We report a rare case of aorto-right ventricular fistula and vegetation in the right ventricle after aortic valve replacement. A 74-year-old woman with a history of aortic valve replacement with a Carpentier-Edwards Perimount pericardial bioprosthesis 7 months earlier was admitted with fever. Methicillin-sensitive Staphylococcus aureus was detected from her blood culture. Transthoracic echocardiography showed an aorto-right ventricular fistula and vegetation in the right ventricle. Under a diagnosis of infective endocarditis, surgery was performed. The operative findings showed a fistula from the previous aortic suture line to the right ventricle, and substantial vegetation in the right ventricular outflow tract. No infective change was observed in the previously inserted prosthetic or pulmonary valves. The vegetation was removed and the fistula was closed directly with a single pledgeted 4-0 prolene mattress suture. The right ventricular outflow tract was reconstructed with a heterogeneous pericardial patch. The patient was discharged in good health on the 59th postoperative day without any infective complications.

A 67-year-old man with aortic insufficiency underwent aortic valve replacement (AVR) with a Freestyle^TM valve (Medtronic Inc.), using the complete subcoronary technique. Although a trivial aortic insufficiency remained on postoperative echocardiography, he continued without chest symptoms. A cardiac murmur developed and dyspnea on effort appeared five months postoperatively. Echocardiography and aortography showed severe aortic insufficiency, and a re-do AVR was performed seven months after the first procedure. Examination of the Freestyle valve revealed that two loops of the suture line on the inflow side of the valve had become detached from the muscular tissue. It is most important to keep the geometry of the Freestyle valve at the time of the implantation using the subcoronary technique, and an unsuitable implantation can cause consequent perivalvular leakage.

We performed echocardiography on 19 hemodialysis patients before and after dialysis session. The patients were divided into three groups (normal pressure group; N=9, pre-dialysis hypertension group; N=6, pre-and post-dialysis hypertension group; N=4). The findings of echocardiography (Left ventricular end-diastolic dimension; LVDd, Left ventricular ejection fraction; EF, Left atrial dimension; LAD, Interventricular septal thickness; IVT) were compared in the three groups. There was no significant difference in LVDd and LAD between three groups. The mean value of EF was significantly (P=0.03) higher in the pre-dialysis hypertention group (68±9.4%) than in the normal pressure group (65±9.6%). The mean value of IVT was significantly (P=0.01, 0.01) higher in the pre-dialysis hypertention group (11±0.9 mm), pre-and post-dialysis hypertention group (11±0.6 mm) than in the normal pressure group (10±1.7 mm). These findings suggested thet hypertension may affect cardiac function. Therefore, we concluded that to keep normal blood pressure is important in hemodialysis patients.

Twelve patients with chronic renal diseases who underwent hemodialysis in the Oriental Medicine Outpatient Clinic of a general hospital were analyzed. The ratio of female to male patients was high, and patients' ages ranged from 31 to 71 years, with a mean age of 53.3 years. Many patients had been receiving hemodialysis for a relatively long time at a frequency of three times a week in most cases. They thus had to maintain a fixed posture for 4-5h per day several times a week. Underlying diseases were chronic glomerulonephritis, diabetic nephropathy, polycystic kidney and nephrosclerosis. Blood biochemical examination revealed high levels of BUN, CRE and UA, while K, Na, Ca and Pi electrolytes were almost normal. The drug therapy consisted mainly of urate biosynthesis inhibitors and electrolyte metabolism amelioraters. Symptoms resulting from long-term maintenance of a fixed posture and abnormalities in K, Na, Ca and Pi electrolytes included headache, stiffness in the neck and shoulder, pain in the arms, low back pain, pain in the legs and pain in the knee joint. Acupuncture was slightly effective or better in 73.1% of the patients, and none of them showed aggravation.

The effect of acupuncture electrotherapy (AET) on siccative symptoms (dry eye, dry mouth) of patients with Sjögren's syndrome (SjS) was examined using changes in the lacrimary secretion volume, the salivary secretion volume, and the skin temperature on the face as well as the dry score.
1) The control group (n=10) was subjected to 1-Hz/30-Hz AET on the face and 1-Hz AET on the posterior neck and upper scapula region. Though, the 30-Hz AET on the face resulted in a significant increase in the lacrimary secretion volume, salivary secretion voloume, and skin temperature on the face, no clear changes were observed in response to stimulus at the posterior neck and upper scapula region.
2) In one group of SjS patients (n=15), 30-Hz AET on the face significant increased the lacrimary secretion volume and salivary secretion volume.
3) In a second group of SjS patients (n=7), no significant difference in effects with elapsed time was observed immediately after, 30 minutes after. 1 hour after, and 2 hours after applying 30-Hz AET on the face.
4) In a third groups of SjS patients (n=10), no significant difference in the cumulative effect of 30-Hz AET applied to the face was observed after the first, fifth and tenth treatments. However, the dry mouth score significantly decreased from the first treatment to the tenth treatment.
The above observations indicate that the effect of AET on siccative symptoms of SjS patients occurs in the order of trigeminal nerve, facila nerves, and glosspharygeal nerve reflexes (somatic-parasympathetic nerve reflex). They also indicate that the reactivity varies according to the frequency of stimulation provided, with high-frequency stimulation being particularly effective in salivation, suggesting that acupuncture may contribute to improving the QOL of patients by mitigating the subjective siccative symptoms experienced by them.

A 33-year-old woman underwent aortic root replacement for aortic regurgitation and an aneurysm of the ascending aorta due to annuloaortic ectasia. Ehlers-Danlos syndrome was diagnosed by skin biopsy when she was 23 years old. At operation, to avoid mechanical stress to the residual aorta, cardiopulmonary bypass was established via cannulation of the left femoral artery and we used the open distal anastomosis method under hypothermic circulatory arrest with selective cerebral perfusion. Moreover, the sutures of the aortic annulus were reinforced sewing the aortic wall together. Her postoperative course was uneventful. Despite the fragility of the cardiovascular tissues in Ehlers-Danlos syndrome, cardiac surgery could be performed safely with appropriate surgical procedures.

Acute aortic dissection causes various complications, but rarely causes rhabdomyolysis before the operation. A 69-year-old woman was found to have fallen unconscious and was transported to our hospital. Chest contrast computed tomography revealed thrombosed type A acute aortic dissection. On admission, hypoxia with paradoxical breathing was recognized and she complained of chest and back pain, and severe leg pain. In blood examination, elevation of myogenic enzymes and acute renal dysfunction were recognized. However computed tomography showed no signs of the ischemia of the intraperitoneal organs and legs. Myogenic enzymes decreased gradually and acute renal dysfunction improved by conservative therapy. In spite of strict antihypertensive therapy, enlargement of the false lumen and re-dissection were occurred, for this reason we scheduled ascending aorta replacement. During the operation we did muscle biopsy, and myogenic changes, such as cytolysis and lymphocyte infiltration, were recognized in muscles pathologically. However all various autologous antibody examinations were negative. We concluded that rhabdomyolysis was due to transient shock and caused preoperative marked elevation of myogenic enzymes.

Blow-out type free wall rupture is a severe complication after acute myocardial infarction and its prognosis is poor. A 68-year-old man was admitted to our hospital for extensive anterior acute myocardial infarction with cardiogenic shock. Echocardiogram and CT strongly indicated the presence of intrapericardial fluid, and we had to perform an emergency operation. Before median sternotomy, we cannulated the femoral artery and vein, and cardiopulmonary bypass was started. We resected the ruptured and necrotic left ventricular myocardium and employed the feltstrip sandwich method. Postoperative recovery of cardiac function and consciousness was satisfactory and he was discharged from hospital on the 37th postoperative day. PCPS or femoro-femoral bypass and consecutive surgical therapy can be a useful method for the treatment of left ventricular free wall blow-out rupture.

A procedure was introduced for determining the thickness of the articular cartilage of the patella. The results revealed that the cratilage was thicker at the site of contact between the patella and the femur than in other parts. CT and X-ray images were used to investigate movement of the patella from full extension to full flexion of the knee joint. As the flexion increased, the patella prorated, i, e., the site of contact with the epicondyle and condyle of the femur shifted from the lateral to the medial facet of the articular face, as deduced from the decrease in the bicondylo-patellar angle. Vertically, the patella moved from the epicondyle to the condyle level, but the distance between the apex of the patella and the tuberosity of the tibia remained almost unchanged. Serial slices (5 mm thick) of a plaster replica of the patella cut at right angles to the central ridge showed a change in the angle between the two facets of the articular face from the proximal to the distal side. The same results were obtained with CT slices. These findings suggest that adequate pressure stimulates development of the cartilage and that CT is a good method for studying movement of the patella.

The systolic time intervals (STI's) and the diastolic time (DT) as functions of the RR interval during exercise were proved to be described by cubic regression equations that converge to the origin of the coordinates. Using the equations, we compared I) the systolic time and DT of trained and untrained men, and II) examined the relations between parameters of STI's. I) Forty healthy male subjects aged 19-22 years old were divided into three groups, i, e., 8 long distance runners (group LD), 16 men with relatively high fitness (group A) and 16 men with relatively low fitness (group B) . They performed submaximal exercise test using a cycle ergometer for measuring the time of electromechanical systole (QS₂) and DT. After test, maximal exercise test was conducted to determine the maximal heart rate (HRmax) in each subject. Means±SD of the minimum QS₂ and the minimum DT of the 40 subjects predicted from the regression equations at the HRmax were 209.7±12.5 and 108.2±15.6 ms, their ratio being about 2: 1. The QS₂ was significantly shorter, whereas DT was longer in the group LD than in the groups A and B at the HR of more than 120 bpm. II) Ten healthy male subjects aged 19-22 years old performed submaximal exercise to clarify the relations between any two of QS₂, the left ventricular ejection time (LVET) and the preejection period (PEP) at the same HR: there were positive and negative significant correlations between QS₂ and LVET, and between LVET and PEP, respectively, at the HR of more than 100 bpm. These results reveal that, when the HR is increased in exercise, the left ventricular systolic time (QS₂) is shortened while the diastolic time is lengthened for the subjects trained as long distance runners. The shortening of the systolic time is mainly caused by shortening of LVET. The changes in the systolic and diastolic times suggest that contractility of cardiac muscle is enhanced during exercise of above moderate intensity after an extensive period of the aerobic training.