We studied the effects of intermittent tepid blood cardioplegia on patients with prolonged aortic cross-clamping. Forty patients undergoing coronary artery bypass grafting with cross-clamp time of greater than 120 minutes were studied. The patients were divided into two groups according to the cardioplegic solutions, cold (4°C) crystalloid cardioplegia (Cold) and tepid (30°C) blood cardioplegia (Tepid). Cardiac function, myocardial enzyme and clinical outcomes were compared between the groups. Mean aortic cross-clamp time were 150±10 minutes in the Cold group and 149±4 minutes in the Tepid group. Recovery rate of spontaneous rhythm after cross-clamp removal and postoperative left ventricular stroke work index were significantly greater in the Tepid group than those in the Cold group. Duration of ventilation and ICU stay were significantly shorter and total release of CK-MB, requirements of dopamine during 48 hours after the operation and the incidence of low-output syndrome were significantly less in the Tepid group. There were no early deaths in the Tepid group versus three early deaths in the Cold group. In conclusion, intermittent tepid blood cardioplegia provided superior postoperative cardiac function and clinical results to conventional cold crystalloid cardioplegia, thus the technique appears to be safe for patients requiring prolonged aortic cross-clamping.

Perioperative changes in thyroid function and hemodynamic state were studied in 6 hypothyroid patients and 15 euthyroid patients who underwent coronary artery bypass grafting. Serum free T₃ and total T₃ concentrations declined significantly in hypothyroid patients after the surgery. Serum total T₃ concentration decreased significantly also in euthyroid patients, indicating the occurrence of“euthyroid sick syndrome”in this group. Hypothyroid patients resulted in significantly lower left ventricular stroke work index despite greater central venous pressure and pulmonary capillary wedge pressure, and greater requirements of dopamine and dobutamine compared with those in euthyroid patients. The results indicated poorer postoperative cardiac performance in hypothyroid patients. Serum free T₃ concentration after cardiopulmonary bypass demonstrated a significant positive correlation with left ventricular stroke work index measured simultaneously. Preoperative serum free T₃ concentration showed a significant negative correlation with the postoperative dopamine and dobutamine requirements. Therefore, the results suggest that free T₃ has inotropic effects and the concentration of this hormone can be a predictor for a incidence of postoperative low cardiac output. In conclusion, since hypothyroid patients undergoing coronary artery bypass grafting are prone to have low cardiac output status, careful perioperative management, including hormone replacement therapy, is required for the patients.

The effects of human atrial natriuretic peptide (HANP, carperitide) were studied in 21 patients undergoing mitral valve surgery. The patients were randomized to receive either no carperitide treatment (control group, n=10) or carperitide (HANP group, n=11). Their hemodynamic status, diuresis and renal function were assessed perioperatively. The HANP group received continuous intravenous infusion of carperitide for 3 hours at a rate of 0.05μg/kg/min 3 hours after cardiopulmonary bypass. The HANP group had significantly lower systemic vascular resistance and less temperature difference between the rectum and the sole, and significantly greater cardiac index compared with those in the control group during infusion of carperitide, suggesting the improvement of cardiac performance by reducing afterload. The HANP group also had greater urinary output during the administration of carperitide, suggesting the significant diuretic effect of the regimen. The results indicated that the administration of carperitide may be a viable alternative strategy for the management of patients with postoperative heart failure. However, since transient oliguria was observed in 2 hypovolemic patients after the discontinuation of carperitide, careful monitoring is required during and after the infusion of the regimen in such patients.

Ventricular Septal Defect (VSD) is the most frequent cardiovascular anomaly. VSD causes pulmonary hypertension through stenotic changes in the pulmonary vasculature, and this progress depends on the size of defect and associated cardiovascular anomalies. Since surgical repair has been performed in childhood for patients without a tendency toward spontaneous closure of VSD, operations in elderly patients, especially those aged over 40, are rare. We report an elderly patient with VSD complicated with severe pulmonary hypertension who underwent surgical repair. A 66-year-old man was admitted to our hospital because of general fatigue, chest oppression and palpitations. The pulmonary to systemic pressure ratio was 0.66. The oxygen saturation stepped up at the right ventricle level. The pulmonary to systemic blood flow ratio was 2.9, shunt ratio was 71% and resistance ratio was 0.12. The VSD was 18mm in diameter at the perimembranous trabecula and was closed with a Dacron patch through a right atrium incision. The lung biopsy specimen revealed little occlusive pulmonary vascular disease, Grade I according to the Heath-Edwards criteria. The patient had an uneventful recovery.

A study was conducted to determine the effect of aging on motor ability and to establish a test battery for physical fitness in the elderly. The subjects were 150 men aged 18 to 83 years. The test items examined were selected, according to Fleishman's list of motor abilities; (1) trunk flexion, (2) grip and isometric knee extension strength, (3) postural sway with eyes open and closed, (4) step test, (5) walking test at preferred and maximum speeds, (6) simple visual reaction time, (7) peg-board test, (8) finger tapping test at maximum rate and in time to metronome sounds. Performances for the test items, except for preferred walking speed and coefficient of variation in finger tapping at 5 Hz, showed significant decreases with aging. The decrease in motor performance at age 80 years relative to the level at age 20 years was less than 30% for finger dexterity and reaction time, 40-60% for muscle strength, maximum walking speed and the step test, and over 70% for trunk flexion and postural sway with eyes closed. A test battery composed of trunk flexion, grip strength, knee extension, step test, walking as fast as possible, postural sway with eyes closed, and finger tapping, is therefore recommended for assessing the effect of aging on physical fitness.

A motor performance test was administered to elderly adults in Koganei City and Nangai Village of Japan as the baseline study of Tokyo Metropolitan Institute of Gerontology, Longitudinal Interdisciplinary Study on Aging (TMIG-LISA) . The participants in this study totaled 405 (183 males and 222 females) aged 65 to 84 from Koganei City, and 734 (295 males and 439 females) aged 65 and over from Nangai Village. The test consisted of measurement of grip strength, one-leg stand-ing, walking at preferred and maximum speeds, and finger-tapping. All motor performances examined were higher among males than females, and they all deteriorated with aging. A regional difference was found in terms of motion speed abilities: finger-tapping rate and walking speed were higher among urban residents than rural residents. Individual differences (coefficient of variation) in the motor ability increased with aging, and reached 106% (maximum tapping rate in female) to 290% (maximum walking speed in female) of those in the twenties. Significant correlations between motor abilities were detected indicating that the specificity of the motor ability found in the young may not account for older adults.

Introduction: In the rehabilitation period following a stroke, rehabilitation therapists must thoroughly evaluate the condition of patients for the purposes of goal-setting and effective training. Postgraduate education in the medical examination of patients after stroke was provided for rehabilitation therapists, and changes in their autonomy during medical examinations were subsequently assessed.
Method: The education consisted mainly of reading case reports about patients who had strokes and learning neurological examination techniques. A total of 35 once-weekly education sessions were provided to rehabilitation therapists working in a convalescent rehabilitation ward. The rehabilitation therapists evaluated their independence with respect to obtaining patient backgrounds, vital signs, physical findings, neurological findings, laboratory results, and basic knowledge of illness at the beginning and end of the education sessions and 6 months after the sessions ended. Each evaluation item was compared according to the time of evaluation.
Results: Rehabilitation therapists’ autonomy over obtaining patient backgrounds, neurological findings, laboratory results, and basic knowledge of illness was greater at the end of the education sessions than at the start of the sessions. Their autonomy over obtaining information in these 4 areas and obtaining physical findings was greater 6 months after the end of the education sessions than at the start of the sessions.
Discussion: We conclude that workplace postgraduate training in the medical examination of patients who have had strokes improves rehabilitation therapists’ autonomy during medical assessments.

The effects of milrinone, a phosphodiesterase III inhibitor, were studied in patients with heart failure following coronary artery bypass grafting. Twenty patients with heart failure (either a cardiac index of less than 2.0l/min/m² or a pulmonary capillary wedge pressure of greater than 12mmHg) were divided into two groups according to whether or not they received postoperative milrinone administration. The control group (n=10) received no milrinone treatment and the milrinone group (n=10) received intravenous milrinone infusion at a speed of 0.5μg/kg/min postoperatively. The hemodynamic measurements were made perioperatively and clinical results were accessed perioperatively. Within-group comparison revealed a marked (p<0.05) decrease in pulmonary capillary wedge pressure and systemic vascular resistance in the milrinone group. Cardiac indices were significantly (p<0.05) greater in the milrinone group than those in the control group and within-group comparison revealed a significant (p<0.05) increase in left ventricular stroke work index in the milrinone group. There was no significant difference in rate pressure product in between- and within-group comparison. The milrinone group had a significantly (p<0.05) lower temperature difference between the rectum and the sole, and significantly (p<0.05) less catecholamine requirements postoperatively. Milrinone was not associated with a significant increase in the prevalence of adverse effects. The results suggest that milrinone possesses positive inotropic and vasodilatory effects in patients with heart failure following coronary artery bypass grafting. In addition to catecholamines and vasodilators, milrinone may become a useful agent in the treatment of patients with postoperative heart failure.

A 71-year-old woman with Lutembacher syndrome was admitted for severe congestive heart failure and cardiac cachexia. The preoperative cardiac catheterization showed a huge secundum atrial septal defect (Qp/Qs=3.08) with mitral valve stenosis, tricuspid valve regurgitation, atrial fibrillation and severe pulmonary hypertension. Patch closure of atrial septal defect, mitral valve replacement (SJM 25mm) and tricuspid annuloplasty (Key's method) were performed. However, she suffered prolonged respiratory failure postoperatively. Enforced alimentation for cardiac cachexia and careful administration for sustained heart failure resuscitated her severe postoperative status. The postoperative cardiac catheterization showed sufficient decrease of pulmonary pressure. Reports of successful surgical correction for Lutembacher syndrome in elderly are extremely rare. This is the oldest case of successful correction for Lutembacher syndrome in Japan. From our experience, the surgical treatment for Lutembacher syndrome should be considered even in elderly patients.

A 36-year-old woman was admitted because of dyspnea on exertion and palpitations, during follow-up for ventricular septal defect since age 5. Physical examination revealed a grade IV/VI ejection systolic murmur at the second left intercostal space. Echocardiogram failed to recognize an unruptured aneurysm of the sinus of Valsalva protruding into the right ventricle which was seen on right ventriculogram (type I of Konno). Surgical treatment was successfully performed. Right ventriculography was much more effective rather than echocardiography in this case.