We studied the effects of the electrolyte composition (K, Ca, Na) and prostaglandin E₁ of the extra-cellular fluid on the tension development of isolated canine coronary arterial strips. In 20mEq/l potassium solution, 4.7mEq/l calcium produced coronary artery contraction. This Ca-induced contraction was partially inhibited dose-dependently (between 10^-15M and 10^-12M) by prostaglandin E₁. Above 10^-11M, intensity of the inhibition did not change. In the presence of 20mEq/l potassium, the reduction of sodium concentration to 12mEq/l increased the tension of coronary artery. Prostaglandin E₁ did not affect this tension development. After 5min perfusion of prostaglandin E₁, Ca-induced contraction was not inhibited. It is concluded that low calcium, high sodium cardioplegic solution may relax the canine coronary artery. Addition of prostaglandin E₁ to cardioplegic solution may reduce the coronary artery contraction partially.

Diffuse peritonitis due to perforation of pyometra is relatively rare. We experienced three cases of this type of peritonitis between 1993 and 1999. Three women aged 77, 83 and 91 years had mild abdominal pain, slight fever and defecation for nearly one week. Following these, severe abdominal symptoms developd. These patients underwent emergency laparotomy as they were diagnosed with diffuse peritonitis. At first, intestinal perforation was suspected, but perforation of pyometra was confirmed when lapasortomy was done. On preoperative examinations, physical findings were scanty in comparison with hemological ones, and free air on abdominal X-ray films was not detected. Thus, we failed to establish the preoperative diagnosis. The prognosis was very poor in two of the three patients. One was with advanced cervical cancer and the other was in multiple organ failure on admission. Differential diagnosis of this disease is important for the management of acute abdominal diseases in elderly women.

We describe two patients who underwent repeat off-pump coronary revascularization by axillocoronary artery bypass grafting. A 63-year-old man (case 1), who had undergone coronary artery bypass grafting (CABG) 13 years previously, was admitted to our hospital with exertional angina. The saphenous vein grafts (SVG) to the left anterior descending artery (LAD), circumflex artery (Cx), and right coronary artery (RCA) all were occluded. The left internal thoracic artery (LITA) also was occluded because it had been injured. Because the patient declined to undergo a redo CABG, percutaneous transluminal coronary angioplasty (PTCA) to the LAD was attempted. However, coronary dissection occurred, and an emergency operation was performed. A 66-year-old man (case 2), who had undergone CABG 12 years previously, was admitted with unstable angina. The LITA to the LAD and the SVG to the RCA were occluded. The SVG to the Cx had 99% stenosis in its mid-portion and was the cause of the angina. PTCA and stenting of this SVG were performed. Two weeks later, an operation was done. In both patients, the left axillary artery was selected as the site of the proximal anastomosis. Both patients underwent off-pump bypass grafting to the LAD from the left axillary artery using a SVG. Both grafts were patent postoperatively. This approach resulted in early symptomatic improvement.

We experienced a case that right massive pleural effusion was successfully controlled with Denver shunt from the right chest cavity to right femoral vein. A 80-years-old woman had received hemodialysis due to chronic renal failure twice in a week. She was diagnosed as right breast cancer and underwent right breast conserving surgery at December, 2008. In postoperative follow-up duration, she had difficulty in breathing and visited to the emergency room in our hospital. She was diagnosed as respiratory failure due to right massive pleural effusion from the X-ray result and the blood gas analysis. There was no pleural effusion within the left chest space. No malignant cell was detected in the effusion. We thought that diuretics and shunt tube from the right chest cavity to the abdominal cavity would be ineffective because of her chronic renal failure, and for that reason, we placed the shunt tuve from the chest cavity to the right femoral vein. Respiratory failure and the quality of life were successfully improved for about 7 months by using it. Palliat Care Res 2011; 6(1): 301-307

Plasma concentrations of tumor necrosis factor α (TNFα), interleukin-1β (IL-1β) and interleukin-6 (IL-6) were measured successively during and after open heart surgery (13 cases). Plasma concentrations of TNFα did not increase during surgery but increased gradually after the 1st operative day reached the maximum level at the 7th operative day (128±15pg/ml, which was a 3-fold increase compared with the previous value). Plasma concentrations of IL-1β remained at the previous level during surgery and increased only once at 6 hours after operation. Conversely, plasma concentrations of IL-6 increased dramatically during cardiopulmonary bypass (CPB) reaching a peak at the end of CPB (260±200pg/ml, which was a 15-fold increase over the previous value) and recovered to previous values rapidly thereafter. Plasma IL-6 concentrations changed rapidly during surgery, while plasma concentrations of TNFα and IL-1β did not increase sharply. This may indicate that IL-6 may play a role as a mediator of acute inflammatory reaction.

We performed surgical treatment for 21 patients of airway obstructions associated with congenital heart disease from December 1986 to March 1993. In all patients perioperative bronchoscopy demonstrated the cause and site of airway obstructions. Seven patients with corrective cardiac surgery (7/7), 7 with palliative cardiac surgery (7/10) and 2 with surgery for airway diseases (2/4) could be weaned from respirators following surgical treatment. Five patients died postoperatively. A respirator was required in 16 patients (76%) preoperatively. The suspension of pulmonary artery with intraoperative bronchoscopy was carried out in 6 patients. Five (5/6) were successfully extubated earlier postoperative day (mean 8.4 days), whereas only five in 10 patients without that procedure could be weaned from the respirator at a mean of 2 months. Identification of potential airway obstruction and early extubation is needed to reduce the mortality and morbidity caused by airway obstruction associated with congenital heart disease. Preoperative bronchoscopy is useful for diagnosis of airway obstructions and essential for decision making concerning surgical treatment. To early extubation in patients with marked airway obstructions, we recommend appropriate choice of the surgical procedure combined the suspension of pulmonary artery.

Seven patients with congenital heart defects suffered from multiple major hemorrhages from the lung after surgery and 5 of them died at 8 to 54 postoperative days because of respiratory insufficiency. In a patient with tetralogy of Fallot associated with pulmonary atresia, bleeding occured after the second shunt operation, presumably from rupture of bronchial collateral vessels. The clinical diagnoses of the other 6 patients were coarctation of the aorta (CoA) with common atrioventricular canal (CAVC) in 1, triple shunt in 1, persistent truncus arteriosus in 2, total anomalous pulmonary venous connection in 1 and CAVC in 1. Subclavian flap aortoplasty was performed without pulmonary artery banding in the patient with CoA and CAVC, whereas complete repair was performed in the other 5 patients. As these patients were associated with severe pulmonary hypertension preoperatively and 4 of them encountered pulmonary hypertensive crisis, the hemorrhage from the lung may be related to pre and postoperative high pressure of the pulmonary artery. Dilatation and rupture of the pulmonary capillary net was demonstrated in the patient with CoA and CAVC. These findings suggest the hypothesis that bleeding occurred due to rupture of the capillary net as a result of transmission of high pressure. Major bleeding from the lung is a rare but catastrophic complication after repair of congenital heart defects. As the treatment is difficult, early surgical intervention and treatment of postoperative pulmonary hypertension are important in complex lesions with severe pulmonary hypertension.

A 61-year-old woman had extracardiac unruptured aneurysms of the right and noncoronary sinuses of Valsalva, detected incidentally on electrocardiogram taken for a physical checkup. Two-dimensional echocardiography revealed that the sizes of the aneurysm of the right and noncoronary sinuses were 41×40 and 38×28mm respectively, but the shape of left coronary sinus was almost normal. The aortic valve leaflet was normal and the diameter of the aortic annulus and sinotubular junction was 23 and 27mm respectively. The Doppler color-flow echocardiogram showed moderate aortic regurgitation which resulted in prolapse of the right aortic cusp due to deformity of the annulus. We performed modified aortic root remodeling using a tailored Dacron graft to preserve the native aortic valve. Right and noncoronary sinuses of Valsalva were all excised with a small button of the aortic wall around the ostia of the right coronary artery. The left coronary sinus was left as it was. Then each commissure received sub-commissural annuloplasty and was pulled up. The defect of Valsalva was reconstructed with a 26mm Dacron tube graft, the proximal end of which was tailored to a scallop shape and that correspond to left coronary sinus was excised. The right coronary artery was reimplanted utilizing the Carrel patch method. Although we needed additional CABG to the right coronary artery and IABP support due to vasospasm of the right coronary artery, the postoperative course was uneventful. Echocardiography of the aortic valve before discharge showed a normal function without regurgitation.