We report a case of aneurysm located at the right sinus of Valsalva with mild aortic regurgitation (AR). The patient was a 55-year-old man with hypertension. When he consulted a local doctor complaining of back pain, aneurysm of right sinus of Valsalva was unexpectedly diagnosed by detailed examinations. He was transferred to our hospital for surgery. An echocardiogram showed mild aortic regurgitation and enlargement of the right sinus of Valsalva. Computed tomography demonstrated an unruptured and extracardiac aneurysm of the right sinus of Valsalva (diameter, 45 mm) and a right coronary artery (RCA) that originated from just above the ostium of the aneurysm. He underwent a partial aortic root remodeling procedure with trimmed Hemashield graft and the RCA was anastomosed to the Hemashield graft by the Carrel patch technique. The postoperative course was uneventful, and he was discharged on the 12th postoperative day. Postoperative angiography revealed that aneurysm of the right sinus of Valsalva was not enhanced and the RCA was patent. This procedure preserve the patient's own aortic valve and normal sinus of Valsalva and enabled him to have more physiologic hemodynamics than patch closure, although progression of the AR requires careful follow-up.

A 75-year-old man was admitted to our hospital with a pulsatile mass in the bilateral groin. He had received placement of a Y-shaped Cooley double velour knitted Dacron graft 20 years previously for arteriosclerosis obliterans. Computed tomography demonstrated an aneurysm near the distal anastomosis of the graft. Based on a clinical diagnosis of a non-anastomotic aneurysm, an operation was performed. When the right aneurysm was incised, it was found that the anastomosis of the graft to the common femoral artery was intact and that the graft itself had a defect, 1.5 cm in size near the distal anastomosis of the graft. The final diagnosis of the right groin aneurysm was a non-anastomotic false aneurysm due to prosthetic graft failure. The left groin aneurysm was a true aneurysm due to arteriosclerosis. After resection of the bilateral aneurysm, graft interposition with an expanded polytetrafluoroethylene (ePTFE) graft was successfully performed. Generally, arterial grafts below the groin are subject to high levels of mechanical stress, and graft failure is not uncommon. Vascular surgeons should keep in mind that graft failure is not rare in patients with long-standing prosthetic graft.

Off-pump coronary artery bypass grafting (CABG) through the diaphragm is effective in redo cases who need right coronary revascularization with a patent graft. This is a rare report of this operation using the splenic artery for inflow. A 64-year-old man on chronic hemodialysis had undergone coronary artery bypass grafting (4 vessels) 9 years previously had chest pain and was transferred to our hospital with a diagnosis of acute myocardial infarction. Coronary arteriography revealed multiple stenoses of the right coronary artery with patent bypass grafts. The patient underwent emergency off-pump CABG through the diaphragm using a saphenous vein graft bridging from the splenic artery to the posterior descending branch and A-V node branch using the sequential method. The graft was patent in postoperative angiography and he was discharged on the 13th day after the operation, free of angina.

A 60-year-old man on chronic hemodialysis was found to have severe aortic stenosis causing refractory atrial fibrillation elected to undergo aortic valve replacement. However, chest CT scan revealed a severely calcified ascending aorta which prevented safe aortic cross-clamping. At operation, arterial cannulation of the systemic circulation was performed to a graft anastomosed to the right axillary artery and venous cannulation to the right atrium. Cardiopulmonary bypass was started and the body was cooled. When a rectal temperature of 25°C was achieved, cardioplegic solution was administered retrogradely to achieve cardiac arrest and circulatory arrest was performed. Immediately, brachiocephalic artery was clamped and a single selective cerebral perfusion (SCP) was started with right axillary perfusion. In addition, a selective cerebral perfusion was added via the left common carotid artery to maintain adequate flow. After anastomosing the tube graft to the distal ascending aorta, cardiopulmonary bypass was restarted, a clamp was placed on the tube graft, and the patient was rewarmed. The aortic valve was excised and a 21-mm SJM-Regent valve was placed in the intra-annular position. The systemic circulatory arrest time was 18 min. The patient was weaned from cardiopulmonary bypass without difficulty and had an unremarkable recovery without complications. The ascending aorta replacement described here for the treatment of aortic valve disease in a patient with a severely calcified aorta is safer than deep hypothermic circulatory arrest alone, allowing a shorter circulatory arrest period. In addition, selective cerebral perfusion by right axillary artery anastomosed graft is advantageous in that we can start selective cerebral perfusion promptly by clamping the brachiocephalic artery.

The patient was a 44-year-old male, who had undergone hemodialysis for these 13 years. He underwent combined aortic and mitral valve replacement for aortic and mitral regurgitation due to infectious endocarditis. Operative findings included torn chorda of the mitral valve associated with perivalvular abscess and perforation of a non-coronary aortic cusp. Double valve replacement was performed with mechanical prosthetic valves. We used continuous hemodiafiltration (CHDF) for his perioperative renal management. Nafamostat mesilate was applied to the CHDF circuit as anti-coagulant therapy. Serum creatinin, urea nitrogen and potassium were maintained at the optimal level. CHDF was continued until the twelfth day after operation, and maintainace hemodialysis was re-started thereafter. CHDF is widely accepted for blood purification in the intensive care unit, and applied safely even in patients with unstable hemodynamic conditions. we considered that CHDF might have helped to avoid multiple organic failure in this case.

Because supraventricular tachyarrhythmias after open heart surgery are often resistant to DC cardioversion and treatment with antiarrhythmic agents, we sometimes have difficulty in the postoperative management of these arrhythmias. We attempted to use intravenous infusion of diltiazem hydrochloride (3-5mcg/kg/min) for 6 patients with supraventricular tachyarrhythmias, 5 of whom had atrial fibrillation and 1 with sinus tachycardia after open heart surgery. The ventricular rate was remarkably reduced from the pretreatment value by this infusion therapy. Diltiazem infusion during atrial fibrillation in 5 patients regularized the ventricular rate (normalization of R-R intervals). These results indicate that diltiazem was effective in obtaining almost constant preload with each cardiac cycle for the postoperative deteriorated cardiac muscle. The hemodynamic parameters obtained with the Swan-Ganz catheter showed that both right and left ventricular functions improved after the infusion of diltiazem. There was no adverse effect due to the administration of diltiazem. We concluded that the intravenous infusion of diltiazem is an effective method to manage supraventricular tachyarrhythmias after open heart sugery without deterioration of the cardiac function or side effects.

We tried to evaluate the right ventricular function using a modified Swan-Ganz catheter with a rapid responsive thermistor. Twenty-four dogs comprised this series. Twelve were the model of left heart failure (Group A), and the other twelve were the model of right heart failure (Group B) produced by multiple ligation of coronary arteries. Dogs were studied for some of the circulatory indices before and after ligation with left atrial pressure at 10, 15 and 20mmHg in group A, and right atrial pressure at 10, 15 and 20mmHg in group B by volume loading. In group A, when the left atrial pressure was kept constant, right ventricular ejection fraction (RVEF) and right ventricular stroke work index (RVSWI) were decreased significantly after the ligation of coronary arteries. But there was no significant change in the peak right ventricular pressure-right ventricular endsystolic volume index ratio (peak RVP/RVESVI) associated with ligation. In group B, significant changes were observed in RVEF, RVSWI and peak RVP/RVESVI. Thus, it was found that right ventricular contractility in selective left heart failure was not reduced. E_max was considered to be a valuable index of ventricular contractility not affected by preload and afterload of ventricle, but this index is not easily measured clinically. The index peak RVP/RVESVI which is nearly equivalent to E_max, has an advantage in that it can be determined by the thermodilution method widely used in general. We conclude that this index is very useful to us for post-operative care in cardiac surgery.

Recently, arterial keton body ratio (AKBR) has attracted attention as a new indicator of liver function which is in equibilium with the ratio between oxidized and reduced forms of free nicotinamide-adenine dinucleotides (free NAD⁺/NADH ration) in the mitochondria. There are few reports on whether AKBR contributes to the hepatic energy charge in the open heart surgery with extra corporeal circulation (ECC) or not. This study was undertaken to clarify the contribution of AKBR to the hepatic energy charge during ECC and the relationship between AKBR and hepatic blood flow. AKBR was determined before, during and after ECC in the open heart surgery for 14 patients. Furthermore, the blood flow in hepatic artery, portal vein and liver microcirculation was measured before, during and after ECC in canine models. Finally, the pulsatile perfusion was performed in canine models and compared with the conventional non-pulsatile perfusion for the blood flow and AKBR. In clinical cases, AKBR was decreased in all cases during the ECC. AKBR which was measured at 2 or 3hr after weaning from the ECC was negatively correlated to the total perfusion time with -0.57 as the correlation coefficient. Six patients who were on the ECC over 180min did not show a good recovery of the AKBR after weaning from the ECC. Especially, three patients presented a clinical picture of acute hepatic failure with jaundice, elevation of the serum levels of transaminase and direct hyperbililubinemia, but only one showed hypoglycemia. These patients showed no improvement in clinical data and AKBR. The patient with improved AKBR recovered clinically. In our experiment, the blood flow in the hepatic artery, portal vein was measured by electromagnetic blood flow meter and the liver microcirculation was measured by laserdoppler flowmeter. The blood flow was decreased remakably in the non-pulsatile group at all sites of measurement: it recovered after ECC in hepatic artery and portal vein, but liver microcirculation did not improve well. AKBR was decreased during ECC and did not recover after ECC in the non-pulsatile perfusion. When the pulsatile perfusion was performed, liver circulation was maintained well, and AKBR recovered well after ECC. The above results suggest that AKBR reflects the liver microcirculation and pulsatile perfusion is beneficial to the liver microcirculation. Pulsatile circulation, however, involves several problems, hemolysis, the decrease of platelets, and so on, but these problems have been improved gradually. We think that the pulsatile perfusion will be used in clinical operations to maintain the good hepatic circulation.

OBJECTIVES: Glucocorticoid (GC) treatment inhibits activation of runt-related transcription factor 2 (Runx2), which is essential for osteoblast differentiation from stem cells. As a result, GC treatment results in bone loss, GC-induced osteoporosis (GIO), elevated fracture risk, and delayed bone healing. Bisphosphonates such as alendronate (ALN) are recommended for treating or preventing GIO, and lowintensity pulsed ultrasound (LIPUS) facilitates fracture healing and maturation of regenerated bone. Combined therapy with ALN and LIPUS may stimulate cancellous bone healing in GIO rats. Here, we examined the effect of ALN and LIPUS on cancellous bone osteotomy repair in the proximal tibia of GIO rats. METHODS: Prednisolone (10 mg/kg body weight/day) was administered for 4 weeks to induce GIO in 6-month-old female Sprague-Dawley rats. Tibial osteotomy was then performed and daily subcutaneous injection of ALN (1-µg/kg body weight) was subsequently administered alone or in combination with LIPUS (20 min/day) for 2 or 4 weeks. RESULTS: ALN significantly increased bone mineral density (BMD) at 2 and 4 weeks, and ALN + LIPUS significantly increased BMD at 4 weeks. Bone union rates were significantly increased after 2 and 4 weeks ALN and ALN + LIPUS treatment. Lastly, ALN and ALN + LIPUS significantly increased the proportion of Runx2 positive cells at 4 weeks. CONCLUSIONS: ALN monotherapy and combined ALN and LUPUS treatment augmented BMD and stimulated cancellous bone repair with increased Runx2 expression at the osteotomy site in GIO rats. However, the combined treatment had no additional effect on cancellous bone healing compared to ALN monotherapy.
Alendronate* ; Animals ; Bone Density ; Bone Diseases, Metabolic* ; Diphosphonates ; Female ; Fracture Healing ; Humans ; Infant ; Injections, Subcutaneous ; Osteoblasts ; Osteoporosis ; Osteotomy* ; Prednisolone ; Rats* ; Rats, Sprague-Dawley ; Stem Cells ; Tibia* ; Transcription Factors ; Ultrasonic Waves*

OBJECTIVES: Rheumatoid arthritis (RA) is characterized by chronic inflammation of the synovium, progressive erosion of the articular cartilage, and joint destruction. RA also causes secondary osteoporosis and muscle wasting. We investigated the effects of ibandronate (IBN), a bisphosphonate; eldecalcitol (ELD), an active vitamin D3 derivative; and combination treatment with both agents on secondary osteoporosis and muscle wasting using adjuvant-induced arthritis rats. METHODS: Arthritis was induced in 8-week-old male Lewis rats. Rats were randomized into 4 treatment groups and an untreated normal control group: IBN (subcutaneously, once every 2 weeks, 10 µg/kg), ELD (orally, once daily, 30 ng/kg/day), IBN + ELD, vehicle, and control. Paw thickness measurements were performed for evaluation of arthritis. The femur was scanned using dual-energy X-ray absorptiometry. Cross-sectional areas of left tibialis and anterior muscle fibers and the expression of MuRF1, atrogin-1, MyoD, and myogenin in the gastrocnemius muscle were measured to evaluate muscle wasting. RESULTS: IBN and/or ELD increased bone mineral density (BMD) in the femur. In addition, there was an additive effect of combination treatment compared with single treatments for BMD. However, IBN and/or ELD did not inhibit muscle wasting in adjuvant-induced arthritis rats. CONCLUSIONS: Combination treatment with IBN and ELD may be effective for secondary osteoporosis associated with RA. Other treatments are necessary for muscle wasting associated with RA. Studies in humans are needed to confirm these findings.
Absorptiometry, Photon ; Animals ; Arthritis ; Arthritis, Rheumatoid ; Bone Density ; Cartilage, Articular ; Cholecalciferol ; Femur ; Humans ; Inflammation ; Joints ; Male ; Muscle, Skeletal ; Myogenin ; Osteoporosis ; Rats ; Synovial Membrane ; Vitamin D