It is essential to evaluate the quality of coronary artery bypass grafting (CABG) anastomosis in the operating room. Transit-time flow measurement has been increasingly used for this purpose, because it is less invasive, more reproducible, and less time consuming. The electrocardiogram-gated flow measurement has made it possible to identify the systolic flow (Qs) and diastolic flow (Qd) and to calculate a new index, diastolic filling index (DFI=100∫Qd/[∫|Qs|+∫|Qd|]) for graft flow analysis. In this study, we investigated the clinical significance of DFI, together with other indexes, including mean flow (Qm), pulsatility index (PI), % insufficiency (INSUF), and F0/H1, where F0 is a power of the fundamental frequency and H1 is a power of the first harmonic in spectral analysis by fast Fourier transformation of the flow curve. We examined the relationships of these intraoperative flow variables of the postoperative angiographic findings of 125 CABG grafts, including 58 in-situ internal thoracic arteries. There were significant differences between patent and non-patent grafts in all of the intraoperative flow parameters (Qm: 47.9±31.8ml/min vs 10.2±3.6ml/min, PI: 3.0±1.4 vs 9.6±2.4, INSUF: 3.3±4.2% vs 29.9±8.1%, F0/H1: 2.8±2.0 vs 0.6±0.2, DFI: 68.5±8.4% vs 38.2±17.2%). Our data suggested that a DFI value of more than 50% can be useful for surgeons to distinguish patent from non-patent grafts in the operating room, in combination with other parameters: Qm>15ml/min, PI<5, INSUF<15%, and F0/H1 ratio>1.0.

We describe our surgical experience of localized thoracoabdominal aneurysm in a 60-year-old woman with hypertension and hyperlipidemia. She was admitted for severe nausea associated with uremia. The initial CT scan revealed bilateral hydronephrosis, retroperitoneal fibrosis, inflammatory abdominal aneurysm, and localized thoracoabdominal aneurysm. To resolve the bilateral urinary tract obstruction, bilateral ureteral stents were inserted. After the renal function improved, the thoracoabdominal aneurysm was removed and replaced with an 18-mm woven-Dacron graft under partial cardiopulmonary bypass. The inflammation and fibrosis along the abdominal aorta did not extend to the thoracoabdominal aneurysm. Following the case presentation, we discussed the pathophysiologic aspects of this patient.

Objective: The aim of this study was to investigate diagnostic characteristics to distinguish bacterial meningitis (BM) from aseptic meningitis (AM) in meningitis patients. Indicators from the initial consultation were combined with a measure of time since the onset of fever.
Methods: This was a retrospective chart review. We examined the sensitivity and specificity of the clinical information for BM. The diagnostic characteristics for BM were analyzed by considering the duration of fever for each patient at consultation, together with the presence or absence of changes in their mental status.The study examined 117 inpatients diagnosed with meningitis in their clinical record at the time of admission. The patients were admitted into two emergency hospitals in Japan between 2001 and 2011. Meningitis was defined as the presence of five or more cells per mm³ of CSF.
Results: Twenty-five patients were diagnosed with BM and 92 patients with AM. There was no single clinical symptom that could distinguish BM from AM in patients suspected of meningitis. The sensitivity and specificity of the clinical information for fever duration and disturbance of consciousness at consultation were 95.0% and 40.3%, respectively, for BM patients with disturbance of consciousness or with duration of fever less than three days. Thus, the proportion of BM patients without disturbance of consciousness for three or more days after fever onset was only 5%.
Conclusions: Patients without disturbance of consciousness for three or more days after fever onset are rarely suffering from BM.

A 32-year-old woman with Marfan's syndrome who had had a heart murmur in childhood was admitted due to congestive heart failure. Her echocardiography showed anterior and posterior leaflet prolapse of the mitral valve, and also severe mitral valve regurgitation. Her chest CT scan showed no evidence of an enlarged ascending aorta. We performed mitral valve replacement using a mechanical valve, because the long-term results of mitral valve repair for Marfan's syndrome are unknown. We reviewed the literature for other examples of this rare adult case with isolated mitral regurgitation associated with Marfan's syndrome.

Reoperations after operations for acute type A aortic dissection were performed in two cases under deep hypothermic circulatory arrest. In case 1, the aortic arch replacement was performed with an inclusion technique seven years ago. The reason for reoperation was the leak from the suture lines of all anastomosis sites. Three sites of leak were closed putting sutures with pledgets. In case 2 the graft replacement of the ascending aorta was performed five years ago. The reason for reoperation was the persistent dissection from the aortic arch to the thoracic descending aorta due to the new entry formation at the site of the aortic clamp. At first the graft replacement of the thoracic descending aorta was performed, followed by arch replacement. As these conditions are preventable, we should perform the open distal anastomosis technique without using a clamp and graft replacement of aortic arch with the branched graft. Moreover, deep hypothermic circulatory arrest may appear to be a valuable adjunct for reoperation after operation on acute type A dissection.

Diffuse hepatic arteriovenous malformation is extremery rare disease. A 69-year-old female was admitted to Nagoya Ekisaikai Hospital because of heart failure in NYHA class III. A selective celiac angiogram, echo cardiography and cardiac catheterization revealed high output cardiac failure secondary to diffuse hepatic areteriovenous malformations. Hepatic artery embolization with steel coils was performed. This resulted in amelioration of heart failure.

A 60-year-old man was admitted to our hospital due to cerebellum infarction. He had undergone replacement of the aortic valve and ascending aorta because of aortitis syndrome 2 years ago. Electrocardiogram showed complete atrioventricular block. Echocardiography showed aortic annular abscess and vegetation on the prosthetic aortic valve. A pulmonary autograft was transplanted of the aortic root (Ross operation) after complete resection of the infected sites. The postoperative course was uneventful. The ross operation was considered to be a treatment of choice for prosthetic aortic valve endocarditis.

A 49-year-old man who had had severe tripple vessel coronary disease and low left ventricular function (EF=29%) underwent coronary artery bypass grafting. Following the procedure he could not be weaned from cardiopulmonary bypass (CPB) even with an intra-aortic balloon pumping (IABP). Left ventricular assist using a centrifugal pump (CFP) together with IABP was then utilized with a dramatic recovery from profound postcardiotomy cardiogenic shock, and the CPB was successfully terminated. The left ventricular function recovered gradually from intraoperative myocardial damage. The CFP was successfully removed at 86 LHB hour and the IABP at 9th postoperative day. At present 12 months after LHB, he reveals no angina. Settting up the left ventricular support using a CFP is simple and not-time-consuming, so this system with IABP is of practical use in the case of unpredicted postcardiotomy cardiogenic shock.

Objective : In 2011, the Ishikawa Prefectural Joint Committee of Blood Transfusion Therapy was organized in Ishikawa Prefecture. Since 2012, pharmacists have promoted educational activities regarding the appropriate use of albumin products for different occupations based on a survey involving all medical institutions in Ishikawa Prefecture. We examined the effects of these activities with respect to the usage of albumin products. Methods : A questionnaire survey regarding blood transfusion therapy, including the total usage of albumin products, departments responsible for the management of albumin products, and health care professionals’ awareness of issues on the appropriate use of albumin products, was conducted from 2011 until 2014 involving all medical institutions where blood transfusion preparations were used in Ishikawa Prefecture. Results : The questionnaire collection rate was ≥70%. The results showed that, in middle- or small-scale medical institutions, departments/physicians other than the Department of Pharmacy were responsible for the management of albumin products. Furthermore, some health care professionals did not recognize/understand problems regarding the appropriate use of albumin products. Pharmacists newly increased educational activities by study meetings for various occupations or panel discussions involving participants. The participants’ occupations varied, and the number of institutions to which they belonged was 20 to 24. The total usage of albumin products in Ishikawa Prefecture decreased by approximately 20% between 2011, when these attempts were started, and 2014. Discussion : This study suggests that the educational activities by pharmacists and other health care professionals at the prefectural level reduced the total usage of albumin products.