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While low-risk patients who undergo elective surgery can tolerate low hematocrit levels, the benefits of higher hematocrit levels might outweigh the risk of transfusion in high-risk patients. Therefore, this study aimed to evaluate the effects of perioperative hematocrit levels on mortality in patients requiring prolonged mechanical ventilation (PMV) after a cardiovascular surgery. This single-center retrospective cohort study was conducted on 172 patients who underwent cardiovascular surgery with cardiopulmonary bypass or off-pump coronary artery bypass grafting and required PMV for ≥72 hours in the intensive care unit (ICU) from 2008 to 2012 at the Yokohama City University Medical Center in Yokohama, Japan. Patients were classified according to hematocrit levels on ICU admission: high (≥30%) and low (

The best priming and replenishment solution in cardiopulmonary bypass remains unknown, and the efficacy and drawbacks of artificial colloid are controversial. We retrospectively compared consecutive patients undergoing elective adult valve surgery in cases wherein cardiopulmonary bypass was primed and replenished with hydroxyethyl starch 130/0.4 (n = 12) or crystalloid solution (n = 11). The fluid overbalance during cardiopulmonary bypass was much lower in the hydroxyethyl starch 130/0.4 group (mean ± standard deviation, + 95 ± 1241 mL) than in the crystalloid solution group (+ 2921 ± 1984 mL) (P

We have reported "sandwich technique," via a right ventricular incision, to treat a post-infarction ventricular septal defect (VSD). This technique involves the placement of patches on both the left and right sides of the septum, pinching the VSD sealed with surgical adhesive between the two patches. In this study, we analyzed factors influencing 1-year mortality to determine the pitfalls in our procedure.We evaluated 24 consecutive patients with post-infarction VSD who underwent the "sandwich technique" via a right ventricular incision. One-year survival and major residual leak were used as the criteria for the analysis of survival and technical success, respectively. In protocol 1, clinical variables were evaluated as predictors of one-year mortality. In protocol 2, surgical techniques were evaluated as predictors of major residual leak, which was found to be related to one-year mortality in protocol 1.In protocol 1, the one-year mortality was higher in patients with major residual leak (75 %, 3/4) than in those without (15 %, 3/20) (p = 0.035). In protocol 2, the patients with major residual leak had smaller patches than those without (41.9 ± 3.8 vs. 47.8 ± 4.8 mm, p = 0.031) and a smaller size difference between the patches and the VSD (22.5 ± 6.5 vs. 30.0 ± 5.7 mm, p = 0.028).For the "sandwich technique" via a right ventricular approach to treat post-infarction VSD, the choice of patch size according to VSD size is an important variable for reducing major residual leak.

Objectives: We report the pathophysiology and treatment results of type A acute aortic dissection from our 20-year experience. Methods: We studied 673 patients with type A acute aortic dissection who underwent initial treatment from 1994 through July 2014. We divided these patients into two groups. The former group comprised 448 patients from 1994 through 2008, and the latter group comprised 225 patients from 2009 onward, when the current strategy of initial treatment and surgical technique including the early organ reperfusion therapies were established. Results: Women were significantly often presented than men in patients over 60 years of age. Thrombosed-type dissection accounted for more than half in patients over 70 years, and significantly often complicated pericardial effusion and cardiac tamponade than patent type. Malperfusion occurred in 26% of patients. Central repair operations were performed in 579 patients. In-hospital mortality for all patients was 15%, and for the patients who underwent central repair operations was 10%. Former period of operation, malperfusion, and preoperative cardiopulmonary arrest were significant risk factor of in-hospital death. Preoperative left main trunk (LMT) stents were placed in eight patients and superior mesenteric artery (SMA) intervention was performed in five, they were effective to improve the outcome. From 2009 onward, in-hospital mortality was 5.0% and there was no significant risk factor. Conclusion: Surgical results of type A acute aortic dissection were dramatically improved in the past 20 years. Early reperfusion strategy for the patients with malperfusion improved the outcomes. (This article is a translation of Jpn J Vasc Surg 2015; 24: 127–134.)

We have occasionally observed a bubble leaving the suture line of an open stent graft; hence, we hypothesized that de-airing an open stent graft could potentially reduce spinal cord injury. Postoperative computed tomography often showed residual air in thoracic aortic aneurysms, confirmed by the presence of a certain amount of air in an open stent graft in a dry lab. We filled CO2 in the sterilized package of an open stent graft and subsequently filled it with saline, which absorbed the CO2 and entered into the gap of the graft. The clinical benefit of de-airing an open stent graft to reduce the incidence of spinal cord injury needs to be evaluated.

Preoperative echography of a saphenous vein graft (SVG) was studied. In 58 cases of consecutive coronary artery bypass grafting, 31 patients underwent SVG echography. Preoperative assessment revealed vein caliber, branching, or varicose saphenous veins. The location of the saphenous vein was marked. Saphenous veins were harvested by the open harvest technique, and the caliber of the veins and the availability of the anastomosis device were recorded. Postoperative morbidity was recorded. Preoperative findings revealed that four (6.5%) of 62 femoral saphenous veins were estimated as “not graftable” because of being a varicose vein or having a small caliber. Seven of 32 lower saphenous veins were estimated as “not graftable”. The mean discrepancy of the caliber was 0.6 mm undersized with preoperative estimation. During harvesting, one of 31 patients had a wrong marking. We were able to use all harvested veins. The morbidity of saphenous harvesting was observed in two (6.5%) of 31 patients. One patient whose marking was wrong had minor skin necrosis. Another patient experienced a hematoma because of the excess effect of warfarin. Preoperative ultrasonic mapping of the saphenous vein reduced useless harvesting, provided information concerning anastomosis device availability, and seemed to reduce morbidity because dissection can be minimal.

A left ventricular (LV) free wall rupture is a highly lethal condition. A 75-year-old female who experienced chest pain was diagnosed as having an acute aortic dissection Stanford type A and underwent emergent surgery. Under cardiopulmonary bypass with LV venting through the right superior pulmonary vein, a proximal aortic stamp was formed. The patient was cooled, selective antegrade brain perfusion was performed, and a hemiarch repair was performed. After the patient was transferred to the intensive care unit, her blood pressure suddenly fell to 50 mmHg. She had a blowout rupture in the left ventricular anterolateral free wall. Since the bleeding hall was not large and the damage to the surrounding left ventricular tissue was not very wide, an off-pump multilayered sutureless repair was performed by using three layers of collagen fleece squares with fibrinogen-based impregnation (TachoComb; CSL Behring, Tokyo, Japan) and three layers of gelatin-resorcin-formalin glue reinforced by an equine pericardial patch (Xenomedica; Edwards Lifesciences, LLC, Irvine, CA). The blow-out rupture seemed to be caused by perioperative myocardial infarction generated by the compression of the left ventricular vent to the LV lateral wall. The patient was free from re-rupture or aneurysm enlargement. The thickness of the hemostatic material seemed to help control the bulging of the aneurysm and to prevent further LV aneurysm enlargement and re-rupture.

A 62-year-old man was referred for an aortic-valve surgery because of severe aortic stenosis. Thirty years ago, he had undergone a mitral valve commissurotomy and after 9 years, the valve had been replaced by a mechanical valve. He had been undergoing hemodialysis for the past 8 years. A computed tomographic (CT) scan of the chest and abdomen showed a dense circumferential calcification in the wall of the entire thoracic and abdominal aorta, pulmonary artery, and left and right atrium. A conventional aortic-valve replacement was performed. To avoid an embolic event, a "stepwise aortic clamp" procedure was attempted and involved the following: (1) brief circulatory arrest and aortotomy during moderate hypothermia; (2) balloon occlusion at the ascending aorta during low-flow cardiopulmonary bypass (CPB); (3) endoarterectomy by using an ultrasonic surgical aspirator to enable aortic cross-clamping; and (4) a cross-clamp reinforced with felt and full-flow CPB. The patient recovered without any thromboembolic events. Using this procedure to treat a porcelain aorta seemed to reduce the time limit and reduced the risk of brain injury during cardiac surgery.

Purpose: The proximal anastomosis of free right internal thoracic artery to ascending aorta is technically difficult when the caliber is not enough. Methods: We incise the proximal stump of the graft longitudinally for 10 mm. One side of start point of longitudinal incision is sewn to the end point of incision by 7-0 polypropylene. The folded sideline (5 mm length) is then closed with a running suture, then formation of pouch like anastomotic end is accomplished. Results: We used this technique in consecutive 34 patients who underwent coronary artery bypass surgery including revascularization to circumflex arteries. Postoperative angiography revealed 97% patency. It does not need another graft material like saphenous vein or radial artery, and possible not only in on pump surgery but also in off pump. Conclusion: This new “Pouch technique” will make it easy to use right internal thoracic artery as a free graft in coronary artery bypass surgery.

Cardiac papillary fibroelastoma is the third most frequent primary cardiac tumor, after myxoma and fibroma. A papillary fibroelastoma that arises from the papillary muscle is rare. We removed a papillary fibroelastoma located at the anterior papillary muscle of the tricuspid valve. The papillary muscle needed reconstruction. We used the loop technique to adjust the length of the papillary muscle and performed annuloplasty by using an artificial ring.

Treatment for postinfarction ventricular septal defect has been improving for several decades. Aggressive resection of the infarcted myocardium (infarctectomy and closure technique) and preserving infarcted myocardium (infarct exclusion technique) have been technically modified. Recent improvement includes use of surgical glue, using an additional patch for infarct exclusion, septal exclusion, sandwich technique via right or left ventricular approach, and endovascular repair. This field still has room for cardiac surgeons to improve surgical strategy and technique.

A 77-year-old woman underwent emergency ascending aortic replacement for type A acute aortic dissection. Fifteen days after the operation, she had motor and sensory disturbances in the lower limbs. Computed tomography revealed multiple aortic thrombi and disrupted blood flow in the right external iliac and left common iliac arteries. She underwent an emergency thrombectomy for acute limb ischemia. Because heparin- induced-thrombocytopenia (HIT) was suspected to have caused the multiple aortic thrombi, we postoperatively changed the anticoagulant therapy from heparin to argatroban. Seventeen days after the first operation, gastrointestinal bleeding developed, and the patient died of mesenteric ischemia caused by HIT. Arterial embolization caused by HIT after cardiovascular surgery is a rare, but fatal event. To avoid fatal complications, early diagnosis and early treatment are essential. Use of a scoring system would probably facilitate early diagnosis.

Ginsenosides such as ginsenoside Rb1 are the principal components in Panax spp. and have been found in some other Araliaceae plants. In our survey of ginsenoside from Araliaceous species based on eastern blotting and ELISA methods using antiginsenoside Rb1 monoclonal antibody, ginsenoside Rb1, one of the principal ginseng saponins, was investigated with concentrations of 0.000016, 0.000014, and 0.000039% dry weight in the leaves, stem, and roots of the well-known medicinal plant Acanthopanax koreanum respectively. The obtained results further support potential and promising application of MAb including eastern blotting and ELISA for surveying ginsenoside sources including ginsenoside Rb1.

Background Residual shunting and mortality are problems associated with current surgical repair techniques for post-infarction ventricular septal defects. Methods We describe the mid-term results of the "sandwich technique" to repair a post-infarction ventricular septal defect (VSD), performed via a right ventricle incision. Application of direct ultrasonography to the right ventricular wall enables a surgeon to visualize the region, perform an appropriate incision into the right ventricle, and perform a trabecula resection. One patch is placed on the left ventricular (LV) side and the other on the right ventricular (RV) side of the VSD. The VSD is sealed with gelatin-resorcin-formalin (GRF) glue between the two patches. Results We had seven consecutive patients. The sandwich technique resulted in geometric preservation of the LV shape. There were no significant leaks, no mortality within a thirty-day postoperative period, and no bleeding problems. Hospital mortality was 14.3% (1/7 cases). Late survival longer than a year was obtained in five cases (71%). The longest patient survival time was nine years. No tissue degeneration was noted. Conclusion This technique may be useful for repairing a post-infarction VSD.

The current surgical technique of using an artificial chord (composed of expanded polytetrafluoroethylene [ePTFE] sutures) to repair mitral prolapse is technically difficult to perform. Slippery knot tying and the difficulty of changing the chordae length after the hydrostatic test are frustrating problems. The loop technique solves the problem of slippery knot tying but not the problem of changing the chordae length. Our "loop with anchor" technique consists of the following elements: construction of an anchor at the papillary muscle; determining the loop length; tying the loop to the anchor; suturing the loop to the mitral valve; the hydrostatic test; and re-suturing or changing the loop, if needed. Adjustments can be made for the entire procedure or for a portion of the procedure.

A 24-year-old man presented with chest pain. He was diagnosed as having a type A acute aortic dissection and an annulo-aortic aneurysm. After emergency surgery for an aortic root replacement, his electrocardiogram showed ST-segment depression and T-wave inversion. Echocardiography showed asynergy of the left ventricle without coronary ostial pathology. Heart catheterization revealed no coronary stenosis, but the true lumen of the residual ascending aorta had extreme diastolic narrowing due to flap suffocation. This resulted in coronary malperfusion. The pullback pressure curve confirmed the mechanism. The patient underwent a surgical re-intervention for a total arch repair, which diminished the coronary malperfusion. At a follow-up appointment four years and four months later, the patient was doing well.

Introduction: We investigated the prognostic value of ST-segment elevation in lead aVR (ST↑aVR) at presentation ECG in type A acute aortic dissection (AAD). Hypothesis: In type A AAD, ischemic ST-T changes at presentation have been shown to be associated with poor outcomes. ST↑aVR, an ECG marker of severe acute myocardial ischemia, may provide important prognostic information. Methods: We studied the relation of ECG findings to clinical features on admission and 30-day mortality in 280 patients who were admitted within 6 h from symptom onset and underwent emergency surgery for type A AAD. Patients with bundle branch block or left ventricular hypertrophy were excluded. Patients were divided into the 3 groups according to admission ECG findings: no significant ST-T changes (n=96, G-A); the absence (n=142, G-B) or the presence (n=42, G-C) of ST↑aVR ≥0.5 mm with ST-T changes in other leads. Estimated glomerular filtration rate (eGFR) was measured on admission, and renal dysfunction was defined as an eGFR Results: There were no differences in age, sex or time from symptom onset to admission in the 3 groups. In G-A, G-B, and G-C, the rates of renal dysfunction were 41%, 56%, and 67% (p Conclusions: In patients with type A AAD who underwent emergency surgery, ST↑aVR on admission ECG was the strongest predictor of 30-day mortality. Our findings suggest the importance of ST↑aVR in early risk stratification for type A AAD.

Undersized mitral annuloplasty alone is not always sufficient to repair functional mitral regurgitation resulting from left ventricular enlargement; the repair requires a three-dimensional approach to the mitral complex. We introduce a surgical procedure that combines papillary muscle approximation to correct lateral shift and papillary muscle relocation using the loop technique to correct the apical shift with accuracy and technical ease.

Skeletal muscle ventricles (SMVs) constructed from electrically conditioned latissimus dorsi muscle (LDM) may become an alternative for assisting the failing heart. Left and right heart circulatory assist using SMVs has been performed successfully in both acute and chronic animal models. The configurations used to connect SMVs to the circulation have included a left atrium to aorta bypass, a left ventricle apex to aorta bypass, aortic counterpulsators, a cavopulmonary bypass, and a right ventricle to pulmonary artery bypass. One SMV used as an aortic counterpulsator functioned effectively in the circulation for more than 27 months. Recent application of the pericardium to the SMV as an inner layer and design changes in the connection of the SMV to the circulation have reduced the risk of thrombus formation and SMV rupture. Although several problems have yet to be solved, the goal of the SMV as a permanent circulatory assist device without the limitation of an external power source seems within reach.

Residual shunting and mortality are problems associated with the current surgical repair techniques for postinfarction ventricular septal defects (VSD). We developed the "sandwich technique" via a right ventricle incision and assessed the surgical outcome of 13 years of experience with this technique.Between June 2001 and March 2013, 25 consecutive patients with postinfarction VSD underwent surgical repair using this technique. This technique includes the following: Application of direct ultrasonography to the right ventricular (RV) wall enables the surgeon to visualize the lesion, perform an appropriate incision into the RV, and perform a trabecular resection. One patch is placed on the left ventricular (LV) side and the other on the RV side of the VSD. The VSD is sealed with gelatin-resorcin-formalin (GRF) glue between the two patches.Thirty-day mortality was 0% (0/25 case). A postoperative major shunt occurred in three patients (12%, 3/25) and two of them required reoperation (8%, 2/25). Hospital mortality was 28% (seven patients). Mean follow-up period was 4.2 ± 3.7 years. The overall survival at one, five, and 10 years was 71 ± 9%, 65 ± 10%, and 56 ± 12%, respectively. There was no cardiac death during follow-up in the patients who survived for six months after the surgery. No tissue degeneration related to GRF glue was noted.The "sandwich technique" via a right ventricle incision results in a low incidence of postoperative leak and good short- and mid-term survival.

Purpose To report successful endovascular repair of Stanford type A acute aortic dissection associated with a proximally extended dissection of the left main coronary artery. Case report A 71-year-old man presented with acute type A aortic dissection. One day after admission, dissection of the left main coronary artery accompanied by severe myocardial ischemia prompted Palmaz stent placement. Three days later, a customized stent-graft was placed across the entry site of the dissection in the descending aorta. The false lumen in the ascending aorta, transverse arch, and the descending thoracic aorta thrombosed, and the left coronary artery remained patent. At 14 months after the procedures, the patient is doing well and has had no cardiac event. Conclusions This staged procedure may be one option for the management of acute type A aortic dissection complicated by coronary artery dissection.

We report an unexpected sudden cardiac death due to variant angina complicated by ventricular fibrillation occurring during routine ambulatory electrocardiographic monitoring. The patient had one previous episode of ventricular fibrillation before the lethal event. He had no significant coronary artery disease and was asymptomatic throughout his illness. In clinical practice, when an episode of ventricular fibrillation is noted, one should be aware of the risk of sudden cardiac death, even if the patient's vasospastic angina is relatively stable and asymptomatic.

A 32-year-old male patient was admitted to the hospital with a pulsing mass of the right palm. He was an electrical construction engineer who frequently used a screwdriver. Computed tomography (CT) examination revealed a 22- × 30-mm saccular aneurysm of the right ulnar artery. The ulnar artery aneurysm was resected, and we could perform direct anastomosis of the ulnar artery. The dilated true aneurysm was compatible with a traumatic origin. A postoperative enhanced CT examination showed smooth reconstruction of the palmar arch. An occupational true aneurysm of the ulnar artery could be treated by resection and direct anastomosis.

We experienced two cases of lung injury resulting from fluted silastic drain extraction under reservoir-generated negative pressure suction. In the first case, a 67-year-old man underwent coronary artery bypass grafting. A 19 Fr BLAKE drain was placed at the pericardial cavity, the mediastinum, and the left thoracic cavity. All three drains were connected to J-VAC reservoirs. After removing the drains (which maintained the negative pressure), subcutaneous emphysema and hemopneumothorax occur. A trocar catheter was inserted. Bleeding and the air leak terminated within a day. In the second case, a 73-year-old man underwent aortic valve replacement. Right pneumothorax occurred after the removal of the pleural cavity drain, which maintained the negative pressure generated by the reservoir. We inserted a trocar catheter, and the air leak terminated within a day. We hypothesized that the reservoir-generated negative pressure causes the pleura to enter the groove of the drain and become damaged during extraction. We stopped using a reservoir to connect to the fluted silastic drain placed at the pleural cavity and removed the negative pressure when extracting the pleural cavity drain. Since implementing this change, we have not experienced a similar lung injury in more than 500 cardiac surgery patients.

破裂性腹部大動脈瘤術後の腹腔内圧と病態の関連は明らかでない.平成12年4月～平成15年1月に腹部大動脈瘤手術を109例(非破裂性71例,破裂性38例)経験し,破裂例のうち30例で腹腔内圧を計測し検討対象とした.最高腹腔内圧20mmHg以上の12例をH群,20mmHg未満の18例をL群とし,両群間の周術期諸因子を比較した.破裂例の在院死亡は38例中5例(13%)で,検討対象30例中ではH群で1例(MOF),L群で1例(循環不全)を失った.年齢はH群79.3±7.6yr,L群70.7±10.1yr(p=0.019),術前急性循環不全はH群83.3%,L群61.1%(p=0.26)で,意識障害はH群50.0%,L群23.5%(p=0.15)であった.腹腔内圧の最高値はH群22.3±2.0mmHg,L群15.4±2.4mmHg,術後挿管時間はH群87.7±110.0h,L群25.1±29.2h(p=0.04),摂食開始はH群14.4±11.2d,L群8.5±4.8d(p=0.094),ICU滞在はH群6.7±6.5d,L群2.9±2.1d(p=0.033),術後入院日数はH群54.1±25.8d,L群25.2±6.8d(p=0.001)であった.合併症はH群73%(急性腎不全2例,腸閉塞2例,呼吸不全2例,腹壁裂開1例,胃潰瘍1例,急性動脈閉塞1例),L群18%(上肢不全麻痺1例,下肢不全麻痺1例,急性腎不全1例)(p=0.0024)で認められた.腹腔内圧計測は破裂性腹部大動脈瘤術後の病態把握と方針決定に有効であった.

From the water-soluble portion of the methanol extract of the fresh rhizome of Atractylodes japonica, five new sesquiterpenoid glycosides, including a compound having a secoguaiane skeleton, and a new aromatic compound glycoside were isolated together with ten known compounds. Their structures were clarified by spectral investigation.

Five sesquiterpenoid glycosides (two guaiane-type glycosides and three eudesmane-type glucosides) and a glucoside of an acetylene derivative were newly isolated from the water-soluble portion of the methanolic extract of Atractylodes lancea rhizome together with 26 known compounds. Their structures were characterized as atractyloside A 14-O-beta-D-fructofuranoside, (1S,4S,5S,7R,10S)-10,11,14-trihydroxyguai-3-one 11-O-beta-D-glucopyranoside, (5R,7R,10S)-isopterocarpolone beta-D-glucopyranoside, cis-atractyloside I, (2R,3R,5R,7R,10S)-atractyloside G 2-O-beta-D-glucopyranoside, and (2E,8E)-2,8-decadiene-4,6-diyne-1,10-diol 1-O-beta-D-glucopyranoside on the basis of chemical and spectroscopic investigation. The presence of six characteristic guaiane-type glucosides in both rhizomes of A. lancea and Atractylodes japonica suggested a close chemotaxonomic relationship between them.

A 75-year-old woman was admitted to our hospital because of dyspnoea. She had been diagnosed as a right coronary artery–left ventricle (LV) fistula with a coronary artery aneurysm and moderate mitral regurgitation (MR) 5 years before. Surgical or …

Five new triterpenoid saponins, nipponosides A-E (1, 3-6), were isolated from Acanthopanax nipponicus leaves, along with a known saponin, kalopanaxsaponin G (2). Nipponosides A-E were characterized as the 28-O-alpha-L-rhamnopyranosyl(1--4)-beta-D-glucopyranosyl(1--6)-beta -D-glucopyranosyl ester of 3-oxohederagenin, oleanolic acid 3-O-beta-D-glucopyranoside, gypsogenin 3-O-beta-D-glucopyranoside, 3beta,23,29-trihydroxyolean-12-en-28-oic acid, and 3beta,20alpha, 23-trihydroxy-30-nor-olean-12-en-28-oic acid, respectively. The structures of these new compounds were based on chemical and spectral methods.

基礎心疾患や薬物乱用歴のない49歳男性. 発熱を主訴に受診し, 抗生物質を投与するも, 軽快と再発を繰り返し入院した. 血液培養にて Str. agalactiae が検出され, 経食道心エコーにて三尖弁に疣贅と, 中等度の逆流を認めた. 感染が遷延したため活動期であったが手術を施行した. 疣贅を含む前尖2/3と後尖の一部を切除, 弁輪縫縮と弁切離断端同士を縫合, さらにDeVega法により弁輪径を2横指に縫縮し, 感染性心内膜炎の治癒と, ほぼ三尖弁逆流を消失せしめることができた.

A 51-year-old female, with a past medical history of resection of cerebellar hemangioblastoma, presented with an atrial tumor detected by sonography after undergoing a series of examinations for fever of unknown origin and subsequent symptoms of heart failure. After removing the atrial tumor, the histological findings demonstrated myxoma. Immunohistopathological study showed that the tumor cells in both the hemangioblastoma and the myxoma had strong cytoplasmic immunoreactivity for vascular endothelial growth factor. Hemangioblastoma associated with myxoma is extremely rare, and was probably a random occurrence in this case.

In type A acute aortic dissection (AAD), ST-T changes on the admission electrocardiogram (ECG) are associated with poor outcomes [(1,2)][1]. Although ST-segment elevation in lead aVR (STE-aVR) is an ECG marker of severe acute myocardial ischemia [(3)][2], its prognostic significance in type A AAD

Further investigation of the leaves of Acanthopanax divaricatus gave two analogues of chiisanoside, which is a lupane triterpenoid oligoglycosyl ester. The structures were established as 28- O -α- l -rhamnopyranosyl(1 → 4)-β- d -glucopyranosyl(1 → 6)β- d -glucopyranosyl esters of 1β,11α-dihydroxy-3-oxo-lup-20(29)-en-28-oic acid and 1( R ),11α,22α-trihydroxy-3,4-seco-lupa-4(23),20(29)-diene-3,28-dioic acid 3,11α-lactone based on chemical and spectroscopic evidence. in biosynthetic terms, one is the precursor of chiisanoside and the other is an oxygenated derivative chiisanoside.

The patient was a 41-year-old female with chronic thromboembolism. She was admitted to an affiliated hospital with exertional dyspnea, leg swelling, and hemoptysis, and she was treated medically with tissue plasminogen activator and warfarin therapy. When transferred to our hospital, she was oxygen-dependent with severe dyspnea. A pulmonary arteriogram showed occlusion and stenosis of the pulmonary arteries. Cardiac catheterization revealed marked pulmonary hypertension. The lung perfusion scintigram showedmultiple defects in the right and left lungs. Preoperative laboratory data showed a markedly decreased protein C antigen level. Magnetic resonance angiography showed that a myoma uteri compressed the pelvic vein and that she had deep vein occlusion of the left leg. After the administration of an epoprostenol infusion and the insertion of an inferior vena cava filter, she underwent an operation. Under deep hypothermia, the bilateral pulmonary artery was opened and an endarterectomy was performed during intermittent circulatory arrest. After surgery, her pulmonary vascular resistance was in the normal range. Her New York Heart Association functional classification changed from class IV to class I. She has been in good condition for 7 years since the surgery.

A left ventricular (LV) free wall rupture is a highly lethal condition. A 78-year-old female, who collapsed while riding a bike, was admitted to our emergency service 7 days after experiencing chest pain. During admission, she had cardiopulmonary arrest. Though cardiopulmonary resuscitation was successful, computed tomography (CT) showed cardiac tamponade. Emergency surgery was then performed. Pericardiotomy revealed a postinfarction blowout rupture of an aneurysm (2 × 3 × 1 cm) on the anterolateral wall of the LV. The top of the aneurysm had a 2-mm wide blowing blood column. Intra-aortic balloon pumping was initiated. An off-pump multilayered sutureless repair using squares of collagen fleece with fibrinogen-based impregnation (i.e., TachoComb) and gelatin-resorcin-formalin glue (GRF glue) was performed. Postoperative coronary angiography revealed occlusion of the second diagonal branch. The patient was free from re-rupture or aneurysm enlargement. An LV blowout rupture, which was caused by myocardial infarction with a limited tear and necrotic area at the second diagonal branch territory, was successfully treated with an off-pump multilayered sutureless repair by using a TachoComb and GRF glue patch. The thickness of the hemostatic material seemed to help control the bulging of the aneurysm and to prevent further LV aneurysm enlargement and re-rupture.