The purpose of this study was to investigate the pharmacokinetics of teicoplanin (TEIC) in patients undergoing open heart surgery. We also attemped to define the optimum TEIC therapy protocol for prevention of perioperative infection and for treatment of staphylococcal endocarditis such as that caused by methicillin-resistant Staphylococcus aureus (MRSA). Serum TEIC concentrations were measured in 14 patients divided into two groups of 7 patients each undergoing elective open heart surgery. Patients in group I received 400mg of TEIC and patients in group II received 800mg, both administered as a slow intravenous infusion over 20min immediately after induction of anesthesia. The peak serum level (mean±standard error) of TEIC was respectively 57±11 and 139±39μg/ml at 2min after administration and then the TEIC level decreased gradually to 26± 7 and 55±10μg/ml at 60min after administration. The serum level of TEIC decreased rapidly to 17±5 and 31±7μg/ml, respectively, at the start of extracorporeal circulation (ECC), and was 11±2 and 27±6μg/ml after 60min of ECC, 8±2 and 23±7μg/ml at 2min after the termination of ECC, 8±3 and 23±6μg/ml at 60min after the termination of ECC, and 7±2 and 22±5μg/ml on admission to ICU. No side effects were seen during the study, such as red neck syndrome, renal dysfunction, hearing disorders, or postoperative infection. Our results suggested that the optimum dose of TEIC for prevention of perioperative infection was around 400mg, providing levels in excess of the MIC for most pathogens that have been found to cause infection following open heart surgery, including MRSA. In addition, a dose of 800mg was needed to keep trough levels above 20μg/ml for treatment of staphylococcal endocarditis. It was also suggested that half of the initial dose should be administered on admission to ICU and also at the start of ECC if the operation is going to last longer than 7h on the basis of the concentration-time curve.

Of 225 patients who underwent surgery for abdominal aortic aneurysm from April 1995 to June 2002, 8 patients. or 3.6%, aged 90 years or more (mean age 90.8±1.4. range 90 to 94, 7 men and 1 woman) were the subjects of this study. Four of these patients (50%) underwent emergency surgery. Of these 4 patients, preoperative shock was found in 1 patient. Preoperative complications were hypertension in 4 (50%), ischemic heart disease in 1 (13%), disseminated intravascular coagulation syndrome in 1 (13%), and pleuritis in 1 (13%). The maximum diameter of AAA was 69.5±16.6mm (range 48 to 100mm). The surgical procedure was median laparotomy. Long-term follow-up by the attending physician, or questionnaire by phone was completed for all patients and range to 6.3 years (median, 2.4 years). There were no hospital deaths. Postoperative complications were delirium in 2 (25%), atelectasis in 1 (13%), and ileus in 1 (13%). There were 5 (63%) late deaths. The causes of death were pneumonia in 2, senescence in 1, cardiac failure in 1, and rupture of a pseudoaneurysm at the anastmotic site in 1. Long-term survivals at 1 year, 2 years, and 3 years were 88±12%, 63±17%, and 20±18%, respectively, whereas expected survivals at 1, 2, and 3 years were 82%, 65%, and 51%, respectively. Longterm survivals were not good, but no significant difference was found between long-term and expected survivals. Therefore, this surgical and long-term treatment can achieve satisfactory results. This result led us to recommend performing the operation for patients aged 90 years or more, except if they were bedridden, had severe dementia, or were at the end stage of a malignant disease.

A 31-year-old woman complained of dizziness. Preoperative aortogram revealed a saccular type of aneurysm of the aortic arch and abnormal origin of the left subclavian artery. She underwent reconstruction of the aortic arch through 4th intercostal thoracotomy on August 10th, 1996. The aneurysm originated distally to the left common carotid artery and its wall was very thin. Aortic arch replacement with woven Dacron prosthesis was performed between the left common carotid artery and the left subclavian artery using the inclusion method under hypothermic circulatory arrest. The post operative course was uneventful. Cystic medial necrosis of the aneurysmal wall, and normal arterial findings of the left femoral artery were recognized by the pathohistological examinations. Kinking of the aorta is a congenital disease due to abnormal embryonal development. The aortic arch elongates between the left common carotid artery and the left subclavian artery, and arch aneurysm originates in this portion, because the aneurysmal wall is very thin and fragile when accompanied with cystic medial necrosis. Therefore, it is important that the left subclavian artery originating distally to the arch aneurysm in this category of the aortic arch aneurysm be recognized. There are 11 cases which were successfully operated for aortic arch aneurysm associated with congenital kinking of the aorta in Japan.