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The external quenching method based on flow microreactors allows the generation and use of short-lived fluoro-substituted methyllithium reagents, such as fluoromethyllithium, fluoroiodomethyllithium, and fluoroiodostannylmethyllithium. Highly chemoselective reactions have been developed, opening new opportunities in the synthesis of fluorinated molecules using fluorinated organometallics.

We initiated an original papillary muscle head approximation procedure, commonly known as Sandwich plasty, for the treatment of ischemic mitral regurgitation (MR). In this study, we evaluated the appropriateness of this procedure for functional MR associated with aortic valve disease. Fifteen patients who had undergone Sandwich plasty combined with aortic valve surgery were included in this study. The mean age of the patients was 69 years. Predominant aortic valve diseases were regurgitation in 8 patients and stenosis in 7 patients. Aortic valve replacement was performed in 14 patients and David surgery in one. The mitral valve was approached through the aortic annulus in 9 patients (the transaortic group). Six other patients with mitral valve annulus of 30 mm or larger underwent concomitant mitral ring-annuloplasty through a left atrial incision (the LA group). The tenting height of the mitral valve and left ventricle diastolic diameter significantly decreased after surgery in both groups. After surgery, residual moderate or mild MR was detected in two patients in the transaortic group. In the LA group, residual mitral regurgitation was not detected. In the follow-up study, prominent MR occurred in two patients in the transaortic group. The MR free rate two years after surgery was 83% in the total patient population. Sandwich plasty was simple and effective in the treatment of functional mitral regurgitation combined with aortic valve surgery. A transaortic approach is effective in obviating a separate left atriotomy and reducing operation time.

症例は60歳男性．2年前に大動脈炎症候群による大動脈弁閉鎖不全症，上行大動脈拡大に対して，大動脈弁置換術，上行大動脈置換術を受けた．以後ステロイドの内服を行いながら外来通院していたが，小脳梗塞で入院した．人工弁感染による弁輪部膿瘍と診断され，準緊急手術を施行した．手術では破壊された弁輪部を郭清・修復後，Ross手術を行い救命した．Ross手術は大動脈弁位人工弁感染に対する選択肢の一つと考えられた．

A new member of the Y-box protein family of the silkworm Bombyx mori (BYB) was co-purified with the fibroin gene enhancer-binding protein FMBP-1, and stimulated the binding of FMBP-1 to its cognate DNA element. However, the stimulatory effect was not specific to FMBP-1, BYB also enhancing the binding of mammalian transcription factors OTF2, SP1 and AP2 to their specific binding elements. Besides the above transcription regulatory factors, BYB facilitated the binding of basal transcription factor TBP, and enhanced transcription from the adenovirus 2 major late promoter in a reconstituted transcription system. Moreover, BYB stimulated the reactions of some restriction endonucleases under cold conditions. The C-terminal region of BYB was sufficient for these stimulatory effects, and the highly conserved cold shock domain (CSD) in the N-terminal region was dispensable. GST-pull down experiments showed that the C-terminal region could interact with DNA independently of the CSD. The above results suggest that the C-terminal region of BYB causes the active interaction of various DNA binding proteins with their targets. Such a function of the C-terminal region of BYB may partly explain the functional diversity of Y-box proteins.

Aims : The hemodynamic and metabolic effects of hypertonic saline (HTS) infusion were studied in normovolemic dogs. Methods : Seven adult mongrel dogs, weighing 10 to 15kg, were used in this study. Under general anesthesia, the pericardium was opened via a right thoracotomy. High-dosage of HTS (10% NaCl, 5ml/kg) was infused intravenously within a five minute period. Results : Systemic blood pressure significantly increased from 110± 10mmHg to 125 ± 10mmHg. Central venous pressure and left atrial pressure also significantly increased (4.6 ± 1.7 → 9.3±1.9mmHg, 3.5 ± 1.4 → 5.7 ± 2.4mmHg, respectively). Cardiac output increased significantly from 2.0±0.2L/min to 3.0±0.2L/min 10 minutes after HTS infusion. Arterial blood gas analysis revealed that pH, base excess and HCO3- had decreased significantly 10 minutes after HTS infusion. Hemoglobin and hematocrit levels significantly decreased after HTS infusion. Although O2 content decreased significantly, the myocardial O2 extraction rate did not change. Serum sodium and chloride values increased significantly and sustained those levels until 60 minutes after HTS infusion. Conclusions : In conclusion, HTS infusion remains a simple and valuable clinical procedure to use in restoring adequate hemodynamic conditions after hypovolemic shock.

慢性肺動脈血栓塞栓症に対して, 2種類の湾曲鉗子を使用し超低体温循環停止法を用いず血栓内膜摘除を行い得たので報告する.患者は44歳の男性で, 呼吸困難, 左下肢浮腫のため平成14年6月当院に紹介された.胸部CT上, 両側肺動脈中枢側に血栓を認め抗凝固療法が無効で, 主肺動脈まで血栓塞栓が増悪したため緊急手術を施行した.完全体外循環, 中等度低体温下に主肺動脈を横切開し, 心耳鉗子および心房鉗子を各々右および左肺動脈末梢側に挿入して21gの血栓内膜摘除を行った.循環停止とはせず肺動脈末梢からの血液back flowによる視野障害を予測し, back flowによるwash out効果と最小限の肺動脈切開による鈍的摘除を組み合わせて低侵襲手術を試みた.大動脈遮断時間43分, 体外循環時間98分であった.術後CTで左肺動脈下葉枝の血栓残存を認めたが, 術前のNYHA IV度からII度まで改善し日常生活に復帰している.

[Purpose] In this report, the clinical features and surgical treatment highlighting areas of concern in treatment of inflammatory abdominal aortic aneurysm (IAAA) are discussed together with a review of literature. [Patients and Methods] Among 287 patients undergoing repair for abdominal aortic aneurysm (AAA) between 1992 and 2003, IAAA was observed in six (2.1%). All six patients were male, and the mean age at the time of surgery was 66 ± 8 years, ranging from 52 to 72. Four patients (67%) had been previously treated for hypertension, and no genitourinary dysfunction occurred in any patients. Two patients (33%) complained of lumbago prior to surgery. The preoperative diagnosis of IAAA was made in only two patients (33%) because the mantle sign and other typical appearances of IAAA were identified in only these patients. [Results] Five patients underwent elective surgery and there was one case of urgent surgery. There was massive adhesion in five patients developed between the aneurysm and the mesentery and/or intestine. Postoperative ileus due to duodenal stenosis occurred in one patient. [Conclusion] The preoperative diagnosis of IAAA is sometimes difficult, and the operation for IAAA should be modified to avoid excessive dissection.

Background : It has been documented that the internal thoracic artery yields better long-term patency rates than saphenous vein grafts for coronary artery bypass grafting. The use of the radial artery for coronary artery bypass grafting is controversial. Radial artery has been used as the promising arterial grafts with the quality similar to the internal thoracic artery. The aim of this study was to evaluate the short-term patency rate of radial artery graft.Methods : From March to December 1999, radial artery graft was used in 15 patients (14 male and one female, mean age, 60.4 years) undergoing myocardial revascularization. Thirteen patients underwent angiographic studies in the early postoperative period (2-42 weeks after surgery).Results : Of 12 grafts studied, all were patent, however, 2 grafts (13%) showed string sign. The flow characteristics of the grafts were mainly graft dominant flow pattern.Conclusions : Our results suggest that with proper care, the radial artery may be used for coronary artery bypass grafting with good early results. Long-term follow-up and angiographic studies will be necessary to establish the merit of the radial artery as a graft for coronary artery operation.

Purpose : Mid-term results of intraoperative radiofrequency ablation (RFA) procedure for the treatment of atrial fibrillation (AF) were evaluated. Methods : A total of 87 patients were followed up for longer than three months after RFA. The mean age of them was 67± 11 years old, including 61 males and 26 females. Preoperatively 64 patients were in persistent AF, 21 had paroxysmal AF and two had atrial flutter. Fifty-eight patients underwent mitral valve repair/replacement concomitantly, including combined CABG or aortic valve replacement (AVR). CABG, AVR and CABG + AVR procedures were performed in 13, five and three patients, respectively. The left atrial RFA lesions were created endocardially in patients with mitral procedures, while epicardially created in patients with AVR/CABG. The right atrial epicardial lesions were common to both groups of patients. The mean follow-up period was 6.3 months ranging from three to 24. Results : No heart muscle or esophageal perforation occurred after RFA. The recovery rate to regular sinus rhythm at the time of three, six and 12 months after surgery was 83%, 88% and 93%, respectively. Conclusions : Mid-term results of RFA suggest that it is safe and effective in the treatment of AF, especially in patients without mitral valve disease.

【背景・目的】軽度低体温体外循環, ice slush使用の方法から, 常温体外循環, ice slush無使用へ手技を簡略化し, 止血関連項目での有用性を検討した.【対象と方法】1998年4月から2001年1月までに施行した冠動脈バイパス術および単弁置換術の43例を対象とした.99年10月よりice slushを用いない常温体外循環による開心術に変更しており, それ以前を低温群, 常温体外循環となってからを常温群とした.【結果】低温群22例, 常温群21例で, 体外循環終了から手術終了までの止血時間が各々, 131±31分, 102±17分と, 常温群で有意に (p

Background & Aims : Although aortic valve replacement (AVR) is the only effective treatment for patients with aortic stenosis (AS), it is generally recognized that the surgical risk increases with age.Methods : We examined the outcome of surgical management for AS in patients above 70 years of age in comparison with younger ones to determine whether age was a risk factor.Results : We obtained relatively good results in 3-and 5-year mortality (17% and 25%) in the elder group which were not significantly different from the younger group (5% and 13%). Perioperative factors were not significantly different between the two group. Elderly patients had significantly smaller body surface areas (BSAs) (1.43 ± 0.15 vs. 1.53 ± 0.16m2) and smaller valves (20.5 ± 1.8 vs. 22.0±2.0mm). The age was significantly correlated with the BSA (correlation coefficient=-0.433, p

Six patients who underwent a reconstruction of the superior vena cava (SVC) area were reviewed. The mean age of the patients was 50 years. Only one patient complained of preoperative SVC syndrome. Pathologic diagnoses were invasive thymoma in five patients including two redo cases, and thymic carcinoid tumor in one patient. Polytetrafluoroethylene (EPTFE) grafts were used for vein reconstruction. The left innominate vein was reconstructed in all six patients. The right innominate vein and the SVC were reconstructed in three patients. Extracorporeal circulation (ECC) was used in one patient with a tumor extension into the right atrium. All patients except for one with a thymic carcinoid tumor received both postoperative irradiation therapy and chemotherapy. Two patients died during the postoperative late periods and four patients survived for three to 18 years (mean ; 10) after the initial operation. Three out of four patients underwent additional surgery during the postoperative late periods. The graft patency rate was 67 % in the SVC area and 50% in the left innominate veins. In conclusion, a radical operation with reconstruction of SVC is treatment of choice for long-term survival and bilateralvenous reconstruction is recommended The indication of ECC for tumor resection is still controversial.

From 1981 through 1997, lobectomy or pneumonectomy with mediastinal lymph node dissection was performed in 604 patients with non-small cell lung cancer, of whom 42 (7%) were diagnosed as having ipsilateral pulmonary metastasis. There were 23 males and 19 females, the mean age was 66 years. Lobectomy was carried out in 37 cases and pneumonectomy in 5. Postoperative histology identified 29 adenocarcinomas, 11 squamous cell carcinomas, 1 large cell carcinoma, and 1 adenosquamous cell carcinoma. Two cases were classified as pathologic stage I, 1 as stage II, 26 as IIIA, and 13 as IIIB. Blood vessel invasion was present in 33 cases and absent in 2 cases. Five and 10-year survival rates were 34.3% and 17.1%, respectively. Patients with pulmonary metastasis had a poorer prognosis than those without metastasis; there were local recurrences in 6 patients, distant metastases in 9, and 15 deaths. There were no significant differences in recurrence sites between patients with and without pulmonary metastasis. Multivariate analysis showed that lymph node involvement and blood vessel invasion were useful prognostic factors. Ipsilateral pulmonary metastasis in the same lobe was regarded as local invasion for which surgical resection is the optimal treatment.

This study was undertaken to investigate the neurological risk factors associated with the retrograde cerebral perfusion (RCP) technique, by examining the relationship between intraoperative parameters and post-operative brain complications. A total of 12 patients who underwent surgery for thoracic aortic aneurysms using the RCP technique were included in this study. Profound hypothermia was induced through cardiopulmonary bypass which was established with a femoral arterial cannula and bicaval return. During RCP, a venous drainage cannula from the superior vena cava (SVC) was switched over to the arterial return circuit, and oxygenated blood was retrogradely infused through the SVC. The perfusion flow rate was maintained at 273 +/- 113 ml/min and the SVC pressure was maintained at 15 +/- 6 mmHg. The RCP time was 68 +/- 27 min with a range of 27-130 min, and the lowest rectal temperature was 16 +/- 1 degrees C. The total elapsed time until emergence from anesthesia after the operation was 12 +/- 6 h. The operation time correlated with the awakening time (r = 0.729, P = 0.0088). Longer RCP times of up to 101 and 130 min tended to result in post-operative brain damage. The lowest rectal temperature also correlated with the awakening time (r = 0.697, P = 0.0149), and an inverse correlation between the SVC pressure and the awakening time was observed (r = -0. 727, P = 0.0091). These findings demonstrate the importance of reducing both the RCP and operation times to decrease the incidence of brain damage. If carried out under optimal conditions, including perfusion pressure and brain temperature, RCP could be marginally prolonged safely without causing major neurological complications.

世界における移植医療のメッカであるピッツバーグ大學で, 心肺移植に関して研修する機会を得た.臨床の現場, それも世界の最先端をいく施設で貴重な経験をすることができた.臓器移植は重症末期患者の治療法として既に確立されている.しかし, この数年心臓移植の件数は減少傾向にあり, ドナー (臓器提供者) 不足が大きな問題となっている.同大学ではドナー不足に対処するため, 移植患者に対する人工心臓装着による治療成績の向上と片肺移植の適応拡大がなされていた.移植は外科医のみならず各科専門医やコメデイカルが同時に参加する総合医療であり, 多くのマンパワーと経費を必要とする.今回の留学での見聞から米国における移植医療の実際に関して報告し, 加えて臓器移植再開に向けて, 我が国における医学的・社会的基盤とその問題点に関して考察したい.

人工心肺を使用しない常温心拍動下の多枝冠動脈バイパス術 (CABG) を4症例に行った.心拍動下CABGを選択した術前の合併症は, 高齢 (80歳以上), 腎不全, 呼吸不全, 低左心機能などであった.胸骨正中切開で心臓に達し, 冠動脈のsnare susure, stabilizerおよびCO2 gas blowerにより吻合部の無血静止野を確保し, 左内胸動脈, 大伏在静脈を用いた2枝バイパスを行った.術前より多臓器不全に陥っていた重症心不全の1例を術後38病日に失ったが, 他の3例は術当日または翌朝までに抜管でき, 術後管理は容易であった.体外循環を使わず常温心拍動下に行うoff-pump法は, 体外循環と心停止による悪影響を回避できるため, 今まで手術適応外とされた症例にもCABGの適応を拡大し得る.吻合部位の制限, 遠隔成績といった問題点もあるが, 症例の選択を慎重にすることにより, 従来の人工心肺を用いたCABGと同等の手術効果と成績を期待できる.

心筋梗塞後の重症心不全症例に対してDor手術を行い, 良好な結果を得た.患者は74歳の男性で, 1992年に左前下行枝領域の心筋梗塞を発症し, 以後内科的治療下にあった.1997年12月以降心機能が著明に悪化し, 1-2カ月に1度心不全, 胸水貯留で入退院を反復していた.1998年6月手術目的で当科に入院した.術前造影では, 左室前壁が広範囲に無動化しており, 心尖部には瘤化と壁の非薄化がみられた.術前の左室駆出率は28%であった.冠動脈造影では, 左前下行枝 (#6) に75%狭窄があったが, 右冠動脈及び回旋枝に有意の狭窄はなかった.手術では, 心尖部より左室を切開し, 左室の前壁・後壁へと延長した.左室内腔の繊維化部分を同定後, 乳頭筋付着部のレベルでタバコ縫合を用いて左室腔を内部より縫縮した.残存開口部 (径2.5cm) に人工血管の一部を用いたパッチを連続縫合で縫着後, 左室切開部を縫合閉鎖した.冠動脈は左前下行枝 (#8) に左内胸動脈を吻合した.術後経過は良好で, 左室駆出率は43%へと改善した.術後造影検査では, 左室腔の縮小と収縮能の改善が得られた.Dor手術は虚血性心筋症患者に対する心臓移植の代替もしくは移植までのブリッジとして有用と考えられる.

当教室で考案・試作した長時間心保存用の冠灌流装置を用いて, ドナー心の長距離搬送実験を行った.摘出心を灌流保存している群大式冠灌流装置を自家用車に積み, 関越自動車道を使い群馬大学病院から練馬インターまでを往復した.ドナー心の全虚血時間は7時間35分で, その後に同所性心移植を行い, 良好な結果を得た.今回, 群大式冠灌流装置を実験室の外へ持ち出し, 実際に保存心を搬送したが, 搬送の間持続冠灌流は支障なく施行できた.臨床応用のためには, 滅菌, 軽量化に向けて今後さらなる改良が必要と考える.

A left ventricular assist device (LVAD) was effective in two patients with intractable heart failure following open-heart surgery. A 47-year-old female was diagnosed as having effort angina with 75% stenosis of the left main trunk, and a 58-year-old female was diagnosed as having persistent unstable angina with twice percutaneous transluminal coronary angioplasties and a stent insertion. In both cases, intra-aortic balloon pumping and pharmacologic support were ineffective at the time of weaning from cardio-pulmonary bypass. Cardiac function improved gradually after the use of LVAD, and both patients were weaned from the device at 6 and 8 days, respectively after the introduction of LVAD without significant complications. Circulatory support using an LVAD is a powerful aid in the treatment of patients with refractory heart failure following open-heart surgery.

Background: We review the results of surgical radiofrequency ablation of both atria in patients of mitral valve disease approached by septal-superior exposure and discuss the availability of this approach. Methods: Eighteen patients with a mean age of 65 years were included in this study. Thirteen patients had mitral valve regurgitation predominantly and five had mitral valve stenosis. Eleven patients underwent mitral valve plasty and valve replacement was carried out in seven. All ablation lesions were created on both atria using radiofrequency energy delivered by a unipolar malleable radiofrequency ablation catheter with seven electrodes at a minimum temperature of 80–85°C for a period of 2 min. Results: At the time of discharge, 14 patients were showed normal sinus rhythm and one patient remained in AF. The other three patients were free from atrial fibrillation; however, they received dual-mode, dual-pacing, dual-sensing pacemaker implantation because of bradycardia during the early postoperative phase. At a mean time of 7 months after surgery, all patients were free from atrial fibrillation; 13 patients showed normal sinus rhythm and five patients received dual-mode, dual-pacing, dual-sensing pacemakers. Conclusion: Septal-superior exposure provides an excellent operative view both for mitral valve surgery and for radiofrequency ablation. However, this exposure has not been considered a first-line approach because of the high rate of pacemaker implantation.

We experienced a case of synchronous multiple lung cancer developed in the right middle and lower lobe in a 69-year-old male. The patient was admitted to our hospital to undergo further examinations of abnormal shadows on his chest X-ray films. A transbronchial lung biopsy revealed squamous cell carcinoma in S4 and adenocarcinoma in S6. A pneumonectomy was performed and his postoperative course was uneventful. The final histologic diagnosis was large cell carcinoma in S4 and adenocarcinoma in S6. We report this case because it represents a rare histologic combination.

術前に組織診や細胞診で悪性細胞が得られず, CTとthin slice CTで診断した小型肺癌の切除例について検討した.1989年9月から当教室で手術した原発性肺癌180例中, 2cm以下の小型肺癌は22例で, そのうち半数の11例が術前に悪性細胞が得られず, CTとthin slice CTで肺癌と診断した.11例すべてが高分化腺癌でリンパ節転移はなく病理病期I期の症例だった.術中に迅速診で肺癌を確認し, 右肺癌8例は葉切とR2bの郭清を, 左肺癌3例は葉切とR3の郭清を施行した.平均観察期間2年9ヵ月で11例全例が健存で良好な手術成績が得られた.CTとthin slice CTは小型肺癌の発見に有効と思われた.

術前診断が困難であった悪性リンパ腫の2症例を経験した.共に36歳の男性で, Gaシンチは陰性であった.症例1は胸腺内に多発した腫瘍に対し胸腺全別を行ない, 症例2は左気管支上下葉分岐部の孤立性の腫瘍を左開胸で別出した.術後化学療法を行ない, それぞれ2年6ヵ月, 2年4ヵ月間再発なく経過している.

冠動脈バイパス術後に原因不明の全身性痙攣を来した慢性腎不全の1症例を経験した.症例は63歳の女性で, 1年前より慢性腎不全に対し血液人工透析を受けていた.術後第4病日に全身性の痙攣を来した.頭部CT像, 脳波等に異常はなく, 電解質を補正して抗痙攣剤を投与したが症状の改善はなかった.そこで, 輸液中にアミノ酸輸液及び微量元素を投与したところ, 痙攣は徐々に沈静化した.慢性透析患者における術後痙攣では, 脳血管障害を除外した上で, 血中の電解質, 微量元素濃度, 使用薬剤など諸々の原因を検索し対処する必要がある.

A 49-year-old woman with a tracheoesophageal fistula due to advanced lung cancer was successfully treated by a stent using an intratracheal silicone prosthesis (Dumon type). The use of a Dumon tube proved to effectively palliate the fistulization and thus resulted in a dramatic improvement of the patient's quality of life.

Background: Early and late results were studied in order to improve the indications for surgery in the elderly. Methods: Two hundred and thirty-seven patients aged 80 years or older underwent cardiac surgery between 1987 and 2001. The mean age of patients, which included 148 men and 89 women, was 82 years. Elective operations were performed in 194 patients and urgent or emergency operations in 43. Coronary artery bypass grafting (CABG) was performed in 104 patients, valve surgery in 60, CABG plus valve in 58, and other surgery in 15. Late results were obtained in 91% of patients, and the mean follow-up period was 54 months. Results: Operative mortality was 9% in total; 7% in CABG, 5% in valve, 10% in CABG plus valve. Operative mortality was significantly higher in the urgent/emergency group than in the elective group (25% vs 6%). The actuarial survival rate for hospital survivors at 60 months after surgery was 75% and the mean survival period 76 months. There were no significant differences among operations. Preoperatively 81% of the patients had been in New York Heart Association class III or IV, and 88% of survivors were in class I or II in the late period. Conclusions: Early and late results for elective surgery in octogenarians are satisfactory. However, for urgent or emergent cases, there is a marked increase in morbidity and mortality.

To elucidate the relationship between the clinical features and pathologic findings of primary pulmonary lymphoma, we reviewed 24 patients with this disease. The pulmonary lymphomas were divided into four groups: (1) B-cell lymphoma composed of small to medium-sized lymphoid cells (19 cases); (2) B-cell lymphoma composed of large lymphoid cells (three cases); (3) T-cell lymphoma (one case); (4) malignant lymphoma of lymphomatoid granulomatosis (LYG) type (one case). Radiographs of the first group revealed a predominance of infiltration associated with ill-defined tumor margins upon gross pathology, corresponding histologically to lymphangitic spread. Air bronchogram and pleural tail or abutment were additional radiographic features. Characteristics of the second group were a nodule or mass evident on radiographs and well-circumscribed tumor margins upon gross pathology. Lack of air bronchogram was an another radiographic feature in this group. Seventeen patients in these two groups underwent complete resection of the tumors and survived without recurrence, whereas four received chemotherapy after biopsy and survived with disease. These results indicate that primary pulmonary B-cell lymphoma is a low-grade malignancy and that complete resection is the only therapy which leads to cure. In a single patient with T-cell lymphoma, the radiographic and pathologic features of the tumor were indistinguishable from those in the first group, but the patient had an unfavorable prognosis. We consider that, from a prognostic viewpoint, it is important to determine the T- or B-immunophenotype of the tumor cells for diagnosis of primary pulmonary lymphoma. The only patient in this series with pulmonary lymphoma of LYG type showed distinctive clinicopathologic findings. We consider that this uncommon disease should be separated from other types of primary pulmonary lymphoma.

A 62-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) had complete atrioventricular (AV) block and subsequent cardiac standstill. A previous electrocardiogram revealed a bifascicular block pattern. Because he also suffered from infective endocarditis of the native aortic valve, surgical therapy (dual-chamber permanent pacing, myectomy of the left ventricular outflow tract, and valve replacement) was performed. Complete AV block unrelated to a procedure is a rare complication in patients with HOCM, but it may be life-threatening. Therefore, a pre-existing cardiac conduction disturbance should be specifically recognized as the aura of a higher degree of AV block.

Four patients with stage III or IVa invasive thymoma successfully underwent surgical intervention and radiotherapy following neoadjuvant intra-arterial chemotherapy including 50 mg/m(2) of cisplatin and 20 mg/m(2) of adriamycin. Remarkable reduction rates (60% or more) of the tumor size were obtained without significant side effects. About 4 weeks after neoadjuvant chemotherapy, an extended thymectomy including invaded organs was easily performed with a small amount of intraoperative bleeding. All patients but one are currently alive and disease-free. This method may be a new therapeutic strategy in the management of invasive thymoma.

AIZAWA, K., ET AL.: Oozing from the Pericardium as an Etiology of Cardiac Temponade Associated with Screw-In Atrial Leads. Screw-in atrial pacing leads are widely used. Cardiac tamponade is a complication. An 81-year-old woman with advanced atrioventricular block underwent permanent pacemaker implantation and subsequently developed cardiac tamponade. At surgery, the lead-tip screw was found penetrated through the right atrium but not through the pericardium. The source of bleeding was confirmed to scratching the inner pericardial membrane by the screw tip. Although cardiac tamponade due to perforation and leakage is known, tamponade caused by the trauma of an atrial screw on the pericardium with resultant ooze is less well described. (PACE 2001; 24:381‐ 383) pacemaker complications, atrial perforation, active fixation, cardiac tamponade

We present a 78-year-old woman with prosthetic valve endocarditis due to Stenotrophomonas maltophilia (S. maltophilia) 3 years after mitral valve replacement. Administration of sulfamethoxazole-trimethoprim was effective; however, it was discontinued because of side effects, which led to failure of antibiotic therapy. Complications of multiple cerebral infarction and paravalvular abscess developed. Although the prosthetic valve was removed 50 days after admission, she died 4 months after surgery. S. maltophilia has been increasingly being considered as a serious nosocomial pathogen. S. maltophilia endocarditis is rare; however, it should be recognized as a possible life-threatening disease in patients with prosthetic valve.

Although surgical resection is a suitable treatment for localized metastases from colorectal cancer, it remains controversial for multiorgan metastases. We present herein a case of a 59-year-old woman, who underwent resection of pulmonary and antecedent hepatic metastases arising from colon cancer. The patient's postoperative course was uneventful, and there has been no evidence of recurrence for 23 months after the first operation. We report this case and discuss the operative indication for multiorgan metastases arising from colorectal cancer.

The impact of drug-eluting stents (DES) on the characteristics and operative results of patients referred for coronary artery bypass grafting (CABG) was studied. We reviewed data from isolated CABG patients 24 months before (group A, n = 134) and 24 months after (group B, n = 98) the introduction of DES for clinical use at Teikyo University Hospital in Tokyo. Group B patients were significantly older than those of group A (66 +/- 9 versus 69 +/- 9 years old). The number of diseased vessels was significantly larger in group B (2.5 +/- 0.6 versus 2.7 +/- 0.5) and left main trunk disease decreased in group B (27% versus 17%). Preoperative IABP support was more frequent in group B (9% versus 17%) and beating heart surgery was significantly more frequent in group B (26% versus 59%). The number of grafts was similar in the 2 groups (3.2 +/- 1.4 versus 3.0 +/- 1.1). The operative mortality rates were 0.7% and 4.1% in group A and B, respectively. Incomplete revascularization followed by postoperative percutaneous coronary intervention (PCI) was performed in 11% and 12%, respectively, and all the patients survived surgery. The operative mortality rates for arrested heart and beating heart surgery were 2% and 2%, respectively. In conclusion, after the introduction of DES, more clinically ill patients were referred to CABG. Combination therapy consisting of CABG and PCI (Hybrid) may be a treatment of choice in critical patients.

To investigate the effectiveness of using a free pericardial fat pad to control air leaks from residual raw parenchymal surfaces after pulmonary resections, 30 consecutive patients were studied. There were 23 males and 7 females with a median age of 69 years. The indication for this technique was any alveolar air leak from a residual raw parenchymal surface which could not been controlled by suturing. There were 25 lobectomies with incomplete fissure and 5 cases of segmentectomy. None of the patients exhibited air leaks beyond 2 days, post-operative space problems, or infections. All patients had chest drains removed within 2 days after the operation. The application of a free pericardial fat pad is a promising new method of treating air leaks from residual raw parenchymal surfaces after pulmonary resections.

Aspergillosis is an uncommon complication of pulmonary carcinoma. A 60-year-old female was performed right lower lobectomy because of adenocarcinoma with pseudocavities. The diagnosis was bronchiolo-alveolar adenocarcinoma, and there was aspergilloma in one of the cysts in the tumor. Cavitation or cystic change in bronchiolo-alveolar adenocarcinoma is rare because of nondestructive growth pattern with an adequate blood supply in this histologic type. Additionally, bronchiolo-alveolar adenocarcinoma associated with pulmonary aspergilloma is rare.

Two episodes of hypotension caused by oral beraprost sodium administration following cardiac surgery are described. The first case was a 67-year-old female who underwent concomitant surgery for mitral valve replacement, tricuspid annuloplasty, and a radiofrequency maze procedure for atrial fibrillation. The second case was a 45-year-old female who underwent 4-vessel coronary artery bypass grafting associated with endarterectomy in the right coronary artery. Beraprost sodium was administered for the treatment of residual pulmonary hypertension in the first case, and was initiated as an antiplatelet agent following coronary endarterectomy in the second case. Hypotension occurred at approximately one hour after beraprost sodium administration in both cases. Careful observation to prevent this adverse effect is critical after the administration of beraprost sodium, especially in patients who have undergone cardiac surgery.

A 53-year-old man with Behcet's disease was admitted to our hospital for investigation of back and lower abdominal pain. Computed tomography (CT) showed a projecting saccular aneurysm below the right renal artery. We placed a stent-graft just below the right renal artery, successfully excluding the abdominal aortic aneurysm (AAA). His C-reactive protein level and white blood cell count remained elevated after stent-grafting. About 5 months later, he was readmitted with recurrent back and lower abdominal pain and CT showed progression of the AAA. Thus, we performed straight grafting using a woven Dacron graft just below the right renal artery. The patient had an uneventful postoperative course. We discuss the controversial issue of treating AAA in patients with Behcet's disease, focusing on the indications and timing of surgery.

Background: The purpose of the present study was to experimentally evaluate a new support adapter, which was created in order to insure a more complete contact between the ablation probe and a beating heart. Methods: Support sleeve adapters for the Cobra Cooled probe were fashioned using a semi-rigid plastic. Forty epicardial radiofrequency ablation (RFA) lesions were created on both atria under the condition of a beating heart in six pigs weighing 26−30 kg. A Cobra Cooled surgical probe was used with continuous internal irrigation of a saline solution (500 mL/h). The ablation temperature was fixed at 80°C and the duration of the RFA in each case was 20, 30 and 60 s. Results: A support adapter ensured a more complete epicardial contact between the probe and a beating heart. An RFA probe supported by the adapter delivered greater power to the tissue. The histopathological transmural coagulation was obtained in 82% and 72% in RFA lesions with and without the adaptor, respectively. Conclusion: A new adapter was effective in the epicardial RFA under the condition of a beating heart.

We report herein the case of a 17-year-old woman with von Recklinghausen's disease who was diagnosed as having a giant malignant Triton tumor located in the anterior mediastinum, which had adhered to the heart and the great vessels. An emergency operation was performed to relieve the tracheobronchial stenosis and congestive heart failure caused by the pressure of the tumor. Extracorporeal circulation was not required and the tumor could be excised only piece by piece. To our knowledge, this is the first report of a malignant Triton tumor being located in the anterior mediastinum.

A 4-year-old boy was diagnosed as having a chromosomal abnormality with trisomy 3p associated with a secundum atrial septal defect and a cleft of the anterior mitral leaflet. His craniofacial features showed microcephaly, micrognathia, ocular hypertelorism associated with epicanthus, and low-set ears. Moderate mental retardation and hypoplasia of the penis were also noted. A left ventriculogram demonstrated grade 2 mitral regurgitation according to the Sellers' classification with a prolapsing of the mitral leaflets. A cleft of the anterior mitral leaflet was detected at the time of operation. The secundum atrial septal defect was directly closed and the mitral cleft was repaired. This is the first report of trisomy 3p associated with an atrial septal defect and a mitral valve cleft.

A 5-year-old male with a ventricular septal defect associated with Down's syndrome, who had a previous history of pulmonary artery banding, underwent intracardiac repair. Severe hypoxemia occurred during the weaning from cardiopulmonary bypass. In postoperative evaluations, a severe intrapulmonary shunt was detected. There was no residual pulmonary stenosis or cardiac failure. Extracorporeal membrane oxygenation and intravenous gamma globulin infusion were attempted for a period of 5 days for the treatment of the hypoxemia. These therapies were not effective and the patient died 10 days after surgery from mediastinitis which occurred on postoperative day 7. Respiratory syncytial virus antibody was detected and lung specimens, which were resected on postoperative day 3, revealed an emphysematous distension of alveolar air space without pulmonary hypertension or pulmonary artery hypoplasia histologically. Respiratory syncytial virus infection in children may be an additional risk in cardiovascular surgery.

We report the case of a 61-year-old man with type B Wolff-Parkinson-White (WPW) syndrome associated with a right atrioventricular (AV) accessory pathway and concomitant mitral stenosis, who underwent successful operative treatment by simultaneous surgery. His preoperative course had been characterized by cardiac failure and repeated episodes of atrial tachyarrhythmia, in the form of fibrillation and flutter, which were difficult to control by conventional medication. Preoperative electrocardiograms (ECGs) had suggested that the accessory pathway was located in the right posterior to posteroseptal wall; however, at the time of surgery, epicardial electrophysiological mapping with sock electrodes revealed a preexcitation area in the AV groove at the lateral right margin of the heart. This discrepancy was thought to have been due to the presence of mitral stenosis or multiple accessory pathways. Thus, division and cryoablation of the accessory pathway by an endocardial approach, in addition to mitral valve replacement, were performed under cardiopulmonary bypass. His postoperative course was uneventful, and subsequent ECGs revealed that the delta waves had disappeared. The successful outcome of this patient demonstrates the effectiveness of simultaneous surgery for WPW syndrome associated with valvular disease.

The aim of this study was to evaluate the screening procedures in Japan economically focusing on the screening costs and the hospital costs for abdominal aortic aneurysm (AAA) surgery.A total of 10,057 residents, 60 years of age or older, including 4 247 men and 5 810 women, participated in the screening test for AAA using ultrasound.Aneurysms were detected in 34 participants, including 32 men and 2 women. The detection rate of AAA was 0.8% in men, 0.03% in women, and 0.3% in total. It cost 8 US dollars to screen each participant, and the cost to detect each aneurysm was thus estimated at 1,250 dollars in men, 23,240 dollars in women, and 2,366 dollars in total. The difference in the mean hospital cost between ruptured and nonruptured AAA was 21,833 dollars in our recent cases. Obesity, male sex, and smoking habits were all significant risk factors for AAA.Screening for AAA using ultrasound is useful not only for the early detection of AAA but also for a reduction in the overall medical cost.

The predictive factors of surgical outcome were evaluated in compromised patients following cardiovascular surgery. Of 608 patients undergoing cardiovascular surgery between 1991 and 1999, 55 stayed in the intensive care unit for 2 weeks or longer. The mean age of these 55 patients was 56 years. There were 35 survivors and 20 nonsurvivors. Postoperative respiratory failure and gastrointestinal complications were significantly more frequent in those who died. The survival rate was significantly higher in patients who had enteral feeding compared to those who did not (88% versus 43%). Serum cholinesterase and total cholesterol concentrations were higher in the survivors. It was concluded that postoperative respiratory and gastrointestinal conditions influenced the surgical outcome, and serum cholinesterase and total cholesterol concentrations were valuable predictors of survival.

An 18-year-old man was admitted to our hospital with abdominal distension and edema of both legs. His total serum bilirubin level was 5.2 mg/dl. Echocardiography showed impaired left ventricular contraction, and computed tomography showed a thickened pericardium with massive pleural effusion and ascites. Cardiac catheterization showed both a dip and a plateau in the right ventricle pressure curve, based on which we diagnosed constrictive pericarditis. The selected treatment option was a pericardiectomy. We dissected the thickened pericardium, which was about 7–10 mm thick, and removed as much as possible through a median sternotomy without cardiopulmonary bypass. Postoperatively, his hemodynamics and renal dysfunction improved, and the serum bilirubin level gradually decreased. We report this case to show how pericardiectomy was effective not only for improving this patient’s hemodynamics, but also for resolving his hyperbilirubinemia. The relevant literature is reviewed following this case report.

Good exposure and the minimization of lung and thorax injuries are important objectives of surgery for descending thoracic aortic aneurysm (DTAA). In this study, three surgical approaches for DTAA were compared to assess postoperative respiratory function. The subjects were 21 patients with DTAA, three of whom had a thoracoabdominal aneurysm. The mean age was 61 years, and there were 12 men and 9 women. The causes of aneurysm were atherosclerosis in 16 patients, chronic dissection in 4, and traumatic pseudoaneurysm in 1. All the patients underwent femorofemoral partial cardiopulmonary bypass. The DTAA was replaced with a prosthetic graft in 18 patients and repaired with a patch graft in 3. Three approaches were selected, namely, posterolateral thoracotomy (PL group, n = 12), median sternotomy combined with anterolateral thoracotomy (M group, n = 5), and spiral incision (S group, n = 4). There were no significant differences in operation time, cardiopulmonary bypass time, intraoperative blood loss volume, or water balance. The duration of respiratory support and intensive care unit stay were significantly (P < 0.05) longer in the M group than in the other two groups. The alveolar-arterial oxygen difference (AaDO2) and respiratory index (RI) levels immediately after surgery were also significantly (P < 0.05) higher in the M group than in the PL group. There were no significant differences in AaDO2 and RI levels 12 and 24 h after surgery among the three groups. These results suggest that posterolateral thoracotomy is a desirable surgical approach for DTAA repair in view of the fact that it has the least effect on postoperative respiratory function.