Language：English   Publisher：(一社)日本循環器学会  

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Language：English   Publisher：(一社)日本循環器学会  

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Language：English   Publishing type：Research paper (scientific journal)  

Despite exhibiting cardiotoxicity, doxorubicin (DOX) is widely used for cancer treatments. Cardiac fibroblasts (CFs) are important in the pathogenesis of heart failure. This necessitates the study of the effect of DOX on CFs. The impairment of calcium (Ca2+) homeostasis is a common mechanism of heart failure. Store-operated Ca2+ entry (SOCE) is a receptor-regulated Ca2⁺ entry pathway that maintains calcium balance by sensing reduced calcium stores in the endoplasmic reticulum. ORAI1, a calcium channel protein and the most important component of SOCE, is highly expressed in human cardiac fibroblasts (HCFs). It is upregulated in CFs from failing ventricles. However, whether ORAI1 in HCFs is increased and/or plays a role in DOX-induced cardiotoxicity remains unknown. In this study, we aimed to elucidate the relationship between ORAI1/SOCE and DOX-induced heart failure. Induction of apoptosis by DOX was characterized in HCFs. Apoptosis and cell cycle analyses were performed by fluorescence-activated cell sorting (FACS). Reactive oxygen species (ROS) production was measured using fluorescence. YM-58483 was used as an ORAI1/SOCE inhibitor. ORAI1-knockdown cells were established by RNA interference. In vivo experiments were performed by intraperitoneally injecting YM-58483 and DOX into mice. We first demonstrated that DOX significantly increased the protein expression level of p53 in HCFs by western blotting. FACS analysis revealed that DOX increased early apoptosis and induced cell cycle arrest in the G2 phase in fibroblasts. DOX also increased ROS production. DOX significantly increased the expression level of ORAI1 in CFs. Both YM-58483 and ORAI1 gene knockdown attenuated DOX-induced apoptosis. Similarly, YM-58483 attenuated cell cycle arrest in the G2 phase, and ORAI1 knockdown attenuated DOX-induced ROS production in HCFs. In the animal experiment, YM-58483 attenuated DOX-induced apoptosis. In HCFs, ORAI1/SOCE regulates p53 expression and plays an important role in DOX-induced cardiotoxicity. ORAI1 may serve as a new target for preventing DOX-induced heart failure.

DOI： 10.1371/journal.pone.0278613

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Language：Japanese   Publisher：The Japanese Society for Cardiovascular Surgery  

A 70-year-old man developed sudden chest, back, abdominal, and lower extremity pain, and clinical findings and contrast-enhanced computed tomography (CT) revealed acute type A aortic dissection with visceral, lower leg, and spinal cord ischemia. The false lumen of the ascending aorta was thrombosed, and the entry site was observed in the proximal descending aorta without a re-entry tear. The true lumen of the aorta extended from the descending thoracic aorta to the abdominal aorta and was significantly narrowed. The celiac and superior mesenteric arteries received blood supply from the narrowed true lumen and several intercostal arteries from the partially thrombosed false lumen. Central repair for resection of the entry tear could impair blood flow through the false lumen and the intercostal arteries ; therefore, we performed open aortic fenestration. Postoperative contrast-enhanced CT revealed that the width of the true lumen and blood flow through the false lumen of the descending aorta were adequately improved with resolution of the patient's clinical symptoms. The patient's postoperative course was uneventful, and he was discharged on postoperative day 30. Emergency central repair has been reported as a first-line approach for acute type A aortic dissections ; however, surgical fenestration may be useful for patients who receive conservative treatment for the ascending aorta and present with multiple sites of malperfusion that causes spinal cord ischemia.

DOI： 10.4326/jjcvs.50.405

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Other Link： https://search.jamas.or.jp/link/ui/2022045771

Language：English   Publishing type：Research paper (international conference proceedings)   Publisher：Mosby Inc.  

Objective: The outcomes of emergency surgery for type A acute aortic dissection have improved. However, ascending aortic replacement sometimes leads to dilatation of the distal aorta. The present study reviewed our outcomes of ascending aortic replacement and total arch replacement in patients with type A acute aortic dissection. Methods: A total of 253 patients with type A acute aortic dissection underwent a central repair operation. Our standard technique was ascending aortic replacement. Total arch replacement was performed only when entry existed in the major curvature of the aortic arch and the proximal descending aorta. A total of 169 patients (67%) underwent ascending aortic replacement, and 84 patients (33%) underwent total arch replacement. Hospital death due to initial surgery, dilatation of the distal aorta greater than 5 cm, new occurrence of aortic dissection, any distal aortic surgery, and aortic-related deaths were defined as distal aortic events. Results: The mortality was 7.1% in the ascending aortic replacement group and 6.0% in the total arch replacement group. Postoperative computed tomography was performed in 162 patients in the ascending aortic replacement group. The false lumen of the residual aortic arch had thrombosed and healed in 94 patients (58%) and remained present in 68 patients (42%). The distal aortic event-free rate in the ascending aortic replacement group decreased from 74% at 5 years to 51% at 9 years, and the rate in the total arch replacement group was 83% at 5 to 9 years (P &lt
.01). For the ascending aortic replacement group, more patients with a dissected arch had a distal aortic event compared with patients with a healed arch (P &lt
.01). Conclusions: Total arch replacement was associated with fewer distal aortic events. We may expand the indications for total arch replacement in stable patients.

DOI： 10.1016/j.jtcvs.2020.02.087

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Springer Japan  

Coronary malperfusion with acute type A aortic dissection is a fatal complication. It is controversial whether to prioritize central repair or coronary reperfusion. Lifesaving becomes even more difficult if a patient has pericardial haemorrhage. Herein, we report a case of acute type A aortic dissection associated with left coronary malperfusion and pericardial haemorrhage, wherein reperfusion of the left coronary artery was performed using only guidewires, and central repair could be performed without major delay. Coronary reperfusion using only guidewires can be a revolutionary therapeutic strategy for this disease.

DOI： 10.1007/s11748-021-01662-w

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Hypoxia during one-lung ventilation is a significant problem in descending aortic surgery via left thoracotomy. Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation (VAPa-ECMO), which consists of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and an additional arterial branch to perfuse a pulmonary artery (Pa), is useful.

DOI： 10.1007/s11748-020-01518-9

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Blackwell Publishing Inc.  

Objective: Postoperative stroke is a serious unsolved complication after acute type A aortic dissection (ATAAD) repair. We investigated the incidence and risk factors of stroke, and hypothesized that dissection of supra-aortic vessels is an important risk factor of this morbidity. Methods: Between 2012 and 2019, 202 (56% men, median age 68 years) patients with ATAAD underwent surgical repair. Clinical data, image findings, method of circulatory support, and repair technique were retrospectively investigated to explore the risk factor of postoperative stroke. Results: Of the 202 patients, operative mortality was 6% and the incidence of postoperative stroke was 12% (n = 25). Brachiocephalic artery (BCA) dissection was associated with a higher risk of stroke (odds ratio, 3.89
95% confidence interval, 1.104–13.780
p =.035) having no relation to the presence or absence of left common carotid artery dissection. Preoperative malperfusion syndrome, circulatory arrest time, isolated cerebral perfusion time, repair technique (total arch replacement), and femoral artery perfusion alone were not related to the incident rate of postoperative stroke. Stroke occurred in both hemispheres, regardless of the laterality of carotid artery dissection. Conclusion: BCA dissection was an independent risk factor of stroke after ATAAD repair.

DOI： 10.1111/jocs.15322

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Language：English   Publisher：(一社)日本循環器学会  

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Language：English   Publisher：(一社)日本心血管インターベンション治療学会  

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A 59-year-old man with no prior neurological deficits developed a massive stroke during the repair of a double-barreled acute type A aortic dissection with major entry in the ascending aorta and an occluded brachiocephalic artery. As right cerebral ischemia was alleviated by the circle of Willis, the patient was alert and conscious preoperatively. Nevertheless, the thrombus in the right carotid artery induced a severe postoperative right cerebral embolism. In conclusion, occlusion of the carotid artery is a risk factor of postoperative severe stroke, even in patients without neurological symptoms preoperatively.

DOI： 10.1177/2050313X211025215

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Springer Japan  

Objective: Postinfarction left ventricular free wall rupture (FWR) has been classified into blow-out type and oozing type. However, considering past papers, oozing type included the cases in which the bleeding had spontaneously stopped or sealed, and the distinction between blow-out type and oozing type was not always clear. We classified FWR into the BO type (combination of blow-out type and oozing type) with continuous bleeding and sealed type and clarified the pathophysiology of the sealed type. Methods: Thirty-five patients who underwent surgical treatment for FWR during the past 21 years were retrospectively evaluated. Results: Twenty-one patients (60%) were sealed. Comparing the sealed type with the BO type, the incidence of sudden collapse with acute onset was significantly lower (sealed type
62%, BO type
100%, P = 0.0118), and there were more cases of transport from outside the hospital (76%, 43%, P = 0.0453). Significantly few cases had electro-mechanical dissociation immediately before surgery (10%, 71%, P = 0.0001). In the sealed type, median sternotomy was performed in 9 patients (43%), and subxiphoid drainage was performed in 12 (57%). Fifteen patients (71%) were supported by IABP postoperatively, and re-rupture occurred in 3 patients without IABP. Long-term outcomes were significantly better in the sealed type than in the BO type. Conclusion: Sixty percent of postinfarction ventricular free wall rupture was the sealed type. Median sternotomy and sutureless repair with postoperative IABP support were reliable treatments. Subxiphoid drainage and strict blood pressure control with IABP may be acceptable surgical strategies in elderly, frail patients.

DOI： 10.1007/s11748-021-01730-1

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Publishing type：Research paper (scientific journal)   Publisher：Oxford University Press (OUP)  

<title>Abstract</title>
<sec>
<title>Background</title>
The present article describes two cases of patients with coronary arteritis (CA) whose identification of CA diagnosis (late vs. early) resulted in different clinical courses and outcomes.


</sec>
<sec>
<title>Case summary</title>
Case 1 is a 53-year-old woman with multiple coronary risk factors who was admitted with acute coronary syndrome (ACS) and significant stenosis in the left main trunk (LMT). Although clues suggested arteritis (LMT lesion without any other stenosis, occlusion of left internal thoracic artery, etc.), the diagnosis of CA (coronary involvement of unclassified arteritis) was delayed and revascularization, including coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), was performed under uncontrolled inflammatory status. As a result, Case 1 experienced repeated ACS episodes due to graft failure and in-stent restenosis, and repeatedly underwent PCI. Case 2 is a 76-year-old woman with no significant coronary risk factors who was admitted with ACS. This patient was successfully diagnosed with coronary involvement of Takayasu arteritis before revascularization. Coronary artery bypass grafting was performed after stabilizing inflammation with prednisolone, and the patient remains angina-free beyond 1-year post-CABG. In both cases, intravascular imaging clearly identified the localization and degree of inflammation related to CA by demonstrating specific findings (ambiguous typical three-layer structure of arterial wall and extended low-echoic areas within adventitia).


</sec>
<sec>
<title>Discussion</title>
Accurate and early diagnosis with meticulous diagnostic and therapeutic strategies appear to be important for favourable clinical outcomes in the medical treatment of patients with coronary involvement of arteritis. Intravascular imaging has the potential to contribute to optimizing clinical management of CA.


</sec>

DOI： 10.1093/ehjcr/ytaa011

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OBJECTIVE: Excessive prostaglandin E2 production is a hallmark of abdominal aortic aneurysm (AAA). Enhanced expression of prostaglandin E2 receptor EP4 in vascular smooth muscle cells (VSMCs) has been demonstrated in human AAAs. Although moderate expression of EP4 contributes to vascular homeostasis, the roles of excessive EP4 in vascular pathology remain uncertain. We aimed to investigate whether EP4 overexpression in VSMCs exacerbates AAAs. Approach and Results: We constructed mice with EP4 overexpressed selectively in VSMCs under an SM22α promoter (EP4-Tg). Most EP4-Tg mice died within 2 weeks of Ang II (angiotensin II) infusion due to AAA, while nontransgenic mice given Ang II displayed no overt phenotype. EP4-Tg developed much larger AAAs than nontransgenic mice after periaortic CaCl2 application. In contrast, EP4fl/+;SM22-Cre;ApoE-/- and EP4fl/+;SM22-Cre mice, which are EP4 heterozygous knockout in VSMCs, rarely exhibited AAA after Ang II or CaCl2 treatment, respectively. In Ang II-infused EP4-Tg aorta, Ly6Chi inflammatory monocyte/macrophage infiltration and MMP-9 (matrix metalloprotease-9) activation were enhanced. An unbiased analysis revealed that EP4 stimulation positively regulated the genes binding cytokine receptors in VSMCs, in which IL (interleukin)-6 was the most strongly upregulated. In VSMCs of EP4-Tg and human AAAs, EP4 stimulation caused marked IL-6 production via TAK1 (transforming growth factor-β-activated kinase 1), NF-κB (nuclear factor-kappa B), JNK (c-Jun N-terminal kinase), and p38. Inhibition of IL-6 prevented Ang II-induced AAA formation in EP4-Tg. In addition, EP4 stimulation decreased elastin/collagen cross-linking protein LOX (lysyl oxidase) in both human and mouse VSMCs. CONCLUSIONS: Dysregulated EP4 overexpression in VSMCs promotes inflammatory monocyte/macrophage infiltration and attenuates elastin/collagen fiber formation, leading to AAA exacerbation.

DOI： 10.1161/ATVBAHA.120.314297

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BioMed Central Ltd.  

Background: Tracheo-innominate artery fistula (TIF) is a rare but fatal complication occurring after tracheotomy. Brachiocephalic trunk transection, one of the surgical treatments for TIF, is mostly associated with a full or partial median sternotomy. We describe a case of TIF with continuous bleeding, which was successfully treated with brachiocephalic trunk transection through a collar incision without the need for median sternotomy. Case presentation: Case 1. An 18-year-old man was referred to our hospital with bleeding from a tracheal stoma, which had ceased prior to admission. TIF was suspected after examination. Innominate artery transection was performed through a collar incision. TIF was not revealed when we cut the innominate artery anterior wall open
therefore, we opted for preventive surgical intervention. The post-operative course was uneventful, and the patient was asymptomatic at the 3-year follow-up. Case 2. A 14-year-old male patient was admitted to our hospital with bleeding from a tracheal stoma, and TIF was suspected after examination. There was persistent bleeding when the cuff of the tracheotomy tube was deflated. Brachiocephalic trunk transection was performed through a collar incision using balloon occlusion. The post-operative course was uneventful, and rebleeding has not occurred 2 years later. Conclusions: Brachiocephalic trunk transection without any median sternotomy may offer the benefits of post-operative infection prevention. In patients with suspected continuous bleeding, using a balloon catheter may be a safe and effective method of treatment.

DOI： 10.1186/s13019-020-1080-y

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Language：English   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：English   Publisher：(NPO)日本血管外科学会  

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Language：English   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Although the efficacy of external stents for vein grafts in coronary artery bypass grafting has been recognized, the ideal diameter and material of the stent remain controversial. We created a new external stent made of soft polyester mesh and performed an animal experiment using canines. Bilateral saphenous vein grafts were interposed in the bilateral common carotid artery of 10 beagles. The grafts in the left carotid artery were designated as the control group, and those in the right rolled by a soft polyester mesh external stent were designated as mesh group. Two of the 10 animals were sacrificed due to severe wound infection. The other eight were observed by echography for 6 months, and then grafts were extracted and thickness of the neointima of the grafts was measured. The control group showed 146% ± 26% postoperative enlargement of the internal diameter of the vein grafts after 6 months, whereas the mesh group showed only 115% ± 15% after the same duration (P = 0.0003). The median thickness of the neointima in the mesh group (170 µm [range: 150-190]) was significantly thinner than that in the control group (260 µm [range: 220-310], P < 0.0001). Some degree of correlation between the thickness of neointima and proportion of enlargement was noted (r = 0.518, P = 0.0024). A soft polyester mesh external stent for vein grafts successfully suppressed the enlargement of the vein grafts and thickness of the neointima after 6 months.

DOI： 10.1111/aor.13399

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Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.1007/s12928-019-00585-x

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：English  

DOI： 10.1016/j.jvs.2018.11.040

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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DOI： 10.1016/j.athoracsur.2018.08.049

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：English   Publishing type：Research paper (scientific journal)  

Coronary malperfusion is one of the most dreadful complications of acute aortic dissection because it causes catastrophic acute myocardial infarction in patients who are already severely ill. Our strategy was as follows. After the administration of heparin, emergency percutaneous coronary intervention (PCI) was urgently performed at the same time as starting to prepare the operating room. A stent was then placed to cover the full length of dissected coronary artery. Patients whose cardiac function improved after successful coronary artery reperfusion were transferred to the operating room to undergo central repair surgery. If the cardiac function did not recover even after coronary reperfusion, and the patient required extracorporeal membrane oxygenation, we considered the best supportive care without performing central repair surgery. In patients with left coronary malperfusion, we believe that preoperative PCI must be performed immediately. Preoperative PCI might delay central repair surgery and potentially increase the risk of catastrophic cardiac tamponade. However, the benefit of PCI in preserving cardiac function exceeds the risk of cardiac tamponade. The indications of PCI before central repair in patients with right coronary malperfusion should be considered after assessing each patient's condition, including the presence or absence of cardiac tamponade and right ventricular infarction, left ventricular function, the immediate availability of cardiologists or cardiac surgeons, and the speed of preparing the operating room.

DOI： 10.1007/s11748-018-1014-y

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：English   Publishing type：Research paper (scientific journal)  

Abdominal aortic aneurysm (AAA) is a life-threatening disease, and no disease-specific circulating biomarkers for AAA screening are currently available. We have identified a smooth muscle cell (SMC)-specific biomarker for AAA. We cultured aneurysmal tunica media that were collected from eight patients undergoing elective open-repair surgeries. Secreted proteins in culture medium were subjected to liquid chromatography/tandem mass spectrometry. Myosin heavy chain 11 (myosin-11) was identified as a SMC-specific protein in the tunica media-derived secretions of all patients. We then examined myosin-11 protein concentrations by ELISA in plasma samples from patients with AAA ( n = 35) and age-matched healthy control subjects ( n = 34). Circulating myosin-11 levels were significantly higher in patients with AAA than control subjects. The area under the receiver-operating characteristic curve (AUC) of myosin-11 was 0.77, with a specificity of 65% at a sensitivity of 91%. Multivariate logistic regression analysis showed a significant association between the myosin-11 level and presence of AAA. When the myosin-11 level was combined with hypertension, it improved the prediction of AAA (AUC 0.88) more than hypertension per se. We then investigated the correlation between aortic diameter and circulating myosin-11 levels using AAA serum samples from patients undergoing endovascular aneurysm repair ( n = 20). Circulating myosin-11 levels were significantly correlated with maximum aortic diameter. Furthermore, changes in myosin-11 concentrations from the baseline 12 mo after endovascular aneurysm repair were associated with those in aortic diameter. These data suggest that circulating levels of myosin-11, which is a SMC-specific myosin isoform, may be useful as a biomarker for AAA. NEW & NOTEWORTHY Extensive studies have revealed that inflammation- or proteolysis-related proteins are proposed as biomarkers for abdominal aortic aneurysm (AAA). Changes in these protein concentrations are not specific for smooth muscle, which is a major part of AAA pathologies. Hence, no disease-specific circulating markers for AAA are currently available. We found, using secretome-based proteomic analysis on human AAA tunica media, that myosin heavy chain 11 was associated with AAA. Circulating myosin heavy chain 11 may be a new tissue-specific AAA marker.

DOI： 10.1152/ajpheart.00329.2018

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BioMed Central Ltd.  

Background: It is well known that there are major differences between the Japanese and Western population regarding the incidence of ischemic heart disease and stroke. The purpose of this study was to evaluate differences of patients' characteristics between Belgian and Japanese cohort with acute type A aortic dissection. Methods: In 487 patients (297 male patients, mean age 61.9 ± 12.2 yrs) who underwent surgery for acute type A aortic dissection, baseline preoperative and intraoperative data were collected. Belgian patients (n = 237) were compared to Japanese patients (n = 250). Clinical data included patient demographics, history, status at presentation, imaging study results and intraoperative findings. Results: The Japanese cohort had significantly more women (48.8% vs. 28.7%, p &lt
0.0001), lower BMI (24.2 vs. 26.4, p &lt
0.0001) and lower prevalence of hypertension (49.2% vs. 65.8%, p = 0.0002). More DeBakey type I dissections and less type III dissections with retrograde extension were reported in Belgium than in Japan (77.2% vs. 48.4%, p &lt
0.0001, 3.4% vs. 38.7%, p &lt
0.0001, respectively). More entries were found in the ascending aorta (78.5% vs. 58.5%, p &lt
0.0001) and aortic arch (24.9% vs. 13.7%, p = 0.0018) in Belgian patients than in Japanese patients, who had more entries in the descending aorta or undetected entries. Conclusions: In acute type A aortic dissection, Belgian patients reveal striking differences from Japanese patients regarding gender distribution, entry tear location and type of dissection. Japanese women are more likely to develop acute type A aortic dissection than Belgian women. (234 words).

DOI： 10.1186/s13019-018-0782-x

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BioMed Central Ltd.  

Background: The relationship between aortic dissection and coronary artery disease is not clear. The purpose of this study was to clarify the difference in the rate of coronary artery atherosclerosis between Stanford type A and type B aortic dissection by reviewing our institutional database. Methods: One hundred and forty-five patients (78 males, 67 females
mean age: 60 ± 12 years) admitted to our hospital with acute aortic dissection who underwent coronary angiography during hospitalization from 2000 through 2002 were enrolled in this study. The background characteristics, coronary risk factors, and coronary angiography findings (number of significant stenoses, stenoses according to Bogaty standards, extent index) of patients were compared between type A (Group A
n = 71) and type B dissection (Group B
N = 74). Results: Significantly more patients had prior histories of complications from ischemic heart disease in Group B than in Group A (P = 0.04), with no significant differences in comparison to other risk factors observed except for hypertension. Significantly (p = 0.005) more stenoses were observed in Group B (1.54 ± 0.04) than in Group A (0.38 ± 0.1). A significantly higher (P &lt
0.05) index score indicating the severity of coronary atherosclerosis was observed in Group B (1.49 ± 0.09) than in Group A (0.72 ± 0.07). Conclusions: Stanford type B acute aortic dissection was significantly more frequently associated with coronary artery atherosclerosis than type A.

DOI： 10.1186/s13019-018-0765-y

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Language：English   Publisher：(一社)日本循環器学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Mosby Inc.  

Objective: The control of malperfusion is the key to improving the outcomes of surgery for type A acute aortic dissection. We revised our treatment strategy to reperfuse each ischemic organ before central repair. Methods: Our current early reperfusion strategy consists of percutaneous coronary artery intervention for coronary malperfusion, direct surgical fenestration for carotid artery occlusion, active perfusion of the superior mesenteric artery for visceral malperfusion, and external shunting from the brachial artery to the femoral artery for lower limb ischemia. Central repair is performed without delay after reperfusion therapy, but if irreversible organ damage is recognized, further aggressive treatment is discontinued. Results: Among 438 patients who underwent initial treatment for type A acute aortic dissection, malperfusion in one or more organs was diagnosed in 108 patients (24%). We applied an early reperfusion strategy in 33 patients, (coronary, 14 patients
carotid, 4
visceral, 7
lower extremity, 8). Central repair was then performed in 28 patients. One patient (3.6%) died of pneumonia
27 patients overcame the ischemic organ damage and survived. Among the 108 patients with malperfusion, 10 patients (9.3%) were treated medically without early reperfusion and central repair. During the same period, mortality from central repair procedures in patients with malperfusion who had not received early reperfusion therapy was 12 of 65 (18%), and the mortality of patients without malperfusion was 9 of 262 (3.4%). Malperfusion was a serious risk factor for hospital death, but the mortality rate of the patients with an early reperfusion strategy was significantly (P &lt
.01) lower than the patients without early reperfusion. Conclusions: Our strategy might improve the outcomes of surgery for type A acute aortic dissection with malperfusion. This strategy enables us to avoid unproductive central repair procedures in irreversibly damaged patients.

DOI： 10.1016/j.jtcvs.2018.02.007

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Language：English   Publisher：JAPANESE CIRCULATION SOC  

Type A acute aortic dissection (AAD) is a serious cardiovascular emergency requiring urgent surgery. Timely accurate diagnosis is essential, but often challenging, because of the wide spectrum of clinical presentations. In patients with type A AAD, chest pain is the most common symptom; furthermore, ischemic ST-T changes such as ST-segment elevation or depression or negative T waves are frequently observed on presentation ECG. These clinical presentations of type A AAD are difficult to differentiate from those of acute coronary syndrome (ACS), which could lead to delayed diagnosis and treatment of type A AAD or misdiagnosis of ACS followed by inappropriate treatment. Of note, ischemic ST-T changes have been shown to be associated with poor outcomes in patients with type A AAD. Because ECG is simple, inexpensive, noninvasive, readily available, and rapidly interpretable at the time of presentation, risk stratification based on ECG findings is considered very useful clinically. ECG findings of type A AAD thus have clinically important diagnostic, therapeutic, and prognostic implications; however, the relationships among these factors remain poorly understood. We review the prevalence of ECG abnormalities, clinical features associated with such changes, and the prognostic importance in patients with type A AAD.

DOI： 10.1253/circj.CJ-17-0309

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Language：Japanese   Publisher：(一社)日本心血管インターベンション治療学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Springer Tokyo  

Background: We have reported “sandwich technique,” via a right ventricular incision, to treat a post-infarction ventricular septal defect (VSD). This technique involves the placement of patches on both the left and right sides of the septum, pinching the VSD sealed with surgical adhesive between the two patches. In this study, we analyzed factors influencing 1-year mortality to determine the pitfalls in our procedure. Methods: We evaluated 24 consecutive patients with post-infarction VSD who underwent the “sandwich technique” via a right ventricular incision. One-year survival and major residual leak were used as the criteria for the analysis of survival and technical success, respectively. In protocol 1, clinical variables were evaluated as predictors of one-year mortality. In protocol 2, surgical techniques were evaluated as predictors of major residual leak, which was found to be related to one-year mortality in protocol 1. Results: In protocol 1, the one-year mortality was higher in patients with major residual leak (75 %, 3/4) than in those without (15 %, 3/20) (p = 0.035). In protocol 2, the patients with major residual leak had smaller patches than those without (41.9 ± 3.8 vs. 47.8 ± 4.8 mm, p = 0.031) and a smaller size difference between the patches and the VSD (22.5 ± 6.5 vs. 30.0 ± 5.7 mm, p = 0.028). Conclusion: For the “sandwich technique” via a right ventricular approach to treat post-infarction VSD, the choice of patch size according to VSD size is an important variable for reducing major residual leak.

DOI： 10.1007/s11748-016-0722-4

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：JAPANESE CIRCULATION SOC  

Background: Stanford type A acute aortic dissection (A-AAD) extends to the brachiocephalic branches in some patients. After ascending aortic replacement, a remaining re-entry tear in the distal brachiocephalic branches may act as an entry and result in a patent false lumen in the aortic arch. However, the effect of brachiocephalic branch re-entry concomitant with A-AAD remains unknown.
Methods and Results: Eighty-five patients with A-AAD who underwent ascending aortic replacement in which both preoperative and postoperative multiple-detector computed tomography (MDCT) scans could be evaluated were retrospectively studied. The presence of a patent false lumen in at least one of the brachiocephalic branches on preoperative MDCT was defined as brachiocephalic branch re-entry, and 41 patients (48%) had this. Postoperatively, 47 of 85 (55%) patients had a patent false lumen in the aortic arch. False lumen remained patent after operation in 34 out of the 41 (83%) patients with brachiocephalic branch re-entry, as compared to that in 13 of the 44 (30%) patients without such re-entry (P&lt;0.001). Brachiocephalic branch re-entry was a significant risk factor for a late increase in the aortic arch diameter greater than 10 mm (P=0.047).
Conclusions: Brachiocephalic branch re-entry in patients with A-AAD is related to a patent false lumen in the aortic arch early after ascending aortic replacement and is a risk factor for late aortic arch enlargement.

DOI： 10.1253/circj.CJ-16-0462

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE BV  

Background: A 5- to 7-day washout period before coronary artery bypass grafting (CABG) is recommended for patients who have recently received a thienopyridine derivative; however, data supporting this guideline recommendation are lacking in Japanese patients.
Methods: Urgent isolated CABG was performed in 130 consecutive patients with acute coronary syndromes (ACS) (101 men; mean age, 69 years). Urgent CABG was defined as operation performed within 5 days after coronary angiography. All patients continued to receive aspirin 100 mg/day. The subjects were retrospectively divided into 2 groups: 30 patients with preoperative thienopyridine (clopidogrel in 15 patients, ticlopidine in 15) exposure within 5 days [dual antiplatelet therapy (DAPT) group] and 100 patients without exposure [single antiplatelet therapy (SAPT) group].
Results: Although the DAPT group had a higher proportion of patients who received perioperative platelet transfusions than the SAPT group (50% vs. 18%, p &lt; 0.001), intraoperative bleeding (median, 1100 ml; interquartile range, 620-1440 vs. 920 ml; 500-1100) and total drain output within 48 h after surgery (577 +/- 262 vs. 543 +/- 277 ml) were similar. CABG-related major bleeding, which was defined as type 4 or 5 bleeding according to the Bleeding Academic Research Consortium definitions, occurred in a significantly higher proportion of patients in the DAPT group than in the SAPT group (20% vs. 3%, p = 0.005). This difference in major bleeding was driven mainly by the higher rate of transfusion of &gt;= 5 U red blood cells within a 48-h period in the DAPT group (13% vs. 1%, p = 0.01). There was no significant difference in the 30 day composite endpoint including death, myocardial (re)infarction, ischemic stroke, and refractory angina between the DAPT group and SAPT group (17% vs. 19%).
Conclusions: Preoperative DAPT increases the risk of CABG-related major bleeding in Japanese patients with ACS undergoing urgent CABG. (C) 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

DOI： 10.1016/j.jjcc.2016.02.013

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SAGE Publications Inc.  

We describe our experience of surgical treatment in a 28-year-old woman with vascular Ehlers-Danlos syndrome. A right subclavian artery aneurysm was detected. The right vertebral artery arose from the aneurysm. Digital subtraction angiography showed interruption of the left vertebral artery. The aneurysm was excised and the right vertebral artery was anastomosed end-to-side to the right common carotid artery under deep hypothermia and circulatory arrest. The patient remained very well 4 years after surgery, with no late vascular complication.

DOI： 10.1177/0218492314553993

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：MEDICAL TRIBUNE INC  

A 77-year-old woman underwent emergency ascending aortic replacement for type A acute aortic dissection. Fifteen days after the operation, she had motor and sensory disturbances in the lower limbs. Computed tomography revealed multiple aortic thrombi and disrupted blood flow in the right external iliac and left common iliac arteries. She underwent an emergency thrombectomy for acute limb ischemia. Because heparininduced- thrombocytopenia (HIT) was suspected to have caused the multiple aortic thrombi, we postoperatively changed the anticoagulant therapy from heparin to argatroban. Seventeen days after the first operation, gastrointestinal bleeding developed, and the patient died of mesenteric ischemia caused by HIT. Arterial embolization caused by HIT after cardiovascular surgery is a rare, but fatal event. To avoid fatal complications, early diagnosis and early treatment are essential. Use of a scoring system would probably facilitate early diagnosis.

DOI： 10.5761/atcs.cr.15-00345

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Language：English   Publisher：The Editorial Committee of Annals of Vascular Diseases  

<p><b>Objectives:</b> We report the pathophysiology and treatment results of type A acute aortic dissection from our 20-year experience. Methods: We studied 673 patients with type A acute aortic dissection who underwent initial treatment from 1994 through July 2014. We divided these patients into two groups. The former group comprised 448 patients from 1994 through 2008, and the latter group comprised 225 patients from 2009 onward, when the current strategy of initial treatment and surgical technique including the early organ reperfusion therapies were established.</p><p><b>Results:</b> Women were significantly often presented than men in patients over 60 years of age. Thrombosed-type dissection accounted for more than half in patients over 70 years, and significantly often complicated pericardial effusion and cardiac tamponade than patent type. Malperfusion occurred in 26% of patients. Central repair operations were performed in 579 patients. In-hospital mortality for all patients was 15%, and for the patients who underwent central repair operations was 10%. Former period of operation, malperfusion, and preoperative cardiopulmonary arrest were significant risk factor of in-hospital death. Preoperative left main trunk (LMT) stents were placed in eight patients and superior mesenteric artery (SMA) intervention was performed in five, they were effective to improve the outcome. From 2009 onward, in-hospital mortality was 5.0% and there was no significant risk factor.</p><p><b>Conclusion:</b> Surgical results of type A acute aortic dissection were dramatically improved in the past 20 years. Early reperfusion strategy for the patients with malperfusion improved the outcomes. (This article is a translation of Jpn J Vasc Surg 2015; 24: 127–134.)</p>

DOI： 10.3400/avd.oa.16-00075

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

A型急性大動脈解離243例を対象に、頸部分枝解離の状態を評価し、術後の弓部偽腔開存に及ぼす影響について検討した。術前の上行弓部の偽腔開存は171例、血栓閉塞は72例で、頸部解離は64例に認めた。上行置換術施行131例の術後の状態は、弓部が血栓化したか、解離腔が全て切除されたものが64例(T群)、頸部分枝リエントリーから弓部偽腔に血流供給が18例(P群)、末梢吻合部leakが14例(L群)、両方ありが15例(PL群)であった。術後弓部偽腔開存は、血栓閉塞37例では3例、偽腔開存94例では51例であった。頸部分枝解離を認めない偽腔開存52例は、T群32例の他はL群13例、PL群1例、分類不能6例であり、術後弓部偽腔開存率34.7%であった。頸部分枝解離あり42例のうちT群7例以外はP群20例、PL群14例であり、術後弓部偽腔開存率82.9%となり、頸部分枝解離の有無により開存率の有意差を認めた。

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：JAPANESE SOCIETY FOR VASCULAR SURGERY  

<b>Objectives</b>: We report the pathophysiology and treatment results of type A acute aortic dissection from our 20-year experience. <b>Methods</b>: We studied 673 patients with type A acute aortic dissection who underwent initial treatment from 1994 through July 2014. We divided these patients into two groups. The former group comprised 448 patients from 1994 through 2008, and the latter group comprised 225 patients from 2009 onward, when the current strategy of initial treatment and surgical technique including the early organ reperfusion therapies were established. <b>Results</b>: Women were significantly often presented than men in patients over 60 years of age. Thrombosed type dissection accounted for more than half in patients over 70 years, and significantly often complicated pericardial effusion and cardiac tamponade than patent type. Malperfusion occurred in 26% of patients. Central repair operations were performed in 579 patients. In-hospital mortality for all patients was 15%, and for the patients who underwent central repair operations was 10%. Former period of operation, malperfusion, and preoperative cardiopulmonary arrest were significant risk factor of in-hospital death. Preoperative LMT stents were placed in 8 patients and SMA intervention was performed in 5, they were effective to improve the outcome. From 2009 onward, in-hospital mortality was 5.0% and there was no significant risk factor. <b>Conclusion</b>: Surgical results of type A acute aortic dissection were dramatically improved in past 20 years. Early reperfusion strategy for the patients with malperfusion improved the outcomes.

DOI： 10.11401/jsvs.15-00005

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Other Link： http://search.jamas.or.jp/link/ui/2015267088

Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：日本胸部外科学会-関東甲信越地方会  

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Language：Japanese   Publisher：(NPO)日本冠疾患学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：OXFORD UNIV PRESS INC  

To identify the risk factors for mortality and establish improved treatment strategies in patients who have acute type A aortic dissection with coronary artery dissection.
From January 1994 through December 2011, we performed surgery in 516 patients with acute type A aortic dissection. We studied 75 (15%) of these patients who had coronary artery dissection. Myocardial ischaemia was present in 48 (64%) of the 75 patients. The culprit coronary artery was the right coronary artery (RCA) in 26 patients, the left coronary artery (LCA) in 19 and the RCA + LCA in 3. For coronary artery reconstruction, preoperative coronary stent placement was done in 7 patients (RCA, 4 and LCA, 3), aortic root replacement in 14, coronary artery bypass grafting in 23 and biological glue application in 28. The relationships of preoperative risk factors and coronary artery reconstruction procedure with in-hospital death and postoperative low cardiac output syndrome (LOS) were analysed using Fisher's exact test.
Hospital death was 18/75 patients (24%), 16/48 (33%) among patients with ischaemia and 2/27 (7.4%) without ischaemia. The culprit lesion involved the RCA in 4/26 patients (15%), the LCA in 9/19 (47%) and the RCA + LCA in 3/3 (100%). Factors related to operative mortality were ischaemia (P = 0.019), LCA territory ischaemia (P = 0.003) and preoperative cardiopulmonary arrest (CPA) (P = 0.013). Postoperative LOS was less common in patients with coronary stent placement (P = 0.042).
In patients who undergo surgery for acute type A dissection with coronary artery dissection, preoperative CPA and myocardial ischaemia (particularly LCA territory ischaemia) negatively affect survival outcomes. Early revascularization by coronary stent placement is effective in preventing postoperative LOS.

DOI： 10.1093/ejcts/ezt060

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Language：Japanese   Publisher：Japan Surgical Association  

An 81-year-old man was scheduled to undergo surgery for an aortic arch aneurysm. The patient was admitted to a local hospital because of congestive heart failure. Computed tomography showed an aortopulmonary fistula due to an aortic arch aneurysm. The patient was therefore transferred to our hospital for undergoing total arch replacement with closure of the fistula and coronary artery bypass grafting (AO-SVG-#4PD). It was difficult to maintain circulation during the cardiopulmonary bypass because of an aortopulmonary shunt. The patient required percutaneous cardiopulmonary support for 2 days and was discharged 49 days after the operation. Aortopulmonary fistula is a rare, potentially fatal condition that can lead to death because of right heart failure.

DOI： 10.3919/jjsa.73.3086

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Language：English   Publishing type：Research paper (international conference proceedings)   Publisher：SPRINGER-VERLAG TOKYO  

Objective: The purpose of this study was to evaluate the short-term results of thoracoabdominal repair using distal aortic perfusion and cerebrospinal fluid (CSF) drainage.
Methods: Between January 2000 and May 2007, we performed 38 thoracoabdominal aortic repairs. Twenty-five ( 66%) were male, and the mean age of all patients was 66 years, (range, 31 to 82 years). The patients distribution of thoracoabdominal aortic aneurysm, according to Safi's classification, was 8 extent 1, 9 extent 11, 7 extent III, 8 extent IV, and 6 extent V. Four patients, who presented with rupture underwent emergency repair. Distal aortic perfusion was used in 38 (100%) and CSF drainage in 14 (37%) of 38 patients. Twenty-nine (76%) of 38 patients inderwent intercostal artery reattachment.
Results: The hospital mortality was 16% (6 of 38 patinets), 9% (3 of 4 emergency repairs) and 9%( three of 34 non-emergency repairs). Immediate neurologic deficit was 2 (6%) of 38 patients, 1(25%) of 4 emergency repairs without CSF drainage, and 1(2.9%) of 34 non-emergency repairs.
Conclusions: The short-term results of thoracoabdominal repair using distal aortic perfusion, CSF drainage and aggressive intercostal aretery reattachment might be acceptable. But neurologic deficit following repairs of TAAA remains a devastating complication.

DOI： 10.1007/978-4-431-99237-0_48

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Language：Japanese   Publisher：The Japanese Society for Cardiouascular Surgery  

The patient was a 39-year-old woman. Malignant rheumatoid arthritis was diagnosed when she was 32 years old, and the patient was treated with oral steroids. She presented at our center with sudden precordial pain. Coronary angiography revealed severe stenosis of the left main coronary artery (segment 5,99%). Acute myocardial infarction and pulmonary edema were diagnosed. The patient underwent off-pump coronary-artery bypass grafting, with anastomosis of the left internal thoracic artery to the left anterior descending artery. One year 3 months later, the patient was readmitted to the hospital because of recurrent angina pectoris and heart failure. Coronary angiography showed patency of the left internal thoracic artery and severe stenoses of the left main coronary artery (segment 5,100%), circumflex artery (segment 11,99%), and right coronary artery (segment 1,90%), suggesting angiitis. On-pump coronary-artery bypass grafting was done, with anastomosis of the right internal thoracic artery to the right coronary artery (segment 2) and the gastro-omental artery to the obtuse marginal branch (segment 12). The patient is being followed up on an outpatient basis. There are few reports describing patients with rheumatoid arthritis who underwent coronary artery bypass surgery. However, the most common cause of death in patients with rheumatoid arthritis is coronary-artery disease. Although the patient was still young, coronary-artery disease progressed rapidly. Such rapid progression was attributed to difficulty in controlling the inflammatory response after initial surgery, as well as to changes in vascular endothelial cells caused directly by treatment with steroids. Possible adverse effects of such treatment should be carefully considered.

DOI： 10.4326/jjcvs.37.259

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Other Link： http://search.jamas.or.jp/link/ui/2008337375

Language：Japanese   Publisher：The Japanese Society for Cardiouascular Surgery  

A 76-year-old woman presented because of bilateral lower-extremity edema and dyspnea. Transthoracic echocardiography revealed a mobile mass in the right atrium. A right atrial mass associated with heart failure was diagnosed. Surgery was performed. Intraoperative transesophageal echocardiography showed that the mass was contiguous with the inferior vena cava. However, the primary lesion was unclear. Therefore, only the intracardiac mass was resected. The margins of the residual tumor were marked with clips. Computed tomography performed immediately after surgery revealed a clip in structures contiguous with the region from a uterine myoma to the inferior vena cava. Intravenous leiomyomatosis was diagnosed on histopathological examination of the resected specimens. Computed tomography 6 months after surgery showed that the clip had moved from the inferior vena cava to a vein contiguous with the uterus. The tumor regressed slightly. Close follow-up is required. Jpn. J. Cardiovasc. Surg. 37: 60-64 (2008)

DOI： 10.4326/jjcvs.37.60

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Other Link： http://search.jamas.or.jp/link/ui/2008109456

Language：Japanese   Publisher：The Japanese Society for Cardiovascular Surgery  

A 74-year-old woman presented with shortness of breath. Cardiac ultrasonography showed that left-ventricular-wall motion was good (left ventricular ejection fraction, 70.2%). The left atrium and ventricle were enlarged (left anterior dimension, 53.4mm; left ventricular enddiastolic dimension, 58.5mm). The posterior cusp of the mitral valve was thickened; the flexibility was decreased. Color Doppler ultrasonography revealed a regurgitant jet toward the posterior cusp of the left atrium. However, there was no deviation of the anterior cusp. Severe mitral-valve insufficiency was diagnosed, and surgery was performed. The second heart sound (P2) of the posterior cusp was shortened because of localized calcification of the posterior mitral annulus. This site may have caused the regurgitation. Mitral annuloplasty with rectangular resection of the valve cusps and annulorrhaphy was performed. The patient had an uneventful recovery after surgery. Postoperative cardiac ultrasonography showed that mitral-valve insufficiency had improved and was regarded as trivial. Mitral annuloplasty is generally considered unsuitable for mitral-valve insufficiency with calcification of the valve annulus. In patients such as the present case who have localized calcification, however, mitral annuloplasty can be performed by resection of the valve cusps with annulorrhaphy.

DOI： 10.4326/jjcvs.36.333

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Language：Japanese   Publisher：The Japanese Society for Cardiovascular Surgery  

A 83-year-old woman suffered pulseless-electrical-activity (PEA) because of cardiac tamponade after acute myocardial infarction with blow-out type cardiac rupture. Immediately median sternotomy was performed and active bleeding from the postero-lateral wall was found. It was impossible to stop bleeding only by putting pressure on the aperture of the myocardium with a piece of TachoComb coated with gelatin-resorcinol-formaldehyde (GRF) glue, however, the chemical action of GRF glue made the delicate myocardium after acute infarction stronger and we managed to stop that bleeding with mattress sutures that had initially seemed to be impossible. She was discharged on POD 103 uneventfully. We think this is a useful and safe operation procedure for blow-out type cardiac rupture.

DOI： 10.4326/jjcvs.36.269

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Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.1097/00005373-200207000-00023

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Language：Japanese   Publisher：Japanese Association for Acute Medicine  

The practical triage for trauma victims is not organized in Japan yet. To identify the importance of field triage in the city of Yokohama, we studied the influence of undertriage on outcome in seriously blunt trauma victims referred to our advanced trauma center from April 1997 to March 1999. We studied the differences in outcome and inhospital clinical course between patients with an injury severity score (ISS) >15 sent directly from the scene (DT group: n=10) and through interhospital transfer (IT group: n=16). Those two groups showed no difference in age, gender, ISS, revised trauma score (RTS) or abbreviated injury scale (AIS) scores at each injury site. Patients in the IT group who required ICU support experienced relatively longer length (3.7±3.3 vs 9.0±11.2 days, p=0.09) and significantly detrimental outcome estimated as severe disability (SD) on the Glasgow Outcome Scale ((GR or MD)/SD: 8/2 vs 5/11, p=0.04). These results demonstrated that undertriage worsened patient outcome and clinical course. The problem in trauma care will be clarified by further study of undertriage. We should study all trauma incidents, hospital transfer, and outcome in our clinical area in cooperation with the Fire Bureau and establish triage tools as a form of medical control.

DOI： 10.3893/jjaam.12.350

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Language：Japanese   Publisher：The Japanese Society for Cardiovascular Surgery  

The purpose of this study was to consider the cause of the prolonged inflammatory reaction that sometimes appears after endovascular stent-graft repair for dissecting aortic aneurysm. Endovascular stent-grafting was performed in 12 patients (11 men and 1 woman, mean age 60±9.8). Endovascular stent-grafting was indicated to close the entry of type B dissections in 10 patients and to exclude ulcer-like projections (ULP) in 2 patients. On the 7th postoperative day (POD), aortography showed no endoleak in 7 type B cases (A-group), remaining endoleak in 3 type B cases (B-group), and complete exclusion in 2 ULP cases (C-group). The value of FDP-E in the A-group was high on the first POD and then decreased gradually. FDP-E also increased up to the 7th POD in the B-group, and increased very slightly after the operation in the C-group. The values of WBC and CRP increased up to the 3rd POD in all groups, but in the A-group it was still high on the 7th POD. On contrast-enhanced CT performed after the procedure and on the 7th POD, edema (over 10mm in thickness) around the descending thoracic aorta was demonstrated in 5 out of 7 cases in the A-group, but in none of the cases in the B- and C-groups. A segmental atelectasis in the left lung was detected in 6 out of 7 cases in the A-group, but in none of the cases in the Band C-groups. In the A-group, endovascular stent-grafting influenced thrombus formation, and the thickened edema around the descending thoracic aorta and the atelectasis produced in the left lung were prominent more than in the other groups. These results suggest that the Inflammation around aortic wall induced by thrombosis in the false lumen, might contribute to the development of the edema around the descending thoracic aorta and the atelectasis in the left lung. We conclude that the inflammatory reaction might have prolonged the postoperative course in the A-group patients.

DOI： 10.4326/jjcvs.29.326

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Other Link： http://search.jamas.or.jp/link/ui/2001039666

Language：Japanese   Publisher：The Japanese Society for Cardiovascular Surgery  

DOI： 10.4326/jjcvs.20.813

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Language：Japanese   Publisher：The Japanese Society for Cardiovascular Surgery  

DOI： 10.4326/jjcvs.20.588

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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Language：English   Publisher：WILEY-BLACKWELL  

BackgroundResidual shunting and mortality are problems associated with the current surgical repair techniques for postinfarction ventricular septal defects (VSD). We developed the sandwich technique via a right ventricle incision and assessed the surgical outcome of 13 years of experience with this technique.
MethodsBetween June 2001 and March 2013, 25 consecutive patients with postinfarction VSD underwent surgical repair using this technique. This technique includes the following: Application of direct ultrasonography to the right ventricular (RV) wall enables the surgeon to visualize the lesion, perform an appropriate incision into the RV, and perform a trabecular resection. One patch is placed on the left ventricular (LV) side and the other on the RV side of the VSD. The VSD is sealed with gelatin-resorcin-formalin (GRF) glue between the two patches.
ResultsThirty-day mortality was 0% (0/25 case). A postoperative major shunt occurred in three patients (12%, 3/25) and two of them required reoperation (8%, 2/25). Hospital mortality was 28% (seven patients). Mean follow-up period was 4.23.7 years. The overall survival at one, five, and 10 years was 71 +/- 9%, 65 +/- 10%, and 56 +/- 12%, respectively. There was no cardiac death during follow-up in the patients who survived for six months after the surgery. No tissue degeneration related to GRF glue was noted.
ConclusionThe sandwich technique via a right ventricle incision results in a low incidence of postoperative leak and good short- and mid-term survival.

DOI： 10.1111/jocs.12546

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Language：English   Publishing type：Rapid communication, short report, research note, etc. (scientific journal)   Publisher：ELSEVIER SCIENCE INC  

DOI： 10.1016/j.jacc.2015.02.075

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Language：English   Publisher：WILEY-BLACKWELL  

Coronary subclavian steal syndrome associated with upper extremity arteriovenous fistula is an uncommon but potentially life-threatening condition. We present a case of a 65-year-old male on hemodialysis with a left upper extremity arteriovenous fistula who underwent coronary revascularization involving bypass with the left internal thoracic artery to the left anterior descending artery. Intraoperative transit-time graft flow measurements and fluorescence imaging showed a reversed flow in the left internal thoracic artery, and the left internal thoracic artery was successfully converted as a free graft from the ascending aorta to the left anterior descending artery. doi: 10.1111/jocs.12444 (J Card Surg 2015;30:154-156)

DOI： 10.1111/jocs.12444

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Language：English   Publisher：WILEY-BLACKWELL  

Coronary subclavian steal syndrome associated with upper extremity arteriovenous fistula is an uncommon but potentially life-threatening condition. We present a case of a 65-year-old male on hemodialysis with a left upper extremity arteriovenous fistula who underwent coronary revascularization involving bypass with the left internal thoracic artery to the left anterior descending artery. Intraoperative transit-time graft flow measurements and fluorescence imaging showed a reversed flow in the left internal thoracic artery, and the left internal thoracic artery was successfully converted as a free graft from the ascending aorta to the left anterior descending artery. doi: 10.1111/jocs.12444 (J Card Surg 2015;30:154-156)

DOI： 10.1111/jocs.12444

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BackgroundWe evaluated clinical outcomes of thoracic endovascular aortic repair (TEVAR) for ruptured descending thoracic aortic aneurysm (rDTAA).
MethodsTwenty-three patients with rDTAA (mean age, 76.88.8 years) underwent TEVAR at our center between January 2008 and April 2013.
ResultsIn twenty-three patients, five patients (21.7%) were in shock before surgery. Technical success was achieved in 21 patients. After TEVAR, retrograde Type A aortic dissection occurred in one patient, Type I endoleak in one patient, and Type II endoleak in three patients. The 30-day mortality rate was 4.3% (n=1), and there were five in-hospital deaths (21.7%). Six patients (26.1%) developed cerebral complications and two patients suffered from paraplegia. In the late phase, four patients died because of the following aortic events: re-rupture in one patient, rupture of another untreated aneurysm in two patients, and esophageal perforation in one patient.
ConclusionsTEVAR is associated with relatively low early morbidity and mortality and can be performed in older and high-risk patients. However, because aortic events during follow-up after TEVAR are not rare, we recommend close follow-up and application of early and aggressive reintervention. doi: 10.1111/jocs.12499(J Card Surg 2015;30:163-169)

DOI： 10.1111/jocs.12499

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Language：English   Publisher：AMER ROENTGEN RAY SOC  

OBJECTIVE. The purpose of this study was to evaluate the usefulness of renal perfusional cortex volume for arterial input function.
MATERIALS AND METHODS. This retrospective study included 45 potential kidney donors-33 patients with aortic dissection and 12 patients with renovascular hypertension- who underwent both MDCT angiography with 0.5-mm collimation and renal Tc-99m-diethylenetriamine pentaacetic acid (DTPA) scanning using the modified Gates method. Each perfusional cortex volume for the arterial input function and parenchymal volume was measured by semiautomatic segmentation using the region-growing technique. Linear regression analysis and correlation coefficients were used to assess the impact of the cortical volume, parenchymal volume, and renal scanning glomerular filtration rate (GFR) on estimated GFR (eGFR) using a modified Modification of Diet in Renal Disease (MDRD) equation.
RESULTS. The correlation coefficient was higher for the total renal DTPA GFR adjusted for body surface area, weight-adjusted perfusion cortex volume, and adjusted total parenchyma volume in rank (r = 0.712, 0.642, 0.510, respectively, p &lt; 0.0001 for each). The coefficient of the right renal perfusional cortex volume percent with a mean value of 52.1% +/- 10.1% was 0.826 (p &lt; 0.0001) for the right renal DTPA GFR percent with a mean value of 51.0% +/- 12.1% (range, 22.0-89.5%), although the value for the right renal parenchymal volume percent with a mean value of 49.5% +/- 5.5% was 0.764 (p &lt; 0.0001).
CONCLUSION. Weight-adjusted perfusional cortex volume for arterial input function can be measured clinically and may replace renal DTPA scanning using the modified Gates method.

DOI： 10.2214/AJR.14.12778

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Purpose: The proximal anastomosis of free right internal thoracic artery to ascending aorta is technically difficult when the caliber is not enough.
Methods: We incise the proximal stump of the graft longitudinally for 10 mm. One side of start point of longitudinal incision is sewn to the end point of incision by 7-0 polypropylene. The folded sideline (5 mm length) is then closed with a running suture, then formation of pouch like anastomotic end is accomplished.
Results: We used this technique in consecutive 34 patients who underwent coronary artery bypass surgery including revascularization to circumflex arteries. Postoperative angiography revealed 97% patency. It does not need another graft material like saphenous vein or radial artery, and possible not only in on pump surgery but also in off pump.
Conclusion: This new "Pouch technique" will make it easy to use right internal thoracic artery as a free graft in coronary artery bypass surgery.

DOI： 10.5761/atcs.nm.14-00301

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Although, tension hemothorax appears along with thoracic injuries in many cases, the incidence is rare and the concept itself has not yet been established. Moreover, reports on tension hemothorax caused by the rupture of thoracic aortic aneurysms are very rare. Herein, we report a case in which thoracic endovascular aortic repair( TEVAR) was carried out following chest drainage in order to treat tension hemothorax accompanying rupture of the descending aortic aneurysm, thus leading to the survival of the patient.

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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We describe our experience with stent-graft placement in a patient with a clinically diagnosed syphilitic aortic aneurysm.
The patient was a 43-year-old man with syphilitic and human immunodeficiency virus (HIV) co-infection. Computed tomography (CT) revealed an aortic aneurysm with 89 mm in maximum size which was located at distal aortic arch and was considered syphilis derived saccular aneurysm. The aneurysm was judged at high risk of rupture from its shape. We decided to perform stent-graft implantation. Before surgery, the patient was given antibacterial and anti-HIV agents. Hand-made fenestrated stent graft by Tokyo Medical University was implanted. The graft was placed from the ascending aorta to Th 9 level in the descending aorta. The aneurysm completely disappeared during follow-up, with no flare-up of syphilitic infection up to 2 years after surgery.
The number of patients with syphilis and human immunodeficiency virus co-infection is now increasing. Stent-graft implantation may be an effective treatment in such immunocompromised patients.

DOI： 10.5761/atcs.cr.12.02211

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The purpose of this study was to describe covered-stent treatment of a ruptured dissection of the superior mesenteric artery (SMA) in a patient with Ehlers. Danlos syndrome. The patient was a 13-year-old girl initially presenting with abdominal pain. Dissection and rupture of the SMA were diagnosed on detailed examination. Conservative treatment was performed initially because open surgery was considered high risk. However, the abdominal pain recurred, and we decided to perform endovascular therapy. A coronary artery covered stent was placed in the true lumen to close the entry site of the dissection. The false lumen was obliterated using a post-dilation technique, completing treatment of the rupture. The patient recovered uneventfully after surgery. Classic-type Ehlers-Danlos syndrome was diagnosed on the basis of physical findings and genetic analysis. The stent has remained adequately patent as of 2 years after surgery. This case report shows that dissection and rupture of the SMA can be treated successfully using a covered coronary artery stent in a patient with Ehlers-Danlos syndrome.

DOI： 10.1016/j.avsg.2013.01.004

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Language：English   Publisher：OXFORD UNIV PRESS INC  

OBJECTIVES: The purpose of this study was to evaluate the clinical outcomes of emergency surgery for acute type B aortic dissection with rupture and to compare results between open surgery and thoracic endovascular aortic repair (TEVAR).
METHODS: Two hundred and ninety-four patients with acute type B aortic dissection were admitted to our hospital between January 2000 and March 2012. At presentation, 30 (10%) patients had rupture (20 men, 10 women; mean age, 71 +/- 15 years), among whom 23 underwent emergency surgery: 9 underwent TEVAR and 14 underwent open surgery. The objective of TEVAR was closure of the primary entry site and the secondary tear site in the descending thoracic aorta.
RESULTS: In the TEVAR group, technical success was achieved: the primary entry site was closed, and bleeding was controlled in all 9 patients. There was no operative death, and 1 (13%) patient had cerebral infarction. In the open surgery group, 2 (14%) patients died during hospitalization, and 4 (29%) had cerebral infarction in the acute phase. Hospitalization tended to be longer in the open surgery group than in the TEVAR group. The overall survival rate at 1 year was 71 +/- 17% in the TEVAR group and 86 +/- 9% in the open surgery group (P = 0.89).
CONCLUSIONS: TEVAR for acute type B aortic dissection with rupture could be performed with relatively low morbidity and mortality, with no significant difference when compared with open surgery. The main objective of TEVAR for acute type B aortic dissection with rupture is control of bleeding, which can be achieved by closing the primary entry site and the secondary tear site in the descending thoracic aorta. If anatomically feasible and performed immediately, TEVAR is the treatment of choice for acute type B aortic dissection with rupture because it is less invasive than open surgery.

DOI： 10.1093/ejcts/ezs703

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OBJECTIVES: Intramural haematoma is defined pathologically as aortic dissection without an intimal tear. We therefore believe that this term is inappropriate as an acute clinical diagnosis, and instead, use the term 'thrombosed-type acute aortic dissection'. We compared the features of thrombosed-type acute aortic dissection with those of classic dissection.
METHODS: Thrombosed type was defined as aortic dissection without flow in the false lumen of the aorta on contrast-enhanced computed tomography. Surgery was indicated for all cases of type A acute aortic dissection, and central repair operations were performed in 509 patients. We retrospectively studied these patients' surgical records.
RESULTS: Three hundred and forty-four patients (68%) had classic dissection, and 165 (32%) had thrombosed type. Thrombosed type was associated with a significantly higher mean age (69 vs 60 years, P &lt; 0.01), a higher incidence of cardiac tamponade (45 vs 28%, P &lt; 0.01) and a lower incidence of malperfusion (6 vs 35%, P &lt; 0.01) than classic dissection. Entry tears were located in the ascending aorta and the arch in 74 patients (45%) with thrombosed type. Since 2007, an intimal tear has been confirmed intraoperatively or on computed tomography in 39 (78%) of 50 patients with thrombosed-type aortic dissection. Mortality was significantly lower in patients with thrombosed-type dissection (6%) than in those with classic dissection (13%, P = 0.02).
CONCLUSIONS: Most cases of intramural haematoma are acute aortic dissections with an intimal tear without re-entry. Intramural haematoma should be referred to as thrombosed-type acute aortic dissection. Thrombosed type can be easily diagnosed on contrast-enhanced computed tomography and has features distinct from those of classic dissection. Our classification may be useful for the diagnosis of these types of aortic dissection.

DOI： 10.1093/ejcts/ezt040

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Language：English   Publisher：EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC  

Although patients with Stanford type A acute aortic dissection often show ST-T abnormalities at presentation, the frequency and implication of such findings remain unclear. To clarify these points, admission electrocardiograms from 233 patients admitted &lt;= 6 hours after symptom onset who underwent emergency surgery for type A acute aortic dissection were studied. The prevalence of electrocardiographic (ECG) patterns was 51% for ST-T abnormalities (4% for ST-segment elevation and 47% for ST-segment depression and/or negative T waves), 30% for normal ECG findings or no significant ST-T changes, and 19% for ECG confounders such as bundle branch block or left ventricular hypertrophy. Patients with ST-T abnormalities had higher prevalence of pericardial effusion (48% vs 9% and 38%), cardiac tamponade (28% vs 3% and 18%), moderate or severe aortic regurgitation (28% vs 7% and 18%), shock on admission (34% vs 3% and 13%), coronary ostial involvement (14% rs 1% and 2%), concomitant coronary artery bypass surgery (9% vs 1% and 0%), and in-hospital mortality (11% vs 1% and 4%) compared with patients with normal ECG findings or no significant ST-T changes and those who had ECG confounders (p &lt;0.05 for all). On multivariate analysis, ST-T abnormalities were the only independent predictor of in-hospital mortality (odds ratio 3.87, 95% confidence interval 1.02 to 14.7, p = 0.035). In conclusion, about 50% of patients who underwent emergency surgery for type A acute aortic dissection had ST-T abnormalities, characterized predominantly by ST-segment depression or negative T waves, in the acute phase. ST-T abnormalities were associated with more complicated features and independently predicted in-hospital death. (C) 2013 Elsevier Inc.

DOI： 10.1016/j.amjcard.2013.03.050

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Language：Japanese   Publisher：一般社団法人日本外科学会  

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Language：English   Publisher：MEDICAL TRIBUNE INC  

Purpose: To study mid-term outcomes in patients admitted to receive treatment for acute type B aortic dissection.
Methods: The study group comprised 229 patients with acute type B aortic dissection treated between January 2000 and July 2010. 128 patients had a thrombosed false lumen, and 101 had a patent false lumen.
Results: In the thrombosed group, 6 had rupture, 4 had malperfusion, and 118 had no complications. There were 5 early deaths (3.9%). In the patent group, 12 had rupture, 19 had malperfusion, and 70 had no complications. There were 6 early deaths (5.9%). Overall survival rates in the thrombosed group and the patent group were 94.7 +/- 2.2% and 90.2 +/- 3.2% at 1 year, and 84.3 +/- 4.6% and 85.9 +/- 4.3% at 5 years (p = 0.892), respectively. Aorta-related event-free rates were 85.6 +/- 3.4% and 48.3 +/- 5.5% at 1 year, and 76.0 +/- 5.1% and 35.2 +/- 7.2% at 5 years (p &lt;0.001), respectively.
Conclusions: The incidences of rupture and malperfusion during the acute phase were higher in the patent group compared with the thrombosed group. At the late period, although the aorta-related event rate was higher in the patent group, the survival rate did not differ between two groups. Close follow-up and aggressive intervention strategy of the patent group may result comparable outcomes with the thrombosed group.

DOI： 10.5761/atcs.oa.12.02077

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Background: Sleep apnea syndrome (SAS) is an independent risk factor for hypertension which is a major risk factor for acute aortic dissection. The purposes of this study were to assess the prevalence of SAS in patients with acute aortic dissection, delineate the characteristics of patients who have acute aortic dissection with SAS.
Methods: Of 95 consecutive patients with acute aortic dissection, 13 had episodes of sleep apnea and nocturnal hypoxemia. A portable sleep monitoring system was used to assess sleep status in the 13 patients.
Results: The SAS-positive group consisted of 12 patients (12.6%), 8 with type A dissection and 4 with type B dissection. Age was significantly lower in the SAS-positive group (47.2 +/- 8.5 years) than in the SAS-negative group (64.9 +/- 10.3 years) (p &lt;0.001). The male: female ratio was significantly higher in the SAS-positive group than in the SAS-negative group (p &lt;0.001). The body mass index was significantly greater in the SAS-positive group than in the SAS-negative group (p &lt;0.001). All 12 patients in the SAS-positive group had hypertension.
Conclusions: Patients who have acute aortic dissection with SAS are characterized by being tall, fat, and relatively young men with hypertension. Sleep

DOI： 10.5761/atcs.oa.12.02014

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Objectives Postoperative disorders of the central nervous system remain a major problem in thoracic aortic surgery. Both retrograde cerebral perfusion and selective antegrade cerebral perfusion have become established techniques for cerebral circulatory management. In this study, we compared neurologic outcomes and mortality between retrograde cerebral perfusion and antegrade selective cerebral perfusion in patients with acute type A aortic dissection who underwent emergency ascending aorta replacement. Methods Between January 2003 and April 2011, a total of 203 patients with acute type A aortic dissection underwent emergency ascending aorta replacement in our hospital. We performed retrograde cerebral perfusion in 109 patients before 2006, and then mainly performed antegrade selective cerebral perfusion in 94 patients from 2006 onward. Results Cardiopulmonary bypass time and systemic circulatory arrest time were significantly longer in the antegrade selective cerebral perfusion group (p = 0.04, p\\0.001, respectively). The incidences of transient brain dysfunction and permanent brain dysfunction after surgery did not differ significantly between the groups. There were also no differences between the groups in other intraoperative variables, such as aortic cross-clamp time and the lowest rectal temperature, or in operative outcomes, including postoperative intensive-care-unit stay, mean peak amylase, and lipase levels until postoperative day 7, and 30-day mortality. Conclusion Both retrograde cerebral perfusion and antegrade selective cerebral perfusion were associated with acceptable levels of postoperative neurologic deficits, mortality, and morbidity. Either of these techniques for brain protection can be used selectively, based on a comprehensive assessment of general condition, in patients undergoing surgery for acute type A aortic dissection. © The Japanese Association for Thoracic Surgery 2012.

DOI： 10.1007/s11748-012-0142-z

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Background. We evaluated the probability of vertebrobasilar system malperfusion due to occlusion of the left subclavian artery as assessed by preoperative magnetic resonance angiography in patients scheduled to undergo thoracic aortic surgery.
Methods. (Study 1) From January 2000 through March 2009, we studied variations of vertebral arteries in 301 patients scheduled to undergo thoracic aortic surgery. We classified vertebral artery variations into 3 categories according to the findings on preoperative magnetic resonance angiography: connection type, interrupted right vertebral artery, and interrupted left vertebral artery. (Study 2) From February 2007 through January 2010, we evaluated the cerebral complication in 41 patients who had occlusion of the left subclavian artery with a stent graft.
Results. (Study 1) On preoperative magnetic resonance angiography, the vertebral artery was classified as connection type in 247 patients, interrupted right vertebral artery in 34, and interrupted left vertebral artery in 20. (Study 2) We performed subclavian obstruction test, left-right subclavian artery bypass, or left subclavian artery-left common carotid artery bypass to the 3 patients with interrupted right vertebral artery, respectively. Forty patients (98%) out of 41 patients had no complication after occlusion of the left subclavian artery.
Conclusions. Preoperative magnetic resonance angiography is useful for detection of the patients with high risk of vertebrobasilar system malperfusion due to occlusion of the left subclavian artery. (Ann Thorac Surg 2011;92:568-70) (C) 2011 by The Society of Thoracic Surgeons ADULT CARDIAC

DOI： 10.1016/j.athoracsur.2011.04.031

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A 30-year-old man had a sudden bout of severe abdominal pain. An enhanced computed tomographic scan revealed dissections of the celiac artery, superior mesenteric artery, left renal artery, and right external iliac artery; stenosis of the right renal artery; and left kidney infarction. After careful evaluation, the patient was diagnosed with fibromuscular dysplasia (medial dysplasia), based on the findings obtained from the enhanced computed tomographic scan. This case is extremely rare because fibromuscular dysplasia occurred concurrently with simultaneous spontaneous dissections of four peripheral arteries in a young man.

DOI： 10.1016/j.avsg.2011.02.018

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Deep sternal wound infection after median sternotomy is one of the severe complications associated with significant mortality, prolonged hospitality and higher cost. Several treatments including omentum flap, muscle flap, musculocutaneous flap, continuous negative pressure dressing are proposed to treat the infectious wound. From January 2007 to March 2010, we experienced 12 cases that underwent open heart surgery through median sternotomy at the Cardiovascular Center and were referred to our department for treatment. We overviewed these cases. The prognosis was poor if the patient has an exposed artificial material such as artificial vessels, while the patient without artificial material or septicemia is safely treated by bilateral pectoralis major myocutaneous advancement flap following continuous negative pressure dressing.

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P&gt;Cardiac rupture is mainly caused by myocardial infarction or blunt chest trauma. We present a case of idiopathic left atrial appendage rupture. (J Card Surg 2011;26:156-157).

DOI： 10.1111/j.1540-8191.2010.01180.x

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We studied the usefulness and problems of multidetector computed tomography (MDCT), a minimally invasive procedure, for the evaluation of grafts in the early phase after coronary-artery bypass surgery. In all patients who had graft patency on MDCT, graft patency was confirmed on coronary angiography (CAG). In patients with poorly controlled heart rates and those with small-caliber coronary arteries or grafts, graft patency can be difficult to evaluate on MDCT; CAG may therefore be required. In some patients in whom grafts were not detected on selective CAG, the grafts could be evaluated on MDCT. The appropriate use of CAG and MDCT may result in a less invasive and more accurate evaluation of coronary-artery bypass grafts as compared with CAG alone.

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Background. Stanford type A acute aortic dissection is a fatal condition requiring emergency surgery. This study was designed to evaluate risk factors for hospital mortality in patients with Stanford type A acute aortic dissection.
Methods. We studied consecutive 301 patients (163 men and 138 women; mean age, 63.3 years) who underwent emergency surgery for Stanford type A acute aortic dissection from January 1997 through December 2007. The subjects were divided into two groups: patients who were discharged from the hospital, and those who died during hospitalization. Preoperative and operative clinical factors were compared between the groups.
Results. Overall, 41 patients (13.6%) died during hospitalization. On univariate analysis, significant preoperative risk factors for hospital mortality were cardiopulmonary resuscitation, coagulopathy, renal dysfunction, elevated aspartate aminotransferase levels, myocardial ischemia, and lower-extremity ischemia. As for factors related to surgery, the duration of operation, cardiopulmonary bypass time, aortic cross-clamp time, and volume of blood transfusion were greater among patients who died during hospitalization than in those who were discharged from the hospital. On multivariate analysis, independent preoperative risk factors were cardiopulmonary resuscitation, renal dysfunction, and lower-extremity ischemia. Shock or cardiac tamponade were not risk factors.
Conclusions. Risk factors for hospital mortality in patients with Stanford type A acute aortic dissection were cardiopulmonary resuscitation, renal dysfunction, and lower-extremity ischemia. (Ann Thorac Surg 2010;90:1246-50) (C) 2010 by The Society of Thoracic Surgeons

DOI： 10.1016/j.athoracsur.2010.05.069

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We introduce our technique for the treatment of aneurysms arising in the descending thoracic aorta and the thoracoabdominal aorta. Thoracotomy is performed at a single site. The costal arch is transected to ensure an adequate field of vision. A lifting hook is used to open the proximal side of the aorta. The diaphragm is not totally transected to preserve respiratory function after surgery. In principle, partial extracorporeal circulation is performed using a percutaneous cardiopulmonary support system. The dose of heparin for systemic treatment is limited to 50 U/kg. The abdominal branches are perfused with the use of balloon catheters. Cardiac arrest is induced for about 10 seconds by intravenous administration of adenosine triphosphate to avoid aortic injury when the proximal aorta is clamped during partial extracorporeal circulation and to prevent massive bleeding when the elephant trunk is clamped. To prevent paraplegia, the Adamkiewics artery and 2 pairs of adjacent intercostal arteries identified by preoperative computed tomography are reconstructed, and cerebrospinal drainage and motor evoked potential monitoring are performed.

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Purpose: To present a technique for endovascular treatment using a fenestrated stent-graft in a patient with ascending aortic rupture in the setting of methicillin-resistant Staphylococcus aureus infection. Case Report: A 62-year-old woman had undergone mastectomy and radiotherapy twice for breast cancer and then coronary artery bypass grafting (CABG). She developed sternal osteomyelitis 5 years after the CABG. Sternectomy and negative-pressure wound drainage were performed, but the infection did not resolve. Ascending aortic rupture occurred 5 months after sternectomy. Endovascular therapy was considered the only effective means of achieving hemostasis. A custom-designed fenestrated stent-graft was deployed from the ascending aorta to the proximal descending aorta via a femoral artery approach without transient cardiac arrest. Bleeding completely stopped after surgery. The postoperative course was uneventful, and the inflammatory activity subsided on antibiotic therapy. At 7 months after surgery, the patient's recovery has been uneventful. Conclusion: Rupture of the ascending aorta associated with infection was successfully treated by stent-graft repair. The use of a custom-made, fenestrated stent-graft was an effective, lifesaving procedure for the management of this ascending aortic lesion. © 2010 by the International Society of Endovascular Specialists.

DOI： 10.1583/10-3033.1

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The number of operations performed for acute aortic dissection increased 2.6-fold during the last 10 years. The hospital mortality rate was 13.4% in 2006, decreasing from 21.8% in 1997. Current points at issue are: indications for surgery for thrombosed type-A acute aortic dissection; selection of the cannulation site for cardiopulmonary bypass; method to protect the brain during open distal anastomosis; extent of prosthetic replacement in acute-phase surgery; treatment strategy for visceral ischemia caused by dissection; and application of endovascular therapeutic techniques such as aortic stent grafts, percutaneous transluminal angioplasty, etc. Remarkable progress has been achieved in understanding the pathophysiology of acute aortic dissection, but the surgical mortality rate is not yet satisfactory. Accurate diagnosis using multislice computed tomography, prompt surgery, and systemic control of visceral ischemia are recommended. Cardiovascular surgeons require assistance from radiologists, cardiologists, neurosurgeons, and gastroenterologists for further improvement of the surgical results.

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A 12-year-old boy had severe chest and back pain of sudden onset while practicing the butterfly stroke in a swimming class. Computed tomography revealed an intimal flap in the descending thoracic aorta with massive right hemothorax. A ruptured type B acute aortic dissection was diagnosed, and then he collapsed. We totally replaced the descending aorta with a woven polyester prosthetic graft during deep hypothermic circulatory arrest. Hemostasis was achieved, but consciousness was not regained after operation, and multiple organ failure occurred. He died on the fifth postoperative day. He and his family had no history of cardiovascular disease. It seems that the swimming provoked a severe Valsalva maneuver, raising blood pressure acutely and thereby leading to dissection. This is then analogous to the propensity for dissection during intense isometic exercise such as weightlifting. © 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

DOI： 10.1510/icvts.2009.202234

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A 40-year-old man was referred to our hospital because of an abnormal shadow on the left cardiac border on the chest roentgenogram at the regular medical health examination without any symptoms. A giant coronary artery aneurysm of left anterior descending artery with a maximum diameter of approximately 50 mm was detected with computed tomography and coronary angiography. The patient was treated and followed up medically. Four years later, the size of the coronary artery aneurysm became larger. Then resection of the coronary artery aneurysm and coronary artery bypass grafting were successfully performed. Coronary artery aneurysms are rare in adults and are usually found in association with Kawasaki disease, coronary atherosclerosis, and so on. We also review the literature of giant coronary artery aneurysms exceeding 50 mm in diameter. (C) 2008 Japanese College of Cardiology. Published by Elsevier Ireland Ltd. All rights reserved.

DOI： 10.1016/j.jjcc.2008.07.015

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We describe our experience with patients who had preoperative cardiac arrest and required cardiopulmonary resuscitation (CPR) with open-heart surgery. Of the 14 patients with preoperative cardiac arrest, 10 survived and resumed normal activities. Of the 7 patients with out-of-hospital cardiac arrest, 5 resumed normal activities owing to a series of lifesaving measures, such as early notification, CPR performed by a bystander, and early electric defibrillation. Some of these patients required hypothermic therapy before operation. Of the 4 patients who died, 3 with severe ischemic heart disease refused surgery despite our recommendations. Patients with cardiac arrest have a high risk of complications, such as serious infections, systemic inflammatory response syndrome, acute respiratory distress syndrome, and gastrointestinal bleeding. We believe that close cooperation between surgeons and specialists in preoperative and postoperative care is essential to improving outcomes and survival.

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We describe our experience with a patient who had a cardiac tumor accompanied by tumors of the inguinal region and lower extremity, electrocardiographic abnormalities, and circulatory failure of the lower extremity. The patient was an 84-year-old man with a subcutaneous tumor in the inguinal region. The tumor was surgically resected. Because cyanosis developed in the left lower extremity 40 days after surgery, he was admitted to the hospital. The tumor extended around the arteries of the lower extremity, affected by arteriosclerosis obliterans. Circulatory failure of the lower extremity was apparently exacerbated. Electrocardiography during hospitalization showed ST elevation. Cardiac ultrasonography and magnetic resonance imaging revealed a cardiac tumor of the right ventricle. The patient died on the 19th hospital day. The direct causes of death were necrotic tissue infection of the lower extremity and sepsis.

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We describe our experience with a patient who had cardiac arrest at home and resumed normal activities after receiving cardiopulmonary resuscitation (CPR) by a bystander, electric defibrillation by an ambulance crew, hypothermie therapy, and coronary-artery bypass surgery. A 75-year-old man became excited during a quarrel with his son and had cardiac arrest at 18: 32 on January 3, 2004. The son performed CPR and called an ambulance. Ventricular fibrillation developed in the ambulance, and electric defibrillation was performed. At 18: 39, the patient presented at the emergency department of our hospital. The level of consciousness was 300, with the presence of spontaneous respiration and regular heartbeats. However, ventricular fibrillation recurred. Electric defibrillation was performed, and the trachea was intubated immediately. The patient was transferred to the coronary-care unit, and hypothermie therapy was started. On January 7, 2005, the endotracheal tube was removed. The patient regained full consciousness, with no tetraplegia. On January 19, angiography was performed. On February 2, two-vessel coronary-artery bypass grafting was done on the beating heart. The patient recovered uneventfully after surgery. He was discharged from the hospital in good condition on February 22 and resumed normal activities.

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Language：Japanese   Publisher：The Japanese Society for Cardiouascular Surgery  

A 76-year-old woman with Stanford type A acute aortic dissection underwent replacement of the ascending aorta with the use of gelatin-resorcin-formalin glue. The patient suffered sudden cardiogenic shock at home 15 months after surgery and was admitted to the Emergency Center of our hospital. A series of examinations revealed an aortic-root pseudoaneurysm associated with anastomotic disruption. Cardiogenic shock caused by obstruction of the ascending aortic graft due to anastomotic disruption was diagnosed. An intraaortic balloon pump (IABP) was inserted, and the patient's circulatory status improved. On the following day, reanastomosis of the aortic root graft was performed. On day 32 after surgery, the patient was discharged from the hospital in good condition. IABP can stabilize circulatory status and improve cardiogenic shock in the short term in patients with an aortic-root pseudoaneurysm caused by narrowing of the graft lumen, as in the present patient. IABP may thus be a useful ancillary measure before radical operation.

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BACKGROUND: Although gelatin-resorcinol-formaldehyde (GRF) glue is used for surgical repair of acute type A aortic dissections, late complications possibly ascribed to toxic effects of GRF glue have been reported. We analyzed the benefits and risks of using GRF glue. PATIENTS AND METHODS: Between January 1990 and August 2003, 269 consecutive patients underwent emergency operations for acute type A aortic dissection. GRF glue was not used in 47 patients (non-GRF group) who were operated on until May 1995 and was used in the 222 (GRF group) who underwent operation subsequently. RESULTS: The rate of in-hospital mortality was significantly higher in the non-GRF group (31.9%) than in the GRF group (12.6%) (p&lt;0.0001). In the GRF group, false aneurysms were found in 31 patients (31/194 survivors, 16.0%) 1-65 (mean, 30+/-18) months after initial operation. Reoperation was done in 24 of these patients. At reoperation, the site to which GRF glue was applied had degenerated, and the anastomosis between the aortic root and prosthesis had opened widely, creating a false aneurysm and resulting in aortic regurgitation with prolapse of the coronary cusps. The mortality rate of reoperation was 4.2% (1/24). CONCLUSION: The use of GRF glue improved the short-term outcome of surgery for acute type A aortic dissection, but was associated with a high incidence of false aneurysms forming at the site of proximal anastomosis, where GRF glue had been applied. Patients in whom GRF glue has been used should be carefully followed up after surgery.

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Language：English   Publisher：H G E UPDATE MEDICAL PUBLISHING S A  

Background/Aims: Today, in light of widespread adoption of H2-RA and PPI, the standard surgical procedure for perforated duodenal ulcer (PDU) is simple closure and/or omental patch (SC). However, the healing process after these techniques has not been fully examined. We have not yet confirmed the propriety of simple suture of the bottom of the ulcer. This technique has been performed based only on experience, and there is insufficient evidence to conclude that this procedure can be definitively considered a safe therapeutic technique for the majority of patients with PDU. The aim of this study is to clarify the macroscopic findings of the healing process after SC for PDU.
Methodology: Thirteen patients with PDU who were treated with SC underwent postoperative gastroduodenal fiberscopy (GF) at the 7th - 16th postoperative day and the healing process was monitored under sufficient informed consent. Patients with severe preoperative disease were excluded from the study. Healing condition of the ulcer and stitches, deformity, and stenosis were evaluated by postoperative endoscopy. Possible adverse effects that were evaluated included: perforation, rise in fever, worsening of inflammation on laboratory data, gastrointestinal symptoms such as abdominal pain, sense of fullness, and vomiting. The indications for SC were as follows: PDU with 1) no stenosis and 2) no prominent ulcer ridge. The surgical technique was as follows: 1) interrupted simple closure with no trimming and debridement of wound (4-5 stitches) with absorbable monofilament suture, and/or 2) omental patch, 3) administration of H2-RA (or PPI) just after operation, and 4) oral feeding 4-5 days after operation independent of postoperative GF.
Results: GF findings in 2 patients showed active and healing stage, in whom surgical technique was thought to be insufficient; the ulcer had been large and included a descending portion, or a small perforation had occurred in the large ulcer bottom (the distance between the stitches and the edge of the ulcer was insufficient). In the other 11 patients, GF findings showed scar phase. There was no morbidity related to endoscopic procedure.
Conclusions: Sutured PDU with SC will be in the scar phase in 1 or 2 weeks. Postoperative GF 1 week after SC for PDU is thought to be a safe examination. This study is a primitive study of a small group, and more cases that can adequately show the frequency of complications and indicate the overall safety of the procedure are needed.

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OBJECTIVE: Transluminal endovascular grafting (TEG) is less invasive than conventional operative procedures for the treatment of DeBakey type III dissecting aortic aneurysms (DAA). We have used two different kinds of stent grafts covered with woven Dacron grafts, a Gianturco Z-stent graft (G-SG) and a Spiral Z-stent graft (S-SG). Because the G-SG lacks adequate flexibility, the end of the graft may injure the intima after long-term deployment in the proximal descending aorta. We have used S-SGs, which are more flexible than G-SG, to improve outcome. We report our late midterm results and discuss treatment policy. SUBJECTS AND METHODS: We studied 45 patients with DeBakey type III DAA. Thirty-two G-SGs and 13 S-SGs were used. Follow-up ranged from 1 year 6 months to 8 years 5 months (mean, 5 years 2 months). RESULTS: 1) Surgical outcome: (a) TEG was technically successful in all patients. There was no operative mortality. (b) One week after surgery, 36 patients had no endoleaks, 5 had minor endoleaks, and 4 had major endoleaks. 2) Late midterm results: (a) Four patients with residual major endoleaks, underwent replacement of the descending thoracic aorta. (b) Intimal injury occurred at the distal end of the stent graft 4 to 18 months (mean, 10.5 months) after surgery in 12 patients with G-SG and 1 with S-SG. One of these patients had recurrent dissection, and 12 had ulcer like projections (ULP). Two patients underwent additional stent implantation to block blood flow. (c) Four patients with S-SG had major endoleaks 3 to 6 months after surgery. In 3 of these patients, the Spiral Z-stents were compressed and occluded, and thrombus had formed in the lumen. Three patients underwent replacement of the descending thoracic aorta. (d) Additional replacement of the descending thoracic aorta was done in 9 of the 45 patients (20%) 4 to 24 months after TEG. All patients responded to treatment and were discharged from the hospital. CONCLUSION: Intimal injury was caused by Gianturco Z-stents because of inadequate flexibility, and endoleaks and stent-graft occlusion were caused by Spiral Z-stents because of insufficient radial force against the aortic wall. The development of stents with these improved properties is expected to further improve outcome.

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Purpose: To report a case of ruptured aneurysm caused by an endoleak 29 months after transluminal endovascular grafting (TEG) for a dissecting aortic aneurysm. Case report: We performed TEG with the use of a stent graft in a patient with a DeBakey type III chornic aortic dissection. The primary entry in the descending thoracic aorta was successfully sealed, and the false lumen was thrombosed. However, a new endoleak developed in the false lumen of the proximal portion of the stent graft 29 months after TEG. The aneurysm ruptured at the site
the patient underwent urgent surgery and survived. Conclusion: The endoleak may have been caused by insufficient radial force of the stent graft. Further investigation is needed to evaluate the structures and shapes of stent grafts providing suitable radial force for placement in the true lumen of the aorta, the diameter of which changes after stent-graft placement. © 2005.

DOI： 10.1016/j.ejvsextra.2005.06.003

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Background. The treatment policy for acute intramural hematoma involving the ascending aorta remains controversial.
Methods. This study compared the pathologic characteristics of intramural hematoma with those of acute aortic dissection with a false lumen. The study group comprised 69 patients with intramural hematoma and 156 with acute aortic dissection who underwent emergency operation between 1995 and 2003.
Results. Patients were significantly older in the intramural hematoma group than in the dissection group (67.7 &PLUSMN; 7.2 years compared with 59.8 &PLUSMN; 11.6 years; p &LT; 0.0001). Pericardial hemorrhage was present in a higher proportion of patients in the intramural hematoma group than in the dissection group (66.7% compared with 50.6%; p = 0.0257). Three patients (4.3%) died in the intramural hematoma group, whereas 26 patients (16.7%) died in the dissection group (p = 0.011). Histopathologic examination showed no difference in the severity of medial changes, but the site of dissection differed. The thickness of the residual media of the adventitia side was 0.21 &PLUSMN; 0.12 min in the intramural hematoma group compared with 0.32 &PLUSMN; 0.22 min in the acute aortic dissection group. Dissection was significantly nearer the adventitia in the intramural hematoma group (p 0.0016).
Conclusions. Dissection is nearer the adventitia in intramural hematoma than in dissection, leading to a greater probability of rupture. These results suggest that operation as soon as possible after the onset of intramural hernatoma will contribute to improved survival. &COPY; 2005 by The Society of Thoracic Surgeons.

DOI： 10.1016/j.athoracsur.2004.11.017

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Language：English   Publisher：ALLIANCE COMMUNICATIONS GROUP DIVISION ALLEN PRESS  

Purpose: To report successful endovascular repair of Stanford type A acute aortic dissection associated with a proximally extended dissection of the left main coronary artery.
Case Report. A 71-year-old man presented with acute type A aortic dissection. One day after admission, dissection of the left main coronary artery accompanied by severe myocardial ischemia prompted Palmaz stent placement. Three days later, a customized stent-graft was placed across the entry site of the dissection in the descending aorta. The false lumen in the ascending aorta, transverse arch, and the descending thoracic aorta thrombosed, and the left coronary artery remained patent. At 14 months after the procedures, the patient is doing well and has had no cardiac event.
Conclusions: This staged procedure may be one option for the management of acute type A aortic dissection complicated by coronary artery dissection.

DOI： 10.1583/03-1120R.1

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This report describes the use of transluminal endovascular grafting for the treatment of a presumed aortoduodenal fistula. The patient was a 71-year-old man who had undergone resection and graft replacement for an abdominal aortic aneurysm. Three years after operation, melena was caused by perforation of the duodenal wall by a pseudoaneurysm at the proximal graft anastomosis. The pseudoaneurysm was treated by transluminal endovascular grafting. The pseudoaneurysm was subsequently thrombosed and absorbed. The ulcer-like lesions at the site of the duodenal wall perforated by the pseudoaneurysm also resolved. Endovascular stent-grafts may have a role to play in management of aortoduodenal fistula.

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Computed tomography (CT) has not been considered useful for early diagnosis of traumatized patients who could hardly hold their breath, particularly patients with tracheal injuries. However, the recent development of spiral CT has made it possible to acquire contiguous patient data, which eliminates the respiratory misregistration. Air is easily differentiated from surrounding tissues by striking contrast, and the trachea can therefore be well displayed by three-dimensional (3D)-CT. We consider that it is possible to show tracheal injury by 3D-CT. The aim of this study is to clarify the usefulness of 3D-CT for detecting the injury site of blunt tracheal injuries. The study was carried out in hemodynamically stable patients who were suspected of having tracheal injury based on clinical manifestations such as hemoptysis, or cervical subcutaneous, deep cervical, or mediastinal emphysema. Repeated bronchoscopy confirmed tracheal injury. The virtual images of the 3D-CT (3D-tracheography) were compared with the direct images of bronchoscopic findings. Five cases were examined. In patients with tracheal injury, bronchoscopy revealed laceration of the tracheal lumen or disruption and dislocation of the tracheal cartilage, partially coated by mucus and clot, findings that confirmed the diagnosis of tracheal injury. The virtual images of the 3D-tracheography clearly showed the injury as a defect in the tracheal wall or a depression in the wall. The site and size of injury shown in the 3D-tracheography were comparable with those detected by bronchoscopy. We succeeded in detecting tracheal injuries by 3D-CT imaging, the virtual images of which were comparable with the bronchoscopic findings. 3D-tracheography is a useful method for diagnosing the site and form of tracheal injury in hemodynamically stable patients.

DOI： 10.1007/s00268-004-7433-1

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A seventy-seven-year-old male patent was admitted for surgical treatment of an aneurysm of the distal thoracic aorta. Because of his many complications, prior CABGs, lung cancer with multiple bone metastases, and his advanced age, we thought that surgical graft replacement was contraindicated. After admission, the aneurysm ruptured and an emergency operation was performed. We used a spiral Zigzag stent covered with a UBE graft via the pull-through method. No complications were observed. Stent-graft placement is effective for high risk cases that might be difficult to repair surgically.

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The mortality rate in acute type A dissection with cardiac arrest (CA) is high. Rapid surgical treatment after CA has improved postoperative survival, but we looked for other predictors. We analyzed the risk factors of operative death in 17 patients undergoing surgical repair for type A aortic dissection with cardiac arrest between September 1990 and November 2000. We found that preoperative complications were an important predictor of postoperative mortality in acute type A dissection with cardiac arrest. We believe that emergency surgical treatment should be done when the right coronary artery and cardiac tamponade are involved.

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Language：Japanese   Publisher：一般社団法人日本外科学会  

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We describe two cases where postinfarction ventricular septal defect (VSD) was treated with a new technique. Application of direct ultrasonography to the right ventricular (RV) wall enables the surgeon to visualize the region and perform appropriate incision into the right ventricle and trabecula resection. The VSD is sealed with gelatin-resorcin-formal (GRF) glue between two patches, one placed on the left ventricular side and the other on the right ventricular side. RV incision provides easy bleeding control and the "sandwich technique" using two patches and GRF sealing provides geometric preservation of the left ventricular shape and prevents residual shunt.

DOI： 10.1111/j.0886-0440.2004.04028.x

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A 63-year-old female with acute aortic dissection underwent emergency surgery. After admission to ICU, wheezing was heard over the chest with concomitant increase in peak airway pressure. Chest CT scan in both inspiratory and expiratory phases with positive airway pressure ventilation was performed. Tracheal lumen was significantly compressed by mediastinal haematoma in the expiratory phase. The chest CT scan in both inspiratory and expiratory phases was helpful to clarify the mechanism of this condition. © 2004 Taylor &amp
Francis Ltd.

DOI： 10.1080/09563070410001697093

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Language：English   Publisher：H G E UPDATE MEDICAL PUBLISHING S A  

Background/Aims: We often encounter patients with bile peritonitis expressing right hypogastralgia who have been easily misdiagnosed as acute appendicitis. The aim of this study is to clarify why patients with bile peritonitis express right hypogastralgia and to recommend a way in which to prevent misdiagnosis of patients with bile peritonitis with right hypogastralgia as acute appendicitis.
Methodology: Subjects were 12 patients with bile peritonitis who underwent laparotomy in Yokohama City Nambu Hospital or Critical Care and Emergency Center of Yokohama Citizen Medical Center Hospital The spread of bile and inflammatory peritoneal fluid confirmed during laparotomy was compared with the preoperative abdominal findings.
Results: Five of the 12 cases (42%) showed signs of,peritoneal irritation only in the epigastric and right hypochondral region; 6 (50%) in the right lateral and hypogastric region; and 1 (8%) in the diffuse abdomen. Four of the 12 cases (33%) showed widespread inflammation and accumulation of fluid in the whole peritoneal cavity (generalized peritonitis). Five cases (42%) showed limited peritoneal inflammation with green coating, leaked bile, and accumulation of inflammatory fluid within the hepatoduodenal ligament, Morison's pouch, right paracolic gutter, and right ileac pouch. Three of these 5 cases and 3 of the 4 generalized peritonitis cases showed signs of peritoneal irritation in the right hypogastric region. US of these cases showed signs of cholecystitis. Three of the 6 cases underwent emergency operation by right hypogastric incision under the diagnosis of acute appendicitis. One of these 3 cases underwent neither US nor CT; the second of these cases showed ileocecal inflammation by US but did not undergo CT; and the last of these cases expressed peritoneal irritation most strongly in the right hypogastric quadrant despite of signs of cholecystitis by US and CT.
Conclusions: If patients who complain of right hypogastralgia like acute appendicitis also complain of right epigastralgia or right hypochondralgia, we should suspect biliary peritonitis due to gangrenous or perforated cholecystitis and should perform upper abdominal scanning, especially around the gallbladder, by US and CT.

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Post-traumatic hepatic pseudoaneurysms are rare. We report a very unusual case of bile duct injury complicated with an asymptomatic post-traumatic hepatic pseudoaneurysm. A previously healthy 17-year-old man sustained multiple traumas after a motorcycle accident. Post-traumatic hepatic pseudoaneurysms were detected after blunt liver injury. The rapid growth of the pseudoaneurysms in the hepatic hilus compressed the common hepatic bile duct and caused extrahepatic bile leakage at the lateral lobe. At first, the hepatic arterial pseudoaneurysms were embolized and bile leakage at the left lobe was treated conservatively. Finally, however, segment 2 and 3 partial liver resection should have been performed to stop the bile leakage. Post-traumatic pseudoaneurysm should be ruled out, in addition to the presence of biliary tract injury, if the intraperitoneal bile leakage appears after liver injury.

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Purpose. Aortic dissection is characterized by fragility of the tunica media, and matrix metalloproteinases (MMPs) are enzymes that degrade the extracellular matrix of the aorta. This study examines MMPs in patients with acute aortic dissection (AAD) in an attempt to elucidate the mechanisms of their actions.
Methods. Enzyme-linked immunosorbent assays were used to measure the quantification of MMP-2, MMP-9, and the tissue inhibitor of metalloproteinase (TIMP)-2 in 30 patients with AAD, 12 patients with abdominal aortic aneurysm (AAA), and 16 control (CON) patients who underwent coronary artery bypass grafting.
Results. MMP-2 and TIMP-2 were significantly lower in the AAD group than in the CON group, at 36 +/- 19 vs 58 +/- 30 (P &lt; 0.01) and at 21 +/- 25 vs 216 +/- 130 (P &lt; 0.001), respectively. The TIMP-2/MMP-2 ratio was 3.7 +/- 1.7 in the CON group and 0.9 +/- 0.8 in the AAD group (P &lt; 0.001 vs CON), and the TIMP-2/MMP-9 ratio was 200 170 in the CON group and 37 80 in the AAD group (P &lt; 0.001 vs CON).
Conclusion. Low TIMP-2/MMP-2 and TIMP-2/MMP-9 ratios might play an important role in the onset of aortic dissection, when the tunica media becomes fragile with chronic breakage and degradation of the extracellular matrix.

DOI： 10.1007/s00595-003-2683-3

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Background/Aims: To clarify changes in the hepatic oxygen metabolism and tissue damage resulting from oxygen-derived free radical generation from polymorphonuclear cells during a hepatic arterial clamp.
Methodology: Subjects were 32 male Wistar rats. Hepatic tissue blood flow, and hepatic venous chemiluminescence, indicating oxygen-derived free radicals from polymorphonuclear cells, and liver lipid peroxide were measured, and hepatic and portal venous blood gas analysis were performed before and after 130 minutes of hepatic arterial clamping.
Results: Hepatic tissue blood flow decreased by hepatic arterial clamp. The values of hepatic arterial oxy-gen pressure (HTBF), hepatic venous oxygen saturation (ShvO(2)), and O-2 contents after hepatic arterial clamp were lower than those before hepatic arterial clamp (P=0.035, 0.024, and 0.028, respectively). Hepatic venous chemiluminescence decreased and the lipid peroxide level of the liver increased by hepatic arterial clamp (P=0.001).
Conclusions: ShvO(2) is useful for the evaluation of hepatic oxygen metabolism and hepatic tissue blood flow during acute hepatic arterial clamp. This condition should prepare the following tissue damage due to oxygen-derived free radicals from polymorphonuclear cells.

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Language：Japanese   Publisher：一般社団法人日本外科学会  

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Language：English   Publisher：Japanese Circulation Society  

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A 52-year-old Japanese man was transferred to our center where screening by means of ordinal ultrasonography and color Doppler ultrasonography revealed an abdominal visceral aneurysm. Although we were unable to confirm the site of this aneurysm by means of ultrasonographic examination, thin-sliced contrast enhanced computed tomography and three-dimensional spiral computed tomographic angiography showed that the aneurysm was situated at the root of the splenic artery. Transcatheter arterial embolization of the aneurysm was performed by metallic coil with occlusion of the main route of the splenic artery because it was technically difficult to embolize the aneurysm alone while preserving the main splenic arterial flow. Angiography of the celiac trunk after transcatheter arterial embolization showed no enhancement of the aneurysm or splenic artery, and superior mesenteric arteriography after transcatheter arterial embolization showed enhancement of the spleen by collateral circulation from the superior mesenteric artery. One year after transcatheter arterial embolization, repeated contrast enhanced computed tomography revealed the enhancement of the spleen, and color Doppler ultrasonography revealed no blood flow in the aneurysm. Color Doppler ultrasonography and 3D-spiral computed tomographic angiography are both useful for diagnosis of a visceral aneurysm, for confirmation of its exact site and form, and for deciding upon a treatment procedure.

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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Language：English   Publisher：Japanese Circulation Society  

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Language：Japanese   Publisher：Japanese College of Surgeons  

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Other Link： http://search.jamas.or.jp/link/ui/2001151703

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The usefulness of ultrasonography for the detection of intraperitoneal free air (IPFA) in abdominal trauma patients was examined. Abdominal blunt trauma patients with gastrointestinal perforation and patients who underwent laparotomy in the previous day were examined by ultrasonography. The right hypochondral region was scanned to detect IPFA on the ventral surface of the liver. High echo line just under the peritoneum, which can easily move by compression of the probe, was diagnosed as IPFA. Air in the lung was easily differentiated from IPFA by detecting the layer of the high echoic line and the relationship with respiration.

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A 73-year-old woman was admitted with sudden-onset back and abdominal pain. Computed tomography scanning revealed type B acute aortic dissection with narrowing of the true lumen. We inserted an oximetric catheter into the right hepatic vein and started continuous measurement of ShvO2. The initial value was 20%. Consecutive aortograms showed an intimal tear in the thoracic descending aorta. Endovascular stent graft placement was performed to close the entry, and ShvO2 rose to more than 60% immediately after the stent graft expansion. ShvO2 is an excellent indicator of abdominal blood flow, not only for early diagnosis but also for the evaluation of treatment.

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Language：English   Publisher：British Institute of Radiology  

40 haemodynamically unstable patients with pelvic injuries were studied to assess the ability of plain radiographs to detect haemorrhagic sites. Pelvic radiographs and bilateral angiograms were reviewed separately for detection of haemorrhagic sites in both anterior and posterior segments. Sensitivity and specificity of pelvic radiographs for the detection of haemorrhagic sites were obtained by analysis of angiographic findings. Angiography demonstrated arterial injury in 106 divisions: 26 right anterior, 22 right posterior, 33 left anterior and 25 left posterior. Sensitivities of the radiographs for predicting haemorrhagic sites were higher in the anterior segment (right, 96%
left, 100%) than in the posterior segment (right, 73%
left, 83%). However, specificities were lower in the anterior segment (right, 79%
left, 78%) than in the posterior segment (right, 100%
left, 100%). In 15 (58%) of 26 patients with in-dwelling Foley catheters, including those with catheter deviation, the severity of anterior injury indicated on plain radiographs was correlated with angiographic findings. Plain radiographs of the pelvis proved useful for predicting haemorrhagic sites in haemodynamically unstable patients with pelvic fractures, especially in those with anterior fractures.

DOI： 10.1259/bjr.73.873.11064646

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From January 1993 through December 1998, Emergency Coronary Artery Bypass Grafting was Performed within 24 Hours after the Onset of Acute Myocardial Infarction (AMI) with Cardiogenic Shock in 22 Patients (17 men and 5 women; aged, 52-81 years). The incidence of AMI involving the left main coronary artery was 50%. The incidence of interventional therapy was 40.9% (PTCA 31.8%; PTCR 9.1%). The condition in 95.5% of the patients could be stabilized hemodynamically by preoperative intraaortic balloon pumping; 4 of the 5 patients suffered from cardiopulmonary arrest required percutaneous cardiopulmonary support. There were 4 (18.2%) deaths overall. Operative mortality was related to the intervals between AMI and operation (less than 6 hours, 25%; 6 to 24 hours, 10%). Three of the 4 patients who received cardiopulmonary support survived. We conclude that early revascularization and minimal reperfusion injury caused by mechanical devices are important determinants of survival in patients who have AMI with cardiogenic shock.

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We experienced a case with acute mitral regurgitation caused by complete posterior papillary muscle rupture as complication of acute inferior myocardial infarction, who underwent successfully emergency operation of mital valve replacement and coronary revascularization in acute stage. A 64-year-old woman developed sudden cardiogenic shock shortly after the onset of acute inferior myocardial infarction. The diagnosis of acute inferior myocardial infarction was based on the electrocardiographic findings. Under IABP support, preoperative coronary angiography visualized total occlusion of segment 3 of the right coronary artery, and preoperative left ventriculography showed akinesis of inferior wall and severe mitral regurgitation. At 6 hours after onset of papillary muscle rupture, emergency operation was performed. At operation, posterior papillary muscle was found to be totally ruptured. Coronary artery revascularization and mitral valve replacement were performed. Postoperative course was uneventful, with 4 days of IABP and 5 days of ventilatory support. She was discharged on the twentieth postoperative day in NYHA class I. Reports of successful emergency operation for total papillary muscle rupture following acute myocardial infarction are rare. Early diagnosis and surgical treatment are mandatory to save this group of patients.

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Language：English   Publisher：MUNKSGAARD INT PUBL LTD  

Purpose. To document changes in tissue oxygen tension as measured directly in an area perfused with contrast medium.
Material and Methods: Changes in tissue oxygen tension in response to the injection of ionic and non-ionic contrast media into the femoral arteries were measured in the femoral adductor (proximal) and gastrocnemius (distal) muscles of 8 dogs. Amidotrizoic acid and iopamidol were injected in two different iodine concentrations (370 mg I/ml and 185 mg I/ml respectively) and tissue oxygen tension in the proximal and distal muscles was monitored continuously using polarographic needle electrodes.
Results and Conclusion: A transient decrease and subsequent increase of muscle tissue oxygen tension were observed after the injection. The extent of these changes depended on the concentration and osmolality of the medium. To minimize changes in peripheral tissue oxygen tension, contrast media with low osmolality and low concentration are recommended for femoral angiography.

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From January 1990 to December 1996, 71 patients aged 33 to 79 years (mean 60 +/- 11) underwent an emergency operation for type A acute aortic dissection. Fifty-three (74.6%) survived, and were followed 7 to 94 months (mean follow up 2.9 +/- 1.8 years) after the first operation. Five patients underwent reoperation for dilatation of the distal false lumen 7 to 52 months (mean period, 25 months) after primary repair. One patient underwent replacement of the arch and descending aorta, three patients underwent replacement of the descending aorta, and one patient underwent the stented graft implantation, resulting in closure of the entry site. Three patients underwent reoperation for severe aortic valve regurgitation 12 to 31 months (mean period, 24 months) after primary repair. Two patients underwent aortic valve replacement, and one patient underwent aortic root replacement. The actuarial freedom from reoperations was 81 +/- 6.9% at 3 years, and 73 +/- 9.9% at 5 years.

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Language：Japanese   Publisher：JAPANESE SOCIETY FOR ARTIFICIAL ORGANS  

Surgical results using ultrafine polyester fiber graft (TORAY GRAFT) in patients with abdominal aortic aneurysm were examined. From January 1992 to May 1996, vascular replacement using this graft were performed in 54 cases. The surgical mortality was 19% and 3% in cases undergoing emergency surgery and elective surgery, respectively. No death was related to the graft. During an average follow-up period of 2.8 years, the cumulative survival rate was 93% at 1 year and 85% at 2 years. Results of computed tomography and digital subtraction angiography during the late phase showed that the internal diameter of the graft extended by 10% compared with the standard size and regenerative intima-like hypertrophy was observed on CT images in 27.7% of the cases.

DOI： 10.11392/jsao1972.27.537

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A 73-year-old woman was admitted with chest pain of sudden onset and hypotension. Enhanced CT showed the dilated ascending aorta with an intimal flap. Emergency surgery was performed under a diagnosis of type A acute aortic dissection and cardiac tamponade. Replacement of the ascending aorta was planned, but during the operation we found that the dissection had extended to the aortic root and that the laceration of the adventitia was located just distal to the aortic annulus. Since the laceration was closer to the aortic annulus than the coronary ostium, it was impossible to reconstruct the aortic stump by classical techniques using Teflon felt strips. Gelatine-Resorcine-Formol (GRF) glue was therefore used to reinforce the proximal aortic stump. We then curved the suture line of the proximal anastomosis so as to resect the laceration while preserving the ostia of the coronary arteries. We were thus able to perform simple replacement of the ascending aorta successfully and the postoperative course was uneventful. By using GRF glue, replacement of the aortic root can be avoided in such cases.

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Long-term results in QOL of patients over 75 years old after emergent cardiovascular surgery were examined. From January 1991 to June 1996, 46 patients underwent cardiovascular surgery. 22 patients who had elective surgery (elective group) and 15 patients who had emergency surgery (emergency group) tolerated with the operation: Two-year survival rate after surgery was 80.7% in the elective group and 78% in the emergency group, and relative survival rate was 0.89 in the elective group and 0.86 in the emergency group. As regards to the ability to live independently, 89% of elective group and 75% of emergency group showed good improvement, and there was no significant difference between two groups. The rate of patients who did not feel anxiety for disease at all was 61.1% in the elective group and 41.7% in the emergency group. The relationship between the patient and his family was good in both groups. For physical condition, the emergency group was superior to the elective group with no significant difference. Although QOL was relatively good after emergency surgery, some items were inferior compared with elective surgery. To improve the long-term results, elective surgery is required to avoid emergency surgery.

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：AMER HEART ASSOC  

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Sixteen cases with mitral valvular disease were studied with regard to the correlation between pathological changes in the pulmonary vasculature and pulmonary hemodynamics during exercise before and after surgery. In muscular pulmonary arteries obtained by open lung biopsy, medial wall thickness (MWT) was 13.8 +/- 3.2% and intimal thickness (IT) was 37.3 +/- 13.5%. MWT was correlated with IT (r = 0.60, p &lt; 0.05). Wall thickness in pulmonary veins was 8.21 +/- 1.8%. Preoperative mean pulmonary arterial pressure (MPAP) during exercise was 45.9 +/- 9.4 mmHg, and decreased significantly to 38.1 +/- 11.3 mmHg postoperatively. However, in 4 patients, MPAP during exercise increased after surgery. Pulmonary vascular resistance (PVR) during exercise was unchanged before and after surgery (2.74 +/- 1.90 U.M2--&gt;2.69 +/- 1.3 U.M2). MWT was significantly correlated with preoperative MPAP at rest only. In patients showing an increase of MPAP during exercise postoperatively, mean MWT was 16.2% and mean IT was 47.4%. In conclusion our data suggest that postoperative pulmonary hemodynamics does not improve in patients whose MWT exceeds 15% and IT exceeds 40% and that irreversibility may be due to pulmonary vascular lesions.

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Five years after coronary artery bypass grafting, 23 internal thoracic arteries (ITAs) were reexamined angiographically, and their luminal diameters were compared with those of one month after the operation. Proximal diameter, just below the subclavian artery, and distal diameter, just above the anstomosis, were measured. One month after surgery, these were 2.38 +/- 0.48 mm and 1.69 +/- 0.39 mm, respectively. After five years, the proximal diameter had not changed significantly (2.48 +/- 0.47 mm), but the distal diameter had increased to 1.96 +/- 0.58 mm (p &lt; 0.05). Especially when there was no competitive flow with the ITA, the distal diameter showed a marked increase from 1.80 +/- 0.35 mm to 2.27 +/- 0.42 mm (p &lt; 0.01). Twelve ITAs were grafted to coronary arteries having less than critical stenosis, and five of them showed distal narrowing or so-called string sign after five years. This seemed to be a form or physiological atrophy resulting from competitive flow, and the patients had no anginal pain in spite of their poor ITA runoff. When coronary artery stenosis is less than 75%, a choice is difficult between an ITA or a saphenous vein graft. We think that the graft must be selected considering the possibility of stenosis progression, if the jeopardized area is important for the patient. An ITA graft would be advisable in such cases.

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Language：English  

We investigated the effects on hemodynamics and myocardial metabolism of nicardipine (NIC) and nitroglycerin (NTG) in experimentally coronary constricted dogs. Coronary constriction was produced by reducing 50 % of the left anterior descending coronary blood flow. After stabilization of hemodynamics, we cross-clamped the descending aorta and administered nicardipine (10 μg · kg-1 · min-1) or nitroglycerin (10 μg · kg-1 · min-1). The drugs were infused for 15 minutes and were discontinued just before the clamp on the aorta was released. In NIC group, the cardiac output (CO) increased 32 % and the heart rate (HR) decreased 17 % significantly, compared with pre-clamping values. The myocardial blood flow (MBF) in ischemic area measured by hydrogen clearance method was maintained. The value of the myocardial oxygen extraction ratio (MO2EX) decreased significantly for 24.3 % compared with the pre-clamping value of 41.4 %. On the other hand, in NTG group, CO, HR, and MO2EX were unchanged, but MBF in ischemic area was well maintained. The results of these experimentally coronary constricted dogs suggest that both NIC and NTG maintain the cardiac function during the aortic cross-clamping, but regarding the improvement of the myocardial metabolism, NIC appears to be the better choice for blood pressure control.

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In the 46 ;patients who underwent operative reair of thoracic and thoraco-abdominal aortic aneurysm, 9 cases showed hypoxemia (PO2&lt;70 mmHg, FiO2 1.0) and rectal temperature lowered less than 34°C in 10 cases intraoperatively. On August 1991, we began to utilize left heart bypass with membrane oxygenator and internal heat exchanger as temporary support. Activated clotting time was maintained between 200 and 250 s during the support. Hemoconcentrator also attached to the inflow side of left heart bypass, and sucked blood from the operative field could be transfused quickly. As applying this system, good clinical results were obtained. The diagnosis of 11 patients was as follows: 7 with descending thoracic aortic aneurysm, 1 with thoraco-abdominal aortic aneurysm, 1 with type A dissection, 1 with type B dissection and 1 with aortic coarctation. The average PaO2 in the proximal portion of cross-clamped aneurysm was 165.2 mmHg and the average of the lowest point of temperature was 35.0°C. It was very easy to prevent from hypoxemia and temperature drop during surgery. But platelet count and fibrinogen value decreased after the support, that were major complications in this procedure. It is necessary to develop a new system without the disturbance on blood coagulation factors.

DOI： 10.11392/jsao1972.22.1332

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From 1982 to March 1991, 68 patients underwent coronary artery bypass grafting (CABG) using bilateral internal thoracic arteries (ITA). There were 62 males (91.2%) and 6 females (8.8%) ranging from 33 to 74 years old (mean 58.5 +/- 9.2). Thirty four patients had old myocardial infarction (OMI) and left main trunk disease was seen in 8.5% of the patients. The number of grafts was 2 to 6 per patient with an average of 3.2 +/- 1.0. In bilateral ITA grafting the combinations of RITA to LAD and LITA to LCX were most frequently used. There were no operative deaths except for one death which occurred while at the hospital. The patency rates for the RITA and LITA were 98.3% and 96.7%, respectively. Postoperative complications included reexploration for bleeding and heart tamponade in 9 patients, and low output syndrome in 7 patients. The frequency of blood transfusion decreased with the use of cell saver. Routine bilateral ITA grafting for multiple CABG is considered safe, with the early patency being relatively better than with saphenous vein grafting.

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A 46-year-old man was referred to our hospital because of prosthetic valve regurgitation. Eight years previously he had undergone aortic valve replacement because of aortic regurgitation due to infective endocarditis. At reoperation, we found prosthetic valve endocarditis and discrete subaortic stenosis. The obstructing fibrous tissue was resected and the aortic valve was replaced. Because discrete subaortic stenosis is usually located just below the aortic valve, the aortic valve cusps are liable to become thickened by the jet through the discrete stenosis and thus are vulnerable to infective endocarditis. It is pointed out that care must be taken not to overlook discrete subaortic stenosis in the presence of other associated cardiac disorders.

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A 49-year-old woman with deep vein thrombosis of the left leg suddenly complained of slight dyspnea during her hospitalization. Enhanced chest CT and pulmonary arterial DSA revealed pulmonary emboli, while phlebography of the left leg and lower abdominal CT showed a uterine myoma compressing the left external iliac vein, which was regarded as a chief cause of deep vein thrombosis of the left leg. The patient became dyspneic severely with a rapid increase of pulmonary arterial pressure and a decrease of arterial oxygen pressure. Therefore, pulmonary embolectomy and deep vein thrombectomy of the left leg and pelvis was performed using a cardiopulmonary bypass. Hysterectomy was also performed after weaning the bypass. The postoperative course was uneventful without recurrence of pulmonary embolism. This was a very rare case of pulmonary embolism, because, as far as we investigated, no literature has reported deep vein thrombosis of the leg caused by uterine myoma. We emphasize the availability of the enhanced CT for diagnosis of pulmonary embolism.

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The clinical characteristics of selection of graft materials were analysed for patients undergoing emergency coronary artery bypass surgery (CABG) following failed coronary angioplasty (PTCA). Ten emergency CABGs were performed from January 1983 to December 1991. Perioperative variables and follow-up were compared to 18 patients undergoing elective CABG after PTCA. The emergency group had shorter operative time (p less than 0.01) and shorter bypass time (p less than 0.05). Moreover the emergency group had decreased use of the internal thoracic artery (ITA) (40% vs 94.4%, p less than 0.01). There was no use of bilateral ITAs in the emergency group. There was not significant difference in hospital mortality and medium term follow-up between two groups. In conclusion, emergency CABG carries a significantly less use of ITA graft than elective CABG although ITAs are superior to SVGs about long term patency rate. So it is desirable that arterial graft should be used under an appropriate selection at emergency operation.

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A 13-year-old boy underwent corrective surgery of CoA + VSD + PH at 50-day. Vascular murmur and hypertension was present so that he was admitted to our hospital. Systemic pressure was 164/106 mmHg (right arm) and systolic blood pressure at right leg was 70 mmHg. The systolic pressure gradient was 94 mmHg. The intracardiac pressure was within normal limit and there was no shunt. And the stenosis of descending aorta was present at the distal of subclavian branch and that pressure gradient was 76 mmHg. The diagnosis was established recurrent coarctation and operation was performed. The recurrent coarctation was 8 mm in diameter and longitudinal incision was made and woven Dacron patch aortoplasty was done. Aortic cross clamping time was 43 minutes. Postoperative clinical course was smooth. At 4 weeks after aortography was performed and no appreciable stenosis of the descending aorta was revealed. The pressure gradient decreased from 76 mmHg to 11 mmHg.

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Language：Japanese   Publisher：JAPANESE SOCIETY FOR ARTIFICIAL ORGANS  

Blood flow is the major factor of the function of skeletal muscle graft. For preparatin of grafts, the ligation of collateral vessels is necessary. This results in ischemia which con-tributes to the fatigue and lower performance of the graft. Tissue blood flow at acute stage after preperation was mesured applying a laser flowmeter. Tissue blood flow in the distal portion of latissimus dorsi muscle graft prepared was significant-ly low. Clinical application of the distalportion at acute stage seemed to be limited.

DOI： 10.11392/jsao1972.20.756

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Language：Japanese  

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The physiological function of acetylcholine as neurotransmitter is still not clear. Although further research on the compound is needed, previous methods of analysis of the compound have been somewhat inadequate. Moreover, few reviews on their analyses have been published. Several procedures for determination of acetylcholine using high performance liquid chromatography have been developed in recent years. These are introduced and the procedures for choline are included.

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Language：Japanese  

It is well established that a large dose of atracurium which is more than twice of ED95 produces significant release of histamine in the blood accompanying hypotension but recovery to control level within a few minutes after the administration of atracurium. We speculated that laudanosine, a metabolite of atracurium may play an important role to prevent this cardiovascular disaster due to histamine release. From this concept, we investigated the effect of laudanosine on the release of epinephrine and norepinephrine in dogs, anesthetized with halothane, nitrous oxide and oxygen. Two different doses of laudanosine (1 μg·kg-1 and 10 μg·kg-1) were selected and serum catecholamine levels were measured with HPLC in six dogs. Intravenous injection of 1.0 μg·kg-1 laudanosine increased NE level from 0.11 ± 0.03 ng·ml-1 to 0.13 ± 0.04 ng·ml-1 at 3 minutes after the injection. Blood pressure, heart rate, pulmonary arterial pressure, pulmonary wedge pressure and central venous pressure did not change significantly. The intravenous injection of 10 μg·kg-1 laudanosine increased NE level from 0.09 ± 0.02 ng·ml-1 to 0.14 ± 0.02 ng· ml-1 at 1 minute after the injection, but there was no remarkable cardiovascular effect. From this study we conclude that the intravenous injection of laudanosine increased serum NE level, but there was no significant hemodynamic change in the dogs.

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