Two Cases of Adventitial Inversion Technique for Stanford Type A Acute Dissecting Aortic Aneurysm / 日本心臓血管外科学会雑誌

We treated two cases of Stanford type A acute dissecting aortic aneurysm with the adventitial inversion technique. Both case 1) a 65-year-old woman and 2) a 74-year-old woman underwent emergency operation. After cardiopulmonary bypass was established as usual, the diseased aorta was resected, and the intima was trimmed about 10mm shorter than the transected adventitial line in both proximal and distal ends. After GRF glue was employed, the adventitia was inverted inward over the false-lumen, and then tacked with horizontal continuous mattress sutures using 5-0 polypropylene. The graft was then anastomosed with continuous sutures using 3-0 polypropylene. No bleeding occurred from the anastomosis site in both cases. This method was completed without the use of artificial reinforcement, nevertheless patent anastomosis was possible. This simple method was easily performed and proved to be safe and useful.

The Role of Preoperative Cerebral Magnetic Resonance Angiography in the Prevention of Cerebral Complications Following Cardiovascular Surgery / 日本心臓血管外科学会雑誌

Screening of carotid and intracranial artery diseases by magnetic resonance angiography (MRA) was performed in forty-one adult patients prior to elective cardiovascular surgery. In twenty patients (48.8%), MRA demonstrated significant cerebrovascular lesions: carotid or main cerebral artery stenosis in 7, diffuse cerebral arteriosclerotic change in 6, vertebral artery lesion in 5 and berry aneurysm in 2. Advanced age (over 70 years) and previous cerebrovascular events increased the incidence of cerebrovascular lesions on MRA. Forty patients underwent scheduled surgery under cardiopulmonary bypass, and pulsatile flow perfusion was used in patients in whom significant cerebrovascular lesions were demonstrated on MRA. One patient with aortic arch aneurysm was judged to be an unacceptable candidate for surgery in light of his marked diffuse arteriosclerotic lesions on MRA. In five patients, staged operation was performed from 10 to 30 days after cerebrovascular surgery (bypass surgery for internal carotid occlusion in 2, aneurysm clipping in 2, carotid endarterectomy in 1). Postoperative neurological complications occurred in one patient (2.5%). In conclusion, screening of carotid and intracranial artery diseases by MRA is a safe and useful method for evaluation of cerebrovascular lesions in patients with advanced age, previous cerebrovascular events and/or arteriosclerotic diseases.

Clinical Features of Hyperosmolar Hyperglycemic Non-Ketotic Diabetic Coma Following Open-Heart Surgery / 日本心臓血管外科学会雑誌

Three patients with hyperosmolar hyperglycemic non-ketotic diabetic coma (HHNKDC) following open-heart surgery are presented. Because the symptoms of HHNKDC are not specific, it is difficult to recognize this unique complication in the early postoperative stage. The mortality rate of this complication is high. Thus, HHNKDC should be recognized as early as possible after open-heart surgery, since it is curable if diagnosed at an early stage.

Valve Replacement with the St. Jude Medical Valve Prosthesis in Children / 日本心臓血管外科学会雑誌

Seven children aged 3 to 14 years, underwent cardiac valve replacement with a St. Jude Medical valve prosthesis. In 4, the valve was placed in the aortic position, in 2 in the mitral position and in 1 in the aortic and mitral position. Three patients underwent Konno's procedure. We followed up them from 2.3 to 9.3 years (mean follow-up 6.0 years). There were no operative or hospital deaths. One patient died after delivery by caesarean section 9.3 years after the operation. All patients recieved warfarin and antiplatelet agents for postoperative anticoagulation and no thromboembolic or bleeding complications occured. All survivors did not need reoperation and they were in New York Heart Association functional class 1 without somatic growth retardation.

Investigation on Improvement of Peripheral Circulation by Continuous Use of Prostaglandin E1 during Open Heart Surgery. Evaluation with Peripheral Blood Flow by Laser Doppler Flowmeter and Temperature Difference between the Periphery and Core / 日本心臓血管外科学会雑誌

Prostaglandin E₁ (PGE₁) was used continuously in adults from immediately after induction of anesthesia, during extracorporeal circulation, to the acute phase after open heart surgery. Using blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core as indices, the effects of afterload reduction and improvement of peripheral circulation were investigated. Subjects were 17 adults who underwent open heart surgery. PGE₁ was used in 7 patients and not used in 10. In the group using PGE₁, continuous injection of 0.015μg/kg/min of PGE₁ was started immediately after induction of anesthesia and was maintained during extracorporeal circulation until the acute phase after surgery. During extracorporeal circulation, perfusion pressure was kept at 50∼60mmHg and PGE₁ injection was controlled within the range of 0.015∼0.030μg/kg/min. At completion of extracorporeal circulation, the dose was fixed at 0.015μg/kg/min again. The degree of improvement of peripheral circulation was evaluated on the basis of hemodynamics, blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core, at induction of anesthesia (before using PGE₁) on completion of extracorporeal circulation, and in the acute phase after surgery. The value of blood flow in the toe determined by laser Doppler flowmeter was significantly higher in the PGE₁ group than in the non-PGE₁ group, from completion of extracorporeal circulation to the acute phase after surgery. Moreover, peripheral temperature was significantly higher in the PGE₁ group than in the non-PGE₁ group at completion of the extracorporeal circulation as well as immediately after surgery, and the temperature difference between periphery and core was significantly smaller. Continuous injection of PGE₁ enabled smooth control of perfusion pressure during extracorporeal circulation. Although there was no significant difference in peripheral vascular and total pulmonary resistance, the coefficients tended to be lower in the PGE₁ group. The use of PGE₁ during open heart surgery seems to be an effective method to improve peripheral circulation.

The Surgical Experiences of Triple Shunts (VSD+ASD+PDA). The Report of Three Cases / 日本心臓血管外科学会雑誌

We experienced three cases of triple shunts (VSD+ASD+PDA) for past ten years. All three cases admittied with cardiac failure and respiratory distress early in the infant period. Ligation of PDA, suture closure of ASD and patch closure of VSD were performed in the two cases. Another case was performed ligation of PDA because of low body weight (1, 700g). Triple shunts were correctly diagnosed in only one case. Another two cases were diagnosed VSD and PDA at operative period. The patient with low body weight was lost at 38 days after operation. Post operative course were uneventfull in the two cases of total repair. Triple shunts should be repaired in the same time. But two staged operations are consider to perform in the low body weight infant and patients with major general pediatric surgical disease.

Successful Konno Operation and Mitral Valve Replacement for Recurrent Subaortic Stenosis with Aortic and Mitral Regurgitation after the Repair of Discrete Subaortic Stenosis / 日本心臓血管外科学会雑誌

It is known that subaortic stenosis (SAS) occasionally progress after the repair of Co/A. And it may progress if the initial repair is incomplete. We successfully repaired a 6-year-old girl with recurrent SAS with aortic and mitral regurgitations and pulmonary hypertension (<i>Pp/Ps</i>=0.74) progressed after the initial repair for SAS. She had been operated at 4-year-old with transaortic resection of subaortic myocardium and the membrane. He SAS had progressed since the coarctectomy at 7 months of her age. At that procedure, right coronary cusp was lacerated and repaired. In may 1989, Konno operation with 21 St. Jude Medical aortic prosthesis and mitral valve replacement with 25 St. Jude Medical prosthesis were performed. Interventricular septum, aortic root and right ventricular outflow tract were reconstructed employing composite patch with preserved equine pericardium and Dacron velour. So mitral annulus was dilated because of the volume over loading due to aortic regurgitation, that complete repair was not able to do with mitral valvulo and annuloplasty. After the procedure severe cardiac and respiratory failure occurred and continued for over 10 days. And hemolytic anemia with homoglobiuria appeared. It continued for 14 days. In spite of those complications, the girl became well and goes to school with the administration of warfarin and dipyridamole. We recommend that Konno operation could be the first indication for the children with narrow aortic root when incomplete repair was made during the initial repair for subaortic stenosis.

Anatomical study of the projection region of the dome of the pleura to the surface of the anterior neck / 全日本鍼灸学会雑誌

The projection region of the dome of the pleura to the surface of the anterior neck was investigated in 31 domes of 17 cadavers. The point “Tentotsu”, and a line connecting that point and the most lateral edge of the acromion were adopted for a basis of measurement of the projection region. The mean length of the Tentotsu-Acromion line was 185mm on either side of the body. Its upward angle to the horizontal plane was 22° and 23° in average on the right and left sides, respectively, while its backward angle to the frontal plane was 23° on the right and 25° on the left. The right pleural domes (17 cases) were included within a range 0-58mm lateral to the Tentotsu and lower than 44mm above, and on the left side (14 cases), these values were 5-58mm and 49mm, respectively. On the other hand, when adopting the Tentotsu-Acromion line as the basis, the pleural domes were located within the medial one-third of the line. Their summits lay on the point of its medial one-fourth in medio-lateral direction, and were situated at levels lower than about 35 (on the right) or 32mm (on the left) above the line.

Topographic anatomical observations of the points of the posterior neck / 全日本鍼灸学会雑誌

The relation of needles inserted to the points of the posterior neck with the anatomical structures was investigated with dissection of four cadavers. The points investigated here are the five points of “Amon”, “Tenchuu”, “Fuuchi”, “Kankotsu”, and “Eifu”. The needles inserted to the respective points of the former three were found to penetrate the posterior atlantooccipital membrane and then the dura mater, and finally to reach the medulla oblongata. The depth from the inserted spots on the surface of the skin to the dura mater are 50, 51, and 49mm in the Amon, Tenchuu, and Fuuchi, respectively, in a cadaver with 39.1cm of circumference of the neck. Furthermore, it was found that the vertebral, the occipital, and the external carotid and the maxillar arteries were penetrated by or located near the needles which were inserted to the Fuuchi, Kankotsu, and Eifu, respectively.

Anatomical consideration to an acupuncture near the middle cervical or the vertebral ganglia / 全日本鍼灸学会雑誌

The incidences of the middle cervical and the vertebral ganglia and their sizes were investigated bilaterally during dissection of 18 cadavers. Furthermore, the positional relations of each ganglion to the vertebral column, the point Tentotsu, the anterior tubercle of the sixth cervical (C₆) vertebra, and the cricoid cartilage were investigated along with the relations of the anterior tubercle of the C₆ vertebra to the point Tentotsu and the cricoid cartilage. The middle cervical ganglion was 14, 4 and 2mm in average length, width and thickness, respectively, on the right, and on the left these values were 14, 5 and 2mm. The ganglion was found in about half the cases, and it was located at about the level of the cricoid cartilage and close laterally and above to the anterior tubercle of the C₆ vertebra. In the cases lacking the middle cervical ganglion, the sympathetic trunk passed immediately medial to the tubercle. The vertebral ganglion was found in almost all cases, with its mean size 8, 5 and 3mm on the right and 9, 5 and 2mm on the left in lenght, width and thickness, respectively. The ganglion was included in many cases within a range 15 to 30mm lateral and 20 (the left) or 25 (the right) to 45mm above the point Tentotsu, and it lay at the level of the C₇ vertebra. The anterior tubercle of the C₆ vertebra was within a range 20 to 30mm lateral to that point, and in the upper to lower direction, it lay at the level slightly upper than the cricoid cartilage in the male and at about the level of the cartilage in the female.

An anatomical observation of the pressure pain zone in the suprascapular region / 全日本鍼灸学会雑誌

A pressure pain, frequently associated by an induration, is usually perceptible in the suprascapular region of the normal subjects. We considered the relation of the pressure pain with the anatomical structures of that region, firstly by investigating the locus of the pressure pain and whether it is associated by an induration or not, using the living subjects and in several cases, followed by a X-ray examination of the final destination of the needle which was inserted in the pressure pain zone; and lastly by dissecting the anatomical structures penetrated by that needle in a woman's cadaver.<br>We obtained the follwing three results from the above investigation and observations. (1) The most conspicuous pressure pain was perceptible in the middle of the upper margin of the suprascapular region, and a long and slender induration extending sagitally was palpable there. (2) The second rib lay in the deepest layer of the pressure pain zone, the layer which were overlain by the serratus posterior superior muscle, the serratus anterior and the omohyoid, many branches of the transversus colli artery and vein and the accessory nerve, and the trapezius muscle with the posterior suprascapular nerves running on its superficial surface, in order of lower to upper layer. (3) The transversus colli vessels, which forms a complex network of branchings crossing sagitally above the second rib, was suggested to have some relationship to the occurence of the pressure pain associated by the induration, because only the formation of such vascular network was peculiar to the pressure pain zone.

Anatomical consideration of the acupuncture into the stellate ganglion / 全日本鍼灸学会雑誌

The anatomical structures penetrated by a needle which was inserted in an acupuncture point into the stellate gaglion, 1.5cm lateral to and 2.5cm above the point Tentotsu, were studied bilaterally with dissection of 19 cadavers. Furthermore, the size of the dissected stellate ganglion, its anatomical position, and its positional relation to structures located near it were measured or observed.<br>Though 8 out of 38 inserted needles pricked the medial margin of the ganglion, the remaining 30 needles all missed medially from the ganglion. In the cases pricking the ganglion, all of 8 needles penetrated either the vertebral or the subclavian artery before reaching the ganglion, and 7 of these did also the dome of the pleura in addition to the artery. In the cases missing from the ganglion, however, a frequency of penetrating the above structures were considerably lower.<br>The dissected stellate ganglion almost lay on beteen the mid-level of the vertebral body of the 7th cervical vertebra and the upper level of body of the second thoracic vertebra, with their mean size 27.1, 7.7 and 2.8mm in length, width and thickness, respectively. All of the ganglions were located dorsal to the vertebral and subclavian arteries and the dom of the pleura the distances from the median line to their upper and lower extremity being 21.9 and 22.7mm in average, respectively.<br>The pricked point for directly aiming at the stellate ganglion from the body surface is within a range 20 to 30mm lateral to and 10 to 40mm above the point tentotsu on the right, and on the left it is within a range 15 to 25mm lateral and 10 to 35mm above; the depth from the point is about 4.0 and 3.8cm on the right and left, respectively. But when directly aiming at the ganglion, the possibility of injuring the vertebral or subclavian artery and the dome of the pleura was suggested to increase considerably owing to their location ventral to the ganglion.

Anatomical position of the point jingei. (II). Relation between the acupuncture point to the carotid sinus and the bifurcation of the common carotid artery / 全日本鍼灸学会雑誌

The posional relation of the bifurcation of the common carotid artery to the needle which was inserted to the position of the bifurcation presumed from the level of the hyoid bone, as well as its relation to the hyoid bone and the transverse process of the cervical vertebra, has been studied bilaterally with dissection of 19 cadavers.<br>Though most of the inserted needles missed medially from the bifurcation of common carotid artery, all of them were located about the level of the bifurcation in the up-to-downward direction, with two cases directly pricking the bifurcation.<br>The bifurcation of the common carotid artery was mostly located about the level of hyoid bone. Thus, 17 cases out of 19 on the right side and 13 cases out of 18 on the left side were within a range of 1.0mm above or below the hyoid bone.<br>The height of the bifurcation of the common carotid artery against the cervical vertebrae was mostly located between the transverse process of the 3rd and that of the 4th cervical vertebra, 21 cases out of 28 being included within this range.

Anatomical position of the point Jingei. 1 Positional relation between the laryngeal prominence and the bifurcation of the common carotid artery / 全日本鍼灸学会雑誌

The positional relation between the point Jingei and the bifurcation of the common carotid artery was investigated with dissection of the neck after inserting a needle into the bilateral Jingei, using nineteen Japanese cadavers. We determined first the position of the point Futotsu as a point in the sternocleidomastoid lying about 10cm lateral to the laryngeal prominence along the neck wrinkle, and defined the location of Jingei in the cadavers as the mid-point between the laryngeal prominence and Futotsu mentioned above. The common carotid artery shows a dilatation, termed the carotid sinus, at its point of division into the external and internal carotid arteries. The needle did not prick the carotid sinus in all of the thirty-eight cases of insertion; it pricked the common carotid artery at a lower level than the carotid sinus in four of these cases, and in the other cases the needle did not prick the vessel, but rather a portion of the neck medial to the vessel at the lower level, similarly as in the former cases. The points of division of the common carotid arteries of the cadavers dissected were all located at a considerably higher level than the laryngeal prominence; the average level was 32.8mm higher than the prominence on the left, with maximum and minimum values of 52 and 11mm, respectively, and 29.9mm upper on the right (maximum and minimum values: 45 and 8mm). Furthermore, it was suggested that the insertion of a needle at the level of the hyoid bone has a higher possibility of reaching the carotid sinus than that at the level of the laryngeal prominence in acupuncture of the sinus.