[Clinical evaluation of hydrocolloidal dressing in 147 patients undergoing cardiovascular surgery].

Recent evidence has suggested that a moist environment plays an important role in wound healing. Karayahesive, one type of hydrocolloidal dressing, contains natural karaya gum as a hydrophilic gel. We applied hydrocolloidal dressing to operative wounds in 147 patients who underwent cardiovascular surgery from April 2001 through August 2002 to evaluate its clinical usefulness. The dressing was kept on the wounds for 7 days after operation, but was immediately switched to conventional dressing with gauze if there was any problem. A total of 144 patients (98%) had no wound chest infections. Good wound healing was obtained with only 1 dressing, removed 7 days after operation, in 128 patients (87%). In 19 patients (13%), the hydrocolloidal dressing was switched to conventional dressing. In 13 of these patients the hydrocolloidal dressing dissolved naturally or exudation occurred; clinically, there were no local problems; however, 3 patients had infection, 2 had fat necrosis, and 1 had burn injury caused by electrocautery. No patients had skin problems caused by this dressing. We conclude that hydrocolloidal dressing can be used safely and effectively in patients undergoing cardiovascular surgery and reduce the workload of healthcare workers.

[Combined operation for left ventricular aneurysm and ventricular septal perforation with normal coronary arteries; report of a case].

We experienced a rare case of left ventricular aneurysm (LVA) and ventricular septal perforation (VSP) with normal coronary arteries, and had a good outcome by undergoing Dor procedure and direct closure of VSP individually. A 68-year-old female was printed out cardiac systolic murmur. Echocardiogram revealed LVA and VSP, but coronary arteriogram showed no significant stenosis. The apex was incised longitudinally, lateral and parallel to the interventricular groove. VSP was directly closed by 2 pieces of 3-0 polypropylene suture with felt strip. Purse-string stitch with 3-0 polyester suture around the transitional zone between fibrotic tissue and viable tissue was secured to firm fibrous tissue. The residual orifice was closed with an elliptical composite patch of equine pericardial patch and polyester velour with 3-0 polypropylene suture. We considered based on the operative finding that myocardial infarction (MI) led to LVA and VSP. Coronary thrombosis rather than coronary spasm may have provoked MI because spasm provocative test was negative.

[Bilateral coronary ostial stenoses with aortic regurgitation in a patient with syphilitic aortitis].

Syphilitic aortitis is now rare in developed countries and is sometimes overlooked. A 61-year-old man with bilateral coronary ostial stenoses (#5:90%, #1:99%) and Sellers III/IV aortic regugitatioin (AR) induced by syphilitic aortitis presented with chest pain. Preoperative rapid plasma reagin titer and Treponema pallidum hemagglutination test were strongly positive, 256 fold and 191.25 C.O.I., respectively. Aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) with bilateral internal thoracic arteries (ITA) was performed successfully. The angiographic features as follows: 1) coronary artery stenosis is generally limited to the ostia, 2) the grade of stenosis is almost always more than 90%, 3) AR is frequently associated with coronary ostial stenosis. CABG should be performed with ITA, not saphenous vein grafts, to avoid occlusion of the ostium of the saphenous vein graft by syphilitic aortitis. Retrograde cardioplegia should be performed if ostial stenosis is severe.

[Surgical repair of left ventricular free wall rupture using layered fibrin glue sheet and fibrin glue; report of a case].

A 57-year-old man with acute myocardial infarction (#13:90%, #6-#8:75%) was admitted to our hospital after the administration of tissue plasminogen activator. Three hours' after emergent percutaneous transluminal coronary angioplasty, he developed left ventricular free wall rupture in the left circumflex artery area. After bleeding was completely controlled by aortic cross clamping, a three-layered of fibrin glue sheet (TachoComb) with fibrin glue was extensively applied to the ruptured site including the infarcted area. He was discharged on the 25th postoperative day and underwent coronary artery bypass grafting to the left anterior descending artery three weeks later. This experience suggests that the layered TachoComb and fibrin glue are effective for left ventricular free wall rupture.

Successful surgical treatment of ventricular tachycardia that induced left ventricular aneurysm in 12-year-old boy.

A surgical treatment of ventricular tachycardia (VT) that induced a congenital left ventricular aneurysm (LVA) in a 12-year-old boy was performed. The VT disappeared after epicardial cryoablation and a reinforcement of LVA with a composite patch. Epicardial cryoablation, based on an intraoperative electrophysiologic study (EPS), is effective in treating VT resistant to antiarrhythmia drugs.

Ostial stenosis of coronary arteries after complete replacement of aortic root using gelatin-resorcinol-formaldehyde glue.

Coronary ostial stenosis between an interposition graft and coronary artery is rare and fatal. A 46-year-old woman who had reconstruction of both coronary arteries using interposition grafts for type A acute dissecting aneurysm presented with acute chest pain. Emergent coronary artery bypass grafting was done with saphenous vein grafts. Inappropriate use of gelatin-resorcinol-formaldehyde glue can be associated with ostial stenosis in the long term. Transesophageal echocardiography is useful to diagnose ostial stenosis of the coronary arteries.

Predicting blood transfusion factors in coronary artery bypass surgery.

OBJECTIVE: Blood conservation has become one of the most important issues in cardiac surgery. We clarified preoperative predictors of the need for blood transfusions during coronary artery bypass graft surgery. METHODS: Subjects were 89 patients--66 men (74%) and 23 women (26%) 40 to 84 years old (mean: 66.2 +/- 8.3 years)--undergoing isolated coronary artery bypass surgery from September 1997 to December 1999. Of these, 66 patients (74%) received transfusion during hospitalization and 23 (26%) did not. Nine risk factors detected by univariate study were entered in a multivariate logistic regression model of the relationship between preoperative variables and blood transfusion. RESULTS: Independent predictors were emergency surgery (P = .0023), lower hematocrit (P = .0027), older age (P = .0043), and the presence of peripheral vascular disease (P = .0070). Optimal cutoff of hematocrit for blood transfusion was 39% and age 64 years via receiver-operating characteristics curves based on the relation between sensitivity and specificity. CONCLUSION: Patients older than 64 years with hematocrit less than 39% and/or peripheral vascular disease should be treated routinely using preoperative storage of autologous blood whenever the patient's condition permits. For patients undergoing emergency surgery, further studies are required, including lowering transfusion threshold and using determinants other than hematocrit.

[Postoperative rupture of abdominal aortic aneurysm in patients with ischemic heart disease and other organ disease].

We experienced two cases of rupture of an abdominal aortic aneurysm during the early postoperative period of coronary artery bypass grafting (CABG). A 71-year-old man on hemodialysis (HD) was diagnosed with ischemic heart disease (IHD) and abdominal aortic aneurysm (AAA) of 70 mm in size. After CABG, he developed symptoms of acute pancreatitis and died of rupture of AAA on the 12th postoperative day. A 74-year-old man with early gastric cancer was diagnosed with IHD and AAA of 70 mm. After CABG and gastrectomy, he died of rupture of AAA due to anticoagulant therapy on the 3rd postoperative day. One-stage operation should be performed in patients with IHD, AAA more than 60 mm in size and other organ disease. It is important to control blood pressure and anticoagulant therapy appropriately during the early postoperative period when graft replacement for AAA is not performed simultaneously. Careful observation is required to establish the differential diagnosis of acute pancreatitis and impending rupture of AAA in patients on HD.

Gastric cancer with Virchow's and multiple lung metastases showing a remarkable response to preoperative chemotherapy: report of a case.

We report herein a rare case with advanced gastric cancer combined with group 4 lymph node and lung metastases that responded remarkably to neoadjuvant chemotherapy. A 65-year-old man was found to have a well-differentiated type 3 gastric cancer that invaded the duodenum locally and was accompanied with Virchow's, para-aortic lymph nodes, and multiple lung metastases based on physical, endoscopic, and radiological examinations. In addition, his carbohydrate antigen (CA) 19-9 was elevated to 3965U/ml, and CA72-4 to 46U/ml. Prior to surgery, he was treated with 5-fluorouracil (5-FU; 500mg/body per day) and low-dose cisplatinum (CDDP; 10mg/body per day) as neoadjuvant chemotherapy for 6 weeks. As a result, a partial response was obtained in all lesions, and CA19-9 and CA72-4 decreased to 463U/ml and 9.4U/ml, respectively. Four weeks after the completion of neoadjuvant chemotherapy, a distal gastrectomy was performed, and a histopathological examination of the resected specimen showed a grade 2 response to chemotherapy. Immunohistochemically, the thymidylate synthase expression level was very low in the tumor tissues, which might account for the good response to the combination chemotherapy with 5-FU and CDDP observed in the present case.

[Experiences of minimally invasive great saphenous vein graft harvest using with endopath].

We have experienced 20 cases of minimally invasive great saphenous vein graft harvest using with endoscopy, Endopath, from March 1999. As we experienced cases, we can harvest great saphenous vein graft, about 30-40 cm in size, from only two 4-cm incisions for about 50 minutes. There are no wound infection, pain, and edema. Great saphenous vein graft harvesting with Endopath is less invasive, painless after surgery and makes patients satisfied about cosmetic problem.

Regression of left main coronary ostium stenosis after surgical revascularization and steroid therapy.

We describe a patient in whom stenosis of the left main coronary ostium completely regressed after steroid treatment following surgical revascularization. A 46-year-old woman with unstable angina underwent double coronary artery bypass grafting. Although she did not fulfill diagnostic criteria for Takayasu's disease, we began postoperative steroid therapy on postoperative day 14 based on clinical manifestations and histological findings. Coronary angiography 33 days after surgery showed the ostial stenosis of the left main coronary artery had disappeared. Steroid therapy for suspected Takayasu's disease should be considered even after surgical revascularization.

[A case of acute pulmonary embolism fourteen days after hysterectomy].

We describe a 54-year-old female with acute pulmonary embolism. She showed a syncope attack and hypotension fourteen days after hysterectomy for uterine cancer. Preoperative echocardiogram revealed that thrombus in the right atrium was coming and going through the tricuspid valve. Emergent pulmonary embolectomy through the sternotomy under cardiopulmonary bypass was performed 4.5 hours after the diagnosis without homologous blood transfusion. Postoperative perfusion scintigram 20 days after the operation showed normal filling of the both lungs except for the localized defect at the distal portion of the right middle lobe. The patient was discharged on the 22nd postoperative day and she has been followed up with anticoagulation therapy. It is essential that we have the opportunity to salvage an otherwise helpless situation by a high index of suspicion and a prompt surgical intervention.

Anatomic biventricular correction by taking down bicaval Glenn shunt.

A 7-year-old boy underwent ventricular and atrial septal defect patch closures, pulmonary valvulotomy, left pulmonary artery dilatation, and bicaval Glenn shunt, which maintained good patency between the superior vena cava and right atrium, because of a reduced right ventricular end-diastolic volume (RVEDV). The RVEDV had increased at 15 years of age; therefore, we performed an anatomic biventricular correction by removing the bicaval Glenn shunt. We found that anatomic biventricular correction becomes possible if RVEDV increases postoperatively.

Giant extracardiac unruptured aneurysm of the sinus of Valsalva: a case report.

Extracardiac unruptured aneurysm of the sinus of Valsalva (ASV) is rare and difficult to diagnose accurately by echocardiography or cardiac catheterization preoperatively. A 63-year-old woman, with dyspnea and palpitations, diagnosed with aortic regurgitation (AR) with congestive heart failure and extracardiac unruptured ASV, was referred to our hospital for surgical repair. The unruptured ASV was well visualized by magnetic resonance imaging (MRI), and diagnosed as an extracardiac type. Surgical repair was performed by aortic valve replacement and aneurysmectomy. It was concluded that early surgical repair of extracardiac ASV should be considered to prevent sudden death, and MRI is an accurate and useful method for preoperative diagnosis.

Left atrial myxoma associated with acute myocardial infarction.

We describe a patient with left atrial myxoma associated with acute myocardial infarction. Since hemodynamics were impaired even with the support of an intra-aortic balloon pump, the patient underwent removal of the tumor concomitant with coronary artery bypass grafting to the right coronary artery on the fifth day from infarction onset. In circumstances of life-threatening of myxoma associated with acute myocardial infarction, removal of myxoma with coronary artery bypass should be performed in an acute phase of myocardial infarction.

Crystal structure determinations of oxidized and reduced plastocyanin from the cyanobacterium Synechococcus sp. PCC 7942.

The crystal structures of oxidized and reduced plastocyanins from Synechococcus sp. PCC 7942 have been determined at 1.9 and 1.8 A resolution, respectively, at pH 5.0. The protein consists of only 91 amino acid residues, the smallest number known for a plastocyanin, and apparently lacks the mostly conserved acidic patch that is believed to be important for recognition with electron-transfer partners. The protein has two acidic residues, Glu42 and Glu85, around Tyr83, which is thought to be a possible conduit for electrons, but these are neutralized by Arg88 and Lys58. Residue Arg88 interacts with Tyr83 through a pi-pi interaction in which the guanidinium group of the former completely overlaps the aromatic ring of the tyrosine. Reduction of the protein at pH 5.0 causes a lengthening of one Cu-N(His) bond by 0.36 A, despite the small rms deviation of 0.08 A calculated for the backbone atoms. Moreover, significant conformational changes of Arg88 and Lys58, along with the movement of a water molecule adjacent to the OH group of Tyr83, were observed on reduction; the guanidinium group of Arg88 rotates by more than 11 degrees, and the water molecule moves by 0.42 A. The changes around the copper site and the alterations around Tyr83 may be linked to the reduction of the copper.

Crystallization and preliminary X-ray analysis of plastocyanin from cyanobacterium Synechococcus sp. PCC 7942.

A plastocyanin from the cyanobacterium Synechococcus sp. PCC 7942 has been crystallized in two different forms by hanging-drop vapour diffusion with ammonium sulfate as precipitant. Form I is hexagonal, space group P61 or P65, with unit-cell dimensions a = b = 34.62 and c = 107.22 A. Form II is tetragonal, space group P41 or P43, with unit-cell dimensions a = b = 43.05 and c = 56.94 A. Form I crystals diffract to 2.5 A using graphite-monochromated Cu Kalpha radiation from a Rigaku RU-300 rotating-anode generator operated at 40 kV and 100 mA. Form II crystals diffract to 1.9 A using synchrotron radiation at beamline BL6A of the Photon Factory (KEK). Molecular-replacement calculations using the structure of plastocyanin from Ulva pertusa have been performed.

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

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

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

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

Heart valve operation in acromegaly.

BACKGROUND: Intractable congestive heart failure is known as a serious complication of acromegaly, but valvular heart disease rarely occurs in acromegalic patients. We experienced 5 surgical cases of valvular heart disease associated with acromegaly. We describe the features of those cases in this report. METHODS: The patient characteristics and operative and pathologic findings were retrospectively studied. RESULTS: There were 4 men and 1 women. Age at operation was 59 +/- 5.5 years. Cardiac lesions consisted of 1 case of aortic regurgitation associated with mitral regurgitation, 1 of aortic regurgitation, and 3 of mitral regurgitation. Operative procedures consisted of 1 double valve replacement (aortic and mitral valve replacement), 1 aortic valve replacement, and 3 mitral valve replacements. The causes of aortic valvular regurgitation were aortic valvular degeneration and aortic annular dilatation. The causes of mitral regurgitation were chordal rupture and mitral valvular degeneration. Histopathologic examination of the excised valves showed mucopolysaccharide deposits and myxomatous degeneration of the leaflets. The myocardium showed fibrosis of interstitial spaces and endocardium, and disarrangement of muscle fibers. CONCLUSIONS: We report 5 successful surgical cases of valvular heart disease associated with acromegaly. Earlier operation is recommended for such cases because of acromegalic cardiomyopathy.