A 39-year-old woman with Marfan's syndrome was referred with a symptom of exertional dyspnea, had mitral valve regurgitation, annuloaortic ectasia with aortic valve regurgitation and Stanford B type chronic aortic dissection. She was successfully treated with a one-stage operation, consisting of aortic root replacement with the Carrel patch method, mitral valve replacement and extended replacement of the thoracic aorta (ascending, arch and thoracic descending aorta), through median sternotomy and left antero-axillary thoracotomy. This operation was performed under hypothermic circulatory arrest with continuous retrograde cerebral perfusion. The postoperative course was uneventful. Although the operation may include complicated procedures, it is important to perform a sufficient operation corresponding to the patient's condition and lesions, employing the most advanced surgical techniques, such as circulatory arrest, myocardial protection and so on.

A 70-year-old man was given emergency admission with severe back pain. Computer tomography revealed type-B acute aortic dissection with a distal aortic arch aneurysm which was 69mm in diameter. The dissection extended from the distal portion of the aneurysm to right external iliac artery, and the false lumen was patent. The right renal artery arose from the false lumen. He was treated conservatively according to the guidelines of AHA, and later we performed total arch replacement electively for the aortic arch aneurysm. Distal anastomosis was applied using the elephant trunk method for reconstruction of only the true lumen. Postoperative computer tomography showed the false lumen was closed in the descending thoracic aorta, but patent below the level of the celiac artery. He was discharged without any complications. Cases of acute aortic dissection coexisting with atherosclerotic thoracic aortic aneurysm are rare. However, with the increase of the elderly population, vascular diseases will become more complicated. Strategy for therapy and operation should be considered carefully especially in such cases with multiple vascular diseases.

Alleviating fatigue of a patient with advanced cancer often meets troubles, for which medication is restricted. We experienced two cases with cancer-related fatigue, in which 4,000mg of taurine a day was administered orally and the improvement of the Cancer Fatigue Scale (CFS) score was identified as a result. There hasn't been any literature reporting the effect of taurine to cancer-related fatigue yet. However, taurine has been known as a medicine with various effects for quite a long time, and it is possible that it will be recognized as one of the medicines effective for cancer-related fatigue.

Fifty-two-year-old man who suffered from headache and left neck pain was brought to a nearby hospital by ambulance. Anisocoria and disorder in the field of view of the left eye were observed. Emergency brain MRA showed obstruction of the left internal carotid artery. The patient was transported to our hospital for emergency surgery for suspected acute type A aortic dissection on CT scan. Operative findings revealed a thrombus attached to the ascending aorta continued to left common carotid artery. Thrombectomy for left carotid artery and partial arch replacement were performed. The patient was discharged in good condition on the 16th postoperative day. We encountered a very rare mural thrombus in the ascending aorta.

A 52-year old man was referred to our hospital for atrial fibrillation ablation therapy. A multislice computed tomography study demonstrated a giant coronary artery aneurysm situated just proximal to the left anterior descending (LAD), LAD stenosis and coronary-pulmonary artery fistula. The fistula was ligated and the aneurysm was resected under cardiopulmonary bypass. The left internal thoracic artery was used as a bypass graft to the LAD as well as a patch for closure of the LAD orifice to avoid left circumflex artery stenosis. We report a rare case of giant LAD aneurysm with coronary-pulmonary artery fistula.

A 22-year-old man with dilated cardiomyopathy (DCM), who was a practicing Jehovah's Witness, was transferred to our hospital for surgical treatment of medically uncontrollable mitral regurgitation (MR). Our original mitral complex reconstruction procedure and permanent pacemaker implantation for biventricular pacing were successfully performed without transfusion of blood products. Blood conservation strategy included: 1) preoperative treatment with erythropoietin, 2) utilization of a shortened extracorporeal circuit and assisted venous drainage system, 3) the use of ultrafiltration to save the residual autoblood in the extracorporeal circuit. The preoperative hemoglobin level was 17.1g/dl and the postoperative lowest level was 9.5g/dl. MR decreased from grade III to none, and NYHA functional class improved from class II to class I postoperatively. He was moved to a cardiology ward on the 13th postoperative day without complications. Transfusion-free surgery for DCM should be performed before DCM advances and requires left ventriculoplasty at risk for major blood loss. A careful follow-up is needed to examine the long-term results of the operative procedure during his expected long survival.

Cardiac angiosarcoma is a rare heart malignancy. The prognosis is reported to be very poor. Here, we report a case of cardiac angiosarcoma which was treated by postoperative conformal dynamic arc radiotherapy. The patient has been in good health with no recurrence for 18 months after surgery. The patient was a 71-year-old woman, who presented edema and general malaise. Echocardiography and computed tomography revealed a right atrial mass and massive pericardial effusion, which was thought to be the cause of tamponade. Intraoperatively, we found a large tumor arising from right atrial wall spreading and invading to the inferior vena cava, diaphragm, and right pericardium. We abandoned complete resection of the tumor. We only resected the part of the tumor under cardiopulmonary bypass. The subsequent defect of the right atrial wall was reconstructed with bovine pericardial patch. The pathological diagnosis was consistent with angiosarcoma, and the margin was positive for the tumor. In addition to reduction surgery, we adopted radiotherapy (conformal dynamic arc radiotherapy, 10MV-X-ray, 54 Gy/18 Fr/4.5 week, fractionated radiotherapy). The CT, one month after the radiation, showed a significant reduction in tumor size. Moreover, no tumor could be pointed out by echocardiography 18 months after surgery. Advances in technology and methodology has made tumor control possible without significant side effects. We conclude that reduction surgery accompanied with postoperative radiotherapy is promising in maintaining quality of life and in improving life expectancy.

A 41-year-old man with focal glomerulosclerosis had been treated by hemodialysis for 22 years. Kidney transplantation from a living donor was performed once, but the transplanted kidney was removed out because it had been infected by methicillin-resistant Staphylococcus aureus about 3 months previously. He was admitted to our hospital with over 38°C fever 2 months after the removal. He had hemoptysis and marked back pain. Computed tomography scan revealed ruptured descending aorta. The descending aorta was circumferentially calcified but not enlarged. We thought that a penetrating atherosclerotic ulcer had formed in a crack of the porcelain aorta and ruptured with infection. First we tried endovascular treatment with stent-graft implantation. It was useful to control hemoptysis, but a small amount of type I leakage remained. Finally, after controlling the infection, we performed prosthesis replacement with extra-corporeal circulation and surrounded the artificial aorta with the omentum. The postoperative course was uneventful and he recovered completely.

Cardiac operations involving cardiopulmonary bypass can cause a systemic inflammatory response such as elevation of inflammatory cytokines, which can cause organ failure. We investigated cytokine production and its inhibition by ulinastatine in patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass. Thirty-three patients received either ulinastatine (300, 000 units, intracoronary artery injection immediately after aortic closs-clamping, UTI group, n=16) or no ulinastatine (control group, n=17). Arterial blood samples were obtained at aortic closs-clamping, 5 minutes after aortic declamping, and 6, 12 and 18 hours after surgery and there were assayed for interleukin-6 (IL-6), interleukin-8 (IL-8), and polymorphonuclear leukocyte elastase (PMNE). In addition, we examined liver function (GOT, GPT, and total bilirubin), renal function (blood urea nitrogen and serum creatinine), and oxygenatory function (PaO₂/FIO₂) postoperatively. IL-8 levels at 5 minutes after aortic declamping and maximum IL-8 levels were significantly lower in the UTI group than in the control group (25.5±12.8 vs. 47.8±38.9pg/dl, p<0.05, and 28.6±13.2 vs. 58.4±40.0pg/dl, p<0.05). Blood urea nitrogen on the second post operative day (POD) and three POD and creatinine on the second POD were also significantly lower in the UTI group than the control group. Furthermore, IL-8 and PMNE levels significantly correlated positively with blood urea nitrogen and creatinine. There was significant negative correlation between IL-8 and oxygenatory function. These results shows that the ulinastatine can inhibit IL-8 levels following cardiac surgery. To combat the increase of inflammatory cytokines such as IL-8 after cardiopulmonary bypass, the ulinastatine should be used for anticytokine therapy to protect the kidneys, lungs, and other organs, and thereby decrease the risk of complications.

Retroperitoneal hematoma (RH) due to radiologic intervention for an intracranial lesion is relatively rare, difficult to diagnose, and can be life-threatening. We report a case of RH that developed in a patient on anticoagulant therapy following endovascular coiling of a ruptured anterior communicating artery (AcoA) aneurysm. An 82-year-old man presented with a 12-day history of headache. Computed tomography (CT) on admission demonstrated slight subarachnoid hemorrhage, and left carotid angiography revealed an AcoA aneurysm. The next day, the aneurysm was occluded with coils via the femoral approach under general anesthesia. The patient received a bolus of 5,000 units of heparin immediately following the procedure, and an infusion rate of 10,000 units/day was initiated. The patient gradually became hypotensive 25 hours after coiling. Abdominal CT showed a huge, high-density soft-tissue mass filling the right side of the retroperitoneum space. The patient eventually died of multiple organ failure five days after coiling. RH after interventional radiology for neurological disease is relatively rare and can be difficult to diagnose if consciousness is disturbed. This case demonstrates the importance of performing routine physical examinations, sequentially measuring the hematocrit and closely monitoring systemic blood pressures following interventional radiologic procedures in patients with abnormal mental status.
Aged, 80 and over ; Anesthesia, General ; Aneurysm ; Angiography ; Arteries ; Consciousness ; Headache ; Hematocrit ; Hematoma ; Heparin ; Humans ; Intracranial Aneurysm ; Multiple Organ Failure ; Physical Examination ; Radiology, Interventional ; Subarachnoid Hemorrhage