[The method of atriotomy, ventriculotomy and their repairs].

In this series, we describe the method of atriotomy, ventriculotomy and their repairs. Right atriotomy is needed for expose tricuspid valve, atrial and ventricular septal defect. Left atriotomy is needed for expose mitral valve disease and technique for, maze or pulmonary vein isolation. Left ventriculotomy is needed for resection of scar and/of thrombus of ventricular aneurysm, repair of ventricular septal rupture and endoaneurysmorrhphy. Recently, this method is also used to repair for ischemic mitral valve regurgitation. These techniques have already been described in many textbooks. Regarding atriotomy and ventriculotomy, the most important point is how to fully expose the tricuspid and mitral valves and others. The repair of ventriculotomy requires strips of teflon felt to strengthen the suture line and to enhance hemostasis. This method of repair is considered standard by many surgeons.

[Early and late results and problems of coronary artery bypass grafting in patients over 80-year-old].

This study evaluated the validity of coronary artery bypass grafting (CABG) in patients over 80-year-old investigating the early and late result, patient's opinion to the surgery, and change of activities of daily living scale. From July 1993 to September 2002, consecutive 94 patients over 80-year-old were performed CABG in our institution. The group consisted of 43 female patients, and mean age of 82.6 years. Of these patients, 36 were operated conventional CABG (CABG group) and 58 patients were operated with off-pump CABG (OPCAB) group. There were no significant differences between 2 groups in preoperative characteristics except for anemia and hypertension. Operative results, including mortality, number of distal anastomoses, operative time had no significant differences between 2 groups. But maximum CK-MB fraction was higher in CABG group. There were 4 operative deaths, indicating operative mortality was 4.3%. Late results showed overall survival rate at 3 years was 81.1% and cardiac event free survival rate at 3 years was 88.8%. Questionnaire revealed over 80% patients were satisfied with the surgery but less than 40% patients felt activities of daily living (ADL) scale was improved. Operative results of CABG in octogenarians were satisfied, but more efforts to remain patient's high ADL were mandatory.

[Changes of serum hepatocyte growth factor in coronary artery disease].

Hepatocyte growth factor (HGF) is an endothelial cell specific growth factor involved in the repair of endothelial cells and collateral formation, however, the role for coronary artery disease is still unknown. We measured serum HGF level in various coronary artery diseases to examine the clinical significance. Serum HGF level was measured using the enzyme-linked immunosorbent assay method in patients with stable effort angina pectoris (n = 26), old myocardial infarction (n = 18), unstable angina pectoris (UAP; n = 10) and acute myocardial infarction (AMI; n = 21). As a control group, we selected 11 patients with neurocirculatory asthenia. Blood samples from peripheral veins were collected at cardiac catheterization before heparin administration. In the AMI group, blood samples were also collected at 48, 72 hr, 1, 2, 3 and 4 weeks from the peripheral veins and 48 and 72 hr after reperfusion from the coronary sinus. Serum HGF level was significantly higher in the UAP (0.41 +/- 0.12 ng/ml, p < 0.001) and AMI groups (0.38 +/- 0.26 ng/ml, p < 0.05) compared to the control group (0.19 +/- 0.09 ng/ml). Serum HGF level peaked 48 hr after reperfusion in both the peripheral veins (0.42 +/- 0.16 ng/ml) and coronary sinus (0.58 +/- 0.23 ng/ml) in the AMI group, with a significantly higher level in the coronary sinus than the peripheral veins (p < 0.05). No significant correlation between peak HGF level in the peripheral veins and peak creatine kinase (CK), CK-MB, ejection fraction and cardiac index was observed. Serum HGF was elevated in acute coronary syndrome, indicating advanced endothelial cell damage. HGF is produced, at least partially, in the heart in patients with AMI. Serum HGF level may be useful to detect endothelial cell damage rather than myocardial cell damage.

Intermittent antegrade warm blood cardioplegia for CABG: extended interval of cardioplegia.

BACKGROUND: Intermittent delivery of warm cardioplegia provides a bloodless surgical field, but it is clinically important to evaluate the periods of normothermic ischemia. The aims of this study are to compare intermittent antegrade warm blood cardioplegia (IAWBC) with intermittent antegrade cold blood cardioplegia (IACBC) groups in terms of myocardial protection, and also to evaluate whether the length of ischemic time in the IAWBC group has an effect on myocardial dysfunction. METHODS: This study is based on a retrospective review of patients who underwent elective coronary artery bypass surgery: 162 consecutive patients with IAWBC and 107 consecutive patients with IACBC. RESULTS: The creatinine kinase peak was smaller in the IAWBC group compared with the IACBC group (p<0.0001). The cardiac index after cardiopulmonary bypass was higher in the IAWBC group (p<0.02), and the amount of inotropic support required to wean from cardiopulmonary bypass was less in the IAWBC group compared with the IACBC group (p<0.0001). CONCLUSIONS: IAWBC with 30 minutes of ischemia provides to be clinically acceptable myocardial protection for coronary bypass surgery.

[Clinical evaluation of VATS lobectomy for lung cancer].

Thoracoscopic lobectomy is now recognized as a possible less invasive surgical option for stage I primary non-small cell lung cancer. We have widely used thoracoscopic procedure for surgical diagnosis of lung nodules especially in lung peripheral region as well as resection of primary lung cancer. Results of 47 thoracoscopic lobectomy during last 5 years were compared with 24 standard lobectomy under postero-lateral thoracotomy. There were no significant differences in the duration of surgery, post-operative hospital stay, intraoperative blood loss and post-operative survival. All but three patients who were diagnosed as n 2 disease or tumor with extrapulmonary extension post-operatively are surviving at the time of survey. We conclude that thoracoscopic lobectomy is safe and less invasive procedure compared to standard thoracotomy. We believe it can provide sufficient outcome for stage I non-small cell lung cancer.

[The impact of relocation on well-being of the elderly].

OBJECTIVE: This study examined direct and indirect effects, mediated by social contact, of residential relocation on well-being of the elderly. METHODS: We used longitudinal data of a national representative sample of individual aged 60 years and over (N = 1,474). The initial survey was conducted in 1987, and the follow-up survey was conducted three years later. Well-being was measured with the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Life Satisfaction Index A (LSIA). Social contacts were measured in terms of frequency of contacts with relatives, friends and neighbors, as well as frequency of social participation. RESULTS: Relocation had a positive direct effect on well-being, assessed by both CES-D and LSIA, but a negative indirect effect mediated by decline of social contacts. CONCLUSION: Our results suggest that residential relocation indirectly has a detrimental effect on well-being of the elderly through decline in social contacts, though it may directly improve well-being of the elderly.

[A longitudinal study on social support and life satisfaction among Japanese elderly].

The purpose of this study was to examine the impact of social support on life satisfaction among Japanese elderly aged 60 and over (N = 1,285), using the longitudinal data of a national representative sample. An initial survey was carried out in 1987, and a follow-up was conducted in 1990. We measured life satisfaction by the Life Satisfaction Index A. Social support was measured from two aspects, providing support and receiving support. The impact of social support and changes in support during a period of three years on life satisfaction were assessed by sex after controlling for influences of socioeconomic status, physical functioning, and initial life satisfaction. Providing support predicted a high life satisfaction three years later only in females. Receiving support was not significantly associated with life satisfaction for either males or females. However changes in providing and receiving support had a significant impact on life satisfaction of the elderly. The findings of this study suggest that the effects of social support on life satisfaction differ by sex and the impacts of changes in support are strong determinant predicting life satisfaction of the elderly.

[Comparison of characteristics between respondents and nonrespondents in a national survey of Japanese elderly using six year follow-up study].

PURPOSES: The purpose of this study were twofold: 1) to examine differences between respondents and nonrespondents in sociodemographic or health characteristics, 2) to study nonresponse effects on relationships between variables, using a 6 year follow-up study for both respondents and nonrespondents at the initial survey. METHODS: The data were collected in 1987 through a national survey of Japanese adults aged 60 and over. A total of 2,200 interviews were completed from the list of 3,288 names. In 1993, 1,010 nonrespondents excluding persons who had died, moved, or whose addresses were unknown in the prior interview, were recontacted through a mail questionnaire. A total of 559 persons completed the mail questionnaire. Of the original 2,200 baseline interviewees, some by proxy interviews, 2,260 persons were reinterviewed, at the same time as the mail survey. Sociodemographic and health variables (age and sex), social indicators (educational attainment, marital status, and job status), health status (mortality, existence of diseases, and activities of daily living), subjective well-being (life satisfaction, self-rated health, and economic satisfaction) were compared between respondents and nonrespondents. Relationships between self-rated health and sociodemographic or health variables were examined by multiple regression analysis. RESULTS: 1. Compared to people who participated in the survey, norespondents were likely to be male, in the lower age categories, and with higher educational attainment at the follow-up survey. Also, life satisfaction and self-rated health were lower in nonrespondents than in respondents. Reasons for nonresponse varied but appeared to be somewhat related to characteristics of nonrespondents. 2. No significant relationships between self-rated health and sociodemographic or health variables appeared for the respondent group and also when including the nonrespondent group. CONCLUSION: While differences between respondents and nonrespondents on certain variables were significant, relationships between self-rated health and sociodemographic variables were not observed.

[Efficacy of mupirocin in eradicating methicillin-resistant Staphylococcus aureus from nasal discharge in carrying cardiovascular surgical patients].

Methicillin-resistant Staphylococcus aureus from nasal discharge was identified in 37 (2.5%) cardiovascular patients operated between 1995 and 1997; 25 male and 12 female, ranging from 1 to 83 years (mean 63); 2 were excluded because of Arbekacin or Isodine-gel treatment. The first 17 were treated with Vancomycin inhalation (V group) and eradication was considered to have been achieved when 3 consecutive negative cultures were obtained; the subsequent 18 were treated with Mupirocin (M group) and eradication was determined by 1 negative culture. In post-eradication electively operated 13 V and 15 M, postoperative MRSA infection was observed in one M (wound infection); the interval from the first nasal culture to the operation was 68 +/- 58 in V and 32 +/- 12 days in M, respectively (p < 0.05). In the remaining 7 who had to undergo emergency surgery while waiting for eradication because of progression of symptoms (2 V) or prior to instituting treatment (2 V, and 3 M), postoperative MRSA infection was observed in 2 M (both pneumonia). No deaths from infection were observed. Though the time required for conversion of the nasal culture was longer in V (13 +/- 20) than in M (7 +/- 1 days) differences were not significant. Mupirocin is easier to use, eradication can be achieved generally within a week.

[The factor structure of coping strategies and their effects on burnout among primary caregivers of impaired elderly persons].

The purpose of this study was to extract the factor structure of coping strategies and to examine their direct and indirect effects on burnout. Eight hundred thirty four valid responses obtained from primary caregivers of impaired persons aged 65 years old and over living in the community were analyzed. The results of covariance structural analysis were as follows: Three second order factors, including "Approach", and "Avoidance," and "Support seeking," were extracted. Five factors, "Keeping their own pace," "Positive acceptance of caregiving role," "Diversion," "Informal support seeking," and "Formal support seeking," were extracted as first order factors. "Keeping their own pace," directly decreased burnout and "Diversion" indirectly decreased burnout through caregiving in involvement. "Informal support seeking" directly increased burnout and "Positive acceptance of caregiving role" indirectly increased burnout through caregiving involvement.

Plastic surgical reconstruction of left main coronary artery.

OBJECTIVE(S): To report the early and mid-term results of surgical plasty of the left main coronary artery in 12 patients operated upon between 1993 and 1997. METHODS: The anterior approach was used in all patients. Saphenous vein (n = 4) of glutaraldehyde treated autologous pericardium (n = 8) were used as patch material. Additional coronary artery bypass grafting was performed in 7 patients, the first 3 as a safety back up, and for coexisting stenosis of other coronary branches not revascularized by the plastic procedure in the remaining 4. RESULTS: Pathologic specimens of the left main coronary artery in 5 revealed atheroma in 3 and myxomatous intimal thickening in 2. The left main coronary artery was widely patent angiographically in all patients prior to discharge. Six patients consented to angiographic restudy 5-40 months after the procedure and revealed excellent results in 5. One patient upon whom autologous pericardial patch had been used underwent percutaneous coronary angioplasty for restenosis of the left main coronary artery and a new lesion of the proximal left anterior descending branch 5 months after the operation. There were no late deaths nor other cardiac events. All patients were in CCS class 1 at their last follow-up. CONCLUSIONS: Surgical angioplasty of the left main coronary artery could be used to revascularize the left heart safely in patients with a discrete localized lesion of the left main coronary artery and is particularly useful in the face of unavailability of other conduits.

[Mental health among elderly relocated to a rural resort area].

OBJECTIVE: This study examined mental health and its related factors comparing elderly relocated to a rural resort area to elderly living in a rural old area. METHODS: Each sample of 400 aged 65 and over were randomly obtained. Valid responses obtained from the resort area and the old area were 193 and 242 respectively. Mental health was measured from two aspects: Geriatric Depression Scale (GDS) and Life Satisfaction Index A (LSIA). We used self-evaluated living environment, social support, social activities, Activities of Daily Living (ADL), economic status, decision to move, and reason for move (push- and pull-factor), as factors which seem to be related to mental health. RESULTS: The findings were as follows: 1) Respondents in the resort area showed lower GDS and higher LSIA than respondents in the old area. 2) Although for the respondents in the resort area assessment that their community was safe, participation in community groups, or involvement in recreational activities occupied a significant higher level in their mental health, these factors had no significant impact on the mental health among the respondents in the old area. 3) A difference in self-evaluated housing condition, ADL, and economic status between both groups had a cause for the area differences in mental health among the elderly. 4) Push-factor had both a direct effect and an indirect effect mediated by decision to move on GDS. Pull-factor had both a direct and an indirect effect on LSIA. CONCLUSION: Elderly relocated to a rural resort area had better mental health than elderly living in an old area, partly because they had better physical health, better economic status, and better housing condition. Self evaluated living environment and social activities were related to the mental health of the elderly in the resort area stronger than that of the elderly in the old area. Reason for move was related to the mental health of the elderly both directly and indirectly mediated by decision to move.

[Results of surgical treatment of T3 lung carcinoma according to the combined resection of involved organs].

A new TNM staging system was decided last year by UICC, consequently T3N0M0 was transferred from stage IIIA to stage IIB. Although T3 is defined to include tumors with direct invasion to adjacent organs. Those are chest wall, parietal pleura, diaphragma and pericardium, however results of surgical treatment according to the combined resection of involved organs described above have not been investigated yet enough. Eighty-nine cases with T3 from 1996 were divided into two groups, patients from 1986 to 1990 and from 1994 to 1998. In the former phase 46 cases were resected and its 5-year survival rate was 15.6%. Better prognosis with significant difference was shown in patients between N0 (5-year survival: 25.1%) and N1 + N2 (5-year survival: 4.0%). In the latter phase 43 cases underwent surgery and its 3-year survival was 24.0%. In the prognoses according to the involved adjacent organs, patients with combined resection of parietal pleura showed the best survival in comparison with patients of chest wall resection and pericardial resection, but there was no significant difference in these 3 groups. Two patients with combined resection of diaphragma are well alive.

Ultrastructural evidence for the formation of amyloid fibrils within cardiomyocytes in isolated atrial amyloid.

Isolated atrial amyloid (IAA) frequently affects elderly human hearts in which only the atria are involved by the deposits. Biochemical analysis has indicated that the major subunit protein of IAA is alpha-human atrial natriuretic peptide (alpha-ANP), which is synthesized by the atrial muscle cells. To define the exact location of the formation of IAA fibrils, right atria from 25 patients undergoing cardiac surgery have been examined by an immunohistochemistry and immunoelectron microscopy with anti-alpha-ANP, apolipoprotein E, amyloid P component, transthyretin, and cathepsin B antisera. Of 25 patients, 19 were involved with IAA deposits which reacted with anti-alpha-ANP, apolipoprotein E, amyloid P component antisera but not with anti-transthyretin antiserum. In 8 of them, amyloid fibrils were seen not only in the interstitium of the atrial myocardium but also in the dilated transverse tubules of the cardiomyocytes. In some cardiomyocytes, amyloid fibrils were also demonstrated within the organelles such as coated and uncoated secretory vesicles or lysosomes. These findings lead to the inescapable conclusion that the polymerization of amyloid fibrils in IAA occurs within the cytoplasm of cardiomyocytes under some conditions.

[Emergent operation after percutaneous transluminal coronary rotational atherectomy (ROTABLATOR)].

Emergent operations were performed in seven patients after percutaneous transluminal coronary rotational atherectomy (PTCRA). The causes of the emergent operations were coronary rupture in three patients, acute coronary occlusion in two patients, perforation of the ascending aorta in one patient and impossible weaning from IABP in one patient. IABP was used preoperatively in all patients. Coronary artery bypass grafting was performed in all patients. Ruptured sites of the coronary arteries were closed and perforated site of the ascending aorta was repaired. Two patients died due to cardiac failure but five patients were recovered. Coronary artery rupture was main complication after PTCRA. It is important to recognize the difference between the complication after PTCRA and that after conventional PTCA.

[The impact of conjugal bereavement and the buffering effect of social support on the health of elderly people].

This study examined the impact of the spouse's death on the mental and physical health of the elderly, sixty years and older, and the buffering effect of social support against the impact. A three-year study was conducted of 1,087 people whose spouses were alive at the time of the initial survey. Changes over the three-year period were compared among the following three groups: (1) the spouse died within a year prior to the second survey (N = 21); (2) the spouse died more than a year before the survey (N = 47); and (3) the spouse was still alive (N = 901: the comparison group). Results were as follows: (1) Mental and physical health declined more rapidly in the first group than the comparison group, while no significant change was found for the second group. (2) Social support after the spouse loss significantly helped buffer the negative effect on the mental health, but support prior to the loss had no such effect. Social support had no moderating effect on the physical health.

[Coronary artery bypass surgery in aged patients].

From January 1993 through December 1996, 749 patients underwent isolated coronary artery bypass grafting. Of these patients, 578 patients were older than 60 years old. We classified them into three groups; Group A were the 60 to 69 year age group (337 patients), Group B were the 70 to 79 year age group (224 patients) and Group C were over 80 years age group (17 patients). Emergency cases and preoperative LV dysfunction cases were more frequently in Group C, but mortality did not differ among three groups. Duration of intubation, ICU stay and hospital stay were longer in Group C than other groups and complications (PMI, arrhythmia and reoperation for bleeding) were more frequently in Group C. Coronary artery bypass surgery can be performed in aged patients, especially for patients over 80 years old, with acceptably low mortality and significant functional benefit but a high incidence of complications necessitates careful postoperative management in aged patients.

[Combined treatment with resection, intraoperative hypotonic and post-operative systemic chemotherapy using cis-platinum for a mediastinal yolk sac tumor: a case report].

Generally yolk sac tumor in the mediastinum is a rare and highly malignant neoplasm. We report a case of yolk sac tumor, which was treated with resection, and then intraoperative hypotonic and postoperative systemic chemotherapy. A 33-year-old man was diagnosed as a mediastinal tumor with chest X-ray and chest CT findings. At operation he had mediastinal tumor which invaded to the part of the right upper lobe and pericardium, disseminated on the right diaphragm. A large tumor was removed with partial pericardiectomy and wedge resection of the right upper lobe. After resection hypotonic chemotherapy with cis-platinum was performed. This tumor had endodermal sinus structure, Schiller-Duval body, and eosinophilic hyaline globolus which were histological characteristics of yolk sac tumor, and the value of serum alpha-fetoprotein (AFP) was high. After operation with this diagnosis systemic chemotherapy consisted of cis-platinum, etoposide were performed. Patient was discharged uneventfully 8 months later.

Cardiac papillary fibroelastomas: rationale for excision.

We experienced a case of papillary fibroelastoma of the left ventricular outflow tract in a patient with severe valvular heart disease that was detected only by transesophageal echocardiography. Preoperative detection of this lesion altered the surgical procedure to include resection of the mass through the aortic valve annulus along with repair/replacement of the valves. The literature documents sufficient morbidity/mortality to support excision of these lesions regardless of symptoms or location.

Calcified ball thrombus in the left atrium.

We experienced a case of calcified ball thrombus that was fixed to the atrial septum in the left atrium. This patient had no symptoms and no cardiac dysfunction. the thrombus was detected during preoperative work-up of a retroperitoneal tumor. The process of fixation to the atrial septum and calcification is unclear.