We report a case of quadricuspid aortic valve concomitant with infective endocarditis. A 73-year-old woman was admitted to our hospital because of general fatigue, loss of body weight and high fever. Transthoracic echocardiography showed moderate aortic regurgitation and left ventricle-right atrium fistulae with vegetation. Infectious endocarditis was diagnosed. Since her fever and hemolytic anemia were not controlled by antibiotics, we operated and the aortic valve had four cusps and there were vegetations on the aortic valve and left ventricle outflow tract. Perforation of the membranous septum was observed. Complete debridement and aortic valve replacement with patch repair of a left ventricle-right atrium (LV-RA) fistula was performed. Although she needed a permanent pacemaker due to complete AV block, her postoperative course was uneventful.

A 56-year-old woman was admitted due to a cerebral hemorrhage two years after undergoing aortic valve replacement, mitral valve annuloplasty, and tricuspid valve annuloplasty. During treatment, she developed infective endocarditis. Although this was successfully treated conservatively, a surgical approach was subsequently adopted due to progressive mitral stenosis. Echocardiography revealed gradual proliferation of abnormal tissue overhanging the mitral valve around the prosthetic mitral annularring, as well as increased flow velocity in the artificial aortic valve. The cause of the increased flow velocity could not be determined on echocardiography. However, multidetector computed tomography revealed abnormal subprosthetic tissue that obstructed the opening and closing of the prosthetic aortic valve. Resection of the abnormal tissue and double valve replacement were performed. Prosthetic valve dysfunction due to pannus proliferation is relatively rare (around 1-2%), but it should be considered as a potential long-term postoperative complication. Though turbulent flow has been suggested as a potential cause, the exact etiology remains unknown. Furthermore, the disease course may be fulminant or gradual and symptomatic, leading to difficulties with diagnosis. A case of double valve replacement conducted for valve dysfunction due to abnormal tissue proliferation occurring two years after aortic valve replacement, mitral valve annuloplasty, and tricuspid valve annuloplasty followed by infective endocarditis is reported, along with a review of the related literature.

There are few reports of prosthetic valve endocarditis due to Corynebacterium striatum. Here we report a case of prosthetic valve endocarditis after mitral valve replacement. A 77-year-old woman, who underwent mitral valve replacement and tricuspid valve annulo-plasty 4 months previously, was admitted to our hospital because of shock and loss of consciousness. A transthoracic echocardiogram showed severe mitral regurgitation due to dehiscence of the prosthetic mitral valve. We used the percutaneous cardiopulmonary support system for the management of circulatory collapse and, performed emergency mitral valve replacement. We detected C. striatum in preoperative blood and vegetation cultures. Antibiotic therapy was continued for 6 weeks, and the patients recovered without any complications.

We evaluated the relation of changes in skin temperature, measured by thermography, to clinical symptoms and findings in patients who underwent coronary artery bypass surgery using the radial artery. All had a negative Allen test before operation. Ten consecutive patients who underwent surgery at least 3 months prior to the study were selected. Left radial artery grafts were harvested in all patients. Skin temperature was measured twice, before and after exercise. Two patients had a cold sensation at the arterial harvest site at rest. Three, including these two, complained of pain along the harvest site after exercise. No differences in temperature were observed before and after exercise in the ulnar aspects of the palm or forearm on either the left or right side. On the other hand, the increase in radial aspect temperature on the left side was smaller than that on the right. Skin temperature was clearly decreased after loaded exercise in 3 patients. We believe that the indications of grafting should be carefully considered because patients can show findings associated with circulatory disturbance at arterial harvest sites.

We report a rare case of acute type A aortic dissection with paraplegia which was reversed using cerebrospinal fluid drainage (CFD). The patient was a 80-year-old man who was admitted with acute back pain and paraplegia. Computed tomographic scans showed an acute type A aortic dissection. Four hours after onset of paraplegia, CFD was initiated by inserting an intrathecal catheter at L3-L4. Cerebrospinal fluid was drained freely by gravity whenever the pressure exceeded 10cmH₂O. After 32h, the neurological deficit was completely resolved. CFD can be considered a useful treatment in patients with paraplegia after acute aortic dissection.

The purpose of this study was to investigate the pharmacokinetics of teicoplanin (TEIC) in patients undergoing open heart surgery. We also attemped to define the optimum TEIC therapy protocol for prevention of perioperative infection and for treatment of staphylococcal endocarditis such as that caused by methicillin-resistant Staphylococcus aureus (MRSA). Serum TEIC concentrations were measured in 14 patients divided into two groups of 7 patients each undergoing elective open heart surgery. Patients in group I received 400mg of TEIC and patients in group II received 800mg, both administered as a slow intravenous infusion over 20min immediately after induction of anesthesia. The peak serum level (mean±standard error) of TEIC was respectively 57±11 and 139±39μg/ml at 2min after administration and then the TEIC level decreased gradually to 26± 7 and 55±10μg/ml at 60min after administration. The serum level of TEIC decreased rapidly to 17±5 and 31±7μg/ml, respectively, at the start of extracorporeal circulation (ECC), and was 11±2 and 27±6μg/ml after 60min of ECC, 8±2 and 23±7μg/ml at 2min after the termination of ECC, 8±3 and 23±6μg/ml at 60min after the termination of ECC, and 7±2 and 22±5μg/ml on admission to ICU. No side effects were seen during the study, such as red neck syndrome, renal dysfunction, hearing disorders, or postoperative infection. Our results suggested that the optimum dose of TEIC for prevention of perioperative infection was around 400mg, providing levels in excess of the MIC for most pathogens that have been found to cause infection following open heart surgery, including MRSA. In addition, a dose of 800mg was needed to keep trough levels above 20μg/ml for treatment of staphylococcal endocarditis. It was also suggested that half of the initial dose should be administered on admission to ICU and also at the start of ECC if the operation is going to last longer than 7h on the basis of the concentration-time curve.

This paper reports on a case in which a heavily-calcified so-called “porcelain aorta” (including the ductus arteriosus) was observed, together with a patent ductus arteriosus and aortic stenosis associated with a bicuspid aortic valve. A 76-year-old man had been referred to our hospital on a diagnosis of aortic stenosis. Since angiography revealed slight contrast in an area on the right side of the heart, echocardiography was performed and revealed patent ductus arteriosus. Severe circumferential calcification of the ascending aorta and aortic arch was observed on CT scans. Almost no calcification was observed in other areas. Aortic valve replacement and closure of the ductus arteriosus (transpulmonary approach) were performed by means of a balloon to temporarily occlude the aorta, as surgical clamping was impossible due to calcification. Hypothermic systemic perfusion and antegrade selective cerebral perfusion were used. The postoperative progress of the patient was good. Bicuspid aortic valve and patent ductus arteriosus are highly likely to be present in combination in cases of congenital cardiac anomaly, and it is therefore necessary to be particularly attentive when diagnosing such cases. It was considered that our patient, an adult suffering patent ductus arteriosus, was a rare case in which the calcified ductus arteriosus was observed and the calcification had spread to the ascending aorta.

A 74-year-old man with renal failure had been treated with maintenance hemodialysis for 1.5 years at another hospital. The patient had an abdominal aortic aneurysm, bilateral iliac artery occlusion and coronary artery stenosis with a lesion in the left main trunk, but had been under observation because of the high risk of surgery. The patient elected to have surgery and was admitted to our hospital. We performed simultaneous surgery for severe coronary artery stenosis and abdominal aortic aneurysm with a maximum diameter of 85mm. The postoperative course was generally uneventful, but the patient required treatment of arrhythmia. We conclude that simultaneous surgery for angina pectoris and abdominal aortic aneurysm is feasible even in hemodialysis patients. It is important to pay attention to arrhythmia in the management of such patients, especially those with decreased cardiac function.

A 60-year-old male who had a history of Buerger's disease was admitted due to chest pain on exertion. Coronary angiography showed severe double vessel disease (the left anterior descending artery and the right coronary artery). Carotid angiography showed severe stenosis of the left internal carotid artery associated with brain ischemia. In addition, angiography of the lower extremities showed segmental occlusion and collateral arteries resembly a “corkscrew” appearance. We implanted a stent in the carotid artery followed by revascularization surgery of the left lower leg and simultaneous coronary artery bypass surgery. The postoperative course was excellent.

In view of the present situation of agriculture in which housewives have to handlethe bulk of farm work, a study was made on the health conditions of women engaged in farming in comparison with those of non-farmers.
The study covered a total of 28, 600 females, aged from 40 to 59, who received masshealth screenings conducted between 1978 and 1980 on rural inhabitants in Nagano Prefecture as part of the outreach program by the health service corps of our hospital.
All the examinees live in areas whose principal crops are rice, vegetables and/or fruits.
The data were arranged according to seasons based on the dates of health examination in order to clarify the seasonal variations of morbidity rates and other indices of health.
Another investigation was made into seasonal changes in the length of time used byhousewives in farming, domestic chores, rest and so on with a view to studying correlation between the mode of living and health conditions.
To sum up, our findings are as fllows:
(1) Seasonal variations in the results of various laboratory tests and morbidity rates were notable, depending on the amount of farm work, dietary habits, coldness and the height above sea level.
(2) During summer months, the incidence of anemia was exceedingly high, obesity rates plummeted, and serum cholinesterase values dropped sharply among housewives who are engaged in farm work, compared with those who are not.
(3) In summer, farm housewives worked long hours in the fields, slept less and rested less. They had not enough time to attend to household duties.