[An aortic valve-sparing procedures (remodeling) for a patient with annuloaortic ectasia: a case report].

A 51-year-old man with annuloaortic ectasia and aortic regurgitation, who did not have Marfan syndrome, underwent an aortic valve-sparing root reconstruction (remodeling). All three sinuses were excised and then the ascending aorta was replaced with a 30 mm collagen-impregnated Dacron graft, one of which ends were scalloped to reproduce pseudosinus. Each coronary artery orifice was anastomosed to the graft with Carrel patch method. Post-operative angiogram showed no aortic regurgitation and no pseudosinus formation, because the graft was slightly larger than the optimal one. The NYHA functional class has been improved III to I 18 months after the operation.

[A case report: surgical treatment of hypertrophic obstructive cardiomyopathy with acute hemodynamic deterioration due to chordae rupture of the mitral valve].

A 70-year-old woman was found to have new heart systolic murmur and was transferred to our hospital for the treatment of high fever and dyspnea. The chest X ray showed cardiomegaly (CTR 63%) and marked pulmonary congestion. The UCG revealed that there was no evidence of infective endocarditis, but there was hypertrophic obstructive cardiomyopathy with the left ventricular pressure gradient of 90 mmHg accompanied by mitral regurgitation (grade 3/4). Two weeks after the admission, mitral regurgitation progressed due to chordae rupture confirmed by UCG. Transaortic subvalvular myectomy and mitral valve replacement were underwent. Post-operative electrocardiogram demonstrated right and left anterior bandle branch block. Eleven months after the operation left ventricular outflow pressure gradient was not detected by echocardiogram and she has been in I/IV NYHA functional class.

[A case of papillary muscle rupture associated with acute inferior myocardial infarction].

A sixty-year-old man was admitted to our hospital due to prolonged left anterior chest oppression and hypotention. The electrocardiogram revealed acute inferior myocardial infarction, confirmed by the coronary angiography which showed occluded right coronary artery (RCA) at the segment 4AV. The intra-coronary pro-urokinase infusion and coronary angioplasty successfully revascularized the occluded 4AV segment. Although the 4AV segment perfused small area, he developed severe pulmonary edema on the second hospital day. A transesophageal echocardiography revealed severe mitral regurgitation due to posterior mitral valve prolapse by the ruptured tendineae with a mobile mass. The damaged mitral valve was replaced by the prosthetic mechanical valve (SJM 25M), resulted in stable hemodynamic state. He discharged one month after the operation.

Autoimmunity induction by human T cell leukemia virus type 1 in transgenic mice that develop chronic inflammatory arthropathy resembling rheumatoid arthritis in humans.

We recently reported on an inflammatory arthropathy resembling rheumatoid arthritis that develops in high incidence among transgenic mice that carry the env-pX region of the human T cell leukemia virus type 1 genome. In an effort to elucidate the pathogenesis of this disease, we found that genes for inflammatory cytokines, including IL-1 alpha, IL-1 beta, IL-6, TNF-alpha, transforming growth factor-beta 1, IFN-gamma, and IL-2, as well as MHC genes were activated in transgenic joints. Serum levels of IL-1 beta and IL-6 were also elevated. Interestingly, these mice produced Ab against IgG, type II collagen (IIC), and heat shock proteins accompanied by IgG hypergammaglobulinemia. The cellular immune response to IIC as well as that to heat shock proteins were activated. Moreover, these mice became immunologically responsive to exogenously administered IIC and developed arthritis, in contrast to their nontransgenic littermates, which showed little response to IIC. Taken together, the results suggest that human T cell leukemia virus type 1 can cause immune system hyperreactivity and induce autoimmunity. The possibility that elevated cytokine and/or MHC gene expression are involved in the development of autoimmunity and arthropathy are discussed.

Left ventricular thrombosis following coronary artery bypass grafting in a patient with nephrotic syndrome: report of a case.

We present herein the case of a 63-year-old man with nephrotic syndrome who developed an apical infarction 4 days after undergoing coronary artery bypass grafting. Echocardiography done 2 weeks postoperatively revealed a left ventricular thrombus which was successfully removed. He has no further thrombotic events since anticoagulant therapy was initiated.

Results of circulatory support for postoperative cardiogenic shock.

Over the last 5 years, 15 patients received ventricular assist devices (VADs) (Group 1) and 5 received percutaneous cardiopulmonary support (CPS) (Group 2) while in postoperative cardiogenic shock. Group 1 consisted of 8 men and 7 women ranging in age from 22 to 73 years (average age, 55 years). Nine of these patients underwent surgery for valve replacement, 5 for coronary artery bypass grafting, and 1 for closure of a ventricular septal rupture. The duration of VAD support ranged from 6 h to 9 days (mean, 3.9 days). Group 2 consisted of 4 men and 1 woman ranging in age from 49 to 68 years (average age, 57 years). One of these patients underwent surgery for valve replacement, 1 for coronary artery bypass grafting, 2 for replacement of a thoracic aneurysm, and 1 for left ventricular aneurysmectomy. The duration of CPS ranged from 4 h to 8 days (mean, 2.8 days). In Group 1, 13 patients were weaned from the VADs and 8 survived. Bleeding occurred in 5 patients, renal failure in 4, infection in 3, cardiac failure in 4, cerebral infarction in 1, perioperative myocardial infarction in 1, arrhythmia in 1, and ileus in 1. In Group 2, 4 patients were weaned from the CPS and 3 survived. Bleeding occurred in 3 patients, renal failure in 2, CNS injury in 2, and cardiopulmonary failure in 1. The 8 survivors in Group 1 have been followed for 2 to 56 months (mean, 28.7 months). Five patients were in NYHA class I, 2 were in class II and 1 was in class III.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of partial anomalous pulmonary venous connection to the high superior vena cava with intact atrial septum].

A 16-year-old female with partial anomalous pulmonary venous connection to the high superior vena cava underwent a successful correction using only autologous pericardium. Right upper pulmonary venous blood returned to the left atrium via the superior vena cava and the constructed atrial septal defect. The right atrium received blood from the brachiocephalic vein through the conduit. The azygos vein was not identified. Post-operative examination revealed that there were no pressure gradients across the superior vena cava and the conduit. She was discharged from the hospital on the 14th post-operative day.

[Coronary revascularization with bilateral internal thoracic artery grafts].

Thirty-two patients underwent coronary revascularization with bilateral internal thoracic artery (ITA) grafts. Each patient received 2.7 grafts in average including double ITA grafts. Seventeen patients had the right ITAs as free grafts. The other sixteen were treated with 13 autologous veins and 9 right gastroepiploic arteries in addition. Fifty-five grafts out of 56 (98.2%) were proved to be patent at the time of hospital discharge. The postoperative morbidity included three reoperations for bleeding and one perioperative inferior myocardial infarction. One patient died of colon perforation after surgery and another died of cerebral infarction late after surgery. These results exhibited that coronary artery bypass grafting with bilateral ITA grafts had relatively low risks and could contribute to complete revascularization in patients with diseased coronary arteries.

Multivessel coronary revascularization with bilateral internal thoracic artery grafts.

Sixteen patients underwent coronary revascularization with bilateral internal thoracic artery (ITA) grafts between 1988 and 1989 at the Okayama University Hospital. A total 39 coronary grafts were performed, being an average of 2.4 grafts per patient. Each patient received bilateral ITA grafts, and in 5 patients an additional 7 grafts were constructed with 5 autologous veins and 2 gastroepiploic arteries. The right ITA was grafted as a free graft in 4 patients. The ITA graft patency rate was 96.8 per cent (31/32) at the time of hospital discharge. The postoperative morbidity included one reoperation for bleeding and one myocardial infarction. Coronary artery bypass grafting with bilateral ITA grafts can be safely performed and its application facilitates complete revascularization with arterial grafts.

Clinical experience of emergency coronary artery bypass grafting following failed percutaneous transluminal coronary angioplasty.

From July, 1981 to December, 1988, 2431 percutaneous transluminal coronary angioplasties were performed on 1901 patients at the Heart Institute of São Paulo University Medical School. Seventy-six patients (4.0 per cent) underwent emergency coronary artery bypass grafting for failed angioplasty. The incidence of failed angioplasty was significantly higher in the impending myocardial infarction group (11.5 per cent) than in the angina group (4.8 per cent) and the acute myocardial infarction group (1.3 per cent). The mean age of the seventy-six patients was 54.4 years, and 54 patients were male. The operative mortality was 15.8 per cent, being 9 males and 3 females. Patients who had had a left main trunk dissection during angioplasty and those who were hemodynamically unstable following the failed angioplasty or who had had a cardiac arrest necessitating a cardiac massage during transportation to the operating room, had a higher mortality than patients in whom the failure occurred in other sites and those who were hemodynamically stable. Perioperative myocardial infarction was documented in 50 per cent of the patients. Patients who had had a cardiac arrest during the procedure had a higher rate of perioperative myocardial infarction than those whose preoperative hemodynamic condition was stable.

[Prosthetic valve endocarditis].

From January/1983 to March/1988, 28 patients were submitted to valve replacements for prosthetic valve endocarditis in 1,512 valve replacements. Seventeen patients were male, their mean age was 36.7 +/- 12.9 years old, and eight cases were operated under emergency condition. The blood cultures were positive in 14 (50%), the agent most commonly found being Streptococcus viridans in 5 cases. Hospital mortality was 28.5%. The causes of death were septicemia in 4 cases, low output syndrome in 2 cases, cerebrovascular accident in 1 case, and coagulopathy in 1 case. Mortality was higher with statistical significance in the cases whose blood cultures were negative, the cases in which the time from valve replacement to the onset of endocarditis was less than one year, and the cases under emergency condition.

Characteristics of chronically paced cardiac functions in the congenital complete atrioventricular block.

Characteristics of morphology, cardiac function, and cardiac reserve at late state were evaluated at rest, by changing the pacing rates, and after exercise in patients with ventricular pacemakers for isolated congenital complete atrioventricular block. Heart size was reduced statistically after pacemaker implantation, and concentric myocardial hypertrophy was observed. Cardiac pump functions at rest seemed fairly well compensated by increased ejection fraction, but the cardiac index was still lower than that of the normal heart. Responses of cardiac function towards the changing rates were considered satisfactory, and those variables had statistic correlations with the pacing rates. After exercise, significant increase of cardiac pump function and also statistic acceleration of myocardial function were observed. This fact proved that cardiac reserve was good, although the increased cardiac output after exercise was still insufficient without an increase in heart rate. More physiological pacing modes would be required as currently recommended.

Twenty-four-hour isolated heart preservation by perfusion method with oxygenated solution containing perfluorochemicals and albumin.

In Experiment 1 the donor hearts (group C) perfused for 24 hours with an intracellular-like solution containing perfluorochemicals, calcium antagonist, and albumin were compared with the hearts immersed for 24 hours in an intracellular-like solution to which calcium antagonist was added (group B) and the hearts in which the ischemic time was less than 1 hour (group A) followed by orthotopic heart transplantation. In Experiment 2 perfusates with (group I) and without (group II) perfluorochemicals and albumin were used for 24-hour isolated heart preservation. Periodic assessment of the hearts was performed during the perfusion. Experiment 1: All transplanted hearts started beating spontaneously. There was no statistically significant functional difference between the three groups. At the end of the preservation the creatinine phosphokinase and lactate releases of group C were at lower levels than those in group B. Electron microscopic examination revealed that the myocardium in group B was damaged more severely than in group C. Experiment 2: The level of the creatinine phosphokinase and lactate dehydrogenase released in group I was lower than that in group II. The lactate concentration was at a lower level in group I. At the end of the preservation the pyruvate concentration was higher in group I. The gain in heart weight in group II was more marked than that in group I. The passive compliance decreased only in group II. It is suggested that the perfusion method is superior to the immersion method for 24-hour isolated heart preservation and that the perfusate containing perfluorochemicals and albumin is useful.