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A 64-year-old woman was admitted due to back pain and dyspnea. She was suffering from fever of unknown origin for a few weeks without aortic aneurysm by enhanced chest computed tomography (CT). Chest CT taken 1 month later revealed rupture of aortic arch aneurysm. Total arch replacement was performed with in situ grafting under selective cerebral perfusion combined with deep hypothermic circulatory arrest. Rifampicin (RFP) was sprinkled on the graft at operation and omentopexy was done 5 days after the 1st operation. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated on the culture of the aneurysmal wall, therefore, polymyxin B immobilized fiber with direct hemoperfusion (PMX-DHP) was also conducted with antibiotic therapy. Her clinical course after the 2nd operation was uneventful with no infective complication. We report a successful case of ruptured aneurysm of aortic arch infected with MRSA and review our strategy as one of feasible options without using homograft or preparative RFP-bonded vascular prosthesis.

Atrial rupture by blunt trauma is lethal and one of controversial problems for cardiovascular surgeons, because of complexed conditions due to multiple organ injuries. Some papers recommend strategy of early diagnosis and treatment at an acute phase for better clinical course, but high mortality rate has not been improved yet, especially that of left atrial rupture. Three patients were reffered to our hospital by blunt chest trauma, one of whom died due to hemorrhagic shock before receiving surgical or interventional treatment. The remaining 2 patients had surgical operations at an early phase and were discharged without severe complications. We review our strategy of atrial rupture of blunt chest trauma. At an acute phase, atrial rupture alone should be repaired urgently unless use of cardiopulmonary bypass is contraindicated by severe hemorrhage of the other organs.

Idiopathic interstitial fibrosis (IPF) is a chronic, usually fatal lung disease of unknown etiology. There are few specific therapies for acute exacerbation of IPF and factors predicting the onset or severity of this syndrome are not clearly understood. A neutrophil elastase inhibitor, sivelestat (ONO-5046) has been commercially available in Japan since 2002. This inhibitor has a potent effect in the treatment of ALI/ARDS. To evaluate the outcome of patients with acute exacerbation of IPF treated with sivelestat and estimate prognostic factors, we investigated 10 patients with acute exacerbation of IPF who were intubated and mechanically ventilated. We analyzed the outcome of patients with acute exacerbation of IPF until day 180 and measured the P/F ratio, PEEP levels, the values of peripheral white blood cell number, and C-reactive protein (CRP) on day 0, 3, 7 after admission. Serum KL-6 and surfactant protein D (SP-D) concentration on day 0 were also analyzed. All patients were treated with sivelestat and methylprednisolone (mPSL) pulse therapy for 3 days from day 0 and maintenance therapy with prednisone (0.5 mg/kg/day) were continued. Of the 10 patients. 4 patients had survived (40%) and 6 patients had died (60%) at day 180 from the onset of acute exacerbation of IPF. In survivors, P/F ratio, PEEP levels, and CRP values significantly improved on day 7 (p<0.05). Serum KL-6 and SP-D were lower in survivors on day 0 (p<0.05). Taken together, serum KL-6 and SP-D may prove valuable as biochemical markers of prognosis in acute exacerbation of IPF. Sivelestat may have potential in the treatment of acute exacerbation of IPF.

We report the familial occurrence of bronchiolitis obliterans (BO) associated with pulmonary aspergillosis. A mother and daughter admitted for dyspnea after taking Sauropus androgynus both had overfiltration of both lungs in chest X-ray and severe obstructive impairment in lung function tests. They were initially diagnosed with severe asthma and treated with high-dose prednisolone (0.5mg/kg/day) for 1 month to no effects. They did not show reversibility in lung function test. They were difinitively diagnosed with BO associated with Sauropus androgynus. Six months later, the mother's symptoms worsened with productive sputum and severe dyspnea, and her chest X-ray showed patty shadow in both upper lung fields. Precipitating antibodies to aspergillus antigen were positive and aspergillus fumigatus was detected from her sputum culture. She was diagnosed with aspergillosis and treatment with Micafungin (MCFG) and Itraconazole (ITCZ) was started. The daughter's symptoms also worsened and her chest tomography showed multiple cavities in both lung fields. Precipitating antibodies to aspergillus were positive. She was diagnosed with Invasive aspergillosis. She was treated unsuccessfully with MCFG and Amphotericin B (AMPH) and ITCZ. Few reports cover BO with aspergillus infection without organ impairment. In these 2 cases, treatment with steroids' or immune suppression of the lung with BO may a trigger aspergillus infection.

We experienced familial occurrence of bronchiolitis obliterans (BO) associated with Sauropus androgynus. The cases were a mother and daughter and both were admitted to our hospital because of dyspnea after taking Sauropus androgynus. Both cases had hyperinflation of both lungs in chest x-ray and lung function test showed severe obstructive impairment. At first, they were given a diagnosis of severe asthma and treated as such. However, neither their symptoms nor lung function improved. They did not show any reversibility on lung function tests. Although we did not perform histological examination of the lung, they were given a diagnosis of BO associated with Sauropus androgynus (SABO), because of the following reasons. Cases of SABO in Taiwan have already been demonstrated in the 1990's, and there were no other reasons to explain their severe airflow obstruction. Neither bronchodilators nor steroid treatment improved airflow obstruction. BO is rare and can mimic asthma and chronic obstructive pulmonary disease (COPD). We should inquire about the intake of food or medication in cases suspected BO.

To evaluate effectiveness of pneumococcal polysaccharide vaccine, we recommended 1378 outpatients aged over 60 with chronic respiratory diseases to be vaccinated from August to October 2002, and 647 patients were vaccinated from August to November 2002. In the 1229 patients without respiratory failure, the incidence of antimicrobial treatment for bacterial respiratory infections in 547 vaccinated patients significantly decreased from 7.9% in the 2001/02 winter season to 5.7% in the 2002/03 winter season, although that in the 682 unvaccinated patients increased from 3.8% to 5.7%. The incidence of antimicrobial treatment for bacterial respiratory infections in 229 vaccinated patients with pneumococcal and influenza vaccines together significantly decreased from 10.5% in the 2001/02 winter season to 5.2% in 2002/03 winter season although that in 110 subjects vaccinated with influenza vaccine only increased from 2.7% to 7.2%. These findings suggest the effectiveness of the pneumococcal polysaccharide vaccine for the prevention of bacterial respiratory infections and the additive effectiveness of pneumococcal and influenza vaccines together.

Background: The objective of this study was to evaluate the efficacy and toxicity of carboplatin plus weekly paclitaxel as first-line therapy in patients with advanced non-small cell lung cancer (NSCLC)., Methods: Forty-nine patients were analyzed retrospectively. Every 4 weeks patients received 70 mg/m(2)paclitaxel on days 1, 8, and 15, and AUC 5-6 carboplatin on day 1., Results: A median of four cycles (range, 1-7) was administered. Twenty-four patients had a partial response, and the overall response rate was 48.9%. The median survival time was 12.8 months and the 1-year survival was 50.7%. Overall toxicities were mild. The most common toxicity was neutropenia, grade 3/4 in 32% of the patients. Grade 3/4 hematologic toxicities included anemia (16%) and thrombocytopenia (8%). Grade 3/4 non-hematologic toxicities included febrile neutropenia (2%), pneumonia (10%) and interstitial pneumonia (2%). Grade 2 peripheral neuropathy was seen in one patient (2%)., Conclusions: These results demonstrate that this regimen is an active and tolerable treatment for patients with advanced NSCLC. It is suggested that this weekly regimen should be considered as one of the standard therapies for future chemotherapy in advanced NSCLC.

Background: The objective of this study was to evaluate the efficacy and toxicity of gefitinib as a first-line therapy in patients with advanced non-small cell lung cancer (NSCLC)., Methods: We analyzed 19 patients with advanced NSCLC retrospectively, who were treated with gefitinib as a first-line therapy. These patients were not considered for systemic chemotherapy secondary to co-morbid conditions, poor performance status (PS) or refusal of chemotherapy., Results: Median age 68 years, male/female 10/9, stage III/IV 7/12, smoker/non-smoker 12/7, adenocarcinoma/non-adeno 13/6, PS 0/1/2/3/4 0/4/7/5/3. Four patients had a partial response and the overall response rate was 21.0%. The median survival time was 6.8 months and 1-year survival was 27%. Overall toxicities were mild. Grade (G) 3 diarrhea was observed in one patient and G1 interstitial pneumonia in one., Conclusions: These results demonstrate that gefitinib is active as a first-line therapy in patients with advanced NSCLC.

We studied the clinical features and efficacy of home noninvasive positive pressure ventilation (NPPV) therapy in 80 patients to ascertain its indications and problems. The causes of chronic respiratory failure were restrictive thoracic diseases of post-tuberculosis sequelae (40 cases) and kyphoscoliosis (9 cases), COPD (8 cases), bronchiectasis (7 cases), and interstitial pneumonia (4 cases). One year survival rate of the patients with post-tuberculosis sequelae was 76% and most of the patients who started NPPV at their acute exacerbation died within several months. About half of the patients of COPD improved their quality of life (QOL) through NPPV. However, their survival rate 3 months later was only 69%. More than half of the patients with bronchiectasis felt that their QOL was improved by NPPV. Most of the patients with interstitial pneumonia died within 3 months indicating that NPPV is less useful for improving QOL of interstitial pneumonia PaCO2, after home NPPV, decreased significantly in the responder group (70.0 +/- 15.4 vs. 57.6 +/- 10.7[SD]Torr, p < 0.05), while PaCO2 in the non-responder group was unchanged (65.4 +/- 12.1 vs. 64.2 - 10.4 [SD] Torr). Body Mass Index (BMI) in the responder group tended to be higher than in the non-responder group. In conclusion, the restrictive thoracic diseases with post-tuberculosis sequelae and kyphoscoliosis are a good indication for NPPV and the therapy is also useful for patients with bronchiectasis who can dispose of their sputum by themselves. Home NPPV is suitable for patients whose PaCO2 decreases through NPPV and whose BMI is relatively high. QOL of interstitial pneumonia barely improves through NPPV, because interstitial pneumonia with hypercapnia is at the terminal stage.

A total of fourteen patients with combined operation of coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) for coronary artery disease (CAD) and aortic stenosis (AS) were reviewed to evaluate the indication of the combined operation. Preoperative pressure gradient across the valve and effective orifice area were 21-89 mmHg (mean 64 mmHg), 0.5-1.9 cm2 (mean 0.92 cm2), respectively. The extent of CAD was 1-3 (mean 2.0). Fractional shortening (%FS) ranged from 13% to 43% with mean value of 28%. All patients underwent CABG and AVR. The number of grafts was 1-4 (mean 2.3) with internal thoracic artery used in 7 cases. Mechanical valves were employed for all patients except 1 case with cerebral aneurysm. There was no operative death, although low output syndrome developed in 2 cases. One had poor left ventricular function preoperatively, and the other was emergency case. Fractional shortening improved postoperatively even in two cases with preoperative %FS less than 20%, and all grafts were patent on postoperative coronary angiography. The event-free survival was 100% during 32 months of mean follow-up. Combined AVR with CABG is recommended to avoid risky secondary operation in patients of CAD and AS, even if one of which is relatively mild, because of the fact that operative and late results of the combined surgery are satisfactory.

We experienced a rare case of the mitral regurgitation due to papillary muscle rupture after percutaneous transvenous mitral commissurotomy (PTMC). This case was a seventy years old female who underwent PTMC. The cardiac tamponade and mitral regurgitation occurred after PTMC. Pericardial drainage was done immediately, and the next day the emergency operation was required. Rupture of the posterior papillary muscle was found at the operation, and mitral valve replacement was performed. Her postoperative course was uneventful and she discharged on the 26th day after the operation. We should take the papillary muscle rupture into consideration if there are severe sub-valvular lesion and shorting of the chorda.

To evaluate the effect of retrograde cerebral perfusion (RCP) and selective cerebral perfusion (SCP) on brain protection, changes of cerebrovascular oxygen saturation (rSO2) were studied in 14 patients with aortic arch reconstruction during the procedure. The rSO2 was monitored with spectroscopy instrument (Invos 3100, Somanetics). The mean value of rSO2 measured just before cardiopulmonary bypass was 65.9 +/- 6.2% in 7 patients with RCP, and was 64.9 +/- 4.7% in 7 patients with SCP. The value of rSO2 during core cooling of cardiopulmonary bypass was increased step by step. Although RCP time with a mean of 38.9 +/- 9.7 min was statistically shorter than SCP time (80.7 +/- 45.1 min), the mean value of rSO2 during cerebral protection in RCP group was decreased from 80.3 +/- 8.1% to 63.4 +/- 10.2%, lowest 46% with a ratio of 21.1%. In contrast, the mean value of rSO2 in SCP group was well maintained from 79.9 +/- 6.5 to 75.6 +/- 6.8%, lowest 63% with a ratio of 5.4%. Although no neurological deficits were recognized after operation in both groups, rSO2 in SCP group was sustained above the control value (65% just before cardiopulmonary bypass) but rSO2 in RCP group was decreased below the control value after 35 min. So we conclude that with regard to brain protection assessed from rSO2 measured by Invos 3100 cerebral oximeter, there is no time limitation of SCP during the procedure but RCP had a limit of the duration.

Twenty-six patients with moderate and severe ischemic mitral regurgitation due to papillary muscle dysfunction underwent mitral valve replacement (MVR) or mitral annuloplasty (MAP) using modified Kay method. Emergent operation was performed in 12 patients of whom 11 had severe congestive heart failure even under IABP, 5 had cardiogenic shock and 9 needed respiratory care with intubation preoperatively. Elective operation was performed in 14 patients of whom 6 had history of congestive heart failure and 1 had episodes of ventricular tachycardia. As intraoperative findings of mitral valve, mural annular dilatation in 84.6%, prolapse of anterior leaflet in 23.1%, papillary muscle scar in 15.4%, chordal elongation in 15.4% and chordal rupture in 3.8% were seen separately or in combination. In 22 patients MAP using modified Kay method and CABG were performed, but in 4 patients MVR was needed because of the prominent prolapse of the anterior leaflet. Fourteen patients who underwent MAP with CABG and one MVR with CABG survived. Hospital mortality was higher in emergent (58.5%) than elective operation (28.6%). In the 15 survivors, mitral regurgitation decreased below Sellers 2, pulmonary wedge pressure decreased significantly (p < 0.01) and NYHA functional class improved to I or II postoperatively. During the follow up period of 15-100 (mean 38.7 +/- 21.6) months, 2 MAP+CABG patients died suddenly, but the remaining 13 patients were in NYHA class I or II and no progression of MR was seen. These results indicated that MAP+CABG is recommendable in the treatment of ischemic mitral regurgitation due to papillary muscle dysfunction, in order to preserve cardiac function and to reduce valve related complications.

A case of acute aortic dissection (Stanford Type A) with severe aortic regurgitation successfully treated by postoperative ECMO was reported. The patient was 41-year-old man in shock condition and was transferred to Kobe University Hospital. Chest CT scan and echocardiogram revealed acute aortic dissection with severe aortic regurgitation. An emergent operation by Collins' method and resuspension of aortic valve were carefully performed. Consequent ECMO was necessitated because of postoperative left ventricular and respiratory failure. Thereby, ECMO using heparin-coated CBAS-MAXIMA membrane oxygenator, centrifugal pump, and tubes was established by arterial cannulation via the anastomotic site of the ascending aorta to prevent the obstruction of the aortic true lumen by the false lumen which may be enlarged by retrograde perfusion via the femoral artery. Left ventricular function and pulmonary function were improved after 6 hours and 20 minutes, thus ECMO was successfully weaned without any complications.

Two cases of acute aortic dissection which developed compression of the true lumen due to retrograde perfusion during cardiopulmonary bypass were reported. In the first case, coronary reperfusion could not be achieved when the aortic cross-clamping was removed after Collins' method of aortic dissection. There was no blood flow from the true lumen through the aortic root while the false lumen was distended by the retrograde perfusion. After completion of antegrade perfusion through the arterial cannula inserted into the anastomosed site of the ascending aorta, coronary reperfusion was established and the heart beating could be thereby obtained. In the second case, the false lumen was gradually expanded, and the true lumen was completely obstructed by it. Reexpansion of the true lumen was achieved by initiation of antegrade perfusion through the cannula inserted into the graft replaced in the ascending aorta. Fortunately cerebral and cardiac complications were not found in both cases postoperatively. Compression of the true lumen is rare, but fatal complication that may occur during retrograde perfusion in surgical repair for aortic dissection of Stanford type A. Therefore, it is very important to replace the perfusion cannula in the true lumen of the reconstructed aorta for preventing insufficiency of coronary and cerebral circulation.

Sixty-seven patients subjected to this study composed of 32 patients treated surgically, 15 patients treated medically and 20 patients examined by autopsy for the past 8 years. Out of 32 surgical cases, 16 were operated on in an acute stage, within 2 weeks after onset and 9 out of these 16 acute cases belonged to DeBakey type I or II and 11 out of 15 autopsy cases belonged to type I or II either. Contrarily most of the medical cases were type III. Both causes of death in the acute autopsy group and operative indications in the acute surgical group were cardiac tamponade, heart failure due to aortic insufficiency, myocardial infarction and aortic rupture. Operative mortality rate was 12.5% in the acute cases and 19% in the chronic cases, late mortality rate was 19% in the acute cases and 0% in the chronic cases. Two cases of operative death had massive bleeding due to aortic rupture and massive myocardial infarction. These were the most dangerous complications of acute aortic dissections. We conclude that all patients with type I or II dissections should be operated on before fatal complications occur.

Since a first successful A-C bypass using saphenous vein graft was performed in 1970, eighty five patients with severe coronary heart disease were operated on in our clinic. Up to date, A-C bypass was carried out in sixty four cases, and aorto-coronary sinus bypass (Ao-Cs bypass) as an arterialization of the coronary venous system was done in one case in the group of angina pectoris. Three cases among sixty four patients who underwent A-C bypass and a case of Ao-Cs bypass died of low cardiac output syndrome postoperatively. Other two cases died of refractory arrhythmia and cardiomyopathy 6 years after surgery. The remaining fifty nine cases are doing well without any complications during follow up from ranging 2 months to 13 years (mean 3 years 4 months). Recently, no operative death was found during past 8 years with development of surgical technique and myocardial protection. Ventricular function (cardiac index, LVedp, Max LV dp/dt, EF, LVEDVI , double products at rest and during treadmill exercise test) disclosed good results especially in complete revascularization group. Graft patency had a close correlation between a diameter of the coronary artery at the anastomosis site and bypass graft flow after completion of bypass. Subsequently, a good patency rate (84%-86%) was obtained in cases with the coronary artery more than 1.5 mm in diameter. It could be concluded that A-C bypass was useful procedure to improve ventricular function as well as clinical symptoms and longevity of the life.

A technique for closure of patent ductus arteriosus in the elderly cases is described. We have operated on eleven adult cases of patent ductus arteriosus cases in 10 years. In five cases cardiopulmonary bypass used and in the other six cases it was not used. The cardiopulmonary bypass was used especially for the patients with pulmonary hypertension (pulmonary artery mean pressure greater than 40 mmHg), or high aged (older than 40 years) patients. No operative death have occurred in both groups, and no complication from air embolism or hemorrhage have been encountered. The technique embodies the profound hypothermia, low flow, and direct suture of the pulmonary end of the ductus arterious through a pulmonary arteriotomy. The ductus has been obstructed by using a Hegar's dilator before core cooling was started. Hegar's dilator is useful for establishing profound hypothermia and satisfactory visualization of the operative field.