Search

症例は6ヵ月間の発熱病歴を有し,小児期より心室中隔欠損症(VSD)と診断されていた44歳の男性である.平成16年7月,VSDに伴った感染性心内膜炎による大動脈弁閉鎖不全症と診断し,生体弁による弁置換術およびVSDのパッチ閉鎖術を施行した.しかし術後,炎症反応は陰転化せず,術後3ヵ月目に血中からCandida albicansが検出された.人工弁感染が疑われたため,術後3.5ヵ月でFree styleブタ大動脈弁により大動脈基部置換およびVSDの再閉鎖術を行った.その後,抗真菌剤の内服を継続して外来経過観察していたが,平成17年5月に再び発熱が出現,CTで左総腸骨動脈瘤を認め,Candida albicansによるmycotic aneurysmを疑い手術を施行した.活動型感染性心内膜炎では抗生剤投与が長期にわたると真菌症を併発することを認識すべきである.真菌性感染性心内膜炎は感染制御の困難性から長期予後は不良とされ,術後の経過観察は長期間,厳重に行うことが必要である.

きわめて希な特発性弓部大動脈破裂症例を経験したので報告する.症例は55歳,女性.突然の胸痛を訴え他院を受診した.心タンポナーデの診断で当院転送となった.来院時血圧70mmHgのショック状態であった.CTにて心タンポナーデ,上行・弓部大動脈周囲に血腫を認めたが,大動脈の解離所見は認められなかった.大動脈破裂の診断で緊急手術を施行した.弓部前面に裂孔を認め,循環停止下に縫合閉鎖した.正確な破裂孔の同定に術中経食道超音波検査が有用であった.上行・弓部大動脈には外膜血腫のみで解離の所見はなく,病理診断においても同様の結果であった.術後経過は良好で16病日に退院した.本症はきわめて希な疾患で,確定診断が困難であり予後不良である.外傷や大動脈瘤がなくても,CTでの迅速かつ詳細な検査において本症を疑い,積極的な外科治療が必要である.

To evaluate the safe and effective use of argatroban, a competitive direct thrombin inhibitor, as an alternative anticoagulant for percutaneous cardiopulmonary support (PCPS) and continuous hemofiltration or hemodiafiltration (CHF/CHDF), a preliminary multicenter clinical trial was conducted between October 1999 and September 2000. Nine patients who underwent PCPS and/or CHF/CHDF were enrolled in the study during this period. The dosage of argatroban was controlled so that the activated clotting time (ACT) was maintained at around 180 to 200 s. The mean duration of argatroban administration was 82 ± 92 h, and the mean dose was 0.67 ± 0.40 μg kg+1 min−1. Severe hemorrhagic complications requiring the discontinuation of argatroban administration were not observed in any of the patients. Platelet loss was prevented to some degree, and plasma levels of fibrinogen were well preserved during PCPS/CHDF. Except for two patients undergoing CHDF, clot formation within the extracorporeal circulation circuit was not identified macroscopically after the discontinuation of the procedures. We conclude that argatroban might be useful as an alternative anticoagulant in cases where heparin cannot be safely used because of the increased risk of bleeding complications, thrombocytopenia, and/or hypofibrinogenemia. Although the optimal dose of argatroban has not been established, we propose an initial starting dose of 0.7 to 1.0 μg kg−1 min−1, followed by adjustments to maintain an ACT of between 180 and 250 s.

Argatroban, a selective and competitive antithrombin agent synthesized in Japan, was assessed for use as an alternative anticoagulant for partial venoarterial bypass with an oxygenator, by determining serial changes in hemostatic molecular markers. Fourteen dogs were divided into 3 groups in which partial veno-arterial bypass was carried out: a group in which no anticoagulant was used (group N, n = 3), a group in which 200 IU/kg of bolus heparin was used (group H, n = 5), and a group in which 10 μg/kg per min of intravenous argatroban was used (group A, n = 6). Both thrombin-antithrombin complex and fibrinopeptide A increased significantly in group N; they did not increase in group H. Group A showed high thrombin-antithrombin complex levels and significantly high fibrinopeptide A levels throughout the bypass procedure in comparison to levels in group H. However, plasma fibrinogen was maintained at higher levels in group A than in group H. Platelet count decreased significantly immediately after the start of bypass in groups N and H, but no significant change in platelet count was observed in group A. In conclusion, argatroban at a dose that prolongs activated clotting time to 200 s suppressed thrombin and fibrin generation less effectively than did full-dose heparin. However, excessive consumption of fibrinogen and accelerated fibrinolysis were not observed, and more platelets were preserved, suggesting that argatroban can be used safely in partial cardiopulmonary bypass with an oxygenator.

腹部大動脈瘤に連続する左総腸骨動脈瘤と左総腸骨静脈との間に動静脈瘻を形成した1手術例を報告した.症例は72歳男性で高心拍出量性心不全,両下肢浮腫,血尿を伴い本症に特徴的な病態を示し,腹部CT,DSAにて術前診断が可能であった.手術はocclusion balloon catheter,自己血回収装置を活用し直径10mmの瘻孔を直接縫合閉鎖し,腎動脈下腹部大動脈・両側外腸骨動脈間に血行再建術を施行し,術後は順調な経過をたどった.動脈瘤破裂の合併症として腸骨動静脈瘻は希であり,その発生形態の理解と的確な外科的処置が必要と考えられた.

大動脈炎症候群が疑われた腹部大動脈縮窄症に胸部下行大動脈瘤を合併した症例に対し下行大動脈置換と下行-腹部大動脈バイパス術を行い良好な結果を得たので報告する.症例は67歳,女性.左側胸部痛精査のCT,DSAで最大径60mmの下行大動脈瘤と腎動脈分岐後の腹部大動脈縮窄を認めた.さらに上腸間膜動脈から下腸間膜動脈に著しく拡張したmeandering mesenteric arteryを介した側副血行路がみられた.血液検査上炎症所見はなかったが形態学的に大動脈炎症候群が疑われた.手術は左第4肋間開胸と左腹部斜切開でF-Fバイパス下に下行大動脈瘤切除,人工血管置換を行い,下行置換のグラフトに作製した分枝と大動脈分岐上の腹部大動脈との間に後腹膜経路でバイパス術を行った.術後経過は良好で術後42日で軽快退院した.大動脈炎症候群では術後の炎症再燃,吻合部動脈瘤の発生が危惧されるが,術後約1年の経過観察中合併症なく社会復帰している.

Objectives: Rapid emergency transport and early diagnosis and surgical treatment for acute type A aortic dissection have improved postoperative survival, which has, however, plateaued at about 80%. End-organ malperfusion is regarded as a strong predictor of postoperative mortality, replacing factors such as cardiac tamponade complications, aortic rupture, and left ventricular dysfunction due to aortic insufficiency. It is thus important to reevaluate risk factors for surgical death to assess current therapeutic strategies.Methods: We statistically analyzed potential risk factors for perioperative death in 88 patients undergoing surgical repair for type A aortic dissection between January 1990 and December 1999.Results: Univariate analysis showed that cardiopulmonary arrest (adjusted odds ratio: 13.78; p

The thoracic cage after a lung resection is filled by the remaining lobes, the elevated diaphragm, the diminished thoracic cage, and by mediastinal shifting. The changes in the thorax after a lung resection were quantified using magnetic resonance imaging. The study group consisted of 39 patients who had undergone a lobectomy, four who had undergone a pneumonectomy, and 14 controls. The left ventricular angle, ascending aortic angle, mediastinal shift, longitudinal length of the thoracic cage, the distance between the thoracic apex and the level of the aortic valve, and diaphragmatic elevation were all measured. After a right lower lobectomy, the mediastinum shifted more rightward than after a right upper lobectomy. The diaphragm became more greatly elevated after a right upper lobectomy than after a right lower lobectomy. When a chest wall resection was added to a right upper lobectomy, the mediastinal anatomical changes decreased. After a left upper lobectomy, the degree of mediastinal shifting was greater than after a left lower lobectomy. A left upper lobectomy shifted the mediastinum at the level of the right atrium. This method is easily reproducible and was found to be effective for quantifying the changes in the thorax after a lung resection.

To avoid systemic thromboembolization and clot formation in the extracorporeal circulation (ECC) equipment in open-heart surgery, full heparinization or an activated clotting time (ACT) longer than 450 seconds has been considered essential. This requirement has been determined both empirically and from hematologic studies of abnormal fibrin monomer or fibrinopeptide A (FPA) production. 8,42 Although ECC materials such as polypropylene and silicone used in the gas-exchange membrane of the oxygenator and polyvinyl chloride tubing retain some degree of thrombogenicity, 6,35,36 improved biocompatibility between these materials and the blood components achieved with heparin coating, improved connector and cannula designs, and use of the centrifugal pump have made it possible to perform some ECC procedures without full systemic anticoagulation therapy. The risk of thrombus formation within the circuit has not yet been eliminated, however, especially in cases of prolonged low-flow perfusion. 6,37 Stagnation or turbulence of the blood flow in the ECC circuit 35 can also increase the thrombotic risk. Therefore, low-dose heparin therapy is commonly used to prolong the ACT to 150 to 200 seconds.

Of a series of resected primary lung cancer at the hospital in a recent 9-year period from January 1986 to December 1994, 90 patients with non-small cell lung cancer underwent “absolutely curative resection” and 72 non-small cell lung cancers underwent “relatively curative resection”. In order to elucidate the prognostic factors, these cancers were evaluated for age, sex, tumor size, pathologic T factor, pathologic N factor, histopathological features, and method of detection. Fifteen of the 90 (17%) patients developed recurrence which was examined for the presence of vessel invasion and involvement of visceral pleura. All of these 15 recurrent cases had evidence of lymphatic vessel invasion. Six of these 15 cases (40%) also had blood vessel ilmvasion. The mean size of the tumors was significantly larger in the recurrent cases after absolutely curative resection than that in all resected cases. However, there was no significant difference between the recurrent cases and all cases of curative resection in the presence or absence of involvement of visceral pleura. Multivariate analysis of all risk factors revealed that the T factor and the presence of vessel invasion are only independent risk factors for recurrence after curative resection. In conclusion, it is important for preventing recurrence after curative resection to detect the tumor in smaller size, to avoid the growth or invasion of the tumor due to delayed treatment, and to perform complete resection with mediastinal lymph node dissection as early as possible.

Background: Argatroban, a selective and competitive antithrombin agent, produces antithrombotic effects without aggravating bleeding tendency. We used argatroban as an anticoagulant during extracorporeal membrane oxygenation (ECMO) in two pediatric patients with low output syndrome following open heart surgery.Patients and Results: Patient 1; A 1-year-old boy underwent a radical operation for repair of a common atrioventricular canal. Following surgery, ECMO was successfully performed with argatroban (1.5 to 7.0μg/kg/min) for 4 days. Patient 2; A 3-year-old girl underwent intraventricular baffle repair for double-outlet right ventricle. ECMO was started with heparin, but it was replaced with argatroban (5.0μg/kg/min) on day 2 because of massive gastrointestinal bleeding. This treatment resulted in a gradual decrease in bleeding. ECMO could be carried out without further bleeding for another 3 days.Conclusions: Our clinical findings suggest that argatroban may be a useful anticoagulant for ECMO.

幼児の医原性両側外腸骨動脈閉塞の症例を経験した. 症例は6歳女児で, 主訴は間歇性跛行と寒冷時下肢痛であった. 既往歴として, 大動脈縮窄複合に対して生後1カ月と1歳3カ月時にそれぞれ右および左大腿動脈穿刺によるカテーテル検査を施行した. 4歳時に縮窄部切除端々吻合術と心室中隔欠損直接縫合閉鎖術を二期的に施行した. 今回血管造影検査時, 大腿動脈を穿刺したところ, 両側外腸骨動脈が閉塞しており, 内腸骨動脈の分枝を側副血行路として大腿動脈が造影された. 成長期に下肢虚血があり, 寒冷時下肢痛があるため, 下肢血行再建の適応とした. 手術は開腹し, 両側とも外腸骨動脈に伴走して, 6mmの expanded polytetrafluoroethylene (ePTFE) グラフトを用いて, 内腸骨動脈と総大腿動脈間に端側吻合によりバイパスを作成した. 術後, 両側とも足背動脈触知可能となり, 自覚症状は消失した. MR-angiogram でもグラフトはよく開存していた.

Inflammatory aneurysms are common in the abdominal aorta, but uncommon in the thoracic aorta and iliac artery. Recently we experienced a rare case of inflammatory aneurysms of the bilateral iliac arteries which was diagnosed by a histopathological study. A 70-year-old man was admitted to the hospital with a 10-year history of a pulsatile mass at the right lower abdomen. Contrast enhanced CT scan of the abdomen demonstrated aneurysms of the bilateral common iliac arteries associated with a periaortic thin layer enhanced by contrast dye, and hydronephrosis of the right kidney. The aneurysms and right ureter were extremely difficult to dissect not capable of being dissected due to retroperitoneal fibrosis, even though the gross appearance of the aneurysms was not identical with that of the classical inflammatory aneurysm. Then graft replacement of the abdominal aorta to bilateral common iliac arteries was performed by using a Gelseal knitted Dacron Y graft.Pathohistological study of the aortic wall revealed heavy infiltration of lymphocytes and plasma cells in the thickened adventitial and medial layers, being compatible with an inflammatory aneurysm. This case appears to be in an extremely early stage in the spectrum of clinical pregress.

急性大動脈解離の早期診断, 早期外科治療が可能になるにつれて大動脈基部外膜破裂, 冠動脈解離腔内断裂などの大動脈基部破壊例あるいは冠動脈解離による冠血行不全併発例に遭遇する機会が増加している. このような病変は大動脈造影検査が診断的であるが, 近年, 非侵襲的検査法によって診断が確定されたならば大動脈造影は除外される傾向にある. したがって, 初期診断上, もっとも利用度の高い造影CTにてこれらの病変を予知することは重要である. そこで, 49例の大動脈解離例の造影CT上の諸所見と大動脈造影像および術中所見から得られた所見とを比較した. 大動脈基部に intimal flap 像が同定しえた6例中4例 (66.7%), 大動脈基部径35mm以上でAAE例を除いた14例中2例 (14.3%) に大動脈基部再建あるいはCABGを要するような大動脈基部破壊例が含まれた. 大動脈基部破壊9例中8例は基部径40mm以上で有意に高値であった. 以上より, 造影CT上の大動脈基部内隔壁同定, 基部径の40mm以上の拡大所見は大動脈基部破壊を伴う基部病変合併例を示唆する重要所見であると結論した.

A 51-year-old man was admitted with acute ischemic pain in the left leg. An angiogram demonstrated a well-developed left internal iliac artery that appeared to be continuous with the left common femoral artery, but no left external iliac artery. The left superficial and proximal deep femoral arteries were obstructed with thrombi. At surgery it was revealed that the distal end of the left common iliac artery was continuous with the dilated left internal iliac artery, forming the continuation with the left common femoral artery in the pelvic cavity. The left external iliac artery was absent between the common iliac and femoral arteries. (J Vasc Surg 2003;37:683-5.)

A study was conducted to characterize the platelet aggregation induced by neuroblastoma tissue to investigate the mechanism of hypercoagulability in patients with neuroblastoma. The patients whose tumor tissues were examined had been shown clinically to have enhanced platelet activity. Platelet aggregation induced by neuroblastoma tissue extract was compared with that of other pediatric tumors. The effects of pretreatment with an antithrombin agent and prostacyclin (PGI2) on the platelet aggregation induced by tumor tissue extracts were also evaluated. Tissue extracts of 12 of 15 neuroblastomas, 3 of 3 Wilms' tumors, and 1 pheochromocytoma were demonstrated to have an activity that potentiated platelet aggregation in vitro. The platelet aggregation induced by tissue extracts of neuroblastomas and other tumor tissues was suppressed almost completely by pretreatment with a PGI2 analogue. The aggregation induced by neuroblastomas and the pheochromocytoma was also suppressed by pretreatment with an antithrombin agent, argatroban, whereas the aggregation induced by Wilms' tumors was not suppressed by this agent. These results suggest that (1) malignant tumors in children also have some chemical substances that sensitize platelet activity, such as those in adult cancers, and (2) thrombin is one of the mediators stimulating platelet aggregation in cases of neuroblastoma, although it is unlikely to be a contributing factor in other pediatric malignancies such as Wilms' tumor.

A novel antiplatelet agent, satigrel (E5510), was administered to 9 patients with arteriosclerosis obliterans (ASO) and 6 patients with thromboangiitis obliterans (TAO) at a dosage of 4mg/day for 2 weeks followed by 8mg/day for another 2 weeks and its effect on platelet function and coagulation-fibrinolytic system as well as hemodynamics were evaluated. Satigrel significantly inhibited platelet aggregation induced by collagen (p

A rare case of an ulcerated hemangioma of the upper arm in a neonate is described herein. Resection of the huge hemangioma, which occupied the axilla and extended down the entire length of the upper arm, was necessary due to massive hemorrhage from the ulcer and progressive heart failure caused by the arteriovenous fistulae in the hemangioma. After complete resection of the hemangioma, extensive defects of the skin and subcutaneous tissue were replaced by a skin flap closure technique which involved considerable difficulty. However, the arm gradually recovered its size and function with good wound healing. The present case illustrates that rapid surgical intervention may be required to prevent clinical deterioration in such cases.

Twenty-one patients underwent operation for Stanford type A aortic dissection at St. Marianna University Hospital from 1980 to 1991. Fourteen patients had an acute aortic type A dissection and seven patients had chronic type A dissection. Operative procedures included replacement of the ascending aorta using Dacron graft in 14 patients, Bentall procedure in 4, ring graft insertion in 2, and primary anastomosis in 1. Aortic valve resuspension was performed to aortic valve regurgitation, except for annulo-aortic ectasia. Operative mortality (within 30 days) was 19% (4 cases). All 4 deaths occurred in the early period of this study, and after July 1989 when open distal anastomosis method was started, there has been occurred any deaths. The cumulative survival rate at 100 month was 78.7% in acute group, and 68.9% in chronic group, with no significant difference. The open distal anastomosis was used in 7 cases without any serious complications. However, careful follow up of further extension of the dissecting process, is necessary.

Prothrombin fragment 1+2 (F1+2) is a coagulation factor newly used as a molecular marker to monitor anticoagulant therapy in patients undergoing heart valve replacement. We evaluated the usefulness of F1+2 against that of prothrombin time (PT) reported as the internationalized normalized ratio (INR) in 93 patients undergoing mechanical heart valve implantation between August 1999 and July 2000. The study group consisted of 38 men and 55 women, with an average age of 61.1±11.2 years. The surgeries were 34 aortic replacements, 9 double valve replacements, and 50 mitral valve replacements. Warfarin doses were controlled based on PT-INR values at a target range of 1.5–2.5 F1+2 levels in the 0.4–1.2 nmol/l level were considered normal. No thromboembolism or bleeding complication occurred in any patient during the mean follow-up period of 12 months. The overall correction coefficient between F1+2 and PT-INR was 0.165 (P 2.50 were less than half of the lower limit of normal. Our analysis involving F1+2 confirmed PT-INR in the 1.5–2.5 range following mechanical heart valve implantation to be optimal. We found that using F1+2 to monitor individual response to anticoagulation therapy is useful when PT-INR values are difficult to obtain.

Gingival metastasis from lung cancer is very uncommon. We report a case of distant metastasis of pulmonary adenocarcinoma in the mandibular gingiva. A 54-year-old man was admitted to our hospital on September 1, 1997 with hemoptysis. Right upper lobectomy with mediastinal lymph node dissection was performed on September 16. On the 14th postoperative day, the patient complained of a gingival swelling. In the lower right premolar area, a wide pedunculated mass was seen on the mandibular gingiva. Excisional biopsy of the tumor was performed, and histopathological examination revealed that the tumor was a metastatic lesion from the pulmonary adenocarcinoma. The patient received 46.8 Gy of linac irradiation to the tumor area and the entire oral condition improved markedly. However, bilateral adrenal gland metastases were recognized, and left inguinal lymph node metastasis was detected 2 months after lung resection. He developed tumor metastases to multiple organs and died of respiratory failure on December 12, 1997.

A 34-year-old man, a heavy drinker, was admitted with a high fever and hematuria two months previously. Surgery was performed for acute sever pancreatitis and postoperatively antibiotics were administered with intravenous hyperalimentation. After discharge he was readmitted and infective endocarditis was strongly suspected because of high fever, hematuria, Osler's nodes, Janeway's lesions, splinter hemorrhages and mitral regurgitation. Penicillin G in combination with Gentamycine therapy was started on the first hospital day. On the second hospital day, blood culture revealed Candida tropicalis so Miconazole therapy was commenced. On the forth hospital day, he underwent surgery for replacement of a mitral prosthesis with a prosthetic valve because he had embolus in the radial artery. Despite intensive antifungal therapy, he showed no improvement in clinical symptoms. Then we changed the antifungal drug from Miconazole to Amphotericin B and 5-fluorocytosine. On the 109th hospital day, his clinical symptoms improved. Antifungal therapy was halted and at present 10 months later, he is healthy.

Positioning a stent graft (SG) that adapts to the anatomical shape of the aorta is important to prevent complications after SG procedures to treat aortic disease. The Gianturco Z-stent has several benefits, but its rigid structure prevents adaptation to flexure. We improved this stent and studied its ability to adapt in the clinical environment. We positioned SGs and inspected their adaptability to flexure in an aortic arch model. We examined several gap lengths and strut directions, and determined the distance generated between the stent and the aortic wall. We found that adaptation was quite satisfactory with a gap of more than 10 mm or when the struts faced the major flexure or the side of the model aorta. Based on these findings and to facilitate placement, we manufactured the unibody Z-stent with 10-mm gaps. The unibody Z-stent was applied to treat thoracic and thoracoabdominal aortic disease in seven patients. The SG was positioned from the femoral or iliac artery in five patients and from an anastomosed graft to the ascending aorta after median sternotomy and bypass of the arch branches in two patients. A minor endoleak developed in one patient. None of the other six patients developed complications or died during the procedure, although one patient died in the hospital due to cerebral infarction. The unibody Z-stent was applied as a SG that adapts to flexure of the aorta and was easy to apply. The frequency of complications was apparently decreased after clinical application of the unibody Z-stent in SG treatment for thoracic and thoracoabdominal aortic disease.

The clinical value of pre- and post-operative serum carcinoembryonic antigen (CEA) concentration (mean +/- SEM, ng/ml) in surgically treated primary lung cancer patients with adenocarcinoma (n=97) was studied. Preoperative CEA in pT2 patients (18.3+/-8.0) was higher than in pT1 (10.5+/-6.4, p0.05) but was not different from pT3 patients (19.7+/-6.7). Preoperative CEA in pN1 patients (5.9+/-1.6) was lower than in pN2 (28.2+/-13.2, p0.05) but not different from pN0 patients (8.8+/-3.8); p-stage II patients (8.2+/-4.7) had lower values than p-stage III patients (26.7+/-10.5, p0.05), but not p-stage I patients (7.9+/-3.9). The CEA was not different between p-stages IA and IIA (3.5+/-0.6, 6.1+/-3.2) and IB and IIB (17.0+/-11.8, 11.7+/-7.8), but was different between IA and IB (p0.05) and IIA and IIB (p0.05). Preoperative CEA did not differ between patients who received complete (12.7+/-4.7) versus incomplete (9.5+/-6.0) resections, nor between patients who developed recurrence after surgery (21.9+/-10.4) versus those who were disease-free (30.9+/-21.7). CEA obtained 2 months after surgery in patients who recurred or metastasized after surgery (63.1+/-47.0) was higher than in disease-free patients (4.8+/-1.6, p0.05). The post-/pre-operative CEA ratio in patients who recurred or metastasized after surgery (146.6+/-53.3%) was also higher than in disease-free patients (91.0+/-10.9%, p=0.05). In conclusion, CEA reflected tumor size but not the tumor invasion nor hilar lymph node disease; patients with mediastinal lymph node involvement had higher CEA values. Preoperative CEA did not reflect the likelihood of complete resection nor postoperative metastasis, but postoperative CEA obtained 2 months after surgery did reflect postoperative metastasis.

Nowadays, trauma victims are quickly transported from the scene to the therapeutic facility, therefore, even patients with traumatic aortic rupture (TAR) who were considered to be unlikely to survive several hours in the past are able to have more chance to undergo surgical treatment. In such patients who need emergency surgical repair of TAR regardless of the presence of multiple other organ injuries, massive contrast dye extravasation into the mediastinum is usually demonstrated on the contrast-enhanced computed tomography (CT) images. But, in most of the cases showing a pseudoaneurysm or dissection, delayed aortic repair is preferable when other organ injuries have therapeutic priority. The use of active adjunct means for distal support is definitely advantageous to prevent paraplegia. Heparin-bonded bypass by the use of low dose of heparin or intravenous argatroban is safe and avoids the risk of bleeding of other injured organs.

We evaluated our hypothesis that morphological change of the aortic dissection can be predicted by serial measurements of hemostatic molecular markers. Between February 1999 and February 2003, 50 patients with chronic aortic dissection of the descending thoracic aorta were studied at random intervals of 1 to 59 months (mean, 15.4+/-14.3) after onset. Morphologies of the false lumen of the aortic dissection determined by computed tomographic (CT) images were divided into four groups. Twenty-two images had aortic dissection associated with intramural hematoma or a completely thrombosed false lumen without ulcer-like projections (group 1), 14 had a thrombosed false lumen with ulcer-like projections (group 2), 18 had patent, but a partially thrombosed false lumen (group 3), and 15 had a completely patent false lumen (group 4). Blood samples for detection of hemostatic molecular markers were collected on the same day or within 1 month of the CT scan being performed. Thrombin-antithrombin complex (TAT) and D-dimer proved to be significantly higher in group 3 than in group 1. There was no significant correlation between the external diameter and hemostatic molecular markers except for prothrombin fragments 1+2 (PTF1+2). Simultaneous determinations of these hemostatic markers and multiple CT scans were performed more than twice in 19 of the patients. These cases were divided into three groups according to the morphological changes of the false lumen in the interval; morphologically progressive, regressive and no change cases. Five cases showed reduction or disappearance of the false lumen (the regressive cases). Only one case showed that the false lumen progressively enlarged and was partially patent thereafter (the progressive case). Mean plasma levels of TAT and D-dimer were changed correlated with the morphological progressive or regressive changes. The morphology of aortic dissection was correlated with hemostatic molecular markers such as TAT or D-dimer. We concluded that the serial measurement of D-dimer and TAT is useful for predicting morphological changes in chronic aortic dissection, and it can be an alternative way to follow up for patients of aortic dissection.

Combined somatosensory evoked potential (SEP) and regional brain oxygen saturation (rSO(2)) monitoring and simultaneous measurement of plasma levels of S100Beta and creatine kinase-isozyme BB (CK-BB) were performed to evaluate how reliable these diagnostic modality complexes are in the early prediction of neurological complications after surgery. Between 1999 and 2002, intraoperative SEP and rSO(2) monitoring combined with measurements of S100Beta and CK-BB levels in blood were performed in 82 consecutive patients undergoing cardiovascular operations with cardiopulmonary bypass (CPB). Twelve (14.6%) of these patients were diagnosed as having neurological complications after surgery; seven with transient neurological dysfunction (8.5%), and five with permanent stroke (6.1%). Twenty one of 82 patients in whom rSO(2) was recorded were judged abnormal; however, only nine of the 21 (42.9%) were diagnosed as having brain damage - diagnostic sensitivity and specificity being 75.0% and 82.9%, respectively. All six patients who showed abnormal SEP during surgery had neurological complications, but normal SEP was recorded in six other patients with apparent evidence of neurological complications - diagnostic sensitivity and specificity being 50% and 100%, respectively. There were no significant differences in S100Beta levels between patients with and without brain complications at 1 h and 24 h after CPB, but significant differences were detected in CK-BB levels at 24 h after CPB. In conclusion, simultaneous abnormalities detected in SEP and rSO(2) are highly predictive of cerebral neurocirculatory disturbances, but they are not so sensitive in diagnosing restricted focal cerebral lesions. Additional determinations of blood CK-BB levels might be valuable only to confirm the newly established brain complications.

Atherosclerotic and dysplastic aneurysms of the extracranial internal carotid artery are rare in Japan. We have experienced only four cases since 1982. The patients were two men and two women with a mean age of 67 years (range 51 to 82 years). All four patients had a saccular type aneurysm; sizes ranged from 30 to 75 mm. Aneurysmectomy and end-to-end anastomosis of the internal carotid artery could be performed in two patients. One patient underwent aneurysmorrhaphy followed by primary closure of the internal carotid artery, and the remaining patient underwent aneurysmectomy followed by a prosthetic graft replacement (6 mm-PTFE graft). During aneurysm repair, simple arterial cross-clamping (time 18 to 57 min; mean +/- SD: 31.3 +/- 18.0 min) was used in all patients. During arterial clamping of the carotid artery in two patients, somatosensory evoked potentials and regional cerebral oxygen saturation detected by near-infrared spectroscopy remained within normal ranges. All patients survived without neurologic deficits. These findings indicate that intraluminal shunting may be unnecessary during aneurysm repair if the patient does not have obstructive disease in the contralateral carotid artery and if no somatosensory evoked potentials or regional cerebral oxygen saturation abnormalities occur during proximal arterial clamping. After aneurysmectomy, end-to-end anastomosis of the internal carotid artery is the preferred method of repair if the length of the distal internal carotid artery permits.

A 72-year-old man with a history of brain infarction presented with left sided anterior chest pain secondary to a thymic carcinoma. He received induction radiotherapy, 45 Gy. Preoperative computed tomography showed the tumor was adherent to a thoracic aortic aneurysm (TAA) which had extensive mural thrombus and calcification. To obtain adequate exposure without exerting tension on the fragile aneurysmal wall, ribs were resected to allow us to separate the tumor from the TAA, after which median sternotomy was performed uneventfully, creating generous exposure. The tumor had invaded the sternum, ribs, innominate vein, phrenic and recurrent laryngeal nerves, and lung. The tumor was removed en bloc, and the chest wall was reconstructed. Intra- and post-operative brain infarction and rupture of the TAA were avoided. The patient is alive and well without recurrence 10 months after surgery.

Values of the international normalized ratio of prothrombin time (PT-INR) were analyzed at the time when anticoagulant-related complications developed in patients undergoing prosthetic valve replacement so as to evaluate the optimal therapeutic range in PT-INR value in Japanese patients. A total of 102 patients with a prosthetic heart valve who have been followed up at our department during the past 25 years were enrolled in this study. PT-INRs were determined regularly in these patients for the period between October 1996 and March 1999. Although no thromboembolic complications occurred during the period of this study, hemorrhagic complications developed in 26 (25.5%) patients. Three (2.9%) patients suffered from life threatening bleeding, such as cerebral bleeding and gastrointestinal bleeding and were defined as the major hemorrhagic group. Another 23 (22.5%) patients had minor bleeding complications such as nasal, gingival or subcutaneous bleeding and were defined as the minor hemorrhagic group. Mean PT-INR values were 3.8 2.0 and 3.2 1.0 at the onset of the complications in major and minor hemorrhagic groups, respectively, and there was no significant difference between the two groups. However, mean PT-INR values in the minor bleeding group differed significantly from that in a patient group with no hemorrhagic complications (N=76). Among the cases with bleeding complications, only 19% of the patients belonged to the range below 2.5 of PT-INR value and 54% of the patients were included in the range from 2.5 to 3.5 (p0.05). In conclusion, the optimal therapeutic range between 2.5 and 3.5 in PT-INR recommended by the American Heart Association for patients with a prosthetic heart value in Western countries may be too high in Japanese patients. PT-INR below 2.5 is considered to be safe to prevent hemorrhagic complications.

Two patients each with a rare combination of aortic coarctation and annuloaortic ectasia underwent successful single-stage repair in which the aortic root was reconstructed with a valved conduit, and an extra-anatomical bypass was made by grafting from the ascending to the abdominal aorta. Although the long-term outcome of such a long extra-anatomical bypass graft has not yet been established, the use of the graft for reducing the risk to coarctation-related complications during the early and late postoperative periods appears promising.

The effectiveness of monitoring somatosensory evoked potentials (SEPs) intraoperatively to detect brain damage early remains controversial. To assess the diagnostic accuracy of this modality, a study was conducted between 1991 and 1994, recording SEPs in 287 consecutive patients undergoing cardiac and aortic surgery using cardiopulmonary bypass (CPB) with moderate hypothermia or deep hypothermic circulatory arrest. From P1 to N2 of the SEPs occurring within 50 ms latency in response to electrical stimulation of the median nerve were recorded over the contralateral postcentral cortex at 5-min intervals using a Neuropack-2 (Nihon Koden, Tokyo, Japan). Normal SEPs were recovered in 247 patients postoperatively; however, 2 of these patients had suffered a cerebral infarction and 1, a transient stroke intraoperatively, demonstrating a false-negative incidence of 1.2%. On the other hand, three different types of abnormal SEPs were recorded postoperatively. P1 and N1 absence, probably caused by a subcortical lesion, was observed in 4 patients; P2 and N2 absence, probably caused by a cortical lesion, was observed in 8 patients; and a flat SEP, representing diffuse damage, was observed in 2 patients. Among these 14 patients with abnormal SEPs, 7 showed no neurologic disturbance at all, demonstrating a false-positive incidence of 50%. Thus, we concluded that when normal SEPs are recovered during weaning from CPB, the incidence of brain damage could be predicted at below 5%. Conversely, when abnormal SEPs are demonstrated, the incidence of brain dysfunction impeding a return to active life is estimated to be about 70%.

A rare case of epicardial cyst diagnosed at surgery was presented. A 64-year old woman was admitted for evaluation of a mediastinal mass shown by echocardiography to be adjacent to both ventricles. Computed tomography (CT) and magnetic resonance imaging (MRI) studies were per-formed. On CT. there was evidence of an abnormal mass lesion at the lateral side of the outlet of the right ventricle. The CT number of the mass was 24.7, suggesting cystic lesion. MRI revealed that the intensity of the lesion signal was higher than that of subcutaneous fat on the T2 weighted image. On the T1 weighted image. a low intensity was identified in the same region. During operation a mass originating from the epicardium was diagnosed as an epicardal cyst.