[A case of double mitral valve with severe mitral regurgitation detected by transesophageal echocardiography].

A 66-year-old woman with double mitral valve (bridge type) and severe mitral regurgitation by spontaneous ruptured chordas is reported. The case with this combination has not been reported in the literature. She had not any other congenital heart diseases. The mitral valve was clearly shown by two-dimensional Doppler transesophageal echocardiography. Mitral valve replacement with Medtronic-Hall valve was carried out successfully.

Myocardial damage caused by free radicals in experimentally induced myonephropathic metabolic syndrome in dogs.

Myocardial damage was studied in the dog heart with experimentally induced myonephropathic metabolic syndrome (MNMS). The animals underwent a ligation of the infrarenal arteries with a re-establishment of arterial flow 5 hours after the operation (group 1) and all showed the typical phenomena of MNMS and revealed basophilic changes in the myocardial cells fixed with 4 per cent formalin in 2 per cent calcium acetate. These degenerated cells were distributed in either the left or right ventricle, or even in both as several foci composed of a considerable number of the myocardial cells. Most of these cells showed a significantly enhanced expression of immunoreactive copper-zinc superoxide dismutase in their sarcoplasm. With luxol fast blue staining, the basophilic myocardial cells appeared to be deep blue in color which indicated an accumulation of phospholipid. Such basophilic cells in the animals undergoing a sham operation (group 2) were only sporadically observed in the myocardium fixed with the same fixative. The present study including morphological procedures indicates that dog MNMS causes severe myocardial damage with superoxidation due to an excessive production of free radicals after the re-establishment of arterial flow.

Analysis of perioperative ventricular arrhythmias in valvular heart diseases by Holter ECG recording.

Seventy-one consecutive patients undergoing cardiac surgery for acquired valvular diseases were analyzed to determine the incidence of and the predisposing factors to postoperative ventricular arrhythmias. We recorded the Holter ECGs before (pre-op), and within 24h (op-day) and 4 to 10 weeks after operation (post-op) and determined the frequency of ventricular arrhythmias and the degree according to the Lown grade. The relationship between the op-day ventricular arrhythmias and clinical, hemodynamic, operative or postoperative variables was examined. The operation included mitral valve replacement or open mitral commissurotomy (49 patients, group M), aortic valve replacement (12 patients, group A) and a combined mitral and aortic operation (10 patients, group A + M). In all groups, the frequency and the degree of ventricular arrhythmias increased at the op-day and decreased at the post-op period approximately to the pre-op level. The frequency and Lown grade of the 3 groups were similar in each of the pre-op, the op-day and the post-op periods. The frequency and Lown grade of the op-day ventricular arrhythmias increased with increases in the arrhythmia frequency and Lown grade at the pre-op period, and in patients with left ventricular (LV) dysfunction at the post-op period, as evidence by an increased LV volume and decreased ejection fraction on echocardiograms. Furthermore, the frequency of ventricular premature contractions in the op-day was significantly less when a cardioplegia solution containing magnesium was used than in the case of a cardioplegia solution without magnesium. The op-day ventricular arrhythmias showed no significant relation to extracorporeal circulation time, aortic cross-clamping time, the antiarrhythmic drugs used and the op-day serum levels of K and CK-MB.

[Extended left atriotomy by temporary division of the superior vena cava].

The extended left atriotomy which combine the standard approach with the superior approach by concomitant temporary division of the superior vena cava is a safe and useful method especially in the case of small atrium or in the case of having anatomically abnormal situation of the left atrium. The technical detail was introduced here, and it is a modification of that reported by Selle and Kyger. We used this technique in three cases. The first was corrected transposition of the great arteries which required prosthetic replacement of the left sided atrioventricular valve. The second and third cases were mitral valve insufficiency with small left atrium which were performed mitral annuloplasty and caspal repair. All three patients have done well without SVC stenosis and perioperative morbidity like arrhythmia or bleeding.

[A case of left atrial ball thrombus without mitral disease].

A 65-year-old man who had a left atrial ball thrombus without mitral disease is reported. Ultrasonic cardiogram gave this diagnosis. His ECG showed atrial fibrillation and severe bradycardia. Thrombus attached to the left appendage with short stalk was removed under extracorporeal circulation and a pacemaker (VVI mode) was implanted. Postoperative course was not eventful.

Extracorporeal circulation for the removal of serum myoglobin in experimentally induced myonephropathic metabolic syndrome in dogs.

The removal of serum myoglobin with extracorporeal circulation using a column filled with methylmethacrylate-divinylbenzene (MMA-DVB) was studied in experimentally induced myonephropathic metabolic syndrome in the dog. All animals showed marked edema in the hind limbs and degeneration or necrosis of the adductor muscle 5 hours after the reestablishment of arterial flow. The serum levels of myoglobin, creatinine phosphokinase, glutamic oxaloacetic transaminase and aldolase increased linearly after the reperfusion of blood in the group of animals which received no extracorporeal circulation (group 1). Sediments of numerous myoglobin casts in the renal tubules and immunoreactive myoglobin in the renal epithelium of almost all the tubules were seen in 4 out of 5 cases. In the group of animals reperfused with extracorporeal circulation using the MMA-DVB column, serum myoglobin was adsorbed selectively by the column and showed a significantly lower value at 0.5, 1, 2 and 3 hours than that of the group 1 animals. Concomitantly, the immunoreactive myoglobin was absent or scant in the renal epithelium of the proximal convoluted tubule. The present study therefore indicates that extracorporeal circulation using the MMA-DVB column is useful for the removal of serum myoglobin from experimentally induced myonephropathic metabolic syndrome.

[The 19mm St. Jude Medical prosthetic aortic valve evaluated by long-term hemodynamic sequelae].

To assess the usefulness of the 19 mm St. Jude Medical (SJM) aortic valve prosthesis for cases of small aortic annulus, post-operative evaluations of pressure gradient of the prosthesis (AVR) and left ventricular (LV) function were performed using bicycle ergometric exercise tests. Seven patients who underwent AVR with 19 mm SJM (19 mm group) and eight control subjects whose SJM was greater than 21 mm in diameter were observed. LV function was assessed by the M-mode echocardiography and the pressure gradients of the prosthesis by the continuous wave Doppler echocardiography. The results were as follows: 1. Mean body surface area (BSA) was 1.35 m2 in the 19 mm group and 1.52 m2 in the control group (p less than 0.01). 2. NYHA functional classes improved equally in both groups after surgery. 3. The post-operative cardiac index at rest measured by cardiac catheterization significantly improved in both groups after surgery. 4. Results of the exercise tests: 1) Left ventricular end-systolic volume index (LVESVI) was decreased on exercise in both groups: from 21.3 to 18.0 ml/m2 in the 19 mm group (p less than 0.01) and from 21.5 to 17.0 ml/m2 in the control group (p less than 0.01). 2) Ejection fraction and fractional shortening significantly increased in both groups on exercise. 3) The pressure gradients significantly increased on exercise in both groups: from 30.4 to 38.3 mmHg in 19 mm group (p less than 0.01) and from 28.8 to 36.6 mmHg in the control group (p less than 0.01). Although the pressure gradients were greater in the 19 mm group, there were no significant differences between the two groups at rest and on exercise. It was concluded that the 19 mm SJM aortic valve prosthesis was acceptable in size for small aortic annulus in elderly women whose body surface area was less than 1.47 m2.

The distribution and structure of the lymphatic system in dog atrioventricular valves.

A morphological study of the lymphatic system in atrioventricular (AV) valves of adult dogs and puppies was carried out using a series of techniques including India ink injection, a hydrogen peroxide technique, light microscopy, and electron microscopy. Lymphatic capillaries were found in all cusps of the AV valves, and were shown to extend delicate networks in the subendocardium of the atrial side of the valves. The extent of their development varied among cusps, being most prominent in the anterior cusp of the mitral valve. Marked differences were noted in the intravalvar distribution between lymphatic capillaries and blood microvessels. The ultrastructures of the lymphatic capillaries in the AV valves were also demonstrated.

[The pathogenesis of adenocarcinoma of the stomach after successful radiotherapy of squamous cell carcinoma of the lower intrathoracic esophagus--case report].

A case of a gastric cancer developed 3 years and 11 months after radiotherapy for esophageal cancer is reported. A 76-year-old man with a squamous cell carcinoma of the lower intrathoracic esophagus had received 50 Gy of irradiation as treatment. Thereafter, signs of the esophageal cancer disappeared radiologically and endoscopically, and a pathological biopsy of specimens taken from the site revealed no further cancer cells. The patient remained well for 3 years and 11 months after radiotherapy, at which time he again was admitted to hospital, having been diagnosed as having a gastric cancer. On admission, an upper G-I series showed a shadow defect along the lesser curvature of the upper-middle stomach but no evidence of any stenosis in the lower intrathoracic esophagus. Endoscopically, the mucosal surface of the esophagus was normal, and biopsy specimens taken from the site in the esophagus that had been treated with irradiation 3 years 11 months ago revealed no recurrence of his esophageal cancer. Endoscopical examination of the stomach showed an infiltrative tumor with ulceration, and a subsequent histological examination revealed a poorly differentiated adenocarcinoma. Upon a laparotomy, a metastasis was detected in the perigastric and paraaortic lymph nodes and the cancer had invaded the retroperitoneum. The stomach could not be removed and he died 3 months after the laparotomy.

Effects of mechanical stretch on the membrane potential of guinea pig ventricular muscles.

We studied the effect of stretch on the membrane potentials and ultrastructure of isolated ventricular papillary muscles of guinea pigs. The muscles were stimulated at 0.5 Hz and stretched stepwise from slack length (90% of Lmax) to 100% (mild stretch), 110-120% (moderate stretch), and 130-140% of Lmax (severe stretch), under microscopic control. In control Tyrode solution (K+ = 5.4 mM, Ca2+ = 1.8 mM, Mg2+ = 0.5 mM), the mild to moderate stretch significantly depolarized the resting potential (RP) by about 6 mV as compared to that in slack length, whereas the severe stretch hyperpolarized the membrane by about 5 mV. The latter finding was new and was focused on in later experiments. Both the hyperpolarization and depolarization became more marked when [K+]o was decreased to 1.35-2.7 mM, and became less with elevated [K+]o to 10.8-21.6 mM, thereby suggesting the participation of altered K+ conductance (gK) with these changes in the RP. Perfusion with low [Ca2+]o (0.45 mM) enhanced the depolarization but eliminated the hyperpolarization; high [Ca2+]o (7.2 mM) inhibited the depolarization without effect on the hyperpolarization. D-600 (1 microM), caffeine (10 mM), and ryanodine (1 microM), all of which may produce decreases in [Ca2+]i, abolished the hyperpolarization with inconsistent effects on the depolarization. Moderate to severe stretches decreased the maximum rate of rise of action potential (Vmax), by shifting the Vmax-RP relationship toward hyperpolarizing direction. The shift could be reversed partially after increasing [Mg2+]o to 8.0 mM. Electron microscopic examination revealed that the sarcoplasmic reticulum (SR) remained intact with mild to moderate stretches with significant lengthening of sarcomere length, while with a severe stretch, the SR showed a structural disarrangement with a non-uniform lengthening of sarcomere length. Our observations suggest that stretch-induced hyperpolarization is probably mediated by the increase in gK, presumably secondary to the increase in [Ca2+]i. Ca2+ may be released from the SR upon mechanical stretch of the organelle.

Two differential mechanisms of automaticity in diseased human atrial fibers.

The ionic mechanisms of automaticity in spontaneously active preparations (n = 38) from "diseased" human atria were investigated. The cycle length (CL) of the automatic action potential (AAP) ranged from 0.6 to 4.5 s (mean +/- S.D.: 2.0 +/- 1.0 s). The AAP from preparations obtained from non-digitalized patients (group 1, n = 29) showed various CLs, in that 16 patients had a CL longer than 2.0 s (slow-type AAP) while in tissues from the other 13 patients, the CL was 2.0 s or less (fast-type AAP). On the other hand, all preparations obtained from the digitalized patients prior to cardiac surgery (group 2, n = 9) had the fast-type AAP (CL less than or equal to 2.0 s). The slow-type AAP was accelerated and changed to the fast one after application of ouabain (1 microM) or by perfusing with 50% [Na+]o Tyrode solution. Ryanodine (1 microM), a specific inhibitor of calcium release from the sarcoplasmic reticulum (SR), markedly lengthened the CL of fast-type AAP, without affecting the slow-type AAP. In contrast, caffeine (15 mM) shortened the CL of the slow-type AAP and remarkably lengthened the CL of the fast-type AAP, as is the case in ryanodine. The rate of slow-type AAP was enhanced with an increase in [Ca2+]o and depressed with a decrease in [Ca2+]o or with application of diltiazem, a Ca2+ channel blocker. The slow-type AAP was changed to the fast-type AAP by stretching the preparation by about 20%. In vitro preparations excised from patients with dilated atria revealed a shorter CL of AAPs. We conclude that in "diseased" human atrial preparations, the ionic mechanism responsible for generation of slow- and fast-type automaticity differs. Slow automaticity (CL greater than 2.0 s) perhaps relates to activation of the slow inward Ca2+ current, while the fast-type automaticity (CL less than or equal to 2.0 s) is linked to cyclic increases in [Ca2+]i.

Occurrence of peptic ulcer in the gastric tube used for esophageal replacement in adults.

Reported in this paper are two cases of peptic ulcer which developed in the gastric tube used for esophageal replacement following esophagectomy for esophageal tumors in adults. The results of our cases suggest that acid secretion from the mucosa of the gastric tube, in spite of truncal vagotomy and the state of the tube, seems to play important roles in the pathogenesis of peptic ulcer of the gastric tube after esophageal replacement, even though circulatory disturbances, due to postoperative irradiation and gastric tube formation, have been suspected as the cause. Therefore, in those cases of gastric tube stasis, surgical drainage of the gastric tube should be performed.

[Choriocarcinoma of the stomach].

A 55-year-old Japanese man was admitted to our hospital in January 1985 complaining of epigastralgia. Radiologic and endoscopic examinations showed gastric carcinoma, but biopsy specimens taken by surgery showed the histologic pattern of choriocarcinoma. On autopsy, multiple metastatic sites wer observed, and histological examination of the primary and metastatic sites revealed choriocarcinoma. Primary gastric choriocarcinoma may develop from gastric cancer by retrodifferentiation.

Carcinoma in adenoma of the papilla of Vater.

Carcinoma in adenoma of the papilla of Vater is extremely rare. We now report a case of adenocarcinoma in adenoma of the papilla of Vater and the clinicopathological findings are discussed. A 73-year-old Japanese woman was endoscopically diagnosed as a case of carcinoma combined with adenoma of the papilla of Vater. She underwent pancreatoduodenectomy and the postoperative course was satisfactory. Histological examination of the resected tissues revealed a superficial adenocarcinoma in the adenoma of the papilla of Vater. In certain cases, carcinoma of the papilla of Vater may develop from a pre-existing adenoma in the region. Therefore, we recommend that pancreatoduodenectomy should be done when an adenoma presents in this region.

[A case of abdominal wall fistula due to cholangioma].

A 59-year-old woman was admitted to our hospital complaining of intractable abdominal wall fistula. Several examinations led to the suspicion of a fistula due to liver cell tumor. Histologically, the tumor was diagnosed as cholangioma. Chemotherapy was very effective after fistulectomy, and to date, she has been doing well for 34 months.