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Right dominant biventricular failure often accompanies the end-stage of combined rheumatic valvular disease and some kinds of congenital heart disease. The management of right ventricular failure with conventional medical treatment, however, has encountered many difficulties. Mechanical support of the right ventricle with an RVAD (right ventricular assist device) has proved useful and effective. Seven patients who could not be weaned from cardiopulmonary bypass were subsequently transferred to an intraaortic balloon pump (IABP) and RVAD. Among these, five had severe combined rheumatic valvular disease, one had congenital heart disease and was advanced in age, and the other had a left atrial myxoma with tricuspid regurgitation. Preoperatively, all of these patients had had biventricular failure. All seven cases were successfully weaned from RVAD, and later from IABP. Five patients were discharged from the hospital and returned to normal daily life. Two patients died during their postoperative course. Long-term survival rate was 71%. Mechanical assist with RVAD and IABP seemed to be effective in the management of right dominant biventricular failure, such as that seen in combined valvular disease and some kinds of congenital heart disease.

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A 40-year-old female who had been treated with steroid for 10 years because of systemic lupus erythematosus (SLE) was admitted to our department for triple-vessel disease with LMT lesion. She underwent bilateral internal mammary artery grafting to the right ventricular branch of RCA and the No. 7 segment of LAD. Intraoperative free flow was 70 ml/min in both bypass grafts. She dropped to severe shock with a high fever of 40 degrees C and decreased the white blood cell count of 900/mm3 on the 6th postoperative day. These clinical and laboratory findings were suggestive of rebound phenomenon of SLE or withdrawal syndrome of steroid therapy. She was treated with pulse therapy of methyl-prednisolone and her condition improved in two weeks. Histological findings of the right internal mammary artery revealed stenotic lesion of about 50%, but on June 24, 1988, postoperative angiography showed a good patency of both internal mammary arteries. Only a few reports of successful attempt of coronary artery bypass grafting for coronary lesion due to SLE are available in the literature. Some important problems concerning the surgical treatment as well as the therapy of steroid involved in this case were discussed.

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Three patients with biventricular failure were managed postoperatively with the aid of a right ventricular assist device (RVAD) and intraaortic balloon pumping (IABP) with favorable results. Among these three cases, two had multiple rheumatic valvular disease with cardiac cachexia and underwent combined valve replacement. Another who was suffered from heart failure with a large ventricular septal defect and tricuspid regurgitation had a VSD closure and tricuspid valve replacement. In all patients, the weaning from pump oxygenator was difficult even with large doses of catecholamine. Therefore, the pump oxygenator was switched to RVAD for right ventricular assistance and IABP for left ventricular assistance because these patients had had right ventricular failure dominant biventricular failure preoperatively. Though case 2 was lost 64 days after the surgery by retroperitoneal bleeding due to inadequate anticoagulant treatment, the other two cases recovered successfully from postoperative biventricular failure and were discharged from the hospital. The indications of this method and the criteria for RVAD weaning were discussed.

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Aortic valve endocarditis is frequently associated with an aortic root abscess, so that it is difficult to insert a prosthetic valve. Between April, 1983 and June, 1988 we treated four out of seven patients with aortic valve endocarditis by translocation of the aortic valve, closure of the native coronary ostia, and placement of saphenous vein grafts on the coronary arteries. In each case, the operation was undertaken because of rapidly progressing heart failure. Infection was due to alpha-Streptococcus in two instances, to Staphylococcus epidermidis and fungus in the other cases. In one of the four patients, the prosthetic aortic valve was sutured to the ascending aorta and two saphenous vein grafts were placed on the proximal coronary arteries. In the other three patients, the composite Woven Dacron graft was used to replace the ascending aorta and two saphenous vein grafts were placed on the distal coronary arteries. One patient died one year postoperatively of LOS because of rapidly progressing coronary grafts ostial stenosis. The other three patients survived and doing well with satisfactory hemodynamic function and no infection. Translocation of the aortic valve for infective aortic valve endocarditis is a useful operative technique when conventional aortic valve replacement technique cannot be utilize.

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Fetal hemoglobin (HbF) levels determined in healthy Japanese adults ranged from 0.3% to 16.0% as F cells and 0.17% to 2.28% as HbF content, which were the same as those obtained in other countries. The frequency distribution of 300 healthy adults with various numbers of F cells consisted statistically of two different groups, low and high F-cell groups. Individuals with greater than or equal to 4.4% of F cells (HbF about 0.7%) were defined as the high F-cell trait, which accounted for 11.3% of males and 20.7% of females. Family studies of 21 probands with this trait and sex-different frequency analyses in the population and probands revealed X-linked dominant inheritance. Two other families of the trait associated with color blindness were described, although no definitive evidence for linkage was obtained between the two. A review of population and family studies reported in the literature indicated that persons with Swiss-type hereditary persistence of fetal hemoglobin (HPFH) are of the same kind as this trait in their incidence and inheritance form, but represent a portion of the trait with higher levels of HbF or F cells. The existence of X chromosome-localized regulatory gene(s) for the developmental switch of human Hb production is discussed.

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