A 60-year-old woman was admitted to our hospital due to abnormal findings on an electrocardiogram. She was a diabetic patient and had been taking neutral protamine Hagedorn insulin previously. After admission, since a coronary angiography was performed and showed three-vessel disease we performed coronary artery bypass grafting. After the cardiopulmonary bypass, she was given protamine sulfate. Subsequently her systolic blood pressure decreased below 35mmHg. Immediately cardiopulmonary bypass was restarted as an assist device for circulation. We administered epinephrine, and her blood pressure increased. After the second cardiopulmonary bypass, protamine administration was not given. Her postoperative course was uneventful, and she was discharged on the 18th postoperative day. A skin test titration to protamine was done. She had positive reaction at a dilution of 1mg/ml. Neutral protamine Hagedorn insulin use may immunologically sensitize patients to protamine, leading to anaphylactic reaction upon subsequent exposure to protamine sulfate during cardiac surgery. It is important to avoid adverse reaction to protamine.

A 43-year-old man was admitted for mitral valve repair. After quadrangular resection of the posterior leaflet, folding plasty was performed. Chordal reconstruction of the anterior leaflet was carried out and a 32-mm Cosgrove-Edwards ring was placed. Seven weeks after the operation, hemolytic anemia developed and serum lactate dehydrogenase elevated to 1,923IU/l. Doppler echocardiography showed only mild residual mitral regurgitation, but the regurgitation jet collided with the annuloplasty ring. The velocity of the regurgitation jet was 5.19m/s. After bisoprolol administration, the hemolytic anemia improved. However, the patient had been complaining of general fatigue; serum lactate dehydrogenase was found to be re-elevated after discharge despite the administration of bisoprolol. Therefore, re-operation was undertaken. The cause of the residual mitral regurgitation was mainly anterior leaflet prolapse. Chordal reconstruction and ring annuloplasty were re-performed. The hemolytic anemia was cured after re-operation. This case showed that a high-velocity regurgitation jet can cause hemolytic anemia, especially by colliding with an annuloplasty ring. It is important to accurately evaluate the severity, direction and velocity of the regurgitation jet by transesophageal echocardiography. It seems that the velocity of the regurgitation jet could become a parameter when deciding on the treatment plan.

A 50-year-old man with an extensive thoracic aortic aneurysm underwent staged surgery which consisted of preceding total aortic arch replacement with the frozen elephant trunk technique using J Graft Open Stent Graft^®, followed by open thoracoabdominal aortic aneurysm repair. During the second operation, the descending aorta was cross clamped along with the preexisting stent graft, and Dacron graft was anastomosed directly to the stent graft using a running 4-0 monofilament suture. The anastomosis site was then covered with a short piece of Dacron graft identical with the stent graft in size to secure hemostasis. We herein discuss our approach in this complex case, focusing on prevention of inadvertent events such as deformation of the preexisting stent graft and unexpected bleeding.

Multiple endocrine neoplasia type 1 (MEN1) is an inherited autosomal dominant disease presenting with pancreatic neuroendocrine tumors (pNETs), parathyroid tumors, or pituitary tumors. Using the PubMed database, we reviewed the literature on information regarding the proper diagnosis and treatment of MEN1-associated pNET. Many cases of MEN1-associated pNET are functioning pNETs. Gastrinomas and insulinomas tend to occur frequently in the duodenum and pancreas, respectively. In addition to diagnostic imaging, the selective arterial secretagogue injection test (SASI test) is useful for localizing functioning pNET. The standard treatment is surgical resection. However, in the case of a functioning pNET, the tumor should first be accurately located using the SASI test before an appropriate surgical method is selected. In cases of a MEN1-associated non-functioning pNET that exceeds 2 cm in diameter, the incidence of distant metastasis is significantly increased, and surgery is recommended. In cases of unresectable pNET, a somatostatin analog has been shown to demonstrate antitumor effects and is considered to be a promising treatment. In addition, molecular-targeted drugs have recently been found to be effective in phase III clinical trials.
Diagnostic Imaging ; Duodenum ; Gastrinoma ; Incidence ; Insulinoma ; Multiple Endocrine Neoplasia ; Multiple Endocrine Neoplasia Type 1 ; Neoplasm Metastasis ; Neuroectodermal Tumors, Primitive ; Neuroendocrine Tumors ; Pancreas ; Pituitary Neoplasms ; Somatostatin

A 73-year-old woman was diagnosed with coronary artery aneurysms associated with coronary-pulmonary arterial fistula in a preoperative examination for transverse colon cancer. One of the aneurysms (28 mm) originated from a branch of the right coronary artery and the other two (16 and 12 mm) originated from a branch of the left coronary artery. We performed surgery to prevent their rupture because the right coronary artery aneurysm showed a tendency to enlarge. Surgery was performed through a median sternotomy under cardiopulmonary bypass. Suture closure of the inflow and outflow of the aneurysm was performed. The coronary-pulmonary arterial fistula was ligated. In addition, suture closure of the outflow of the coronary-pulmonary artery fistula into the pulmonary artery was performed, under direct view after incision of the pulmonary trunk. No residual shunt blood flow in the coronary-pulmonary arterial fistula was observed on postoperative echocardiography. Furthermore, no coronary aneurysm and coronary-pulmonary arterial fistula was recognized on postoperative coronary computed tomography. The patient made an uneventful recovery and was discharged from the hospital on postoperative day 12.