An 85 year-old woman underwent mitral valve replacement with Carpentier-Edwards PERIMOUNT (CEP) at the age of 72 because of rheumatic mitral stenosis. Thirteen years after its implantation, prosthetic valve dysfunction developed increasingly severe aortic valve stenosis and she underwent double valve replacement. Prolapse was found in one leaflet of the explanted CEP valve, while neither visible calcification nor tear was detected.

A 70-year-old man with dextrocardia with situs inversus, presented to our hospital complaining of chest pain. ECG showed ST elevations in leads II, III and _aV_f , and ST depressions in leads V3 through V6. Blood tests showed creatinine kinase elevation. He underwent coronary angiography, which revealed obstruction of the anatomical right coronary artery and we diagnosed acute inferior myocardial infarction. However, the anatomical left coronary artery was not clearly identifiable because of its anomalous origin. He was transferred to our intensive care unit and intra-aortic balloon pumping was initiated. Coronary 3D-CT was then performed to obtain an anatomical overview of the coronary artery system. This enabled a second coronary angiography which showed obstruction of the left anterior descending artery and stenosis of the left main trunk in the first diagonal branch and the ramus intermedius branch. Coronary artery bypass grafting surgery (CABG) was indicated. He underwent conventional quintuple CABG using the right internal thoracic artery and saphenous vein grafts. Preoperatively we made digital mirror images of the original coronary angiographic images to clarify his coronary artery anatomy. During surgery, the main surgeon continuously stood on the patient's left side except when opening and closing the chest, which enabled us to perform CABG. The postoperative course was uneventful. CABG in a patient with situs inversus totalis is very rare. We present this case with a review of the relevant literature.

Objective: Aerobic exercise on land decreases arterial stiffness, however, the effect of exercise in water on arterial stiffness has not been clear. This study investigated the effect of a 15-min cycling exercise on land and that in water on pulse wave velocity (PWV) as an index of arterial stiffness. Methods: Nine healthy young men were randomly performed exercise on land and exercise in water equivalent to 50% of each maximum oxygen uptake on separate days. The PWV from carotid to femoral artery (aortic PWV) and femoral to posterior tibial artery (leg PWV) were measured at baseline and 15, 30, 60 min after exercise. Results: The heart rate in water was significantly lower during exercise than that on land. In addition, the carbon dioxide output and respiratory exchange ratio during exercise were significantly greater in water. Body temperature increased after the exercise on land but decreased after the exercise in water. Although the aortic PWV and leg PWV decreased concomitantly with decrease in SBP and DBP after the exercise on land, there were no significant changes after the exercise in water. Conclusion: Although acute exercise on land decreased arterial stiffness after exercise, acute exercise in water of the same exercise load did not. The differences in body temperature and blood pressure after exercise may result in diverse arterial stiffness after exercise.

Extracorporeal shock wave lithotripsy (ESWL) represents the preferred treatment for most upper ureteric and renal calculi. Complication rates associated with ESWL are low, justifying the enthusiasm and acceptance of this treatment modality. We report a case of abdominal aortic pseudoaneurysm due to ESWL. A 47-year-old man had undergone ESWL treatment for ureteric calculi since 1990. He was admitted to our hospital because of lumbar pain. Physical examination revealed a pulsatile mass in his abdomen. Abdominal CT scan showed an abdominal aortic aneurysm (5.3cm in diameter). Angiography showed a fusiform aneurysm of the infrarenal abdominal aorta. Y-graft replacement was performed after aneurysm resection. Histological examination revealed that it was a pseudoaneurysm. The patient had no history of trauma, inflammation or operation except ESWL. This is the first report of abdominal aortic pseudoaneurysm due to ESWL.

A 53-year-old woman underwent mitral valve replacement for congestive heart failure due to mitral stenosis and regurgitation. She had been receiving hemodialysis because of diabetic nephropathy since 1993, and had had congestive heart failure since 1999. Echocardiography demonstrated mitral stenosis (MVA; 1.10cm²) and regurgitation with a severely calcified mitral annulus. Annular calcification extended to the posterior wall of the left ventricle and the base of bilateral papillary muscles. After removing all calcium from the mitral annulus to the base of the papillary muscle, the left ventricular posterior wall and mitral annulus were reconstructed by glutaraldehyde-preserved autologous pericardium. Then, a Carbo-Medics mechanical valve was placed at the mitral annulus using everting mattress sutures. Although her hemodynamics were stable, bacteremia and multi-organ failure developed 3 months after surgery and she died. Autopsy showed that the reconstructed left ventricular posterior wall and mitral annulus using glutaraldehyde preserved autologous pericardium were in excellent condition without any thrombus. No dehiscence was found at the suture line of the mechanical valve. Mitral annulus reconstruction with glutaraldehyde preserved autologous pericardium is thought to be effective for patients with calcified mitral annulus who require mitral valve surgery.

A 75-year-old male visited Fuchu general hospital on foot because of possible acute mushroom poisoning. He had no symptom on admission. He twice ate some toxic mushrooms for lunch and for dinner on the previous day with his wife, who was found dead in her bed on the morning of his admission. A legally ordered autopsy was held on his wife, and a-amanitin was detected in her liver, brain and blood samples. Detection of a-amanitin in blood samples has never been reported in the literature. His liver and kidney failure rapidly progressed. He died on the 10th hospital day despite intensive treatment including hemodialysis and plasma exchange. On histological examination, his necropsy liver specimen revealed massive liver necrosis and new growth of pseudocholangioles, which apparently bore testimony to acute toxic mushroom poisoning.

We report two cases of paraganglioma originating in the paraseller region (case 1) and in the urinary bladder (case 2). The subject in case 1 was a 59-year-old man who was admitted into the hospital with dizziness, muscular weakness of the left extremities and cold sweating. Magnetic resonance imaging (MRI) revealed a tumor in the parasellar region. The subject in case 2 was a 39-year-old man who was hospitalized because he had a sense of residual urine. Computed tomography and MRI showed a mass of tumor tissue in the posterior region of the left ureteric orifice of the bladder. Imprint cytology of both tumors showed isolated, loosely attached sheet-like cells with abundant cytoplasm and round or oval nuclei. Histologically, both tumors consisted of round or polygonal cells in small packets separated by vascular fibrous septa. Immunohistochemically, both tumor cells were positive for NSE, S-100 protein, chromogranin A, and synaptophysin. Electron microscopic examination revealed neurosectretory granules in the cytoplasm of tumor cells in either of these two cases.