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Many technologies have been developed for minimally invasive monitoring of cardiac output. Estimated continuous cardiac output (esCCO) measurement using pulse wave transit time is one noninvasive method. Because it does not require any additional sensors other than those for conducting 3 basic forms of monitoring (electrocardiogram, pulse oximeter wave, and noninvasive (or invasive) arterial blood pressure measurement), esCCO measurement is potentially useful in routine clinical circulatory monitoring for any patient including low-risk patients. We evaluated the efficacy of noninvasive esCCO using pulse wave transit time in this multicenter study.We compared esCCO and intermittent bolus thermodilution cardiac output (TDCO) in 213 patients, 139 intensive care units (ICUs), and 74 operating rooms (ORs), at 7 participating institutions. We performed electrocardiogram, pulse oximetry, TDCO, and arterial blood pressure measurements in patients in ICUs and ORs; a single calibration was performed to measure esCCO continuously. TDCO measurement was performed once daily for ICU patients and every hour for OR patients, and just before the removal of the pulmonary arterial catheter from patients in both the ICU and OR. We evaluated esCCO against TDCO with correlation analysis and Bland and Altman analysis and also assessed the change of bias over time. Furthermore, we inspected the impact of change in systemic vascular resistance (SVR) on change in bias because abnormal SVR was assumed to be a factor contributing to the change of the bias.From among 588 esCCO and TDCO datasets (excluding calibration points), 587 datasets were analyzed for 213 patients. The analysis results show a correlation coefficient of 0.79 (P0.0001, 95% confidence limits of 0.756-0.819), a bias (mean difference between esCCO and TDCO) of 0.13 L/min (95% confidence interval of bias 0.04-0.22 L/min), and a precision (1 SD) of 1.15 L/min (95% prediction interval was -2.13 to 2.39 L/min). There were no significant differences among 3 defined time intervals over 48 hours after calibration (repeated-measures analysis of variance P = 0.781) in the ICU. The influence of SVR on esCCO analysis showed a correlation coefficient between SVR and an error of 0.37 (P0.0001, 95% confidence interval 0.298-0.438).The efficacy of noninvasive esCCO technology was compared with TDCO in 213 cases. Five hundred eighty-seven datasets comparing esCCO and TDCO showed close correlation and small bias and precision, which were comparable to current arterial waveform analysis technologies.

Although it has been generally believed that parturients have delayed gastric emptying during anesthesia, the most recent reports suggest that gastric emptying is not delayed during pregnancy except during labor. Electrical slow waves in the stomach determine the frequency and the peristaltic nature of gastric contractions. In this study we performed electrogastrography during and after elective cesarean section (CS) in an attempt to evaluate gastric motility.Sixteen American Society of Anesthesiologists physical status I or II term parturients undergoing elective CS were enrolled. Combined spinal-epidural anesthesia was initiated with 10 mg of bupivacaine plus 10 microg of fentanyl. Four-channel electrogastrography was obtained for 10 min prior to venous catheter insertion (baseline), 10 min following spinal injection of bupivacaine and fentanyl (Sp-1), 10 to 20 min following spinal injection (Sp-2), 10 min prior to the end of operation (end), and finally 10 min on the seventh postoperative day (POD 7).The mean +/- SD values for dominant frequency of electrogastrography (DF) were determined as: 1.57 +/- 0.36 cpm (baseline), 1.81 +/- 0.32 cpm (Sp-1), 2.08 +/- 0.36 cpm (Sp-2), 1.96 +/- 0.36 cpm (end), and 3.02 +/- 0.28 cpm (POD 7). The DF of Sp-1, Sp-2, and end were significantly higher than that of baseline (P0.05). The DF of POD 7 was significantly higher than that of baseline, Sp-1, Sp-2, and end (P0.01).Electrogastrography analysis suggests that the frequency of gastric contractions during CS was less than that in the postpartum period.

During off-pump coronary artery bypass (OPCAB), the displacement of the heart causes mitral regurgitation. We hypothesized that patients with impaired left ventricle (LV) function would be more prone to develop mitral regurgitation, due to further LV end-diastolic pressure elevation and mitral annulus distortion. Therefore, in this study, we examined the relationship between LV function and the severity of mitral regurgitation.We studied 41 patients undergoing elective OPCAB. LV function was evaluated by LV ejection fraction (LVEF), serum brain natriuretic peptide (BNP) levels, the Tei index (myocardial performance index) and mitral inflow propagation velocity (Vp).Among all of the anastomoses performed mitral regurgitation was most severe during anastomosis of the left circumflex artery (LCX) territory (P0.001). Twenty-five patients (61%) had no to mild mitral regurgitation during anastomosis of the LCX territory (M-MR group) and 16 patients (39%) had moderate to severe mitral regurgitation during anastomosis of the LCX territory (S-MR group). There were significant differences between these groups in preoperative serum BNP levels (median, 26 pg.ml(-1) interquartile range [IQR, 14 to 75 pg.ml(-1)] versus median, 173 pg.ml(-1) [IQR, 91 to 296 pg.ml(-1)]; P0.001), Tei index values (median, 0.35; [IQR, 0.27 to 0.41] versus median, 0.53 [IQR, 0.47 to 0.57]; P0.001), and Vp (median, 63 cm.s(-1); [IQR, 57 to 72 cm.s(-1)] versus median, 47 cm.s(-1); [IQR, 40 to 57 cm.c(-1)]; P = 0.008), while there was no significant difference in LVEF between the patients in the M-MR group and those in the S-MR group.Preoperative LV dysfunction is a predictor of severe mitral regurgitation during OPCAB. When poor LV function is suggested, it is necessary to be prepared for further hemodynamic deterioration caused by mitral regurgitation.

Recently, we demonstrated that beta2AR and several other Galphas-coupled receptors in human atria also couple to Galphai, a G protein that inhibits adenylyl cyclase (AC). The present study was undertaken to determine whether age increases expression of Galphai in human atrium, and more specifically whether it results in an increase in receptor-mediated activation of Galphai. Right atrial appendages were obtained from 14 mature adult (40-55 years) and 14 elderly (71-79 years) patients undergoing cardiac surgery. Immunoblotting of atrial membranes indicates that elderly atria have 82 +/- 18% more Galphai2 than atria from mature adults (P < 0.002); this increase in Galphai with age is confirmed by pertussis toxin-catalyzed ADP-ribosylation as well as by photoaffinity labeling with [32P]azidoanilido-GTP. We also find that receptor-mediated activation of Galphai is greater in elderly atria and that both basal and receptor-mediated AC activities decrease in elderly atria. These decreases in AC activity can be reversed by disabling Galphai with pertussis toxin, indicating that the age-dependent increases in Galphai expression and activation have functional consequences. Because beta2ARs in human atria mediate contractility through cAMP-mediated phosphorylation of phospholamban, we conclude that an age-induced increase in Galphai may have a role in depressing cardiac function in aged human atria.

The postoperative courses of 112 patients with pulmonary disease (59 with obstructive disease = Group 0, 38 with restrictive disease = Group R and 15 with mixed disease = Group M) who underwent elective coronary artery bypass grafting were retrospectively reviewed. Preoperative pulmonary function test (percentage of vital capacity =%VC and percentage of forced expiratory volume at 1 second = FEV1.0%) of these group showed typical abnormal values, and velocity ratio of 50% and 25% of maximum expiratory flow volume ({ie149-1}/{ie149-2}) of each groups were measured abnormal values (3.99 ± 1.44 of Group O, 4.26 ±1.42 of Group R and 3.74 ± 1.82 of Group M). The our strategy for these groups were a). Using skeletonization method for harvesting internal mammary artery (IMA) b) Take care not to injure the phrenic nerve and open the pleural cavity as surgical techniques (Harvesting IMA) and c) Administration of theophylline derivatives and corticosteroids to prevent bronchospasm d) Administration of concentrated serum albumin and diuretics to prevent pulmonary edema as therapeutic measures. The length of stay in the intensive care unit and ventilation time of each groups were not significantly longer. Patients of group M had more respiratory complications (atelectasis, pleural effusion, pneumothrax, bronchospasm, and pneumonia) than did patients of group R (p

esCCO (estimated continuous cardiac output, Nihon Kohden, esCCO) is a new cardiac output measurement system which uses pulse wave transit time to calculate cardiac output continuously and non-invasively. One of the most commonly used methods to monitor cardiac output is continuous cardiac output CCO (Edwards Lifesciences) which has an accuracy equivalent to that of thermodilution method.We compared esCCO to CCO in 67 operating room patients and 128 intensive care unit patients. CCO and esCCO were measured simultaneously in patients with a pulmonary artery catheter inserted after admission to the operating room or intensive care unit.CCO and esCCO showed a high correlation with a correlation coefficient of 0.84 in 496 total data points, and 95% limits of agreement between these two methods were -2.49 to 2.35 l x min(-1).This result suggests that esCCO could be used to measure cardiac output accurately and non-invasively in different cases.

A new non-invasive continuous cardiac output (esCCO) monitoring system solely utilizing a routine cardiovascular monitor was developed, even though a reference cardiac output (CO) is consistently required. Subsequently, a non-invasive patient information CO calibration together with a new automated exclusion algorithm was implemented in the esCCO system. We evaluated the accuracy and trending ability of the new esCCO system. Either operative or postoperative data of a multicenter study in Japan for evaluation of the accuracy of the original version of esCCO system were used to develop the new esCCO system. A total of 207 patients, mostly cardiac surgical patients, were enrolled in the study. Data were manually reviewed to formulate a new automated exclusion algorithm with enhanced accuracy. Then, a new esCCO system based on a patient information calibration together with the automated exclusion algorithm was developed. CO measured with a new esCCO system was compared with the corresponding intermittent bolus thermodilution CO (ICO) utilizing statistical methods including polar plots analysis. A total of 465 sets of CO data obtained using the new esCCO system were evaluated. The difference in the CO value between the new esCCO and ICO was 0.34 ± 1.50 (SD) L/min (95 % confidence limits of −2.60 to 3.28 L/min). The percentage error was 69.6 %. Polar plots analysis showed that the mean polar angle was −1.6° and radial limits of agreement were ±53.3°. This study demonstrates that the patient information calibration is clinically useful as ICO, but trending ability of the new esCCO system is not clinically acceptable as judged by percentage error and polar plots analysis, even though it’s trending ability is comparable with currently available arterial waveform analysis methods.

Previous studies have shown that neurokinin 1 receptor (NK1R) occurs naturally in human glioblastomas and its stimulation causes cell proliferation. In the present study we show that stimulation of NK1R in human U373 glioblastoma cells by substance P increases Akt phosphorylation by 2.5-fold, with an EC(50) of 57 nM. Blockade of NK1R lowers basal phosphorylation of Akt, indicating the presence of a constitutively active form of NK1R; similar results are seen in U251 MG and DBTRG-05 glioblastoma cells. Linkage of NK1R to Akt implicates NK1R in apoptosis of glioblastoma cells. Indeed, treatment of serum-starved U373 cells with substance P reduces apoptosis by 53 +/- 1% (p < 0.05), and treatment with NK1R antagonist L-733,060 increases apoptosis by 64 +/- 16% (p < 0.01). Further, the blockade of NK1R in human glioblastoma cells with L-733,060 causes cleavage of Caspase-3 and proteolysis of poly (ADP-ribose) polymerase. Experiments designed to elucidate the mechanism of NK1R-mediated Akt phosphorylation revealed total involvement of non-receptor tyrosine kinase Src and phosphatidyl-3-kinase, a partial involvement of epidermal growth factor receptor, and no involvement of mitogen-activated protein/extracellular signal-related kinase. Taken together, the results of the present study indicate a key role for NK1R in glioblastoma apoptosis.

心房細動の80歳の女性に脳梗塞が再発し, 経食道心エコーにより, 左心耳内に2×3cmの可動性血栓像を認めた. 体外循環心停止下に左心耳内部に付着した血栓を除去後, 左心耳入口部を縫合閉鎖した. 血栓は大部分は白色血栓化していた. 術後経過良好であり, 合併症もなく元気に退院した. 左房内血栓の診断には経食道心エコーが有効であり, 高齢者であっても塞栓症を繰り返す症例では検査を行い, 全身状態が良好であれば除去すべきと思われた. 本邦では非弁膜症性心房細動に伴う左房内血栓の除去術はこれまでに6例報告され, 80歳以上は本例が2例目であった.

Atrial fibrillation (AF) is a frequent complication after coronary artery bypass surgery. Postoperative AF can lead to thromboembolic events, prolonged hospital stay, and increased costs. Recent reports have shown that an elevated plasma brain natriuretic peptide (BNP) level is associated with AF. The purpose of this prospective study was to test the hypothesis that preoperative BNP level is a predictor of postoperative AF following off-pump coronary artery bypass surgery (OPCAB). One hundred and fifty patients without a history of AF undergoing elective isolated OPCAB were enrolled. Plasma BNP level was measured preoperatively. Heart rate and rhythm were continuously monitored during the first 72 h after surgery. Twenty-six patients (17.3%) exhibited postoperative AF. This proportion is similar to those reported in earlier studies. Univariate analysis demonstrated that age (odds ratio [OR], 1.060; 95% confidence interval [CI], 1.008 to 1.114; P = 0.023), previous myocardial infarction (MI; OR, 2.628; 95% CI, 1.031 to 6.697; P = 0.043), and BNP level (OR, 7.336; 95% CI, 2.401 to 22.409 / log BNP level; P < 0.001) were accurate predictors of postoperative AF. Stepwise multivariate regression analysis indicated age (OR, 1.059; 95% CI, 1.002 to 1.120; P = 0.043) and BNP level (OR, 6.272; 95% CI, 1.980 to 19.861/log BNP level; P = 0.002) as the only independent predictors of postoperative AF. Preoperative BNP level is an independent predictor of postoperative AF following OPCAB. Our findings permit us to stratify the risk of AF and to plan prophylactic strategies in high-risk patients.

We experienced anesthetic management of a 2 year-old girl with Pierre-Robin syndrome. She had received respiratory support for 6 months from the birth. As soon as we induced general anesthesia, she had a skin rash. We suspected that this rash was caused by hypersensitivity to the latex-containing facemask. We stopped anesthesia and postponed operation. After a month, operation was performed under general anesthesia using latex-free anesthetic circuit and equipments. Perioperative course was uneventful. Since the first report in 1979, the number of patients with latex allergy has progressively been increasing. It has been reported that latex allergy occurs in persons considered at high risk for latex allergy including patients with spina bifida, urogenital abnormalities and atopic dermatitis, and in health care workers and rubber industry workers. If patients suspected of having latex allergy undergo surgical procedures, anesthesiologists must check patients' past history and possibility of chronic exposure to latex products. In these cases, preoperative preparation is essential and thorough precaution should also be taken to avoid life-threatening allergic reaction.

Central venous catheterization is commonly performed by puncturing the internal jugular vein. However, placement of central venous catheters is not without risk. We compared the Argyle and the Insyte in terms of usefulness and incidence of complications during central venous catheterization.Twenty adult patients for cardiac operation were randomly allocated into two groups; 10 patients in the Argyle group (Group A) and 10 patients in the Insyte group (Group B).In both groups, no kinking or stucking of the guide wire occurred during insertion. No accidental puncture of the carotid artery occurred in Group B, while it occurred in one case in Group A. The time required for insertion of the guide wire was not significantly different between the two groups, though it tended to be shorter in Group B than in Group A (19.3 +/- 14.6 sec vs 34.6 +/- 34.0 sec). On ultrasonography, the Argyle was observed to compress the internal jugular vein and to be prone to penetrate both anterior and posterior walls.Using the Argyle makes it a little more difficult to place the needle in the appropriate venous lumen. We conclude that central venous catheterization with the Insyte was quicker and safer than with the Argyle.

Cardiac G protein-coupled receptors that function through stimulatory G protein Galpha(s), such as beta(1)- and beta(2)-adrenergic receptors (beta(1)ARs and beta(2)ARs), play a key role in cardiac contractility. Recent data indicate that several Galpha(s)-coupled receptors in heart also activate Galpha(i), including beta(2)ARs (but not beta(1)ARs). Coupling of cardiac beta(2)ARs to Galpha(i) inhibits adenylyl cyclase and opposes beta(1)AR-mediated apoptosis. Dual coupling of beta(2)AR to both Galpha(s) and Galpha(i) is likely to alter beta(2)AR function in disease, such as congestive heart failure in which Galpha(i) levels are increased. Indeed, heart failure is characterized by reduced responsiveness of betaARs. Cardiac betaAR-responsiveness is also decreased with aging. However, whether age increases cardiac Galpha(i) has been controversial, with some studies reporting an increase and others reporting no change. The present study examines Galpha(i) in left ventricular membranes from young and old Fisher 344 rats by employing a comprehensive battery of biochemical assays. Immunoblotting reveals significant increases with age in left ventricular Galpha(i2), but no changes in Galpha(i3), Galpha(o), Galpha(s), Gbeta(1), or Gbeta(2). Aging also increases ADP-ribosylation of pertussis toxin-sensitive G proteins. Consistent with these results, basal as well as receptor-mediated incorporation of photoaffinity label [(32)P]azidoanilido-GTP indicates higher amounts of Galpha(i2) in older left ventricular membranes. Moreover, both basal and receptor-mediated adenylyl cyclase activities are lower in left ventricular membranes from older rats, and disabling of Galpha(i) with pertussis toxin increases both basal and receptor-stimulated adenylyl cyclase activity. Finally, age produces small but significant increases in muscarinic potency for the inhibition of both beta(1)AR- and beta(2)AR-stimulated adenylyl cyclase activity. The present study establishes that Galpha(i2) increases with age and provides data indicating that this increase dampens adenylyl cyclase activity.

We present herein the case of a 65-year-old man who suddenly developed fresh perigraft bleeding into the space between a knitted Dacron bifurcated graft and the aneurysmal sac, 12 years after undergoing graft replacement. Intraoperative findings did not show Dacron fiber degeneration at the nonanastomotic sites or a pseudoaneurysm at the anastomotic site. Widened Dacron fiber interstices resulting from graft dilation without sufficient graft healing was thought to have caused delayed hemorrhage through the macroscopically intact graft material, followed by massive clot retention between the graft and the aneurysmal sac. This case report serves to demonstrate that careful long-term follow-up is essential for patients who have undergone vascular graft replacement.

Revascularization of the hypogastric artery often tends to be neglected in aortoiliac reconstructive surgery; however, its incomplete revascularization can result in unfavorable complications such as buttock claudication or necrosis, vascular impotence, and colonic ischemia. Multiple vascular lesions in the abdominal aorta and bilateral iliac arteries were reconstructed using a newly designed double bifurcated graft in five male patients. All five patients demonstrated excellent graft limb patency and postoperative improvement of the ankle-brachial pressure index without any clinical signs of ischemia in regions of the hypogastric artery. Thus, we conclude that an aggressive approach toward hypogastric circulation maintenance is essential in aortoiliac reconstructive surgery. By using this double bifurcated graft, rapid and safe revascularization of the bilateral hypogastric arteries concomitant with the external iliac or femoral arteries can be performed.

Cardiopulmonary bypass (CPB) was established via a sutured collagen sealed knitted Dacron graft in two patients who had undergone extraanatomic bypasses for lower limb ischemia, whose ascending aorta was not suitable for cannulation. One patient, with a history of femorofemoral bypass, underwent surgery for a ruptured aortic arch aneurysm (AAA) and the other patient, with a history of axillobifemoral bypass for chronic dissection involving the aortic arch and descending aorta, had unstable angina and underwent coronary artery bypass grafting. This technique of perfusion was found to be safe and effective for patients with an impaired ascending aorta who have undergone an extraanatomic bypass for the lower limb.

The dual-stage venous cannula is widely used but can obstruct the surgeon's view and interfere with operative procedures in the aortic root. We designed a new stainless steel sheath for a dual-stage venous cannula that enables the cannula to bend and maintain the appropriate angle for the surgical procedures. We suggest that operative procedures in the aortic root can be performed faster during safety cardiopulmonary bypass by use of a dual-stage venous cannula bent by application of this new sheath.