Transfection of human HGF plasmid DNA improves limb salvage in Buerger's disease patients with critical limb ischemia.

AIM: Hepatocyte growth factor is a potent angiogenic agent. This study investigated the efficacy and safety of intramuscular injection of naked plasmid DNA encoding the human hepatocyte growth factor gene in Japanese patients with Buerger's disease and critical limb ischemia. METHODS: An open-label clinical study was performed at eight hospitals in Japan from May 2004 to April 2008. Ten patients were enrolled. They had Buerger's disease with ischemic ulcers, were not candidates for revascularization, and were unresponsive to conventional drug therapy. Treatment consisted of 8 injections (total dose: 4 mg) of hepatocyte growth factor plasmid, which were administered into the calf muscles and/or distal thigh muscles of the ischemic limbs under ultrasound guidance. Administration was done twice at an interval of 4 weeks. If there was no improvement after 2 doses, a 3rd dose could be administered. The response to treatment was evaluated from the reduction of ischemic ulcer size. RESULTS: The size of ischemic ulcers showed a decrease in 6/9 (66.7%) patients and the ulcers healed completely in 5/9 (55.6%) patients after gene therapy. Major amputation was not required. There were no deaths and no major safety concerns. CONCLUSION: Hepatocyte growth factor gene therapy is safe and effective for critical limb ischemia in patients with Buerger's disease.

[Safety management for the patient after cardiovascular surgery in the intensive care unit].

In safety management after cardiovascular surgery, the system responding to patients' life-threatening changes must be established. Just a trivial error or the delay of medical treatment will increase the risk of shortening patients' lives in the intensive care unit Ventilators and circulatory assist devices such as a percutaneous cardiopulmonary support (PCPS) and a defibrillator should be well-maintained to be ready to be used. The communication among the staff of various jobs is also important. The effort to reconfirm everything as much as possible is necessary, which will certainly reduce adverse drug events and malpractice of the medical equipment in critical situations. The causes of errors must be thoroughly analyzed for the prevention of recurrences of similar events.

Prevention of abdominal aortic aneurysms by simultaneous inhibition of NFkappaB and ets using chimeric decoy oligonucleotides in a rabbit model.

Abdominal aortic aneurysm (AAA) is one of the major vascular diseases caused by atherosclerosis. Because treatment for AAA mainly consists of surgery to prevent deaths from AAA rupture and there is a conspicuous absence of alternative therapeutic strategies, the development of minimally invasive treatment is needed. To develop a novel therapeutic approach, we examined the simultaneous inhibition of the transcription factors NFkappaB and ets, which regulate inflammation and matrix degradation, in a rabbit AAA model. In this study, we employed chimeric decoy oligodeoxynucleotides (ODN), containing the consensus sequences of both the NFkappaB- and ets-binding sites, to inhibit both the transcription factors simultaneously. Using a delivery sheet, we examined the inhibitory effect of chimeric decoy ODN on aortic dilatation. Ultrasound and angiographic analysis demonstrated that treatment with chimeric decoy ODN significantly prevented the progression of elastase-induced aortic dilatation. The inhibitory effect of chimeric decoy ODN on aortic dilatation was also confirmed by histological studies. Treatment with chimeric decoy ODN reduced the activities of matrix metalloproteinase (MMP)-2 and MMP-9 and markedly inhibited the proteolysis of elastin as compared to scrambled decoy ODN. Interestingly, treatment with chimeric decoy ODN also suppressed VCAM-1 and MCP-1 gene expression, leading to inhibition of macrophage infiltration in the adventitia and media. The present study in a rabbit model provides a novel strategy to treat AAA by the simultaneous inhibition of both NFkappaB and ets using chimeric decoy ODN. Further modification of chimeric decoy ODN would be useful to treat AAA as a decoy-based therapy.

The expression of platelet-derived growth factor and connective tissue growth factor in different types of abdominal aortic aneurysms.

AIM: An atherosclerotic abdominal aortic aneurysms (AAAA) differ from inflammatory abdominal aortic aneurysms (IAAA), which are characterized by a non specific inflammatory reaction leading to considerable aneurysmal wall thickness from the media to adventitia and retroperitoneal fibrosis in the surrounding tissue. Platelet-derived growth factor (PDGF) and its receptor have been localized to specific cell types within atherosclerotic plaques. Human connective tissue growth factor (CTGF) is a cysteine rich polypeptide that has similar structures to PDGF and has been implicated in connective tissue formation. PDGF and CTGF may play a role in the development of aneurysmal walls in both AAAA and IAAA. METHODS: Using in situ hybridization technique with DIG-labeled RNA probes and immunostaining, we investigated CTGF gene expression, and expression of PDGF and its receptor protein, in human aneurysmal walls. RESULTS: Expression of CTGF mRNA was found on vascular smooth muscle cells (VSMC) in specimens from AAAA and IAAA. Strong CTGF expression was localized in VSMC around calcification in AAAA. In IAAA, strong expression of CTGF was observed around inflammatory cells. In the aneurysmal walls of AAAA, PDGF A and B chains were strongly stained on small vessels, and the PDGF beta receptor was also strongly stained on VSMC around calcification. In the aneurysmal wall of IAAA, weak expressions of PDGF A and B chains were observed in endothelial cells of vessel walls around the inflammatory cells, but the intensity of expression was much weaker than that on the vessel walls in AAAA. CONCLUSIONS: Such differences in fibrogenic cytokine expression may be involved in characteristic aneurysmal formation.

Direct measurement of nitric oxide during experimental cardiopulmonary bypass.

We developed a system to measure nitric oxide (NO) concentration during cardiopulmonary bypass in anaesthetized pigs (n = 6). A T-shaped connector, attached to an NO sensor, was mounted in the extracorporeal circuit at two measuring sites: proximal to the membrane oxygenator (venous side) and distal to the arterial line filter (arterial side). After performing a preliminary validation study, we measured plasma NO concentration before and during total cardiopulmonary bypass circulation (non-pulsatile flow 1.5 l/min) and without pulmonary ventilation. After establishing bypass, PaO2 was 318 - 393 mmHg; when PaO2 was decreased to 80 - 100 mmHg, plasma NO concentration in the arterial circuit fell by 39.2 +/- 15.6 nM. There was no observable change in plasma NO concentration at the venous circuit. This new system could be useful in monitoring NO concentration during cardiac surgery with cardiopulmonary bypass, and for understanding the possible pathophysiological roles of hyper-nitric oxaemia in cardiopulmonary bypass-related cardiovascular complications.

Equivalence of the acute cytokine surge and myocardial injury after coronary artery bypass grafting with and without a novel extracorporeal circulation system.

Cardiopulmonary bypass (CPB) contributes to a morbidity-inducing systemic inflammatory response after cardiac surgery. We compared this response in patients receiving coronary artery bypass grafting (CABG) with (CPB group; n = 7) or without (off-pump group; n = 8) the Minimal Extracorporeal Circulation (MECC) system. Serum concentrations of tumour necrosis factor (TNF)-alpha, soluble TNF receptors, pro- and anti-inflammatory interleukins (ILs) and other myocardial injury markers were measured after anaesthetic induction, at 1 h, 4 h and 24 h after completing all anastomoses or serially. Soluble TNF receptor type I (sTNFRI) and IL-8 peaked early after CABG in both groups and did not decline. Serum sTNFRI was significantly higher in the CPB compared with the off-pump group at 1 h, whereas IL-8 was significantly lower in the CPB group throughout. The MECC system, therefore, produces an equivalent acute cytokine response and degree of myocardial injury to off-pump CABG, and may be useful when CABG cannot be performed without CPB.

beta2-adrenergic receptor stimulation-induced immunosuppressive effects possibly through down-regulation of co-stimulatory molecules, ICAM-1, CD40 and CD14 on monocytes.

We examined the effects of beta2-adrenergic receptor (beta2-AR) agonists on the expression of co-stimulatory molecules on lipopolysaccharide (LPS)-stimulated human peripheral blood mononuclear cells. The study found that beta2-AR agonists inhibited the expression of intercellular adhesion molecule-1 (ICAM-1), CD40 and CD14 on monocytes, and that AR agonist activity was antagonized by the selective beta2-AR antagonist, butoxamine. The selective beta2-AR agonists salbutamol and terbutaline induced a similar co-stimulatory molecule expression pattern. The LPS-induced production of tumour necrosis factor-alpha was inhibited by AR agonists, and this was also antagonized by butoxamine, and mimicked by salbutamol and terbutaline. The AR agonists also inhibited T-cell proliferation through beta2-AR stimulation. This study clearly demonstrated that endogenous catecholamines elicited immunosuppressive effects through beta2-AR stimulation, possibly due to down-regulation of the expression of ICAM-1, CD40 and CD14 on monocytes. These results suggested that the sympathetic nervous system might regulate the T-helper cell balance via the peripheral end-effectors of the stress system.

[Surgical treatment of thymic carcinomas].

Five cases of surgically treated thymic carcinoma are reported. The patients (4 men and a woman) ranged in age from 46 to 76 years old with a mean of 64.6. Four patients were asymptomatic and an abnormal shadow on X-ray films was noted. One remaining patient suffered from hoarseness. One patient had stage II disease and the others had stage III. Surgical tumor resection was performed in all cases. Only 1 patient among the 5 underwent a successful complete resection. Histological examinations of the resected specimens revealed squamous cell carcinoma of thymus. Four specimens were poorly differentiated and 1 is moderately differentiated carcinoma. All patients received radiation therapy post operatively. Three patients are alive without any recurrence 6, 8 and 109 months after the surgery. Thymic carcinomas are frequently invasive or metastatic at the time of diagnosis. But poorly differentiated group, in squamous cell carcinoma, mucoepidermoid carcinoma and besaloid carcinoma, are characterized by a low incidence of local recurrence and distant metastasis. They also have a good sensitivity for the radiation. Therefore complete surgical resection combined with postoperative radiation therapy should be a choice in treating thymic carcinomas. We considered that complete resection and postoperative radiation therapy is a curative therapy for thymic carcinomas.

Platelet activity of residual blood remained in the cardiopulmonary bypass circuit after cardiac surgery.

AIM: We measured the platelet count and platelet function in residual blood in the cardiopulmonary bypass (CPB) circuit after cpb and compared them with data before CPB operation. METHODS: The subjects included 34 cases of patients subjected to CPB surgery. The residual blood was concentrated by ultrafiltration after CPB, collected in the bag and the platelet count and platelet activity was measured. ADP 2, 5, 10 microM was used as agonists and measurement was made by turbidimetry. RESULTS: The mean value of the platelet count was 18.3+/-5.65x10(4)/mm(3) before surgery and 17.2+/-8.39x10(4)/mm(3) in the residual blood, there is no difference. Concerning the platelet aggregation activity, the maximum aggregation rate decreased significantly with ADP 2 microM from 47.4+/-19.6% before surgery to 27.1+/-17.2% in the residual blood (p<0.01). Likewise, it decreased significantly with ADP 5 and 10 microM. The reduction rate of the platelet aggregation activity was higher in the group of not less than 100 minutes compared with the group of less than 100 minutes, but no significant difference was found. CONCLUSION: Autotransfusing whole blood per se without the "cell saver" treatment is more advantageous to keep hemostasis function after surgery since many platelets having the aggregation activity exist in residual blood in the CPB circuit.

[Cardiac surgery for chronic dialysis patients].

Chronic dialysis patients who received open heart surgery were examined, and main concern was perioperative management. There were 12 chronic dialysis patients and open heart surgeries were performed between October 1990 and June 2000. The patients were comprised of 7 men and 5 women with the average age being 64 with plus or minus 7.9. The operative procedure of 6 coronary artery bypass grafting (CABG) [on-pump], 1 CABG + mitral valve replacement (MVR), 3 aortic valve replacement (AVR), 1 mitral valvuloplasty (MVP) and 1 ascending aorta replacement were performed. All patients were discharged from the hospital with good conditions 27.1 days after operation. There were no hospital deaths. One postoperative complication of mediastinitis of the sternum has been found. A conventional dialysis was performed the day before the operation and an intra-operative hemodialysis (HD) was performed, placing a dialyzer into a cardiopulmonary system during the operation. For the perioperative management, HD was started the day or 2 days after the operation with no immediate postoperative hemocatharsis and returned to the normal HD 7 days after the operation. The result of the perioperative management has been good.

[Thrombus entrapped in a patent foramen ovale of the atrial septum].

A 59-year-old women was referred to our hospital due to severe dyspnea and shock status 12 days after intracranial hematoma evacuation for the hypertensive right putaminal hemorrhage. Transthoracic echocardiography revealed right ventricular dilatation and floating structures in the right atrium. Transesophageal echocardiography demonstrated a large, snake-like structure crossing her foramen ovale of the interatrial septum, and impending paradoxical embolism was diagnosed. She did not receive any anticoagulation and surgery due to recent cerebral hemorrhage. Follow-up TEE showed complete disappearance of the thrombus in the atrium two weeks after the onset. Phlebogram of deep vein demonstrated several thrombus in her leg. She underwent placement of inferior vena cava filter and was discharged from our hospital without any symptom of paradoxical embolism.

Relation of QT-interval variability to ventricular arrhythmias during percutaneous transluminal coronary angioplasty.

The present study investigated the role of the dispersion of QT interval in percutaneous transluminal coronary angioplasty (PTCA)-induced ventricular tachyarrhythmias. Patients with effort angina without a previous myocardial infarction (n = 22), who had single-vessel disease of the anterior descending coronary artery (LAD), underwent PTCA if the coronary lesion was 75% or more stenosed in segment 6 or 7 of the LAD. The standard 12-lead ECG was continuously recorded during the procedure. Averaged QTc and QTac intervals, where QTac was the interval from the beginning of QRS complex to the nadir of T wave corrected by Bazett's formula, did not change significantly during PTCA. Of the 22 patients, 7 showed ventricular arrhythmias during PTCA. The maximum difference (deltaQTc) and the standard deviation (QTcSD) of the corrected QT interval in the standard 12-lead ECG increased significantly during PTCA in the 7 patients with ventricular arrhythmias, whereas they decrreased in the 15 patients without ventricular arrhythmias. deltaQTac and QTacSD were not affected by PTCA regardless of ventricular arrhythmias, which shows that the increases in the variation of the ventricular repolarization process play a role in PTCA-induced ventricular arrhythmias.

Intralobar pulmonary sequestration supplied by multiple anomalous arteries: report of a case.

Pulmonary sequestration is abnormal pulmonary tissue that has separated from the normal pulmonary parenchyma, is not connected to the tracheobronchial tree, and is supplied by a systemic artery. We describe herein a case of intralobar pulmonary sequestration found in a 66-year-old man who was admitted to our hospital with hemoptysis, coughing, and fever. Angiography showed that the branches of the 11th left intercostal artery and a bronchial artery had formed a hypervascular area in the lower part of the left lung. Bronchial artery embolization and subsequent embolization of the left 11th intercostal artery were performed in an attempt to control the recurrent hemoptysis. These treatments were unsuccessful, and he was transferred to our department of surgery after coughing up about 400 ml of fresh blood. A left lower lobectomy was performed. The resected lung contained a large feeding artery, some acute and partly organizing inflammatory lesions within collapsed lung parenchyma, and massive intra-alveolar hemorrhage in the peripheral area. The patient had an uneventful recovery and was discharged 22 days after his operation.

Anchoring the Duran flexible annuloplasty ring with continuous sutures.

We practised a deviced method of anchoring the Duran flexible ring with continuous sutures. After passing through 3/0 monofilament sutures at the right and left fibrous trigones, both sutures are passed through the ring between the corresponding ring marker and continuous sutures are placed to attach the ring to the mitral valve annulus. This technique requires less time to anchor the ring than the original method with interrupted sutures and can prevent narrowing the mitral valve annulus following the deformity of the flexible ring. This technique can contribute to extend the indication of the prosthetic ring in mitral valve surgery.

[Thromboembolic and bleeding complications in patients treated with oral anticoagulant therapy after mechanical heart valve prostheses implantation].

Thromboembolic and bleeding events are major cause of morbidity and mortality in patients with mechanical heart valves. Ninety-three patients had been received anticoagulant (warfarin with bucolome 300 mg) for mechanical prosthetic valves, and the regulation of anticoagulation was performed within a prothrombin time international normalized ratio (PT-INR) about 2.0 of normal. The mean duration of follow-up was 64.1 months, and the total duration of follow-up was 496.8 patient-years (py). The valve related complications occurred in 10 cases (2.0 per 100 py). Anticoagulant related hemorrhagic events occurred in 7 cases, and valve thrombosis in 3 cases. All three cases of valve thrombosis were in cases with Björk-Shiley valve at the mitral position. An artificial valve in mitral position increased the valve related risk compared with the aortic position (3.1%/py vs 0.0%/py). Bileaflet valve showed a lower incidence of thromboembolism than tilting disc valve (2.3%/py vs 0.0%/py). The risk of valve related complication varied with the type and the position of the prosthesis, it is desirable that the intensity of anticoagulation would be changed according to the prosthetic valve type and its position. These results suggest that the intensity of anticoagulation is optimal when the PT-INR is 1.8-2.0 for patients with bileaflet valve in the mitral position, and is 1.6-1.8 in the aortic position. Tilting disc valve needs more intensity of anticoagulation, and needs additional antiplatelet agent in the mitral position.

Rat lens epithelial cell damage and cataract formation induced by immunological response to bovine lens membrane protein

Purpose: To evaluate the correlation of cataractogenesis and immune mechanisms, we investigated the rat lens morphologically and immunologically.Methods and Results: Wistar rats were divided into three groups: Group A was immunized with bovine-lens membrane protein (B-LMP) and adjuvant, Group B was immunized with adjuvant only, and Group C was not given any treatment as a control. Titer levels of anti-B-LMP antibody and anti-rat-LMP antibody were elevated and posterior subcapsular cataract was developed in Group A. In flat preparations, a noncellular part in the lens epithelium was observed in all members of Group A. In this noncellular part, a lens capsule protruding into the lens epithelial cell layer was observed by light microscopy.Conclusion: These data suggest that lens epithelial cells may be damaged by immune response, causing the development of cataract.

[Rat lens epithelial cell damage and cataract formation induced by immunological response to bovine lens membrane protein].

PURPOSE: To evaluate the correlation of cataractogenesis and immune mechanisms, we investigated the rat lens morphologically and immunologically. METHODS AND RESULTS: Wistar rats were divided into three groups: Group A was immunized with bovine-lens membrane protein (B-LMP) and adjuvant, Group B was immunized with adjuvant only, and Group C was not given any treatment as a control. Titer levels of anti-B-LMP antibody and anti-Rat-LMP antibody were elevated and posterior subcapsular cataract was developed in Group A. In flat preparations, a noncellular part in the lens epithelium was observed in all members of Group A. In this noncellular part, a lens capsule protruding into the lens epithelial cell layer was observed by light microscopy. CONCLUSION: These data suggest that lens epithelial cells may be damaged by immune response, causing the development of cataract.

Identification of the region in the N-terminal domain responsible for the cytoplasmic localization of Myoc/Tigr and its association with microtubules.

Mutations in the MYOC/TIGR gene are associated with juvenile open-angle glaucoma and in some cases may be involved in the formation of sporadic primary open-angle glaucoma in humans. To better understand the functions of the MYOC/TIGR protein, its intracellular distribution was investigated using green fluorescent protein (GFP) as a marker. The results indicated that the recombinant mouse and human Myoc/Tigr-GFP proteins are located in the cytoplasm of the transfected cells in which they colocalize with microtubules. Deletion analysis demonstrated that the N-terminal region (positions 1-124 and 15-138 in the mouse and human proteins, respectively) encoded by exon 1 is critical for the cytoplasmic localization of Myoc/Tigr. Most of the known mutations in the human MYOC/TIGR gene implicated in juvenile and sporadic primary open-angle glaucoma formation are located outside the region responsible for the cytoplasmic localization of the protein. However, some of these mutations may alter the tertiary structure of the protein and subsequently modify its interaction with microtubules.

Septal branch right ventricular fistula: a complication in coronary artery snaring.

We report a septal branch right ventricular fistula complicated after coronary snaring in coronary artery bypass surgery without aortic cross-clamping. The tip of the needle of the snaring suture is made blunt in order to decrease the risk of mechanical injury, but trauma to the septal branch is possible. This rare complication of snaring should be taken into consideration in performing aortic nonclamping coronary artery bypass surgery.

Aortic and mitral valve replacement in an 83-year-old female. 3 years follow-up of 16 mm bileaflet valve at the aortic position.

An 83-year-old female with aortic and mitral stenosis showed orthopnea. The aortic valve pressure gradient was 139 mmHg. The mitral valve orifice was 0.92-1.05 cm2 and the right ventricular pressure was 70 mmHg. The body surface area of the patient was 1.23 m2. Double valve replacement was performed with 16 mm CarboMedics pediatric bileaflet valve for the aortic position and 25 mm CarboMedics mitral valve for the mitral position. The patient leads a normal daily life with NYHA class II three years after surgery.