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This study examined the fungal flora contained in the dust of bedding used in 50 houses in Japan. The result showed that the mycoflora having the largest isolation rate was yeasts, which were isolated by 42 out of 50 houses (84%), and exceeded the isolation rate of Cladosporium spp. (80%) and Aspergillus spp. (66%). In addition, the isolation rate of Alternaria, which was an important fungus causing asthma, 66% was being considered as a high isolation rate, and this result was very interesting. The isolation rate of xerophilic fungi such as Aspergillus restrictus and Wallemia often found in house dust on the floor, was not very high. Forty-one strains of yeasts isolated from each dust sample were identified, and Naganishia diffluens species complex and Filobasidium magnum had a larger number of 13 strains, respectively. Since N. diffluens was the yeasts often isolated from human skin, it was thought to be an association between the fungal skin flora and fungal flora of bed dust. Meanwhile, there was no report of isolation of F. magnum from house dust previously. To the best of our knowledge, this is the first study showing its isolation from bedding with relatively high frequency.

Objective: We investigated the prevalence of asthma, rhinitis, and atopic dermatitis in children, evaluated the mite allergen levels in their bedding after the Great East Japan Earthquake, and assessed changes in allergic symptoms in children and their families after allergen avoidance practices. Methods: We performed a survey for the International Study of Asthma and Allergies in Childhood (ISAAC) comprising 1109 children, aged 7–8 years, living in Ishinomaki, Japan. We collected responses from 464 children, and in 2016, measured the level of Dermatophagoides group 1 (Der 1) in the bedding of 202 of these children. The intervention group of children attended at least one allergen avoidance seminar. The levels of Der 1 in their bedding were measured, along with changes in allergic symptoms, in 17 children in 2017 and 14 children in 2018. The nonintervention group comprised children who did not attend an allergen avoidance seminar at any time. Results: Of the 464 children who participated in the ISAAC, 50 (10.8%) reported having asthma, 179 (38.8%) allergic rhinitis, and 126 (27.3%) atopic dermatitis. The average level of Der 1 measured in the bedding of the 202 children in 2016 was 295.8 ng/m2. The levels of Der 1 in the intervention group—but not in the nonintervention group—significantly decreased in 2017 and 2018. The symptoms of asthma, allergic rhinitis, and atopic dermatitis in the children of intervention group and their families decreased after allergen avoidance practices. Conclusions: Allergen avoidance practices relieved allergic symptoms in school children after the Great East Japan Earthquake.

Left ventricular thrombus( LVT) formation is a known complication of ischemic heart diseases including acute myocardial infarction, dilated cardiomyopathy (DCM) and myocarditis. Among them, few cases involve DCM. Two DCM patients with LVT developed acute cerebral infarction and underwent thrombectomy. Both patients presented with sinus rhythm and neither had previous thromboembolic event. However, their transthoracic echocardiography (TTE) showed left ventricular ejection fractions35% and left ventricular diastolic diameters≥60 mm, indicating high possibilities of LVT formation. The TTE findings suggest that DCM patients require anticoagulation therapy and frequent imaging examination, even with sinus rhythm and no history of thromboembolic events. Once a thromboembolic event occurs, thrombectomy is urgently needed.

Introduction: We previously reported an increased prevalence of asthma in adults who lived in temporary housing after the 2011 Great East Japan Earthquake. The goal of the current study was to investigate changes in asthma prevalence and mite-specific immunoglobulin E (IgE) titers in temporary housing residents during 2014–2019. Methods: By using the Global Initiative for Asthma guidelines, we diagnosed asthma in Ishinomaki city temporary housing residents aged 15 years or older. We then analyzed serum antigen-specific IgE levels to Dermatophagoides farinae (Der f), Dermatophagoides pteronyssinus (Der p), and Aspergillus fumigatus. Results: The prevalence of asthma exceeded 20% across all age-groups throughout the study period. The proportion of study participants with a “positive” antigen-specific IgE titer (i.e., ≥0.35 IUA/mL) was higher in asthmatics than in nonasthmatics for Der f and Der p but not for Aspergillus fumigatus. Among residents ≥50 years old who were diagnosed with asthma, the percentage with a Der f-specific IgE titer ≥0.10 IUA/mL was higher than the proportion with ≥0.35 IUA/mL. Among study participants, asthma onset occurred before the earthquake, during residence in shelters or temporary housing, and (starting in 2016) after moving out of temporary housing. The Der p-specific IgE level was positively correlated with the duration of temporary housing (p < 0.05, r = 0.41) and inversely correlated with the time elapsed since moving out of temporary housing (p < 0.05, r = −0.35). Conclusion: Mite allergen sensitization was found in both asthmatic and nonasthmatic temporary housing residents after the 2011 Japan earthquake and tsunami; asthma developed even after subjects moved out of temporary housing.

Calprotectin, an inflammation-related protein, is present in gingival crevicular fluid (GCF), and the determination of calprotectin is useful for diagnosing periodontal diseases. The authors have recently developed a novel immunochromatographic (IC) chip system to determine calprotectin levels in GCF. In the present study, the usefulness of this diagnostic system is investigated in patients with periodontal diseases.Thirty-six patients with periodontal diseases participated in this clinical test at multiple centers. Periodontitis sites (n = 118) and non-periodontitis (healthy) sites (n = 120) were selected after periodontal examination. GCF collection and periodontal examination were performed at baseline, after supragingival and subgingival scaling and root planing. Calprotectin levels in GCF were determined using a novel IC chip system and evaluated as a visual score and an IC reader value. Correlations between GCF calprotectin levels, clinical indicators, and changes in calprotectin levels by periodontal treatments were investigated. Receiver operating characteristic (ROC) analysis of IC reader value for GCF calprotectin was performed to predict periodontal diseases.The visual score of GCF calprotectin was highly correlated with the IC reader value. IC reader values of GCF calprotectin in the periodontitis group were higher than those of the healthy group at three dental examination stages, and they significantly decreased with periodontal treatments. Visual scores and IC reader values of GCF calprotectin were correlated to levels of clinical indicators. ROC analysis for GCF calprotectin showed an optimal cutoff value to predict periodontal diseases.Determination of GCF calprotectin using a novel IC chip system is useful for diagnosis of periodontal diseases.

To investigate the relationship between body mass index (BMI) and early outcomes, and specific types of morbidities associated with low and high BMI, in patients undergoing coronary artery bypass grafting.This was a retrospective study on isolated coronary artery bypass grafting patients (aged ≥60 years) between 2008 and 2017 in the Japan Cardiovascular Surgery Database. The primary end point was defined as operative mortality. The secondary end point was combined morbidity (ie, operative mortality, reoperation for bleeding, stroke, new onset of hemodialysis, mediastinitis, and prolonged ventilation). Patient characteristics and outcomes were compared among BMI groups. Spline curves were fit between BMI and outcomes. Multivariable logistic regression models with categorized BMI and generalized additive models with spline-transformed BMI were used to estimate and visualize the effect of BMI adjusted for other covariates.A total of 96,058 patients were included in the analysis. Low (18.5) and high (≥30) BMI were both associated with a higher risk of mortality (low: adjusted odds ratio, 1.34; 95% confidence interval, 1.16-1.54; P .0001, and high: adjusted odds ratio, 2.10; 95% confidence interval, 1.70-2.59; P .0001) and combined morbidity (low: adjusted odds ratio, 1.18; 95% confidence interval, 1.08-1.29; P = .0002 and high: adjusted odds ratio, 1.82; 95% confidence interval, 1.63-2.03; P .0001). Low and high BMI were associated with different types of morbidities. In models using spline transformation, the deviation of BMI from a proximately 21 to 23 was proportionally associated with increased risk.In patients undergoing coronary artery bypass grafting, low and high BMI were risk factors of mortality associated with different types of morbidities, which may warrant tailored preventive approaches.

Generally, anticoagulation therapy is not essential for patients who maintain sinus rhythm after mitral valvuloplasty. A 66-year-old woman who had undergone mitral valvuloplasty and maze procedure for treatment of mitral valve regurgitation and atrial fibrillation 4 years ago was diagnosed as having left atrial thrombosis despite maintenance of sinus rhythm on electrocardiography. Echocardiography showed narrow mitral valvular area(1.5 cm2), loss of A wave and a huge left atrium. Repeat surgery was performed to replace the mitral valve and to remove the thrombus. The thrombus attached to the posterior wall of the left atrium with a wide basis, and was unrelated to the ablation line of maze procedure. Careful follow-up and anticoagulation therapy should be considered for patients who have a large left atrium and/or rheumatic mitral valve after valvuloplasty even though sinus rhythm is maintained.

Mutations in the epidermal growth factor receptor (EGFR) gene are associated with a favorable clinical response to the EGFR tyrosine kinase inhibitors gefitinib and erlotinib in non-small cell lung cancer (NSCLC). We present here, a new method for the rapid detection of the two most common EGFR mutations (delE746-A750 and L858R) from clinical samples. The methodology involves the combination of newly designed mutation-specific primers and a novel real-time PCR machine with an innovative thermo-control mechanism that enables ultrarapid PCR. We evaluated this method using a cell mixture composed of various ratios of lung cancer cells harboring mutated or wild-type EGFR, lung cancer tissues obtained by surgery, and a cytology sample obtained by bronchoscopy from a lung cancer patient. In the cell mixture analysis, our method detected 0.1% of cells with delE746-A750 and 1% of cells with L858R among cells with wild-type EGFR. In 143 lung cancer tissues, the result of this assay was concordant with those of direct sequencing in 138 samples. The five samples with discordant results were tested using a PCR-Invader assay and the result matched those of our method at 100%. We also successfully detected EGFR mutations in the lavage obtained from a lung cancer patient. The turnaround time for this method was

BACKGROUND We conducted in vivo examinations of a newly designed stentless mitral valve (SMV), formed by suturing 2 leaflets with the "legs" serving as chorda tendinea, made from bovine pericardium, to a flexible ring. METHODS AND RESULTS: Seven pigs underwent implantation of the SMV constructed with a 23-mm (n=5) or 25-mm (n=2) Duran ring. Baseline echocardiography examinations were used to evaluate the annular anteroposterior diameter, and distance between the mitral annulus (MA) and papillary muscles (PMs) to determine SMV-leg length. After removing the native valve, the SMV-legs were fixed to the anterior and posterior PMs, followed by fixation of the ring to the native MA. Immediately after surgery, all animals presented none or trivial mitral regurgitation, with mean and peak trans-SMV pressure gradient values of 1.9±0.8 and 6.0±3.1 mmHg, respectively. The mean length of the SMV-leg was 19.4±3.9 mm, which correlated with the distance between anterior and posterior MA-PM (r=0.96 and 0.94, respectively, P

Background: Hyperoxemic management during cardiopulmonary bypass (CPB) is still common, and there is no consensus about physiologic oxygen tension strategy (normoxemic management) during pediatric CPB. In this study, we compared the postoperative conditions and measures of inflammatory response among patients with acyanotic congenital heart disease subjected to either hyperoxemic or normoxemic management strategy during CPB. Methods: We studied 22 patients with a ventricular septal defect and pulmonary artery hypertension. The patients were divided into two groups. Group I (n = 9) received normoxemic management (PaO2 = 100-150 mm Hg) and group II (n = 13) received hyperoxemic management (PaO2 = 200-300 mm Hg) during CPB. There was no difference between groups with regard to age, body weight, duration of CPB, and aorta clamping time or preoperative pulmonary hypertension (pulmonary pressure/systemic pressure [Pp/Ps]). In each group, the blood samples to measure the cytokine levels were collected before and after the CPB. Results: Although we observed no statistically significant differences in postoperative intubation time, alveolar–arterial oxygen difference, creatine kinase MB level, and pulmonary hypertension (Pp/Ps) between group I (10.7 ± 13.4 hours, 197 ± 132 mm Hg, 148 ± 58.6 IU/L, 42.8% ± 22.1%, respectively) and group II (27.8 ± 36.5 hours, 227 ± 150 mm Hg, 151 ± 72.6 IU/L, 50.4% ± 16.0%, respectively), levels of median interleukin 6 and tumor necrosis factor α were lower in group I (129.8 and 17.0 pg/mL, respectively) than that in group II (487.8 and 22.5 pg/mL, respectively). Conclusion: During the CPB in acyanotic pediatric patients, normoxemic management can minimize the systemic inflammatory response syndrome associated with CPB. We can apply this physiologic oxygen tension strategy to surgical advantage during heart surgeries in acyanotic pediatric patients.

A single coronary artery, arising from the left sinus of Valsalva, associated with a bicuspid aortic valve and annuloaortic ectasia, is very rare. We report on a surgical case of bicuspid aortic valve regurgitation, annuloaortic ectasia, and dilation of the ascending aorta to the aortic arch in a patient with a single coronary artery. We successfully performed aortic root replacement with reimplantation of the single coronary artery and total arch replacement. The reimplantation of the coronary orifice required particular attention. Postoperative CT demonstrated the expected contours from the aortic annulus to the aortic arch with a patent implanted coronary artery.

Left ventricular pseudo-false aneurysms are a very rare complication of myocardial infarction. Occasionally, they will perforate into the right ventricle. Their haemodynamic presentation is similar to postinfarction ventricular septal defect. Even with no early clinical symptoms, they can lead to congestive heart failure or sudden fatal rupture. We report on a 67-year old man who developed a large left ventricular pseudo-false aneurysm that perforated into the right ventricle late after acute inferior myocardial infarction. He had undergone percutaneous coronary intervention to the right coronary artery in August 2013. During the surgery performed in July 2014, with only incision at the aneurysm, the small perforation to the right ventricle was closed directly and the large perforation to the left ventricle was closed with a bovine pericardial patch. Considering the late mechanical complications attendant to left ventricular remodelling, physicians should conduct careful long-term follow-up of patients with transmural myocardial infarction, even if previous percutaneous coronary intervention was successfully performed.

A 41-year-old female with hereditary deficiency of antithrombin III (ATIII) was diagnosed with atrial septal defect( ASD) and scheduled for the closure of ASD. She had been taking warfarin since she suffered from deep vein thrombosis 10 years ago. Preoperative management of anticoagulation included discontinuation of warfarin, and supplementation of antithrombin with heparin infusion. On the day of operation, antithrombin activity was maintained above 80% by administering antithrombin, and closure of ASD was carried out under standard cardiopulmonary bypass support using heparin. Heparin infusion was continued with antithrombin supplementation until prothrombin time-international normalized ratio(PT-INR) recovered to around 2.5 with warfarin. Her intra-and postoperative courses did not show any thromboembolic events, and she was discharged 20 days after the surgery.

Background: The feasibility of synchrotron radiation-based phase-contrast computed tomography (PCCT) for visualization of the atrioventricular (AV) conduction axis in human whole heart specimens was tested using four postmortem structurally normal newborn hearts obtained at autopsy. Methods: A PCCT imaging system at the beamline BL20B2 in a SPring-8 synchrotron radiation facility was used. The PCCT imaging of the conduction system was performed with “virtual” slicing of the three-dimensional reconstructed images. For histological verification, specimens were cut into planes similar to the PCCT images, then cut into 5-μm serial sections and stained with Masson’s trichrome. Results: In PCCT images of all four of the whole hearts of newborns, the AV conduction axis was distinguished as a low-density structure, which was serially traceable from the compact node to the penetrating bundle within the central fibrous body, and to the branching bundle into the left and right bundle branches. This was verified by histological serial sectioning. Conclusion: This is the first demonstration that visualization of the AV conduction axis within human whole heart specimens is feasible with PCCT.

This study aimed to profile the microflora in infected root canals before and after root canal treatment using culture-independent methods. Six infected root canals in single-rooted teeth with periapical lesions from five subjects were included. Quantification of total bacteria was performed by real-time PCR with primers targeting 16S rRNA genes. PCR products with universal 16S rRNA gene primers were cloned and partially sequenced, and bacterial identification at the species level was performed by comparative analysis with the GenBank database. The concentration of extracted DNA before treatment was higher than that after root canal treatment, although the difference was not statistically significant. Sequence analysis revealed that oral bacteria such as Fusobacterium, Streptococcus, Olsenella, and Pseudoramibacter detected in cases before root canal treatment disappeared after treatment. These results suggest that the root canal microflora are distinct before and after root canal treatment, and that treatment changes the microflora in both quantity and quality.

Highlights ► A super high speed qRT-PCR (SHRT-PCR) was developed. RT reaction and PCR (40 cycles) can be completed in less than 20 min. ► Despite the high speed, the sensitivity and specificity of the SHRT-PCR are comparable to conventional qRT-PCR system. ► The SHRT-PCR can be used to test clinical samples., The development of a rapid and sensitive system for detecting influenza viruses is a high priority for controlling future epidemics and pandemics. Quantitative real-time PCR is often used for detecting various kinds of viruses; however, it requires more than 2 h per run. Detection assays were performed with super high-speed RT-PCR (SHRT-PCR) developed according to a newly designed heating system. The new method uses a high-speed reaction (18 s/cycle; 40 cycles in less than 20 min) for typing influenza viruses. The detection limit of SHRT-PCR was 1 copy/reaction and 10−1 plaque-forming unit/reaction for viruses in culture supernatants during 20 min. Using SHRT-PCR, 86 strains of influenza viruses isolated by the Tokyo Metropolitan Institute of Public Health were tested; the results showed 100% sensitivity and specificity for each influenza A and B virus, and swine-origin influenza virus. Twenty-seven swabs collected from the pharyngeal mucosa of outpatients were also tested, showing positive signs for influenza virus on an immunochromatographic assay; the results between SHRT-PCR and immunochromatography exhibited 100% agreement for both positive and negative results. The rapid reaction time and high sensitivity of SHRT-PCR makes this technique well suited for monitoring epidemics and pre-pandemic influenza outbreaks.

Postoperative left ventricular pseudoaneurysm is a rare, but potentially lethal, complication because of the high risk of rupture and high mortality of repair. We report a 64-year-old man with Marfan syndrome who underwent the reimplantation valve-sparing aortic root replacement complicated by a postoperative left ventricular pseudoaneurysm that required urgent repair. Careful handling of the aortic root is required to avoid a left ventricular pseudoaneurysm, particularly in patients with connective tissue disorder.

Background The objective of this study was to reassess the validity of defining patient-prosthesis mismatch (PPM) in the aortic position on the basis of an indexed effective orifice area (iEOA) less than 0.85 cm 2 /m 2 . Methods From June 1996 to March 2008, 342 patients underwent aortic valve replacement with a Carpentier-Edwards Perimount valve. From the data collected, the transvalvular pressure gradient was determined by the modified Bernoulli equation, and EOA was calculated from the standard continuity equation. Results The actuarial survival rate at 10 years after surgery was 84.0% ± 8.2%. The prevalence of PPM was 6.1% when a projected iEOA less than 0.85 cm 2 /m 2 was defined as indicating significant PPM. There was no difference between patients with moderate PPM (85.2% ± 9.8%) and patients without PPM (81.0% ± 8.7%; p = 0.44). The relation between mean transvalvular pressure gradient and iEOA demonstrated a gentler slope than that reported previously. Postoperative mean transvalvular pressure gradient was 17.4 ± 5.6 mm Hg and 14.5 ± 5.6 mm Hg in patients with an iEOA less than 0.85 and 0.85 or greater, respectively. Most patients had a postoperative mean transvalvular pressure gradient more than 10 mm Hg regardless of PPM. Conclusions Our analysis suggested that an iEOA less than 2.0 cm 2 /m 2 might be the threshold for PPM, which should not be passed to achieve a low mean transvalvular pressure gradient (less than 10 mm Hg) with the Carpentier-Edwards Perimount valve. The implications of these findings include the necessity for reassessing the hemodynamic performance of each type of prosthesis when attempting to define PPM, to avoid residual significant transvalvular pressure gradient.

Although numerous reports have described suturing techniques for tricuspid annuloplasty, most studies were not based on a detailed anatomy of the tricuspid annulus. Thus, the definition of the tricuspid commissures remains unclear. This study aimed to clearly define the commissures and leaflets of the tricuspid valve and subvalvular structures, and to define a standard method for tricuspid annuloplasty.In 27 normal heart specimens without cardiac disease, the tricuspid commissure was defined using indentations of the leaflets as a point, not an area, and the length of each tricuspid annulus was measured. The relationships between the leaflets and the subvalvular structures were then examined.In most specimens, the posterior leaflet had 2 (62.9%) or 3 (29.6%) scallops, providing further evidence of posterior leaflet diversity. In addition, the posterior leaflet had 1 or 2 indentations, which can be mistaken for true commissures. The annulus of the posterior leaflet was significantly longer than the annuli of the other 2 leaflets (P .00428). The annuli of the septal and the anterior leaflets were supported by the interventricular septum and the supraventricular crest, respectively, whereas the posterior leaflet annulus was distributed largely along the right ventricular free wall.There was a structural gap between the tricuspid leaflet indentations and the subvalvular structures. The relationships among the leaflets, commissures, and subvalvular structures differed in the septal, anterior, and posterior leaflets. This new definition of the commissural point may aid the development of a clear-cut methodology for prosthetic ring annuloplasty.

Objectives. Surgical treatment of a prolapsed anterior leaflet of the mitral valve is relatively difficult and controversial compared with management of a prolapsed posterior leaflet. The aim of this study was to assess the long-term results of mitral valve repair, focusing on triangular resection of the anterior leaflet. Methods. Between October 1991 and December 2006, surgical treatment for a prolapsed anterior leaflet was performed in 57 patients with degenerative mitral valve disease, including 49 patients who had anterior leaflet resection. Patients with mitral stenosis, ischemic mitral regurgitation, and congenital valvular disease were excluded. The mean age of the patients was 51.7 ± 15.9 years, and the mean follow-up period was 6.2 ± 3.8 years. Results. The overall actuarial survival rate and noreoperation rate at 10 years were 91.7% ± 4.1% and 92.3% ± 3.7%, respectively. Reoperation was performed in 2 (4%) of 49 patients who had anterior leaflet resection. All patients survived after reoperation, which involved mitral valve replacement. Postoperative echocardiographic studies showed that the mitral valve area was significantly smaller after repair in patients with anterior leaflet resection, but the area was still large enough for a functional valve. Among the 57 patients, 42 had no mitral regurgitation, whereas it was mild in 7 patients and moderate in 3 patients. Conclusion. Triangular resection of a prolapsed anterior leaflet of the mitral valve provides durable and reliable long-term results.

Triple-valve procedures are associated with high early and late mortality. We reviewed our experience in 25 patients who underwent combined mitral and aortic valve replacement with tricuspid valve repair or replacement between 1979 and 2004. The mean follow-up was 7.8 years (range, 10 days to 24.5 years). The mean age at operation was 52 years (range, 31 to 72 years). Four patients underwent triple-valve replacement and 21 had double-valve replacement and tricuspid annuloplasty. Perioperative mortality was 20% and late mortality was 24%. Cumulative survival, calculated taking perioperative mortality into account, was 71% ± 10% at 10 years and 36% ± 15% at 15 years after surgery. Only 1 of 20 perioperative survivors required re-operation for prosthetic valve dysfunction. Double-valve replacement with tricuspid annuloplasty offers satisfactory long-term survival with freedom from thromboembolism and re-operation.

The objective of the present study was to compare long-term results of single aortic valve replacement (AVR) with mechanical (St. Jude Medical valves: standard) and biologic (the Carpentier-Edwards pericardial) prostheses. Method: Between 1995 and 2002, 95 patients who underwent single AVR with mechanical (n=46) or biologic (n=49) prostheses were enrolled in this study. The mean age at the operation was 54.0±9.6 years (range: 20 to 69 years) with the mechanical and 68.8±7.1 years (range: 44 to 85 years) with the biologic prosthesis. Results: The 9-year actuarial survival rate, which was calculated by taking perioperative mortality into account, was 90.3±4.6% for patients with mechanical valves and 87.6 ±4.8% for patients with bioprostheses, with no difference between the two groups (p=0.342). The 9-year freedom rate from thromboembolism, reoperation, endocarditis was 94.8+3.6%, 100% and 97.8 ±2.2% for patients with mechanical valves and 98.0 ±2.0%, 97.5 ±3.4% and 95.0 ±3.4% for those with bioprostheses, respectively. After 9 years, freedom from cardiac death averaged 97.8% in the group with mechanical valves compared with 95.3% in those with bioprostheses (p=0.541). Conclusion: We conclude that the mid-term durability of the Carpentier-Edwards pericardial valve in the aortic position for the elderly is excellent. Nevertheless, the risk of tissue valve reoperation progressively increases with time, and a longer follow-up may be necessary to provide its value compared with the mechanical valves in a country like Japan with a high life expectancy. (Jpn J Thorac Cardiovasc Surg 2005; 53:465-469)

Objective Surgical strategies for patients who have a small aortic annulus associated with a small mitral annulus remain controversial. The objective of this study was to assess the validity of the Manouguian procedure for double valve replacement with patch enlargement of the annuli. Methods We reviewed 57 consecutive patients who underwent double valve replacement for combined aortic and mitral disease between September 1991 and October 2000. Thirty patients underwent the Manouguian procedure with patch enlargement of the aortic and mitral annuli, and the other 27 patients had standard double valve replacement. The Manouguian procedure was selected for a small aortic annulus of less than 21 mm in diameter. The patients were followed for a median of 7.5 years. Results of echocardiography and the dobutamine stress test were compared postoperatively. Results Double valve replacement with the Manouguian procedure did not increase the early or midterm mortality because the survival (including operative death) at 8 years was 83% in the Manouguian group and 84% in the double valve replacement group (P = .82). The event-free rate at 8 years was 79% in the Manouguian group and 84% in the double valve replacement group (P = .6). The prostheses implanted at the aortic and mitral positions were smaller in the Manouguian group, even after annular enlargement. However, the transprosthetic gradient across the aortic valve evaluated by means of dobutamine stress echocardiography did not differ between the 2 groups, possibly because of a smaller body surface area in the Manouguian group. Conclusions The Manouguian patch enlargement procedure is useful during double valve replacement when associated with the problem of small-valve annuli.

A patient with multiple leaks caused by active mitral prosthetic valve endocarditis with an annular abscess underwent repeat mitral valve replacement. To secure the new mitral prosthesis, sutures were placed through the healthy interatrial septal wall from right to left at the posteromedial region and then to the new prosthetic valve sewing cuff. In the anterolateral region, sutures were placed through the reconstructed annulus after debridement of the abscess and then reinforced with a pericardial xenograft patch. Postoperatively, the perivalvular leakage stopped and the patient recovered uneventfully.

We herein report a case of a 14-month-old infant who revealed a progressive hearing loss by repeated auditory evoked brainstem responses (ABR) during his 1 year stay in the neonatal intensive care unit (NICU). He was born prematurely with asphyxia, hyperbilirubinemia and respiratory distress. During his 1 year stay in the NICU he was under constant mechanical ventilation. Repeated ABRs over this year initially showed normal waves but subsequently demonstrated progressive hearing impairment (HI) leading finally to no responses. Possible causes of this progressive deafness (PF) include the multiple problems of asphyxia, hyperbilirubinemia and pulmonary disorders.

Left ventricular pseudoaneurysm is a rare, but potentially fatal, condition that generally occurs as a complication of myocardial infarction, infective endocarditis, or cardiac surgery. Surgical repair is the treatment of first choice because of the marked risk of rupture, but deteriorated hemodynamics and complicated procedures to treat the pseudoaneurysm may lead to a high mortality rate. We report a 62-year-old woman with a large left ventricular pseudoaneurysm after mitral valve replacement for rheumatic mitral valve stenosis. Surgical repair was not performed due to the patient’s refusal, but her pseudoaneurysm resolved spontaneously by 2 years after mitral valve replacement. Spontaneous obliteration of a large left ventricular pseudoaneurysm is very rare in a patient on warfarin therapy. This case suggests that a left ventricular pseudoaneurysm with a narrow neck may resolve spontaneously in rare settings.

A 25-year-old woman was admitted to our hospital with chest pain and dyspnea, and was diagnosed as having a right atrial myxoma complicated with pulmonary embolism. An emergency operation was performed with cardiopulmonary bypass. A papillary pedunculated tumor was found having a narrow-based attachment to the free atrial wall. After the tumor was carefully removed together with the atrial wall around the attachment, pulmonary embolectomy was performed. Several fragments of the tumor were removed, and sufficient back-flow from the pulmonary artery was established. The postoperative course was uneventful. However, a non-perfused area was observed in the left lower lung on pulmonary hemodynamic scintigraphy at 3 months after the operation. Long-term observation is required due to the high risk for metastasis and recurrence, and further surgical treatment remains the most appropriate treatment option. A second operation may be needed to prevent progression in complications.

Objective: This study is the first comparative investigation of hepatic blood flow and oxygen metabolism during normothermic and hypothermic cardiopulmonary bypass. Methods: Twenty-four patients undergoing coronary bypass operations were randomly divided into 2 groups according to their perfusion temperatures, either normothermia (36°C) or hypothermia (30°C). The clearance of indocyanine green was measured at 3 points. Arterial and hepatic venous ketone body ratios (an index of mitochondrial redox potential) and hepatic venous saturation were measured. Results: Hepatic blood flow in both groups was identical before, during, and after cardiopulmonary bypass (normothermia, 499 ± 111, 479 ± 139, and 563 ± 182 mL/min, respectively; hypothermia, 476 ± 156, 491 ± 147, and 560 ± 202 mL/min, respectively). The hepatic venous saturation levels were significantly lower during cardiopulmonary bypass in the normothermic group (normothermia, 41% ± 13%; hypothermia, 61% ± 18%; P 0.7) until the second postoperative day. However, the reduction in arterial ketone body ratio was less severe in the normothermic group. The difference in hepatic venous ketone body ratios was more obvious, and the hepatic venous ketone body ratios in the normothermic group were statistically superior to those of the hypothermic group throughout the course (P

Background The aortic Carpentier-Edwards pericardial bioprosthesis offers good long-term clinical outcomes with a low rate of structural deterioration. However, little in vivo hemodynamic data is available for this bioprosthesis. Methods To determine the hemodynamic performance of the 19-mm Carpentier-Edwards pericardial valve, both cardiac catheterization and dobutamine stress echocardiography were electively performed in 10 patients. The mean age at the study was 71.6 +/- 4.4 years and the mean body surface area was 1.39 +/- 0.11 m2. The peak-to-peak gradient, instantaneous peak gradient, mean gradient, and valve orifice area were measured by standard cardiac catheterization. The Doppler-derived gradients and valve orifice area were also measured both at rest and during dobutamine infusion. Results The average peak-to-peak gradient, instantaneous peak gradient, mean gradient, and valve orifice area measured by catheterization were 13.0 +/- 5.4 mmHg, 28.5 +/- 7.7 mmHg, 12.0 +/- 4.9 mmHg, and 1.55 +/- 0.45 cm2, respectively. The peak and mean Doppler gradients, and valve orifice area by resting echocardiography were 27.7 +/- 9.5 mmHg, 12.3 +/- 4.8 mmHg, and 1.39 +/- 0.26 cm2, respectively. At a dosage of 10 microg/kg/min of dobutamine, the mean Doppler gradient rose mildly to 22.2 +/- 4.8 mmHg, while the cardiac output increased from 4.49 +/- 0.44 to 6.64 +/- 0.87 L/min. The valve orifice area during the 10 microg/kg/min dobutamine infusion (1.55 +/- 0.25 cm2) was significantly larger than its value at rest (p Conclusions With acceptable hemodynamic performance, use of the aortic 19-mm Carpentier-Edwards pericardial valve is a reliable option for elderly patients with a small annulus.

The minimal effective dose of aprotinin on hemostasis under normothermic perfusion, the influence of anticoagulant therapy on graft patency, and the thromboembolic and hemorrhagic events were investigated after aortocoronary bypass graft operation (CABG). One hundred CABG patients under normothermic perfusion were randomly divided into the following groups: (1) coumadin plus acetylsalicylic acid (ASA) (n=32); no aprotinin used during cardiopulmonary bypass (CPB); (2) minimal-dose, 10(6) KIU during CPB, aprotinin used, followed by ASA and coumadin (n=36); and (3) very low-dose, total of 2x10(6) KIU before CPB and during CPB; aprotinin used; anticoagulation therapy with heparin early after surgery and followed by replacement with ASA and coumadin (n=32). The patency of arterial grafts was 100% in all groups. The patency of vein grafts was 95-98% and there was no difference among the groups. The blood loss was significantly reduced in both aprotinin groups (groups 2 and 3) compared to the coumadin plus ASA group, although no difference existed between the 2 aprotinin groups. Postoperative thrombotic and hemorrhagic events were not observed in any group. From this study, it was concluded that 10(6) KIU aprotinin in pump-prime-only followed by oral ASA and coumadin was the recommendation from the benefit/cost consideration.

Cranial ultrasonography was carried out at least three times a week during the first 16 days of life in all 53 premature newborns born within study period. If a cyst of more than three mm was detected in the periventricular region by fourteenth day of life, it was judged to be antenatal PVL. Periventricular echodensity was classified into mild, moderate or severe periventricular echodensity (PVE). Among 53 newborns, 11 babies (20.8%) were diagnosed as having antenatal PVL. Cysts were observed in the first two days in 9 cases (81.8%) out of 11 babies, and in bilateral periventricular regions in 8 cases (72.7%) out of 11 babies. All 3 babies with severe PVE in the periventricular region had PVL at the time of diagnosis or developed PVL shortely after severe PVE was detected.

The causes of mitral valve operation for patients who underwent aortic valve replacements (AVR)are rheumatic heart diseases, nonrheumatic insufficiency, infective endocarditis, prosthetic valve dysfunction and so on. No specific recommendation for surgical strategy of mitral valve surgery for those patients has been described and surgical strategy should be selected to each patient. The patients with rheumatic heart disease had higher risk for reoperation as compared with those with nonrheumatic heart disease and majority of patients with AVR who need reoperation because of mitral valve diseases had history of open or closed mitral commissurotomy. Therefore, mitral valve repair should be limited to lesions in which excellent durability of the repair can be expected to prevent re-operation.

Lower body ischemia due to bending of a stented graft at the thoracic aorta was rare, particularly when it occurred in several days after surgery. We experienced this complication and performed the 3rd-time thoracic endovascular repair( TEVAR).A 49-year-old man with a chronic aortic dissection of Stanford type B underwent TEVER;however we failed to close the entry because of the tortuously bended distal arch of the aorta. Then it was decided the patient undergo a hybrid treatment with arch replacement and frozen elephant trunk. Seventeen days after the surgery, the blood pressure of the patient's lower limb was reduced rapidly and his renal function deteriorated. Bending of the stent was revealed by computed tomography( CT). The patient underwent the 3rd-time emergency TEVAR, and his symptoms improved.

Persistent fifth aortic arch (PFAA) associated with interruption of the fourth aortic arch is a rare malformation, usually requiring surgical intervention in childhood. A 51-year-old woman developed a distal aortic arch aneurysm associated with PFAA after patch aortoplasty for coarctation of the aorta at the age of 18. To our knowledge, this is the first reported case of a distal aortic arch aneurysm associated with PFAA. Residual tissues of the ductus and PFAA, which is not a definitive aortic arch, and the implanted synthetic patch may have been related to the development of the aneurysm. Graft interposition between the proximal border of PFAA and the descending aorta was performed because severe adhesions impeded the application of the fourth aortic arch as a proximal anastomotic site of the graft. Accurate diagnosis and sufficient understanding of PFAA allow an appropriate surgical treatment in childhood with a good result over the long term.

Total cavopulmonary connection with use of an autogenous intraatrial tunnel to create a straight tube between the inferior vena cava and the pulmonary artery was attempted in several types of cardiac anomaly in eight consecutive candidates for the Fontan operation. A small right atrium with an extraordinary location of the inferior vena cava and a short superior vena cava prevented the use of this procedure in two cases. By preserving the crista terminalis and the sinus node and its arteries we prevented the development of postoperative atrial arrhythmias in the short follow-up period, and the P trigger-signal averaged P waves were not different from those of other cardiac anomalies. The proximal stump of the superior vena cava was not incised in any case to enlarge the anastomosis, even when size mismatch between the superior and inferior venae cavae existed, as in a case of bilateral superior venae cavae. Stretching the vessels by approximately 150% was possible and permitted an adequate anastomosis. Cavopulmonary connections via the intraatrial tunnel ensured smooth, nonturbulent, somewhat pulsatile flow without a pressure gradient. We concluded that the creation of an autogenous intraatrial tunnel was possible in many cases without serious complications and that this procedure has potential benefit for the pulmonary circulation in the aspect of pulsatility. (J THORAC CARDIOVASC SURG 1995;110: 625-32)

The influence of aortic valve prosthesis-patient mismatch (VP-PM) on the clinical outcome has been an ongoing controversy. The reported prevalence of VP-PM after aortic valve replacement (AVR) ranges widely between 20 and 70 %. The inconsistent impact of VP-PM on short-term and long-term mortality, regression of left ventricular (LV) hypertrophy, and exercise capacity may be explained by differences of the patient populations, the definition of VP-PM, and the use of different prostheses. Moreover, many factors other than the severity of VP-PM should be taken into account when considering its impact on individual patients after AVR. Although the concept of VP-PM is easy to understand, it cannot be applied to the whole patient population. In Japan, the age of the candidates for AVR has increased markedly in recent years, but almost all elderly patients with a small BSA (1.6 m(2)) have received newer-generation prostheses with a small outer diameter and large effective orifice area. Indeed, previous studies of Japanese patients have demonstrated that VP-PM was no more than moderate in most cases and its impact on clinical outcomes was generally acceptable. Although severe VP-PM is infrequent and its clinical implications are still unproven in elderly Japanese patients, it would seem reasonable to try to prevent severe VP-PM. Thus, VP-PM itself cannot be accepted as an independent risk factor in Japanese patients, but the useful preventive strategies for severe VP-PM in inactive very elderly persons remain controversial. The implantation of newer-generation biological or mechanical prostheses with or without aortic annular enlargement should be considered according to the characteristics of the patient and the risk-benefit ratio for carrying out a particular procedure in an individual patient.

It was thought that the performance of heart valve surgery in Japan would decline with the decrease in cases of rheumatic heart disease, but there has been a clear increase over the last 10 years. Aortic valve stenosis related to aging and an increase in degenerative mitral valve disease are important factors in this increase. The results of surgical treatment based on annual reports from the Japanese Association for Thoracic Surgery, Japanese Society for Cardiovascular Surgery database, and Society of Thoracic Surgeons database in the USA were compared. The outcome of aortic valve replacement was stable and excellent, with operative mortality rates of 2.7% to 3.7% in all areas (Japan, Europe, and the USA) and no differences among the areas. From 2004 to 2005, the use of bioprosthetic valves exceeded that of mechanical valves in all three areas. While the operative mortality rate remains at around 4.7-6.0% for mitral valve replacement, the results are similar in all areas. The operative mortality rate for mitral valvuloplasty has been in the range of 1.2-1.8% over the past 10 years, and the number of valvuloplasty cases has exceeded replacement cases since 2005. There are no differences among the areas, with excellent results reported. In conclusion, although outcomes in Japan are not superior to those in Europe and the USA, results at the same level were clearly achieved in the field of valve surgery.

Leaflet resection for posterior leaflet prolapse has been a standard repair procedure with good longterm durability. The aim of this study was to review our experience of mitral valve repair, in which resection of the anterior and/or posterior leaflets was performed. Between October 1991 and December 2010, 172 patients with degenerative mitral valve regurgitation underwent mitral valve reconstruction,including 98 patients with the posterior leaflet prolapse, 47 patients with the anterior leaflet prolapse, 17 patients with both leaflets and 10 patients with the commissure prolapse. Most patients in this study were supposed to be caused by fibroelastic deficiency and we have not experienced systolic anterior motion after repair. The mean follow-up period was 8.7 ± 5.5 years. The freedom from reoperation rates at 15 years in 88.7 ± 5.3% of the anterior leaflet procedure, 96.6 ± 2.5% of the posterior leaflet, and 100% of both leaflets. The results of resection of a diseased prolapsed mitral leaflet have been promising so far. However, reoperation was required in 7 patients (4.1%) and reoperation rate was higher in patients with anterior prolapse and longer follow-up will evaluate precisely be benefit.

We report a rare case with severe intestinal ischemia due to chronic aortic dissection. A 75-year-old man was admitted to our hospital with abdominal and right leg pain. The patient had a history of aortic dissection (Stanford type B) 12 years before admission and had been treated medically. Although a throaco-abdominal aneurysm due to aortic dissection (Crowford type III) had been diagnosed 1 year before admission, he had rejected the operation. Computed tomography (CT) revealed an increased diameter of the aneurysm (6 cm). As abdominal pain was increased, emergent surgery was performed on day 1 after admission. Although perfusion of the superior mesenteric artery and marginal artery was maintained, intestinal ischemia was worsening and general condition was deteriorated during surgery. Bypass surgery and/or resection of colon were not indicated because of peripheral colon artery ischemia, and he expired day 1 after surgery.

The anticoagulant effect of heparin in the milieu of altered antithrombin III levels was investigated in adult (n = 7) and pediatric (n = 14) patients undergoing open heart operations. The pediatric patients were subdivided into a control group (n = 8) and an antithrombin III group (n = 6), which received 1,000 units of antithrombin III. The reduction in antithrombin III levels during cardiopulmonary bypass was obvious in patients of all ages, showing a greater reduction (although not statistically significant) in the pediatric patients. However, the antithrombin III group patients maintained their preoperative levels of antithrombin III. The elevated fibrinopeptide A levels in pediatric and adult control group patients suggested that considerable subclinical plasma coagulation occurred during open heart operations, especially during the normothermic period of cardiopulmonary bypass and after the administration of protamine. Antithrombin III levels in the children were the most predictive (r = -0.58; p0.001) for production of fibrinopeptide A during moderate hypothermic cardiopulmonary bypass, but the heparin levels were most predictive (r = -0.57, p0.03) in the adults. This result may be related to the different actions of heparin when antithrombin III levels are reduced. Supplementation with antithrombin III succeeded in suppressing the activation of the coagulation cascade and resulted in no statistical change in fibrinopeptide A levels at any time. We conclude that heparin and (in some patients) antithrombin III levels are important variables for the inhibition of fibrin formation and the possible preservation of coagulation proteins.

To profile plaque microflora on root-caries lesions, and to examine the protein-denaturing activity as a pilot study.Six subjects with root-caries were investigated. Plaque samples on root caries lesions (R), as well as from healthy supragingival sites (S) and periodontal pockets (or = 5 mm) (P) were collected and cultured anaerobically on blood agar plates. The isolated bacteria were identified by 16S rRNA sequencing analysis, and examined for the protein-denaturing activity using the skim-milk plates and the SDS-PAGE, and for the acidogenicity using the FAB broth containing 1% glucose.Propionibacterium, Actinomyces, Streptococcus, Lactobacillus and Bifidobacterium were predominant in R, while Actinomyces, Streptococcus, Veillonella and Capnocytophaga in S, and Actinomyces, Prevotella, Actinobaculum, Streptococcus, Olsenella and Eubacterium were predominant in P. Proteolytic bacteria comprised 40%, 26% and 57% of microflora in R, S and P, respectively. The skim-milk plates distinguished between protein-degrading and protein-coagulating bacteria, which comprised 7 and 33%, 0 and 26%, and 17 and 40% of microflora, in R, S and P, respectively. The SDS-PAGE analysis revealed that protein-degrading isolates were capable of degrading collagen molecules. Furthermore, the final culture pHs of protein-degrading and -coagulating bacteria were 5.0-5.4 and 3.8-3.9, respectively. The latter pH was low enough to denature proteins in skim milk. The microbial composition of R was distinct from those of S and P.

Streptococcus species has been most common causative micro-organism in infective endocarditis, but the rate of Staphylococcus species increased lately, particularly the increase of methicilline resistance Staphylococcus was issue. We advocate early surgical intervention in cases with infective endocarditis involved congestive heart failure, resistance of antibiotics and/or embolism. In mitral valve endocarditis, many surgeon have tried valve plasty, the result has been improved. In case with prosthetic valve endocarditis, particularly involved annular abscess, preoperative worse condition, the necessity of complicated surgical technique, and the recurrence of infection resulted in poor outcomes. We strongly advocate earlier surgical intervention and wish easy access and availability of homograft.

We describe the successful use of a combination of nonsurgical root canal treatment and ultrasonic irrigation for collaborative management of a maxillary left lateral incisor with perforation of the apical third of the root. During the endodontic treatment procedure, the ultrasonically activated tip was used for intracanal irrigation. The area of perforation in the apical third of the root and the main root canal space were obturated with gutta-percha and root canal sealer, using a lateral condensation method. A follow-up clinical and radiographic examination at 5 years after treatment showed an asymptomatic tooth with excellent osseous healing. (J Oral Sci 52, 659-663, 2010)

The possibility of minimizing organ damage following cardiopulmonary bypass (CPB) was examined. In the control group,n = 21, upon completion of CPB, elevation of the lysosomal enzyme β-glucuronidase, which is a sensitive indicator of cellular damage, was affected by the concentration of granulocyte elastase (r = 0.59) or the endothelial-derived constricting factor, endothelin, (r = 0.8). Renal damage, which was detected by an increase in renal tubular enzymes (N-acetyl-β-D-glucosaminidase and γ-glutamyltranspeptidase) in urine, was also affected by endothelin (r = 0.79, r = 0.56), elastase (r = 0.6, r = 0.71), and by free hemoglobin levels (r = 0.76, r = 0.82). Next, the efficacy of pharmacological intervention for the prevention of renal damage was evaluated. During CPB, the administration of an elastase inhibitor (ulinastatin, 3 × 105IU),n = 8, or a calcium antagonist (nicaldipine HCl, elastase release inhibitor; 5 γ/kg per min),n = 8, significantly reduced the elevation of β-glucuronidase and renal tubular enzymes (p < 0.05). Although the ulinastatin and nicardipine groups demonstrated low values of elastase in the Intensive Care Unit (ICU), only the values of the nicardipine group reached statistical significance (p < 0.05). A reduction in endothelin levels compared to the control group was observed in the nicardipine group. However, preventive and counteractive effects of nicardipine against vasoconstriction caused by endothelin were also considered to play an important role in the prevention of renal damage. The addition of haptoglobin (4,000 IU) to the priming solution of the CPB also reduced levels of renal tubular enzymes (p < 0.05). We concluded that elastase, endothelin, and free hemoglobin were causes of renal damage during CPB. The administration of ulinastatin, nicardipine, or haptoglobin possibly prevent apparent renal dysfunction after CPB.

Administration of exogenous adenosine triphosphate (ATP) as a vasodilator during cardiopulmonary bypass was assessed in consecutive adult patients (n = 24) who demonstrated a high arterial perfusion pressure (mean, >90 mm Hg). The action of ATP was characterized by rapid induction and stabilization of the blood pressure level. The dose of ATP ranged from 0.68 to 2.68 mg/min. Within 1 minute after the administration, there was a significant reduction in the perfusion pressure from 102 ± 18 mm Hg (mean ± standard deviation) to 72 ± 19 mm Hg. The ATP was then able to maintain the desired pressure of 69 ± 12 mm Hg at 5 minutes, 67 ± 12 mm Hg at 10 minutes, and consistent values thereafter. After the ATP administration was discontinued, there was a prompt recovery of pressure without bradyarrhythmia. The frequency and amount of inotropes used were consistent with the control group (n = 26). Although the administration of ATP reduced the increase in serum catecholamine concentration, there were no significant changes in other vasoactive mediators (eicosanoid, angiotensin II, endothelin) between the two groups during cardiopulmonary bypass. There was neither an accumulation of metabolic products (uric acid, phosphate) nor a decrease in the level of divalent cation (Ca 2+ ), which is observed when the cations combine with phosphates or adenosine nucleotides. This study confirmed the efficacy and safety of ATP infusion during cardiopulmonary bypass.