[Planned combination therapy of coronary artery bypass and PTCA in ischemic heart disease].

Concomitant planned therapy consisting of a coronary artery bypass operation and percutaneous transluminal coronary angioplasty (PTCA) was attempted to shorten the period of cardiac arrest and make operations safer in patients undergoing emergency coronary artery bypass operations or coronary artery bypass operations in cases of significantly reduced left ventricle function or small perfusion lesions. The bypass operation was performed to treat only the main lesion and PTCA was undertaken 1-2 months later for coronary revascularization to treat secondary lesions. Finally, complete coronary revascularization was achieved. This concomitant method was performed on three cases. In all of these cases, two grafts were made and 1-2 lesions were dilated by PTCA. It was suggested that planned concomitant coronary artery bypass operations and PTCA provide a safer method of treatment in certain selected cases.

New side-holed sheath for intraaortic balloon pumping to maintain limb perfusion.

We developed a new side-holed shunt sheath for inserting intraaortic balloon pumps to maintain lower limb perfusion in patients with stenotic and tortuous aortoiliac arteries. This sheath has a large internal diameter and several side holes, which act as an internal shunt. It was useful and effective in 11 patients with severe aortoiliac occlusive lesions who required assistance by intraaortic balloon pumping.

Diagnostic validity of fecal occult blood tests for detecting gastroenterological cancers.

In order to estimate the diagnostic validity of chemical fecal occult blood tests, i.e. orthotolidine (Shionogi A) and guajac (Shionogi B) slides for detecting cancers of the esophagus, stomach and colorectum, the authors followed up all the examinees (n = 3,449) of comprehensive medical check-ups at the Center for Adult Diseases, Osaka, by means of record linkage to the Osaka Cancer Registry's files. Then, diagnostic validity was calculated based on the results of two years' follow-up. Sensitivity for the respective cancers was 20.0%, 11.8% and 62.5% for Shionogi A, and 20.0%, 5.9% and 43.8% for Shionogi B slides. Likelihood ratio for the respective cancers was 1.4, 0.8 and 4.5 for Shionogi A, and 3.3, 1.0 and 7.5 for Shionogi B. Specificity was analogous among the three cancer sites, being 86% for Shionogi A and 94% for Shionogi B. These results suggest that the diagnostic validity of chemical occult blood tests for detecting cancers of the esophagus and the stomach is very poor, and therefore imply that close examinations of these sites for screening positives is unnecessary in mass screenings for colorectal cancer.

[Assessment of left ventricular contractile characteristics following coronary artery bypass grafting].

The present study was designed to assess a left ventricular function, particularly contractile characteristics following coronary artery bypass grafting (CABG). The subject was 29 post-CABG patient consisting of 4 groups; 6 patients with complete revascularization (CR) and no myocardial infarction (MI) (CR.MI(-) group), with CR and MI (CR.MI(+) group), 5 with incomplete revascularization (IR) and no MI (IR.MI(-) group) and 8 with IR and MI (IR.MI(+) group). Ejection fraction (EF), systolic pressure/end-systolic volume index (SP/ESVI) and end-systolic volume index (EDVI) were evaluated utilizing radionuclide angiography at rest and during exercise (Ex). Increase of SP/ESVI and EF and no change of EDVI during Ex were observed in CR.MI(-) group. Increase of SP/ESVI and no change of EF and EDVI in CR.MI(+) group, no change of SP/ESVI, EF and EDVI in IR.MI(-) group and no change of SP/ESVI and EDVI and decrease of EF in IR.MI(+) group were observed. The SP/ESVI and EF of CR.MI(-) group were respectively highest among 4 groups and showed no difference compared with control group during Ex. Ex-induced increase ratio of SP/ESVI had linear correlations with Ex-induced increment of EF (r = 0.81, p less than 0.001) and Ex-induced increase ratio of EFVI (r = 0.54, p less than 0.005). It is concluded that both CR and no MI lead to normalization of EF and SP/ESVI during Ex. Furthermore, in the case of poor contractile reserve, systolic function may deteriorate in spite of increased preload during Ex.

[Biventricular assist support using centrifugal pump in cardiogenic shock following coronary bypass grafting--a case report of long survival].

Biventricular assist support (BVAS) with centrifugal pump was used for the treatment of 48 y/o male patient with cardiogenic shock following coronary bypass surgery. Assist flow was 2 to 4 l/min in LVAS and 2 to 3 l/min in RVAS. RVAS was weaned in the fourth postoperative day and LVAS in the sixth. Cerebral infarction developed in the weaning period of LVAS. Post operative examination revealed good right and left ventricular function. Patient was well and returned to full work in a two years and two months after surgery. BVAS may be useful for the treatment of severe biventricular failure associated with stunned myocardium.

Prediction of contractile reversibility in impaired left ventricular wall motion following coronary artery bypass grafting.

Interventional left vertriculograms (LVGs) using postextrasystolic potentiation (PESP), nitroglycerin (TNG) and a combination of both were analyzed in order to decide the degree of efficacy of each intervention as a predictor of reversibility in impaired left ventricular segments. Segmental wall motion (SWM) in less severely impaired segments increased to the normal range and SWM in severely impaired segments increased but remained in the abnormal range after CABG. The effects of both PESP and TNG on SWM in impaired segments correlated (r = 0.78 and 0.78) with that of CABG. The increase in SWM due to TNG + PESP was significantly (p < 0.01) greater than that due to either PESP or TNG alone or that of CABG. Either PESP or TNG was clinically reliable for prediction of contractile reversibility in the segments with impaired wall motion prior to CABG. Including the global left ventricular function, PESP reflected the efficacy of CABG more sufficiently than TNG. TNG + PESP provoked more contractile reserve and exaggerated the results of CABG, but may predict reversibility in severely reduced wall motion.

[Clinical experience of mechanical ventricular support with centrifugal pump for severe ventricular failure after open heart surgery].

Five adult patients (pts) with age 15-67 (mean 43) received mechanical circulatory support with centrifugal pump (Biomedicus, BP-80, Sarns centrifugal pump) for postcardiotomy profound shock. Three pts underwent left ventricular support (LVS) alone, and the other 2 required biventricular support (BVS). Duration of the LVS ranged from 33 to 240 hours (mean 126 hours) and the right ventricular support 92, 120 hrs. Pump flow rate was 1.1 to 2.5 (mean 1.9) L/min/m2. Sixteen pumps were used and the pump exchange was performed 9 times in five pts and an average perfusion time per pump was 57 hrs. Two of 3 pts with LVS alone survived and one died of multiorgan failure associated with right heart dysfunction. In two pts with BVS, one survived and the other died of persistent low cardiac output early after pump removal. As the complication during mechanical support, bleeding was seen in 3 pts and cerebral infarction in one. Although centrifugal pump has potential limitation in antithrombogenicity and durability, this device provides a simple and effective mechanical circulatory support.

[Evaluation of the effects of coronary artery bypass grafting on left ventricular function in patients with previous myocardial infarction].

The present study was designed to assess a left ventricular function following coronary artery bypass grafting (CABG) in patients with previous myocardial infarction (MI). The subject was consisted of 10 patients with MI (MI(+) group) and 6 without it (MI(-) group). Both groups underwent complete revascularization. Stroke index (SI), ejection fraction (EF), systolic pressure/end-systolic volume index (SP/ESVI) and end-diastolic volume index (EDVI) were evaluated utilizing radionuclide angiography at rest and during exercise (Ex) before and after CABG. The influence of size of myocardial infarction on left ventricular function were also analyzed. Preoperatively during Ex, EF showed decrease, SP/ESVI no change and EDVI increase in both MI(+) and MI(-) group compared with those at rest. Postoperatively during Ex, SI, EF and EDVI showed no change and SP/ESVI increase in both MI(+) and MI(-) group compared with those at rest. Ejection fraction and SP/ESVI during Ex in MI(+) group had significant differences compared with those in both MI(-) group and control group. Ejection fraction and SP/ESVI during Ex in MI(-) showed no difference compared with those in control group. The size of MI suggested by ECG scoring system (proposed by Wagner GS et al, Circulation '82) had negative correlations with both Ex-induced increment of postoperative EF and Ex-induced increase ratio of postoperative SP/ESVI. These data indicated that complete revascularization improved EF and SP/ESVI in patients with MI, and moreover normalized those in patients without MI. But in the case of extensive MI, even complete revascularization might not recover poor functional reserve during Ex.

[A case of aorto-coronary bypass in Jehovah's Witness].

An aorto-coronary bypass grafting was performed in a 50 year-old man, a Jehovah's Witness, suffering from effort angina pectoris. Preoperatively, he was underwent PTCA for LAD occlusion, which failed. Single aorto-coronary bypass grafting using IMA was performed under the extracorporeal circulation primed with Ringer's Lactate and albumin. Moderate hypothermia with core temperature of 31.5 degrees C was used, and minimal level of the hematocrit was 18% during the perfusion. At the start of the operation, 800 ml of blood were withdrawn from the jugular vein to the blood bag which connected to a peripheral venous line uninterruptedly. During the operation, the autologous blood was continuously transfused very slowly and most of the autologous blood was transfused after the termination of extracorporeal circulation. The blood in the extracorporeal circuit was hemoconcentrated with ECUM (extracorporeal ultrafiltration method) from hematocrit level 22% to 35% and transfused. The postoperative course was uneventful. At the time of discharge from hospital on the 42nd postoperative day the hemoglobin level was 13.1 g/dl and hematocrit level was 42%.

[Four operative cases of lung carcinoma with intra-atrial extension via the pulmonary vein].

We experienced four operative cases of lung carcinoma with intra-atrial extension via the pulmonary vein. In two cases, after assessment of the cardiac involvement, we performed extensive surgery under cardiopulmonary bypass. Their postoperative courses were uneventful, and their performance status was improved. However, seven months later one patient died of widespread metastases, while the other is alive but has recurrence. The other two patients underwent ordinary lobectomy because there were no abnormal findings in the hilar examination. However, the lumen of the resected pulmonary vein was filled with tumor tissue. One patient had massive embolism and died on the second postoperative day. The last case had residual tumor dislodging from the left atrium to the aorta. Though he was discharged without any complication, he developed multiple brain metastases 4 months after operation. We conclude that extensive surgery using cardiopulmonary bypass for lung cancer patients with such intracardiac involvement is effective for improvement of PS and reduces the risk of sudden death due to cardiac failure or emboli. Accurate diagnosis of intracardiac extension in these unusual cases is important.

Thallium-201 imaging in a patient with mid-ventricular hypertrophic obstructive cardiomyopathy.

Findings specific to mid-ventricular hypertrophic obstructive cardiomyopathy were obtained in a patient by means of 201Tl planar myocardial scintigraphy. Namely, a myocardial band-like image dividing the left ventricle into two chambers was clearly shown. This was identified as hypertrophic muscle with sphincter-like muscular stenosis at the mid portion of the left ventricle.

Specific perfusion pattern in stress 201Tl myocardial scintigraphy of left main coronary artery disease.

The usefulness of stress 201Tl myocardial scintigraphy for identifying left main coronary artery disease was evaluated with data from 23 patients with 50% or more narrowing of the left main coronary artery and 56 patients with 75% or more narrowing of the major coronary arteries but without left main coronary artery involvement (no left main coronary artery disease). Quantitative evaluation of stress perfusion scintigrams in all five patients with narrowing of the left main coronary artery of 90% or more showed a characteristic perfusion pattern (left main pattern) of extensive homogeneous defect over the whole anterolateral segment and simultaneous defects in all radii of the high anteroseptal and high posterolateral segments. On the other hand, such a perfusion pattern was noted in only 1 of 18 patients with less than 90% stenosis of the left main coronary artery and in only 1 of 56 patients with no left main coronary artery disease.

Percutaneous transluminal coronary angioplasty for multiple lesions in a coronary artery--report of two cases.

Percutaneous transluminal coronary angioplasty (PTCA) was performed successfully in two patients with angina pectoris who had two separate significant stenotic lesions in a coronary artery. One patient had stenoses in segments 6 and 7 of the left anterior descending coronary artery. After PTCA, angina disappeared, an exercise ECG became negative and a 201Tl myocardial scintigram returned to normal. In the other patient, two separate stenotic lesions were found in segment 3 of the RCA. Angina and an exercise ECG improved after PTCA. These results suggest the validity of PTCA for multiple stenotic lesions in the same coronary artery.

Relation between the location of the infarcted area in body surface isopotential mapping and the location of myocardial infarction in vectorcardiography.

In order to examine whether our method of determining the location of the infarcted area in body surface isopotential mapping (MAP) is adequate for clinical use, a comparison was made between the location of the infarcted area using MAP and the location of myocardial infarction using vectorcardiography (VCG). The percentage of agreement between MAP and VCG in the retrospective study was 91.7% in the anterior wall, 76.7% in the lateral wall, 93.3% in the inferior wall and 73.3% in the posterior wall. The reason for the disagreement between these two methods was investigated, and criteria for determining the infarcted area using MAP and vectorcardiographic criteria for myocardial infarction were partly corrected in anterior, lateral and (high) posterior infarction to increase the clinical accuracy of both methods. Consequently, the percentage of agreement in the four walls ranged from 83.7% to 87.9%, and the diagnostic value of MAP for the infarcted area was not inferior but was more sensitive than that of VCG except in anterior infarction. In the prospective study, the same result was obtained. Secondly, in order to establish the superiority of MAP or VCG, the sensitivity and specificity of MAP and VCG to SCG (thallium-201) were calculated. Except in the anterior wall, the sensitivity of MAP to SCG was higher than that of VCG to SCG, especially in the lateral and posterior walls. Accordingly, it is suggested that MAP is the method of choice in determining the infarcted area in clinical cases.