A 69-year-old male complained of intermittent claudication of the right leg. Computed tomography revealed a right femoral artery stenosis with severe calcification and intimal thickening extending to the superficial and deep femoral arteries. Femoral endarterectomy and decalcification was carried out using the Cavitron Ultrasonic Surgical Aspirator (CUSA). All arteries were repaired by an ePTFE Y-shaped patch. Postoperative CT showed no stenosis and progressive calcification of the common, superficial and deep femoral arteries 2 years after surgery.

A 74-year-old woman presented to our hospital with complaints of dysphagia. On examination, we diagnosed extensive thoracic aortic aneurysm and esophageal compression due to a descending thoracic aortic aneurysm. We planned a two-stage approach for repairing the extensive thoracic aortic aneurysm ; the first stage involving the repair of the ascending and arch segments, and the second stage involving the repair of the descending aorta. In the first stage, we performed the Bentall procedure and total arch replacement with a long elephant trunk. Following this, her dysphagia resolved, although the size of the descending aortic aneurysm was the same as that before the procedure (49 mm in diameter). We decided to treat her conservatively in the outpatient clinic without the second stage, because the descending aorta was asymptomatic and not sufficiently large. One year later, she presented with a sudden recurrence of dysphagia and swelling of buttocks. She was diagnosed with an expansion of the descending aortic aneurysm (62 mm in diameter) and a hematoma in the gluteal muscle due to aneurysm-induced disseminated intravascular coagulation (DIC). After emergency admission, she underwent a successful thoracic endovascular aortic repair and was discharged following a smooth recovery from dysphagia and aneurysm-induced DIC. We report this case along with a review of the literature.

“Depolarized arrest”, induced by hyperkalemic (moderately increased extracellular potassium) cardioplegia is the gold standard to achieve elective temporary cardiac arrest in cardiac surgery. Hyperkalemic cardioplegic solutions provide good myocardial protection, which is relatively safe, and easily and rapidly reversible. However, this technique has detrimental effects associated with ionic imbalance involving sodium and calcium overload of the cardiac cell induced by depolarization of the cell membrane. Hence, the development of an improved cardioplegic solution that enhances myocardial protection is anticipated as an alternative to hyperkalemic cardioplegia. In this review, we assess the suitability and clinical potential of cardioplegic agents to induce “non-depolarized arrest” from the viewpoint of rapid cardiac arrest, myocardial protection, reversibility, and toxicity. “Magnesium cardioplegia” and “esmolol cardioplegia” have been shown to exert superior protection with comparable safety profiles to that of hyperkalemic cardioplegia. These alternative techniques require further examination and investigation to challenge the traditional view that hyperkalemic arrest is best. Endogenous cardioprotective strategies, termed “ischemic preconditioning” and “ischemic postconditioning”, may have a role in cardiac surgery to provide additional protection. The elective nature of cardiac surgery, with the known onset of ischemia and reperfusion, lends it to the potential of these strategies. However, the benefit of preconditioning and postconditioning during cardiac surgery is controversial, particularly in the context of cardioplegia. The clinical application of these strategies is unlikely to become routine during cardiac surgery because of the necessity for repeated aortic crossclamping with consequent potential for embolic events, but offers considerable potential especially if “pharmacological” preconditioning and postconditioning could be established.

Congenital heart disease of partial anomalous pulmonary venous drainage of entire left lung without other cardiac anomaly was very rare. 21-year-old man, who was pointed out heart disease 6 months ago, was diagnosed as partial anomalous pulmonary venous drainage of entire left lung without other cardiac anomaly by cardiac catheterization and angiography. The patient underwent surgery through the left forth intercostal incision without cardiopulmonary bypass. The end-to-side anastomosis was made between the vertical vein and the left atrial appendage following ligation of the vertical vein near the innominate vein. Surgical treatment was satisfactory in the postoperative angiography which was shown widely patent anastomosis. He was discharged with uneventful postoperative course and returned to full activity.

Surgery and cryoablation have been the preferred method for treating drug resistant ventricular tachycardia (VT). Cryoablation, the therapeutic usefulness of which has been documented in many reported studies, is nevertheless not free from technical difficulaties. The advent of Bard^® System 6000 Argon beam coagulator (ABC) as a new procedure alternative to cryoablation offered us a hope for solving problems with conventionally used techniques. Preliminary experiments with this device on dog myocardium permitted us to determine therapeutically adequate irradiation time and depth of cauterization and to locate an optimum area of myocardium to be coagulated. Based on these experiences, an attempt was made to use ABC as an adjunct to surgery in the surgical treatment of 4 patients with monofocal non-ischemic VT. In 1 of these 4 patients, VT disappeared postoperatively, making use of antiarrythmia drugs quite unnecessary, while in the remaining 3, a marked diminution of ventricular arrhythmia with a consequent reduction of drug dosage was achieved, use of the device thus being judged to be beneficial. These results led to the conclusion that ABC will provide a valuable adjunct to operation in selected cases of VT and, if the probe and other appliances are further refined, can reasonably be anticipated to be used as frequently as cryoablation.

We studied cardiac function and outcome long after aortic valve replacement using a 19mm bileaflet valve. The subjects consisted of 10 of 12 patients living 10 or more years after the operation and 7 of 8 living 5-9 years after the operation. We measured the left ventricular ejection fraction (LVEF), %fraction shortening (%FS), left ventricular diastolic dimension (LVDd), systolic dimension (LVDs), PWT, IVST, and LV-aortic pressure gradient (PG) of in 6 patients each in 10 more years after the operation (Group I) and 5-9 years after the operation (Group II) who underwent ultrasonography, and calculated the left ventricular mass index (LVMI). No statistically significant differences were seen in either parameter in either group. Prognosis was 1 cardiac 2 cancer deaths each in 10 or more years after the operation group. The cumulative survival rate was in 85.7% post operative 5-9 years and 72.7% in 10 years. Although cardiac function was maintained in both groups, more observation is needed from now on because the pressure difference or LVMI may increase.

Treating a thoracic aortic aneurysm (TAA) after coronary artery bypass graft (CABG) surgery requires an appropriate surgical procedure to preserve the functional graft. We present a case of hybrid procedure of thoracic endovascular aortic repair combined with a redo off-pump CABG via median sternotomy. The patient was a 76-year-old man with a history of CABG and abdominal aortic replacement in a different country. Chest computed tomography revealed a saccular-shaped aortic aneurysm in the distal aortic arch with diameter of 5.6 cm. Coronary angiography revealed theLIMA graft was patent but anastomosed to the diagonal branch and the left anterior descending artery (LAD) was totally occluded and was opacified through the right coronary artery. Significant ischemic change in the anteroseptal wall suggested a requirement of surgical revascularization of LAD. The chest was opened via re-midsternotomy. Then the 3 arch vessels were reconstructed with a trifurcated artificial graft attached to the ascending aorta and coronary artery bypass grafting was performed on the beating heart. Finally, the aneurysm was excluded by introducing a stent graft through the graft to zone 0. The patient's postoperative course was uneventful and he was discharged on postoperative day 16. A hybrid procedure via median sternotomy was useful in the surgery for TAA with the functional LIMA after CABG.

BACKGROUNDTo summarize the effect of Iressa for refractory patients with advanced non small cell lung cancer (NSCLC) failed to prior chemotherapy.

METHODSThirty-one patients, with unresectable stage IIIB or IV NSCLC who had disease progression or relapse after prior chemotherapy using platinum-based regimen for at least 2 cycles, were admitted to the Osaka Prefectural Hobikino Hospital. Iressa 250 mg was administered once a day until disease progression was noted. Weekly chest x-ray and monthly CT scan were performed for response assessment each month.

RESULTSAmong the 31 patients, one complete response (CR) and 7 partial responses (PR) were observed. CR rate was 3.2% (95% confidence interval: 0-17%), PR rate 22.6% (95% confidence interval: 10%-41%), disease control rate including both tumor responses and stable disease was 80.6% (95% confidence interval: 52%-92%). The rate of symptoms relieves was 51.6% (95% confidence interval: 33%-70%), the most effective symptoms being cough and pain. The median time to improved symptoms was 14 days. The most common adverse events were grade I or II skin rash and diarrhea which were readily manageable and reversible. No patients were withdrawn due to the adverse events

CONCLUSIONSMonotherapy using Iressa is effective and tolerable for the patients with advanced NSCLC who failed prior chemotherapy.