Visualization of intracerebral arteries by synchrotron radiation microangiography.

BACKGROUND AND PURPOSE: Small cerebral vessels are a major site for vascular pathology leading to cerebral infarction and hemorrhage. However, such small cerebral vessels are difficult to visualize by using conventional methods. The goal of our study was the development of methodology allowing visualization of small cerebral arteries in rodents, suitable for experimental models. MATERIALS AND METHODS: Using barium sulfate as a contrast material, we obtained microangiographic images of physiologic and pathologic changes consequent to cerebral infarction in mouse brain by monochromatic synchrotron radiation (SR). To achieve high-resolution and high-contrast images, we used a new x-ray camera with a pixel size of 4.5 microm, and we set the energy level at 37.5 keV, just above the K absorption of barium. RESULTS: Small intracerebral arteries ( approximately 30 microm in diameter) were clearly visualized, as well as the cortical branches (50-70 microm in diameter) at the brain surface. The limit of detection appeared to be vessels approximately 10 microm in diameter. Compared with the noninfarcted side, the number of intracerebral arteries was dramatically decreased in the middle cerebral artery area affected by stroke. CONCLUSIONS: These results indicate the potential of SR for evaluating pathologic changes in small cerebral arteries and for monitoring the impact of pro- and antiangiogenic therapeutic strategies.

[Surgical management of papillary muscle rupture following acute myocardial infarction].

Papillary muscle rupture is a rare but severe complication of acute myocardial infarction. Two cases successfully underwent mitral valve replacement and concomitant coronary artery bypass grafting (CABG) for acute myocardial infarction with the anterior papillary muscle rupture in cardiogenic shock. Each of them needed preoperative massive inotropic infusion, respiratory support and intraaortic balloon pumping assist. The first case was a 76-year-old female. Double vessel disease (seg 7 : 90%, seg 11 : 100%) was revealed by coronary angiography and rupture of the papillary muscle was confirmed by transesophageal echocardiography. The second case was a 69-year-old female. Double vessel disease (seg 2 : 90%, seg 11 : 100%) was revealed and severe mitral regurgitation due to prolapse of the anterior leaflet was confirmed by transthoracic echocardiography. To assess the diagnosis of postinfarction papillary muscle rupture, transthoracic and/or transesophageal echocardiography is mandatory. Coronary angiography is also desirable because concomitant myocardial revascularization may improve the prognosis.

[Early and long-term outcome for surgical treatment of aortic arch aneurysm].

This study was undertaken to determine the factors that influence the final outcome after the operation of aortic arch aneurysm. Sixty-six patients, the median age was 72 years (range 44 to 90), were operated at our hospital during the 16-year period between 1985 and 2001. Preoperative complications included cardiac in 6 and vascular in 21, ruptured in 13, myocardial ischemia in 21 and stroke in 14. The distal hemiarch (11) and total arch replacement with or without ascending aorta and descending aorta (46) and proximal hemiarch with or without valve operations (7) and other procedures were performed mainly using cardio-pulmonary bypass with moderate deep hypothermia and selective cerebral perfusion. The in-hospital mortality were 6 (9%) and 14 (23%) late deaths occurred. One out of 14 was aneurysm related death. The survival rates were 81% at 1 year and 59% at 5 years. The multivariably determined risk factors for early death and postoperative neurological dysfunction were as follows (p < 0.05) cardiac anoxic arrest time, intubation time and gender.

Is preservation of the aortic valve different between acute and chronic type A aortic dissections?

OBJECTIVES: In repair of acute type A aortic dissection, the type of proximal repair of the ascending aorta has been of great interest; however, very few reports are available regarding this issue in chronic aortic dissection. The surgical strategies for proximal repair in chronic dissection may not the same as those for acute dissection. We reviewed our 10-year experience of both acute and chronic type A aortic dissections in order to elucidate the validity of valve preservation and the long-term results of aortic regurgitation (AR). METHODS: From 1990 to 1999, 93 patients (55 acute and 38 chronic dissections) underwent operation for type A aortic dissection. Five Marfan patients were included in each group. The degree of AR was evaluated by echocardiography before and after (at hospital discharge and late follow-up) operation. RESULTS: In acute type A aortic dissection (n=55), 16 patients had AR grade II or greater (29%), of whom seven had AR grade III (13%). In 29 patients, dissection was found below the sinotubular junction (STJ) and 14 patients had AR grade II or greater (48%). The aortic valve was replaced in four patients (7%), of whom three had Marfan's syndrome. Only one non-Marfan patient required aortic valve replacement because of valve stenosis. In those whose aortic valve was preserved (n=51), three patients still had AR grade II at hospital discharge, while at late follow-up, AR had deteriorated to grade III in two of them, although no reoperation has been required so far. In chronic type A aortic dissection (n=38), 14 patients had AR grade II or greater (37%), of whom 11 had AR grade III or greater (29% vs. 13% in acute dissection; P=0.051). In 15 patients, dissection was found below the STJ and 12 patients had AR grade II or greater (80% vs. 48% in acute dissection; P=0.043). The aortic valve was replaced in eight patients (21% vs. 7% in acute dissection; P=0.051), including three Marfan patients. Of those whose aortic valve was preserved (n=30), two patients required reoperation for severe AR. The freedom from postoperative AR grade III or greater was 89% at 5 years for operative survivors with acute dissection and 92% for those with chronic dissection, respectively. CONCLUSIONS: This retrospective study suggests that preservation of the aortic valve in acute type A aortic dissection is feasible in non-Marfan patients regardless of the degree of AR. In chronic dissection, aortic root replacement needs to be considered when the degree of AR is greater than moderate because of a dilated STJ and/or annulus. In both acute and chronic dissections, satisfactory mid- to long-term results with a low incidence of reoperation were obtained in those whose aortic valve was preserved.

[Chronic dissecting aneurysm of the sinus of valsalva: report of a case].

The subject was a forty five year old female who was admitted to our hospital with chief complaints of cough and thoracic distress. After detailed examination, she was diagnosed as having aneurysm of the noncoronary sinus of Valsalva and aortic regurgitation. The finding during operation showed chronic aortic dissection localized to the noncoronary sinus of Valsalva. The entry of aortic dissection was just above the noncoronary annulus, which was found to be detached and leaned to the left ventricule. An operation for aortic root replacement was performed with Carrel patch method and had a good postoperative course. Only a few reports have been made on cases of aneurysm of the noncoronary sinus of Valsalva caused by chronic regional aortic dissection.

[A case of left atrial thrombus complicated with coarctation of the aorta].

The case was a sixty one year old female who was diagnosed as having acute arterial embolism of right upper arm and underwent embectomy. The detailed examination which followed revealed left atrial myxoma and coarctation of the aorta. Due to the risk of embolism, an emergency operation was performed to install a right axillofemoral bypass with an 8 mm artificial graft. Left atrial myxoma was then excised in an operation using an artificial heart-lung apparatus. Pathological examinations of excised tumor offered no trace of tumor but only of left atrial thrombus. Postoperative results were satisfactory. The pressure difference between upper and lower arms was improved to 0.8 in pressure index from preoperative 0.5 and it became possible to control the blood pressure of upper arm within the level of 130 to 150 mmHg. Axillofemoral bypass is an effective method for a case like the above where a site of coarctation of the aorta cannot be directly repaired.

[A case of mitral valve replacement and left atrial plication for infantile Marfan syndrome with giant left atrium due to mitral valve regurgitation].

In Marfan syndrome, there is a subset, called infantile Marfan syndrome, in which the disease is diagnosed during infancy and cardiac lesions including mitral regurgitation and aortic root dilatation tend to be deteriorated rapidly. In infantile Marfan syndrome, respiratory function is sometimes impaired when skeletal abnormalities such as scoliosis and pectus excavatum are severe. In this report, we describe a 2-year and 4-months old boy with infantile Marfan syndrome who presented with severe mitral regurgitation and the collapsed left lung. In addition to the impairment of respiratory function due to severe scoliosis, the left lung was collapsed because of the compression of the left bronchus by the enlarged left atrium. The patient required mitral valve replacement concomitantly with left atrial plication, resulting in the decompression of the left bronchus and the re-expansion of the left lung. Characteristics and surgical management of infantile Marfan syndrome are discussed in this report.

[Surgery for the valvular disease in children].

We report the results and long-term follow up in 34 children (17 girls and 17 boys, aged 12 days to 13 years, average age 3.3 years, average body weight 11.7 kg) who underwent valvular surgery in the period between May 1989 and November 1996. Operative mortality was 11.8%. Actuarial survival curves (including hospital mortality) indicate a 68.6% survival rate at 5 years and that 64.7% of patients are free from reoperation at 5 years. For aortic regurgitation two patients applied aortic valvuloplasty and four applied aortic valve replacement. Nine children had aortic stenosis, three of them had balloon valvuloplasty, seven had valvotomy, two had aortic valve replacement. Ten patients were treated for mitral regurgitation. There were nine valvuloplasty and four mitral valve replacement including three times of reoperation. One membranous pulmonary atresia and seven pulmonary stenosis children had valvotomy. There were four cases of tricuspid disease. One had tricuspid valve stenosis with pulmonary stenosis, three had severe tricuspid regurgitation who applied tricuspid valve replacement. Mortality was high in the critical AS, severe MR and TVR groups. Patients who survived the surgery and had no complications showed satisfiable results.

[Aneurysm of the nonpatent ductus arteriosus in the adult--a report of the case and review of the literature].

Aneurysm of the ductus arterious in adult in rare. 28 cases have been previously reported in the Japanese literature. A new 73-year-old male case, preoperatively diagnosed and successfully repaired, are presented. The patient with hoarseness was admitted to our hospital. Contrast-enhanced CT scans and aortograms made a diagnosis for the aneurysm of the ductus arteriosus. Operation was done through left thoracotomy with the aid of partial cardiopulmonary bypass. The pulmonary arterial end of the ductus arteriosus was closed and a Ligamentum arteriosus was identified. A 3 by 2.7 cm saccular aneurysm was resected and segmental replacement of the aorta with woven dacron graft was performed. Because of it's critical location and the high incidence of complications, aneurysm of the ductus arteriosus in the adult should be surgically corrected when diagnosed.

[Early and long-term outcome for surgical treatment of acute aortic dissection].

This study was undertaken to determine the factors that influence the final outcome after the operation of acute aortic dissection. Twenty-one patients, the median age was 59 years (range 44 to 81), were operated at acute phase in 92 admitted into our hospital during the 13-year period between May 1985 and Jan. 1998. Preoperative complications included cardiac in 5 and ruptured with shock in 7, myocardial ischemia in 3 and stroke in 4. The ascending aortic reconstruction (9, 43%), ascending aorta and arch reconstruction (7, 33%) and other procedures (4, 19%) were performed using cardiopulmonary bypass with deep hypothermia and circulatory arrest or selective cerebral perfusion. The 30-day operative deaths were 6 (29%) and 5 (24%) late death occurred. Three out of 5 were aneurysm related deaths. The cause specific survival rates were 61% at 5 years and 51% at 8 years. The multivariably determined risk factors for death were as follows (p < 0.05): preoperative FDP; bleeding volume; postoperative renal complications; postoperative stroke.

[Long-term results of operation for acute type A aortic dissection].

We report results of surgical treatment in 30 patients with acute type A aortic dissection. The average age of the 25 patients without the Marfan syndrome was 59.2 (range 51-76), and male/female ratio was 11/14. The average age of the five patients with the Marfan syndrome was 36.8 (range 27-48), and male/female ratio was 2/3. As an adjunct, we used deep hypothermic circulatory arrest during ascending aortic replacement, while selective cerebral perfusion was employed during aortic arch replacement. Operative procedures for the non-Marfan patients included 14 ascending aortic replacement and 11 ascending and aortic arch replacement, while the Marfan patients underwent extensive aortic replacement that included three aortic arch replacement combined with the Bentall operation, one extensive replacement from the ascending aorta to the descending thoracic aorta and one ascending and aortic arch replacement. One patient died early after the operation and the early mortality rate was 3.3%. No patient developed new brain complication related to the operation. During the follow-up period, three patients died and two patients required a total of three subsequent distal operations. Cumulative survival rate was 89% at one year, 85% at three years, 85% at five years. Cumulative cardiovascular event-free rate was 89% at one year, 85% at three years, 77% at five years. Early and long-term results of surgical treatment for acute type A aortic dissection was satisfactory. This seems to result from the use of deep hypothermic circulatory arrest and selective cerebral perfusion as an adjunct and application of aortic arch replacement when the aortic arch is dilated or intimal tear is located in the aortic arch or more distally.

[An emergent operation for metastatic cardiac tumor of malignant cystosarcoma phyllodes].

A 47-year-old woman was transferred to our hospital under endotracheal intubation with severe hemodynamic deterioration. A left mastectomy had been performed 8 months earlier and histology of the specimen showed malignant cystosarcoma phyllodes. An angiography and echocardiography suggested massive mass of the right ventricle extending to the pulmonary artery. An emergent life-saving operation was required using cardiopulmonary bypass. A huge multilobular tumor was resected from the right ventricle through the pulmonary artery as much as possible and a tricuspid valvuloplasty was also performed. The patient was weaned from cardiopulmonary bypass, then satisfactorily recovered from hemodynamic disturbances. Nevertheless, she died 15 days later due to multiple organ failure. Microscopic examination of resected specimen showed the neoplastic stromal cells that increase mitotic activity and have sarcomatous characteristics, consistent with a metastatic cystosarcoma phyllodes. This is a second case of operation for cardiac metastasis of cystosarcoma phyllodes using cardiopulmonary bypass, so far presented in the literature of the world reviewed by the authors.

[Primary leiomyosarcoma of the heart, report of a case and review of the literature].

Primary cardiac neoplasms are unusual and are found in only about 0.0017% of autopsies. Approximately 25% of primary cardiac neoplasms are malignant. A case of primary leiomyosarcoma arising from the right ventricle and the pulmonary artery is reported. A 37-year-old man had sudden dyspnea and chest pain. Angiocardiography and MRI revealed moving masses throughout the right ventricle and the pulmonary arteries. An emergent surgery was performed. The multiple tumors were observed and incomplete resection was done. The patient was survived with the aid of a veno-arterial bypass as an assisted circulation on the first postoperative day. However, he gradually became deteriorated again and died 8 days after the operation due to the right ventricular failure. Eleven cases of the primary cardiac leiomyosarcoma including our case in the Japanese literature were reviewed briefly.

[The surgical results of aged thoracic aortic aneurysm].

Eighty-five patients with thoracic aortic aneurysm (TAA) (36 dissection, 49 non-dissection) underwent surgical intervention in our service from December 1985 to March 1997. 31 patients aged over 70 (aTAA) were compared with 54 patients under 69 years of age (non-aTAA) about preoperative condition, surgical invasion, and operative morbidity and mortality. No significant differences were observed in preoperative associated condition and laboratory data between two groups except more non-dissection were included in aTAA (74.2%) than non-aTAA (48.1%). There were no significant differences in intraoperative variables and endotracheal intubation time and ICU staying time were shorter in aTAA (not significant). No significant differences were revealed in operative morbidity, mortality and five-year actual survival rate between two groups. 16.1% of early mortality and 9.7% of hospital mortality for operated aTAA were acceptable, which let us conclude that aTAA must be operated positively before rupture by careful selection considering life expectancy, evaluation of risk factors or reserved physiological status, and surgical invasion.

[Candida costochondral osteomyelitis, report of a case and review of the literature].

A 49-year-old man was admitted to the hospital with swelling and redness overlying the left anterior chest wall. He had been treated by percutaneous transluminal coronary recanalization for acute myocardial infarction with central venous catheter one year and four months earlier. Since then, he had had no symptoms. An incision and drainage was performed and specimen showed acute and chronic granulation tissue containing pus with involvement of underlying left third rib and cartilage. Candida albicans was cultured from the drainage specimen. Treatment with fluconazole was began. The lesion failed to clear following incision and drainage, continuing to exude pus, then open surgical excision and curettage of the cartilage and rib was performed. After 2 months of therapy, the lesion had resolved. This is a rare case of candida costochondral osteomyelitis without a definite proof of former hematogenous candida infection.

Resection of hepatoblastoma with right atrial extension using cardiopulmonary bypass.

A 3-year-old boy underwent a successful combined resection of a hepatoblastoma and its intracaval right atrial extension using a cardiopulmonary bypass. This type of extension is extremely rare in hepatoblastoma. The cardiopulmonary bypass enabled complete resection of the intracardiac mass of the hepatoblastoma. In addition, dissection and ligation of the right hepatic vein under cardiopulmonary bypass made the following right hepatectomy easy and safe.

[Clinical study on measurement of cerebral metabolism and oxygenation during cardio-pulmonary bypass by near-infrared spectrophotometry].

We studied the non-invasive method of monitoring of cerebral metabolism and oxygenation of patients mainly with thoracic aortic aneurysm during Cardio-pulmonary bypass (CPB) by Near-infrared Spectrophotometry (NIRS) to establish the safety limits of cerebral perfusion. NIRS monitoring of all 12 patients showed that cerebral oxygenation levels were maintained within the pre-CPB range when mean arterial perfusion pressure (MAPP) was above 60 mmHg. With considering rectal temperature, the cerebral oxygenation levels were maintained above the pre-perfusion baseline when MAPP was above 50 mmHg at rectal temp. < or = 25 degrees C, and 73 mmHg at > or = 25 degrees C. It was suspected that cerebral autoregulatory mechanism could exist even in hypothermia (< or = 25 degrees C) because cerebral oxy-Hb and blood volume was significantly declined when MAPP was reduced to 40 mmHg or less. In 5 patients who underwent selective cerebral perfusion, the base line level of blood volume was preserved when the perfusion flow rates were above 0.5l/min, and the desirable oxy-Hb levels were obtained when the flow rates were above 0.4l/min. During deep hypothermic circulatory arrest (18 degrees C), cerebral oxy-Hb level was gradually reduced from baseline, reflecting proceeding metabolic activity even in profound hypothermia. These findings led us to conclude that non-invasive, continuous, and direct monitoring of cerebral oxygenation using NIRS can provide valuable data to prevent cerebral injury after CPB. It is hoped that the safety limits of cerebral perfusion and circulatory arrest can be established in the future using multiple analysis of pressure, flow, temperature, Hb concentration and so far by NIRS.

[Closing aortic dissection--it's clinical manifestation and treatment].

15 cases (31.6%) with closing aortic dissection have been experienced among 46 cases in acute dissecting aneurysm of the aorta during past 8 years and 9 months. Ulcer like projection was recognized in 81.8% of closing aortic dissection. Serum FDP level measured within 48 hours after onset was significantly lower and serum fibrinogen level was significantly higher in closing aortic dissection than in patent false lumen type. Especially, the case with FDP < or = 10 micrograms/ml, fibrinogen > or = 300 mg/dl is strongly suspected as closing aortic dissection. There was no death among patients with closing aortic dissection except one who died after operation at chronic phase. These patients were well controlled by medical therapy except one who received emergent operation. We showed 3 interesting cases with Stanford A type closing aortic dissection. One patient was treated surgically because of cardiac tamponade and shock, but the other two patients were treated medically. From these results, we conclude that medical therapy should be a first choice for patients with closing aortic dissection regardless of Stanford classification.

[Experience with a operated cervico-mediastinal neuroblastoma in infant].

Cervical neuroblastoma is relatively rare and shows very good prognosis. We reported a case of surgically resected cervico-mediastinal neuroblastoma. A 7-month-old boy was pointed out to have Horner syndrome (right ptosis and anhidrosis) and an abnormal shadow at right cervico-mediastinum on chest X-ray film during his stay in another hospital because of acute bronchitis. On examination after admission in our hospital, 3 x 4 cm size mass was palpated at the right neck and urine VMA and HVA level were elevated. The close examination demonstrated no sign of tumor in any other organ and tissue, which suggested that the tumor was cervical origin. 9 x 5, 5 x 3 cm tumor was almost removed and patient received chemotherapy. He is now free from disease at 1 year after operation.

[Two cases of thymic cysts and review of the 220 Japanese cases].

Thymic cyst is relatively rare disease among mediastinal tumors. We reported two cases of surgical resected thymic cysts. Case 1: A 72-year-old female was found to have an abnormal shadow at right cardio-phrenic angle on chest X-ray film. Operative and pathological diagnosis was thymic cyst. Immunohistochemical study showed the epithelial cells lining the cyst to contain keratin and CEA but not CA19-9. Case 2: A 67-year-old male was pointed out to have an abnormal shadow at left mediastinum on a chest X-ray film during his stay in our hospital for acute myocardial infarction. Preoperative diagnosis was made to be a thymic cyst and operation was done. Pathological diagnosis was the same. Behçet's disease was accompanied in this patient. It is very rare to be complicated with thymic cyst. We reviewed 220 operated cases of thymic cyst in the Japanese literature.