We reviewed 223 cases of isolated coronary artery bypass grafting (CABG) during the past 6 years, and used the EuroSCORE to assess the differences in clinical outcomes between off-pump CABG (OPCAB) and on-pump CABG (conventional CABG: CCABG). After March 2000, our first choice has been OPCAB, with CCABG selected only for cases with unstable hemodynamics. The total of 223 isolated CABG cases consisted of 129 OPCAB and 94 CCABG, but after March 2000, 94 OPCAB and 42 CCABG were performed. Mean EusoSCORE was 5.8 for OPCAB and 4.1 for CCABG, and corresponding expected survival rates were 7.20% and 5.04%. The 3 cases of hospital death (mortality, 1.3%) all belonged to the earlier CCABG groups and were not related to cardiac death. After March 2000, no hospital deaths occurred in either group. Midterm results showed 5 deaths, but these were not related to cardiac death, either. There were no significant differences between the 2 groups in terms of hospital complications other than long mechanical ventilation time, which was markedly longer only for the OPCAB groups (p<0.01). Mean number of grafts was significantly high for patients in the CCABG groups (OPCAB 2.1 vs. CCABG 2.8; p<0.05). We have therefore been using OPCAB for high-risk cases, and midterm results of our CABG patients were satisfactory.

Surgery for right atrial isomerism usually has a poor outcome because of complex congenital cardiac malformations. Here we rearn the outcomes of all 71 consecutive patients with right atrial isomerism whom we treated from their initial operation at Shizuoka Children's Hospital between January 1987 and October 2006. We categorized 34 patients treated between 1987 and 1996 as the ‘early’ group, and 37 patients between 1997 and 2006 as the ‘late’ group. The early group was more commonly associated with pulmonary stenosis (p=0.010), and the late group was more commonly associated with neonatal status (p=0.010), body weight less than 3.0kg (p=0.037), and pulmonary atresia (p=0.013). All 71 patients were scheduled for single ventricular repair. Survival in the early group was 52.9% at 1 year, and 32.4% at 5 years, and this poor outcome was related to 2 factors; cardiac dysfunction from volume loading and inappropriate lung perfusion area for Fontan completion. We therefore changed our surgical strategy in the late group as follows: earlier right heart bypass operation and aggressive atrioventricular valvoplasty to prevent volume overloading, and central pulmonary artery (PA) strategy (central PA plasty and blood flow source anastomosed to the central PA) and improvement of anastomosis of total anomalous pulmonary venous connection (TAPVC) to preserve appropriate lung perfusion area. If severe unbalanced pulmonary blood flow occurred, it was treated with a novel surgical approach consisting of ‘intrapulmonary-artery septation’. Survival in the late group was 66.8% at 1 year, and 53.1% at 5 years, which was better than the early group, but not with statistical significance (p=0.102). Univariate analysis identified significant risk factors for mortality as neonatal status (p=0.036), extracardiac TAPVC (p=0.049), and preoperative pulmonary vein obstruction (PVO) (p=0.001) in the early group, and mixed TAPVC (p=0.001) in the late group. Multivariate analysis identified preoperative PVO (p=0.038) in the early group, and mixed TAPVC (p=0.007) in the late group as significant risk factors for mortality. Outcome is improving with our current strategy of preventing volume overloading and preserving an appropriate lung perfusion area, even in the late group with more severe cases, and neonatal status, extracardiac TAPVC, and preoperative PVO are no longer risk factors for mortality, but mixed type TAPVC remains a serious problem and is associated with high mortality.

We report a case of Takotsubo cardiomyopathy that developed after elective coronary artery bypass grafting (CABG) in an 80-year-old woman. She had been given a diagnosis of unstable angina complicated with mild hypertrophic obstructive cardiomyopathy (HOCM). Her cardiac index began to fall 7 h postoperatively, and we needed to infuse fluids and increase dopamine dose (up to 5 µg/kg/min) to maintain cardiac index and blood pressure. CPK-MB level increased up to 140 IU/l at 12 h postoperatively. Transthoracic echocardiography showed akinesis and ballooning of the apex and hyperkinesis of the base with accelerated left ventricular outflow tract (LVOT) flow and increased mitral regurgitation (MR). Emergency coronary artery angiography showed good patency of all bypass grafts and no new coronary lesion. We diagnosed Takotsubo cardiomyopathy. To improve the hemodynamic status, we started intra-aortic balloon pumping (IABP) instead of adding catecholamines. Blood pressure and cardiac index had improved temporarily, but became unstable again because of increased LVOT pressure gradient and moderate-to-severe MR. LV wall motion gradually improved, but the hemodynamic status stayed unstable, but improved after removal of IABP. In general, the prognosis of Takotsubo cardiomyopathy is favorable with supportive care. However, when it is associated with LVOT stenosis and significant MR, low cardiac output syndrome can become intractable, thus we should manage critical conditions with extreme caution.

We report a case of septal branch aneurysm. A 61-year-old woman was referred to our hospital because of heart murmur. Septal branch aneurysm (25×15 mm) was diagnosed by echocardiography and coronary angiography, and followed up annually with multi-detector row computed tomography (MDCT). Nine years later, another aneurysm proximal to the known aneurysm, which protruded above the epicardium, has rapidly dilated from 5 to 11 mm. We therefore performed closure of the orifice of the septal branch concomitant with bypass grafting ; left internal mammary artery to distal LAD. After the procedure, the aneurysm in the septum had completely collapsed. Her postoperative course was uneventful.

We report a case of re-expansion pulmonary edema (REPE), which complicated mitral valve plasy via right small thoracotomy. A 56-years old man underwent mitral valve plasty for severe mitral regurgitation caused by P2 prolapse. After separation from heart-lung machine, massive yellow foamy secretion has begun to spout from the right side endotracheal tube and hypoxemia has ensued. Differential ventilation with high airway pressure and steroid pulse therapy could not counteract the exacerbation of hypoxemia. Echocardiography showed severe diffuse hypokinesis of left ventricular wall. Intra-aortic balloon pumping and percutaneous cardiopulmonary support (PCPS) were introduced, and they were very effective. After five-days' support, PCPS was successfully weaned. The patient recovered well. REPE complicated by mini-thoracotomy approach cardiac surgery, is rare, but can be fatal.

Objectives: To evaluate the efficacy of tegafur–uracil (UFT), a prodrug of 5-fluorouracil, plus cisplatin and dexamethasone in patients with docetaxel-refractory prostate cancers.

Methods: Twenty-five patients with docetaxel-refractory prostate cancer were administered oral UFT plus intravenous cisplatin (UFT-P therapy) and dexamethasone. Treatment responses were assessed monthly via prostate-specific antigen (PSA) level measurements. Treatment-related adverse events and overall survival were also assessed.

Results: UFT-P therapy resulted in decreased PSA levels in 14 (56%) patients and increased PSA levels in 11 (44%). In patients with increased PSA levels, 7 (64%) of the 11 patients displayed decreased PSA doubling times. The UFT-P therapy response rate was 84% (21/25 patients). Imaging studies revealed that tumor shrinkage during UFT-P therapy occurred in 1 patient in whom bilateral hydronephrosis caused by lymph node metastasis improved. The median survival time from docetaxel initiation was 36 months. In UFT-P-treated patients, the median PSA progression and overall survival times were 6 and 14 months, respectively. UFT-P treatment-related adverse events were mild diarrhea, general fatigue, and anorexia. Treatment was not discontinued for any of the patients. UFT-P therapy did not cause serious hepatic or renal dysfunction or pancytopenia.

Conclusions: UFT-P therapy is a safe and effective treatment for patients with docetaxel-refractory prostate cancer, although large-scale, multicenter, prospective studies are needed to validate these findings.