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A 22-year-old man was hospitalized after 3 months of persistent fever and malaise. He had undergone abdominal surgery 24 months before admission. Echocardiography demonstrated two mobile pedunculated masses in the right ventricle. Multiple blood cultures were positive for Candida parapsilosis. After 4 weeks of miconazole treatment, the two masses were excised via a right atriotomy incision and the transtricuspid value approach. Histological examination revealed that they were fungal vegetation. Antifungal agents were continued for 1 year after surgery. The patient has remained well with no further symptoms for 3 years. This case suggests the necessity for careful evaluation of past history to avoid diagnostic delay in fungal endocarditis.

We studied 279 patients who underwent mitral valve replacement at the Department of Thoracic and Cardiovascular Surgery, Hyogo College of Medicine, between November 1973 and December 1998. The patients were divided into two groups based on the type of replacement valve (154 patients in the biological xenograft group and 125 patients in the mechanical valve group), and the long-term results were compared. Clinically satisfactory results were obtained in both the biological xenograft group and the mechanical valve group according to the surgical results, long-term survival, and incidence of prosthetic valve endocarditis. At 15 years, fewer patients in the mechanical valve group than in the biological xenograft group were free of bleeding events (92.5 +/- 3.7% vs 100% P0.05). At 15 years, the biological xenograft group was lower than the mechanical valve group with respect to freedom from thromboembolism (72.2 +/- 4.6% vs 93.5 +/- 3.6% P0.01), freedom from valve failure (22.0 +/- 5.2% vs 87.0 +/- 4.1% P0.005) and freedom from cardiac events (16.5 +/- 3.9% vs 47.2 +/- 14.5% P0.01). Though it has previously been suggested that biological xenografts used in mitral valve replacement do not need anticoagulation, the current study suggests the need for anticoagulation with the use of biological xenografts. Mechanical valves require close monitoring of anticoagulation, but their use has decreased the incidence of valve failure and thromboembolism, as compared with the use of biological xenografts. Therefore, mechanical valves are currently the preferred choice for mitral valve replacement. We believe that biological xenografts are indicated only for the older patient (or =65 years).

われわれは,すでにTNF-α産生阻害剤でp38 mitogen-activated protein kinase阻害剤でもあるFR-167653(Fujisawa Pharm. Co., Ltd., Osaka)によって,ラットinterposition vein graftモデルにおける術後内膜肥厚が抑制される可能性を報告した.今回,FR-167653の投与時期および投与量を変えて比較検討し,術後内膜肥厚を抑制する作用機序について考察した.顕微鏡手術下にLewisラット(雄,484±5g)の総大腿動脈に腹壁静脈グラフトを端々吻合した.手術開始直前にFR-167653 2.0μg/gを腹腔内投与した群(単回投与群,n=5),直前および術後2週目に追加投与した群(追加投与群,n=5),4.0μg/gを直前に投与した群(倍量投与群,n=5),同量の生理食塩水を投与した群(コントロール群,n=6)の4群に分け,術後内膜肥厚の程度を比較検討した.術後4週目に腹壁静脈グラフトを採取し,コンピューター画像処理(NIH Image Ver. 1.61)により内膜断面積を測定した.術後内膜肥厚はコントロール群0.43±0.05mm2で,単回投与群0.16±0.06mm2(p

Recently we reported that there is a direct correlation between monocytes/macrophages (Mo/Mo) infiltration and the development of intimal hyperplasia (IH) in rat interposition vein graft. Monocyte chemoattractant protein-1 (MCP-1) is the most potent chemoattractant and activating chemokine for Mo/Mo. We evaluated rat serum MCP-1 levels as the indicator of inflammatory response, before and after operation. In twenty five male Lewis rats (484±7 g) we interposed epigastric vein graft into the right common femoral artery. Rat serum MCP-1 levels were measured before skin incision and before and after bypass (0 hour, two weeks and four weeks), using enzyme linked-immuno-sorbent assay method. Rat serum MCP-1 levels were significantly increased at 0 hour (154 pg/ml,p

Background . Spinal cord injury is a most dreaded and unpredictable complication. In this study, based on our experimental results in dogs and early clinical results, we reviewed the incidence of paraplegia and the detection of spinal cord injury. Methods . Eighty-two patients who underwent elective surgical repair of the descending thoracic and thoracoabdominal aorta over 17 years were subjects for this study. Sixty-two patients were male and 20 were female. Their mean age was 61.6 years (range, 17 to 81 years). Monitoring somatosensory evoked potentials (SEP) and measurement of mean distal aortic pressure and cerebrospinal fluid pressure were performed perioperatively. Results . Sixty patients had no ischemic change in SEP. In 17 patients with significant ischemic changes of SEP, SEP recovered by increasing spinal cord perfusion pressure to more than 40 mm Hg. Two patients with complete loss of SEP experienced paraplegia. One patient had delayed paraplegia. Conclusions . These results strongly suggest that SEP, mean distal aortic pressure, cerebrospinal fluid pressure should be monitored during aortic cross-clamping. Maintaining spinal cord perfusion pressure at more than 40 mm Hg by increasing mean distal aortic pressure or withdrawal of cerebrospinal fluid is valuable for preventing paraplegia.

腹部大動脈瘤術後人工血管感染症に対し保存的治療にて救命した1症例を経験した. 症例は65歳女性, 1996年4月2日, 腹部大動脈瘤に対し人工血管置換術を施行したが, 術後14日目の腹部CT検査にて左後腹膜腔膿瘍を認めた. 緊急再開腹術を施行, 膿瘍腔の debridement および強酸性水による持続洗浄ドレナージ術を行った. 膿汁からはメチシリン耐性黄色ブドウ球菌が検出され, バンコマイシン®, ゲンタマイシン®を投与し, 術後82日目に細菌培養検査は陰性化した. 術後144日目に退院, 3年を経過した現在も炎症所見を認めず, 外来通院中である. 腹部大動脈領域の人工血管感染症は重篤な合併症であり, 感染グラフト除去, 非解剖学的バイパス術が一般的であるが, 抗生剤やポビドンヨードを希釈した溶液による持続洗浄法により良好な結果が報告されている. 強酸性水は広い抗菌スペクトルを有し, 生体に無害な溶液であり, 同液による持続洗浄は有用であると考えられる.

今回われわれは当科において過去20年間に経験した心臓粘液腫連続17例の臨床像・手術術式・手術成績について検討を加えた. 男性5例・女性12例, 年齢は22～78歳 (平均55歳), 発生部位は左房13例・右房2例・右室1例・多発例1例であった. 左房粘液腫摘出術は2例を除き, 両心房縦切開を用いた心房中隔合併切除・腫瘍摘出術を標準術式とし, うち2例に僧帽弁輪縫縮術を追加した. 摘出した粘液腫の重量は6～310g (平均54g) であった. 手術・病院死亡はなかったが, 術後9年目に再発1例 (多発例・他院にて再手術) を認めた. おもな術後合併症は洞不全症候群 (ペースメーカー植え込み術) を1例, 術後一過性心房細動を2例, 術後急性肺水腫 (右室粘液腫摘出術直後) を1例認めた. 長期遠隔成績は追跡率100%, 平均観察期間約7年1カ月で, 17例中2例を非心臓死で失い, 10年累積生存率は75% (n=6) であった. 左房粘液腫に対しては発生母地を直視下に観察でき腫瘍を en bloc に摘出できる両心房縦切開を用いた心房中隔合併切除・腫瘍摘出術は有用であると思われる.

術前1カ月以上のステロイド投与開心術症例13例を対象とした. 男性4例・女性9例, 年齢は12～80歳 (平均61歳), ステロイド治療対象疾患は膠原病3例・気管支喘息2例と大動脈炎症候群・自己免疫性溶血性貧血・発作性夜間血色素尿症・脳腫瘍・蕁麻疹・紅斑性天疱瘡・尋常性乾癬・腎移植術後それぞれ1例であった. 術式はACバイパス術9例, MVR・reMVR・AVR・心房中隔欠損孔パッチ閉鎖術それぞれ1例であった. 術前投与量 (以下プレドニゾロン換算) は平均9.4mg/日, 投与期間は平均4年11カ月であった. 緊急手術を除く8例に術前 rapid ACTHテストを施行し, 副腎機能低下は5例 (63%) 認めた. 術中は人工心肺充填液中リンデロン®4mg/kg添加 (通常例と同量) に加え, 麻酔前または人工心肺前にもソルコーテフ®ないしソルメドール®を25～1,250mg追加投与し, 術中ステロイド投与総量は平均2,488mgであった. 術後は全例ステロイド投与を継続し以後漸減した. 手術死はMVR後左室破裂の1例で, 主な術後合併症は心タンポナーデ・一過性痙攣発作・創部感染・腰椎骨折がそれぞれ1例であった. 今後も感染防止および出血に留意し, 術中および術後のステロイド投与は慎重かつ必要最少量にとどめる必要があると思われる.

In situ electrochemical scanning tunneling microscopy (STM) was employed for observing GaAs semiconductor electrodes in an aqueous sulfuric acid solution. Well-ordered surfaces were prepared by chemical etching in a mixed solution of H2SO4 and H2O2. Atomically flat terrace-step structures were consistently observed on the chemically etched GaAs(111)A surface in 0.05M H2SO4. Atomic steps observed in the STM images correspond to the double layer step with a height of 0.33 nm. Atomic images of the Ga-terminated GaAs(111) surface were successfully obtained under electrochemical conditions for the first time. The STM images reveal a hexagonal structure with an interatomic distance of ∼ 0.4nm. The results presented here clearly demonstrate that the ideal GaAs(111)A-(1 × 1) structure exists for several hours in a pure H2SO4 solution in a cathodic potential region.

Two men, 58 and 72 years old, were diagnosed as severe aortic regurgitation complicated by aortic annular abscess due to active endocarditis infection diagnosed by echocardiography. We conducted aortic valve replacement using gelatine-resorcine-formol biological glue to close the abscess cavity and remodel the new aortic annulus. Although 1 man developed complete atrial-ventral blockage postoperatively and required that a permanent pacemaker be implanted, neither experienced recurrence of infectious peri-valvular leakage.

1995年4月から2002年6月に施行した90歳以上の高齢者に対する腹部大動脈瘤(AAA)手術8例を対象とした.男性7例,女性1例.平均年齢90.8±1.4歳(90～94歳).緊急手術は4例でこのうち術前ショックを1例に認めた.術前の併存疾患は高血圧症4例,虚血性心疾患,播種性血管内凝固,胸膜炎をそれぞれ1例に認めた.AAAの最大径は69.5±16.6mm(48～10mm)であり,全例全腹部正中切開を行った.手術成績は全例軽快退院した.術後合併症は,術後譫妄2例,無気肺,イレウスを1例ずつ認めた.遠隔成績は,遠隔死亡5例で,死亡原因は肺炎2例,老衰,心不全,吻合部仮性瘤破裂がそれぞれ1例であった.遠隔生存率は1年,2年,3年がそれぞれ88±12%,63±17%,20±18%と不良であったが,期待生存率との差は少なかった.手術成績ならびに遠隔成績はほぼ良好であり90歳以上の高齢者であっても,積極的に手術を勧めるべきであると思われる

We encountered a 75-year-old man who complained of exertional dyspnea. An echocardiographic examination showed aortic regurgitation and a tumor in the left ventricular outflow tract. Under complete extracorporeal circulation, we surgically made an incision of the ascending aorta with a slight thickening of the aortic valve and an enlarged annulus. After excising the aortic valve, an examination of the subvalvular region revealed mitral valve-like tissue extending from the annular region of the right coronary cusp to the ventricular septum, while the chordae tendinae was attached to the septum. This issue was excised, and the aortic valve was replaced with a 27-mm SJM valve. The postoperative course was uneventful, and the patient was discharged in good condition on postoperative day 30. An accessory mitral valve is extremely rare. Since this indication for surgical treatment is associated with congenital heart disease or a left ventricular outflow tract obstruction, most patients are young. Our patient had no associated cardiac anomalies and no pressure gradient attributable to a left ventricular outflow tract obstruction. This accessory mitral valve was discovered during aortic valve replacement surgery. To our knowledge, our patient is the oldest reported with an accessory mitral valve to have undergone a surgical resection.

We have investigated an elliptic-shaped surface defect on GaAs layers grown by molecular beam epitaxy on GaAs substrates. The presence of microscopic defects in GaAs substrates, which are revealed by AB etching, is not essential to the formation of surface defects of this type. They are convex to the epilayer surface and have one dislocation including a screw component near propably formed by spiral growth. We have also studied the effects of growth rate and substrate misorientation on the elliptic-shaped defects. As the growth rate increases, the sizes of the defects become smaller and they disappear at a rate of 4 μm/h. They are not formed on substrates oriented 2° off the (100) towards the

症例は55歳の男性. 昭和56年5月に直視下僧帽弁交連切開術を受け外来通院中であったが平成5年12月よりうっ血性心不全の症状が出現し心臓カテーテル検査の結果, 術後収縮性心膜炎の診断で心膜剥皮術を施行した. 閉胸時に弁膜症の再手術を考慮し, 0.1mm Expanded Polytetrafluoroethylene 心膜シートを代用心膜として用いた. 心膜剥皮術後早期に心内圧は改善したが, 術後7日目より再度心不全の症状が再発した. 不完全な心膜の剥皮または収縮性心外膜炎を疑い再手術を施行した. 心膜シートで被覆した部位に一致し右房, 右室, 左室の一部の心外膜が肥厚していた. 心外膜の剥皮を試みたが不可能で心外膜を横方向と縦方向に約2cm間隔で切開を加えた. 心外膜の切開により心臓の収縮拡張は良好となり, 再手術後の第48日目の心臓カテーテル検査にて心内圧は正常範囲内に低下した.

We have investigated the surface defects of GaAs epitaxial layers grown by low-pressure organometallic vapor phase epitaxy on GaAs substrates oriented (100)±0.5°, at growth temperatures of 630 to 650°C, at V/III ratios of 20 to 100, and at growth pressures of 0.1 to 76 Torr. We have observed the shapes and internal structures of the surface defects in detail by using scanning electron microscopy and transmission electron microscopy. Elliptic cone-shaped surface defects formed at lower growth pressure below 1 Torr are convex to the epilayer surface, like the so-called “hillocks” in chloride vapor phase epitaxy, and certainly have one dislocation near each of the centers. These results form strong evidence for the formation of the elliptic cone-shaped surface defects by spiral growth at the dislocations propagated from the substrates. Four corner-shaped surface defects generated at higher growth pressure above 1 Torr are concave to the epilayer surface, and they have usually one dislocation near each of the centers and sometimes stacking faults. Four corner-shaped surface defects seem to be formed by vapor etching at threading dislocations and/or stacking faults. The reason the shape of these surface defects changes with growth pressure is also discussed.

In situ electrochemical scanning tunneling microscopy (STM) was used to examine n‐type GaAs(001), (111)A, and (111)B surfaces in 0.05 M sulfuric acid. Cathodic polarization of the GaAs electrodes effectively inhibited the oxidation of the surface, making it possible to acquire STM images with atomic resolution. Atomically‐flat terrace‐step structures were consistently observed on all surfaces prepared by the chemical etching method. Steps observed on these surfaces are composed of double layers with step heights of 0.28 and 0.33 nm for the (001) and (111) surfaces, respectively. In situ STM atomic images revealed that those surfaces have (1×1) structures with the square and hexagonal lattices, respectively.

症例は1992年3月24日に胸腹部大動脈瘤 Crawford III型に対し胸腹部大動脈人工血管置換術 (Gelseal Triaxial 直型26mm)・腹腔動脈・上腸間膜動脈・左腎動脈再建術を施行した慢性血液透析療法中の61歳男性である. 術後1年10か月目に左下腹部痛にて緊急入院し精査にて吻合部仮性瘤と診断した. 同日緊急手術を施行したところ, 左腎動脈と人工血管との吻合部が約2/3周離開していた. そしてこの離開部を直接吻合・閉鎖し左腎動脈は結紮した. 患者は術後18日目には軽快退院した. 近年 preclotting が不要である porosity 0の人工血管の使用が増加しているが, knitted Dacron 人工血管を使用する際, 術後人工血管の拡大により端側吻合部の離開をきたし仮性瘤を形成する危険性があることが示唆された.

A 35-year-old woman diagnosed with a cardiac tumor by echocardiography and cinecardiography underwent surgical excision in December 1988. The port-wine tumor had invaded from the surface of the right atrium to the anterior wall of the right ventricle, preventing us from removing it completely. Pathohistologically, it was diagnosed as angiosarcoma of the pericardium. She died due to lung metastasis on the postoperative day 107. To our knowledge, only 9 such cases have been reported in Japan.

This study was aimed at evaluating early and long-term follow-up results of surgical reconstruction of infrarenal abdominal aortic aneurysms (AAA). A consecutive series of 392 patients who underwent elective abdominal aortic repair from 1974 to 2000 was reviewed retrospectively. The mean age was 69.8 years (range 34-90), with 329 males and 63 females. The hospital mortality rate was 3.8% (15/392). Of the 203 patients that died during the follow-up period, 28% (56/203) were due to atherosclerotic diseases and 25% (51/203) were malignancies. The Patients whom underwent AAA surgery associated with ischemic heart disease had a 5-, 10-, and 15-year survival rate of 62%, 30%, and 9%, respectively. On the other hand, a survival rate of those not associated with ischemic heart disease were 71%, 38%, and 16%. The patients associated with aortoiliac occlusive disease in AAA surgery had a 5-, 10-, and 15-year survival rate of 51%, 11%, and 0%; those without aortoiliac occlusive disease had a survival rate of 72%, 43%, and 18%, respectively. There were statistically significant differences between the ischemic heart disease and the non-ischemic heart disease, the aortoiliac occlusive disease and the non-aortoiliac occlusive disease in long-term survival rates respectively. These findings demonstrate that AAA patients associated with ischemic heart disease or aortoiliac occlusive disease are at a higher risk than those with AAA alone. Therefore, AAA patients with aortoiliac occlusive disease and or ischemic heart disease should be managed more intensively before, during and after the operation.

Spinal cord injury is the most dreaded, unpredictable complication following repair of the descending thoracic and thoracoabdominal aorta. In this study, based on our experimental results in dogs and early clinical results we reviewed the incidence of paraplegia and the perioperative detection of spinal cord injury. Between October 1, 1985 and June 31, 1999 a total of 73 patients who underwent elective surgical repair of the descending thoracic and thoracoabdominal aorta entered the study. Somatosensory evoked potentials (SEPs) were monitored, and the mean distal aortic pressure (MDAP) and cerebrospinal fluid pressure (CSFP) were measured perioperatively. No patients developed paraplegia in this study, although one patient with significant changes in SEP, whose spinal cord perfusion pressure (SCPP) was 60 mmHg, developed delayed paraplegia. Another 20 of the remaining 72 patients showed significant ischemic changes in the SEP; in 13 of these 20 patients the SEP gradually recovered by increasing the SCPP up to more than 40 mmHg. In 51 of the other 53 patients without ischemic SEP changes, the SCPP was kept at more than 40 mmHg; the other two patients did not develop paraplegia. These results strongly suggest that SEP, MDAP, and CSFP should be monitored during aortic repairs. Moreover, maintaining the SCPP at more than 40 mmHg by increasing the MDAP, withdrawing cerebrospinal fluid, or both valuable for preventing paraplegia.

Ab initio pseudopotential calculations of C and Si impurity atoms on an As-terminated GaAs(001) surface have been performed, First, the C atom is found to stay near a midpolnt between the As atoms on the surface and the Si atom a cation site Secondly, we find that the C atom is more strongly bound to the GaAs surface than the Si atom. Geometrically as well as energetically, the C atom is more difficult to remove from the GaAs surface The present results agree with an experimental fact that in contrast with the case of Si, eliminating the C impurity through the surface requires thermal etching at such a high temperature of 750°C.

症例は16歳の女性で,嗄声と左背部痛を主訴として来院した.胸部単純X線写真にて左上縦隔に異常陰影が認められ,胸部大動脈造影では左総頸動脈分岐後の弓部大動脈は延長して峡部で軽度の狭窄を示し,その内側に二つの嚢状動脈瘤が並んで認められた.分離体外循環下に動脈瘤壁を楕円形に切除し欠損部をダクロンパッチにて閉鎖した.動脈瘤を合併した偽性大動脈縮窄症の手術報告例は文献上検索しえた限りでは,われわれの症例を含め16例であった.手術時年齢は16歳から51歳(平均34.1歳)であり,男性3例,女性13例であった.動脈瘤の存在部位に関しては下行大動脈7例,弓部大動脈8例,左鎖骨下動脈1例であった.術式に関しては,端端吻合術5例,人工血管置換術8例,パッチ閉鎖術はわれわれの症例を含め2例であった.以上,弓部大動脈瘤を合併した偽性大動脈縮窄症の1手術例について文献的考察を加え報告した.