Rupture of the posterior wall of the left ventricle is rare but it is one of the fatal complications which can follow mitral valve replacement (MVR). Of 216 MVR patients, including 51 who had double valve replacements, we have had four patients (1.9%) with this complication. The rupture occurred on the table in one patient and about 40 to 90min after entering ICU in the others. All the ruptures were repaired under cardiopulmonary bypass and cardioplegic arrest. The site of rupture was type I in two cases and type II in the other two. Two patients expired. One patient who had been repaired in the operating room died from multiple organ failure after a stormy course of two week's duration, and one who had been repaired in ICU died from uncontrollable hemorrhage. In the remaining two patients, one with a type I and one with a type II rupture, successful treatment in ICU was achieved by suturing an equine pericardial patch to the normal endocardium and mitral ring over the entire area of laceration through endocardial site after removal of the valve prosthesis in the first place, and then wrapping the area of epicardial laceration with another equine patch. In order to reduce mortality in patients with left ventricular rupture, repair from inside of the heart using an equine patch described above was very effective, and the preparation to perform the operation immediately after the onset of rupture in ICU is an important consideration as well.

Two patients with an aorto-iliac arteriovenous fistula as a complication of abdominal aortic aneurysms were presented. Both patients showed pulsating abdominal mass, and swelling of unilateral leg. The fistula was preoperatively diagnosed in one and in another it was suspected intraoperatively by careful palpation of continuous thrill on the aneurysm. Successful surgical management was accomplished in both patients. Awareness of this clinical entities is necessary to manage this rare complication in abdominal aortic aneurysm surgery.

Arterial reconstructions for iliac artery obstruction (IAO) were performed in 81 patients (70 males and 11 females) with arteriosclerosis obliterans (80) and thromboangiitis obliterans (1) from January 1979 to January 1991. Ages ranged from 36 to 79 with a median age of 63.4. Aortofemoral bypass (AF-B) was performed in 46 cases (including 21 Y graft patients), thromboendarterectomy (TEA) in 11, femoro-femoral cross-over bypass (FF-B) in 26 and axillo-femoral bypass (AXF-B) in 2. No patients in the AF-B, TEA or AXF-B group showed postoperative early occlusion, while two in the FF-B group had early occlusion. The bypass flow measured intra-operatively using an electro-magnetic flowmeter was 50-1, 100 (average 382) ml/min in the AF-B, 190-500 (331) ml/min in the TEA, 90-650 (219) ml/min in the FF-B, and 200ml/min in the AXF-B group. Two patients died; one from ischemic colitis and the other from myonephropathic metabolic syndrome. The long-term cumulative patency rates at 1, 2 and 5 years were 100, 96, and 96% in the AF-B, 100, 100, and 100% in the TEA, and 90, 84, 63% in the FF-B group, respectively. The two AXF-B cases had good patency one year and three years postoperatively. AF-B should be recommended for aorto-iliac obstruction even in high risk patients as long as severe heart disease is absent, because of the long-term patency rate. An additional bypass to the popliteal region should be performed, if bypass flow to the distal region is low.

BACKGROUND/AIMS: The sensitivity of the upper and lower esophageal mucosa to acid is considered to differ. We investigated the relationship between pH changes in different sites of the esophagus and generation of gastroesophageal reflux symptoms during an acid infusion test. METHODS: An acid infusion catheter was placed at 5 or 15 cm above the lower esophageal sphincter (LES) in 18 healthy volunteers, while a 2-channel pH sensor catheter was also placed in each with the sensors set at 5 and 15 cm above the LES. Solutions containing water and hydrochloric acid at different concentrations were infused through the infusion catheter. RESULTS: Acid infusion in the upper esophagus caused a pH drop in both upper and lower esophageal sites, whereas that in the lower esophagus resulted in a significant pH drop only in the lower without a corresponding pH decline in the upper esophagus. Stronger heartburn, chest pain, and chest oppression symptoms were noted when acid was infused in the upper as compared to the lower esophagus, while increased intra-esophageal acidity strengthened each symptom. Regurgitations caused by upper and lower esophageal acid infusions were similar, and not worsened by a larger drop in intra-esophageal pH. Chest pain was caused only by lowered intra-esophageal pH, while heartburn, chest oppression, and regurgitation were induced by a less acidic solution. CONCLUSIONS: Higher intra-esophageal acidity caused stronger heartburn, chest pain, and chest oppression symptoms. However, regurgitation was not significantly influenced by intra-esophageal acidity. The upper esophagus showed higher acid sensitivity than the lower esophagus.
Adult ; Catheters ; Chest Pain ; Esophageal pH Monitoring* ; Esophageal Sphincter, Lower ; Esophagus ; Gastroesophageal Reflux* ; Heartburn ; Humans ; Hydrochloric Acid ; Hydrogen-Ion Concentration ; Mucous Membrane ; Thorax ; Water

Objective:Marketing specialists (MSs) from pharmaceutical wholesalers might shore up post-marketing surveillance (PMS) by pharmaceutical manufacturers. The purposes of this study were as follows: to research problems in PMS found by market specialists, to find solutions for these problems, and motivating MSs to work on PMS. Methods: We conducted a workshop with 12 MSs, who were already working on PMS operations. Participants were divided into three groups. Each group discussed problems with their PMS operations using the KJ method, discussed the potential solutions for the problems, and finally presented them in a plenary debate session. Questionnaire surveys were conducted for the participants before, immediately after, and 6 months after the workshop. Results: This workshop revealed two crucial and urgent problems on PMS faced by MSs: lack of feedbacks to clinical site and lack of publicity of the significance of PMS by MSs. Several solutions were suggested: browsing system of collected information, publication of the stages of improvement in pharmaceutical preparations and packaging, and distributing leaflets about PMS by MSs. In addition, this workshop conferred a positive influence on the participants: in the post-workshop questionnaires, most of the participants answered that they could well understand the problems (92%) and the solutions (75%) on PMS, and that they could improve their attitudes toward PMS operations (83%). . Conclusion: This workshop was quite effective for most of the participants in searching the problems, considering the solutions, and improving their attitudes. Organization of several such workshops might result in better PMS by MSs.

Takotsubo cardiomyopathy is a transient wall motion abnormality of the left ventricular apex, accompanied by emotional or physical stress. Although Takotsubo cardiomyopathy is generally considered a benign disease, severe clinical complications may occur, and early detection of the disease is important. In this report, we present the case of an 86-year-old bedridden woman with a history of bronchial asthma who was transferred to our hospital because of wheezing. She was diagnosed with Alzheimer’s disease and had communication difficulties. After an asthma attack and improvement, Takotsubo cardiomyopathy was identified via electrocardiography. She was unable to complain of any symptoms but showed serial electrocardiographic changes, elevated myocardial markers, and transient left ventricular apical ballooning. The prevalence of dementia increases dramatically with age. This case indicates that Takotsubo cardiomyopathy may occur even in patients with severe dementia, who are bedridden and show communication difficulties in a clinical setting.