The present study was performed to investigate heart rate responses and occurrence of arrhythmias caused by various diving maneuvers and swimming in infants. Forty four healthy infants (mean age 2.5±1.1, mean ±SD) served on this study. Condition of telemetry electrocardiograph recording was 1) rest on the land and in the water, 2) diving, 3) swimming and 4) “pass in water (PW) ”. Moreover, diving styles was classified for five patterns by presence of body movement or expiration (Apneic not move diving, Expiratory not move diving, Apneic kick diving. Expiratory kick diving and Underwater swimming) . “Diving bradycardia” was observed during diving and PW, and the magnitude of heart rate reduction was grater in diving without body movement than diving combined with body movement. Presence of expiration did not influence on the level of bradycardia during diving. Any kinds of arrythmias was observed 13 out of 44 subjects. In premature contractions, supraventricular premature contraction (SVPC, 7 subjects) was observed more often than ventricu-lar premature contraction (PVC, 3 subjects) . Another arrhythmias observed was atrioventricular junctional rhythm (AVJR, 1 subject), atrioventricular junctional escaped beat (AVJEB, 3 subjects) and wandering pacemaker (1 subject) . The danger arrhythmias which is necessary to restrict on exercise or swimming was not observed in this study.

In atrioventricular (AV) discordance, a morphologic tricuspid valve functioning as a systemic AV valve often becomes incompetent and needs to be replaced. However, mitral valve replacement concomitant with tricuspid valve replacement is unusual in the disease. Here, we report a case of successful double AV valve replacement long after functional biventricular repair in AV discordance. A 32-year-old man with AV discordance was admitted with orthopnea. He had undergone the Rastelli procedure at age 10 and removal of the deteriorated conduit valve at age 24. Preoperative examinations revealed not only tricuspid but also mitral regurgitation. Both deteriorated valves were replaced with mechanical valves. In AV discordance after Rastelli procedure, a non-valved conduit may accelerate mitral deterioration because pulmonary hypertension from tricuspid regurgitation increases the afterload of the pulmonary ventricle.

A case of 65-year-old man of aorto-caval fistula induced by ruptured abdominal aortic aneurysm is reported. The symptoms were hematuria and chest pain, and an emergent operation was performed. In the operation, Fogarty's balloon occlusion catheter was used to reduce bleeding from inferior vena cava, and to prevent pulmonary embolism. The fistula was 3cm in size, and abdominal aorta was replaced with a low porosity polyester Y-graft. The symptoms of pulmonary congestion and hematuria were improved after operation. The balloon occlusion catheter was effective for reducing bleeding from IVC, and prevention from pulmonary embolism after operation.

A 43-year-old man visited another hospital because of dry cough and dyspnea in a supine position after having experienced chest pain about 1 month prior to his visit. He had undergone open aortic commissurotomy and ligation of the ductus arteriosus due to congenital bicuspid valve aortic stenosis and patent ductus arteriosus at age 13. CT scan showed a dissected giant aortic aneurysm (12.0cm in diameter) of the DeBakey Type II which compressed surrounding organs, such as his trachea, bilateral main bronchus, superior vena cava, and right main pulmonary artery. Echocardiograms revealed severe aortic stenosis and a dissecting ascending aortic aneurysm. The patient was admitted to our hospital and an urgent operation was performed. Under cardiopulmonary bypass with selective cerebral perfusion, a replacement of the aortic root and the ascending-arch aorta with the inclusion technique was performed. Postoperatively, the patient suffered from ventilatory disturbance under mechanical ventilation. CT scan showed a giant aneurysmal sac containing a hematoma in the perigraft space and the false lumen of the aneurysmal wall and remaining tracheobronchial compression. A reoperation was performed for removal of the hematoma and placation of the aneurysmal sac. The subsequent postoperative course was good. The patient was weaned from mechanical ventilation at 12 days and discharged at 67 days after the initial operation. Histologically, the resected aortic wall showed cystic medial necrosis.

A 56-year-old man had aneurysms of the right subclavian artery and cerebral artery in association with congenital absence of the right internal carotid artery. The aneurysm of the subclavian artery was successfully surgically repaired through a partial sternotomy. Congenital absence of the internal carotid artery is rare vascular anomaly. This anomaly contributes to the occurrence of intracranial aneurysms. However, aneurysm of subclavian artery associated with congenital absence of the internal artery is very rare. This is the 3rd case reported in the literature.

We applied a new circulatory support system to three patients with descending aortic operation between 1989 and 1990. The new system consisted of a polyvinylchloride tube coated with hydrophilic heparinized polymer and a roller pump. Low doses of heparin (0.5mg/kg) were administered in two patients and none in one patient before aortic bypass. The aortic crossclamping time ranged between 52 and 64 minutes. In two patients, whose inflow cannulae were 18Fr. or 20Fr., successful bypass flow exceeded 2l/min and optimal distal aortic pressure were maintained during aortic cross-clamping. The postoperative courses of these patients were uneventful, free from thromboembolic episodes and subsequently discharged from hospital. Furthermore, postoperative careful examination revealed no thrombus formation occurred in the three devices. In conclusion, our new simple, antithrombogenic circulatory system is extremely useful for descending aortic operations.

This multicenter study was designed to clarify the positive effects of recombinant human erythropoietin (EPO; epoetin alfa) by subcutaneous administration on anemia after autologous blood donation in cardiac surgery. A total of 55 patients undergoing elective heart surgery were enrolled in this study and subcutaneously given EPO at a dose of 200IU/kg (200IU group, n=23), 400IU/kg (400IU group, n=16) or 600IU/kg (600IU group, n=16) once a week for 3 weeks prior to surgery. Autologous blood (400g) was drawn twice from each patient, at 14 days and 7 days before surgery. Oral iron was given daily throughout this study. The mean reticulocyte counts increased significantly 2 weeks after the first administration of EPO in the 200IU group or 1 week after the first administration in the 400IU and 600IU groups. There was an increase in mean hemoglobin (Hb) levels 1 week after the initiation of EPO by 1.7, 2.8 and 2.1% in the 200IU, 400IU and 600IU groups, respectively. After the first drawing of autologous blood, the Hb levels decreased gradually in all groups despite the second administration of EPO. The change in Hb level immediately before surgery however, was a 4.2% decrease (p<0.05) in the 200IU group and 0.8% decrease (N. S.) in the 400IU group and 0.7% increase (N. S.) in the 600IU group in comparison with the initial Hb level. In conclusion, subcutaneous administration of EPO was effective in improving anemia after autologous blood donation in cardiac surgery.

A minimally invasive approach to coronary artery revascularization without cardiopulmonary bypass has been performed recently and its feasibility and effectiveness have been proved. However, occlusion of the coronary artery during anastomosis in the beating heart is liable to cause myocardial ischemia or infarction. To prevent these and to perform minimally invasive coronary artery bypass on the beating heart safely, intra-coronary shunt was developed and applied in animal experiments. Materials and methods: The left internal mammary artery was harvested endoscopically and anastomosed to the left anterior descending coronary artery in the beating heart without cardiopulmonary bypass in seven pigs. Three of them utilized intracoronary shunt tubes (group S) and the other did not (group C). Results: Use of an intracoronary shunt tube facilitated non-blood exposure of the coronary artery during anastomosis. In group C, three pigs out of four had ventricular fibrillation during occlusion for the anastomosis. In group S the anastomosis was accomplished without change of ECG except one case and without any elevation of CPK-MB and Troponin T during and after the anastomosis. Conclusion: These results showed that an intra-coronary shunt can prevent myocardial ischemia and may be very useful especially to those who do not develop collateral branches from other coronary arteries.

Though preoperative autologous donation is not acceptable for all cases partly because some are preoperatively in a severe condition, intraoperative predonation is possible in almost all cases. We retrospectively evaluated the major factors related to the prevention of homologous blood transfusion by intraoperative predonation in 25 cases following valvular surgery without preoperative autologous donation. Homologous blood was not transfused in 18 cases {Group-(-)} but in 7 cases only after CPB {Group-(+)}. The male/female ratio, type of operation, body weight, CPB dilution, CPB duration, and perioperative change in hematocrit were comparable in the 2 groups. However, the autologous blood pooled before CPB in Group-(-) was significantly more than in Group-(+) (11.3±2.5 vs 7.3±1.8ml/kg, p<0.001). In conclusion, homologous blood transfusion may be prevented by appropriate intraoperative predonation during surgery for valvular disease.

Background: Masticatory muscle tendon-aponeurosis hyperplasia (MMTAH) is a relatively newly identified clinical condition that manifests as trismus with a square-shaped mandible. Herein, we report a case of MMATH that was initially misdiagnosed for polymyositis due to trismus and simultaneous lower limb pain, with literature review.Case presentation A 30-year-old woman had a history of lower limb pain after exertion for 2 years. Initial physical examination had been performed at the Department of General Medicine in our hospital. There was also redness in the hands and fingers. Although polymyositis was suspected, it was denied. The patient visited our department for right maxillary wisdom tooth extraction.Clinical examination revealed that the patient had a square-shaped mandible. The maximal mouth opening was 22 mm. There was no temporomandibular joint pain at the time of opening. Furthermore, there was awareness of clenching while working. Panoramic radiography revealed developed square mandibular angles with flattened con‑ dyles. Computed tomography showed enlarged masseter muscles with high-density areas around the anterior and lateral fascia. Magnetic resonance imaging also showed thickened tendons and aponeuroses on the anterior surface and inside bilateral masseter muscles. Finally, the patient was diagnosed with MMTAH. Bilateral aponeurectomy of the masseter muscles with coronoidectomy and masseter muscle myotomy was performed under general anesthesia.The maximum opening during surgery was 48 mm. Mouth opening training was started on day 3 after surgery. Histo‑ pathological examination of the surgical specimen showed that the muscle fibers were enlarged to 60 μm. Immuno‑ histochemistry testing for calcineurin, which was associated with muscle hypertrophy due to overload in some case reports, showed positive results. Twelve months after surgery, the mouth self-opening and forced opening were over 35 mm and 44 mm, respectively. Conclusions Herein, we report a case of MMATH. Lower limb pain due to prolonged standing at work and overload due to clenching were considered risk factors for symptoms onset of MMATH.