A 55-year-old man was referred to our hospital for hemolytic anemia 21 months after an ascending aortic replacement for acute type A aortic dissection. The enhanced CT revealed an aortic pseudoaneurysm formation at the proximal anastomosis. The cause of hemolysis was verified to be the pressure by an aortic pseudoaneurysm formation at the vascular graft stenosis. At the reoperation, the previous vascular graft was found to have partially detached from the aortic stump over the non-coronary cusp. Ascending aortic replacement was performed with a tailoried vascular graft in a scallop shape, corresponding to the non-coronary cusp. The postoperative course was uneventful and hemolysis diminished soon after the operation.

The patient was a 65-year-old man who had undergone AVR (SJM Regent : 19 mm) for AR in June 2007. Since March 2008 there had been an increase in the pressure gradient between the aorta and the left ventricle on transthoracic echocardiography (peak PG : 46 mmHg, mean PG : 27 mm Hg). Plain x-ray films of the valve showed limited opening of the metallic valve. However, no symptoms of heart failure were observed on a physical examination. Blood tests performed in December 2007 showed a PT-INR value of 1.22. Since the effects of warfarin anticoagulant therapy were insufficient, its dose was adjusted on follow-up. An examination in June revealed further stenosis of the valve (peak PG : 93 mmHg, mean PG : 58 mmHg). Valve thrombosis was suspected because the condition was poorly controlled by warfarin. Thus, thrombolytic therapy using t-PA was performed (800,000 units). However, the patient complained of chest pain 1 h 30 min after initiation of thrombolytic therapy. Twelve-lead electrocardiography was performed, and ST-segment elevations were observed in the limb and chest leads. Acute myocardial infarction due to a free-floating thrombus was suspected, and emergency cardiac catheterization was performed. Segment 7 was totally occluded, and reperfusion was achieved by thrombus aspiration. Embolization of the coronary artery was speculated to have occurred because of the improved mobility of the metallic valve and dissolution of a thrombus adhering to the valve. A case of acute myocardial infarction as a complication of thrombolytic therapy for valve thrombosis is rare. This case reaffirms the necessity of careful monitoring during thrombolytic therapy.

Divers' heart rates were measured under real ocean diving conditions with the purpose of evaluating the workload during SCUBA diving. For the subjects, all-out tests were conducted and evaluated in each of the following conditions: 1. ergometer cycling, 2. ergometer cycling using diving regulator, 3. fin-swimming in a swimming pool with diving equipment. No significant heart rate difference was found between the pre-dive and post dive of each subject; although, in novice divers, high heart rates such as 140/min or more were observed especially during the dive gear wearing phase on the topside and/or floating on the surface phase, suggesting there should be some high heart rate inducing factors, other than the exercise, like stress. Whereas, in the results of the all-out tests, the heart rate for fin-swimming was 16~18 beats/min lower, as well as 5.7~14.2 ml/kg/min lower for VO₂max, as compared to the ergometer cycling. This may suggest that fin-swimming like scuba diving could give a diver some degree of physical load without on increased heart rate.

An 89-year-old man with a past history of paroxysmal atrial fibrillation was urgently admitted to our hospital because of sudden-onset pain in the left forearm. The pulse of the left brachial artery had disappeared. Angiography demonstrated left brachial artery occlusion due to a thrombus. The day after an emergency thrombectomy, abdominal pain occurred after eating. Enhanced computed tomography and aortography revealed that the superior mesenteric artery (SMA) was occluded with collateral circulation from the inferior mesenteric artery (IMA). Under a diagnosis of angina abdominalis, the bypass procedure, using a saphenous vein graft (SVG) from the abdominal aorta to the SMA, was carried out under the support of cardiopulmonary bypass. To maintain antegrade alignment of the SVG, the SVG was anastomosed proximally to the infrarenal abdominal aorta. Severe atherosclerotic changes were observed in the main trunk of the SMA. However, no intestinal necrosis occurred because of the well-developed collateral flow from the IMA. The mechanism of angina abdominalis is probably due to thromboembolism in the SMA which had preexisting stenotic organic lesions.

A special Students' Committee on Medical Education was established by the Student Union of Nippon Medical School. The members of this committee are all volunteers and have carried out several plans to improve the educational environment at our school. In 1999, the Students' Committee on Medical Education proposed holding joint meetings with the Education Committee of Nippon Medical School. The meeting was to allow communication between students and teachers for improving the curriculum. The volunteer faculty members of the Education Committee and students have held joint meetings seven times from November 1999 through February 2001. Discussions between students and teachers have changed ideas on both sides and have led to improvements in some educational programs, such as clinical internship during the summer vacation.

During the past 7 years from January 1991 through October 1997, we treated 30 cases of aortic root reconstruction by the Carrel patch method. The cases included annulo-aortic ectasia (AAE), root aneurysm with aortic regurgitation (AR), aortic dissection with AR, and true aneurysm (ascending and arch) with AR. The surgical treatment consisted of 28 modified Bentall operations and 2 aortic root remodelings, similar to the Yacoub operation. The aortic root and valve were resected, the coronary arteries were dissected free, mobilized, and then implanted into the composite graft. Coronary anastomosis was performed by mattress suture reinforced by Teflon felt strips. In 5 cases it was necessary to undergo coronary artery bypass grafting for myocardial ischemia. Blood transfusion was unnecessary in 11 cases. Post operative death was seen in only one patient who underwent an emergency operation for cardiac tamponade due to aortic dissection on the 25th postoperative day. The operative mortality rate was 3.3%. The complications of anastomosis, for example leakage and dilatation of the coronary ostia, were not seen in our experience. Reoperation and late death were not observed during the follow-up period (average 23 months). Cerebral hemorrhage occurred in only one case, at 5 years after the operation, and all other patients had an uneventful postoperative course. The event-free rate is 75% (n=1) at 6 years. The operative procedure is considered feasible in any anatomic variation of aortic root diseases, even if dislocation of the coronary ostia is minimal, and this method holds hope for the prevention of anastomotic pseudoaneurysm formation and long-term survival. Although further long-term follow-up study is necessary, our experience suggests that the Carrel patch procedure has few late term complications.

We performed aortic remodeling using a tailored Dacron graft (Yacoub's procedure) in two cases of root aneurysm combined with aortic regurgitation. The cases were 20-year-old and 45-year-old women. The leaflets did not coapt at a central portion, but the lack of coaptation did not produce significant prolapse. No organic change was found, so we attributed aortic regurgitation to sinotubular junction. Remodeling of the root was selected as the operative procedure because degeneration in the annulus was unlikely in these two cases. All three sinuses were excised, with 3mm of the arterial wall left above the aortic annulus and a small button of the aortic wall around the ostia of the coronary arteries. Then each commissure was pulled up and the height of the commissure was measured. The proximal end of the graft was then tailored to a scallop shape, so that the top of the scallop matched the commissure level. The graft was then sutured to the aortic rim with continuous 5-0 polypropylene sutures. Both coronary arteries were reimplanted utilizing the Carrel patch method and the distal graft anastomosis was completed. The aortic crossclamp times were 147 minutes and 163 minutes and the total pump times were 166 minutes and 189 minutes. One patient has mild or 1+ aortic regurgitation on postoperative echocardiogram and aortography, but she has no activity restrictions, and no evidence of congestive symptoms. Yacoub's remodeling procedure which spares the aortic valve, requires no anticoagulant therapy in the post-operative period. Aortic valve-sparing replacement of the aortic root is an excellent procedure for any patient with an ascending aneurysm and an anatomically salvageable valve. Although further long-term follow-up is required, we believe that preserving the native aortic valve is useful for preventing complications associated with mechanical valves.

Left ventricular wall motion was evaluated after mitral valve replacement (MVR). MVR for mitral regurgitation (MR) was performed with preservation of both anterior and posterior chordae tendineae (Group I, n=12) or posterior chordae tendineae (Group II, n=9). MVR for mitral stenosis was performed with the preservation of the posterior chordae alone (MS Group, n=12). Postoperative regional wall motion was analyzed from the shortening fraction (SF) of the centerline method in 5 of antero-basal (AB), anterolateral (AL), apical (AP), diaphragmatic (DP) and posterobasal (PB) regions. The percentage of post-operative SF for preoperative value (%SF) was compared between Group I and Group II. The value of %SF improved much more in Group I than in Group II at the AL and AP regions. %EF was more significantly increased in Group I than in Group II, although postoperative ESVI and EDVI decreased in both groups. In the MS Group, EF, ESVI and EDVI did not change after surgery. The regional wall motion improved except in the calcified PB region. These results demonstrated that the preservation of both anterior and posterior chordae tendineae for MR was a useful procedure to improve postoperative LV regional wall motion. The preservation of posterior chordae for MS was sufficient to improve the regional wall motion except in the calcified submitral region.

We report a case of a solitary iliac aneurysm-fistula of the sigmoid colon. A 68-year-old male was diagnosed as having diverticulum of the sigmoid colon by barium enema at a near-by hospital with a major complaint of melena. He continued to have massive melena although he received sigmoid colectomy. His condition eventually deteriorated into shock and he was transferred to our department. Angiographic findings showed a left common iliac aneurysm. Under the diagnosis of a rupture of a sigmoid colon, emergency operation was performed including aneurysmectomy and bypass formation between the femoral and femoral artery as an extraanatomical bypass. The patient developed multipul organ failure following the sepsis and died 8 days postoperatively. An aneurysm-intestinal fistula is a complication of an aneurysm. The problem of this disease is the difficulty in making a definite diagnosis with high mortality rate. We should consider the possibility of an aneurysm-intestinal fistula for the patient with gastrointestinal bleeding of the unknown origin.

Postoperative cardiac function and the occurrence of arrythmia depend upon myocardial protection during open heart surgery in severe concentric hypertrophy. The effect of myocardial protection was evaluated in terms of several released cardiac enzymes before and after reperfusion, and postoperative left ventricular (LV) cardiac function from cardiac pool scintigram in 21 cases with aortic stenosis (AS Group). These data were compared with 20 cases with aortic regurgitation (AR Group). Heart weight and aortic cross-clamping time were not significantly different in these two groups. The enzymatic values in peak total creatine-kinase (CK) and peak CK-MB fraction were higher in the AS group than in the AR group, and peak GOT was significantly elevated in the AS group (peak GOT: 93±32 in AS group, 64±17IU/l in the AR group, p<0.01). Among the cases in the AS group, six cases with LV small cavity (LVDd<4cm) and severe concentric hypertrophy were associated with high values of released enzyme and the occurrence of ventricular arrythmia. Postoperative cardiac function was estimated from both systolic parameters such as LV ejection fraction (LVEF) or peak ejection rate (PER) and diastolic parameters such as peak filling rate (PFR) or early diastolic filling rate (1/3PFR). Postoperative LVEF and PER improved to normal control levels in the AS group with preoperatively depressed systolic function, although values were decreased in the AR group with impaired systolic function. The postoperative early diastolic peak filling rate did not recover to control levels in the AS group as well as the AR group, and was impaired in the AS group with severe concentric hypertrophy due to elevated chamber stiffness and the delay of time to peak filling rate. In severe concentric hypertrophy, we used several techniques for myocardial protection of terminal blood cardioplegia, and gradually increased reperfusion pressure and LV venting after reperfusion. Late results revealed a good clinical course in all 21 cases except for the occurrence of arrythmia in three.