A 15-year-old boy who had been treated for TOF (tetralogy of Fallot) at 3 years of age was admitted with dysphagia due to esophageal stenosis. He also suffered from malrotation of the intestine. The esophageal stenosis was caused by recurrent cyclic vomiting and subsequent esophagitis. Three years earlier, he had received an implantation of a totally implantable central venous access device via the right cephalic vein. Echocardiography revealed a floating mass in his right atrium, which was assumed to be a thrombus at the catheter tip of the central venous access device. We suspected that the cause of atrial thrombus in this case was complicated by the long-term (3 years) use of the venous central port. He was suspected to have a pulmonary embolism. A perfusion lung scan (99mTc-MAA) revealed multiple diminished uptake in both lungs. The thrombus was removed successfully under partial cardiopulmonary bypass. The postoperative course was uneventful.

The internal thoracic artery is a useful conduit for coronary artery bypass grafting (CABG). Recently we have developed a method for increasing blood flow by directly injecting a phosphodiesterase III (PDE III) inhibitor into the left internal thoracic artery (LITA) to inflate the artery and prevent its contraction. In the present study we compared the reactivity of the LITA to three drugs: PDE III inhibitor, papaverine hydrochloride and isosorbide dinitrate (ISDN). Forty-two patients with a mean age of 66.8±11.5 years old who were undergoing primary CABG were enrolled in this study and were randomly separated into one of three groups based on the vasodilating drug administered. Each drug was used in 14 cases. Graft free flow (GFF) and systemic blood pressure were measured before and one minute after drug administration to calculate blood vessel resistance (R). All the drugs significantly increased GFF, and reduced both R and blood pressure. A comparison of the change rate of blood pressure did not differ significantly among the three drug groups. The PDE III inhibitor significantly increased change rates of both GFF and R, compared with the other drugs. These results indicate that PDE III inhibitor is most effective for increasing the blood flow of LITA grafts for CABG.

Multisite pacing has recently been available as a new treatment for patients with congestive heart failure. This study was intended to evaluate the effects of atrioventricular myocardial pacing on left or biventricular sites. Eleven patients (4 men, 7 women) who had undergone atrioventricular myocardial pacing between January 2000 and April 2002 were selected for this study. They ranged in age from 24 to 74 years (mean age 58.5 years). The diagnosis was dilated cardiomyopathy in 3 patients, ischemic cardiomyopathy in 4, complete atrioventricular heart block in 2, sick sinus syndrome in 1, and atrial fibrillation with bradycardia in 1. The method of pacemaker implantation was atrioventricular myocardial pacing on left or biventricular sites by means of mini-thoracotomy under general anesthesia. A DDD-R pacemaker was used. When biventricular pacing was employed, the ventricular pacing lead was cut, connected with a Y adapter, and implantation was made biventricularly. We analyzed pre- and postoperative hemodynamic states by means of a Swan-Ganz catheter, and clinical course (NYHA class). There was a significant difference between pre- and postoperative clinical course and hemodynamic state. The atrioventricular myocardial pacing on left or biventricular sites was a useful method of improving the clinical course and hemodynamic state. It is concluded that this method is available as a new therapeutic option in patients with congestive heart failure.

Horseshoe kidney is an unusual abnormality occurring in 0.25% of the population. In surgery for AAA with horseshoe kidney, reconstruction of aberrant renal and preservation of renal isthmus is important. We report 3 cases of AAA with horseshoe kidney treated successfully without division of the isthmus.

We have long advocated the usefulness, accuracy and safety of carbon dioxide angiogrphy for patients with iodine allergy and renal dysfunction. In addition to its utility, no specialized apparatus is necessary for carbon dioxide angiography. Carbon dioxide as a contrast material has been adopted by consensus for use in endovascular revascularization. Here we report 4 cases of endovascular revascularization using carbon dioxide angiography. Two of the four patients had an iodine allergy, one had renal dysfunction, and the remaining one was complicated by diabetes mellitus. All patients exhibited intermittent claudication and were treated for iliac arterial stenotic lesions with percutaneous angioplasty and sequential endovascular stenting using carbon dioxide gas as a negative contrast material. All cases demonstrated improvement of the chief complaint. There were no direct or indirect complications of carbon dioxide angiography and endovascular intervention after the procedures. All 4 patients were discharged without event within 1 week after the endovascular intervention. Carbon dioxide is useful not only as an angiographic contrast material but also for endovascular intervention in patients with iodine allergy or renal dysfunction.

We experienced the usefulness of the superficial femoral vein as an autogenous graft replacement of an infected prosthetic graft. Case 1: A 75-year-old man complained of right leg intermittent claudication due to arteriosclerosis. Prosthetic femoro-femoral crossover bypass was performed. Three months after the operation, prosthetic bypass graft infection was diagnosed. Case 2: A 72-year-old man underwent an aortobifemoral graft surgery for an abdominal aortic aneurysm (5cm in diameter) . Ten days after the operation, the patient suddenly had a high fever and bacterial culture of the blood demonstrated Gram-negative bacilli. Prosthetic bypass graft infection was diagnosed. Both cases were resistant to conservative therapies including antibiotics. The infected prosthetic grafts were removed and autogenous reconstructions were performed extra-anatomically using the superficial femoral vein: in Case 1, with femoro-femoral crossover bypass, and in Case 2, with axillo-unifemoral bypass with anastomosis of bilateral common iliac arteries. Both infections eventually resolved. Since the deep femoral vein had been preserved during harvesting of the superficial femoral vein, no problems, such as venous congestion of the leg, occurred in either of the two cases. Their postoperative courses were uneventful and the patients were given ambulatory their own feet. We reviewed the literature about the utility of superficial femoral veins as arterial substitutes.

A study was carried out to confirm the present states of physical training and nutritional condition in sportsmen on the growing stage. Energy expenditure (EE), caloric intake (CI), food items, body weight, running distance for 12 min and hematological and biochemical parameters of blood and urine were measured in 17 high school boys during intense summer baseball training for seven days. EE was estimated from the records by direct observation of activities during the baseball training (RMR method), and CI was calculated from the dietary record supplied each subject for the seven observation day.
Following results were obtained.
1) The average EE was 55.4±7.5 kcal/kg/day, and the CI corresponded to 87.2% of the EE, although no significant reduction of body weight was observed at the termination of the training session.
2) Running distance for 12 min gradually decreased.
3) Significant decreases in serum TG, TP and Hgb concentrations, and a remarkable increase in CPK activity were observed on the 4 th and final days. Urinary excretion of phosphate, urea nitrogen and catecholamines also increased gradually.
4) The greater the increase in negative energy balance (CI-EE), the greater the decrease in TG, TP and Hgb concentrations, and the greater the increase in serum CPK and urinary excretion of catecholamines.
The present results suggest that greater intake of total energy, protein and fat is recommended for development of endurance capacity, baseball techniques and sound growth in occasion such as the present baseball training program in high school boys.

The present study was carried out to investigate differences in hormonal and metabolic responses to moderate exercise in the post-absorptive state and during a 33-hour fast. Secretory factors and the roles of regulatory hormones of carbohydrate and lipid metabolism during moderate exercise were assessed baesed on these data. Energy substrates in the blood (glucose, BG; lactate, LA; triglyceride, TG; free fatty acids, FFA; free glycerol, FG) and plasma hormones (ACTH; GH; Cortisol, Corti; glucagon, IRG; insulin, IRI) concentrations were measured from 12 h to 33 h during the fasting period (12: 00, 24: 00, 06: 00, 09: 00), and 3min, 10 min and 30min after moderate treadmill exercise (estimated 70-80% of VO₂max) for 20 min under fasting conditions between 09: 00 and 11: 00. These results (in the fasting experiment, Fast) were compared to the results on a normal diet (N-D) .
The results were as follows:
1. No differences in mean VO₂ and respiratory exchange ratio (RER) during exercise were observed between the Fast and N-D experiments. Mean heart rate during exercise in Fast was higher by 3.3±2.2 bpm (p<0.05) .
2. Serum FFA and FG concentrations were significantly higher as a results of 24-hour fasting than the values measured at the same time in N-D. No significant change in serum TG concentrations were observed in Fast. While BG and LA concentrations remained low, and in small changes occurred in then both during Fast.
3. Slightly higher levels of plasma ACTH, GH and IRG were found in Fast, but they were not significantly different from N-D. Plasma Corti concentrations gradually increased after 24 hours of fasting, and were 1.9 times higher at 09: 00 after 33 hours of fasting than on N-D. Plasma IRI levels, however, remained low, and the molecular ratio of IRG to IRI (IRG/IRI) was higher throughout Fast (1.8 to 10.6 times higher than on N-D ) .
4. Plasma ACTH, GH and Corti concentrations increased markedly after exercise, and remained high until 30 min on Fast. No significant change in IRG and depression of insulin secretion were demonstrated after exercise on both treatment.
5. Significant correlation between changes in plasma ACTH and Corti concentrations were observed throughout the experiments (Fast, r=0.562; N-D, r=0.528) .
6. All of the energy substrates except blood TG increased after exercise, and the net increases in LA and FG (Δ) on Fast were significantly higher than on N-D. Significant correlations between the changes in the concentrations of FFA and FG (Fast, r=0.745; N-D, r= 0, 696), LA and BG (Fast, r=0.689; N-D, r=0.623), and FFA and LA (Fast, r=0.579; N-D, r= 0.479) were detected throughout both experiments.
7. The coefficients of correlation between changes in plasma ACTH and FFA, and between BG and LA concentrations were higher on Fast than N-D. However, changes in plasma IRI and IRG concentrations were not directly correlated with any other changes in energy substrates in the blood in either treatment.
The results indicated that moderate exercise for 20 min after a 33-hour fast causes marked responses in ACTH, Corti and GH secretions. It appeared that Corti secretion de-pended on ACTH, and that Corti facilitated fatty metabolism during exercise on Fast. However, secretion factors and the role of GH during exercise remain a matter of conjecture.

The present study was done to elucidate the medical problems and physical fitness of under-weight elementary schoolboys. Eighty nine volunteers, ranging in age from 9 to 12 yrs, were divided into five groups based on the grade of obesity, expressed as % of the standard, taking into account height, age and sex.
The mean grade of obesity for under-weight boys was -12 %, and this group was defined as the experimental group (group I; n=15) . The group III, which contained 23 boys of grade 0 %, and the group V made of 13 boys of grade +33.5 % was defined as the normal control and obese control, respectively.
The measurement of blood pressure, EKG recording, and blood sampling were done in the state of fasting before and after exercise. The exercise was a step test of 5 min duration with a temp of 1 step per 2 seconds, jumping over a bench 25 cm high for 9 years old boys, and 33 cm high for boys of 10 to 12 years. The step test score (PFI) and recovery rate of heart rate (RR (HR) ) were calculated from the EKG. The test battery of physical fitness performance was also done on another experimental day.
The serum levels of total cholesterol (TC), triglyceride (TG), total protein (TP) and hemoglobin (Hgb) were lower in experimental group (EG) than in control groups (CG) . The cholesterol-HDL/TC ratio was conversely higher in EG than in CG. There were no significant differences in the other biochemical measurements between the five groups.
Any abnormal EKG was not recorded before and after exercise throughout the subjects. The frequency of hypertension (above the 135/80 mmHg) was 10.2 % at pre-exercise time. But, none of the boys in EG was found to be hypertensive.
The PFI and physical fitness performance test score showed no differences between EG and group III, however, the score of group V was inferior to that of EG and/or group III. The RR (HR) in EG and over-weight group was lower compared to that for the average-weight boys.
Almost all components in blood measured were elevated after exercise in all the groups. The finding of the highest interest of the exercise-induced elevations of blood constituent levels was an increase in WBC measured as an indicator of stress. The magnitude of increase in WBC (ΔWBC) was higher in EG and the over-weight group than in the average-weight group. In normal subjects, ΔWBC was generally proportional to the work intensity, which, in the present exercise, depended upon the stature and body weight, because the height of bench, tempo and duration of exercise were same for all groups. The work intensity in EG was presumed milder, becasue the mean stature was slightly taller and bodyweight was less heavy compared to those in control groups. But, the greater increase of WBC in EG was observed in spite of a lighter work intensity. According to the Selye's literature, the particular WBC reaction to exercise in the under-weight boys was interpreted as a over-reaction to stress in the state of malnutrition.
From some biochemical parametors, the leaner subjects were assumed to be in a slight malnutrition. And also a later recovery of HR and over-reaction to exercise stress were shown in the under-weight boys group.
It is emphasized that the malnutrition resulting from excessive effort for preventing obesity was unfavourable for children in the growing stage for their healthy growth and development.

A 53-year-old woman was admitted because of cardiac failure caused by mitral valve stenosis and regurgitation. She had been treated by an aortic valve replacement with a Björk-Shiley convexo-concave valve (21mm) 22 years previously in our institute. Her clinical symptoms and the histological findings of the lung specimen from the operation led to a diagnosis of Swyer-James syndrome. The diagnosis was confirmed by pulmonary blood flow scintigraphy on the present admission. With her informed consent, we treated her cardiac disease by mitral valve replacement and a second aortic valve replacement was carried out because of the structural brittleness of the Björk-Shiley convexo-concave valve. She was discharged from our institute after the operation without any complications.