A 77-year-old woman was given general anesthesia for an ascending aortic aneurysm operation and went into anaphylactic shock. The operation was canceled. Vecuronium, pancuronium, protamine and famotidine revealed positive prick test reactions. Ascending aortic replacement underwent under minimum dose of heparin for cardiopulmonary bypass (CPB). Heparin was injected immediately before CPB (2.5mg/kg) and nafamostat mesilate was injected continuously during CPB (2mg/kg/h). The ACT value was over 1, 400sec during CPB. However, protamine was not used after CPB. The operation time was 4h and 30min. CPB time was 1h and 26min. After the patient returned to the ICU, bleeding from the chest drainage tubes increased temporarily. The bleeding decreased gradually after administration of FFP and MAP.

Myosin light chain patterns were examined in single fibers from the extensor digitorum longus (EDL) and soleus muscles of Wistar strain rats. The fiber type composition of both muscles was also determined to estimate the relationship between myosin light chain patterns and histochemical fiber types.
The results were summarized as follows ;
1. All of single fibers from the EDL muscle was typical fast type which contained fast light chains only (fLC 1·fLC 2·fLC 3), except that there was one mixed type fiber cotaining both fast and slow light chains (fLC 1·fLC 2·sLC 1·sLC 2) .
2. There were two myosin light chain patterns in single fibers from the soleus muscle. One was typical slow type which contained slow light chains only (sLC1·sLC 2) and the other, mixed type in which fast and slow light chains coexisted. Mixed type fibers were divided into eight groups based on the light chain composition. The percentage occurence of typical slow type and mixed type fibers was 35.4% and 64.6%, respectively.
3. The average percentage of type II fibers was 94.6% in the EDL muscle 5.4% in the soleus muscle.
4. These results suggest that both fast and slow skeletal muscles contain mixed type fibers. The results further imply that in slow skeletal muscle, myosin light chain pattern of mixed type occurs not only in type II but also in type I fibers.

Systemic lupus erythematosus (SLE) is a chronic systemic inflammatory disease associated with the production of various autoantibodies and involvement of multiple organs. We report that steroid therapy for the SLE might play a major role in accelerating atherosclerosis and the patient suffered an aortic dissection. A 53-year-old woman had been receiving steroid therapy for 10 years due to SLE. The patient had thoracoabdominal aortic dissection. Conservative therapy was commenced, but the diameter of the dissecting aneurysm was enlarged. Therefore, grafting for the thoracic descending aorta and the abdominal aorta was performed. The patient experienced no significant postoperative complications.

A 31-year-old woman had an aneurysm of the brachiocephalic artery and aortic regurgitation due to aortitis syndrome. As C-reactive protein (CRP) levels were high (27.5mg/dl), steroid therapy was initiated. After CRP became negative, the brachiocephalic aneurysm was repaired using a GELWEAVE^® Y-graft, and the aortic valve was replaced with an ATS^® mechanical valve. Regional cerebral oxygenation (rSO₂) was monitored during the operative period. The level of rSO₂ did not change during the period when the brachiocephalic artery was clamped, resulting in no cerebral damage after the operation. Homer's syndrome appeared after the operation but the symptoms gradually improved spontaneously. A mechanical valve was chosen because the patient did not want to undergo a reoperation. No cerebrovascular event occurred after the operation and the patient was discharged on the 28th postoperative day.

We report mitral valve replacement (MVR) in a patient who had undergone left pneumonectomy for thoracic empyema 8 years previously. A 75-year-old man had heart failure due to mitral valve regurgitation and medication therapy was initiated. Although the heart had shifted to the right side, MVR was performed using a SJM valve with primary median sternotomy. The tracheal intubation tube was removed 17h after the operation, and the patient was discharged on the 43rd postoperative day. Careful preoperative assessment, preoperative control of heart failure, and careful attention to perioperative fluid management are important components of successful clinical management.

The operation for constrictive pericarditis after coronary artery bypass grafting (CABG) needs complete pericardiectomy without injury to the bypass graft. A 60-year-old man had pleural effusion a month after CABG. Right atrial pressure (RAP), right ventricular pressure (RVP), and pulmonary capillary wedge pressure (PCWP) were elevated and RVP showed a dip and plateau sign on cardiac catheterization. We diagnosed heart failure due to constrictive pericarditis following CABG. Pericardiectomy was performed using a cardiopulmonary bypass through a median sternotomy. The Harmonic Scalpel was useful for dissecting the pericardium. After the operation, it took a month for the patient to improve. RAP, RVP and PCWP were decreasing, and the dip and plateau sign of RVP was improved. The pleural effusion disappeared and the patient was discharged on the 73rd postoperative day.

Herein, we describe a novel posterior lumbar interbody fusion (PLIF) technique with annulus fibrosus (AF) release and the use of expandable cages (called “anterior-release PLIF” [ARPLIF]). In this technique, posterior column osteotomy (PCO) and AF release provide excellent intervertebral mobility. AF release involves circumferentially peeling off the AF above or below the endplate between the fixed vertebrae under radiographic guidance without cutting the AF and anterior longitudinal ligament. Subsequently, high-angle variable-angle expandable cages are used to simultaneously expand both sides before inserting the percutaneous pedicle screws and correcting to achieve good local lumbar lordosis. PCO and AF release achieve excellent intervertebral mobility. Intervertebral mobility and simultaneous expansion of both cages disperse the force on the endplates, reducing cage subsidence, and the high-angle cages facilitate high intervertebral angle creation. The novel ARPLIF intervertebral manipulation technique can promote good local lumbar lordosis formation.

Vertebral fractures occur with only slight trauma in patients with diffuse idiopathic skeletal hyperostosis (DISH). However, a lumbar vertebra fracture, due to an intraoperative body position has not been previously reported. An 87-year-old woman with kyphosis sustained a left trochanteric fracture of her femur. The patient was placed in a supine position during the operation. Postoperatively, the patient experienced severe right thigh pain. Magnetic resonance imaging revealed an L4 vertebral fracture. Computed tomography revealed ankylosis from the upper thoracic spine to the sacrum. While in a supine position under general anesthesia, the contact of the patient's lower back with operating table likely created a fulcrum at her lumbosacral spine acting as a long lever arm, bearing the mass of her upper body. We performed L1-S2 posterior stabilization. DISH patients with kyphosis placed in a supine position have an increased risk for lumbar vertebral fracture.
Aged, 80 and over ; Anesthesia, General ; Ankylosis ; Arm ; Female ; Femur* ; Humans ; Hyperostosis, Diffuse Idiopathic Skeletal* ; Kyphosis ; Magnetic Resonance Imaging ; Operating Tables ; Sacrum ; Spine ; Supine Position ; Thigh

Background/Aims: Proteinase 3 antineutrophil cytoplasmic antibody (PR3-ANCA) is a serologic marker for granulomatosis with polyangiitis. However, recent studies have also shown their role as diagnostic markers for ulcerative colitis (UC). This study was performed to investigate the clinical roles of PR3-ANCAs in the disease severity, disease extension, and clinical course of UC. Methods: Serum PR3-ANCAs were measured in 173 UC patients including 77 patients with new-onset patients UC diagnosed within 1 month, 110 patients with Crohn’s disease, 48 patients with other intestinal diseases, and 71 healthy controls. Associations between the PR3-ANCA titer and clinical data, such as disease severity, disease extension, and clinical course, were assessed. The clinical utility of PR3-ANCA measurement was evaluated by receiver operating characteristic (ROC) analysis. Results: PR3-ANCA ≥3.5 U/mL demonstrated 44.5% sensitivity and 95.6% specificity for thediagnosis of UC in all patients. PR3-ANCA positivity was more prevalent in the 77 new-onset UC patients (58.4%). In this group, the disease severity and extension were more severe in PR3-ANCA positive patients than in PR3-ANCA negative group (p<0.001). After treatment, the partial Mayo scores were significantly decreased with the PR3-ANCA titers. The proportion of patients who required steroids for induction therapy was significantly higher among PR3-ANCA positive than negative group. ROC analysis revealed that PR3-ANCA ≥3.5 U/mL had 75% sensitivity and 69.0% specificity for steroid requirement in new-onset UC patients. Conclusions Our results indicate that PR3-ANCA measurement is useful not only for diagnosing UC but also for evaluating disease severity and extension and predicting the clinical course.

Objective : The objective of this study was to assess the safety and efficacy of left atrial appendage (LAA) amputation during cardiovascular surgery. Methods : Fifty-seven patients underwent LAA amputation using a stapler from 2016 to 2017. The presence of remnant LAA was estimated by transesophageal echocardiography (TEE). Results : All LAA amputations were performed with the heart beating, without collapse. Additional amputation for remnant LAA was required in 14 patients. Sutures were needed to control bleeding in 7 patients. There was one case in which the coronary artery ended up being clamped with the LAA. The average duration for LAA amputation was 6.1±3.2 (1.5-15.2) min. There were 25 cases with postoperative atrial fibrillation (POAF), one case of cerebral infarction without POAF and one case of re-exploration for bleeding. Three patients died during hospitalization. Conclusion : LAA amputation using a stapler does not require cardiac arrest, and rarely requires an extended operation time. However, sufficient caution is required as there is the possibility that the coronary artery is obstructed and that remnant LAA is present.