We encountered an instructive case of anterolateral papillary muscle rupture after acute myocardial infarction. A 73-year-old woman with rapidly progressive dyspnea came to our emergency room. Her symptoms associated with acute heart failure rapidly worsened. We diagnosed anterolateral papillary muscle rupture after acute myocardial infarction due to occlusion of the first diagonal branch, based on transesophageal echocardiogram and coronary angiography. We immediately performed mitral valve replacement and coronary artery bypass grafting (CABG) to the diagonal branch. Although she required postoperative intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS), she eventually recovered. Mitral papillary muscle rupture causes rapidly deteriorating hemodynamics and requires surgical treatment. Because of a serious complication of myocardial infarction, this case emphasizes that early diagnosis and aggressive treatment are required for mitral papillary muscle rupture.

We report a case of mitral regurgitation due to an atypical variant of Fabry disease. A 60-year-old man was admitted to our hospital. He had a history of myocardial infarction and heart failure, and was repeatedly admitted for worsening heart failure (NYHA class II to III). A follow-up echocardiogram revealed deteriorating dilated cardiomyopathy and mitral regurgitation. We performed valvuloplasty for mitral regurgitation. Cardiomyopathy was suspected during the operation and myocardial biopsy was performed. We diagnosed Fabry disease by histopathological findings. After the operation, his heart failure temporarily improved. Heart failure worsened 4 months later. He died of heart failure a year later from the operation. Fabry disease (α-galactosidase-A deficiency) is an inherited metabolic disease. In Fabry disease, angina, myocardial infarction, hypertrophic cardiomyopathy, dilated cardiomyopathy, and mitral regurgitation are common cardiac manifestations. Recently, an atypical variant of Fabry disease, with manifestations limited to the heart, has been increasingly reported. This case suggested that we might encounter Fabry disease with only cardiac manifestations such as cardiomyopathy and valvular disease in routine clinical work.

A 33-year-old man presented with respiratory distress and lower leg edema in April 2006. Atrial septal defect (ASD), complicated with moderate mitral regurgitation (MR), advanced tricuspid regurgitation (TR) and pulmonary hypertension (95/32mmHg), was diagnosed. Qp/Qs was 6.3 and L-R shunt ratio was 84.4%. An “edge-to-edge” mitral valve plasty for MR complication as well as closure of the septal defect and tricuspid annuloplasty was performed, and a good result was obtained. It is known that ASD has a tendency to be accompanied by MR, and the strategy for treatment course for MR is debatable. The mitral lesions of MR complicating ASD are often seen in the posteromedial side of the anterior mitral leaflet, and usually many of the tendinous cords and valve leaflets are in the normal range in length. There have been reports on the mid-term results of edge-to-edge repair of mitral regurgitation due to degenerative lesions but the mid- and long-term results for MR complicating ASD, such as this case are unknown. We need to carefully observe the time course of this case.

Purpose: Since malodor of a malignant fungating wound decreases quality of life of patients, its management is important. Metronidazol ointment, clindamycin ointment, and cadexomer iodine ointment have been used for treatment of malodor of a malignant fungating wound because they have antibacterial activity for anaerobic bacteria. Nevertheless, management of malodor of a malignant fungating wound has been unsatisfactory and it needs improvement. Methods: A mixture ointment of clindamycin and cadexomer iodine was employed in a case with malodor of a malignant fungating wound that had not been successfully controlled by cadexomer iodine ointment. Results: Malodor and exudate of a malignant fungating wound reduced. In addition, no adverse event such as skin troubles was observed and it was used safely. Conclusions: It was suggested that the clindamycin-cadexomer iodine ointment was more effective for treatment of refractory malodor of a malignant fungating wound than cadexomer iodine ointment.

We administered Seki-gan-ryo to 24 patients with severe asthenia and cold syndrome as judging by Japanese traditional Kampo medicine. The patients were separated into responder, and non-responder groups. There were 12 patients in the non-responding group. We investigated the clinical indicators of Seki-gan-ryo with special reference to the type of cold and pulse diagnosis. The type of cold wass divided into three groups; heat in the upper and cold in the lower, and limbs type. Pulses superficialis-profundus and excess-efficiency were graded from the diagram.
Seven of the 11 patients in the non-responder group appeared to have a general type of cold. There was, however, no statistical difference between the responders and the non-responders, in their type of cold. All patients in the responder group presented with relatively strong pulses (excess: 1, relative excess: 4, and balance: 5). On the other hand, the strength of pulses in the non-responder group appeared to vary.
If patients with severe asthenia and cold syndrome present with a relatively strong pulse, Seki-gan-ryo may be thought of as discriminating formula.

We have reviewed the Recommendations on Undergraduate Medical Education published by the General Medical Council (GMC) of the United Kingdom in 1993, and have visited the University of Leicester to see how they have revised their medical course to take account of the GMC's recommendations. The aim of the GMC's recommendations is to promote a culture of self directed learning which will be of value to the future medical practitioners in their postgraduate careers. To achieve this the GMC recommends a reduction in the burden of factual information delivered to the student while promoting learning through curiosity and the exploration of knowledge. The students are given an integrated view of clinical and basic scientific disciplines. The University of Leicester has reorganised its medical teaching around modules relating to body function rather than the traditional disciplines, with contributions being made by clinicians and basic scientists in the same module. The new course places great emphasis on carefully guided and structured self directed study and a reduced number of lectures. Clinical skills are introduced early in the curriculum, while a deeper understanding of selected scientific disciplines are achieved by a series of special study modules where the students undertake supervised scientific research.

Endovascular aortic aneurysm repair using stent graft (SG) for both thoracic and abdominal aortic aneurysms (SG therapy) rapidly became widespread in Japan because of its relatively low invasiveness. Pre- and postoperative contrast enhanced CT are mandatory in SG therapy and angiography is required during SG therapy. Therefore contrast induced nephropathy (CIN) might occur after SG therapy. In our hospital, a renal protection protocol (oral N-acetylcysteine, perioperative normal saline infusion and bicarbonate infusion during SG therapy) was introduced in June 2010. In this report, the effect of the renal protection protocol on renal function after SG therapy was evaluated. During May 2008 and March 2012, 229 patients underwent SG therapy in our hospital. Serum creatinine (CRTN) was higher than 1.5 mg/dl and estimated glomerular filtration rate (eGFR) was less than 50 ml/min/1.73 m² in 26 patients. In these 26 patients, the renal protection protocol was applied in 15 patients (group P) and group P was compared with the 11 patients without renal protection protocol (group N). Also the relationship between CIN occurrence and preoperative renal function was evaluated in 192 patients who did not receive the renal protection protocol. CIN was defined as more than 25% or 0.5 mg/dl increase of CRTN based on the European Guidelines. As renal protection protocol, N-acetylcysteine (600 mg) was given 4 times every 12 h. Normal saline infusion was started on the evening of the day before surgery at the rate of 50 ml/h and was continued until 1h before surgery. Sodium bicarbonate solution (151 mEq/l) was started 1 h before surgery at the rate of 180 ml/h and the infusion rate was decreased to 60 ml/h during surgery. After surgery, 1,000 ml of normal saline was given at a rate of 60 ml/h. In group N, CRTN increased 1 and 3 days after SG therapy and returned to baseline level 6 days after SG therapy. On the other hand, CRTN was lower than baseline after SG therapy in group P. At 3 days after SG therapy, the percent change of CRTN component with baseline level was significantly lower in group P (14.5±19.1% in group N, -3.7±15.8% in group P, p=0.014). CIN occurrence tended to be more in group N (45% in group N, 7% in group P, p=0.054). Among the 192 patients without the renal protection protocol, CIN occurred in 16 patients (29.1%) out of 55 patients with preoperative CRTN≥1.0 mg/dl and eGFR≤50 ml/min/1.73 m², however CIN occurred in only 1 patient (0.7%) among 137 patients with preoperative renal function out of this range (p<0.001). Renal protection protocol seemed to be effective to prevent CIN after SG therapy. Renal protection might be useful for patients with a CRTN≧1.0 mg/dl and eGFR≦50 ml/min/1.73 m².

In off-pump coronary artery bypass grafting (OPCAB), adequate exposure under stable hemodynamic condition is mandatory. We introduced left side pericardiotomy to expose the left anterior descending artery without lifting up the ventricle in 2008. With this pericardiotomy approach, the exposure of the circumflex and right coronary artery territory became easier and OPCAB with left side pericardiotomy was compared with OPCAB with midline pericardiotomy. From 2004 to 2011, 194 elective first time coronary artery bypass grafting (CABG) were performed in our hospital. Before 2008, 62 patients underwent OPCAB with midline pericardiotomy which constituted 61% of the CABG in that period. After 2008, the pericardium was dissected on the left side and a small pericadiotomy was made on the left side of the main pulmonary artery. This incision was then extended to the apex. With this pericardiotomy, only two patients underwent CABG with cardiopulmonary bypass (one patient with 15% left ventricle ejection fraction and one more patient who developed acute coronary syndrome during anesthesia induction). Thus 91 out of 93 patients underwent OPCAB (98%) (Group L). In Group L, old myocardial infarction and unstable angina patients were frequent. The frequency of the patients with left ventricular ejection fraction less than 40% tended to be more in Group L. The operation time was significantly shorter in Group L (Group M 305±71 min, Group L 223±54, p<0.0001) and the number of distal anastomoses number was significantly more in Group L (Group M 2.3±0.7, Group L 2.8±1.0, p<0.0001). Blood pressure during left circumflex coronary artery and right coronary artery anastomosis was significantly higher in Group L, and even continuous dopamine infusion requirement was significantly less in Group L (92% in Group M, 13% in Group L, p<0.001) among the patients with left ventricle ejection fraction less than 60%. There was only 1 hospital death in Group M. Postoperative maximum CK-MB was significantly lower in Group L (Group M 48±107 IU/l, Group L 13±16 IU/l, p=0.005) and the patients with CK-MB more than 12 IU/l was significantly frequent in Group M (Group M 73%, Group L 33%, p<0.0001). Postoperative ICU and hospital stay period was significantly shorter in Group L (ICU stay : Group M 3.4±2.3 days, Group L 2.0±1.4 days, p<0.0001, hospital stay : Group M 27±21 days, Group L 16±7 days, p<0.0001). The patency of the graft to the left anterior descending artery did not differ significantly (Group M 94%, Group L 99%), however the patencies of the grafts to left circumflex artery and right coronary artery were significantly better in Group L (left circumflex artery : Group M 75%, Group L 98%, p=0.001, right coronary artery : Group M 81%, Group L 98%, p=0.014). Left side pericardiotomy seemed to be useful because OPCAB with left side pericardiotomy yielded shorter operation time, less myocardial enzyme release, improved postoperative recovery and better patency of graft to the left circumflex and right coronary artery.

The patient was a 58-year-old woman with untreated diabetes. She consulted a local doctor in May 2006 complaining of constipation that had persisted for 2 weeks, under gradually worsening abdominal pain. She was transferred to our hospital with a diagnosis of aortic aneurysm. Blood tests indicated high inflammatory response, and CT showed hematoma around the aorta from directly under the diaphragm to the level of superior mesenteric artery and influx of contrast medium into the hematoma. Control of the infection was first attempted with antibiotics, but eventually surgery was performed because the hematoma increased. The hematoma and aortic wall were completely excised from the local of the diaphragm to the level beneath the renal artery, with partial cardiopulmonary bypass and selective perfusion to abdominal branches, and anatomic reconstruction was performed with a synthetic graft and omental implantation. The hematoma was fetid and Citrobacter koseri was detected in culture. The patient was discharged after 4 weeks of antibiotic treatment, without complications and with satisfactory progress. At present, there has been no recurrence of infection in the 22 months since her discharge.

Endovascular repair for abdominal aortic aneurysm (EVAR) has become widespread in Japan because of its low invasiveness. However adequate proximal neck length is required for EVAR. Unfortunately the surgical mortality of para-renal aortic aneurysm cases has been higher than that of infrarenal aortic aneurysm cases, especially in high-risk patients. A manufacture-modified fenestrated Zenith stent graft system has already been developed, however this new device is not yet available in Japan. Furthermore this device could not be used in an emergency situation because it takes 2-3 weeks for preparation. Therefore we introduced a surgeon-modified fenestrated Zenith stent graft (fenestrated Zenith) system in December 2010 for patients with a proximal neck length of 5-10 mm. The fenestrated Zenith was not indicated if the supra-renal angle and proximal neck angle exceeded 35°. From May 2007 to February 2012, abdominal aortic aneurysms (AAA) with a short neck were repaired with fenestrated Zenith in 11 high-risk patients (group Fene), and AAAs with a proximal neck length of more than 15 mm were repaired with a standard Zenith in 43 patients (group IFU). There were two ruptured AAA in the Fene group. Proximal neck length was significantly shorter in the Fene group (5.5±1.4 mm in the Fene group, 26.4±9.5 mm in the IFU group, p<0.0001) and proximal neck angle was significantly less in the Fene group (20±13° in the Fene group, 36±18° in the IFU group, p=0.008). The Zenith stentgraft system was deployed successfully in all patients. The frequency of type Ia endoleak detected by angiography after stent graft deployment and balloon attachment did not differ significantly (36% in the Fene group 26% in the IFU group, p=0.475) and the frequency of Palmaz stent requirement for type Ia endoleak which persisted after 10 min of additional balloon attachment also did not differ significantly (27% in Fene group, 9% in IFU group). All fenestrated renal arteries were shown to be patent by angiography. There was no hospital death despite 2 cases of ruptured AAA, nor were these major complications in either group. Serum creatinine levels at 1, 3, 6 and 30 days after EVAR did not differ significantly between the 2 groups. In 9 out of 11 patients, only type II endoleaks were detected and aneurysm shrinkage tended to be more in Fene group (9.9±5.7 mm in Fene group, 5.4±6.1 mm in IFU group, p=0.062) on enhanced CT 6 months after EVAR. Also all fenestrated renal arteries were patent in these 9 patients. The surgeon-modified fenestrated Zenith system seemed to be effective for AAA patients with short proximal necks, but long term follow up is mandatory.