PDA is easily diagnosed clinically when a continuous murmuris heard in normally grown up children and adults on the routine physical examination.
We have experienced 12 cases of PDA in 7 years from 1960 to 1957, and these 10 cases were received surgery. They were 9 females and 3 males and their age ranged from 5 to 57 years old.
One case died from the postoperative bleeding due to coagulation defect. 3 cases were complicated with the other congenital cardiac anomalies; in 2 cases VSD was found and in other one case PS, PAPVR and pulmonary A-V fistula.
One case was asymptomatic with a small left-to-right shunt. Seven cases without any other heart anomalies had abnormal pulse pressurs of more than 50mmHg.
The most significant general finding is a harsh machinery continuous murmur, which is heard maximally in the second left intercostal space. Thi murmur was heard in 8 cases, except 3 cases who were complicated with the other congenital cardiac anomalies. On the other hand, an atypical murmur was heard in 4 cases, in 2 cases of whom a only basal systolic murmur was heard.
Electrocardiogram showed left ventricular hypertrophy in 5 cases. On roentgenographic examination, the findings in heart and lungs were normal in one-fouth of our cases. But the pulmonary artery was prominent in 7 cases and pulmonary vascular markings were increased in 3 cases. Left ventricular enlargment was present in 5 cases without other heart anomalies. Angiocaridography was performed in 5 cases, and only in 3 cases we could recognize “blanching sign” on the main pulmonary artery. Cardiac catheterization was performed in 8 cases, 6 of whom showed pulmonary hypertension and 7 had the higher oxygen contained blood in the pulmonary artery than in the right ventricle, from which we could find the presence of PDA.

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The author reports clinical evaluation of cardiovascular surgery using plethysmography. The plethysmogram were taken on 126 normal person and 205 cases of cardiovascular disease. The pattern were analysed in I, II & III type.
The most cases of normal person and congenital cardiac disease were located in type I Acquired cardiac disease, however, especially mitral insufficiency were demonstrated as type II. The arterio-venous fistula reveaied different pattern. These patterns were suggestive for considerable significance on clinical evaluation of cardiovascular surgery.

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In order to investigate on the factors which affect the immediate and long term prognosis, mortality rate or survival rate of the myocardial infarction were examined. The material consisted of 109 cases for the initial stage observations and 310 cases for the long term follow-up analysis. The ratio of male to female was 83:17 in the initial stage series, and 86:14 in the long term series.
Results:
1) Age. The higher the age, the worse the immediate progaosis. In the long term follow-up analysis, the survival rate of the patients over fifty years of age were worse than those under forty years of age.
2) Location of infarction, as determined by EKG. The immediate and long term prognosis of the patients with anterior infarction was similar to that with posterior infarction, but the prognosis was poor in the patients with co-existing anterior and posterior wall infarctions.
3) Complication The patients without complication did better than those with complication both in the immediate and long term prognosis. The long term prognosis of the patients with diabetes mellitus was not particularly poor in this series.
4), Anginal pain and congestive failure. The longer the duration of congestive failure, theworse both immediate and long term prognosis.
It was shown, however, that persistence of anginal pain had no correlation with the long term prognosis.
5) Shock. Four of the twelve cases who had shock, died within four weeks. after the first infarction. Accordingly, the immediate prqgnosis of myocardial infarction accompanied with shock seems to be poorer than that with out it.
6) Systolic blood pressure. In the long term, follow-up of the two groups divided by the systolic blood pressure level of 120mmHg, the long term prognosis of patients having the systolic blood pressures always below 120mmHg was worse than those with the presrsures above 120mmHg.
7) So-called “new coronary dilators”. The influence of the administration of the so-called “new coronary dilators” (Dipyridamol, propyl-amin derivatives, Carbochromen etc.), was examined; the mortality, in the administered group was lower than that of the non-administered group.
8) Subsequent infarction. The occurrence of subsequent episode during the initial stage within four weeks. fromthe intial episode was observed in eight cases, and all of them died. The occurrence of second episode after an infarction in the long term basis was observed in 10.3% with in five years, and after that period the percentage did not increase significantly. The survival rate after second infarction was markedly lower than that of an initial infarction during the first year. Accordingly, the occurrence of second infarction is an important factor worsening the progngris. of myocardial infarction.

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Ten cases of pure mitral stenosis were studied by Frapk system VCG and the following results were obtained, QRS maximum vectors were inscribed to right inferiorly in the three cases of ten and left inferiorly in the seven cases of ten.
T maximum vectors were inscribed to left inferiorly in most of the cases as normal.
Efferent half protrusion of QRS loop to the right posterior direction was noted in most of the cases.
The direction of QRS loop inscription was normal in all of the cases and T loop inscription was retrograde to QRS in a few cases.
QRS angle was large in frontal plane, showing right ventricular hypertrophy, in the cases of which pulmonary artery oxygen saturation was under seventy per cent.
Vector loops inscribed the almost normal configuration from one to two months after operation, showing the increase of QRS/T ratio and the decrease of QRS, T angle.

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On thirty-six patients with diabetes electrocardiographic test, retinal examination. blood pressure measurement and estimations of fasting blood sugar, total cholesterol, β lipoprotein and triglyceride were carried out, and mutual relation of the findings was investigated.
The results obtained were summarized as follows:
1) Depressed ST segment and T wave were observed in the majority of the patients underresting condition, and 36.6 percent of the patients were found to be positive in Master's “double two step” test.
It was of clinical significance that Master's test was frequently found to be positive in the patients who showed normal electrocardiographic findings under resting condition, who were young and had a short history of the disease.
There was no relation between electrocardiographic findings and serum lipid levels.
2) Retinal changes were found in 32.1% of the patients. The frequency of retinal changes was observed to run parallel with age and elapse of time suffered from the disease, with levels of fasting blood sugar, total serum cholesterol and serum β-lipoprotein, but not with triglyceride level.
3) The majority of the patients with retinal changes were hypertension. On the other hand, there was no relation between retinal changes and the results of Master's “double two step” test.

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Capillary blood pH, Pco₂ and base excess of patients with congenital heart diseases were compared to those of arterial blood after cardiac cathetrerization under narcosis or during hypotension.
This study has demonstrated the following conclusion:
In patients without peripheral circulatory insufficiency pH, Pco₂ and base excess of arterialized capillary blood reflectclosely the vaiues of arterial blood even under slight surgical intervention. in patients with peripheral circulatory insufficiency, such as hypotension or shock, remarkable discrepancy of pH and Pco₂ values was found between capillary and arterial blood, but only values of base excess were almost the same in blood from two sources.

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Under mild hypothermia of 30°-32°in rectal temperature with the use of surface cooling method, intracardiac operation under direct vision was carried out with the extracorboreal circulation in 23 cases of noncyanotic congenital heart disease. In these cases, acide base balance in blood was measured by Astrup method before and after the extracorporeal circulation and at the end of cardiac operation. As the result, pH was decreased to below 7.30 in the most cases immediately before perfusion. BE value was also decreased to 5 -10mEq/L, while pCo₂ rose in the most cases above 50mmHg, indicating the preseace of uncompensatory respiratory metaboiic acidosis already immediately before perfusion. No further progress of acidosis was noted immediately after perfusion and at the end of operation. BE value did not require correction in acid base balance except for 2 cases. At the end of operation, arterial blood pH, pCo₂, and BE values were found to be on the way of returning to the physiological range. No unfavorable influence was noted on the prognosis of operation.

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Fifteen cases with the congenital heart disease were operated upon utilizing the heart-lung machine during one year period from August 1966 at the division of Thoracic and CardiovaScular Surgery, the National Childre's Hospital.
ACD stored blood was used as a prime in addition to heparin, five or seven per cent sodium bicarbonate and ten per cent calcium dichloride solutions.
The determimtion of acid-base balance, serum or plasma electrolyte concentrations, serum or plasma total protein, plasma hemoglobin and hematocrit in the arterial blood was done before, during and after the cardiopulmonary bypass.
Insignificant deviation of the above mentioned determinants from the control values suggested that ACD stored blood could be used safely as a substitute of freshly drawn heparinized blood.

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The number of intracardiac surgery during the period from Feb. 1963 to the end of 1967 at Chiba National Hospital is 107. Operative deaths in this period were8 or 7.5%. There was only one death among 47 cases operated with our low-priming-volume technique since March, 1967.
The majority of the patients were congenital with the high incidence of VSD and ASD. Our series comprise 2 cases successfully replaced with Kay-Shiley disc valve under the perfusion of more than 2 hours.
Our perfusion technique has been converted from the conventional disc-type oxygenator with a large priming volume to the compact disc with a miniimum priming or the disposable sheet oxygenator. The compact disc oxygenator, operable with as small priming volume as the disposable sheet, is relatively free from the defects inevitable in the bubble-type oxygenator.
The authors found the irrationability of the large priming volume technique from the view-point of the postoperative liver function. In addition, the definite advantage of the small priming technique was confirmed in the relation between the hemolysis, hemorrhage or urine-out-put and the ratio of the circulating blood volume per se to the primed blood volume.
Changes in the blood fraction distribution during the perfusion were determined with the RISA in dogs and men. This study gave us a conclusion that the disc oxygenator primed with Haemaccel was best in our experience.
Our recent study revealed that intravenous injection of the oxygen-bubbled canine blood induced hypotension, and most probably the homologous plasma should becriminal for this phenomenon.
These fundamental studies strongly suggest the rationale of our low-priming technique, and the authors will continue these study.
Our routine technique in the extracorpreal circulation is also summarized in this paper.

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Electrocardiographic studies were made on the 31 cases of atrial septal defects before and after the cardiac surgery.
Various types of extrasystoles and abnormal cardiac rhythms appeared immediately after surgery, but these disappeared as the patients improved.
Post-operatively, the electrical axis altered towards the normal range in the majority of cases, but the electrical position of the heart did not change significantly.
The amplitude of P waves in lead II decreased after surgery. In the immediate post-operative periods atrio-ventricular blocks occurred in a certain number of cases, but these disappeared in a week or two, except for one case of complete block, which did not improve at all. P-Q intervals were shortened post-operatively.
In many cases, the amplitude of R in V₁ decreased, R in V₆ increased and S in V₆ decreased after sugery. Therefore, QRS configurations in the chest leads altered significantly towards the normal.
ST segments were either elevated or depressed, and T waves were inverted immediately after surgery. The altered ST segmepts returned to the normal level in a week or two, but the inverted T waves persisted for several months after surgery in many cases.

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The cases operated for heart disease during the period from Sept. 1962 to July 1967 at Chiba National Hospital were 148, in which anesthesia 54 received closed-technique and 94 had open-method.
The anesthesia in cardiac surgery is specific in many respects. This should be attributed to the abnormal hemodynamics inherent in the disease, i. e., the sludging phenomena, homologous blood syndrome and post perfusion low cardiac out-put syndrome, provoked by the use of unphysiologic pump-oxygenator, as well as the hypothermia.
Comparisons were made of the respects as above quoted between the GOE and GOF. The former was superior to the latter in the incidence of arrhythmia upon induction, the influence of muscle relaxants on cardiac rhythm, the anesthetic managememt during perfusion and the necessity of defibrillation, while the latter was better in the postoperative complications of the respiratory system.
The postoperative liver damage was not significantly different between the both groups, but essentially related with the post transfusion hepatitis.
The authors also reported the marked effect of isopropyl-arterenol for the low cardiac out-put immediately after the perfusion.

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Recently, the advanced examination concerning pulmonary physiology has been applied in routine. Blood gas is analized frequently by the IL meter before, during and after operation, and the results were discussed. Patients subjected to this study were with pulmonary tuberonlosis, pulmonary abscess, bronchiectasis and spontaneous pneumothorax and the performed surgical procedures were pulmonary resection, thoracoplasty, extraperiostal plombage, decortication and other thracotomies.
1) It is necessary to prevent PO₂ decrease accompanying with the hypoventilation especially soon after operation by O₂ inhalation using a nasal catheter.
2) The paradoxical respiration is frequently caused by thoracoplasty, in which the recovery of PO₂ delays as compared with the other surgical procedures. In extraperiostal plombage, there is a little influence on the arterial PO₂, PCO₂ and PH. Generally, the arterial PO₂, PCO, ₂ and PH become stable seven days after the chest surgery.
3) The PO₂, PCO₂ and PH in blood sampled from the pulmonary artery and vein under the general anesthesia and controlled respiration suggest that the decrease of pulmonary compliance must be prevented by the occasional lung inflation during operation. Rapid recovery from the anesthesia is necessary to prevent partial atelectasis and collapse of the lung.
4) Prognosis of cardio-pulmonary crisis after chest surgery is improved by the active tracheostomy followed by the O₂ inhalation through the tracheostomy cannuia.

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Clinical findings of 427 patients with atrial fibrillation or flutter (243 males. and 184 females), who were examined at the Nagoya National Hospital during the last five years, were reviewed.
As to the chronicity of atrial fibrillation or flutter, it was chronic in 79.0%, paroxysmal in 7.0%, recurrent in 2.8% and unknown in 11.2%.
The underlying diseases were valvular diseases in 39.0%, hypertension or coronary heart disease in 38.3%, hyperthyroidism in 3.3% and miscellaneous conditions in 8.0%. In 5.2% no substantiated diseases existed.
When the ages were represented by those at the time of initial examination, the highest incidence (108 cases, i. e., 25.3%) was seen in the 7th decade. The incidence of atrial fibrillation associated with valvular diseases was highest in the 4th and 5th decades and that associated with hypertension was highest in the 7th decade.
Atrial flutter was seen in 13 cases, that is, 3% of the whole material. It was paroxysmal in 2 and recurrent in the other 2 out of the 13 cases. In atrial flutter the predominant underlying disease was hypertension. Occurrence of atrial flutter in mitral valvular disease was rather rare.
Further, cases with atrial fibrillation or flutter in which the arrhythmias occurred paroxysmal or recurrent were analysed in some detail with regard to etiology and precipitating factors. In 4 out of the 13 cases of hyperthyroidism the arrhythmias were paroxysmal (fibrillation 3, and flutter 1), being the highest rate of paroxysmal occurrence among other underlying diseases. Also, a paroxysmal atrial fibrillation was observed in 3 cases immediately after mitral commissurotomy (among 41 operations in cases with sinus rhythm) and in 3 cases soon after onset of myocardial infarction. There were 3 cases with a poor general condition in which paroxysmal atrial fibrillation occurred.
As to the direct complications of atrial fibrillation, systemic arterial embolization including that in the brain occurred in 33 cases, and 26 of the 33 were cases of valvular disease. Thus, the incidence of embolism in valvular disease was 15.6% (26 among 166).
There were 48 fatal cases including 26 cases with valvular diseases and 5 cases with hypertension or coronary disease. The immediate cause of death was sudden cardiac death in 12, progressive heart failure in 13, cerebral vascular accident in 7 and malignancy in 9.

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