Tsuyoshi Fujita

Aortocoronary bypass grafting in a child with coronary artery obstruction due to mucocutaneous lymphnode syndrome: report of a case.

A four-year-old boy with a myocardial infarct and total occlusion of the right coronary and the left anterior descending coronary arteries due to mucocoutaneous lymphnode syndrome (MCLS). confirmed by selective coronary arteriography, underwent successful double aortocoronary bypass grafting. Patency of the grafts was demonstrated by graft angiography and the improvement of the contractile pattern of the left ventricle was reflected by the increase in ejection fraction from 0.45 to 0.61. This is the first patient successfully treated by aortocoronary bypass grafting for coronary artery obstructive lesions due to MCLS. This experience has demonstrated the feasibility of surgical management in a child with coronary artery obstruction due to MCLS. However, there are unanswered questions regarding the fate of the saphenous vein graft in relation to the growth of a child. Long-term clinical and angiographic follow-ups are mandatory to determine the significance of this mode of surgical treatment for the sequela of MCLS.

Left ventricular function in patients with coronary arteritis due to acute febrile mucocutaneous lymph node syndrome or related diseases

Abstract Reports of a mucocutaneous lymph node syndrome that frequently affects the coronary arteries have been increasing in Japan and other countries including the United States. Twelve patients with a documented history of mucocutaneous lymph node syndrome or a related coronary arteritis were studied with right and left heart catheterization, cardiac output measurements, left cineventriculography and selective coronary arteriography. These patients were separated into two groups on the basis of coronary arteriographic findings. Group 1 comprised six patients with normal coronary arteriograms; group 2 included the remaining six patients with coronary arterial aneurysm or occlusion. Left ventricular function differed in the two groups. It remained essentially normal in group 1 whereas decreased ejection fraction, increased end-diastolic volume, elevated end-diastolic pressure or mitral regurgitation were evident in four of the six patients in group 2. Two ventriculographic abnormalities were identified: (1) regional contraction abnormality secondary to myocardial infarction, and (2) generalized hypokinesia without electrocardiographic evidence of infarction, probably caused by myocarditis resulting from arteritis. Two patients with severe coronary arterial obstruction and myocardial infarction underwent successful aortocoronary bypass grafting. Postoperatively both had patency of all grafts and one had improved left ventricular function. These experiences have first shown the feasibility and significance of surgical management for selected patients with coronary arterial lesions due to coronary arteritis caused by the mucocutaneous lymph node syndrome or related diseases.

Ventricular Septal Defect Associated with Aortic Insufficiency Anatomic Classification and Method of Operation

Thirty-five consecutive patients with ventricular septal defect (VSD) associated with aortic insufficiency (AI) who underwent corrective surgery are presented. There were seven operative and three late deaths among the patients operated upon before 1968. No death, however, was encountered among the most recent 18 consecutive patients. The VSD was closed directly in 14 patients and with a Teflon patch in 21. The aortic valve was repaired in 16 patients, replaced in eight, and no interference was indicated in 11.They were classified from the surgical viewpoint according to the location of the VSD, the anatomic type of the right ventricular outflow tract, and the severity of the aortic herniation as follows: type Ia, supracristal VSD and AI without aortic cusp herniation; type lb, supracristal VSD and AI with aortic cusp herniation and conal muscular rim beneath the pulmonic valve; type Ic, supracristal VSD and AI with aortic cusp herniation without conal muscular rim beneath the pulmonic valve; type IIa, infracristal VSD and AI without aortic cusp herniation; type IIb, infracristal VSD and AI with aortic cusp herniation; type III, infracristal VSD and AI with infundibular pulmonic stenosis (PS); type IV, supracristal VSD and AI with infundibular PS.In type Ia and IIa, VSD was closed directly and the aortic valve was replaced. In most of type Ib, VSD was closed directly and no direct procedure was performed upon the aortic valve. In most of type Ic, VSD was closed with a Teflon patch and the aortic valve was repaired. In type IIb, VSD was closed with a Teflon patch and the procedure upon the aortic valve was not uniform. In type III, VSD was closed with a Teflon patch and the aortic valve was repaired in most of them. In type IV, VSD was closed with a Teflon patch and no direct procedure was performed upon the aortic valve.The basic policy for repair of this association of anomalies is selected according to the above mentioned anatomic classification.

Anticoagulation with a synthetic thrombin inhibitor after cardiovascular surgery and for treatment of disseminated intravascular coagulation.

A synthetic thrombin inhibitor, MD-805, was used to anticoagulate 15 patients after cardiovascular surgery (CVS). A mean infusion rate of 0.71 ± 0.1 (SD) μg/kg.min maintained an activated coagulation time of about 150 sec in all patients, and significantly prolonged both activated partial thromboplastin time and prothrombin time. MD-805 was also administered to ten patients with disseminated intravascular coagulation (DIC), eight of whom had not responded to either heparin or gabexate mesilate (FOY), and eight of whom had circulating antithrombin III levels below 20 mg/dl. MD-805 therapy was successful in nine DIC patients. These results recommend MD-805 anticoagulant therapy after CVS and for treatment of DIC, especially when circulating levels of antithrombin III are low.

Echocardiographic study of abnormal position and motion of the posterobasal wall of the left ventricle in cases of giant left atrium

In 35 of 70 patients with rheumatic mitral valve disease, two dimensional echocardiography revealed the posterobasal wall of the left ventricle to be entrapped between the left ventricular and atrial cavities and bent inward. The motion of the bending segment was paradoxical. This abnormality was assumed to be induced by the left atrial dilatation extending inferiorly behind the left ventricle, because the length of the bending segment correlation with the left atrial dimension. There was no correlation between the degree of abnormal bending and left atrial pressure, mitral valve pressure gradient or left ventricular dimension. The systolic excursion of the posterobasal wall of the left ventricle was reduced according to the length of the bending segment. This abnormal feature was also observed in five postmortem heart specimens with an extremely dilated left atrium. The macroscopic and microscopic findings in the myocardium of the bending segment were not different from those of the remaining segment of the left ventricle. Therefore, the asynergic motion of the bending segment is assumed to be caused by the abnormal spatial orientation of the left ventricle and the left atrium. It should be considered that the giant left atrium not only oppresses the surrounding organs but also affects the left ventricle.

Mitral cleft in ostium primum atrial septal defect assessed by cross-sectional echocardiography.

We attempted to detect mitral deformities in ostium primum atrial septal defect using realtime cross-sectional echocardiography. Transverse sections of the anterior mitral leaflet echo were examined in 11 patients with this malformation who subsequently received surgical treatment. The section for observing the transverse view of the anterior leaflet was along the sagittal plane of the body, because of the deformity of the mitral annulus. Each echocardiographic finding was compared with the surgical and angiographic findings. On the echocardiogram, the superior and inferior parts of the anterior mitral leaflet separated into two parts during diastole in all patients with mitral cleft. Thin linear echoes connected the ridges of the cleft and the ventricular septum in seven patients in whom the accessory chordae at that area were revealed at surgery. The systolic configuration of the anterior leaflet echo varied among the patients. The severity of the mitral regurgitation seemed to relate not only to the size of the cleft but also to the systolic configuration of the anterior mitral leaflet. After surgery, diastolic separation of the anterior leaflet echo was no longer observed. However, the abnormal systolic configuration of the anterior leaflet was unchanged.

Multiple Organ Failure in Low Cardiac Output Syndrome After Cardiac Surgery

Major advances in the care of critically ill patients have resulted in fewer deaths. However, multiple organ failure (MOF) remains a principal cause of fatality. Low cardiac output syndrome after cardiac surgery (LOS) is defined as the imbalance of oxygen demand and supply in tissues as the result of impaired cardiac function [1]. Insufficient oxygen delivery due to LOS produces MOF [2]. Here, we present an analysis of MOF in LOS patients after open heart surgery as well as continous measuring of mixed venous oxygen saturation (SV02) for estimating oxygen metabolism in LOS upon MOF.

Performance and shortcomings of typical environmental pollution control programs for automobile traffic in Kobe city and surrounding areas. Social cost evaluation of noise pollution by hedonic price method

This paper evaluates the environmental cost due to automobile traffic pollution in the Kobe Region, Japan. The empirical analysis was carried out, using the hedonic price method, on the ambient noise, land prices, and other data in the Route 43 roadside areas of two municipalities, where the environmental deterioration problem is most serious. Regression analysis consists of two steps. The first step is to establish a noise level estimation model, while, on the second step, the land price data are regressed by several explanatory variables including noise levels data obtained by the noise estimation model. The results show significant and expected impact of the Route 43 oriented noise on the property value.

Clinical considerations of life-saving effect of left ventricular assist device

Our left ventricular assist device (LVAD), containing an automatic level control of total systemic flow and left atrial pressure, was clinically applied in 16 patients (aged 3–73 years) with cardiogenic shock following acute myocardial infarction (AMI; nine cases) and cardiac surgery (seven cases). The entire circulation was well maintained at the normal level and the LVAD was successfully removed in nine patients (56%). Three patients (19%) could be discharged with a satisfactory condition. Removal of left ventricular overload with the use of the LVAD prevented overextension of the impaired myocardium, and the gradual increase in left ventricular work promoted the compensatory ability of the residual myocardium. This recovery mechanism was established in chronic animal experiments using goats. However, the clinical problem with the treatment was the preexisting myocardial damage, such as fibrosis caused by rheumatic myocarditis and ischemia in the residual myocardium. In addition, although the natural heart recover, several patients died of multiple organ failure, which had developed during the prolonged low perfusion period prior to left ventricular assistance. In conclusion, the timely use of LVAD proved to be effective in treatment of cardiogenic shock, but preexisting myocardial damage and delayed application will considerably decrease the chance of a favorable recovery in clinical cases.

Rapid emergency testing using blood plasma

A method of blood analysis, using plasma instead of serum, is very valuable in shortening the time for reporting an emergency test by about 50-60%, by eliminating the serum separation step. Good correlation between plasma and serum was obtained for common chemical analyses.