A 64-year-old woman with an atrial septal defect (ASD) closure was referred to our hospital ; she presented with dyspnea at the time of admission. An echocardiogram showed mitral valve regurgitation, tricuspid valve regurgitation, and a residual ASD shunt. Coronary angiography revealed coronary-pulmonary artery fistulae originating from both the left anterior descending coronary artery and the right coronary artery (RCA). Closure of the coronary-pulmonary artery fistulae was performed in addition to mitral valve replacement, tricuspid valve plasty and ASD closure. The postoperative course was uneventful. Coronary angiography was performed, and some of the contrast medium remained in parts of the RCA fistulae. Ligation of the fistulae and direct closure of the intra-pulmonary openings during cardiopulmonary bypass had to be performed because of complete obstruction of the coronary-pulmonary artery fistulae.

Habitual smoking adversely affects the functions of the respiratory system. A Survey was conducted on 100 patients with respiratory diseases in the authors' institute regarding individuals' smoking habit and the following results were obtained.
1) Some respondents say they have difficulty abstaining from smoking though they perceive its unfavorable effects on their health. However, they feel a persuasive “recommendation to give up smoking” by the attending physicians a great help, and 2) earnest instruction and education for the patients are very important as many patients feel good after giving up smoking.
The relationship between habitual smoking and carbon monoxide (CO) concentration in the expired air was determined in 67 healthy volunteers with an ambulatory CO analyzer and the following results were obtained.
1) There was a significant difference in the CO concentrations in the expired air between non-smokers and smokers, 2) there were positive relationships between the CO concentrations in the expired air and daily numbers of cigarettes smoked and smoking index, 3) problems relating to passive smoking became evident, and 4) the ambulatory CO analyzer for the determination of the concentration of CO in the expired air is considered useful for the anti-smoking guidance and instructions.

Papillary fibroelastoma is a rare, benign heart tumor. We successfully treated a patient with multiple fibroelastomas derived from both the mitral valve and the chordae by surgical excision. A 59-year-old man was admitted to our hospital with a history of myocardial infarction three years before admission. Preoperative transthoracic and transesophageal echocardiograms showed multiple, mobile, rounded cardiac tumors in the left ventricular cavity and the mitral valve. Under cardiopulmonary bypass, we performed prosthetic mitral valve replacement after excising the valve with the tumor. The patient was discharged and remains asymptomatic. Histologic examination of 6 specimens of the excised tumor confirmed the diagnosis of papillary fibroelastoma. When papillary fibroelastoma is diagnosed, surgical treatment must be considered because of the high risk of embolization.

We report the case of a 52-year-old man who presented with a 2-week history of exertional dyspnea and was admitted to our hospital with heart failure. Coronary angiography showed severe three-vessel disease ; left ventriculography revealed an aneurysm in the inferior left ventricular (LV) wall perforating into the right ventricle. We suspected the LV aneurysm was from a previous myocardial infarction (MI) that had perforated into the right ventricle, although the time of MI was unclear. The patient was treated with medications initially. We subsequently treated the patient by LV aneurysm closure using a patch and direct closure of the perforation by incising the aneurysm. Coronary artery bypass grafting was performed in the left anterior descending artery, the diagonal artery, and the right coronary artery simultaneously. After having an uneventful postoperative course, he was discharged from the hospital in a stable condition. A pathology examination confirmed a diagnosis of LV pseudo-false aneurysm.

Distigmine has reversible and persistent cholinesterase (ChE) antagonism, and is used for the dysuria due to low activity bladders such as the neurogenic bladder dysfunction widely postoperatively, but fatal cases were reported by cholinergic syndrome. Therefore a dose was limited to 5mg only for adaptation of “the dysuria due to hypotonic bladder such as after surgery and the neurogenic bladder dysfunction” in March, 2010. In the current study, we examined a ministerial policy in the package insert revision using Japanese Adverse Drug Event Report database (JADER). Using a side effect report registered with JADER from January, 2004 to June, 2016, we calculated Reporting Odds Ratio (ROR) which was the index of the safe signal of the medical supplies adverse event and we compared number of reports and ROR of the cholinergic syndrome by the distigmine in approximately the measure in March, 2010 and evaluated it. The number of reports of the cholinergic syndrome by the distigmine was 138 cases before March 2010 and 65 cases after March 2010. After a measure, the number of reports decreased. The possibility that the package insert revision of the distigmine contributed to a decrease in cholinergic syndrome onset was suggested. Whereas monitoring careful sequentially needs the onset of the cholinergic syndrome in constant frequency to be found.