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Objectives Endotoxins derived from bacteria in the oral cavity enter the bloodstream, leading to the onset of various systemic diseases, including heart valve disease. However, information on the oral bacteria involved in aortic stenosis is limited. Materials and Methods We comprehensively analyzed the microbiota in aortic valve tissues collected from patients with aortic stenosis using metagenomic sequencing and investigated the relationships between the valve microbiota and the oral microbiota and oral cavity conditions. Results Metagenomic analysis revealed the presence of 629 bacterial species in five oral plaque and 15 aortic valve clinical specimens. Patients were classified into two groups according to their aortic valve microbiota composition using principal coordinate analysis. Examination of the oral conditions of the patients showed no difference in the decayed/missing/filled teeth index; however, patients were divided into two groups (A and B) based on the aortic valve microbiota composition. Bacteria in group B tended to be associated with severe disease, and the number of bacteria on the dorsum of the tongue and the positive rate of bleeding during probing were significantly higher in this group than in group A. The pathophysiology of aortic stenosis may be related to the presence of oral bacteria such as Streptococcus oralis and Streptococcus sanguinis following bacteremia. Conclusions Systemic inflammation in severe periodontitis may be driven by the oral microbiota, supporting the indirect (inflammatory) association between oral bacteria and aortic stenosis. Clinical Relevance: Appropriate oral hygiene management may contribute to the prevention and treatment of aortic stenosis.

Coronary artery fistula (CAF) is a relatively rare disease, many of which are asymptomatic and are not indicated for surgery. However, CAF's patients with angina, heart failure due to shunt, and fistula hemangiomas are usually indicated for surgical treatment. A 49-year-old woman with severe congestive heart failure was found to have a fistula from the main trunk of the left coronary artery to the left atrium, and a fistula aneurysm. This patient had heart failure due to shunt blood flow, and also had a fistula aneurysm, so surgical treatment was indicated. During surgery, the fistula aneurysm was incised and the origin and opening of the fistula were closed without any problems. The postoperative course is good, and as of three years after the operation, the patient is being followed up at an outpatient clinic without recurrence of shunt flow and heart failure.

To assess the difference in hyperlipidemia between patients with bicuspid aortic valve (BAV) and those with a normal aortic valve (NAV), and to compare aortic valve stenosis (AS), with aortic valve regurgitation (AR). Among 32 patients with BAV and 142 patients with NAV who underwent aortic valve replacement, 81 patients had AR and 91 patients had AS. The preoperative clinical characteristics were compared between the BAV and NAV patients. Patients with replacement of the ascending aorta were included, and those who underwent combined valvular surgery, coronary artery bypass grafting, or statin treatment were excluded. The proportions of females patients (p = 0.42), patients with diabetes (p = 0.26) and patients on dialysis (p = 0.69) were similar in the two groups. Mean age was significantly lower, the mean diameter of the ascending aorta was significantly larger, and the rate of surgical intervention for the ascending aorta was significantly higher in the BAV group than in the NAV group (all p

Coronary artery bypass grafting (CABG) has been widely performed for coronary artery disease. Therefore, cases requiring reoperative CABG are increasing. We performed a minimally invasive direct coronary artery bypass (MIDCAB) procedure on four patients, as reoperative CABG surgery for the right coronary artery (RCA), employing the right gastroepiploic artery (RGEA). The target sites were the distal RCA in two patients and the posterior descending (PD) branch in the other two. Complete revascularization was accomplished in all patients without sternotomy, cardiopulmonary bypass (CPB), or blood transfusion. The mean operative time was 3.0 h (range: 2.4-3.7 h). Postoperative coronary angiography showed all grafts to be patent. All patients were discharged without postoperative complications and remained free from cardiac events during a mean follow-up period of 1.5 years (range: 0.5-3.0 years). MIDCAB for the RCA, employing the RGEA via a subxiphoid incision showed, excellent revascularization in redo CABG cases. This technique is a safe and effective method for redo cases.

Having more than 20 years of experience as an independent cardiac surgeon,so far,I have no chance to see any of patients to refuse their surgical treatment because of suffer in poverty. That phenomenon is owing the government-organized insurance system. That system is concluded as the best one among ever made in all kinds and all period of human societies.In daily circumstances in Japanese medical institute, nobody cares about the cost. For example,to perform heart valve surgery,it will cost more than 30 thousands USD per each patient, to buy an artificial heart valve and disposable unit parts for heart-lung machine. However,patient doesn’t care, doesn’t want to know, nor doesn’t show any interest, neither do doctors nor nursing staff. That phenomenon is never observed in any country on this planet.Since 1958, all of Japanese citizen are covered by government-organizedinsurance system and even in case of cardiac surgery, they may pay a very small amount of money and have a position to receive the first class medical care in view of medical equipment and expendable supplies.Those environment has created two special attitude for medicine in Japanese social culture.The first one is, people stop to think “cost”and “efficiency”in medicine, and blindly believe anything should be done in any situation for dying people.They strongly and distinctively desire any possible treatment, even in a hopeless situation, for high aged and weakened, and nobody talks about efficiency on cost, or possibility that would be sacrificing medical infrastructural resource and human resource.That kind of thinking is strictly “Taboo”.The other is, also, people stop to think “quality”of individual medical expertise,ex.Surgeon. All medicine is provided by something governmental,means formal,sometimes sounds “noble”. This aspect has created a competition-less society of medical practitioners, in which they never discuss about quality of medicine. All doctors are fed by this insurance systems, with definite stability.Recent financial aspect gives us a lot of pressure to built-up more efficient one because of limited and non-promising budget.In conclusion, it is the best distinctive character of Japanese society that people never concern “we all are going to another place someday,definitely”.It can be said “very much immatured”in a meaning.

Marfan syndrome is a hereditary disease that presents ocular, skeletal, and cardiovascular abnormalities. In recent years, there have been several reports of patients with familial cardiovascular disease but no physical features of Marfan syndrome. We encountered 3 cases of familial annulo-aortic ectasia (AAE). Their father had also had aortic regurgitation, and died during surgery 10 years before. No case demonstrated any physical characteristics of Marfan syndrome or any other connective tissue disease. All cases were operated successfully. One case showed cystic medial necrosis, and 2 cases showed degenerative change. The present report suggests that familial AAE may be caused by weakness of the aortic wall related to heredity. If AAE is left untreated, it can lead to aortic dissection. Thus, we recommend that patients with familial AAE should undergo screening and follow-up similar to patients with Marfan syndrome.

Background: The number of reoperative (redo) coronary artery bypass grafting (CABG) for patients with long-term hemodialysis has been increasing. Off-pump CABG (OP-CAB) may decrease risks associated with redo CABG. Methods: Two patients on chronic hemodialysis with calcification of the ascending aorta underwent redo double coronary OPCAB for the left anterior descending artery (LAD) and the posterior descending artery (PDA) via median sternotomy. The LAD was bypassed with the left internal thoracic artery (LITA). The PDA was exposed with minimum dissection and bypassed with a composite graft of the right internal thoracic artery (RITA) and the saphenous vein (SV). Results: Both patients made a quick recovery with no complications and one had postoperative angiography that showed the patent grafts. Both patients were free from angina pectoris at follow-up of 6 months and 3 months, respectively. Conclusion: Redo OPCAB of the LAD and PDA can be performed with minimal dissection via median sternotomy using the LITA and a composite graft of the RITA and SV.

大動脈炎とそれに起因する胸部大動脈瘤と大動脈の高度石灰化・蛇行，さらに左内胸動脈閉塞を合併したハイリスクな不安定狭心症に対し心拍動下冠動脈バイパス術を施行した．患者は66歳女性，労作時胸部不快感を訴え外来受診した．精査の結果，両冠動脈入口部の重度狭窄および左内胸動脈閉塞を有する不安定狭心症と診断され，冠動脈バイパス術が第1治療選択となった．術前検査にて両下肢のABI低下，CTにて大動脈炎による大動脈の高度石灰化，胸部下行大動脈瘤と大動脈の蛇行を合併していた．このため体外循環，補助循環サポートは使用困難であり，手術は全身麻酔下に胸骨正中切開し，右内胸動脈と大伏在静脈グラフトを使用してcomposite graftを作製し，心拍動下に4枝バイパスを施行した．術中SPY system（intraoperative ICG-based imaging system, Novaq Technologies ; Toronto, ON, Canada），術後3カ月に冠動脈Multi-Detector CT（MDCT）にてグラフトの開存を確認し，良好な結果を得た．

心臓外科手術の進歩に合わせるように, 麻酔科学もこれに伴走, 時にリードしながら心臓麻酔の領域を確立してきた. 1980年代のハロタン, モルヒネ, 大量フェンタニル時代を経て, 少量フェンタニル, レミフェンタニル, セボフルランの併用, 硬膜外麻酔の併用などにより, 比較的早期に術後人工呼吸を終了させる, いわゆるFast Trackの概念が台頭してきている. Fast Trackは患者周術期のQOLを上昇させることは間違いないだろう. これからもわれわれは心臓麻酔のガイドライン的知識, 教科書的技術の習得に加え, “知恵, 技”を日々の経験, 実践をとおして研鑽し, 自分なりの心臓麻酔のスタンダードを創り上げていく必要がある.

A 76-year-old female, who had received Carpentier-Edwards perimount (CEP) pericardial bioprostheses for aortic and mitral valves 6 years before, was diagnosed with reduced mobility of the valvular cusps by echocardiogram 2 years after the surgery. The symptoms of heart failure gradually aggravated. Significant stenosis and regurgitation were observed of the prosthetic valves, and a second surgery was performed. Calcification and severe pannnus formation were observed of both CEP valves that were excised.

Utilizing PCR, the 16S rRNA detection rates for Porphyromonas gingivalis , Actinobacillus actinomycetemcomitans , Bacteroides forsythus , Treponema denticola , and Campylobacter rectus in samples of stenotic coronary artery plaques were determined to be 21.6, 23.3, 5.9, 23.5, and 15.7%, respectively. The detection rates for P. gingivalis and C. rectus correlated with their presence in subgingival plaque.

Between January 1987 and October 1992, 11 neonates and 2 infants (12 males and 1 female) underwent arterial switch operation (ASO). There were 9 simple transpositions of great arteries (TGA), 3 TGA with ventricular septal defect (VSD), and 1 double outlet of right ventricle (Taussig-Bing) with TGA. There were 12 cases of patent ductus arteriosus (PDA) and 6 cases of atrial septal defect (ASD). Nine patients had Yacoub type A coronary pattern, 3 had type B, and 1 had type D. The neonates' mean age was 15.5 days (one 120 days old and one 22 months old). The average body weight of the neonates was 4.2 kg. The Lecompte maneuver was performed on all patients. The average bypass time was 187.8 min, and mean aortic cross-clamp time was 76.2 min, with a mean circulatory arrest time of 10 min in 6 cases. Early hospital mortality was 15.4% (2 deaths)—1 patient died during operation from myocardial infarction, and another died postoperatively from poor heart function. All survivors experienced early postoperative heart failure and needed temporary inotropic support. One patient was lost to follow-up. The other 10 patients were free from any cardiac symptoms at follow-up, with good left ventricular function. Mild to moderate aortic regurgitation and stenosis and the same in the pulmonary valve were seen on echocardiogram. Seventeen months after ASO, 1 patient required reoperation for severe postoperative pulmonary stenosis. We concluded that ASO can be performed with an acceptable mortality rate in a new unit with no previous experience of such surgery.

An 8-year-old girl with Kawasaki disease underwent surgical revascularization to the left anterior descending coronary artery on the beating heart via a left anterior short thoracotomy. Angiography 21 months after surgery showed excellent graft patency. This case--the first success in minimally invasive surgical coronary artery revascularization in a child in the world--suggests that minimally invasive methods are a reasonable alternative in coronary artery revascularization in a child with Kawasaki disease whose left anterior descending artery is the only requiring it.

A 28-year-old male with total occlusion of the main trunk of the left coronary artery underwent successful coronary artery bypass surgery with bilateral internal mammary arteries. He did not have hypercholesterolemia and the ascending aorta, bilateral internal mammary arteries, and peripheral part of the left coronary artery were normal in character and size, which indicated that no systemic or inflammatory diseases caused the lesion. Smoking was the only risk factor identified.

The multidetector computed tomography (MDCT) scan is now widely used especially to find lesions of the coronary artery stenosis. In this report the images of a postoperative study of coronary artery bypass grafting (CABG) by MDCT are introduced to reveal their feasibility and reliability. Shown is one of the patients whose saphenous vein graft (SVG) was connected from the descending aorta to the left anterior descending artery (LAD) via the obtuse marginal branch (OM). This is because the left internal thoracic artery (ITA) was not available and the ascending aorta could not be used for highly calcified degeneration. That kind of graft in CABG should be recognized as "extra routine," and its use will cause some difficulties to arise in postoperative elucidation for graft function. The images by MDCT reported here showed an excellent view of the route and lumen of the graft, suggesting the feasibility and usefulness of MDCT in CABG postoperative study.

A 52-year-old male patient with left main trunk disease and absent right coronary artery underwent successful coronary artery bypass grafting with in situ arterial conduits. Bilateral internal mammary arteries and the gastroepiploic artery were employed, with the inferior epigastric artery as a composite graft to the left internal mammary artery. The postoperative angiogram showed excellent patency of all 4 grafts and cardiac performance during exercise monitored by scintigram was found to be satisfactory.

Utilizing PCR, the 16S rRNA detection rates for Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Bacteroides forsythus, Treponema denticola, and Campylobacter rectus in samples of stenotic coronary artery plaques were determined to be 21.6, 23.3, 5.9, 23.5, and 15.7%, respectively. The detection rates for P. gingivalis and C. rectus correlated with their presence in subgingival plaque.

In 308 right gastroepiploic artery (GEA) grafting procedures performed for myocardial revascularization, 38 GEA, 34 in situ, and four free grafts were used to bypass the left anterior descending coronary artery (LAD). Indications for using the GEA for the purpose of LAD bypass were: unavailability of the internal thoracic artery (ITA) at reoperation, surgical damage to the ITA at the time of the operation, or an apparently better free flow versus that in the left ITA, particularly in patients with diabetes meltitus in whom it was considered inadvisable to use bilateral ITAs. There were 21 male and 17 female patients with a mean age of 62 years (range, 31 to 77 years). Ten patients had undergone a previous myocardial revascularization. The mean number of distal anastomoses was 2.8 (range, 1 to 5). Concomitantly used conduits were the ITA in 27 patients, saphenous veins in 21 patients, the inferior epigastricartery in 4 patients, and the bovine internal thoracic artery in 1 patient. All but 1 patient survived. Follow-up ranged from 3 to 84 months (mean, 27 months). Postoperative angiography was performed in 33 patients. At the short-term evaluation (mean, 1 month), 32 of 33 (97%) GEA grafts were found to be patent; all 4 GEA grafts studied at the long-term evaluation (mean, 25 months) were also found to be patent. In no patients did angina recur postoperatively. In 25 patients who underwent an exercise study postoperatively, the stress test results were negative in 23. In the 2 patients whose stress test results were positive, this was due to stenosis of the large diagonal artery and stenosis of the saphenous vein graft to the circumflex artery. We conclude that the GEA is a suitable conduit for LAD revascularization when the ITA is unavailable.

Objective: A single surgeon conducted One hundred and twelve patients underwent minimally invasive direct coronary artery bypass grafting for the left anterior descending coronary artery 112 patients at Yamato Seiwa Hospital from September 1996 until August 1999.Methods: All procedures were performed via left anterior short thoracotomy using a stabilizer during graft anastomosis.Results: No operative deaths occurred but 3 patients died while hospitalized due to noncardiac events. Graft occlusion was seen in 3 patients early postoperatively. Other angiography graft failure such as stenosis was seen in 11 patients. Occlusive lesions of other coronary arteries occurred in 77 patients (69%) and 53 patients underwent percutaneous transluminal coronary angioplasty the pre/postoperatively for those lesions.Conclusions: These results suggest that minimally invasive direct coronary artery bypass grafting is seen by cardiologists as a reasonable form of revascularization in conditioned patients having left anterior descending artery lesion, and that minimally invasive direct coronary artery bypass grafting has a spectrum of candidates different from that of conventional surgical revascularization for the coronary artery.

A technique is described for side-to-side anastomosis as a functional end-to-side anastomosis, in which no direct contact with the vessel walls by surgical instruments is required during suturing, thus avoiding the possibility of damage to the graft.

The effects of baroceptor reflex on mean cardiac (MCSNA) and renal sympathetic nerve activity (MRNA) were analyzed before and after atropinized (0.1 mg/kg, i.v.) states in conscious cats at rest. Resting values of MCSNA, MRNA, mean aortic pressure (MAP), and heart rate (HR) were 85 +/- 6 imps/s, 76 +/- 11 imps/s, 100 +/- 4 mmHg, and 164 +/- 10 beats/min, respectively. Both MCSNA and MRNA changed almost inversely to changes in the absolute MAP in the range of 90-140 mmHg. Within this pressure range the gain of baroceptor-sympathetic system to the heart and kidney was 2.31 and 1.84, respectively. MCSNA as well as MRNA was reduced to the noise level at the MAP of 142 and 150 mmHg, respectively. With atropine, MCSNA and MRNA were inhibited centrally whereas HR increased to 192 beats/min. The increase in MAP caused by norepinephrine (2.1 micrograms/kg, i.v.) was enhanced to 75 +/- 7 mmHg by atropine from 31 +/- 4 mmHg in control. The piecewise linear MAP-MCSNA and MAP-MRNA relationships changed to a remarkable clockwise hysteresis loop. During the rising MAP period, the gain of the baroceptor-sympathetic system decreased to 0.91 and 0.97 in MCSNA and MRNA, respectively. During the returning MAP period, a delayed activation in MCSNA and MRNA occurred centrally. We conclude that the baroceptor reflex effect on MCSNA is larger than those on MRNA, and that the baroceptor control of MCSNA and MRNA is modified centrally by atropine in the awake cat at rest.