Early and late outcomes of inflammatory abdominal aortic aneurysms: comparison with the outcomes after open surgical and endovascular aneurysm repair in literature reviews.

AIM: The aim of this study was to analyze the clinical characteristics, operative management and early and late outcomes of Inflammatory abdominal aortic aneurysms (IAAAs) in our vascular service, retrospectively and to compare with the outcomes of open and endovascular aneurysm repair (EVAR) in the patients with IAAAs in literature reviews. METHODS: Between January 1990 and December 2011, this series included twenty-four patients with IAAAs who underwent surgical treatment. The mean length of follow-up was 37.6 months (range 3-108). Kaplan-Meier life tables were used to calculate survival rate. RESULTS: Fifteen patients (60%) were symptomatic including 3 patients with hydronephrosis. Seven patients with severe symptoms underwent emergency operations. Twenty four patients underwent open surgical AAA repair. The 30 - day mortality rates were 0%. All patients had successful post operative courses and followed as outpatients in an elective situation. The ten year cumulative survival rate was 70%. The early and late mortality was the same for open repair compared to non-inflammatory AAA. CONCLUSIONS: IAAA compared with non-IAAA is associated with a higher incidence of preoperative morbidity, however operative mortality rates are lower. EVAR has lower early operative mortality rates, however, there are some problems such as remaining periaortic fibrosis and hydronephrosis in approximately half of IAAA patients after EVAR.

Postoperative early hemolytic anemia due to inverted teflon felt strip after emergency repair for type A dissection.

A 39-year-old man underwent emergency surgery for type A acute aortic dissection complicated by paraplegia. However, hemolytic anemia increased significantly due to severe stenosis of the proximal anastomosis one month after surgery. He finally underwent a redo procedure 4 months after the initial operation whereupon it was verified that half of the inner felt strip used for proximal stump fixation had turned up and was protruding into the inner lumen. We report here on a rare case of survival of postoperative early hemolytic anemia due to severe graft stenosis caused by an inverted inner Teflon felt strip without any extra vascular compression.

Field Application of Calcium to Reduce Phytophthora Stem Rot of Soybean, and Calcium Distribution in Plants.

The effect of calcium compounds [Ca(HCOO)2-A and Ca(NO3)2] on the incidence of Phytophthora stem rot of soybean (Glycine max) cv. Tanbakuro was investigated in the field. Disease incidence in control plants in three fields naturally infested with Phytophthora sojae ranged from 11.7 to 52.0% at 140 days after transplanting. Independent of the pathotype diversity, 4 and 10 mM of the calcium compounds applied twice (prior to transplanting and 14 days after transplanting) significantly suppressed disease incidence and delayed onset. Ca(HCOO)2-A (Suicaru) was more effective than calcium nitrate for reducing disease incidence. In most cases, the calcium amendments increased plant height, number of nodes and pods, and seed yields, and reduced low-quality seeds. Scanning electron microscopy with fresh samples showed increased accumulation of calcium crystals around the cambium and xylem elements of soybean plants treated with 10-mM Ca(HCOO)2-A and Ca(NO3)2. Mycelial penetration was inhibited at these sites. These results indicated that calcium-rich areas may be more resistant to invasion by P. sojae, and the calcium crystals may play an important role in calcium ion storage and its availability for those tissues to maintain long-term field resistance.

The G1556S-type tuberin variant suppresses tumor formation in tuberous sclerosis 2 mutant (Eker) rats despite its deficiency in mTOR inhibition.

Tuberin, a tumor-suppressor protein produced by the tuberous sclerosis gene TSC2, downregulates the Rheb-mTOR-S6K pathway (mTOR axis). Comparison of the effects of human tuberin mutations, such as G1556S, suggests that pathways other than the mTOR axis might also be involved in the pathogenesis of tuberous sclerosis. Here we test this possibility using the rat G1556S-type mutation (GSM) and a transgenic Eker (Tsc2 mutant) rat system. Cells expressing GSM-tuberin failed to downregulate the mTOR axis. GSM-tuberin had an altered localization, which underlie its reduced ability to form a complex with hamartin, and a site-specific alteration in phosphorylation status indicating diverse regulation by Akt. GSM-transgenic (GSM-Tg) rats exhibited suppression of macroscopic renal tumors following N-ethyl-N-nitrosourea treatment. Intriguingly, rats with weaker GSM-Tg expression showed microscopic cystic and pre-tumorous lesions that were restricted in size and expansion, although they had hyper-phosphorylation of ribosomal protein S6. These results highlight a novel pathway involving tuberin that regulates tumor suppression independently of the mTOR inhibitory function. Identification of such a novel pathway will provide clear implications for generation of new therapeutic targets in the treatment of these tumors.

Interaction of folliculin (Birt-Hogg-Dubé gene product) with a novel Fnip1-like (FnipL/Fnip2) protein.

Birt-Hogg-Dubé (BHD) syndrome is characterized by the development of pneumothorax, hair folliculomas and renal tumors and the responsible BHD gene is thought to be a tumor suppressor. The function of folliculin (Flcn), encoded by BHD, is totally unknown, although its interaction with Fnip1 has been reported. In this study, we identified a novel protein binding to Flcn, which is highly homologous to Fnip1, and which we named FnipL (recently reported in an independent study as Fnip2). The interaction between FnipL/Fnip2 and Flcn may be mediated mainly by the C-terminal domains of each protein as is the case for the Flcn-Fnip1 interaction. FnipL/Fnip2 and Flcn were located together in the cytoplasm in a reticular pattern, although solely expressed Flcn was found mainly in the nucleus. Cytoplasmic retention of Flcn was canceled with C-terminal truncation of FnipL/Fnip2, suggesting that FnipL/Fnip2 regulates Flcn distribution through their complex formation. By the employment of siRNA, we observed a decrease in S6K1 phosphorylation in the BHD-suppressed cell. We also observed a decrease in S6K1 phosphorylation in FNIP1- and, to a lesser extent, in FNIPL/FNIP2-suppressed cells. These results suggest that Flcn-FnipL/Fnip2 and Flcn-Fnip1 complexes positively regulate S6K1 phosphorylation and that FnipL/Fnip2 provides an important clue to elucidating the function of Flcn and the pathogenesis of BHD.

[Reoperation for a Starr-Edwards ball valve prosthesis implanted in mitral position 31 years ago].

The patient is a 61-year-old woman who had undergone mitral valve replacement with the Starr-Edwards cloth-covered ball valve 31 years ago. She had dyspnea on effort 1 month before admission. The echocardiography revealed mitral and tricuspid regurgitation. Re-replacement of the mitral prosthetic valve with an ATS valve and tricuspid annuloplasty were successfully performed without any complication. The cloth wear of the Starr-Edwards ball valve cage was recognized and no thrombus was found at operation. To our knowledge, there has been no such a reoperative case who underwent so long postoperative period after initial implantation of the Starr-Edwards ball valve in Japan. This experience made us realize again the importance of attention to the complications related to a prosthetic valve like a cloth wear during long-term follow-up for the Starr-Edwards ball valve.

The estimation of cardiac function from the rotary blood pump.

The rotary blood pump is implanted as a bridge to cardiac transplantation. Mechanical, histological, and biochemical improvements have been described in patients after implantation of left ventricular assist devices (LVADs). Thus, the rotary blood pump might be used as a bridge to recovery of myocardial function. However, unlike a pulsatile pump, the rotary blood pump cannot be stopped to estimate cardiac function: if the rotary blood pump stops, backflow will occur. In this study, a new method that can estimate cardiac function without pump stop was examined. Six pigs were the subjects of this acute study. The pump was implanted as an LVAD: the inlet cannula was inserted into the left ventricle, and the outlet cannula was inserted into the ascending aorta. The motor speed was regulated at a pump flow rate of 0 L/min at diastolic phase. Then, the relationship between the dp/dt of left ventricular pressure and external stroke work of actuator was examined. This method was studied at normal, hyperdynamic, and heart-failure conditions. There was a high positive correlation between the dp/dt of left ventricular pressure and external stroke work of actuator. This method is useful and simple to estimate cardiac function without pump stop.

Effects of left ventricular assist device on cardiac function: experimental study of relationship between pump flow and left ventricular diastolic function.

The left ventricular assist device (LVAD) with centrifugal pump has two characteristics. One is a pump flow wave of the centrifugal pump, consisting of the pulsatile flow of the native heart and the nonpulsatile flow of the centrifugal pump. The other is that the centrifugal pump fills from the native heart not only in the systolic phase, but also in the diastolic phase. In the case of the apex outlet LVAD with centrifugal pump, blood flows from the left atrium through the left ventricle to the pump. Pump flow is regulated by preload, and preload is regulated by diastolic hemodynamics. The aim of this study is to analyze the relationship between pump flow and the diastolic hemodynamics of the native heart. Ten anesthetized intact pigs were studied after placement of an LVAD. Data were recorded with the LVAD off (control) and the LVAD on. The assist rate was changed to 25%, 50%, and 75%. The indexes of left ventricular (LV) diastolic function included LV myocardial relaxation (time constant of isovolumic pressure decay [Tau] and maximum negative dP/dt [LV dP/dt min]) and LV filling (peak filling rate [PFR], time to peak filling rate [tPFR], and diastolic filling time [DFT]). Stroke volume decreased significantly in 75% assist. LV end-systolic pressure decreased significantly in 50% and 75% assist. LV end-diastolic volume decreased as assist rate increased, but there were no significant changes. Stroke work decreased significantly in 50% and 75% assist. LV dP/dt min decreased significantly in 50% and 75% assist. Tau prolonged as assist rate increased, but there were no significant changes. DFT shortened significantly in 75% assist. PFR increased significantly in 75% assist. tPFR shortened significantly in 50% and 75% assist. In this study, LV relaxation delayed as an increasing of pump assist rate, but it suggested a result of reduction of cardiac work. Also, it was suggested that LVAD increases the pressure difference between the left atrium and the left ventricle in the diastolic phase. This phenomenon is due to the filling of the left ventricle. In this study it was suggested that as pump assist rate increases, it is more effective to keep cardiac function in the diastolic phase.

Evaluation of St. Jude Medical valve's long-term function by Doppler echocardiography.

In this study, the long-term function of St. Jude Medical valve (SJM valve) is evaluated by Doppler echocardiography. The subjects were 191 patients who underwent mitral or aortic valve replacement using SJM valve in our institute since July 1978 and had no clinical problem showing more than 50% of left ventricular ejection fraction. The patients were classified into 3 groups according to measurement period (within 5 years, 10 years and 15 years and more), and further classified by size and their results were compared. In every group by size, there was no significant difference among groups by measurement period. In the mitral valve position, peak pressure gradient and pressure half-time were not significantly different among groups by size. On the other hand, in the aortic valve position, pressure gradient in 21-mm group was significantly high among 21-mm, 25-mm, and 27-mm groups, showing a negative correlation with size. As the result, it was suggested that SJM valve kept a good function more than 15 years after operation. From these results, it was considered that the patients with small annlus of the aortic valve needed annulus-enlarging procedure or use of Hemodynamic Plus series valves to keep the size of more than 23 mm.

Doppler echocardiographic evaluation of St. Jude Medical valves in the tricuspid position: criteria for normal and abnormal valve function.

BACKGROUND: Although this examination for mitral and aortic prosthetic valves has been frequently reported to be available for the early diagnosis of complications, there are few reports on examinations for tricuspid prosthetic valves, particularly the mechanical valve such as the St. Jude Medical (SJM) valve. Furthermore, the criteria for early diagnosis of complications are unknown. The purpose of this study is to evaluate the SJM valve in the tricuspid position by Doppler echocardiography and to analyze valve-related complications. METHODS: Between September 1978 and March 1997, 46 patients underwent tricuspid valve replacements with SJM valves; these cases were evaluated by Doppler echocardiography. We divided the cases into Normal and Complication groups. RESULTS: In the Normal group, peak pressure gradient was 4.2+/-1.5 mmHg and pressure half-time was 123.5+/-22.9 msec. In the Complication group, peak pressure gradient was 12.7+/-3.6 mmHg and pressure half-time was 271.8+/-76.4 msec. In the Complication group, the lowest peak pressure gradient case was 8.0 mmHg and the shortest pressure half-time was 160.0 msec. CONCLUSIONS: We concluded that when the peak pressure gradient is more than 8 mmHg or the pressure half-time is more than 160 msec, there is a possibility of complications. Despite the problems, the absence of any structural change after more than ten years suggests that the SJM valve can be used in the tricuspid position with careful follow-up.

Transfer of canine embryos at various developmental stages recovered by hysterectomy or surgical uterine flushing.

In dogs, embryo transfer (ET) techniques such as induciton of excessive ovulation and synchronization of estrus have not progressed well. Therefore, using embryos at various developmental stages, ET was investigated in dogs from a beagle colony in which the ovulation days were close, as estimated by the progesterone level. Embryos were, recovered 8-11 days after ovulation (4-9 days after mating) by excising the oviducts and uteri (excision method) in 16 animals and by surgical flushing of the uteri at laparotomy (surgical method) in 3 animals. In 24 dogs with -4 to +2 days of difference in the timing of ovulation between donor and recipient dogs, 1-10 embryos at the 8-cell to blastocyst stages were transferred per animal. The mean embryo recovery rate by the excision method (97.1%) was significantly higher than that by the surgical method (42.5%) (p<0.01). Twelve (57.1%) of 21 animals with -1 to +2 days difference in ovulation day became pregnant after the transfer of 8-cell to blastocyst stage embryos. Although 3 dogs with -4 to -2 days of difference of ovulation day underwent ET of morula or compacted morula, none of these dogs became pregnant. The mean ratio of the number of newborns to the number of transferred embryos was only 51.9%. The mean duration of the period between ovulation and delivery in the pregnant recipients was 65.8 days, which tended to be longer than that in natural mating. These results demonstrate that pregnancy can be induced by ET at the 8-cell to blastocyst stage in dogs with -1 to +2 days difference in ovulation day.

Caged and clustered structures of endothelin inhibitor BQ123, cyclo(-D-Trp-D-Asp--Pro-D-Val-Leu-)-Na+, forming five and six coordination bonds between sodium ions and peptides.

BQ123 is a cyclic pentapeptide and a potent endothelin-1 inhibitor. The crystal structure of the BQ123 sodium salt was determined as the first example of an endothelin inhibitor. Four independent molecules and many solvent molecules were found in the asymmetric unit; the total weight was about 3000 Da. The precise structure including the solvent molecules was determined using high-resolution data collected on a synchrotron source. Sodium ions formed unique structures with five and six coordination bonds and their forms were distinguished into three classes. An ion was sandwiched by two BQ123 molecules. This peptide-sodium (2:1) complex showed a cage-like structure and octahedral coordination was observed. Sodium ions also formed a cluster composed of hydrated water molecules and peptides. Two sodium ions were contained in this cluster, making five coordination bonds. Despite having the same coordination numbers, these ions were distinguishable by differences in the polyhedra. One was trigonal bipyramidal (having six planes) and the other was square pyramidal (having five planes). Both shapes were very similar to each other, although the synchrotron data clearly revealed slight geometrical differences.

Ab initio structure determination of icosahedral Zn-Mg-Ho quasicrystals by density modification method.

A novel density modification method is applied for the first time to phase reconstruction of x-ray single crystal data of quasicrystals. The structure of icosahedral Zn-Mg-Ho quasicrystals has been determined by means of this ab initio structure determination within a framework of a 6D description. The location, size, and shape of the occupation domains are deduced. The suggested Ho sites in the 3D structure are consistent with the results of magnetic diffuse scattering [T. J. Sato et al., Phys. Rev. Lett. 81, 2364 (1998)].

Ab initio structure determinations by direct-space methods: tests of low-density elimination.

The low-density elimination method, which was developed for phase extension and refinement, has been investigated regarding its power to solve crystal structures starting from completely random phase sets. The method employs a multi-solution strategy. Low-symmetry structures are easily solvable where phase restrictions are only applied to a few reflections. Even with high-symmetry structures, a reasonable solution was obtained regarding centric reflections as general reflections. It is also shown that the structure of a small protein ribonuclease Ap1 is solvable if the positions of the five S atoms in the protein are known.

Strategy of circulatory support with percutaneous cardiopulmonary support.

We evaluated the efficacy and problems of circulatory support with percutaneous cardiopulmonary support (PCPS) for severe cardiogenic shock and discussed our strategy of mechanical circulatory assist for severe cardiopulmonary failure. We also described the effects of an alternative way of PCPS as venoarterial (VA) bypass from the right atrium (RA) to the ascending aorta (Ao), which was used recently in 3 patients. Over the past 9 years, 30 patients (20 men and 10 women; mean age: 61 years) received perioperative PCPS at our institution. Indications of PCPS were cardiopulmonary bypass weaning in 13 patients, postoperative low output syndrome (LOS) in 14 patients, and preoperative cardiogenic shock in 3 patients. Approaches of the PCPS system were the femoral artery to the femoral vein (F-F) in 21 patients, the RA to the femoral artery (RA-FA) in 5 patients, the RA to the Ao (RA-Ao) in 3 patients, and the right and left atrium to the Ao in 1 patient. Seventeen (56.7%) patients were weaned from mechanical circulatory support (Group 1) and the remaining 13 patients were not (Group 2). In Group 1, PCPS running time was 33.1 +/- 13.6 h, which was significantly shorter than that of Group 2 (70.6 +/- 44.4 h). Left ventricular ejection fraction was improved from 34.8 +/- 12.0% at the pump to 42.5 +/- 4.6% after 24 h support in Group 1, which was significantly better than that of Group 2 (21.6 +/- 3.5%). In particular, it was 48.6 +/- 5.7% in the patients with RA-Ao, which was further improved. Two of 3 patients with RA-Ao were discharged. Thrombectomy was carried out for ischemic complication of the lower extremity in 5 patients with F-F and 1 patient with RA-FA. One patient with F-F needed amputation of the leg due to necrosis. Thirteen patients (43.3%) were discharged. Hospital mortality indicated 17 patients (56.7%). Fifteen patients died with multiple organ failure. In conclusion, our alternate strategy of assisted circulation for severe cardiac failure is as follows. In patients with postcardiotomy cardiogenic shock or LOS, PCPS should be applied first under intraaortic balloon pumping (IABP) assist for a maximum of 2 or 3 days. In older aged patients particularly, the RA-Ao approach of PCPS is superior to control flow rate easily, with less of the left ventricular afterload and ischemic complications of the lower extremity. If native cardiac function does not recover and longer support is necessary, several types of ventricular assist devices should be introduced, according to end-organ function and the expected support period.

Two cases of quadricuspid aortic valve: preoperative diagnosis and surgical treatment.

Two cases of severe aortic regurgitation were treated surgically. Both patients had a quadricuspid aortic valve, which was diagnosed preoperatively by aortography and/or transesophageal echocardiography (TEE). In the first patient, both aortic and mitral valve replacement were performed with an ATS prosthetic valve. In the second patient, only aortic valve replacement was performed. The postoperative course was uneventful in both cases. Quadricuspid aortic valve is relatively rare. We discuss the preoperative diagnosis of quadricuspid aortic valve, as well as reviewing the relevant literature.

Jostra Rota Flow RF-30 pump system: a new centrifugal blood pump for cardiopulmonary bypass.

The Rota Flow pump is a fully integrated centrifugal pump system in the Jostra heart-lung machine HL-20 with features such as a less friction mono-pivot bearing system, sealless pump housing, and spiral housing. To evaluate its biocompatibility, antithrombogenesity, and hemolysis, we used it as a main pump of cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) cases and compared it with the BioMedicus pump. From February 1999 to May 1999, 30 consecutive patients underwent CABG under conventional CPB. Fifteen cases were supported by the Rota Flow RF-32 (Group R), and the remaining 15 were pumped by the BioMedicus BP-80 (Group B). In both groups, the flow rate was controlled in an equivalent value. Blood sampling was as follows: preoperative, 60 min after, postoperative Days (POD) 0, 1, and 2. We evaluated the plasma free hemoglobin (fHb) as the hemolysis parameter, beta-thromboglobulin (beta-TG) and platelet factor IV (PF-4) as the platelet deterioration index, C3, C4, and CH50 as complement activation, coagulation function, fibrinolytic factor and thrombomodulin, nitric oxide (NO), and endothelin as endothelial deterioration. This system was very easily and simply controlled and had excellent response. Perioperative laboratory data were not markedly changed in either group. The Rota Flow demonstrated equivalent value of biocompatibility and hemolysis as compared with the BioMedicus BP-80, which is a standard centrifugal pump. After pumping, no thrombus formation or pivot wear was observed inside the pump. This atraumatic, small centrifugal pump is suitable not only for CPB but also for long-term circulatory support.

Pathological findings of tissue reactivity of gelatin resorcin formalin glue: an autopsy case report of the repair of ventricular septal perforation.

A seventy-three-year-old man was treated for ventricular septal perforation with Gelatin Resorcin Formalin (GRF) glue. The patient died of multiple organ failure 36 days after the surgery. In autopsy, macroscopically, the inferior wall was reconstructed successfully by the GRF glue. Furthermore, microscopic study revealed the excellent growth of collagen and elastic fiber where the GRF was glued. No infiltration of inflammatory cells was evident. There have been no reports that the safety and efficacy of GRF glue was pathologically proven in an autopsy case.

Removal of a chronically infected bipolar pacemaker electrode: a successful case report.

A chronic infected bipolar pacemaker electrode with a fin tip was successfully removed 7 years and 9 months after its original implantation from a 72-year-old Japanese man, using the Cook pacemaker lead extraction system. The locking stylet could not advance to the lead tip over the positive pole because of firm adhesions. Because the scar tissue between the positive pole and myocardium could not be freed by the inner sheath, it was disrupted by the slanted end of the outer sheath. The firmest adhesion was on the positive pole, not on the fin tip. The complete extraction success rate of bipolar tined or fin leads is worse than for other types of leads. When extracting a bipolar pacemaker lead, dissection of the positive pole from scar tissue should be taken into account in addition to the lead tip. Rotating the slanted end of the outer sheath is a useful technique when dissecting firm adhesions.

Low-dose continuous infusion of human atrial natriuretic peptide during and after cardiac surgery.

BACKGROUND: We evaluated the effects of human atrial natriuretic peptide (hANP) during cardiopulmonary bypass (CPB). METHODS: Forty patients undergoing coronary artery bypass grafting were investigated. A group of patients given hANP for 24 hours from the start of CPB (hANP group) was compared with a non-hANP group. Parameters examined were hemodynamics, urine volume, dosage of furosemide, respiratory index, pleural effusion, ANP, cyclic guanosine monophosphate, renin activity (renin), angiotensin-II, aldosterone, and glomerular filtration rate. RESULTS: Central venous pressure, systemic vascular resistance index, and pulmonary vascular resistance index were significantly lower in the hANP group than in the non-hANP group. The hANP group showed significantly higher levels of ANP, cyclic guanosine monophosphate, glomerular filtration rate, and respiratory index, and significantly lower levels of renin, angiotensin-II, aldosterone, and pleural effusion, as compared with the non-hANP group. The dosage of furosemide was significantly lower and the urine volume was significantly larger in the hANP group. CONCLUSIONS: hANP can satisfactorily compensate for the shortcomings of CPB by decreasing the peripheral vascular resistance, suppressing the renin-angiotensin-aldosterone system, and exerting a strong diuretic effect.