Left Atrial Appendage Rupture due to Blunt Chest Trauma during a Motor Vehicle Accident / 日本心臓血管外科学会雑誌

Blunt traumatic rupture of the heart carries a high mortality rate. Anatomical injuries have included the atrium, appendage and ventricle but injury to the left appendage has been reported very rarely. We present the case of a 71-year-old female who was a driver in a motor collision with major front-end damage where air bags were deployed. After being intubated and receiving pericardiocentesis for cardiac tamponade at an advanced critical care and emergency medical center, the patient was taken to our hospital and emergently to the operating room for exploration. There was brisk bleeding coming from a 2 cm laceration on the left atrial appendage. The injury was repaired using 4-0 polypropylene felt pledget-supported horizontal mattress sutures on the beating heart with the assistance of cardiopulmonary bypass. The present report describes this patient and our findings from a literature review.

A Mobile Thrombus in the Aortic Arch / 日本心臓血管外科学会雑誌

A 51-year-old man was referred to our hospital with pain and coldness of the upper left extremity. Contrasted computed tomography revealed a silhouette protruding into the aortic arch. Peripheral embolism in upper left extremity by tumor or thrombosis was suspected. Magnetic resonance imaging revealed a mobile mass in the aortic arch. To prevent recurrent embolization, the mass and the aortic arch to which the mass was attached were excised and partial arch replacement was performed under cardiopulmonary bypass. Histologically, the mass was a fibrin thrombus with no malignancy. The aortic wall showed only mild atherosclerosis of the intima. No thrombotic predisposition such as protein S or C deficiency or antiphospholipid antibody syndrome was observed. Anticoagulant therapy was started and the patient was discharged on postoperative day 10 without recurrent thromboembolism. Three years have passed since the operation and there is no recurrence of thromboembolism.

A Case of Scimitar Syndrome in an Adult with an Atrial Septal Defect / 日本心臓血管外科学会雑誌

The patient was a 34-year-old woman who had been routinely monitored after receiving a childhood diagnosis of partial anomalous pulmonary venous connection, but unilaterally discontinued follow-up examinations after the age of 18. At 33 years of age, she was admitted to our hospital after a physical examination revealed an abnormal shadow on a chest X-ray. Transthoracic echocardiography detected an atrial septal defect (ASD), and contrast-enhanced computed tomography showed that the right lower pulmonary vein drained to the inferior vena cava. The patient was diagnosed with scimitar syndrome with ASD. Cardiac catheterization showed a pulmonary/systemic flow ratio (Qp/Qs) of 2.48 and a left-to-right shunt rate of 59.7%. Surgical treatment was deemed to be indicated. The right lower pulmonary vein was anastomosed to the anterolateral wall of the right atrium, and an intra-atrial baffle repair was performed from the orifice within the right atrium to the left atrium through the existing ASD using untreated fresh autologous pericardium. Two years after the operation, good blood flow was maintained within the baffle with no stenosis at the anastomotic site. This report describes a rare case of scimitar syndrome with ASD in an adult woman, and provides a review of the existing literature.

Successful Surgical Aortic Valve Replacement for Prosthetic Valve Endocarditis 10 Months after Transcatheter Aortic Valve Implantation / 日本心臓血管外科学会雑誌

An 87-year-old man underwent a transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. Approximately 8 months later, he was readmitted to our institution because of a cerebral infarction. Viridans Streptococcus was identified from the blood culture, and transesophageal echocardiography revealed a mobile mass on the leaflet. Prosthetic valve endocarditis (PVE) was diagnosed and we initially administered intravenous antibiotic therapy for 4 weeks, after which the patient underwent surgical aortic valve replacement. Herein, we report on the surgical AVR in the patient using a pericardial valve after successful removal of the infected prosthetic valve, and discuss some issues related to this rare complication after TAVI.

Exercise training and cutaneous vasodilator function / 体力科学

<p>Cutaneous vasodilator function plays a role in the thermoregulatory system during rest and exercise, and its dysfunction, especially in elderly people, can influence the system’s vulnerability in heat-stressed conditions. In this review, firstly, we describe the mechanisms that control the cutaneous vasculature in humans. The reflex mechanisms by which sympathetic nerves mediate vasoconstriction and active vasodilation during whole-body thermal stress are examined, including discussions of the mechanisms involving cotransmission, nitric oxide (NO) and other mediators. The mechanisms that effect local cutaneous vasomotor responses to local skin warming are also examined, including the roles of axon reflexes as well as NO and other mediators. Next, we highlight the effects of aerobic exercise training on reflexes and local vasomotor control in the skin. Factors that modulate control mechanisms of the cutaneous vasculature, such as aging and clinical conditions, are discussed. Finally, the beneficial influences of exercise training on cutaneous vasodilator function in healthy young and elderly people with or without chronic diseases are emphasized.</p>

Giant Right Coronary Artery Aneurysm with Coronary Artery Fistula to Right Atrium / 日本心臓血管外科学会雑誌

We describe successful surgical treatment of a right coronary artery aneurysm associated with a fistula to the right atrium (RA). The patient was a 50-year-old man who complained of palpitations. ECG showed supraventricular extrasystole, and coronary CT revealed a remarkably dilated and undulating fistulous tract originating from the region corresponding to the orifice of the normal right coronary artery (RCA). The fistulous tract detoured to the posterior wall of the RA. An RCA of normal size originating from the midway of the fistulous tract was observed. The patient was operated on under cardio-pulmonary bypass. An aortocoronary bypass was performed, using a radial artery graft to section of the RCA that had a normal diameter. The RCA was subsequently ligated at the proximal side of the anastomosis. The orifice of the fistulous tract from the aorta was closed with a patch, and the entrance to the RA was also closed with mattress sutures. The postoperative recovery was uneventful, and he was discharged on the 19th postoperative day. Currently, the patient has been doing well without any complaints at 2 years postoperatively.

Left Atrial Undifferentiated Pleomorphic Sarcoma / 日本心臓血管外科学会雑誌

We report a case of a 24-year-old woman who presented with orthopnea, in whom an echocardiographic exam showed a very large mass in the left atrium. We diagnosed this as cardiac failure due to the tumor occupying it. Although the tumor malignancy remained unclear, we had to perform emergency surgery to excise the tumor. The tumor was excised in its entirety, including the interatrial septum and a large segment of the left atrial wall. We reconstructed them with the autologous pericardium. The pathological diagnosis was undifferentiated pleomorphic sarcoma. Conventional adjuvant chemotherapy and radiotherapy was performed. Primary cardiac malignant tumor prognosis is very poor, but she has survived over 1 year without recurrent symptoms after complete excision and adjuvant therapy. In addition to reporting this case, we discussed the diagnosis and treatment of undifferentiated pleomorphic sarcoma.

A Case of Aortopulmonary Artery Fistula / 日本心臓血管外科学会雑誌

Acute aortopulmonary artery fistula is a rare but potentially fatal disorder. We encountered a case in which this disorder was successfully treated by urgent total arch graft replacement and repair of the left pulmonary artery. A 74-year-old man was referred to Shizuoka City Hospital with a 2-day history of worsening dyspnea and thoracic aortic aneurysm. The patient had a history of hypertension and dyslipidemia. Physical examination showed diastolic hypotension, marked peripheral coldness, and systolic murmur. Arterial blood gas analysis showed severe metabolic acidosis with base excess of −16 mmol/<i>l</i>. Contrast-enhanced computed tomography (CT) revealed an aortic arch aneurysm on the lesser curvature, almost obstructing the left pulmonary artery. A Swan-Ganz catheter study confirmed severe low-output syndrome and uncompensated congestive heart failure. After amelioration of critically ill conditions with dopamine, milrinone, and carperitide, oxymetry revealed significant left-to-right shunt with Qp/Qs＝3.2 at the pulmonary artery level. Acute aortopulmonary artery fistula was diagnosed and urgent surgery was planned. Transesophageal echocardiography showed systolic shunt flow from the aneurysm into the left pulmonary artery. Surgery was performed through a median sternotomy. Aortic arch graft replacement with a 24-mm Dacron graft and repair of the left pulmonary artery with an equine pericardial patch were accomplished under hypothermic circulatory arrest and selective antegrade cerebral perfusion. Flooding of pulmonary circulation until circulatory arrest was prevented by manual control through the main pulmonary artery incision. Postoperative recovery was uneventful, and the patient is doing well at one year postoperatively.

The Hemodynamic Performance of Carpentier-Edwards PERIMOUNT Magna for Aortic Valve Stenosis / 日本心臓血管外科学会雑誌

This study compared the hemodynamic performance of the Carpentier-Edwards PERIMOUNT Magna bioprosthesis (Magna) with the Carpentier-Edwards PERIMOUNT bioprosthesis (CEP) for aortic valve stenosis (AS). Between January 2005 and May 2010, 164 patients underwent aortic valve replacement for AS with either the Magna (<i>n</i>=68) or the CEP (<i>n</i>=96) at our institute. Patients undergoing a concomitant mitral valve procedure were excluded from this study. The 21-mm Magna and CEP prostheses were the most frequently used during this period. Transthoracic echocardiography was postoperatively performed within 2 weeks. The peak velocity (PV) of the Magna was significantly lower than that of the CEP (2.59±0.36 vs. 2.75±0.47 m/s ; <i>p</i>=0.022). The mean pressure gradient (PG) was not significantly different. For the 19-mm prostheses, the mean PG and PV of the Magna were significantly lower than those of the CEP [16.4±4.5 vs. 19.7±6.4 mmHg ; <i>p</i>=0.034 (PG) and 2.70±0.36 vs. 3.03±0.49 m/s ; <i>p</i>=0.008 (PV)]. The effective orifice area (EOA) of the Magna was larger than that of the CEP [19 mm : 1.29±0.18 vs. 1.11±0.24 cm² (<i>p</i>=0.007) ; 21 mm : 1.46±0.23 vs. 1.42±0.18 cm² (<i>p</i>=0.370) ; and 23 mm : 1.70±0.34 vs. 1.52±0.25 cm² (<i>p</i>=0.134)]. In this study, the EOA of the Magna was approximately 80% of that described in the manufacture's description. Patient-prosthesis mismatch (PPM ; EOA index≤0.85 cm²/m²) was seen in 26.8% of patients with the Magna and in 47.2% of patients with the CEP (<i>p</i>=0.018). Severe PPM (EOA index≤0.65 cm²/m²) was not seen in any patients with the Magna. The EOA of the 19-mm Magna was significantly larger and the mean PG was lower than those of the 19-mm CEP. Compared with the CEP, the Magna significantly reduced the incidence of PPM, and had superior hemodynamic performance.

Application of Mohs paste for patients with easy-bleeding superficial malignant tumor regarding control of bleeding

In Palliative care, we meet patients with easy-bleeding superficial malignant tumors, such as head and neck cancer, skin metastasis of all kinds of cancer and unresectable breast cancer. But it is not easy to control bleeding even though we use various means, and many doctors have difficulties in stopping bleeding. We report a case with a recurrent tumor of pharyngeal cancer that showed easy-bleeding and discharged massive exudates. Although she received several alcohol local injections because of bleeding of the tumor, she needed a dressing change over 5 times in a day. It made her QOL worse. In this case, we used Mohs paste and after using it, the surface had been fixed and dried up, resulting in a decrease in bleeding, exudate, frequency of dressing change and bad odor. Mohs paste was made of distilled water, zinc chloride, zinc starch and Glycerol. Zinc chloride changes to zinc ion by water in the wound and makes protein cohere and thereafter tissues, vessels and cell membrane of bacteria are fixed chemically. We could stop bleeding for 15 days with only 20 minutes contact with Mohs paste, and massive exudates and bad odor decreased. Mohs paste, which is made in your hospital pharmacy with cheap materials, can be used for bleeding or massive exudates repeatedly if there is not a thick blood vessel anatomically under the tumor. It was effective to improve her QOL. Palliat Care Res 2009; 4(2): 346-350

CARDIOVASCULAR RESPONSE TO STATIC AND DYNAMIC MUSCLE CONTRACTIONS AT EQUIVALENT TENSION-TIME INDICES / 体力科学

In the present study, we examined cardiovascular response to static and dynamic hand-grip exercise at equivalent work load (peak tension) and tension-time index (TTI, integrated tension for time) in healthy young (n=8) and elderly (n=8) males. Static and dynamic exercises were conducted for 75 s and 150 s at 30% of maximal voluntary contraction (MVC) and for 45 s and 90 s at 50%MVC, respectively. Arterial pressure was continuously measured on a beat basis. Blood pressure at the end of exercise and the magnitude of pressor response induced by exercise did not differ significantly between static and dynamic exercises at the two work loads. The magnitude of pressor response tended to depend on work load. These findings were the same in both age groups. Consequently, it was indicated that blood pressure responses to static and dynamic hand-grip exercise at equivalent work load and TTI did not differ both in young and elderly people. Furthermore, it was suggested that central command and muscle metabolite induced stimulation of the exercise pressor reflex during static and dynamic exercise were similar based on the results of relative perceived exertion and blood pressure response during post-exercise arterial occlusion.

A Case of Aortic Valve Replacement Complicated by Autoimmune Hemolytic Anemia / 日本心臓血管外科学会雑誌

A 72-year-old woman, who had been treated for autoimmune hemolytic anemia with prednisolone and azathioprine since 2002, was found to have mild aortic stenosis in 1994. In December 2003, she suffered congestive heart failure, and was on temporary mechanical ventilation. In February 2004, the maximum pressure gradient between left ventricle and aorta increased to 115.8mmHg on echocardiographic examination. On April 6, aortic valve replacement was carried out with a 19mm bioprosthesis (Carpentier-Edwards PERIMOUNT^®, Edwards Lifesciences, Irvine, California). Preoperative prednisolone administration was continued until the day of the operation. Four packs of washed red blood cells were transfused intraoperatively and four packs of red blood cells were transfused postoperatively. Before transfusion, haptoglobin and water-soluble prednisolone were administrated to prevent hemolysis. Oral prednisolone and azathioprine were reestablished on the third postoperative day. Her postoperative course was uneventful and she did not suffer either infection or hemolysis. She was discharged on the 30th postoperative day.

Recovery of respiratory cardiac cycle variability after strenuous exercise / 体力科学

A study was conducted to examine the recovery of vagal activity after strenuous exercise based on changes in the magnitude of respiratory cardiac cycle variability, changes in the phase of this variability and the mechanism of the change. Six healthy male university students were studied for 5 h after exhaustive treadmill running. For cardiac cycle (RR) and blood pressure, the magnitude of respiratory variability and phase difference between respira-tory variability and respiration were measured. Respiratory period and tidal volume were maintained at 6 s and 21, respectively.<BR>1. The amplitude of respiratory RR variability decreased markedly after exercise and returned almost to normal after 2 h of recrvery. The phase of RR delayed with exercise, proceeded rapidly 2 h after exercise and progressively after that.<BR>2. The amplitude and phase of respiratory systolic blood pressure variability were almost stable before and after exercise.<BR>Based on these results, we conclude that vagal activity inhibited by strenuous exercise recovers about 2 h after the end of exercise. The delay in the phase of respiratory cardiac cycle variability with exercise may reflect inhibition of vagal activity.

Relationship between respiratory period and respiratory cardiac cycle variability. The influence of respiratory blood pressure variability / 体力科学

This study was undertaken to clarify the influence of respiratory blood pressure variability upon the relationship between respiratory period and respiratory cardiac cycle variability. In 4 healthy male university students respiratory period was varied over the range of 6-20 sec while tidal volume was maintained constant (21) and in 5 other male students tidal volume was varied over the range of 1.0-2.5<I>l</I> while respiratory period was maintained constant (6 sec) . For cardiac cycle (RR) and systolic and diastolic blood pressure (SBP and DBP), amplitude of respiratory variability and phase difference between respiratory variability and respiration were measured.<BR>1. Patterns of change of amplitude of RR and of SBP were similar when respiratory period was changed.<BR>2. When respiratory period was short (6sec), RR was nearly in phase with SBP. However, as respiratory period increased, the phases of RR and SBP had a tendency to proceed, with the tendency being more pronounced in the latter. Thus, when respiratory period was prolonged (20 sec), SBP led RR.<BR>3. Phase relationship between respiratory SBP variability and respiration did not change when tidal volume was changed.<BR>4. Respiratory DBP variability became more marked as respiratory period increased, and showed more marked phase shift than did respiratory SBP variability. Therefore, of those parameters DBP occurred earlier.<BR>Based on these results, it is concluded that respiratory RR variability is closely related to respiratory SBP variability when respiratory period is changed, but that the phase difference between RR and SBP reflects the effect of pulmonary stretch reflex which is dependent on respiratory period.

Heart rate and plasma catecholamines responses to exercise at various intensities / 体力科学

To investigate the responses of heart rate and plasma catecholamines to exercise at various intensities, seven healthy adult males performed 6-min bouts of cycling exercise at 30, 50, 70 and 90% of maximal oxygen consumption (VO<SUB>2</SUB>max) . Heart rate (HR), plasma noradrenaline (NA), plasma adrenaline (A), blood lactate (La) and coefficient of variation of R-R intervals (CVRR) were determined i n each case.<BR>The following results were obtained:<BR>1) CVRR showed a sharp decline to the extent of 50%VO<SUB>2</SUB>max, then fell more slightly for heavier exercise.<BR>2) NA and A significantly increased from resting value at 50%VO<SUB>2</SUB>max, and followed by further increase with exercise intensity. NA/A increasd in proportion to exercise intensity.<BR>3) The results of multiple regression analysis of HR (dependent variable) and NA, A and CVRR (independent variables) indicated the greatest standardized partial regression coefficient for CVRR in the case of low intensity exercise, and for NA with high intensity exercise.<BR>4) La increased abruptly at 70%VO<SUB>2</SUB>max, whereas NA and A rose drastically at 90%VO<SUB>2</SUB>max.<BR>The conclusion based on these results is as follows: HR is mainly influenced by change in parasympathetic tone to the extent of 50%VO<SUB>2</SUB>max, whereas sympathetic and adrenomedullary activity are the main factors controlling HR in heavier exercise. Within the submaximal level of exercise, sympathetic activity increases more markedly than that of adrenomedullary activity. Abrupt increase in La may be independent of catecholamines.

Relationship between respiratory period and respiratory arrhythmia / 体力科学

This study was undertaken to clarify the relationship between respiratory period and respiratory arrhythmia. Five healthy male university students voluntarily changed the respiratory period over a range of 3-30 seconds while maintaining tidal volume constant (; 21) . Maximum and minimum cardiac cycles (RRmax and RRmin) and amplitude of cardiac cycle variability (ΔRR), the difference between RRmax and RRmin, were measured from electrocardiogram and respiratory curve.<BR>1. Amplitude of cardiac cycle variability was small for shorter respiratory periods and increased with respiratory period, attaining maximum at respiratory periods of 8-14 seconds followed by decrease at longer respiratory periods.<BR>2. The time from the onset of inspiration to the minimum cardiac cycle was the same for respiratory periods of 8-14 seconds (about 3.6 seconds) .<BR>3. Phase difference between cardiac cycle variability and respiration was determined at each respiratory period. When the minimum or maximum cardiac cycle coincided with the onset of inspiration, this situation being defined as 0°, RRmin was delayed by 180°, 90°, and 0° at respiratory periods of 2.3, 14.4, and 26.5 seconds, respectively and by 360°, 270°, and 180° at respiratory periods of 2.7, 15.0, and 27.3 seconds, respectively.<BR>Based on these results, respiratory arrhythmia is concluded to be quite stable at respiratory periods of 8-14 seconds. At short respiratory periods, tachycardia was found to occur during inspiration and bradycardia during expiration. During long respiratory periods, bradycardia was noted during inspiration and tachycardia during expiration.