An 82-year-old male patient who had a history of ischemic heart disease (IHD) and Debranching Thoracic Endovascular Aortic Repair (TEVAR) (right axillary artery-left axillary artery-left common carotid artery) was admitted to our hospital due to sudden chest pain. The diagnosis revealed acute coronary syndrome: 2-vessel lesions, including the left main trunk (LMT) (right coronary artery (RCA) #2 75%, #3 90%, LMT #5 50%, and left anterior descending (LAD) branch #7 75%). Plain Old Balloon Angioplasty (POBA) was performed on the responsible lesion, RCA (#2-3). Off-pump Coronary Artery Bypass Grafting (OPCAB) was initially planned for the remaining lesion. However, cardiogenic shock occurred, and an emergency OPCAB (SVG-LAD, SVG-#4PD) was performed via partial sternotomy (inverted L-shaped incision on the left side), using intra-aortic balloon pumping (IABP). The patient underwent revascularization using great saphenous vein grafts due to the potential for postoperative pleuroperitoneal communication in patients undergoing peritoneal dialysis, as well as the risk of impaired internal thoracic artery (ITA) flow caused by debranching in future involving internal shunts for dialysis. It is important to consider not only the graft but also the thoracotomy, taking into account the perspectives of early weaning and the prevention of perioperative complications.

Background and Objectives: The influence of pre-intervention coronary physiologic status on outcomes post percutaneous coronary intervention (PCI) is not well known. We sought to investigate the prognostic implications of pre-PCI fractional flow reserve (FFR) combined with post-PCI FFR. Methods: A total of 1,479 PCI patients with pre-and post-PCI FFR data were analyzed. The patients were classified according to the median values of pre-PCI FFR (0.71) and post-PCI FFR (0.88). The primary outcome was target vessel failure (TVF) at 2 years. Results: The risk of TVF was higher in the low pre-PCI FFR group than in the high pre-PCI FFR group (hazard ratio, 1.82; 95% confidence interval, 1.15–2.87; p=0.011). In 4 group comparisons, the cumulative incidences of TVF at 2 years were 3.8%, 4.1%, 4.8%, and 10.2% in the high pre-/high post-, low pre-/high post-, high pre-/low post-, and low pre-/low post-PCI FFR groups, respectively. The risk of TVF was the highest in the low pre-/low post-PCI FFR group among the groups (p values for comparisons <0.05). In addition, the high pre-/low post-PCI FFR group presented a comparable risk of TVF with the high post-PCI FFR groups (p values for comparison >0.05). When the prognostic value of the post-PCI FFR was evaluated according to the pre-PCI FFR, the risk of TVF significantly decreased with an increase in postPCI FFR in the low pre-PCI FFR group, but not in the high pre-PCI FFR group. Conclusions Pre-PCI FFR was associated with clinical outcomes after PCI, and the prognostic value of post-PCI FFR differed according to the pre-PCI FFR.

Background and Objectives: Recent guideline recommends evaluation using of coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) in patients with functionally insignificant stenosis. We evaluated clinical implications of CFR and IMR in patients with high fractional flow reserve (FFR) and deferred revascularization. Methods: A total of 867 patients (1,152 vessels) consigned to deferred revascularization who underwent comprehensive physiologic assessments were enrolled. Patients with high FFR (>0.80) were categorized by CFR (≤2) and IMR (≥23 U). Clinical outcome was assessed by patient-oriented composite outcome (POCO), a composite of any death, myocardial infarction (MI), and revascularization at 5 years. Results: Patients with low CFR (≤2) showed significantly greater risk of POCO than those with high CFR (>2) in both high-FFR (p=0.024) and low-FFR (p=0.034) groups. In patients with high FFR, those with low CFR and high IMR (overt microvascular disease) displayed the greatest risk of POCO overall (p=0.015), surpassing those with high CFR and low IMR (HR, 2.873; 95% CI, 1.476–5.594; p=0.002) and showing significantly greater risk of cardiac death or MI (HR, 5.662; 95% CI, 1.984–16.154; p=0.001). Overt microvascular disease was independently associated with POCO in the high-FFR population (HR, 2.282; 95% CI, 1.176–4.429; p=0.015). Conclusion Among patients with deferred revascularization, those with low CFR showed significantly greater risk of POCO than those with high CFR, regardless of FFR. In patients with high FFR, those with overt microvascular disease showed significantly greater risk of POCO and cardiac death or MI at 5-year, compared with the others.

Elderly people with chronic lung diseases are always suffered from dyspnea, so they also have much troubles in gastrointestinal functions on the basis of anxiety and insomnia. As a result, they become malnourished with a weakened immune system and are often hospitalized due to respiratory infections for a long time. Their quality of life deteriorates. This time, we experienced an elderly female patient with old pulmonary tuberculosis who was generalized weakness, showed improved appetite loss, physical activity, and dementia symptoms by taking ninjin'yoeito and kososan. She could avoid re-hospitalization due to respiratory infections. Ninjin'yoeito enhanced her energy and physical strength. As a result, she seems to have become markedly healthy. This prescription is expected to be useful for the rapidly increasing number of elderly patients with chronic lung diseases.

Number of chronic obstructive pulmonary disease (COPD) patients tend to increase in middle and older aged people. They have shown a certain degree of improvement with various Western medicine treatments including smoking cessation guidance, rehabilitation, home oxygen therapy, inhalation therapy and so on. However, it is a clinical problem that some elderly people have acute exacerbations frequently due to infectious diseases and have poor prognoses. This time, we experienced an elderly COPD patient with type II respiratory failure. He was repeatedly hospitalized and needed treatment with a ventilator temporarily. We conducted Kampo medical examination on him, and diagnosed that he had cold state in the lungs. So, we administered ryokankyomishingeninto to him. As a result, he recovered dramatically, and he was never hospitalized again due to respiratory failure for a long time. It is suggested that ryokankyomishingeninto may be effective for some COPD patients who have cold state in the lungs.

The number of elderly people with chronic heart failure is increasing ; they have acute exacerbations at a high rate due to mergers of infections and others. At that time, they received furosemide intravenous injection and tolvaptan oral medication as internal treatments. However, there are refractory patients (tolvaptan nonresponder) at a certain frequency. In these cases we experienced two cases in which goreisan were effective for untreatable congestive heart failure. Goreisan administration resulted in an increase in urine volume in both cases, marked improvements in symptoms, physiological findings and various laboratory findings. In addition, they continued taking these medicines after discharge. As a result, for about a year, they were never rehospitalized due to heart failure. It is conceivable that goreisan normalized the uneven distribution of water in organs and tissues, and reactivated the action of tolvaptan in the renal collecting duct. These results suggest that the combined use of goreisan will be useful for untreatable congestive heart failure.

Molecularly-targeted agents such as cetuximab, an anti-EGFR (epidermal growth factor receptor) monoclonal antibody have been used for the treatment of head and neck cancer. However, these agents frequently induce adverse skin reactions including acne-like rash and paronychia. For these problems, minocycline oral and heparinoid or steroid ointments, are commonly used. Some patients, however, cannot be controlled just by using these drugs. This case report shows a man in his 50s, who was treated for recurrence of nasal cancer. He received a long-term cetuximab therapy for 1 year and a half, and had severe paronychia and skin rash. Medication of unseiin and shiunko ointment decreased these adverse skin reactions, especially, paronychia on his first toes didn't need to be treated by steroid ointment anymore. When the common skin therapies are not effective, these Kampo therapies are possibly one of the options for the supportive care for the patients using cetuximab.

A 72-year-old man presented with abdominal aortic aneurysm (AAA) and was referred to our hospital by his physician. A computed tomography revealed a 95-mm AAA with three right renal arteries. The main right renal artery branched from the AAA, and two remaining arteries branched from the same level as the left renal artery. The patient underwent AAA repair and main right renal artery reconstruction without any renal protection. After the operation, renal function did not deteriorate. 3D-CT was useful for diagnosing renal artery branching, evaluation of renal blood perfusion, and determining the operation method.

We studied 90 consecutive cases undergoing open heart surgery with preoperative collection of autologous blood and ultrafiltration during extracorporeal circulation. Among the 58 out of 90 patients (64.4%), open heart surgeries were achieved without homologous blood. We evaluated 13 factors (age, height, weight, body surface area, cardiopulmonary bypass time, aortic cross clamping time, dilutional rate, Hct before predonation, lowest Hct during cardiopulmonary bypass, amount of predonated autologous blood, term of autologous blood predonation, amount of bleeding during surgery, amount of bleeding after surgery) in connection with open heart surgery without homologous blood. Among these factors, age, body surface area, cardiopulmonary bypass time, aortic cross clamping time, lowest Hct during cardiopulmonary bypass, amount of predonated autologous blood, amount of bleeding during surgery and amount of bleeding after surgery demonstrated differed significantly between the only autologous blood transfusion group and the homologous blood transfusion group. According to the evaluation by multivariate regression analysis of these factors, the amount of bleeding after surgery was the most contributor to open heart surgery without homologous blood, followed by amount of bleeding during surgery and body surface area. We concluded that open heart surgery without homologous blood may be achieved in more patients by understanding these factors. Autologous blood predonation by the “leapfrog” method, control of the dilution rate by ultrafiltration during extracorporeal circulation and fresh autologous blood transfusion after extracorporeal circulation were effective to achieve open heart surgery without homologous blood.

This is a case report of a rare combination of a single coronary artery and a coronary artery fistula. An 8-year-old girl was asymptomatic with a grade II continuous murmur in the third left intercostal space. Selective coronary angio-graphy revealed that a single coronary artery arising from the left aortic sinus was dilated and ended as a fistula to the outflow tract of the right ventricle. At operation, the fistula could not be exposed on the surface of the heart. On cardiopulmonary bypass, the aorta was clamped, and the fistula was closed by direct suture in the right ventricle. The postoperative course was uneventful with no complications.