Alleviation of myocardial ischemia after Kawasaki disease by heparin and exercise therapy.

BACKGROUND: Heparin promotes angiogenesis. We evaluated the effects of combined treatment with heparin and exercise on myocardial ischemia in the chronic stage of Kawasaki disease. METHODS AND RESULTS: This study was conducted in 7 patients (aged 6 to 19 years) who had a totally occluded coronary artery and stress-induced myocardial ischemia in the collateral-dependent areas. Twice-daily exercise using a bicycle ergometer was performed with increments of 0.5 W/kg every 3 minutes up to maximal exertion for 10 days. Heparin, which immediately increased circulating hepatocyte growth factor, was given intravenously 10 minutes before each exercise period. Newly developed myocardial infarction, ventricular tachyarrhythmia, anginal attack, or hemorrhagic complication was not observed in any patient. Dipyridamole-loading single photon emission computed tomography documented improved myocardial perfusion in the collateral-dependent areas and a significant reduction in total defect scores in all patients after the completion of 20 sessions (P=0.01). In control patients who did not receive the heparin-exercise therapy, however, stress defect scores remained unchanged (n=1) or increased (n=2) during follow-up. Computerized quantitative coronary angiography provided evidence that the heparin-exercise therapy increased the diameter of the occluded artery to which collaterals terminated (P=0.001) but not that of the reference artery with which collaterals were not connected (P=0.96). CONCLUSIONS: The findings suggest that a series of heparin and exercise treatments over 10 days may have a dramatic effect on the alleviation of myocardial ischemia in collateral-dependent regions. This may be a safe, noninvasive revascularization therapy for patients with coronary artery occlusion in the chronic stage of Kawasaki disease.

Expression of tumor necrosis factor-alpha protein in the myocardium in fatal myocarditis.

BACKGROUND: Tumor necrosis factor (TNF)-alpha is the most studied cytokine in the failing human heart and in experimental murine myocarditis. We have investigated the expression of TNF-alpha in the myocardium in human myocarditis. METHODS: We examined endomyocardial biopsy (n = 4) and autopsy (n = 5) tissues obtained from nine patients diagnosed with myocarditis by the Dallas criteria. Expression of TNF-alpha in the hearts was immunohistochemically studied using monoclonal antibodies against human TNF-alpha. RESULTS: Tumor necrosis factor-alpha protein was expressed in the myocardium of six of the nine patients studied. Four of five fatal patients showed intense immunoreactivity for TNF-alpha compared with survivors. Furthermore, left ventricular systolic function was reduced in patients with TNF-alpha-positive hearts. CONCLUSIONS: These findings may support the suggestion that TNF-alpha plays an important role in cardiac dysfunction and myocytic damage in fatal human myocarditis.

Dramatic decrease of circulating levels of monocyte chemoattractant protein-1 in Kawasaki disease after gamma globulin treatment.

Kawasaki disease (KD) is a systemic vasculitis preferentially affecting coronary arteries. Extensive monocytes/macrophages infiltrate in the vascular lesions, implying the involvement of a chemotactic cytokine in their recruitment. We investigated the role of monocyte chemoattractant protein-1 (MCP-1, also termed monocyte chemotactic and activating factor) in KD. In the immunohistochemical studies using the cardiac tissues of patients with fatal KD, MCP-1 but not interleukin (IL) -8 or macrophage inflammatory protein-1alpha was localized at the extracellular matrix associated with mononuclear cellular infiltration. The sites of MCP-1 expression correlated with the distribution of the acute inflammation, including early coronary vasculitis. In prospectively studied patients with KD, circulating levels of MCP-1, IL-8, tumor necrosis factor alpha (TNF-alpha), and IL-1alpha were elevated in 73, 77, 57, and 0% of samples before gamma globulin (GG) treatment (400 mg/kg x 5 days = total 2 g/kg), respectively, compared with respective control values. GG treatment correlated with a rapid decrease in the circulating levels of MCP-1 (P = 0.001) but not IL-8 (P = 0.19) or TNF-alpha (P = 0.33). In the sensitive Western blotting, MCP-1 bound to GG. Furthermore, GG inhibited the MCP-1-induced Ca2+ influx in a human monocytic cell line in vitro. These findings suggest a role of MCP-1 in KD, and indicate that GG treatment may block MCP-1 activity, thus alleviating KD vasculitis.

Three-dimensional power Doppler sonography of tumor vascularity.

PURPOSE: To assess the clinical value of three-dimensional (3D) power Doppler imaging of intratumoral blood flow. MATERIALS AND METHODS: Two hepatocellular carcinomas (HCC), one renal cell carcinoma, one hepatic focal nodular hyperplasia (FNH), and one iliac bone metastasis of HCC were used. Images were collected by power mode using the GE-Yokogawa LOGIQ 700. Power Doppler images were recorded on S-VHS videotape and fed into a workstation. Flow information was then extracted, and 3D images were constructed by surface rendering. RESULTS: Preparation of 3D images could be accomplished in one minute after feeding flow information into the workstation. Intratumoral vascular structure could be easily evaluated. This 3D imaging was useful for the differential diagnosis of hepatic tumors, especially HCC and FNH, which were confirmed in 3D imaging to have distinctly different intratumoral vascular structures. CONCLUSION: 3D imaging of intratumoral blood flow was possible by 3D processing of the power Doppler images. 3D power Doppler imaging is expected to be helpful for the differential diagnosis of tumors.

Three-dimensional power Doppler sonography of tumor vascularity.

The purpose of this study was to assess the value of routine clinical examination using three-dimensional power Doppler sonography of intratumoral blood flow. Twenty-two hepatocellular carcinomas, seven cases of hepatic metastasis, four hepatic hemangiomas, six renal cell carcinomas, two cases of hepatic focal nodular hyperplasia, and one case of splenic metastasis were included in the study. Three-dimensional images were reconstructed by maximum intensity projection method using cine-loop data on a built-in computer in a LOGIQ 500 and a LOGIQ 700 from GE Yokogawa Medical Systems. The three-dimensional images obtained were viewed multidirectionally on a monitor screen. Three-dimensional representations of intratumoral blood flow became available for all tumors approximately 5 s to 30 s after scanning. In every case, the entire vasculature of the tumor was appreciated more easily from three-dimensional images than from cross-sectional two-dimensional images. These three-dimensional images of intratumoral blood flows corresponded to the tumor vessels that could be visualized by angiography at the early arterial phase. Differential diagnosis of hepatic tumors based on distinct difference in their intratumoral vascular structures was performed. Our results suggest that three-dimensional power Doppler sonography can be used for routine clinical examination of tumor vascularity and may provide improved diagnostic information.

[An experience of the modified Norwood's operation for hypoplastic left heart syndrome with aberrant origin of right subclavian artery and persistent left superior vena cava--the procedure without total circulatory arrest and cardiac arrest].

We reported a successful case of the modified Norwood operation for a 21-day-old neonate with hypoplastic left heart syndrome (MS and AS) associated with an aberrant right subclavian artery and a persistent left superior vena cava. The modified Norwood operation was performed without total circulatory arrest and Cardiac arrest. A 4 mm Gore-Tex graft, which was anastomosed between the right carotid artery and the right pulmonary artery for systemic-pulmonary shunt, was used for cerebral perfusion during aortic arch reconstruction. Coronary perfusion was performed with a small cannula placed on the relatively large ascending aorta during anastomosis between the main pulmonary artery and the ascending aorta. Equine pericardial patch was used for aortic arch reconstruction and the ascending aorta was directly anastomosed to a part of the main PA. Postoperative course was uneventful and postoperative MRI revealed no stenosis of the aortic arch and the pulmonary artery.

[Guillain-Barré syndrome associated with anti-GQ1b antibody--nosological relationship between Fisher's syndrome and Guillain-Barré syndrome].

A 15-year-old man developed diplopia, ataxic gait and bulbar palsy. Two days after the onset of neurological symptoms, neurological examination revealed external ophthalmoplegia, cerebellar ataxia, and areflexia. Muscle weakness in the areas innervated by cranial nerves and in the four limbs, and glove and stocking type sensory impairment were also observed. On the 13th hospital day, CSF protein was elevated with normal cellularity. Serum IgM anti-GQ1b antibody was increased, which decreased concurrently with the clinical improvement. Recent studies have revealed the frequent presence of serum anti-GQ1b antibody in Fisher's syndrome. Therefore, this patient showed Fisher's syndrome at the beginning, then evolved to Guillain-Barré syndrome associated with anti-GQ1b antibody, which would support close association between Fisher's syndrome and Guillain-Barré syndrome.