Search

Background Although many patients complaining of chest pain visit the emergency department, very few are diagnosed with spontaneous pneumomediastinum (SPM). We present the management of 20 patients with SPM. Methods We retrospectively analyzed the clinical features, past history, chest X-rays (CXRs), 64-slice helical computed tomography (CT) images, and clinical course of 20 patients with SPM (19 men and 1 woman) who visited the emergency department of the Tokyo Metropolitan Bokutoh Hospital between 2005 and 2010. Results SPM predominantly resulted from physical exertion during such activities as sports and weight lifting (8 patients). The most common complaint was chest pain (15 patients), followed by dysphagia (10 patients), and dyspnea (8 patients). Subcutaneous emphysema was detected in 9 patients. The mean body mass index of the patients was 20.8±1.4kg/m 2 . Although CXR findings of pneumomediastinum were absent in 5 patients, CT showed findings of the Macklin effect in all patients—interstitial gas was observed in the perihilar area in all patients and in the peripheral lung area in 9 patients (45%). Ten patients were hospitalized. The others received ambulatory care in the form of analgesics without antibiotics. All patients fully recovered without complications. Conclusions Our results showed that 64-slice helical CT is more reliable than CXRs for diagnosing SPM. Moreover, some patients with SPM can be treated without hospitalization, thus decreasing medical expenses for these patients.

The prognostic factors following aortic root reconstruction were studied in 19 patients including 13 with annuloaortic ectasia (AAE) and 6 without AAE (non-AAE). The preoperative diagnosis of six non-AAE patients was a dissecting aneurysm in five of the patients and supravalvular aortic stenosis associated with stenosis of the right coronary ostia in one patients. In the AAE group, the Bentall's method was initially selected in 11 patients and the Cabrol's method in the remaining 2 patients. In the non-AAE group, ascending aortic replacement was performed in 4 patients, patch plasty of the ascending aorta in 1 patient, and entry closure in the other patient. In this group, aorto-coronary bypass grafting using a saphenous vein graft was performed in 4 patients, ostioplasty of the right coronary artery (RCA) in 1, and the Bentall's method in 1. During the postoperative acute phase, one AAE patient died of acute myocardial infarction 3 days after surgery; the remaining 18 patients survived. In the follow-up study, 3 patients died of cardiac events which included two cardiac failures and one arrhythmia. The preoperative left ventricular diameter in the end-diastolic phase (LVDd) of 2 AAE patients who died of cardiac failure was 80 mm or larger and the left ventricular function remained unchanged after surgery. One non-AAE patient who underwent RCA ostioplasty suddenly died of arrhythmia. Postanastomotic leakage around the left coronary ostia associated with the patent Cabrol's trick occurred in 1 AAE patient and mitral valve regurgitation occurred in the other non-AAE patient. Reoperation using Cabrol's procedure and mitral valve replacement were performed for these 2 patients, respectively. Preoperative low cardiac function and large LVDd may influence the late results in AAE patients, therefore, earlier operations should be recommended.

We evaluated the availability of original “sandwich plasty” for the treatment of functional mitral regurgitation (FMR) associated with ischemic heart disease (IHD) and aortic valve disease (AVD). Forty-three patients were reviewed, including 27 IHD patients and 16 AVD patients. Preoperatively severe FMR was detected in 14 patients, moderate FMR in 26, and mild FMR in 3. The papillary muscle heads of anterior leaflets and posterior leaflets were approximated using Teflon-pledgeted 3-0 Ticron sutures at anterolateral and posteromedial commissural portions. After surgery, residual moderate FMR was observed in 1 patient and mild FMR in 3 patients. Tenting height of the mitral valve significantly decreased. FMR free rates 2 years after surgery were 93% among IHD patients and 83% in AVD patients. “Sandwich plasty” was simple and effective for the treatment of functional FMR caused by tethering effects due to left ventricular dilatation.

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.

心臓手術後急性期における短時間作用型β1 遮断薬・塩酸ランジオロール（オノアクト®）の有効性と安全な投与方法を検討した．心臓大血管手術後の成人10症例を対象とした．年齢は平均66（53～81）歳で男女比は9対1であった．主疾患は弁膜症7例，虚血性心疾患，胸部大動脈瘤，大動脈解離が各1例であった．頻脈の内訳は上室性（心房細粗動，上室性頻拍）が6例，心室性（心室性頻拍）が4例であった．頻脈性不整脈に対して，上室性ではIa，Ic群抗不整脈薬を，心室性ではIb群抗不整脈薬を第1選択として投与し，無効例でオノアクトを投与した．オノアクトの投与は初期負荷投与は行わず，静脈内少量持続投与とした．投与量は，導入量が平均0.018 mg/kg/分で，効果発現後は平均0.01 mg/kg/分で維持した．臨床効果：10例中9例で有効であった．上室性では，心房細動の4例中3例が洞調律に復帰し，1例で心房細動が持続したが心拍数の安定が得られた．心房粗動の1例では効果が不十分であり他剤に変更した．上室性頻拍の1例では心拍数の安定を得た．心室性では4例全てで頻拍症（VT）が消失した．血行動態：オノアクト投与により脈拍は140±42/分から95±21/分へと有意に（p＜0.05）低下した．収縮期血圧は，投与前の118±24 mmHgから106±21 mmHgへと軽度低下したが有意差はなかった．心係数（CI）は投与前の2.4±0.5 l/min/m2 より2.7±0.6 min/m2 へと有意に（p＜0.05）上昇した．拍出係数（SI）は17±7 ml/回/m2 より27±4 ml/回/m2 へと有意に（p＜0.05）増加した．副作用：血圧低下，徐脈，気管支喘息発作はなかった．血液生化学検査では異常を認めなかった．短時間作用型β遮断薬（オノアクト®）は心大血管手術後の頻脈性不整脈に対して有用であった．少量持続投与法は心血行動態には大きな影響が無く，開心術後でも安全に用い得る．

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．

SummaryA 65-year-old female with catecholamine-dependent ischemic cardiomyopathy was admitted to our hospital. Preoperative examination revealed severe triple vessel coronary artery disease, severe mitral valve regurgitation and left ventricular (LV) dilatation associated with low ejection fraction. Coronary artery bypass grafting with four distal anastomoses, mitral valve plasty using original papillary muscle application method, LV volume reduction using overlapping method and biventricular pacing were performed. Postoperative course was uneventful and quality of life at 2 years after surgery was good. Active combined surgery has the possibility of improving the outcome of patients with severe ischemic cardiomyopathy.

We developed a new apparatus for long-term heart preservation that combines simple immersion with coronary perfusion. In a previous study, we reported that suppression of pro-inflammatory cytokines, such as tumor necrosis factor alpha (TNF-alpha) and interleukin-1beta (IL-1beta), improved results after transplantation. In this study, we evaluated whether long-term preservation using our apparatus for continuous coronary perfusion, combined with suppression of pro-inflammatory cytokines, improves donor heart function after transplantation in a canine model.We used adult mongrel dogs in this study. Coronary vascular beds were washed with University of Wisconsin (UW) solution after arresting hearts with glucose-insulin-potassium solution. The heart was then excised and preserved for 12 hours with a combination of immersion and coronary perfusion using a preservation apparatus. Adult mongrel dogs were divided into 2 groups: the coronary perfusion (CP) group (n = 7) and the FR167653 (FR-CP) group (n = 6). In the CP group, we used a 4 degrees C UW solution for immersion and coronary perfusion. In the FR-CP group, we used a 4 degrees C UW solution supplemented with 20 mg/liter of the anti-inflammatory agent FR167653 for immersion and coronary perfusion. At 2 and at 3 hours after orthotopic transplantation, we compared hemodynamic parameters with pre-operative values in donor animals, with right atrial pressure at 10 mm Hg and with 5 microg/kg/min dopamine infusion. We compared serum concentrations of TNF-alpha from the coronary sinus and compared electron microscopic studies between the 2 groups.Three hours after transplantation, cardiac output (CO), left ventricular pressure (LVP), and -LVdp/dt were significantly greater (p0.05) in the FR-CP group than in the CP group (CO, 178% +/- 65% vs 93% +/- 40%; LVP, 115% +/- 22% vs 73% +/-26%; -LVdp/dt, 168% +/- 13% vs 61% +/- 17%, respectively). Electron microscopic studies showed that glycogen was well preserved in the FR-CP group compared with the CP group. Serum concentrations of TNF-alpha were decreased significantly in the FR-CP group compared with the CP group at 3 hours after reperfusion (161 +/- 54 pg/dl vs 642 +/- 636 pg/dl, respectively).Hemodynamics after transplantation were significantly better in the FR-CP group than in the CP group. The combined preservation method of continuous perfusion and immersion using our apparatus in conjunction with suppression of pro-inflammatory cytokines improves donor heart function after transplantation.

Summary Background Mast cells (MCs) arise from haematopoietic stem cells. We have recently reported that CD34+ progenitors derived from human bone marrow (BM) develop into tryptase+, chymase+ MCs when cultured in the presence of recombinant human stem cell factor (rhSCF) and recombinant human IL-6 (rhIL-6). In an experiment for the expression of chymase during differentiation, chymase+ cells were detected in human BM, but tryptase+ cells were not found. Objective The purpose of this study was to show the appearance of chymase+ cells in CD34+ cells with an origin different from MC differentiation. Methods CD34+ cells from human BM were sorted with anti-CD117 monoclonal antibody (mAb), and cytospins of CD34+, CD34+CD117+, or CD34+CD117− were prepared. These cells were cultured with rhSCF+rhIL-6 for 12 weeks. Some of the cells were subjected to either histological stain with Wright–Giemsa or immunocytochemistry with anti-chymase mAb. Real-time RT-PCR was also performed to compare the transcriptional level of chymase from each cell preparation. Results Chymase was expressed in CD34+ cells as well as human MCs by immunocytochemistry. Substantial CD34+CD117− cells, but not CD34+CD117+ cells, were stained immunocytochemically with anti-chymase mAb. For 1 week culture with rhSCF+rhIL-6, no cells expressed chymase in any preparation. Real-time RT-PCR revealed positivity for chymase mRNA in CD34+ cells, but it reduced at 1 week of culture, and increased as cells developed into MCs. Chymase mRNA in CD34+CD117+ cells was negligible compared with that in CD34+CD117−. Tryptase mRNA was below the detectable level in CD34+ cells, and increased along with MC differentiation. After 12 weeks of culture, CD34+CD117+ developed predominantly into MCs, whereas CD34+CD117− developed into monocytes/macrophages. Conclusion Our findings suggested that chymase is present not only in MCs but also in CD34+CD117− BM progenitors, but that its origin is different from the MC lineage.

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.

A 62-year-old female with Osler's disease was admitted to our hospital because of fever and cardiac failure. The patient had undergone a mitral valve replacement (MVR) using a Carpentier-Edwards prosthetic valve 14 years earlier. A bacterial examination of arterial blood identified Streptococcus mitis. No arteriovenous malformations were detected in visceral organs. The patient underwent MVR using the same prosthetic xenograft after conservative treatment and management of repetitive epistaxis and decayed teeth. Intra- and postoperative bleeding were typical of a mitral valve reoperation. This is the first reported experience, to the best of our knowledge, of a second MVR in a patient with Osler's disease.

Background The Cox maze procedure has shown to be effective in treating atrial fibrillation. Radiofrequency ablation, with a similar objective, has been used as an adjunct to conventional cardiac surgery for the treatment of atrial fibrillation in more than 20 centers in Australia and New Zealand since March 2000. This is a report of those results. Methods One hundred thirty-two patients in 20 centers underwent radiofrequency ablation as an adjunct to conventional cardiac surgery, with a standardized lesion set created with a flexible, 7-electrode, temperature-controlled probe (Cobra; EPTechnologies, San Jose, Calif). All data were entered into a central registry, with regular follow-up prompted by the registry cocoordinator. Each radiofrequency scar was made with standard parameters requiring 2 minutes of tissue coagulation at 80°C to 85°C. Patients undergoing mitral procedures had radiofrequency ablation performed in the left atrium endocardially. Patients undergoing aortic valve replacement or coronary artery bypass surgery underwent epicardial radiofrequency ablation of the left atrium. Epicardial radiofrequency ablation lesions on the right atrium were common to both groups of patients. Preoperatively, 75% of the patients had chronic atrial fibrillation, 21% had paroxysmal atrial fibrillation, and 4% had flutter. Surgical procedures performed included mitral valve procedure in 60%, coronary artery bypass grafting in 14%, aortic valve replacement in 7%, and coronary artery bypass grafting plus aortic valve replacement in 4%. Results There were no major complications related to the use of radiofrequency ablation. There were no soft tissue or cardiac perforations. Ten patients were defibrillated into sinus rhythm within 3 months postoperatively. The freedom from atrial fibrillation was 84% at 3 months, 90% at 6 months, and 100% at 12 months. All patients at 12 and 18 months' follow-up were in sinus rhythm. There were no thromboembolic complications. Conclusions Surgical radiofrequency ablation can be performed safely as an adjunct to conventional cardiac surgery. A standardized lesion set created by using similar temperature settings can be adopted in multiple centers and might be effective in treating atrial fibrillation. Data collection through a central registry has helped in monitoring the effectiveness of this new technique in a scattered population.

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

動静脈瘻を形成した孤立性総腸骨動脈瘤の手術症例を経験した.71歳の慢性透析患者で,術前に心不全症状を自覚していなかった.大動脈から左総腸骨動脈には,血腫の器質化したような堅い組織を認め,瘤は右総腸骨動脈に限局していた.瘤の切開後,約13×8mm大の動静脈瘻を直接縫合閉鎖し,瘤の中枢と末梢側の動脈は縫合閉鎖した.下肢血行再建には8mmの人工血管を用いて腹部大動脈と右外腸骨動脈間にバイパスを作製した.大動脈周囲に器質化した血腫が認められた事から,動静脈瘻は破裂した総腸骨動脈瘤が静脈壁に穿通して形成されたと考えられた.慢性透析により水分コントロールが厳重に為されていたために,心不全症状はなかった.総腸骨動脈瘤の破裂により動静脈瘻をきたした症例は稀であること,慢性透析患者であったため,水分管理が厳重に為され心不全症状が出にくい特殊な症例と考え,報告した.

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

The University of Wisconsin (UW) solution has been widely utilized in the process of organ preservation. Its high potassium content and high viscosity however, have been reported to cause vasoconstriction or endothelial damage during heart procurement. We previously reported that the Celsior solution with its high buffer capacity, low potassium content, and low viscosity was equivalent to or superior to the UW solution for cardiac preservation. In this study, myocardial temperature during the washout of coronary vascular beds and myocardial energy metabolism soon after the excision of hearts were evaluated by focusing on the initial flush effect of both solutions. Adult mongrel dogs weighing 9.5 to 13.5 kg were used. Following cardiac arrest using cardioplegia, the heart was cooled with ice slush and coronary vascular beds were washed out with a 4°C UW solution (UW group; n = 5) or Celsior solution (Celsior group; n = 5) at a pressure of 80 cm H2O. During the period of initial washout using 200 ml of solution, both the myocardial temperature and the time required to reach myocardial temperature of 15°C, were noted. The time required to complete the initial washout was also measured. Phosphocreatine (PCr), s-adenosine triphosphate (ATP) and inorganic phosphate (Pi) levels were measured by using 31P-nuclear magnetic resonance spectroscopy soon after the excision of hearts. PCr/Pi and s-ATP/Pi values were identified as indicators of myocardial high-energy phosphate levels. The Celsior group tended to require a shorter time to reach a myocardial temperature of 15°C compared with the UW group. The total initial washout time was significantly shorter in the Celsior group than in the UW group. PCr/Pi and s-ATP/Pi values were significantly higher in the Celsior group than in the UW group. The Celsior solution appears to have significant advantages when used as an initial flush solution compared with the UW solution in heart procurement.

A 61-year-old Japanese female was referred to our hospital for surgical treatment of a localized heavily calcified abdominal aorta. Preoperative angiograms and computed tomograms revealed severe stenosis of the aorta, resembling a slit. Bypass grafting between the thoracic and abdominal aorta was successfully performed together with the reconstruction of the celiac artery, superior mesenteric artery, and bilateral renal arteries without extracorporeal circulation. Postoperative angiograms showed patency of the graft and branches. A localized heavily calcified abdominal aorta is relatively rare, and the cause of this entity might be Takayasu's aortitis.

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.

A rare case of bilateral pneumothorax in a 54-year-old woman with advanced breast cancer associated with lung and pleural metastases is presented. The patient was admitted to our hospital complaining of unexpected severe dyspnea. A chest X-ray showed bilateral pneumothorax associated with multiple lung metastases and pleural effusions, followed by immediate pleural drainage. Although air leak and effusions of the right lung were well controlled by the conservative management, massive air leaks of the left lung had continued for 40 days. Because of patient's poor general status a surgical closure of the leaking site was selected using video-assisted thoracoscopic surgery techniques. Thoracoscopy revealed a ruptured bulla in the lower lobe (S6), thus, followed by a successful bullectomy with a stapling device. We speculate that multiple pleural metastasis may disturb the normal repair mechanism of the lung tissue and cause prolonged persistent air leaks.

Background. We have recently identified basic transcription factor-binding protein 2 (BTEB2), which is involved in phenotypic modulation of vascular vascular smooth muscle cells. The aim of this study was to investigate the expression of BTEB2 in cardiac allograft vascular disease. Methods. Heterotopic cardiac transplantation was performed in rats. All grafts were stained with antibodies against for BTEB2 and cyclin-dependent kinase 4 for immunohistochemical study. The intensity of BTEB2 expression was also calculated. Results. In the allografts at 4 and 8 weeks after transplantation, smooth muscle cells were positive for BTEB2 in the diffusely thickened coronary arteries and the perivascular space. BTEB2 expression was closely associated with cyclin-dependent kinase 4 expression. The BTEB2 expression score was significantly higher in the allografts compared with the isografts. Conclusions. The induced expression of BTEB2 may play a potential role in the development of the cardiac allograft vascular disease. Cardiac transplantation as a treatment for end-stage cardiac disease has gained popularity, although the problem of the cardiac allograft vascular disease remains. This disease is characterized pathologically by diffuse intimal thickening composed of phenotypically modulated vascular smooth muscle cells (SMCs). The early vascular lesion involves the adhesion of monocytes/macrophages to the vessel wall between day 7 and day 14 after transplantation. Subsequently, various cytokines and growth factors are secreted from the activated cells, such as T lymphocytes or macrophages and may stimulate the migration of SMCs from media to neointima between day 28 and day 75 after transplantation. Thus, it is useful to investigate the promoter of the proliferation of vascular SMCs in cardiac allograft vascular disease. Although a number of genes are differentially expressed between proliferating and quiescent vascular SMCs, the transcription factors that play a role in this process remain largely unknown. We have demonstrated that the basic transcription element-binding protein 2 (BTEB2), GC box-binding zinc finger protein, is a transcription factor regulating the SMemb gene, also known as nonmuscle myosin heavy chain-B isoform gene (1). We indicated that a developmentally regulated BTEB2 was induced in neointimal smooth muscle in response to vascular injury in vivo (1‐3) and demonstrated that the BTEB2 gene is regulated by mitogen activated protein kinase-mediated intracellular signalings and immediate early response gene Egr-1 in SMCs in vitro (3). Moreover, BTEB2 was also expressed in monocytic leukemia cells and BTEB2 mRNA levels were increased in response to macrophage differentiation (4). Immunohistochemistry of the cholesterol-fed rabbits revealed that BTEB2 was expressed not only in neointima but also in the site of macrophage accumulation (4) Thus, we have postulated that BTEB2 may play a regulatory role in activated vascular SMCs and macrophages. BTEB2 may play an important role in even the development of the cardiac allograft vascular disease; however, BTEB2 expression in the cardiac allograft remains uninvestigated. The aim of this study was to determine whether the expression of BTEB2 was regulated in the cardiac allograft vascular disease.

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.

Severe pulmonary oxygenation impairment resulting from peripheral lung atelectasis occurred in some patients with pleurotomy during the harvest of the internal mammary artery graft followed by coronary artery bypass grafting (CABG). We studied the efficacy of intraoperative positive end-expiratory airway pressure (PEEP) therapy for the prevention of postoperative pulmonary oxygenation impairment. A total of 66 patients with solitary CABG procedure were included in this study. The pleural cavity was intraoperatively opened in 44 patients and not opened in 22. PEEP therapy was not used in any patient before May 1996 (referred to herein as the former period) and was used more recently in eight patients with pleurotopmy (referred to herein as the latter period). PEEP was initiated immediately after pleurotomy during the harvest of the internal mammary artery graft. Without PEEP therapy, values of PaO2, A-aDO2, and respiratory index (RI) were worse in patients with pleurotomy than in those without pleurotomy. Meanwhile, there were no major differences in these values between patients with or without pleurotomy after the induction of PEEP therapy. Respiratory insufficiency (A-aDO2 > 400 mmHg and RI > 1.5) was detected in six patients with pleurotomy in the former period. Three of these six patients required over 1 week of long-term mechanical respiratory support. No respiratory insufficiency occurred in patients of the latter period. In conclusion, PEEP therapy, which is initiated just after pleurotomy, may prevent oxygen impairment and pulmonary atelectasis after extracorporeal circulation (ECC) and is recommended for patients with pleurotomy, especially for patients with preoperative low respiratory function.

Objective: There have been various reports on prognostic factors in non-small-cell lung cancer (NSCLC) under a complete resection, but an incomplete interlobar fissure has not been discussed yet. We attempted to clarify whether this influences survival or recurrence. Patients and methods: From 1981 to 1994, 239 patients (43%) who had a single lobectomy with mediastinal lymph node dissection were pathologically diagnosed as stage IA/IB or IIA/IIB (excluding T3N0M0). These patients were divided in two groups: patients with a complete interlobar fissure group (group L); and patients with an incomplete one (group NL). Postoperative survivals and cancer-free periods were retrospectively assessed. Patients’ characteristics had no statistical difference between groups L and NL by N category. Results: The 5-year survival was 77.0% in group L-N0, 79.3% in group NL-N0, 48.7% in group L-N1, and 66.2% in group NL-N1. No statistical difference was found between groups L-N0 and NL-N0, L-N1 and NL-N1, L-T1N0 and NL-T1N0, L-T1N1 and NL-T1N1, L-T2N0 and NL-T2N0, and L-T2N1 and NL-T2N1. The 5-year-relapse-free survival was 81.2% in group L-N0, 85.4% in group NL-N0, 69.4% in group L-N1, and 72.2% in group NL-N1. No statistical difference was found between groups L-N0 and NL-N0, L-N1 and NL-N1, L-T1N0 and NL-T1N0, L-T1N1 and NL-T1N1, L-T2N0 and NL-T2N0, and L-T2N1 and NL-T2N1. There was no statistical difference in recurrent sites between groups L-N0 and NL-N0, and L-N1 and NL-N1. Conclusion: We conclude that the incomplete interlobar fissure does not influence the prognosis of resected stage I or II NSCLC (excluding T3N0M0).

Chronic ischemic mitral regurgitation (IMR) is recognized as functional regurgitation and a common cause of congestive heart failure caused by the myocardial infarction remodeling process. IMR is a strong predictor of poor outcomes in patients with ischemic cardiomyopathy. Various types of mitral valve repair (MVR) techniques, such as annuloplasty, 1 the edge-to-edge technique, 2 and chordal cutting, have been reported. However, these procedures have yet to result in clearly improved patient outcomes, and the best surgical intervention is still controversial. Therefore the development of new techniques is necessary for better results in patients with IMR. Conventional MVR procedures, such as edge-to-edge repair or repair with an artificial chordae with an undersized ring were original options; however, satisfactory results were not obtained because of recurrent mitral regurgitation and late death. In this article we introduce our new simple procedure, the so-called sandwich plasty.

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.

We report a very rare occurrence of a primary collision tumor in the lung consisting of squamous cell carcinoma and T-cell lymphoma. A squamous cell carcinoma was diagnosed histologically following a transbronchial lung biopsy in a 71-year-old woman, but the other component was diagnosed histologically and immunohistochemically only on examination of the resection specimen. The malignant lymphoma was stained by the monoclonal antibody UCHL-1 (anti-D45RO) against T-lymphocytes but was not stained by the L26 (anti-CD20) antibody against B-lymphocytes. Immunostaining for CD3 was positive, confirming a T-cell lineage. Despite systemic chemotherapy, the patient died 7 months after operation, from progression of the lymphoma. Our case, which illustrates interesting attributes of collision tumors, consisted of an ordinary squamous cell carcinoma and a rare T-cell lymphoma arising in the lung, with the latter part of the combination dictating subsequent treatment and outcome.

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.

This is a report of two-year-old female monozygotic twins, both having a ventricular septal defect (VSD, Kirklin type II) and accompanying moderate pulmonary hypertension (PH). The two patients underwent a patch closure procedure to repair the VSD at the same time, and their postoperative courses were uneventful. Rubenstein and Weaver have reported the only case of surgical treatment for monozygotic twins having both VSD and PH. Our patients are the second such case of surgical treatment of VSD and PH in monozygotic twins.

A 62-year-old woman with inoperable lung cancer received systemic combined chemotherapy with cisplatin and vindesine sulfate. Lower extremity edema occurred after chemotherapy and an iliocavagram revealed a large intraluminal solitary thrombus, which was floating in the inferior vena cava (IVC) and extending up to the level of the renal vein. A thrombectomy using the simple IVC clamping procedure was successfully performed. Primary thrombosis of the IVC is rare, and this is the first reported case associated with lung cancer. A thrombectomy using the simple clamping of the IVC is considered to be a safe and effective procedure for the treatment of a free-floating thrombus in the IVC even in the case of a lung cancer patient.

Primary adenoid cystic carcinoma in the lung is an uncommon disease, which is regarded as a slow growing low-grade malignancy. However, this disease has a high risk of incomplete resection because of its unique histological invasion patterns. The cases of two patients who recently underwent surgery for adenoid cystic carcinoma in the lung are reported. Both patients received postoperative radiotherapy treatment as a follow-up to a histologically incomplete resection. Both patients have survived for 51 months and 7 months, respectively, with no recurrence. Postoperative radiotherapy is an acceptable treatment of choice to control residual lesions and provides long-term survival even in cases of incomplete resection.

A cardiac hormone, α-human atrial natriuretic polypeptide (α-hANP), acts as a vasodilator and a diuretic by activating cyclic GMP. The purpose of this study is to evaluate hemodynamic effects of continuous intravenous infusion of α-hANP on patients undergoing open-heart surgery. A total of 10 patients, including six patients with CABG, two with AVR, one with CABG plus AVR, and one with AVR plus MVR, had intravenous administration of α-hANP on postoperative day 1 with a dose of 0.05μg/kg/min. The mean age of the patients was 69 years, ranging 64 to 77. The plasma concentration of α-hANP increased sufficiently after beginning of contiunous intravenous infusion without any adverse side effects, and also the urine volume increased. The administration of α-hANP induced a significant decrease in central venous pressure, and decreasing tendencies in pulmonary capillary wedged pressure and pulmonary vascular resistance index. Systemic vascular resistance index and cardiac output remained unchanged. Since the administration of α-hANP decreases preload and facilitates adequate urination, it is useful for the management of patients associated with volume overload following open-heart surgery. In this study, it was obscure that α-hANP increased cardiac output by decreasing afterload and by intensifying the contractile force of the heart.

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.