[Aortic valve repair with minimal access "J" sternotomy].

Recently many cardiovascular operations have been performed with minimally invasive cardiac surgery (MICS). It is reported that MICS is superior to standard full sternotomy in regard to cosmetic and post-operative recovery. In our institution, aortic valve repair operations have been performed to aortic valve insufficiency. This time, we performed aortic valve repair by minimal access "J" sternotomy. A 63-year-old male with degenerative aortic regurgitation underwent aortic valve repair by MICS. He had experienced dyspnea on exertion 7 days before admission. Preoperative transthoracic echocardiogram showed the grade of aortic regurgitation (AR) was severe. Surgery was successful and the grade of AR became trivial. This combined procedure have merits for patients because of freedom from anticoagulation and small incision. Such combined surgery may be indicated in the treatment in a subset of patients with degenerative AR.

Selection of surgical methods for infected infrarenal abdominal aortic aneurysms.

BACKGROUND: There is no standard treatment for patients with infected abdominal aortic aneurysm (AAA). To determine the basis for selection of a surgical method, we reviewed our experiences with all patients who underwent surgery for infected infrarenal AAA. METHODS: Between 1993 and 2000, 6 patients with infected infrarenal AAA underwent surgery. Extra-anatomic bypass grafting was performed in 2 of 3 patients with infection extending into the retroperitoneum. In situ grafting was performed in 3 patients with localized infection and in 1 patient with extended infection. RESULTS: Severe peritonitis occurred in 2 patients with extended infection in the early postoperative phase. One patient, who had undergone in situ grafting, died of sepsis. The other patient, who had undergone extra-anatomic bypass grafting, was treated by continuous irrigation with an electrolyzed strong acid aqueous solution (ESAAS). He recovered gradually and was discharged. After a follow-up period with a mean of 40 months (range: 17-102 months), all 5 patients who survived surgery are alive and asymptomatic. CONCLUSIONS: It was suggested that the method used for revascularization should be selected based on the degree of diffusion of infection. For a patient with extended infection, postoperative continuous irrigation with ESAAS appears to be effective in eradicating retroperitoneal infection.

[Redo coronary artery bypass grafting using the patent left internal thoracic artery graft as an in flow with composite internal thoracic artery Y grafting; report of a case].

In redo coronary artery bypass grafting (CABG), graft selection and revascularization methods are major problems. We experienced a redo-CABG with occluded previous vein grafts. These grafts were to the circumflex artery and right coronary artery. We conducted operation using cardiopulmonary bypass. We at this operation, chose right internal thoracic artery (RITA) as a conduit and anastomosed it to the side of functioning left internal thoracic artery (LITA) graft, and then diogonal branch, posterolateral branch, and atrioventricular branch were revascularized with the RITA. Post operative course was uneventful. Internal thoracic artery (ITA) is superior to vein graft and other arterial graft as to long term patency. We believe composite Y graft with the use of bilateral ITA can be one of the revascularization strategy in redo CABG.

Assay of spherical cell surface molecules by thermal lens microscopy and its application to blood cell substances.

To detect and quantitate uneven cell surface molecules, such as blood group antigens on a blood cell and immunoglobulin molecules on a mast cell, an improved method of thermal lens microscopy was employed. The antigen molecules were immunologically stained with their antibodies, which were labeled with colloidal gold. Since the surface of the biological cells was not flat but spherical, the focal point of the probe laser beam inevitably deviated from the sample surface on the moving stage. Therefore, the deviation of the focal point of the probe beam was corrected by adjusting the phase of the signal. Using this technique, a three-dimensional antigen distribution on each cell surface was imaged. Despite the convex surface of cells, labeled colloidal gold was correctly quantified. In the measurement of erythrocyte antigens, a small quantity of Lewis antigens was successfully detected on the umbilical cord erythrocytes. Immunoglobulin E on a mast cell, derived from the allergic human mucosa fungus, was also observed by this method, and the distribution of IgE molecules on the cell surface was quantitatively imaged. A thermal lens microscope, which measures spherical samples correcting the deviation, made it possible for us to observe and assay the substances on biological specimens that have complicated forms, such as living cells in vivo or in situ.

Survival and sinus rhythm maintenance after modified Cox/maze procedure and mitral valve operation in patients with chronic atrial fibrillation.

OBJECTIVE: Sinus rhythm gained after the Cox/maze procedure concomitant with mitral valve operation has demonstrated long-term attrition during the follow-up, no information exists on whether the type of mitral valve operation--(repair vs. replacement)--affects this sinus rhythm maintenance rate. We retrospectively studied patients undergoing concomitant mitral valve operation and Cox/maze procedure to answer this question. METHODS: Between April 1993 and August 1995, 87 consecutive patients--35 men and 52 women (mean age: 59.3 years)--with chronic atrial fibrillation and mitral valve disease underwent the modified Cox/maze procedure and concomitant mitral valve operation, with 56 having mitral valve repair (repair group) and 31 mitral valve replacement (replacement group). Patients were followed up and changes in rhythm studied retrospectively. RESULTS: Follow-up for a mean 51.3 +/- 11.6 months was completed in 82 of 83 long-term survivors (99%). Repair group surgery survival was 98.1 +/- 1.9% at 1 year and 94.2 +/- 3.2% at 5 based on the Kaplan-Meier method. Replacement group surgery survival was 85.7 +/- 5.9% at 1 year and 82.9 +/- 6.4% at 5. Probability in sinus rhythm maintenance for the repair group at 1 year was 88.6 +/- 5.4% and at 5 years was 67.6 +/- 9.1%. Probability in sinus rhythm maintenance for the replacement group at 1 year was 95.7 +/- 4.3% and at 5 years was 65.0 +/- 11.1%. CONCLUSIONS: Medium-term results after the Cox/maze III procedure concomitant with mitral valve operation are good. The attrition of sinus rhythm maintenance appears similar by the completion of 5-year follow-up.

Autophagy in embryonic erythroid cells: its role in maturation.

Yolk sac-derived embryonic erythroid cells differentiate synchronously in the peripheral blood of Syrian hamster. The stage of differentiation on day 10 of gestation is equivalent to polychromatophilic erythroblast stage and that on day 13 is equivalent to the reticulocyte stage in adult animals. The cytoplasm of embryonic erythroid cells became scant and devoid of most organelles on day 12 of gestation. In addition, there were very few non-erythroid cells in circulation before day 13. Thus the embryonic erythroid cells serve a pure and synchronous system to study the mechanisms of terminal differentiation. The number of mitochondria in the embryonic erythroid cells decreased to about 10% of the initial number during the period between day 10 and day 12 of gestation. In contrast, the frequency of autophagy of mitochondria increased 4.6-fold in the same period. The cytochrome c content of the cell decreased as the mitochondria became extinct. However, release of cytochrome c into the cytoplasm was not detectable through day 10-13 of gestation, suggesting that the mitochondria were digested within a closed compartment. Decomposed mitochondria and ferritin particles were detected in lysosomes by electron microscopy on and after day 12 of gestation, which also suggested digestion in a closed compartment. Mitochondrial ATP synthase subunit c, which is known to be a protease-refractory protein, was retained in the cells even after the disappearance of mitochondria, indicating that most of the mitochondria were not extruded from the cells. The digestion of mitochondria in autolysosomes may allow the cells to escape from rapid apoptotic cell death through concomitant removal of mitochondrial death-promoting factors such as cytochrome c.

The personal identification of many samples recovered from under the sea.

An automatic and rapid DNA typing system was employed for personal identification, using fragmentary tissue samples from victims in an airplane accident. Two victims were crushed into small pieces, and 33 samples suspected to belong to them were recovered from under the sea. From each sample, 10 mg was used for testing. The parents' bloods of two presumptive victims were also examined. DNA extraction from samples was performed by the NaI method, and the obtained DNA samples were analyzed with the ABI PRISM system. Among 33 samples, 31 samples were identified to be human tissues, possibly from two victims. The other two samples seemed to be parts of marine animals. ABO blood group, STR polymorphism, and mitochondrial DNA polymorphism typing were possible in every examined human sample. Two victims' fragmentary tissues were identified by determining ABO genotype, STR type and mitochondrial DNA type. The system we employed enabled an accurate typing of many fragmentary samples in a short time, thus contributing to the fast and secure identification of many victims in such cases as big air accidents.

Dual-label time-resolved fluoroimmunoassay of psychopharmaceuticals and stimulants in serum.

A new method to measure two different drugs simultaneously by time-resolved fluoroimmunoassay (TR-FIA) has been developed. In the TR-FIA reported here, psychopharmaceuticals [chlorpromazine (CPZ) and desipramine (DSP)] and methamphetamine (MA) contained in serum are assayed by a combined use of a new europium (Eu) chelate and a samarium (Sm) chelate, as labels. The drug concentrations were determined by the competition between a labeled antigen with Eu(3+) or biotin and a sample antigen. A microtiter plate coated with a mixture of rabbit IgGs (anti-MA and anti-CPZ or anti-MA and anti-DSP) was used. In the assay of MA and CPZ, Eu(3+) labeled MA-bovine serum albumin conjugate (MA-BSA) and biotinylated CPZ-BSA were added to the well with their non-labeled standard solutions or samples. MA was assayed by measuring the fluorescence intensity of Eu(3+) at 615 nm. After incubation of the Sm(3+) labeled streptavidin, CPZ was assayed by measuring the fluorescence of Sm(3+) at 643 nm. In the assay of MA and DSP, Eu(3+) labeled DSP-BSA and biotinylated MA-BSA were used. In our dual-assay, the minimum detection limits of these drugs were 1ng/ml for MA, 10 ng/ml for CZP and 10 ng/ml for DSP. Since the simultaneous detection of different drugs by TR-FIA is time and sample saving, the method can be employed in rapid and sensitive screening tests.

Postoperative renal function after an abdominal aortic aneurysm repair requiring a suprarenal aortic cross-clamp.

We describe herein the postoperative renal functions of patients who required a suprarenal aortic cross-clamp during abdominal aortic surgery. Seven patients required a unilateral suprarenal aortic cross-clamp (group A) and six patients required a bilateral suprarenal clamp (group B). Eighty-three patients who required an infrarenal aortic clamp were assigned to group C. Renal hypothermia with renal perfusion or topical cooling during suprarenal clamp was not performed. No hospital deaths were encountered. In group B, the postoperative creatinine and blood urea nitrogen (BUN) levels remained statistically significantly higher than that of group C until the seventh postoperative day. The postoperative renal dysfunction (serum creatinine level >2.0 mg/dl) was 28.6% in group A and 50% in group B, while it was only 8.4% in group C, although no patient required either temporary or permanent hemodialysis. The postoperative peak BUN over 30 min suprarenal clamp was significantly higher than that within 30 min. In summary, the postoperative renal function was impaired after an extended bilateral suprarenal clamp. These findings suggest that if prolonged renal ischemia is thus expected, then renal preservation should be considered.

[Genotyping of blood-groups by denaturant gradient gel electrophoresis (DGGE)].

The denaturant gradient gel electrophoresis (DGGE) method was used in order to simultaneously estimate the genotypes of different factors in a gel plate consisting of one sheet. A genotype analysis of the blood groups (MN, Duffy, Kidd type) and serotype (Gc system) was carried out. DNA samples extracted from the leucocytes of volunteers, whose blood group had already been proven, were used. The PCR amplification fragments were amplified from the gene which controlled each blood group. The primers were designed in order to analyze genotypes with from 1-3 base substitutions in the amplification product. The concentration of the denaturant most suitable for the DGGE method to detect each genotype of the blood groups (MN, Duffy, Kidd type and Gc system) was calculated using a computer simulation method. The denaturant concentration limit of the gel which was suitable for performing a DGGE analysis was determined to range from 15-36%. Electrophoresis was performed at 60 degrees C and with 100 V using this gel on each amplification fragment for 3 hours. The gel after electrophoresis was treated in ethidium bromide in order to detect the DNA band. The genotype (M/M, M/N and N/N) of the MN blood group, the genotype (Fya/Fya, Fya/Fyb and Fyb/Fyb) of the Duffy blood group, the genotype (Jka/Jka, Jka/Jkb and Jkb/Jkb) of the Kidd blood group and each allele (GC*1S, GC*1F and GC*2) of the Gc system were all simultaneously distinguished in one plate. As a result, it was possible to estimate multiple gene polymorphism, while substituting bases 1-3, by PCR, DGGE and ethidium bromide staining. The polymorphic results obtained using this DGGE method is very useful for cases in which a multiple gene analysis is required such as for the personal identification.

Detection of stimulants in hair by laser microscopy.

In order to detect methamphetamine, a common stimulant, laser microscopy and immuno-histochemical staining, which uses anti-methamphetamine labeled with colloidal gold, were employed. The intensity of reflection of colloidal gold at a 488- and 514-nm line of Ar laser was measured with a laser microscope equipped with a computerized image processing system. Microtomed hair samples from five drug users who died from methamphetamine intoxication were used. The drug distribution in the hair was quite different in these five cases, but the levels of drug concentration in two different hair samples from the same abuser were correlated. The results from two hair samples with roots showed a correlation between drug concentration in hair roots and plasma samples. The proposed method needs no melanin bleaching and is simple and sensitive enough to estimate the drug concentration using only a segment of hair.

[Aortic valve papillary fibroelastoma in a patient with mitral valve regurgitation].

Papillary fibroelastoma is a rare cardiac tumour. We describe a patient with mitral valve regurgitation and aortic valve papillary fibroelastoma. The patient was 62-year-old woman. She was referred to us for surgical treatment of mitral valve. Preoperative echocardiography showed rheumatic mitral valve regurgitation (Sellers grade III) and it also demonstrated mobile masses of the aortic valve. At operation, mitral valve was repaired by a posterior annuloplasty. Through the aortotomy, small tumors were found to be attached to each cusps of the aortic valve and they were successfully removed. The histopathologic diagnosis was papillary fibroelastoma of the aortic valve. The postoperative course was uneventful.

[Polymorphism of hypervariable region in D-loop of mitochondrial DNA].

DNA sequences of PCR products from mitochondrial DNA (mtDNA) of 80 healthy Japanese volunteers (40 pairs, mother and child) were determined by the direct sequencing method for polymorphism. Thirty (15 pairs) of 80 samples analyzed showed a T-to-C transition at position 16189 (T16189C) of the C-stretch region in the hyper-variable region of mtDNA. For seven pairs randomly selected from the 15 T16189C pairs (C-stretch) and a single pair without the transition (non C-stretch), PCR products from the D-loop region were cloned and then sequenced. The repeat number of C in the C-stretch region was found to show heteroplasmy by sequencing multiples clones from each mtDNA. Statistical analyses of the distribution patterns of the repeat number revealed no significant differences between the mother and child in each lineage but significant differences between the lineages. The seven lineages could be then classified into four groups. The result of our data confirmed the existence of heteroplasmic polymorphism in the C-stretch region and the inheritance of the heteroplasmy from mother to child. Therefore, the analysis of heteroplasmy is applicable to individual identification.

Highly sensitive quantitation of methamphetamine by time-resolved fluoroimmunoassay using a new europium chelate as a label.

A simple and highly sensitive time-resolved fluoroimmunoassay of methamphetamine (MA) using a new fluorescent europium chelate (BHHCT-Eu3+) as a label is described. Two variations of competitive immunoassay were attempted. In the first (one-step) assay, microtiter plates coated with anti-MA were used, and the new label was bound to a conjugate of bovine serum albumin and N-(4-aminobutyl)-MA (MA-BSA). In the second (two-step) assay, instead of the labeled MA-BSA, biotinylated MA-BSA and BHHCT-Eu3+-labeled streptavidin-BSA were used. The lowest measurable concentrations of MA for the one-step and the two-step methods were 1 ng/mL (25 pg/assay) and 1 pg/mL (25 fg/assay), respectively. These were 10 to 1000 times superior to the detection limits of MA in any other immunoassay. Intra-assay coefficient of variation was approximately 2-8% at eight different concentrations (n = 4). Analysis of 34 urine samples with the new method and conventional gas chromatography showed a good correlation (r = 0.954). The high detectability of the present assay also enabled segmental hair analysis with a few centimeters of a hair.

[Blood-group genotyping by constant denaturing gel electrophoresis (CDGE)].

Constant Denaturing Gel Electrophoresis (CDGE) was used as an analytical method of the genetic markers. Even a single base change in a fragment amplified by PCR was detected exactly by CDGE. The computational simulation of CDGE gave the calculation whether a single base change in a fragment amplified by PCR could be detected by CDGE or not. In this report, genotyping of three blood groups, MN, Duffy and Kidd, and Gc system is described. The regions reflecting allelic differences of each system were amplified from genomic DNAs. The concentration of denaturants (urea and formamide) in CDGE gels was decided with the computational simulation as follows: 15% for MN, 27% for Duffy, 24% for Kidd, 30% for Gc. CDGE was run in TBE buffer at 60 degrees C, 100 V constant voltage. PCR amplified fragments with 1-3 base changes were separated clearly in each gel. By staining the gels with ethidium bromide, the genotype of each system was determined. The genotyping of system by CDGE can avoid mistakes in the conventional method, which requires complicated and multiple troublesome operations. Analysis of PCR amplified fragments by CDGE will make a beneficial contribution to medico-legal practice.

[Ruptured dissecting aneurysm of the transverse arch after replacement of the descending and ascending aorta].

A 28-year-old Marfan's syndrome woman was referred to our hospital because of sudden chest and back pain. She had received replacement of the descending and ascending aorta for acute aortic dissection previously in other two institutions. CT scan revealed the massive mediastinal hematoma and hemothorax which suggested ruptured dissecting aneurysm of the transverse arch. Emergent total arch replacement, re-ascending replacement and aortic root plasty successfully weve performed. She recovered uneventfully although she had residual thoracoabdominal dissecting aneurysm. It was suggested that total arch replacement should be performed for Stanford A type dissection in Marfan's syndrome.

[Case report of surgical repair of left ventricular free wall rupture using GRF glue and pericardial patch].

A 73-year-old woman with acute myocardial infarction (Seg. 6: 100%) was admitted to our hospital. She underwent percutaneous transluminal angioplasty (PTCA) and stent insertion to Seg. 6 on that day and anticoagulant therapy with urokinase and heparin was started in CCU. On the 4th day, chest pain developed suddenly and echocardiography revealed cardiac tamponade, so we suspected left ventricular free wall rupture. When blood pressure increased to 100 mmHg in the operating room, the left ventricular free wall rupture became "blow out" type. After establishing extracorporeal circulation, we glued Xenomedica and autologous pericardium using gelatin-resorcin-formaldehyde glue (GRF glue) to the linear tear without damaging the myocardium and coronary arteries and reducing left ventricular volume. Bleeding was completely controlled. This experience suggests that this procedure might be effective for left ventricular free wall rupture.

Detection of bathsalts in the lungs of a baby drowned in a bathtub: a case report.

This case is one in which a baby was found dead, apparently drowned in a bathtub. To confirm the inhalation of bathwater, an extract taken from the baby's lungs was analyzed with high-performance liquid chromatography. Bathsalts contained in the bathwater were detected in the extract. Bathsalts are usually used in home bathtubs and, as a dye material, they contain fluorescein which is highly sensitive to detection. The presence of fluorescein in the lung tissue and in the other tissues greatly helps to confirm the bathwater drowning.

The apoptotic and nonapoptotic nature of the terminal differentiation of erythroid cells.

The morphology of erythroid cells changes dramatically during the course of their terminal differentiation. According to calculations made with cytospin preparations obtained from Syrian hamster yolk-sac-derived erythroid cells, the area of nuclei at day 10 of gestation ranges from 25 to 85 micron 2 and is reduced to 15-25 micron 2 on day 13 [K. Morioka and R. Minamikawa-Tachino, Dev. Growth Differ. 35, 569-582, 1993]. The DNA and protein contents of each nucleus also decrease during this period. Nonspecific fragmentation of DNA was detected by agarose gel electrophoresis in all samples obtained from day 10 to day 13 of gestation, while distinct ladders of DNA fragments were not detected. DNA fragmentation was also detected by an in situ DNA-end labeling (TUNEL) assay. As the terminal differentiation proceeded, gradual decreases in levels of both histone H1 and most nonhistone proteins were observed by SDS-polyacrylamide gel electrophoresis, while levels of core histones appeared to be constant. In particular, lamin B2 was almost completely lost from the nuclear matrix fraction on day 11. These results suggest that the terminal differentiation of erythroid cells and apoptosis might have common mechanisms. However, expansion of the cytoplasm during the terminal differentiation distinguishes these processes. In addition, in the erythroid terminal differentiation, nuclei never form lobules or become fragmented; no apoptotic bodies are formed, occurrence of the apoptosis-like cellular change is not sporadic but rather synchronous, and the process is slow, with at least several days being required for cell death. These characteristics are different from those of typical apoptosis. Thus, the terminal differentiation of nucleated embryonic erythroid cells exhibits both apoptotic and nonapoptotic features.

[Three cases of right-sided active endocarditis with multiple pulmonary infarction].

We have experienced three patients with right-sided active endocarditis combined with multiple pulmonary infarction. Ventricular septal defect (VSD), aortic regurgitation (AR), tricuspid regurgitation (TR) and congestive heart failure were present in case 1. TR was present in case 2. VSD, TR and patent ductus arteriosus were present in case 3. alpha-Streptococcus caused endocarditis in case 1 and 3; Candida albicans caused endocarditis in case 2. Antibotic therapy had no effect in case 2 and 3. Case 1 and 3 developed pulmonary hemorrhage, which resolved before the operation in case 1, but not in case 3. Our three patients underwent surgery and recovered successfully. They were discharged on the 43th, 58th and 32th postoperative day and are presently free of clinical symptoms. These experiences suggest surgery should be undertaken in the following situations: 1. antibiotic therapy has no effect on the infection, 2. hemodynamics are worsening, and 3, pulmonary infarction and pulmonary hemorrhage occur repeatedly.