[Pneumothorax and abdominal free air occurred after percutaneous tracheostomy (PCT)].

We report a case of pneumothorax and abdominal free air after percutaneous tracheostomy (PCT). A 80-year-old female was intubation for upper respiratory stenosis. We thought tracheal stenosis recurrence after extubation. PCT was performed. Respiratory insufficiency and subcutaneous emphysema appeared rapidly at face, neck and precordia Subcutaneous emphysema was pushed away. PCT was performed once more. Chest X-ray showed pneumothorax in right thoracic cavity. Thoracostomy tube was intubation. Chest computed tomography (CT) scan showed pneumothorax another thoracic cavity and abdominal free air. Vital signs was not worse, so observation. Postoperative course was uneventful. The patient was recovered. We thought that PCT was effective under bronchofiber.

Relations of preoperative hemodynamics and coronary blood flow to improved left ventricular function after valve replacement for aortic regurgitation.

In this study of the limits of reversibility of left ventricular function after aortic valve replacement for aortic regurgitation, measurements were made of pre- and postoperative coronary blood flow and left ventricular volumes. Eighteen patients who had undergone aortic valve replacement for pure aortic regurgitation using the Björk-Shiley valve or the Bicerval valve were restudied an average of 8 +/- 3 months after surgery. Postoperative left ventricular end-systolic and end-diastolic volumes returned to near normal values. The slight left ventricular wall thickening apparent before surgery remained unchanged after surgery and, consequently, left ventricular mass, though somewhat reduced, remained abnormally high. Ejection fraction, which was low preoperatively, returned to normal postoperatively. Total coronary sinus blood flow decreased after surgery, but coronary sinus blood flow per 100 g of left ventricular mass increased. This recovery of coronary flow per unit mass was believed to cause the improvement in left ventricular function. A significant correlation was found between postoperative systolic function and preoperative left ventricular end-systolic and end-diastolic volumes, wall thickness and, especially, left ventricular mass, the latter indicating that, if preoperative left ventricular mass is less than 350 g/m2, postoperative improvement of systolic function is attainable. Another significant correlation was indicated by measurements of coronary sinus blood flow per 100 g of left ventricular mass. If this is greater than 35 ml/min before surgery, a postoperative improvement in systolic function to within the normal range may be expected.

Platelet adherence to bioprosthetic cardiac valves.

Tissue from porcine aortic bioprosthetic valves (Hancock) and bovine pericardial valves (Ionescu-Shiley) were incubated with platelets tagged with chromium-51. There was a significantly decreased platelet-collagen adhesion reaction in both porcine and bovine glutaraldehyde-treated valves compared with reactions in fresh porcine aortic valve and fresh bovine pericardium (p less than 0.001). There was no significant difference in the platelet-collagen reaction between porcine aortic valve and bovine pericardium, whether treated with glutaraldehyde or in the fresh state (p greater than 0.05). The addition of aspirin did not significantly decrease the platelet-collagen reaction on glutaraldehyde-treated or fresh valves (p greater than 0.05). Rinsing fresh valves in plasma appeared to offer more protection against platelet adhesion than rinsing them in saline solution (p less than 0.01). It is concluded that there is no difference in platelet adherence to porcine aortic valve or bovine pericardium and that glutaraldehyde, and perhaps plasma, offers a protective effect against platelet adhesion.

Changes in myocardial oxygen consumption and coronary sinus blood flow before and after resection of left ventricular aneurysm after myocardial infarction.

The patients in this study consisted of eight men who underwent resection of left ventricular aneurysm. Right and left heart catheterization at rest and measurement of coronary sinus blood flow by continuous thermodilution were performed preoperatively and an average of 6 months after the operation. Coronary sinus blood flow decreased significantly from 161 to 118 ml/min and myocardial oxygen consumption decreased significantly from 17.2 to 10.5 ml/min postoperatively. Cardiac index increased postoperatively. Ejection fraction increased from 0.31 to 0.49 and mean velocity of circumferential fiber shortening significantly increased from 0.53 to 1.0 circ/sec postoperatively. Left ventricular end-diastolic volume decreased significantly from 166 to 120 ml/m2 postoperatively. The mean systolic circumferential tension significantly decreased postoperatively. We believe that the decrease in wall tension postoperatively brought about the reduction in myocardial oxygen consumption. Thus the high wall tension and myocardial oxygen demand, present preoperatively, were improved postoperatively, with a resultant lowering of oxygen consumption and equivalent or better left ventricular function.

Severe Kawasaki heart disease treated with an internal mammary artery graft in pediatric patients. A first successful report.

Two Japanese boys, 6 and 10 years old, required operation for severe Kawasaki heart disease. Both had multiple coronary arterial aneurysms and stenoses, and one had mitral regurgitation as well. The operations consisted of anastomosis between the left internal mammary artery and the left anterior descending artery and insertion of an autologous saphenous vein between the aorta and the posterior descending artery in both patients. The mitral valve was replaced in the one with mitral regurgitation. Angina pectoris has been completely relieved as confirmed by postoperative angiocardiography. Late results of coronary bypass grafting with the saphenous vein in pediatric patients with Kawasaki disease have been less than satisfactory because of the high occlusion rate of the graft. The internal mammary artery may be superior, at least theoretically, to the saphenous vein graft because it is a "living graft" with a high possibility of growing and with less susceptibility to degeneration. This is the first report of successful operation utilizing an internal mammary artery graft in coronary bypass for Kawasaki disease.

Ultrafiltration during cardiopulmonary bypass: laboratory evaluation and initial clinical experience.

Ultrafiltration during crystalloid hemodilution cardiopulmonary bypass (CPB) was evaluated in two groups of mongrel dogs: in one group during 2 hours of CPB with the heart empty and beating and in the other during 90 minutes of cold cardioplegic arrest followed by 30 minutes of recovery. In both groups, the accumulation of extravascular lung water was less in the dogs undergoing ultrafiltration than in control animals. In 10 patients with clinical evidence of severe fluid overload, ultrafiltration was employed during CPB. The amount of fluid removed ranged from 1,700 to 6,100 ml (mean, 3,240 +/- 1,481 ml [standard deviation]) and resulted in an average intraoperative fluid balance of -901 +/- 2,537 ml, a weight gain of 1.9 +/- 2.5 kg, and a decrease in extravascular lung water from 1,132 +/- 183 ml to 919 +/- 267 ml (p = 0.209). Ultrafiltration is a safe, effective means of removing body water and of preventing further accumulation of such water during hemodilution CPB.

Valvotomy in young patients with rheumatic mitral stenosis.

Twenty-nine patients younger than 18 years of age with mitral stenosis were operated upon in the Osaka University Hospital. Five patients who underwent operation in the early period of this study died postoperatively. Follow-up study was made in 20 of the surviving patients for a period of 6 to 20 years. Three died during the follow-up period. Twelve of the survivors were in NYHA Functional Class I, 4 were in Class II, and 1 was in Class III. Reactivation of rheumatic disease did not occur after mitral valvotomy.

Coronary sinus blood flow and myocardial oxygen consumption after valve replacement for aortic insufficiency.

Seven cases are reviewed in which the aortic valve was replaced with a Björk-Shiley tilting disk valve to treat aortic insufficiency. Comparative studies were made to determine coronary sinus blood flow (CSF) and myocardial oxygen consumption (MVO2) by using a continuous thermodilution method both before and after the operation. Additionally, indexes of left ventricular function were obtained by catheterization of the right and left heart and by left ventriculography. Postoperative total CSF decreased significantly compared with the preoperative value (p less than 0.02). However, in all cases, the postoperative CSF per 100 g of left ventricle (LV) increased compared with the preoperative measurement (p less than 0.001). The CSF per beat per 100 g LV also increased postoperatively (p less than 0.001). Total MVO2 decreased postoperatively (p less than 0.02). However, the MVO2 per unit mass tended to increase postoperatively; these increases were not significant. Postoperatively the left ventricular mass and left ventricular wall stress decreased considerably. The left ventricular ejection fraction (EF) and the mean velocity of circumferential fiber shortening (mVCF) remained at normal levels, whereas the left ventricular function improved markedly. In short, the total CSF decreased, along with LVM and left ventricular wall stress. However, because CSF per unit mass increased and EF and mVCF remained at normal values, it is assumed that the increase in CSF is associated with improvement in postoperative contractility.

A new method of closing the ventricular septal defect in corrected transposition of the great arteries.

A new method of closing a perimembranous malalignment ventricular septal defect (VSD) in corrected transposition of the great arteries (TGA) of the [S,L,L] type is presented. The method consists of combined approaches to the VSD through both a right atriotomy and an aortotomy without a ventriculotomy. The VSD is patched obliquely from the morphological right ventricular side of the septum, cranially through the aortic valve to the left ventricular side of the septum, caudally through the mitral valve. Although this method has been successfully applied in only one adult patient, some advantages may be expected: (1) prevention of trauma to the His bundle, which runs along the anterosuperior rim of the VSD on the left ventricular side; and (2) prevention of trauma to the tricuspid, mitral, and aortic valves without having to open the ventricles. We believe that this new method warrants a further trial as possibly better for closure of the VSD in corrected TGA of the [S,L,L] type.

Interruption of the aortic arch associated with patent ductus arteriosus and ventricular septal defect. Proposal of a new surgical technique for total correction.

A four-year-old girl underwent complete correction of the association of interruption of the aortic arch (Type A, Celoria and Patton's classification), patent ductus arteriosus, and ventricular septal defect. The surgical procedure consists of establishment of a continuity between the ascending and descending aortas utilizing the patent ductus arteriosus and the anterior wall of the pulmonary arterial trunk, reconstruction of the rest of pulmonary arterial trunk with pericardium, and closure of the ventricular septal defect. Though the patient expired from cerebral complications, the hemodynamic result after repair was quite satisfactory. The procedure described makes total correction of this complex anomaly feasible at one operation through a median sternotomy and seems to be a method of choice for most patients with this association of anomalies, unless there is severe narrowing of the patent ductus arteriosus.

Left ventricular function and coronary morphology with anomalous origin of the left coronary artery from the pulmonary artery.

Reconstructive surgery of the left coronary artery system was performed in two adult patients with anomalous origin of the left coronary artery from the pulmonary artery. Postoperative studies were carried out at 2 months and at 49 months. Left ventricular volume, left ventricular myocardial mass, and ejection fraction were normal postoperatively in one patient. In the second patient, the left ventricular volume was markedly reduced, but the decrease in left ventricular mass was less pronounced. Dilatation and tortuosity of the right coronary artery disappeared postoperatively in both patients. However, the dilatation and tortuosity of the left coronary artery persisted on coronary arteriogram.

[Effectiveness of tiaprofenic acid on clinical symptoms of acute simple cystitis in women].

Acute simple cystitis is very easily cured by the proper use of an antibiotic. However, at times, such irritation symptoms in the bladder as micturition pain, pollakisuria and pyuria disappear. Consequently, medication to remove these irritation symptoms in the bladder at the earliest possible date, is required. However, there are no established standards for treatment in terms of the administration method and the administration period, etc. We gave a new non-steroid anti-inflammatory drug, tiaprofenic acid (SURGAM) to women suffering from acute simple cystitis who strongly complained of bladder irritation symptoms especially of micturition pain. The administration was carried out concurrently with an antibiotic, and its effectiveness was studied. As a result, micturition pain showed 86% improvement on the 1st day after starting administration, and it is thought that the concurrent use of this product with an antibiotic can probably remove the patients' complaints quickly and prevent the meaningless administration of antibiotics due to the persistence of symptoms and, subsequently, there is the possibility of shortening the period of administration.

[Prostate specific monoclonal antibody gained by glycolipid immunization].

Extraction of glycolipid component from hypertrophic and cancerous prostatic tissue were performed using chloroform-methanol solution and isopropanol-hexan-solution. The extract was separated into the "upper phase" and "lower phase" by Folchs fractionation technic. Each fraction was conjugated with acid treated salmonella minesota and than it was injected subcutaneously, intra-peritoneally and finally intravenously to BALB/c mice. Spleen cells from immunized mice were fused with P3X63, and antibody APG1 was obtained. APG1 shows a preferential reactivity towards prostatic tissue by the immunohistochemical analysis. Furthermore, the immunohistochemical analysis using enzyme and acid treated tissue and TLC immunostaining indicate that this monoclonal antibody specifically recognizes the sialylglycochain expressed in the prostatic tissue.

[Angioscopic prediction of late vascular patency after transluminal balloon angioplasty for arteriosclerotic obstructions of the artery of the lower extremities].

Arterial occlusion or stenosis of the lower extremity due to arteriosclerosis obliterans (ASO) was treated by transluminal balloon angioplasty (TBA). Angioscopic observation of the vascular lumen, performed immediately after TBA, provided five major findings: (1) abrasion of the intima, (2) irregularity of the lumen due to poor expansion, (3) laceration of the wall, (4) mural thrombus and (5) calcification. The degree of each of these abnormalities was scored with a 3-grade scale (0, 1 and 2), and scores for the 5 abnormalities were totaled in each patient. Analysis of the relationship between scores and postoperative vascular patency demonstrated that patients without vascular patency in the early (within 6 months) or late period (6 months or more) after the operation had higher total scores as compared to those in whom the vessel remained patient in the corresponding postoperative periods (p less than 0.01, p less than 0.05). Among others, patients with a total score over 5 showed markedly lower patency rates in the early period (10%) as well as late period (0%) after the operation (p less than 0.01). These results indicate the usefulness of post-TBA angioscopic observation of vascular lumen in predicting the long-term patency of the vessels operated on.

[A right common iliac aneurysm perforating into the inferior vena cava with resultant congestive heart failure].

A 69 year-old male with a right common iliac aneurysm perforating into the inferior vena cava was admitted with severe cardiomegaly and dyspnea. He had been suffering from recurrent congestive heart failure for the last 8 years prior to surgery. At operation, the fistula of 15mm diameter was closed with interrupted sutures of 3-0 nylon with pledgets within the aneurysm by controlling bleeding from the fistula by digital compression. The right common iliac aneurysm was resected and replaced with a double velour knitted dacron graft of 10mm diameter. The postoperative course was uneventful. The CTR was reduced to 57% from 70%, and the cardiac index was normalized from 6.10 to 3.39 l/min/m2. This complication is rare with only 4 previous reports in Japan. Hemodynamic improvements were dramatic after surgery in spite of poor response to medical treatments. This complication should be surgically managed as soon as the diagnosis is confirmed.

[Evaluation of the effectiveness and safety in the use of cold-diltiazem-potassium cardioplegia in coronary artery bypass surgery: a first clinical trial].

The effectiveness and safety of diltiazem (DIL), a slow channel calcium blocker, added in cold potassium cardioplegic (CP) solution was evaluated in coronary artery bypass graft (CABG) surgery for 2 purposes; (1) protection of ischemic myocardium during cardiac arrest and (2) prevention of perioperative coronary artery spasm (PCS). Diltiazem of 15 mg was added to a liter of CP which was administered 10 ml/kg B.W. initially and 5mg/kg thereafter. The serum concentration of DIL was 570 ng/ml at the time of aortic declamping, 210 ng/ml at cardioversion and 150 ng/ml one hour after surgery. The left ventricular stroke work index was increased significantly (p less than 0.05) in patients treated by DIL-CP, compared with the patients treated by regular CP without DIL. However, CPK-MB values were not significantly different in either group. The incidence of PCS has decreased from 9.1% to 0.8% (p less than 0.01) after the use of DIL-CP. Perioperative myocardial infarction rate has also decreased from 5.5% to 1.6%. No major or long-lasting side-effects were encountered. We consider that DIL-CP is a safe and excellent CP in CABG surgery and we are now utilizing this CP in all patients requiring CABG surgery.