta. Aortic valve dysfunction was noted in 18 patients. We performed a valved conduit operation in 7 patients, AVR and wrapping of the ascending aorta in 6, AVR and graft replacement of the ascending aorta in 3, replacement of the ascending aorta in 3, graft replacement of the ascending aorta and total arch in 3, AVR and graft replacement of the descending aorta in 1. No hospital deaths occurred in our patients. Pathological examination of surgical specimens of the aortic wall showed cystic medical necrosis in 9 patients and mucoid degeneration in 5. Besides complication by valve dysfunction, patients with congenital bicuspid aortic CARDIOVASCULAR
SURGERY
SEPTEMBER
1997
Society for Cardiovascular
D. KIKUGA WA, Y FUJUHIRO, A. TABUCHI, I. MORITA and A. ISHIDA, Kurashiki, Japan Of the 3.57patients who underwent isolated coronary bypass grafting, 26 patients (7.3%) underwent a second operation. Mean interval between operations was 85.6 months ranging from 8 to 173 months. The ages at the second operation ranged from 44 to 74 years (mean:63). The angiography at the first operation showed 1 vesseldisease in 6, 2 vessel in 7, 3 vessel or left main in 13 patients. Saphenous vein grafts were used in all patients and arterial grafts in 3. At the second operation, the angiography disclosed stenotic vein graft to the LAD in 20 patients, new lesions in 3 (LAD in 2 and RCA in 11, occluded vein grafts to the RCA and CX in 1 and coronary stenosis following PTCA in 2 (RCA in 1 and CX in 1). In 22 patients, coronary bypass grafting for the LAD was performed using 17 arterial grafts and 5 vein grafts. 26 patients received 46 bypass grafts including 23 arterial grafts. Follow-up was conducted on 26 patients. There were 4 deaths at reoperation and 2 late cardiac deaths. The acturial survival rate was 73.4% at 18 years and that after the second operation was 72.7% at 8 years. The survivors were in NYHA class I or II in 19 patients and class III in 1. During the past 8 years, 17 patients underwent PTCA following CABG. The ages ranged from 44 to 75 years (mean: 60). The angiography disclosed 1 vessel disease in 2, 2 vessel in 4, 3 vessel in 10 and left main in 1. Eight patients had LAD or LAD graft stenosis (Group 1) and 9 had intact LAD or LAD graft (Group 2). Group 1 consisted of PTCA of LAD in 3, LAD graft in 3, RCA graft in 1, and CX graft and RCA in 1. PTCA was successful in 5 and failed in 3. Among the 3 patients with PTCA failure, there were 2 late deaths. Group 2 consisted of PTCA of RCA graft in 3, CX graft in 2, RCA in 1, CX in 2 and D in 1. PTCA was sucessful in 7 and failed in 2. These 2 unsuccessful cases underwent CABG. In a majority of cases,the indication for a second operation was a stenotic vein graft to the LAD or a new lesion in the LAD. Therefore, it is preferable to use an arterial graft to the LAD at the primary operation and also at the second operation. PTCA after CABG is an alternative therapy for the patient with recurrent angina but prognoses of the patients with failed PTCA of LAD or LAD graft were poor.
P37 The Management Type III
of Dissecting Aneurysm for DeBakey
0. SHIGEMITSU, T. HADAM4, Y MORI, S. MIXAMOTO, H. SAKO, H. ANAI, T. SOEDA, H. YOSHIMATSU, X RHI, Y UCHIDA, Oita, Japan We experienced 99 cases of DeBakey type III dissection aneurysm from October 1982 to November 1996. Stanford type (St.) B was 89 cases,St. A was 10 cases.In the cases of St. B, 54 case were treated conservatively. 35 case were operated. The reasons of conservative therapy were mainly early thombosed cases, small chronic cases, and the cases refusing operation. In operative cases of St. B, 25 cases s20
Surgery
were performed graft replacement for descending aorta, 3 caseswere closed the entry portion, 3 caseswere plastid by reducing the pseudolumen, and 3 cases were performed extra-anatomical bypass. The operative reasons in acute period for St. B were rupture (2 cases), impending rupture (4 cases), and visceral ischemia (3 cases). The operative reasons in chronic period for St. B were dilatation of entry portion (7 cases) or pseudolumen (17 cases),and rupture (1 case). In the cases of St. A, 2 caseswere not operated due to early thrombosis in the pseudolumen of ascending aorta, 8 cases were operated. 5 cases were performed graft replacement of ascending aorta or arch to add to that, 3 cases were performed graft replacement of descending aorta. 2 casesout of that 3 cases occurred postoperatively redissection of ascending aorta. The operative death of St. A was 2 cases(20%), that of St. B in acute period was 4 cases(44%), and that for St. B in chronic period was 3 cases(13%). The outcome of the patients needs operation in acute period was poor. The operation for St. B was easier in early chronic period (within 2 month) than after that because of rare adhesion to lung and short length of dilatation of aorta. In the case of St. A and DeBakey type III, the graft replacement from ascending aorta to descending aorta at the same time is ideal, but the operative damage may be too much. We think it better that firstly ascending aorta or involving arch is replaced, secondly descending aorta is replaced as occasion demands.
P38 Thoracic Aortic Aneurysm Associated with Congenital Bicuspid Aortic Valve M. ANDO, Y OKITA, T. MOROTA S. TAKXMOTO, Osaka, Japan
and
Congenital bicuspid aortic valve is a relatively rare malformation. It is reported that the presence of this anomaly predisposes the patient to development of true aortic aneurysms or dissecting aortic aneurysms. Between 1978 and October 1996,23 patients with aneurysm of the thoracic aorta associated with congenital bicuspid aortic valve underwent surgical treatment at our institution. There were 19 males and 4 females. The age of patients ranged from 27 to 74 years (mean 53 years). There were 16 patients with true ascending aortic aneurysm (of which 7 presented with annulo-aortic estasia) and 7 with dissecting aortic aneurysm (4 with DeBakey type I dissection, 2 with type II, and 1 with type III b). These 23 patients constituted 2.6% (23/899) of all casesof surgical operations for aneurysm of the thoracic aorta. Aortic valve dysfunction was noted in 18 patients. We performed a valved conduit operation in 7 patients, AVR and wrapping of the ascending aorta in 6, AVR and graft replacement of the ascending aorta in 3, replacement of the ascending aorta in 3, graft replacement of the ascending aorta and total arch in 3, AVR and graft replacement of the descending aorta in 1. No hospital deaths occurred in our patients. Pathological examination of surgical specimens of the aortic wall showed cystic medical necrosis in 9 patients and mucoid degeneration in 5. Besides complication by valve dysfunction, patients with congenital bicuspid aortic CARDIOVASCULAR
SURGERY
SEPTEMBER
1997