Objective : The ascending aortic cannulation (Ao-C) is the routine procedure for cardiopulmonary bypass (CPB) in our hospital. However, for patients with diseased ascending aorta, such as severely calcified aorta, dissected or aneurysmal aorta, we used brachiocephalic artery (BCA) cannulation. The effectiveness and simplicity of BCA cannulation was evaluated. Methods : For patients with diseased ascending aorta, BCA was cannulated when the diameter of BCA is larger than 10 mm and is free from calcification, since January 2013. There were 62 patients who underwent aortic valve replacement (AVR) for aortic valve stenosis and BCA cannulation was applied for 11 patients. Standard Ao-C was used for remaining 51 patients. There were 44 patients with dissected or aneurysmal ascending aorta and BCA cannulation was applied for 7 patients, axillary artery perfusion was used for 15 patients and standard Ao-C was used for 22 patients. Consciousness level at the time of awaking from general anesthesia and any complication related with BCA cannulation was evaluated for the effectiveness. Simplicity was evaluated by the time required to establish CPB after skin incision. Results : In AVR patients, there was 1 patient with delayed consciousness level recovery with BCA cannulation and this patient was found to have cerebral infarction by CT. Intraoperative aortic dissection, probably due to BCA cannulation was observed in 1 patient, very old fragile and long period steroid user. In diseased ascending aorta patients, no patient suffered neurological accident nor any complication due to cannulation. In AVR patients, the time required to establish CPB after skin incision was 51+/-9 min in BCA cannulation and 47+/-10 min in Ao-C patients (p=0.34). In diseased ascending aorta patients, the time required to establish CPB after skin incision was 49+/-49 min in BCA cannulation and 51+/-16 min (p=0.82). Conclusion : BCA cannulation is a very simple and safe technique to establish CPB for patients with diseased ascending aorta. However great care should be taken, and BCA cannulation should be avoided for the long term steroid users or patients with connective tissue disease.

Cardiac angiosarcoma is a rare heart malignancy. The prognosis is reported to be very poor. Here, we report a case of cardiac angiosarcoma which was treated by postoperative conformal dynamic arc radiotherapy. The patient has been in good health with no recurrence for 18 months after surgery. The patient was a 71-year-old woman, who presented edema and general malaise. Echocardiography and computed tomography revealed a right atrial mass and massive pericardial effusion, which was thought to be the cause of tamponade. Intraoperatively, we found a large tumor arising from right atrial wall spreading and invading to the inferior vena cava, diaphragm, and right pericardium. We abandoned complete resection of the tumor. We only resected the part of the tumor under cardiopulmonary bypass. The subsequent defect of the right atrial wall was reconstructed with bovine pericardial patch. The pathological diagnosis was consistent with angiosarcoma, and the margin was positive for the tumor. In addition to reduction surgery, we adopted radiotherapy (conformal dynamic arc radiotherapy, 10MV-X-ray, 54 Gy/18 Fr/4.5 week, fractionated radiotherapy). The CT, one month after the radiation, showed a significant reduction in tumor size. Moreover, no tumor could be pointed out by echocardiography 18 months after surgery. Advances in technology and methodology has made tumor control possible without significant side effects. We conclude that reduction surgery accompanied with postoperative radiotherapy is promising in maintaining quality of life and in improving life expectancy.

In order to examine the personal space perception, measurements were conducted on both elbows in 14 men and 46 women. Each subject, with his (or her) eyes closed and with his upper arm fixed horizontally, was instructed to stop the vertical and horizontal swing motion of his lower arm at the point he considered to be the middle of the range of possible motion on the front and side of plane at his shoulder, and this was repeated ten times. In various conditions, similar measurements were also done to study factors affecting the personal space perception in 14 men.
Mean values of bisected angles in percentage against range of motion were deviated from the middle points in the direction of the elbow extension, although there were large differences between the individuals. The deviation was smallest in the vertical. side of plane, and was larger in the horizontal plane than that in the vertical plane. The deviation was not so much affected by the various conditions.
It was suggested that the gain of the personal space perception is higher in the elbow extension than in the elbow flexion and its difference is larger in the horizontal plane than in vertical plane of the human elbow joint.

Objective: We describe a case of lung cancer complicated with esophageal achalasia (EA), which was successfully treated with endoscopic pneumatic dilation (EPD). Case: A 66-year-old woman was admitted to our hospital because of frequent episodes of emesis and dysphagia after receiving an escalating dose of sustained release oxycodone (SRO) for cancer-related multifactorial back pain. She had been diagnosed with EA and treated with EPD at the age of 50. Her symptoms were refractory to the conventional anti-emetic agents such as prochlorperazine and metoclopramide. Computed tomography imaging showed marked dilatation of the esophagus with food residue. We diagnosed EA based on the presence of rosette-like esophageal folds on endoscopy and narrowing of the esophagogastric junction on esophagography, and subsequently performed EPD, which alleviated the symptoms. Discussion: The effects of opioids on esophageal motility have not been elucidated thus far. Recent studies using high-resolution manometry reported that long-term use of opioids was associated with esophageal dysmotility similar to that observed in EA. Although we have no evidence to directly demonstrate the causal relationship between the use of SRO and anti-emetic agents and EA, we speculate that our patient’s symptoms might be associated not only with SRO-related emesis during the gradual worsening of EA, but also partly with the SRO-induced esophageal dysmotility and the constrictive effect of dopamine D₂ receptor antagonists on the lower esophageal sphincter. Care must be taken to avoid drug-induced esophageal motor dysfunction, which might lead to deteriorate EA.

A 2-month-old boy developed Methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after bidirectional Glenn anastomosis for hypoplastic left heart syndrome. After reexploration, only the skin was closed but the sternum left open, and continuous mediastinal irrigation using saline containing isodine was commenced at an infusion rate of 20-40ml/h. The sternum was closed on day 7 and irrigation was stopped on day 21. The patient was weaned from the ventilator 4 days later, and is currently in a good condition awaiting a Fontan operation.

Purpose : Easy and safe implantability, good post-operative valve function and good long-term durability are required for any bioprosthetic valve implanted in aortic position. The Carpentier Edwards Perimount Magna valve (Magna) was introduced in 2009 and the St. Jude Medical Trifecta valve (Trifecta) was introduced in 2012 to our institution. In this study, we compared implantability, early post-operative valve function and structural valve deterioration (SVD) between these two valves. Patients and Methods : Between January 2009 and December 2019, Magna or Trifecta were electively implanted for 254 patients (Magna 151 patients and Trifecta 103 patients) and these patients were included in this study. Implantability was evaluated by occurrence of intraoperative valve dysfunction. Early post-operative valve function was evaluated by mean pressure gradient (m-PG) and indexed aortic valve area (AVAI) by ultrasonography performed 10 days after surgery. The relationship between indexed bioprosthetic valve orifice area calculated from internal diameter (GOAI) and AVAI was evaluated. If there was a significant relationship between GOAI and AVAI, maximum body surface area (BSA) to obtain AVAI≥0.85 cm2/m2 was estimated from 99% reliable interval of regression line. Results : Age, gender, and BSA did not differ between the two groups. There was no intraoperative valve dysfunction in Magna ; however we experienced one patient with severe aortic regurgitation due to stent distortion by the aortic wall during surgery with the 25 mm Trifecta valve. For this patient, Trifecta was replaced with Magna intra-operatively. In the 19 mm valve, AVAI was significantly larger (1.12±0.27 cm2/m2 vs. 0.88±0.21 cm2/m2, p<0.001) and m-PG was significantly lower (8.7±2.7 mmHg vs. 17.2±6.3 mmHg, p<0.001) in Trifecta. The frequency of AVAI<0.85 cm2/m2 (24% vs. 49%, p=0.036) and the frequency of m-PG≥20 mmHg (0% vs. 26%, p=0.006) were significantly less in Trifecta. There was significant relationship between GOAI and AVAI in both valves. Maximum BSA to obtain AVAI ≥0.85 cm2/m2 was estimated as 1.35 m2 in Magna and 1.50 m2 in Trifecta. In the 21 mm valve, AVAI was significantly larger (1.14±0.23 cm2/m2 vs. 0.92±0.22 cm2/m2, p<0.001) and m-PG was significantly lower (7.8±3.2 mmHg vs. 14.6±4.7 mmHg, p<0.001) in Trifecta. The frequency of AVAI<0.85 cm2/m2 was significantly less in Trifecta (11% vs. 42%, p=0.002) ; however, the frequency of m-PG≥20 mmHg did not differ significantly. There was a significant relationship between GOAI and AVAI in Magna and Trifecta. Maximum BSA to obtain AVAI ≥0.85 cm2/m2 was estimated as 1.49 m2 in Magna and 1.70 m2 in Trifecta. In the 23 and 25 mm valves, AVAI was significantly larger and m-PG was significantly lower in Trifecta. However neither the frequency of AVAI<0.85 cm2/m2 nor m-PG≥20 mmHg differed between the two valves. There was one early (27 months after surgery) SVD due to leaflet tear in Trifecta and two SVDs due to leaflet calcification more than 10 years after surgery in Magna. Conclusion : For Trifecta implantation, valve size selection seemed to be important and larger valves should be avoided with narrow ST junctions. Selection of 19 and 21 mm Magna valves should be limited for the patient with a BSA less than 1.35 and 1.49 m2 respectively. In Trifecta, early SVD might occur and careful follow-up is necessary.

Background : Post-operative fluid management after cardiac valvular surgery is very important. In our institute, carperitide 0.0125 γ was started during surgery and oral furosemide 20-40 mg/day and spironolactone 25 mg/day were started at post-operative day (POD) 1 as the standard therapy. Tolvaptan, vasopressin V2 receptor antagonist, was started when fluid retention such as pleural effusion occurred. With this strategy, the frequency of pleural drainage was more than 40%. Therefore we changed our standard therapy in February 2018. In this new standard therapy, carperitide (0.0125 γ) was started and maintained until oral intake became possible and tolvaptan 7.5 mg was started with furosemide 20 mg and spironolactone 25 mg as oral medicine usually at POD 1. In this study, whether tolvaptan prevents pleural effusion or not after cardiac surgery was examined. Subjects and Methods : Sixty-four patients were operated during February 2017 and December 2018 were included in this study. Thirty-two patients operated in the period until January 2018 served as control group and were compared with 32 patients for whom tolvaptan was started on POD 1 (tolvaptan group). Results : There was no significant difference between two groups for background, operative procedure, operation time, cardiopulmonary bypass time, aortic cross clamp time and fluid balance during procedure. Tolvaptan was given to all patients in the tolvaptan group and in 22% of patients in the control group. Oral furosemide dose (tolvaptan group 21±5 mg/day, control group 31±20 mg/day, p＝0.0112), and the frequency of patients with intravenous furosemide administration (tolvaptan group 9%, control group 44%, p＝0.0038) were significantly less in tolvaptan group. In the tolvaptan group, intravenous furosemide administrated only once in all patients, whereas the frequency of intravenous furosemide administration was 1-32 times, average 6.6 times in control group. Tolvaptan was stopped within 1 week because of too much urination in two patients and the elevation of liver enzyme in two patients without any adverse effects. Post-operative urination volume until POD 5 did not differ. In both groups, body weight increased at POD 1 and 2 and returned to pre-operative weight at POD 3. Pleural effusion was significantly less in the tolvaptan group at POD 3 (tolvaptan group : none 66%, small amount 22%, moderate amount 3%, drain tube inserted 9%, control group : none 16%, small amount 34%, moderate amount 13%, drain tube inserted 38%, p＝0.0003), at POD 7 (tolvaptan group : none 72%, small amount 28%, vs., control group : none 47%, small amount 19%, moderate amount 22%, drain tube inserted 13%, p＝0.0041) and at discharge (tolvaptan group : none 94%, small amount 6%, vs., control group : none 69%, small amount 22%, moderate amount 9%, p＝0.0301). The frequency of pleural drainage was also less in the tolvaptan group (tolvaptan group 9.4%, control group 44%, p＝0.0038). Conclusion : After cardiac valvular surgery, tolvaptan started at POD 1 is very effective to reduce the frequency of pleural effusion and pleural drainage, and careful checking for too much urination and the elevation of liver enzymes is mandatory.