[Successful Resuscitation Using Percutaneous Cardiopulmonary Support in a Woman with Acute Heart Failure during a Thyroid Storm].

Thyroid storm is a rare, life-threatening condition characterized by severe manifestations of thyrotoxico- sis. Acute heart failure is one of the well-known com- plications of thyrotoxicosis. Thyrotoxicosis-induced heart failure sometimes causes circulatory collapse with high mortality. A 43-year-old woman had palpitations and exertional dyspnea without medical history. She developed con- gestive heart failure, due to tachycardiac atrial fibrilla- tion with no acute ischemic changes. High serum level of FT3 and FT4, and low level of TSH were shown in thyroid function tests, and thyromegaly in carotid ultrasound test She was admitted to the intensive care unit for acute heart failure caused by thyroid storm. Two days after admission, cardiopulmonary resuscitation and endotracheal intubation were necessary due to sudden cardiac arrest Transthoracic echocardiogram showed normal cardiac function after successful resuscitation. Five days after admission, her condition deteriorated with severe cardiac dysfunction, and she received PCPS (percutaneous cardiopulmonary support) for cardiovascular collapse resulting in persistent tachy- cardiac atrial fibrillation. Ten days after initiation of PCPS, the patient's cardiovascular function improved with estimated left ventricular ejection fraction of 50 percent and she was weaned off PCPS. In the case of acute heart failure with untreated hyperthyroid and refractory atrial fibrillation, careful hemodynamic management is required to avoid cardio- vascular collapse.

[Anesthetic management of a patient with severe subcutaneous and mediastinal emphysema due to pertussis infection].

A 20-month-old girl, with respiratory failure due to severe subcutaneous and mediastinal emphysema, was scheduled to undergo percutaneous drainage of emphysema and induction of extracorporeal membrane oxygenation. Paroxysm, a symptom of the infection of Bordetella pertussis, was the cause of emphysema. In patients with severe neck subcutaneous emphysema, management of difficult airway is the most important safety issue in the practice of anesthesia. Following the American Society of Anesthesiologist (ASA) guidelines for management of difficult airway, we prepared various types of equipment to facilitate intubation and surgeons were beside the patient during induction of anesthesia for emergency invasive airway access. To prevent the progression of emphysema, preservation of spontaneous breathing during the perioperative period was also important. Combined with propofol and midazolam, pethidine was an effective agent for safe anesthetic induction because it produces less respiratory depression compared to other opiate analgesics. In conclusion, this case demonstrates the importance of prediction of and preparation for difficult airway. Furthermore, anesthesiologists should consider the optimization of anesthesia to avoid progression of emphysema.

[Anesthetic management of a patient with moyamoya disease undergoing mitral valve repair].

Moyamoya disease is the result of progressive steno-occlusive changes in the internal carotid arteries followed by formation of bilateral abnormal vascular networks. The disease may present with cerebral ischemia causing cerebral hemorrhage in the perioperative period. There are few reports of cardiac surgeries in patients with moyamoya disease, and the management during cardiopulmonary bypass for moyamoya disease has not been established. We gave general anesthesia for mitral valve plasty in patient with the moyamoya disease. A 52-year-old woman underwent mitral valve plasty. She had been diagnosed with moyamoya disease and during the cardiopulmonary bypass, we used alpha-stat blood gas management with mild hypothermia, and maintained PaCO2 around 40 mmHg. We maintained the perfusion flow of CPB above 3.0 l x min(-1) x m(-2) and the mean perfusion pressure above 70 mmHg. In addition, we used the pulsatile perfusion assist with intraaortic balloon pumping to maintain cerebral circulation. Postoperative course was uneventful without apparent neurologic deficit, and she was discharged from hospital on 10th postoperative day.

Aromatase inactivation by 2-substituted derivatives of the suicide substrate androsta-1,4-diene-3,17-dione.

To gain the structure-activity relationship of Delta(1)-androstenediones (Delta(1)-ADs) as mechanism-based inactivator of aromatase, series of 2-alkyl- and 2-alkoxy-substituted Delta(1)-ADs (6 and 9) as well as 2-bromo-Delta(1)-AD (14) were synthesized and tested. All of the inhibitors examined blocked aromatase in human placental microsomes in a competitive manner. In a series of 2-alkyl-Delta(1)-ADs (6), n-hexyl compound 6f was the most powerful inhibitor with an apparent K(i) value of 31 nM. The inhibitory activities of 2-alkoxy steroids 9 decreased in relation to length of the alkyl chain up to n-hexyloxy group (K(i): 95 nM for methoxy 9a). All of the alkyl steroids 6 along with the alkoxy steroid 9, except for the ethyl and n-propyl compounds 6b and 6c, caused a time-dependent inactivation of aromatase. The inactivation rates (k(inact): 0.020-0.084 min(-1)) were comparable to that of the parent compound Delta(1)-AD. The inactivation was prevented by the substrate AD, and no significant effect of l-cysteine on the inactivation was observed in each case. The results indicate that the 2-hexyl compound 6f act as the most powerful mechanism-based inactivator of aromatase among Delta(1)-AD analogs and may be submitted to the preclinical study in estrogen-dependent breast cancer.