[Perioperative myocardial infarction due to graft atheroembolism during coronary artery bypass surgery]

We presented a female patient who had complicated perioperative myocardial infarction resulting from intraoperative embolization with atheromatous debris during coronary artery bypass surgery. On separation from cardiopulmonary bypass, ventricular function was poor and she suffered from severe low cardiac output syndrome postoperatively. The intraoperative electrocardiographic monitoring showed conduction abnormalities, elevation of the ST-T segments and new Q waves. Though it is difficult to diagnosis the onset of perioperative myocardial infarction early, adequate treatment is necessary to preserve ischemic myocardium and to reduce the size of myocardial necrosis.

[Perioperative management for type A acute aortic dissection]

Twenty nine cases of type A acute aortic dissection were subjected to a retrospective study concerning perioperative management. Two keys pointed out for the management were as follow; (1) An optimal control of blood pressure is the most important measure to avoid advance of aortic dissection or rupture of dissecting aneurysm. Both pericardiac tamponade and aortic valve insufficiency should be taken care of from their onset, since they are often complicated after aortic dissections and their onset is fatal. (2) Separated brain perfusion and profound hypothermia with total circulatory arrest might involve a high risk of inducing postoperative brain damage and mortality, especially for old patients.

[Post-operative respiratory management of patients with ventricular septal defect with pulmonary hypertension (VSD+PH)]

Post-operative respiratory management was evaluated in patients with VSD+PH. Comparison was made between Group I (6 patients under 6 months) and Group II (10 patients 6 months or above). Oxygenation after surgical operation in Gp I was poor and the patients needed longer period of mechanical ventilation (MV), while Gp II patients required shorter duration of MV. In Gp I, the duration of MV after the cardiac surgery correlated with the length of cardiopulmonary bypass. In conclusion, cardiopulmonary bypass may influence the post-operative pulmonary function and patients who require longer period of MV are younger infants or newborns whose pulmonary function is immature and PH is severe.

[Clinical observation of hemodynamic changes during anaphylactic reaction]

Four cases of anaphylactic shock are reported. In two patients who underwent A-C bypass operation, we evaluated hemodynamic changes systemically when the anaphylactic reaction occurred. At that time it was observed that arterial pressure, central venus pressure, left atrial pressure and systemic vascular resistance decreased and that cardiac index increased. In other two patients it was not possible to evaluate hemodynamic changes during reaction. But one of these two patients developed coronary spasm accompanied with anaphylactic shock and the other patient who had depressed cardiac function and had developed cardiogenic shock, died of cardiac failure after 47 days. It is suggested that hemodynamic changes in anaphylactic reaction varies depending on different general conditions of the patient.

[Rapidly progressive periodontitis combined with plasma cell gingivitis: a case report]

A case of rapidly progressive periodontitis combined with plasma cell gingivitis with marked enlargement of the gingiva was presented. Clinically, in the plasma cell gingivitis, the gingiva appear red, friable and bleed easily; usually it does not induce loss of attachment. Histologically, a dense infiltration of the normal plasma cells in the connective tissue is a common finding. A hypersensitivity reaction to some antigens, often flavorings or spices, is generally recognized. In this case, a rapidly progressive loss of attachment was observed, so rapidly progressive periodontitis was diagnosed. Differential diagnosis of the plasma cell gingivitis could be determined by histological and ultrastructural examination. Allergens, however, could not be identified. Conventional periodontal therapy, including intensive plaque control, could not cure the plasma cell gingivitis completely but recurrence of gingival enlargement and loss of attachment could be well controlled.

[Conversion to 2nd degree from 1st degree atrioventricular (AV) block by the reversal of neuromuscular blockade]

A case of intraoperative conversion to 2nd degree from 1st degree AV block by the reversal of neuromuscular blockade was reported. A 78 year old male, who originally suffered from 1st degree AV block, underwent choledocholithotomy and T-tube drainage for choledocholithiasis. He was administered 4 mg of pancuronium at the time of intubation. The operation lasted for 160 minutes under epidural anesthesia, NLA and nitrous oxide-oxygen. The patient started spontaneous breathing and the recovery was confirmed after the operation which finished without any problem. Neuromuscular blockade was reversed with atropine 0.5 mg and neostigmine 1.0 mg that were administered simultaneously taking 3 minutes. Then he was extubated without any troublesome stimulation. Suddenly, however, he suffered from the worse condition of bradycardia with the 2nd degree AV block. It took about 45 minutes until he recovered to the original 1st degree AV block despite atropine treatment. We believe that this accident was induced by a vasovagal reflex which was triggered by extubation under the effect of neostigmine which acts longer than that of atropine. We should be careful in reversing the effect of the non-depolarizing neuromuscular blockade. A short acting neuromuscular blockade, i.e. vecuronium, is preferable so as to avoid neostigmine reversal, and extubation should be performed when the effect of neuromuscular blockade is confirmed to be exhausted.

[Perioperative hemodynamic changes and management of hemodialysed patients]

Perioperative hemodynamic changes of hemodialysed patients were investigated and the changes of emergency cases (group E, n = 8) were compared with those of scheduled ones (group S, n = 13). By preoperative hemodialysis (HD), the values of blood urea nitrogen, serum creatinine, serum potassium, serum bicarbonate, and hematocrit were adjusted within normal range in group E, with no significant difference from those of group S. On the other hand, concerning the effect of preoperative removal of body water by HD, cardio-thoracic ratio (CTR, 53.6 +/- 3.1%) and pulmonary artery diastolic pressure (PADP, 11.6 +/- 5.0 mmHg) of group E were significantly higher than those of group S (CTR = 46.9 +/- 4.5%, PADP = 7.8 +/- 3.0 mmHg), indicating that the removal of body water by preoperative HD might be less in group E. However, group E patients required more administration of fluid and pressor agents in order to maintain their blood pressure and/or cardiac output during operation. Although with less water removal preoperatively and more fluid intraoperatively, postoperative PADP was significantly reduced (8.3 +/- 3.0 mmHg) in group E, suggesting that the requirement of perioperative water is more in group E. We conclude that the safe perioperative hemodynamic management for emergency surgery of hemodialysed patients requires following points; (1) The excessive removal of body water by preoperative HD should be avoided. (2) Intraoperative fluid infusion should be adequate so that they do not fall into hemodynamic collapse.

[Intraoperative coronary artery spasm--retrospective review of 10 cases]

Ten cases of intraoperative coronary artery spasm were reviewed retrospectively. Four cases were open heart surgeries, one was a surgery for aortic dissecting aneurysm, and the other five were abdominal ones. In the cases of open heart surgery under anesthesia with high dose fentanyl, coronary artery spasm occurred at weaning period from cardio-pulmonary bypass. In the cases of abdominal surgery, all under neuroleptanesthesia with continuous epidural block, coronary artery spasm occurred within one hour after the beginning or before the end of operation. In four of five abdominal surgeries, systolic blood pressure became less than 90 mmHg when coronary artery spasm occurred. Coronary artery spasm brought severe depression of myocardial contractility and life threatening arrhythmias by which weaning from cardiopulmonary bypass became difficult during open heart surgery. There was a case which required several hours before hemodynamics became stable also in abdominal surgery. It was suggested that general anesthesia with continuous epidural block could be a triggering factor of coronary artery spasm when hypotension and insufficient depth of general anesthesia are present simultaneously.

[Anesthesia for patients receiving hemodialysis--a report of 122 cases]

A hundred and twenty-two cases of anesthesia for patients receiving hemo-dialysis were reported and peri-operative management of them was analyzed, retrospectively. For the past ten years, most of the patients were anesthetized with neurolept-anesthesia and post-operative mechanical ventilation was continued until the patients regained stable hemodynamics and complete awareness. The procedures of pre-operative hemo-dialysis and intraoperative management were almost compatible with previous reports. In the cases of emergency operation, pre-operative control was not enough and intra-operative water intake was larger than that of scheduled cases. The detailed analysis of peri-operative management of water which affects the pathophysiological state of each patient will be the problem in future.

[Intraoperative management of emergency coronary artery bypass grafting]

Intraoperative hemodynamics during emergency coronary artery bypass grafting (CABG) for acute evolving myocardial infarction (26 cases) were measured and compared with those during elective CABG (39 cases). Before cardiopulmonary bypass period, it was strongly suggested that the cardiac function of emergency cases was worse than that of elective cases because of the following 5 factors; (1) hypotension, (2) tachycardia, (3) low stroke volume index, (4) pulmonary congestion and (5) metabolic acidosis. Proper usage of inotropic supports, vasodilators, anesthetic agents, and control of acidosis and hypoxemia seemed to be more important in emergency CABG. These prudent intraoperative hemodynamic managements have played important roles in the progress of the operative outcome of emergency CABG.

[Anesthesia in patients undergoing valvular replacement and coronary artery bypass grafting]

We investigated the intraoperative hemodynamic changes in patients who underwent combined valvular replacement (VR) and coronary artery bypass grafting (CABG). The data of 8 patients who under went VR + CABG were compared with those of 50 patients who underwent VR during the same period (1986). Heart rate before the institution of cardiopulmonary bypass (CPB) was not different between these two group, but blood pressure of VR + CABG cases was significantly higher than that of VR cases. This required a higher dosage of fentanyl in VR + CABG cases.

Diversity of IgG antibody responses in the patients with various types of periodontitis

Serum IgG antibodies to seven periodontopathic bacteria were assessed with an enzyme-linked immunosorbent assay (ELISA) in 56 patients with periodontitis. Patients were selected according to the severity of bone loss, and were also classified into three categories by age: juvenile periodontitis (JP), advanced destructive periodontitis (ADP), and adult periodontitis (AP). Bacteroides gingivalis, B. loescheii, Fusobacterium nucleatum, Actinobacillus actinomycetemcomitans, Eikenella corrodens, B. intermedius, and Capnocytophaga ochracea were the bacterial strains of interest. Antigens were prepared by cold ultrasonication of washed bacterial cells. Association of high- or low-IgG antibody titer to the bacteria was evaluated. High or low titers of IgG were based on ELISA measurements in 28 healthy subjects. Values exceeding 100% above or below the normal standard deviation were classified as high or low titers, respectively.

Most patients with three types of periodontitis (76.8%) exhibited high-IgG antibody titers against various periodontopathic bacteria. The sera mostly included high-IgG titer against one or some of B. gingivalis, E. corrodens, F. nucleatum, and/or A. actinomycetemcomitans. B. gingivalis was predominantly associated with three categories of periodontitis (60.7%). However, high-IgG antibody titer against B. gingivalis alone was found in relatively low percentage (21.4%). Most of the cases were associated with one or more of the other periodontopathic bacteria. High-IgG titer against A. actinomycetemcomitans was found in a few patients (12.5%), who showed severe and more rapid bone loss. Nine patients (16.1%) showed lower IgG antibody titer than did the healthy control subjects. Of the nine, three patients who belonged to the JP category showed the chemotaxis dysfunction of their PMNs. Some immunodepression was suspected in these patients.

Antiepileptic effects of globulin-N, an intact human immunoglobulin and its tissue-distribution in kindled cats

The antiepileptic effects of globulin-N, an intact human immunoglobulin was examined, using the amygdaloid kindled animals prepared by the method of Goddard et al. [1969] and Wada et al. [1974 b]. In the non-treated kindled cats, kindled convulsion and after-discharge (AD) were simultaneously created at 24-hour intervals by electrically stimulating generalized seizure-triggering threshold (GST) in amygdala, hippocampus and neocortex. The kindled cats, treated intravenously with 200 mg/kg of globulin-N, the generalized convulsion and AD produced by GST-stimulation disappeared entirely from 30 min to 8 days in 8 out of 10 cases. Furthermore, kindled cats treated with phenobarbital and phenytoin showed inhibition of GC and AD by GST-stimulation for 24-48 hours. Globulin-N was determined to have a plasma half-life of about 10 days in the kindled cats, and was presented immunohistochemically in the visceral organ, brain and spinal cord. The administered globulin-N passed through the BBB easily in the kindled cats with GST stimulation induced epileptic seizures, and was apparently taken up by the nerve and glial cells in the cerebral cortex and other deep structures of the central nervous system. These results may not only yield clues for the elucidation of the antiepileptic mechanisms of globulin-N, but may also support the clinical use of globulin-N in patients with intractable epilepsy [Ariizumi et al. 1982], including epileptic psychosis.

[Antiepileptic effects of globulin-N as an intact human immunoglobulin and its tissue-distribution in kindled cats]

The antiepileptic effects of Globulin-N as an intact human immunoglobulin were examined using the amygdaloid kindled animals, which was prepared by the method of Goddard et al (1969) and Wada et al (1974). In the non-treated kindled cats, generalized convulsion (GC) and after-discharge (AD) in amygdala, hippocampus and neocortex was caused synchronously by electrical stimulation with generalized seizure-triggering threshold (GST) at constant intervals of 24 hours. By contrast, in kindled cats treated intravenously with 200 mg/kg Globulin-N, the GC and AD due to the GST-stimulation disappeared entirely for the period 4 to 8 days after medication in 8 out of 10 cases. Further, kindled cats treated with anticonvulsant, phenobarbital or phenytoin inhibited GC and AD to GST-stimulation until 24-48 hours after medication. On the other hand, the plasma half-life of Globulin-N was determined as about 10 days in the kindled cats, and Globulin-N was distributed immunohistochemically not only in the visceral organ-tissues but also in the tissues of the brain and spinal cord. The administered Globulin-N or 14C-human immunoglobulin pass through the blood-brain barrier easily in kindled cats with GST induced-epileptic seizure, and was apparently taken up by the nerve cells and glial cells in the cerebral cortex and other extensive deep structure involved in the central nervous system. These results seem to support the clinical usefulness of Globulin-N in patients with epilepsy (Ariizumi et al, 1982) and also epileptic psychosis.