Primary cardiac tumors are rare. Myxoma is the most common type of benign cardiac tumor and papillary fibroelastoma (PFE) is the second most common. We report a case of coexisting left atrial myxoma and aortic valve PFE. A 77-year-old Japanese woman with a left atrial mass was referred to our hospital for further diagnostic evaluation and surgical treatment. The mass was detected by coronary computed tomography, which was performed by her general practitioner. Investigation with an echocardiogram revealed a mass on the fossa ovalis, extending into the left atrium. Intraoperative transesophageal echocardiography (TEE) showed another mass attached between the left coronary cusp (LCC) and the right coronary cusp of the aortic valve. After cardiopulmonary bypass and cardioplegic arrest, we performed an aortotomy, and observed the aortic valve. We found a mobile mass on the LCC and resected it. After left atriotomy, a left atrial myxoma was identified and resected, together with its margin. Postoperatively, sinus bradycardia, sinus pauses, and atrial fibrillation tachycardia were identified. Therefore, we implanted a permanent pacemaker on the 29th postoperative day. The patient was discharged on the 38th postoperative day. Simultaneous existence of two different primary cardiac tumors is rare. We believe that preoperative and intraoperative TEE in patients with cardiac tumors is important.

We report a patient who underwent an operation for an infectious abdominal aortic aneurysm 10 months after intravesical bacillus Calmette-Guerin therapy. A 68-year-old man had previous gastrectomy for early gastric cancer and intravesical BCG therapy for early stage urinary bladder cancer. His follow up CT scan revealed an abdominal aorta pseudoaneurysm. We performed aneurysmectomy, omentopexy and bilateral axillo-femoral bypass. The culture of an abscess in the aneurysm identified Mycobacterium bovis. The patients improved clinically with antituberculosis agents after operation. Intravesical bacillus Calmette-Guerin therapy is effective in the treatment of early stage urinary bladder cancer. Although this treatment is generally considered safe, serious complications including vascular complications have been reported.

We report 2 patients with unilateral pulmonary edema after heart surgery who were successfully treated using venovenous extracorporeal membrane oxygenation (VV ECMO). Case 1 : A 35-year-old woman presented with dyspnea. Echocardiography showed severe mitral regurgitation (MR) and tricuspid regurgitation (TR) and therefore, mitral valve plasty (MVP) and tricuspid annular plasty (TAP) were performed via right thoracotomy. After weaning from cardiopulmonary bypass, respiratory failure occurred with expectoration of foamy sputum and it was difficult to maintain oxygenation. Therefore, we performed VV ECMO to maintain oxygenation. A chest X-ray film after surgery showed ipsilateral pulmonary edema. After weaning from VV ECMO, deep venous thrombosis occurred and therefore we inserted an IVC filter. Case 2 : A 67-year-old man, who had previously received aortic valve replacement experienced dyspnea and visited our hospital. Echocardiography showed an aortic root abscess, and therefore Bentall operation was performed. After weaning from cardiopulmonary bypass, oxygenation was difficult to maintain, and therefore we performed VV ECMO. A chest X-ray film post operatively showed right ipsilateral pulmonary edema. The patient was weaned from VV ECMO 5 days post operatively and was discharged 60 days post operatively. We believe that VV ECMO can be beneficial for patients with respiratory failure after heart surgery, but complications related to this approach such as DVT should also be considered.

A 67-year-old man was admitted to our emergency room with strong chest and stomach pain. Electrocardiography and echocardiography revealed myocardial infarction of the anterolateral wall and cardiac tamponade. To investigate the cause of cardiac tamponade, we recommended 16-slice-non-gated MDCT. However, this revealed no aortic dissection, but did show loss of contrast in the anterior apex myocardial wall, diffuse stenosis of the LAD (left anterior descending artery ; Seg.7) and occlusion of D2 (second diagonal branch). A definitive diagnosis of blow-out type free wall rupture of the left ventricle was obtained. In the operating room, pulseless electrical activity (PEA) developed, so median sternotomy was immediately performed and bleeding from the anterolateral wall was found. After establishing extracorporeal circulation, surgical repair with a direct mattress suturing technique using felt-strips and CABG (SVG to #8) were performed. Complete hemostasis was achieved. The postoperative course was eventful : respiratory dysfunction due to deteriorating interstitial pneumonia developed. However, MDCT is a useful and non-invasive tool for the immediate detection of ventricular rupture and acute dissection of the ascending aorta, both of which may be the cause of cardiac tamponade.

The purpose of this study was to examine the effects of aquatic exercise training on the trunk muscles function and activities of daily living in abdominal obese women. Nineteen abdominal obese (abdominal circumference: 90 cm or more) and fifteen age-matched non-obese women were recruited as participants in this study. The aquatic exercise training (60 min/day, three days/week for 8 weeks) based on abdominal twists for activating the trunk muscle function. Physical parameters, biochemical characteristics, arteriosclerotic parameters and activities of daily living scores were assessed before and after the training period. In both groups showed abdominal circumference, percent of body fat, blood pressure and lower extremity muscle strength increased significantly after aquatic exercising training. In particular, endurance capacity of abdominal and back muscles increased significantly and activities of daily living scores were significantly improved in the obese group. Moreover, the improvement in the strength of lower extremities and improvement in the activities of daily living scores, such as climbing and descending stairs, in the obese group tended to be higher than non-obese women. Additionally, in abdominal obese group, the amount of the reduction of abdominal circumference was significantly associated with that of the increase in the strength of lower extremities. Taken together, these findings suggest the possibilities that the present aquatic exercise training based on trunk muscle exercise improving the function of trunk and lower extremity muscles with reduction in the abdominal obesity, contributing to improve activities of daily living in abdominal obese women.

We performed redo off-pump coronary artery bypass (OPCAB) through a left thoracotomy using a PAS·Port system for proximal vein graft anastomoses for a patient with symptomatic ischemia in the left circumflex system. A 60-year-old man underwent OPCAB (LITA-LAD, RA-4PD) 7 years previously. Coronary angiography revealed a remarkable lesion in the left circumflex system, but the left internal thoracic artery graft (ITAG) and the radial artery graft (RAG) were patent. OPCAB was performed through a left thoracotomy to avoid injury to the patent grafts. With the heart beating, a saphenous vein graft (SVG) was anastomosed sequentially from the descending aorta to the first and second obtuse marginary arteries. Avoiding descending aortic clamping, a proximal anastomosis was made using the PAS·Port system and the SVG was routed anterior to the pulmonary hilum. The postoperative course was uneventful and he was discharged on the 22nd postoperative day. Cardiac CT showed patent SVG and adequate proximal anastomosis. In this case OPCAB through left thoracotomy was effective. The selection of the graft inflow source and bypass routes according to the individual patient is essential for the success of the procedure.

The excellent long term-patency rates achieved using the internal thoracic arteries (ITAs) have expanded the variety of graft arrangements of these conduits for multivessel coronary revascularization. We encountered 2 patients who underwent multivessel coronary artery bypass, by using these terminal branches of the left ITA effectively. In both patients, LITAs were taken down using the skeletonization technique with a harmonic scalpel. One patient had 2 grafts using the off-pump technique with the Y-composite grafts constructed by the main LITA trunk and LITA terminal branch, which were anastomosed with the left anterior descending branch (LAD) and diagonal branch (D₁), respectively. The other patient had 6 grafts under on-pump cardiac arrest, including the natural LITA terminal branches which were anastomosed with the LAD and D₁. Postoperative multidetector computed tomography (MDCT) revealed excellent long-term patent grafts in both patients. In conclusion, the terminal branches of the ITA, if of suitable size and length, could be used effectively to construct a Y-anastomosis for the coronary arteries, when consideration for the size of the target coronaries and native-coronary blood flow competition.

We report a case of total aortic arch replacement for ruptured aortic arch aneurysm in an oldest-old person. The patient was a 92-year-old woman with hypertension, who had normal daily activity. She consulted another hospital because of hemoptysis. A chest roentgen exam showed an outpouching of the first left arch. In our hospital, chest computed tomography revealed a saccular thoracic aortic aneurysm, 43mm in maximum diameter, which seemed to be the cause of hemoptysis. The patient and her family wanted to have operation. While waiting for the operation, she coughed up a large amount of blood and suffered respiratory failure, requiring a mechanical respirator. Two days later, in the operation room, she coughed up a large amount of blood again and suffered long term hypoxygenation. Though she underwent total aortic arch replacement, she developed septic shock with MRSA pneumonia. However, she was weaned from ventilatory support on the 24th postoperative day. On the 86th postoperative day, ambulatory was possible. She had no ischemic cerebral damage. In extensively elderly patients, careful attention must be paid to decide an the indications for highly invasive surgery such as total aortic arch replacement.

The purpose of the present study was to develop a new method that enables individualized determination of the optimal exercise intensity for health promotion. Our study was based on the following observations : (1) physical activity at ventilatory threshold (VT) has been useful for enhancing physical fitness and even improving medical conditions such as heart failure, hypertension and diabetes, (2) exercise intensity at VT is characterized by suppressed vagal activity, and (3) vagal activity can be evaluated by analyzing heart rate variability (HRV) . In the first study we defined a criteria for determining the exercise intensity corresponding to VT using HRV analysis (heart rate variability threshold, THRV) . In 16 normal subjects, a time series of ECG RR interval were recorded and the means of the sum of the squared differences in successive RR intervals (MSSDs) were calcu-lated during a ramp exercise test with a cycle ergometer. Based on the values of MSSD and the dif-ferences in successive MSSDs (ΔMSSD) at the intensity of VT, we defined the criteria of THRV as follows : MSSD<25 msec²and ΔMSSD<6 msec². Another exercise test with a cycle ergo-meter was performed to evaluate the relationship between THRV and VT in 63 normal subjects. Heart rate (HR) and oxygen uptake (VO₂/wt) at THRV were 111.8±13.2 beats/min and 15.2±4.4 ml/kg/min, and HR and VO₂/wt at VT were 116.2±11.6beats/min and 16.5±3.7ml/kg/min, respectively. There was a significant correlation between THRV and VT (HR : r=0.82, p<0.001, VO₂/wt : r=0.88, p< 0.001) . Thus, THRV and VT provided almost identical exercise intensities. As a result, we propose that, similar to VT, THRV can be used as an indicator of the optimal exercise intensity suitable for health promotion in normal subjects.