A 73-year-old man had been followed up in our hospital after surgery for mitral regurgitation. At the age of 67, he underwent mitral valve plasty through a right mini-thoracotomy approach for atrial functional mitral regurgitation at our hospital. The mean trans-mitral pressure gradient was 5 mmHg after surgery but no heart failure symptoms were observed. At the age of 72, he began to notice fatigue during exertion. Transthoracic echocardiography revealed that the mitral valve regurgitation was controlled to a trace level, but the mean trans-mitral pressure gradient increased to 10 mmHg. Transesophageal echocardiography and contrast-enhanced cardiac computed tomography revealed the restricted opening of the mitral valve and pannus formation around the prosthetic ring. We thus diagnosed mitral stenosis due to pannus overgrowth. He underwent pannus excision and removal of the artificial ring. Postoperative echocardiography revealed that the mean trans-mitral pressure gradient was reduced to 3 mmHg and no residual mitral regurgitation was observed. He was discharged on postoperative day 11 with no major symptoms. He was in New York Heart Association functional class I at 1 year after the surgery and continues to be an outpatient.

A 74-year-old woman was scheduled for total arch replacement because of an enlarging thoracic aortic aneurysm in the aortic arch. Her preoperative blood test showed an elevated cold agglutinin with a titre of 2,048. There was concern about hemagglutination during hypothermia and hemolysis when returning to natural temperature under hypothermic circulatory arrest. We usually use moderate hypothermia (a minimum rectal temperature of 27℃) with circulatory arrest during total arch replacement. A cooling test was performed with her blood, which found no coagulation reaction in vitro at 25℃. There was a possibility that the total arch replacement would be carried out under moderate hypothermia, but it was by no means certain. After discussing the case with the hematologist, anesthetist, and clinical engineer, we decided on a minimum temperature of 30℃ during circulatory arrest because hemagglutination or hemolysis can become an issue in cardiopulmonary bypass. Coronary perfusion was maintained by infusing blood cardioplegia at 30℃ every 30 min. The intra-aortic occlusion balloon was inflated in the descending aorta, and perfusion of the spinal cord and lower body was initiated via the left femoral artery during circulatory arrest. Total selective cerebral perfusion flow was maintained at 1.5 times normal (20 ml/kg/min). There was no hemagglutination or hemolysis during the operation and no neurological complications in the postoperative period. For patients with cold agglutinin, individual cardiopulmonary bypass planning is necessary, depending on the severity of the condition and operative method.

BACKGROUND: The Hokkaido Study on Environment and Children's Health is an ongoing study consisting of two birth cohorts of different population sizes: the Sapporo cohort and the Hokkaido cohort. Our primary objectives are to (1) examine the effects that low-level environmental chemical exposures have on birth outcomes, including birth defects and growth retardation; (2) follow the development of allergies, infectious diseases, and neurobehavioral developmental disorders, as well as perform a longitudinal observation of child development; (3) identify high-risk groups based on genetic susceptibility to environmental chemicals; and (4) identify the additive effects of various chemicals, including tobacco. METHODS: The purpose of this report is to provide an update on the progress of the Hokkaido Study, summarize recent results, and suggest future directions. In particular, this report provides the latest details from questionnaire surveys, face-to-face examinations, and a collection of biological specimens from children and measurements of their chemical exposures. RESULTS: The latest findings indicate different risk factors of parental characteristics on birth outcomes and the mediating effect between socioeconomic status and children that are small for the gestational age. Maternal serum folate was not associated with birth defects. Prenatal chemical exposure and smoking were associated with birth size and growth, as well as cord blood biomarkers, such as adiponectin, leptin, thyroid, and reproductive hormones. We also found significant associations between the chemical levels and neuro development, asthma, and allergies. CONCLUSIONS Chemical exposure to children can occur both before and after birth. Longer follow-up for children is crucial in birth cohort studies to reinforce the Developmental Origins of Health and Disease hypothesis. In contrast, considering shifts in the exposure levels due to regulation is also essential, which may also change the association to health outcomes. This study found that individual susceptibility to adverse health effects depends on the genotype. Epigenome modification of DNA methylation was also discovered, indicating the necessity of examining molecular biology perspectives. International collaborations can add a new dimension to the current knowledge and provide novel discoveries in the future.
Biomarkers/blood* ; Child ; Child Health ; Child, Preschool ; Cohort Studies ; Environmental Exposure/adverse effects* ; Environmental Health ; Environmental Pollutants/adverse effects* ; Female ; Fetal Blood/chemistry* ; Follow-Up Studies ; Growth/drug effects* ; Humans ; Hypersensitivity/etiology* ; Infant ; Japan/epidemiology* ; Male ; Neurodevelopmental Disorders/etiology* ; Pregnancy ; Prenatal Exposure Delayed Effects/etiology* ; Prevalence ; Smoking/adverse effects*