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Pyopneumothorax is a rare but troubling complication of bevacizumab. We herein report a case of pyopneumothorax in a patient with metastatic breast cancer during bevacizumab treatment. A 60-year-old female who was diagnosed with metastatic breast cancer (ER+ , PgR+ , HER2-, Ki67

降下性壊死性縦隔炎（DNM）は口腔や咽喉頭周囲に生じた感染が，気管支周囲の疎性結合組織に波及し，縦隔に下降して生じる縦隔炎で，救命のためには早期診断・治療が必須の疾患である．症例は59歳，女性．扁桃炎の加療中，心不全症状と不明熱が認められるようになった．この時点で初めて全身CTが施行され，DNMと診断された．胸腔鏡下に縦隔ドレナージおよび心膜開窓術を施行し救命し得た．術中所見では，抗生剤が奏効し縦隔炎はすでに沈静化していたが，心嚢内へ顕著な線維素の析出がみられ，急性線維素性心膜炎の状態となっており，心不全症状の原因と推測された．DNMでは早期診断が重要であるが，本症例のように診断が遅れても，抗生剤が奏効した場合は，急性線維素性心膜炎による心不全症状などの非特異的で多様な症状を呈する結果となる．今後は抗生剤が奏効したDNMでは，本症例のような臨床症状がみられることを考慮すべきである．

ヘリカルCTの普及により，肺の小結節病変が発見される症例が増え，診断のためのCTガイド下針生検や，手術に先んじたCTガイド下マーキングが行われる機会が増加した．一方で，これらの処置では肺穿刺に伴う重篤な合併症として空気塞栓症が広く認識されてきている．当科ではこれまで，CTガイド下針生検およびCTガイド下マーキングで各々1例ずつ，処置後の心腔内空気栓が発生した．1例目は56歳男性，左上葉肺癌の術後経過観察中に，右肺S6に肺癌が疑われる陰影が指摘され，CTガイド下針生検を施行した．2例目は75歳女性，扁桃癌の治療歴あり．右肺S9/10の肺転移巣に対し手術の予定となり，術前CTガイド下マーキングを施行した．2例とも，処置後のCTで心腔内空気栓が確認されたため，姿勢保持のまま経時的にCTを行い，その消失が確認された．重篤な空気塞栓症は回避できたが，肺穿刺の適応については熟慮が必要と考えられるため報告する．

Pleuroperitoneal communication is a complication of continuous ambulatory peritoneal dialysis (CAPD) that can necessitate cessation of CAPD. Hemodialysis was started on a 52-year-old woman and shifted to CAPD 1 month later. However, 18 days after initiation of CAPD, her chest radiograph showed a right-side hydrothorax. Thoracentesis yielded a colorless pleural effusion with markedly higher glucose levels than in her serum, indicating the presence of pleuroperitoneal communication. Three days later, thoracoscopic surgery was performed. A colored dialysis solution preoperatively injected into the abdominal cavity identified intraoperatively leakage from the diaphragm. The leakage points were closed by a no-knife-type automatic stapler with absorbable polyglycolic acid felt and fibrin glue. CAPD was restarted on the operative day, and there was no recurrence of the right hydrothorax. We conclude that this simple method can be used effectively to treat pleuroperitoneal communication.

We have noticed the possibility that preoperative spirometry may discover latent COPD patients. When COPD is discovered before operation, we can start to treat COPD promptly. Consequently, the better perioperative care is given to COPD patients. On discharge, patients are referred to their family doctors, so that they can receive COPD treatment.There activities were started in July 2012. During the initial twelve months, 90 patients of COPD II x III were discovered and treated before admission. FEV1.0 was significantly improved (1.54 l vs. 1.71 l in average) on repeated spirometry on admission. There was no adverse event in COPD treatment All patients have shown good clinical courses.Latent COPD patients can be discovered by preoperative spirometry.

左肺癌症例に対して左肺全摘術を施行したが, 術後肺血栓塞栓症を生じた. 血栓吸引や薬物治療を行い救命できた. 肺血栓塞栓症発症後に施行した全身CTで左内頸静脈に血栓を認め, これが原因血栓と考えられた. 術後肺血栓塞栓症の原因血栓は通常, 手術中から形成されることが多いが, 本症例で認められた左内頸静脈血栓は術中に行った無名静脈のテーピングによる血流鬱滞が原因になったと推察され, この様な術中操作には細心の注意をはらわなければならない. また本症例では肺血栓塞栓症発症直後の血液ガス分析において肺血栓塞栓症で特徴的とされる低CO2血症は認められず, 逆に高CO2血症を示した. これは左肺全摘術後の片肺状態に生じた肺血栓塞栓症であるため肺血管床の減少が高度となりCO2排出能が激減し, 低CO2血症ではなく, 逆に高CO2血症を示したものと考えられた. このように肺切除後に肺血栓塞栓症が発症した場合は低CO2血症を示さず高CO2血症を示すことがあり診断上注意を要する.

急性大動脈解離で救命率を100%にできない主因は,経過中に発生する合併症が重篤であるにもかかわらずその発生が突然で診断が困難なこと,全身状態が不良でCTや血管造影などの検査が十分できないことである。ベッドサイドでリアルタイムに患者の病態を把握することが最重要と考え,急性解離の診療に経食道心エコー法(TEE)を積極的に導入した。急性大動脈解離27例(男性15例:女性12例,35～84歳)においてTEEの有用性を検討した。TEEで次の評価を行った。1)解離の確定診断,2)解離の範囲,3)エントリー部位,4)合併症の診断(心タンポナーデ,血胸など),5)偽腔内血栓化,6)分枝灌流,7)術中の変化,8)治療のnavigation。27例中24例で手術を行い,手術死亡は3例で全体の生存率は88.9%であった。TEEを用いてはじめて把握できる病態が決してまれならず起こっていることが明らかになるとともに,TEEの情報に基づいて診断,除外診断,状態変化時の診断,モニター,治療手技のガイド,血行再建後のon-siteの評価などが可能であった。TEEのメリットとして,豊富な情報,ベッドサイドでの評価,リアルタイムの情報,非観血的,治療時の目としての役割などが明らかであった。一方デメリットとして,半侵襲的であること,learning curveがあること,食道内膜への傷害の可能性(このシリーズでは経験しなかったが)が挙げられた。弓部分枝や腹部内臓分枝が従来TEEのblind zoneとされていたが,われわれの開発した方法を用いて,この領域の解離の進展,血流などの情報が得られるようになった。急性大動脈解離の診断にはCTがgold standardであることに変わりはないが,TEEを相補的に用いることによって解離の診断,治療において貴重な情報を得ることができる。定型的でない経過に対し,異常を早く発見し対処する方法を決定するうえでTEEが有用であると結論した。

重症筋無力症を合併した胸腺腫症例では胸骨縦切開による拡大胸腺摘除術が標準的である. しかしながら術前から気管切開され呼吸管理された症例では気管切開部と術野が通じ縦隔炎の発症が危惧される. 今回, このような気管切開症例を経験した. 通常の胸骨縦切開を選択せず, 縦隔炎の合併を回避すべく胸骨T字切開を行い拡大胸腺摘除術を行った. 術後経過は良好で, 気管切開口と術野が連絡することなく, 縦隔炎等の術後感染症を免れることができた.胸骨T字切開では頭側の術野が不良で無名静脈より上方の操作はやや困難となるものの, 縦隔炎等の術後感染を予防する上で有用な手技と考えられた.

Objective: We have experienced transaortic stent-grafting for treating distal arch aneurysm or type B dissection. This paper is to mainly report the surgical aspect of these procedures. Methods: Fifteen patients underwent this surgery, including 12 men and three women ranging from 47 to 83 years. Twelve had aneurysms and three aortic dissection. Concomitant surgery was necessary in seven patients (coronary artery bypass grafting in five, tricuspid annuloplasty in one, and replacement of ascending aorta and/or total arch replacement in three cases). A stent graft (Gianturco Z-stent and Intervascular prosthesis) was loaded in a 30-F sheath catheter. Under circulatory arrest, selective cerebral perfusion was established, and the sheath catheter was inserted through aortotomy into descending aorta and the stent graft was deployed at an appropriate level. The proximal end of graft was sutured to the aorta just distal to the left subclavian artery with inclusion method at the posterior wall. Concomitant surgery was done during cooling or rewarming period. TEE was utilized to visualize every endovascular manipulation to avoid unintended intimal injury or misplacement of graft and to assess the surgical results in the operative theater. Results: Aneurysm was successfully excluded except in one patient who had a proximal endoleak and distal endoleak due to underestimation of aortic diameter. There was one operative mortality caused by cerebral infarction, possibly due to debris from femoral arterial cannulation. In the remaining patients, there was no enlargement of residual aneurysm. The excluded aneurysmal sac gradually regressed and disappeared within 2 years in five patients and the thrombosed false lumen completely shrunk within 1 year in two patients. One patient had paraplegia, possibly because the graft was intentionally advanced deeply to cover the thick and fragile atheromatous layer in order to avoid destruction of the atheroma by an expanded graft. Conclusions: Endovascular stent graft via the aortic arch is an acceptable treatment for distal arch aneurysms close to or involving left subclavian artery or type B dissections, especially for those cases requiring other cardiac procedures. It can lead to regression and disappearance of aneurysm or dissection in the mid-term follow-up. q 2001 Elsevier Science B.V. All rights reserved.

Background . Haissaguerre and colleagues emphasize the importance of the pulmonary veins as a source of ectopic foci for initiating paroxysmal atrial fibrillation (AF). We hypothesized that ectopic foci from the pulmonary veins could also act as drivers for maintaining chronic AF, and that surgical ablation of the pulmonary vein orifices could terminate chronic AF. Methods . Using a computerized 48-channel mapping system, we performed intraoperative atrial mapping in 12 patients with chronic AF associated with mitral valve disease. Patient age ranged from 24 to 82 years (mean, 60.4 years). AF duration ranged from 3 to 240 months (mean, 92 ± 84 months). Simple surgical isolation of the pulmonary vein orifices was performed during the mitral valve operation. Results . Regular and repetitive activation was found in the left atria of 9 out of 12 patients, and irregular and chaotic activation was found in both atria of 3 out of 12 patients. Chronic AF in the 9 patients (75%) with regular and repetitive activation of their left atria was successfully treated by a simple surgical isolation of the pulmonary vein orifices. The other 3 patients did not recover sinus rhythm after this procedure. In 1 case of recurrent AF, the patient recovered sinus rhythm during the follow-up period (AF-free rate, 83%). Conclusions . Surgical ablation of the pulmonary vein orifices was effective in the treatment of chronic AF associated with mitral valve disease. Intraoperative mapping may be useful in predicting the efficacy of a single pulmonary vein orifice isolation procedure.

Objective: Cytokine induction can occur routinely in cardiac surgery with cardiopulmonary bypass. We have studied the relationships between the kinetics of pro-inflammatory cytokine release and the postoperative organ function.Methods: Ten adult patients (6 men and 4 women) undergoing elective cardiac surgery with cardiopulmonary bypass, at Hiroshima University Hospital were studied. Patients with acute infection, insulin-dependent diabetes, acute or chronic respiratory failure, renal or hepatic failure, acute cardiogenic shock, and emergency patients were not included. The age of the patient ranged from 44 to 78 years (mean 69±2.0 years). The type of surgical intervention performed was coronary artery bypass grafting in four patients, mitral valve plasty or replacement with modified maze procedure in another five patients, and both procedures in the other one patient. Plasma cytokine levels until 48 hours after aortic declamping were measured in blood samples. The Respiratory Index and the serum levels of choline esterase and creatinine were also measured. The plasma levels of the pro-inflammatory cytokines (interleukin-6 and interleukin-8) were measured.Results: The highest interleukin-6 levels were significantly correlated with hepatic dysfunction (r=−0.80, p=0.0) and with renal dysfunction (r=0.78, p=0.009). The highest interleukin-8 levels were significantly correlated with respiratory dysfunction (r=0.86, p=0.001).Conclusion: The highest proinflammatory cytokines levels at 1 hour after aortic declamping were related to damage to postoperative organ functions, involving the lung, kidney and liver.

Objective: Transesophageal echocardiography was applied to visualizing endovascular procedures during transaortic stent grafting for aneurysm and dissection at the distal arch, and the use of transesophageal echocardiography was evaluated. Methods: The 16 consecutive patients (13 with aneurysms and 3 with dissections) were examined. Transesophageal echocardiography was used for (1) determining graft size, (2) guiding placement of the catheter in the descending aorta at an appropriate position without intimal damage, (3) guiding graft tailoring with a balloon catheter, and (4) examining the results after the procedures. Results: Visualization was disturbed in one patient who had undergone a previous operation. The graft size was appropriate, except in one patient as a result of underestimation. Transesophageal echocardiography was helpful for navigating the graft placement and tailoring without intimal damage. We tried to keep a distance from the diaphragm of 9 cm and an attachment portion of 4 cm. In one patient the graft was placed too distally (7 cm from the diaphragm) to cover the thick atheromatous plaque with the graft. The patient had paraplegia. Transesophageal echocardiographic assessment of endoleak and thromboexclusion was identical to that of postoperative computed tomography or angiography, with a sensitivity of 100% (1/1) and a specificity of 100% (13/13). Leakage at the proximal suture and graft kinking were found in 3 patients. Successful thromboexclusion by transesophageal echocardiographic assessment (13 patients) was predictive of subsequent regression of aneurysm and dissection in the midterm follow-up period: there was complete and partial regression in 5 and 8 patients, respectively. Conclusion: Transesophageal echocardiography enables echocardiography-assisted operations with secure step-by-step endoluminal procedures and immediate intraoperative assessment, which is predictive of the postoperative results. (J Thorac Cardiovasc Surg 2000;120:672-8)

サルコイドーシスは炎症性肉芽腫性病変を主病変とし, 悪性新生物の発生頻度が高いとされる.症例は66歳の男性で, 心房細動に対するMaze手術を4年前に受け, サルコイドーシスと診断されていた.術後4年目に右肺上葉に睡瘤が指摘され, TBLBで扁平上皮癌と診断された.CTで縦隔・肺門リンパ節腫大を認め, サルコイドーシスによる変化も否定出来ないが, 転移が疑われた.咳嗽・発熱などの症状強く, 手術を施行したが, 術前病期はstage IIIBであった.術後病理病期はstage IBで, 腫大したリンパ節はすべてサルコイドーシスによるものであった.炎症性肉芽腫病変に生じた悪性腫瘍の病期診断には画像診断に加えてリンパ節生検が必要と考える.

症例は72歳の男性.63歳時と64歳時の度重なる脳梗塞の進行により, 歩行が困難となっていた.次第に仰臥位困難となり, 近医にて縦隔・両側胸腔に広がる巨大腫瘤を指摘された.心肺圧迫症状を来たし, 緊急手術を行った.仰臥位での気管内挿管が不能で, 右側半坐位での挿管, 直ちに仰臥位, 胸骨正中切開を行った.血圧は一時的に低下したが, 圧迫が解除となり血圧は回復した.腫瘤は32×27×6cm大で, 縦隔・左右胸腔に連続的に広がり, 充実性腫瘍と結合組織・脂肪組織から成り, 一部出血壊死を伴っていた.腫瘤内には最大径10×8×6cm大の比較的軟らかな球状結節を十数個認めた.CD34, Desmin, Vimentin, NSE, S-100, AE1/AE3, α-smooth muscle actinなどの免疫組織化学的染色でSolitary Fibrous Tumorと診断された.皮膚のcafe-au-lait spot部と皮下結節の病理組織的検索を行い術前に疑われたvon Recklinghausen病と合致した.術後経過は良好で術後24病日に転院となった.転院後1ヵ月で退院したが, 1年後脳梗塞発生時にSFTの胸腔内再発が指摘され術後1年4ヵ月で死亡した.

A case of thoracoscopic resection of a esophageal duplication cyst is reported. An 18-year-old woman was seen at the hospital because of epigastralgia, Chest roentgenogram and CT scan revealed a mediastinal tumor. Chest CT showed a 3cm in diameter cystic tumor at the left side of the lower esophagus. Endoscopic ultrasonography was suggestive of esophageal cyst, therwfore, thoracoscopic resection of the tumor was performed. To prevent recurrence, the residual mucosa was cauterized as well. The tumor contained viscosous and mucinous mucus. The postoperative pathologic diagnosis was esophageal duplication cyst. Thoracoscopic resection is thought to be necessary for differential diagnosis of cysts of unknown origins, and that because the esophageal duplication cyst is a benign tumor, it is a good indication for thoracoscopic resection.

When a patient with Ehlers-Danlos syndrome (EDS) presents with a vascular emergency, performing life-saving surgery can be difficult because of the profound fragility of the arterial tissue. We report the case of a 27-year-old woman with EDS in whom a spontaneous arterial rupture was successfully treated with transcatheter embolization. The patient was brought to our hospital in shock, with left lower abdominal pain. She had been diagnosed with EDS type IV following a colonic rupture 8 years earlier. An emergency angiogram revealed rupture of the left external iliac artery. The active bleeding was managed by transarterial embolization of the ruptured artery using stainless steel coils, which took 30 min to achieve. The patient has not suffered any further vascular complications during the year since this procedure. Transcatheter coil embolization may be a reliable option for treating sudden arterial rupture in patients with this syndrome.

What the most causative factor affecting hemolysis is still controversial. To resolve this problem, we investigated the relationship between hemolysis and heat generation in six types of centrifugal blood pumps (Bio-Pump, Delphin, Capiox, Nikkiso, Isoflow, and Toyobo). The analyzed parameters were index of hemolysis in fresh goat blood, pumping performance, and heat generation in a thermally isolated mock circuit. These parameters were analyzed at a flow rate of 5 L/min by changing the pressure head (100 mm Hg and 500 mm Hg). At 500 mm Hg of pressure head, the Bio-Pump needed the highest rotation number and showed the highest hemolytic rate and heat generation. The index of hemolysis is well correlated to heat generation (r2 = 0.721). Heat may originate from the motor by conduction, hydraulic energy loss, and mechanical friction between the shaft and seal. We strongly suspect that hemolysis was caused by a factor such as mechanical friction which generates heat locally.

We report the case of a patient with a rare papillary fibroelastoma on the pulmonary valve visualized before surgical intervention. The tumor was an encapsulated, rounded mass. The gelatinous membrane on the surface tore easily, and multiple fronds appeared. This case emphasizes that when there is an encapsulated mass attached to a valve, the initial excision of valve tissue should be as minimal as possible. To avoid unnecessary injury to the valve, it is simple and practical to confirm that the tumor has the appearance of a sea anemone, thus identifying it as a papillary fibroblastoma, a benign tumor.

We present a 61-year-old woman with chronic atrial fibrillation (AF) associated with mitral valve disease. Chronic AF was successfully treated by simple isolation of pulmonary vein orifices concomitant with mitral valve replacement. AF did not recur during a subsequent follow-up period of 12 months. This procedure has numerous advantages, such as short duration of surgical time, no requirement for cryoablation, and a reduced risk of coronary artery injury.

J Thorac Cardiovasc Surg 1999;117:825-7

The patient was an 84-year-old male. About 7 months after surgery for a non-small cell lung cancer StageIII B, granular shadows were noted on his bilateral lungs on CT; and the level of CA 19-9 , a tumor marker, had increased. These findings led to a diagnosis of intrapulmonary tumor metastasis. Treatment with a platinum-based antineoplastic agent was recommended,but the patient refused it because of his age. The patient was thus placed under observation. Because the tumor appeared to increase in size, treatment was initiated using S-1 capsules (hereafter abbreviated to S-1) alone. Each course consisted of S-1 at a dosage of 100 mg/body/day, twice daily for 21 days, followed by 14 days of drug withdrawal. After the completion of one course, the level of the tumor marker was reduced to normal. After 6 courses were completed, CT indicated a marked reduction or elimination of the intrapulmonary metastatic foci. Malignant phenomenon exceeding grade 3 was no longer recognized,and it was possible to deliver the scheduled dosage of S-1 throughout the entire series of courses. At the end of the 14th course, no signs of exacerbation or recurrence were recognized. It has been about 18 months after the S-1 single therapy was started. This therapy is still being continued.

Circulatory support using both intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) can improve general hemodynamics; however, sometimes brain damage occurs caused by hypoperfusion. Such cerebral hypoperfusion is likely to be caused by PCPS when applying the conventional femoral cannulation. We have developed a new IABP catheter which incorporates a conduit for PCPS with an outlet at the catheter tip, the goal of which is the improvement of cerebral perfusion. The hemodynamic characteristics of this new IABP catheter were compared with those of the conventional combination of IABP and PCPS. Studies were performed by mock test using a pulsatile artificial heart. A polyvinyl chloride tube acted as the aorta with 2 branches at the proximal and distal portions representing the upper and lower portions of the body. The IABP balloon was positioned between the 2 branches, and changes in flow at the 2 branches were examined at varying PCPS flow rates. Flow in the proximal branch using the new device was greater than it was using the conventional PCPS device. We conclude that cerebral perfusion could be improved with the use of this new special IABP catheter.

A pump circuit was assembled and examined for use as an implantable artificial heart. The circuit consisted of a gear pump and 4 artificial heart valves. Mitral and pulmonary arterial valves were placed at the inflow port of the pump, and aortic and tricuspid valves were placed at the outflow port. The mitral and the tricuspid valves were connected to each reservoir at 10 mm Hg, and the aortic and the pulmonary arterial valves were connected to the head tanks at 80 and 20 mm Hg, respectively. The pump discharged pulsatile flows into both systemic and pulmonary arteries alternately by switching the direction of rotation periodically. Because the rated discharge was 1.7 L/min for the gear pump used, the measured flow rate was 0.8-0.75 L/min at a heart rate of 60–110 bpm.

We have experienced a surgically treated case of midventricular obstruction. A simple mitral valve replacement was effective to relieve the obstruction and to increase the cavity of the left ventricular outflow tract without a myectomy through the aortic valve.

Background . We have performed a simple left atrial procedure for eliminating chronic atrial fibrillation (AF) associated with mitral valve disease. This article analyzes the midterm results of this procedure. Methods . Thirty-two patients were enrolled in this study concomitant with mitral valve operations. Patients were divided into two groups (AF− and AF+). We examined the efficacy of this operation and atrial function for more than 12 months of follow-up. Results . In a total of 98.5 patient years of follow-up, AF was absent 3 years after operation in 74%. Of preoperative and intraoperative variables, only long duration of AF was a predisposing factor for recurrence of AF ( p Conclusions . A simple left atrial procedure is effective for chronic AF with mitral valve disease and restores atrial transport function during midterm follow-up. However, other atrial arrhythmias occur in some patients postoperatively.

Background . We evaluated clinical relevance of orbital ultrasound (OUS) monitoring to neurological events in aortic surgery associated with selective cerebral perfusion (SCP). Methods . In 24 consecutive cases, blood flow was monitored at central retinal artery (CRA) and retrobulbar vessels. The threshold perfusion pressure for detecting CRA flow in the color Doppler mode (BPt) was determined in individual eyes. Results . The BPt ranged from 25 to 71 mm Hg. Events (infarction, anisocoria, delirium) occurred in 8 cases. Infarction occurred in all 3 cases when retrobulbar flow was severely impaired for 40 minutes or longer, while none of the remaining 21 cases had infarction ( p = 0.0005). Among the latter cases, perfusion pressure was below BPt for longer than 100 minutes in all 5 cases with events, and in 5 of 16 cases without events ( p = 0.0124). No significant difference was found in age, duration of cardiopulmonary bypass, SCP, and circulatory arrest, and duration of blood pressure below 50 mm Hg. Conclusions . Sustained hypoperfusion detected with OUS monitoring is related to an occurrence of neurological events.

Background . Endovascular stent-grafting is an innovative procedure; we have developed a novel approach to treat distal arch aortic aneurysm through a small incision in the aortic arch. Methods . Eight patients with thoracic aortic aneurysms were treated with an endovascular stent-graft that was introduced into the thoracic aorta through a small incision in the aortic arch. Of these patients, 7 had distal arch aortic aneurysms, and 1 had chronic aortic dissection of Stanford type B. Four of these patients had received concomitant coronary artery bypass grafting, and 1 patient had undergone tricuspid valvular annuloplasty. The stent-graft was introduced into the distal arch aorta and descending aorta through a small incision in the aortic arch, under selective cerebral perfusion and hypothermic circulatory arrest. Results . The selective cerebral perfusion time ranged from 52 to 86 minutes (mean, 68 minutes) and the operating time from 289 to 422 minutes (mean, 318 minutes). There was no endoluminal leakage into the aneurysm. Seven patients survived and were discharged, but 1 patient suffered a cerebral infarction and died during the follow-up period. Conclusions . Placing an endovascular stent-graft through the aortic arch is an acceptable alternative treatment for distal arch aortic aneurysms.

Creating an interatrial shunt to achieve left-right flow balance and modification of the blood chambers to improve the basic performance of the device were performed in developing an eccentric roller type total artificial heart (ERTAH). Smaller blood chambers reduce friction loss and increase durability and energy efficiency. We changed the left blood chamber volume of 60 ml to 40 ml and the right blood chamber volume of 53 ml to 35 ml compared with previous types. Designs of inlet and outlet ports were modified to prevent backflow. In the mock circulatory system, redesigning the blood chambers resulted in a 20% increase in energy efficiency, about a two-fold increase of cardiac output and improved durability compared to the previous type. In an animal experiment, the ERTAH operated at a driving rate of 160 rpm with a left flow rate of 6.0 L/min and a right flow rate of 5.4 L/min. Interatrial shunt flow rate was 250-400 ml/min.

Percutaneous cardiopulmonary support (PCPS) has come to be applied for cardiopulmonary resuscitation and in the management of severe respiratory failure as well as severe heart failure. We investigated cerebral tissue oxygen saturation during PCPS in a canine model of respiratory failure using near-infrared spectroscopy. Animals were mechanically ventilated with 10% oxygen to make a respiratory failure model. Perfusion with PCPS was performed via the left femoral artery and switched to that via the right axillary artery. Cerebral tissue oxygen saturation was 54.2 +/- 3.4% during PCPS via the femoral artery and was 82.3 +/- 4.6% during PCPS via the axillary artery (p = 0.001). Hepatic tissue oxygen saturation was not significantly different. LV dP/dt max increased significantly after switching to the axillary blood supply (p = 0.001). Conventional PCPS may not have the capability of supporting cerebral circulation under severe respiratory failure without organic heart disease.

Objective: To assess the utility of spinal cord monitorings for prediction of spinal cord ischemia, we investigated the role of both motor evoked potentials and sensory evoked potentials during thoracoabdominal aortic aneurysm surgeries.Methods: We monitored two kinds of sensory evoked potentials; descending evoked spinal cord potentials from the lumbar enlargement after cervical spinal cord stimulation and segmental evoked spinal cord potentials at the lumbar enlargement elicited by peroneal nerve stimulation, and motor evoked potentials from the lumbar enlargement elicited by direct subcranial stimulation in 9 thoracoabdomonal aortic aneurysm surgeries.Results: Postoperative paraplegia occurred in one case in which the patients died during the perioperative period. One case showed transient paraparesis, but recovered following rehabilitatation. These cases showed a decrease in the amplitude of descending evoked spinal cord potentials and motor evoked potentials.Conclusion: The recovery of the amplitude of the motor evoked potentials and the descending evoked spinal cord potentials after declamping correlated with the neurologic outcome.

We have made an eccentric roller type total artificial heart (ERTAH). The ERTAH is a positive-displacement device comparable to a DeBakey roller pump. Its left and right outputs are determined by the size of its blood chambers, and the ratio of its left and right output is almost constant. We focused on an interatrial shunt to achieve left-right balance. We have conducted numerical simulation, a mock test, and an acute animal experiment to analyze left-right heart balance during ERTAH operation. Numerical simulation was performed under conditions in which the flow of the left artificial heart was fixed at 6 L/min, the flow of the right artificial heart was varied from 4.8 to 6 L/min, and the interatrial resistance was also varied. The relationship between the interatrial shunt flow rate and the output of the left and right artificial hearts was balanced when the flow of the right artificial heart was at 5.45 L/min. In a mock test, 2 DeBakey roller pumps were connected to the left and right sides of a Donovan mock circulatory system, and an interatrial shunt was created between the inlet ports of the left and right roller pumps. The interatrial resistance of the mock system was varied from 7.7, to 4.3, and to 2.9 mm Hg x min/L when the inner diameter of the interatrial shunt was 6, 8, and 10 mm, respectively. As in the mock test, 2 roller pumps were used to bypass the right and left hearts of a goat weighing 60 kg. The flow rate of the left heart was almost constant (4.7 L/min). The flow of the right heart was approximately 4.1 L/min when the interatrial shunt flow rate was zero. A leading consideration was that the left to left shunt through the bronchial arteries in this goat was approximately 0.6 L/min. In developing the ERTAH, we considered that creating an interatrial shunt between the inlet ports of the ERTAH as well as making a difference between the chamber volumes might be effective in balancing the left-right sides of the artificial heart.

Introduction Recent clinical trials have shown significant survival benefits from postoperative adjuvant therapy for respectable nonsmall cell lung cancer (NSCLC). However, evaluation of adjuvant chemotherapy with carboplatin combination is still uncertain. The purpose of the study was to test the feasibility of adjuvant chemotherapy with carboplatin and separate weekly paclitaxel after complete resection of pStage IB, II, IIIA NSCLC in a multicenter study. Methods The study was conducted from 2001 to 2006 in the outpatient setting. A total of 61 patients were enrolled. Patients received adjuvant chemotherapy with 4 cycles of carboplatin (AUC 5) on day 1 and paclitaxel (70 mg/m 2 ) on day 1, 8, and 15 every 4 weeks. Primary endpoints were toxicity and chemotherapy compliance. Secondary endpoints were disease-free survival and overall survival. Results More than 65% of eligible patients had pStage IIIA. The median number of chemotherapy cycles was 4 (range 1–4). Grade 3 or 4 toxicities of neutropenia were 34% (grade 4: 2%). Other hematologic adverse effects were extremely less frequent. Regarding the nonhematologic adverse effect, hair loss was frequent; however, peripheral neuralgia was less frequent. Treatment-related death was not registered. During median follow-up of 21 months, 24 patients developed recurrent disease. Estimated disease-free survival and overall survival at 2 years was 51.2% and 84.6%, respectively. Conclusions Postoperative carboplatin and weekly paclitaxel showed favorable feasibility and acceptable toxicity in comparison with the cisplatin-containing regimen. Consequently, it is desirable that this regimen would be validated in a phase III clinical trial for NSCLC after curative resection.

Objectives: Branch arteries of the aortic arch have been a blind zone for transesophageal echocardiography. Information regarding blood flow, which is important in both planned and emergency operations on the aorta, has therefore been limited. We have established a technique for visualizing these arteries in nearly all cases. Methods: In 25 consecutive patients requiring either planned or emergency operations on the aorta, the branch arteries were visualized whenever cerebral malperfusion was suspected. Lateral flexion of the probe tip was used when the trachea interfered with visualization of the arteries. Results: The left subclavian, left and right common carotid, right subclavian, innominate, and left and right vertebral arteries were visualized in 96% (24/25), 92% (23/25), 96% (24/25), 100% (25/25), 84% (21/25), 92% (22/24), and 88% (21/24), respectively. The origin of the innominate artery was visualized in 36% (9/25). In some cases, dissection extended into branch arteries during surgery or during conservative therapy. When the subclavian artery was clamped, retrograde flow was detected in the vertebral artery (steal flow). The cannula for selective cerebral perfusion occasionally was entered into the right common carotid or subclavian artery and obstructed the other branch with a balloon. Conclusions: The branch arteries of the aortic arch, including the vertebral artery, are no longer a blind zone for transesophageal echocardiography. The information obtained with our new transesophageal echocardiography technique is helpful for diagnosis, monitoring, and decision making during aortic surgery and in critical care medicine. Visualizing these vessels is worth the effort. (J Thorac Cardiovasc Surg 2000;120:466-72)