We reviewed our experience with 19mm size aortic valve prostheses for cases with small aortic annulus. Forty-six patients operated on between 1990 and Septembr 2002 were enrolled in this study. Clinical late assessment was performed to evaluate the incidence of valverelated complications, residual transprosthetic gradient, left ventricular mass index (LVMI), and NYHA functional class. Postoperative echocardiography was performed to evaluate hemodynamic performance of the prostheses. Follow up was 1 to 12.7 years (mean 5.3±3.6). There was no hospital mortality (0%). Actuarial survival rates at 10 years were 81.4±1.5%. The late postoperative peak gradient was 25±11mmHg. LVMI was significantly reduced in late phase. NYHA functional class significantly improved in the late period. Although 19mm size aortic valve prosthesis remains small transprosthetic pressure gradient, LVMI significantly reduced and patient activity was satisfactory maintained in the late period.

A 53-year-old woman underwent mitral valve replacement for congestive heart failure due to mitral stenosis and regurgitation. She had been receiving hemodialysis because of diabetic nephropathy since 1993, and had had congestive heart failure since 1999. Echocardiography demonstrated mitral stenosis (MVA; 1.10cm²) and regurgitation with a severely calcified mitral annulus. Annular calcification extended to the posterior wall of the left ventricle and the base of bilateral papillary muscles. After removing all calcium from the mitral annulus to the base of the papillary muscle, the left ventricular posterior wall and mitral annulus were reconstructed by glutaraldehyde-preserved autologous pericardium. Then, a Carbo-Medics mechanical valve was placed at the mitral annulus using everting mattress sutures. Although her hemodynamics were stable, bacteremia and multi-organ failure developed 3 months after surgery and she died. Autopsy showed that the reconstructed left ventricular posterior wall and mitral annulus using glutaraldehyde preserved autologous pericardium were in excellent condition without any thrombus. No dehiscence was found at the suture line of the mechanical valve. Mitral annulus reconstruction with glutaraldehyde preserved autologous pericardium is thought to be effective for patients with calcified mitral annulus who require mitral valve surgery.

Abdominal aortic aneurysms (AAA) are frequently associated with clinically significant coexistent ischemic heart disease (IHD). Cardiac events are the most common cause of death after AAA repair. Preoperative coronary evaluation and revascularization have been recommended to reduce postoperative cardiac complications following AAA repair. In this study, we retrospectively reviewed all patients who underwent AAA repair and compared operative results in patients with and without IHD. Of 388 patients who underwent elective AAA repair, 382 (98.5%) had aortography and coronary angiography for preoperative evaluation. Significant coronary artery disease was seen in 124 patients (32.5%). As a result of the evaluation, 46 patients (12.0%) were considered candidates for medical therapy, 18 for percutaneous coronary intervention (PCI), and 60 for coronary artery bypass grafting (CABG). In 24 patients (6.3%) who needed CABG and had large sized AAAs (>60mm), simultaneous CABG and AAA repair were performed. In the remaining 36 patients (9.4%) who needed CABG and had medium sized AAAs (40mm<, <60mm), staged operation was performed. We performed retrospective review comparing postoperative cardiac events and operative mortality among these treatment groups. There were 5 operative deaths (5/388, 1.3%) in patients following AAA repair. There were 2 operative deaths (2/124, 1.6%) in patients with significant IHD and 3 deaths (3/258, 1.2%) without IHD. In patients with IHD, 1 patient who received medical therapy died of acute renal failure and another one who received PCI died of acute myocardial infarction. There were no operative deaths or cardiac-related events in patients who received CABG before or concomitant AAA repair. There was only 1 cardiac-related event in all patient groups following AAA repair. Coronary arteries were preoperatively evaluated in almost all patients with AAA. If IHD was significant, the treatment for the IHD preceded AAA repair. Our strategy succeeded in reducing operative mortality and cardiac-related events in patients with both AAA and IHD. If a patient with a large sized AAA (>60mm) needs CABG, one-stage operation is recommended.

To demonstrate the quality assurance of the comprehensive examination of sixth-year students at Nippon Medical School, 4 undergraduate examinations were compared with the national examination for medical practitioners (NEMP) using scatter graphs and Pearson's correlation coefficient. Of the 93 sixth-year students at Nippon Medical School, 57%(n=53) reported their scores on the NEMP in response to a request from the Academic Quality and Development Office. Correlation coefficients of the grade point average (years 1 to 5), average scores on graduation examinations of 24 subjects, scores on the trial examination of NEMP, and scores on the sixth-year comprehensive examination with overall scores on the NEMP were 0.62, 0.46, 0.68, and 0.63, respectively. These results suggest that the sixth-year comprehensive examination is more suitable than are graduation examinations for predicting the NEMP score.

To demonstrate the quality assurance of comprehensive examinations for fourth-year students at Nippon Medical School, scores on comprehensive examinations were compared with those on a trial of computer-based testing (CBT) of a nationwide medical and dental student evaluation system in 2003. Pearson's correlation coefficients between scores of two comprehensive examinations and the CBT score were 0.45 and 0.67, and the correlation coefficient between the average score of the two comprehensive examinations and the CBT score was 0.55. Fourth-year comprehensive examinations are useful tools for summative evaluation and prediction of CBT performance.

An emergency percutaneous cardiopulmonary support system (PCPS) was employed 11 arrest victims (5 males, 6 females; mean age 59.3 years) refractory to conventional resuscitation measures. Cardiac operation was subsequently performed in two patients and coronary angioplasty in two. The 7 other patients continued on cardiopulmonary support by PCPS after successful resuscitation. Duration of support was 10.5±9.1 (mean±S. D.) hours, the flow rate was 2.5±0.7l/min, and PCPS was applied 5-70min (mean, 24.9min) following the onset of cardiac arrest. The entire intraluminal surface of PCPS device had been heparin coated, activated coagulation time was maintained about 150 seconds, with or without minimal systemically administered heparin. Seven of 11 patients (63.6%) were successfully weaned from the PCPS. The early survival (<30 days) was 6 patients (54.5%), and late survival was 4 patients (36.4%). We conclude that PCPS can improve survival in patient unresponsive to conventional resuscitation when instituted soon after cardiac arrest.

Between December of 1989 and May of 1993, 7 of 338 patients (2.1%) who underwent median sternotomy for cardiac operations developed mediastinitis. All of these infections caused by Staphylococcus species. Six of seven patients with mediastinitis were successfully treated with debridement, irrigation and omental transposition into the mediastinum. Between December of 1989 and May of 1992, sterile bone wax was used as a hemostatic agent in 233 of these patients. Between June of 1992 and May of 1993 an argon beam coagulator was used in place of bone wax in 105 patients. The incidence of mediastinitis significantly differed in relation to whether patients received bone wax or not (7 of 233 patients who did (3.0%) versus none in 105 patients who did not (0%) p<0.01). We conclude from this study that bone wax may be a promoting agent in postoperative mediastinitis, so the routine use of bone wax should be reconsidered.

Extracorporeal shock wave lithotripsy (ESWL) represents the preferred treatment for most upper ureteric and renal calculi. Complication rates associated with ESWL are low, justifying the enthusiasm and acceptance of this treatment modality. We report a case of abdominal aortic pseudoaneurysm due to ESWL. A 47-year-old man had undergone ESWL treatment for ureteric calculi since 1990. He was admitted to our hospital because of lumbar pain. Physical examination revealed a pulsatile mass in his abdomen. Abdominal CT scan showed an abdominal aortic aneurysm (5.3cm in diameter). Angiography showed a fusiform aneurysm of the infrarenal abdominal aorta. Y-graft replacement was performed after aneurysm resection. Histological examination revealed that it was a pseudoaneurysm. The patient had no history of trauma, inflammation or operation except ESWL. This is the first report of abdominal aortic pseudoaneurysm due to ESWL.

Retroperitoneal hematoma (RH) due to radiologic intervention for an intracranial lesion is relatively rare, difficult to diagnose, and can be life-threatening. We report a case of RH that developed in a patient on anticoagulant therapy following endovascular coiling of a ruptured anterior communicating artery (AcoA) aneurysm. An 82-year-old man presented with a 12-day history of headache. Computed tomography (CT) on admission demonstrated slight subarachnoid hemorrhage, and left carotid angiography revealed an AcoA aneurysm. The next day, the aneurysm was occluded with coils via the femoral approach under general anesthesia. The patient received a bolus of 5,000 units of heparin immediately following the procedure, and an infusion rate of 10,000 units/day was initiated. The patient gradually became hypotensive 25 hours after coiling. Abdominal CT showed a huge, high-density soft-tissue mass filling the right side of the retroperitoneum space. The patient eventually died of multiple organ failure five days after coiling. RH after interventional radiology for neurological disease is relatively rare and can be difficult to diagnose if consciousness is disturbed. This case demonstrates the importance of performing routine physical examinations, sequentially measuring the hematocrit and closely monitoring systemic blood pressures following interventional radiologic procedures in patients with abnormal mental status.
Aged, 80 and over ; Anesthesia, General ; Aneurysm ; Angiography ; Arteries ; Consciousness ; Headache ; Hematocrit ; Hematoma ; Heparin ; Humans ; Intracranial Aneurysm ; Multiple Organ Failure ; Physical Examination ; Radiology, Interventional ; Subarachnoid Hemorrhage

BACKGROUND: We hypothesized that cross-clamping of the descending thoracic aorta (CcDTA) would result in significant changes in plasma propofol concentrations (Cp) proximal and distal to the cross-clamp. We investigated the effect of CcDTA on Cp centrally and distally, including the pulmonary artery and the cardiopulmonary bypass (CPB) cannula. METHODS: The bispectral index (BIS) was recorded during CcDTA in eight patients undergoing thoracic aortic surgery using target-controlled total intravenous anesthesia with propofol. The calculated Cp was maintained at 3 microg/ml. Cp was measured in blood samples drawn from the right radial artery, left dorsalis pedis artery, pulmonary artery, and the long venous CPB cannula. RESULTS: Complete data were obtained from six patients. BIS decreased significantly in all cases 5 minutes after initiating CcDTA. BIS continued to decrease in association with increasing propofol concentrations. During CcDTA, Cp in samples from the radial and pulmonary arteries (3.5 +/- 0.50 and 2.9 +/- 0.63 microg/ml, mean +/- SD) was significantly higher than in samples from the dorsalis pedis artery and the venous cannula (1.1 +/- 0.22 and 1.4 +/- 0.02 microg/ml) (P < 0.05). CONCLUSIONS: The results suggest that almost all of the blood returning from the superior vena cava during CcDTA directly enters the pulmonary circulation without mixing with blood from the inferior vena cava. Observed changes in anesthetic blood concentrations could be due to the presence of a split circulation and asymmetrical distribution of propofol induced by CcDTA and CPB.
Anesthesia, Intravenous ; Aorta, Thoracic ; Arteries ; Cardiopulmonary Bypass ; Catheters ; Humans ; Plasma ; Propofol ; Pulmonary Artery ; Pulmonary Circulation ; Radial Artery ; Vena Cava, Inferior ; Vena Cava, Superior