[A surgical case of acute massive pulmonary embolism associated with a giant free-floating inferior vena cava thrombus].

The risk and mortality of pulmonary embolism is high in patients with free-floating inferior vena cava thrombi. We present a successful surgical case of a 70-year-old male who had acute massive pulmonary embolism associated with a giant free-floating inferior vena cava thrombus extending above the renal veins. Emergent thrombectomy of the pulmonary artery and the inferior vena cava using cardiopulmonary bypass was carried out because he was considered at high risk for fatal recurrent pulmonary embolism. Prophylactical insertion of a Greenfield filter in the inferior vena cava was added. In this report, diagnosis and treatment of inferior vena cava thrombosis is also discussed.

Myocardial ischemia enhances the expression of acidic fibroblast growth factor in human pericardial fluid.

Acidic fibroblast growth factor (FGF) is a potent mitogen that can induce angiogenesis in vivo. We have recently reported a marked increase of basic FGF in the pericardial fluid of patients with severe coronary stenosis and an increase in vascular endothelial growth factor (VEGF) in the pericardial fluid of patients with severe myocardial ischemia. The purpose of this study was to evaluate whether acidic FGF levels in the pericardial fluid are associated with severe myocardial ischemia. Immediately after incision of the pericardium in 48 patients during open-heart surgery, 3-5ml of pericardial fluid was obtained. Concentrations of basic FGF and VEGF in the pericardial fluid were measured using an enzyme-linked immunosorbent assay (ELISA). The ELISA system for human acidic FGF was newly developed using a rabbit antibovine acidic FGF antibody. The patients were divided into three groups (group A: 13 patients undergoing emergency coronary artery bypass grafting (CABG) for unstable angina; group B: 17 patients undergoing elective CABG for stable angina; group C: 18 patients undergoing nonischemic open-heart surgery). The VEGF level in the pericardial fluid in group A was 68 +/- 59pg/ml, which was significantly higher than 33 +/- 9 pg/ml in group B and 31 +/- 20 pg/ml in group C (P < 0.05). The concentrations of basic FGF in the pericardial fluid in groups A and B were 722 +/- 601 and 773 +/- 763pg/ml, respectively, significantly higher than 263 +/- 349pg/ml in group C. The pericardial acidic FGF level in group A was 4,291 +/- 2,336 pg/ml, which was also significantly higher than 2,386 +/- 1,048 pg/ml in group B and 2,589 +/- 990 pg/ml in group C (P < 0.05). The acidic FGF level correlated well with the level of VEGF (r = 0.61, P < 0.0001). It is concluded that the level of acidic FGF in pericardial fluid is associated with severe myocardial ischemia. This result indicates that the release of acidic FGF from the myocardial tissue into pericardial fluid is closely related to severe myocardial ischemia.

Development of enzyme-linked immunosorbent assay for acidic fibroblast growth factor and its clinical application.

We have developed, for the first time, an enzyme-linked immunosorbent assay (ELISA) system for the measurement of human acidic fibroblast growth factor (aFGF). Anti-bovine aFGF rabbit IgG was conjugated with N-hydroxysuccimidobiotin, and the resulting IgG-biotin conjugate was used as the second antibody. This assay was highly specific and reproducible, enabling us to detect aFGF at a concentration as low as 1 microg/l without any prior processing of samples. With this method, it was possible to determine human aFGF up to 833 x 10(3) ng/l, with the use of anti-bovine aFGF IgG as the first and second antibody. There was no significant cross-reactivity of the antibody with other growth factors, such as basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF). The aFGF concentration in pericardial fluid was significantly higher in patients with unstable angina than in those with other heart diseases, suggesting that the aFGF plays an important role(s) in the course of collateral growth in coronary artery disease. Therefore, our ELISA system may be useful in determining unknown biological function(s) or pathological role(s) of aFGF in various disease entities.

Oxygen concentration regulates NO-dependent relaxation of aortic smooth muscles.

Nitric oxide (NO) functions as an endothelium-derived relaxation factor and regulates vascular resistance. Recent studies in this laboratory(Arch.Biochem.Biophys.323, 27-32, 1995) revealed that the lifetime of NO significantly increased at physiologically low levels of oxygen concentrations and, hence, this gaseous radical strongly inhibited mitochondrial electron transport for a fairly long duration at low oxygen concentrations. The present work describes the effect of oxygen concentration on NO-induced relaxation and guanylate cyclase (GC) activity of endothelium-denuded aorta of the rat. Both NO and 2,2 '-(hydroxynitrosohydrazono)bis-ethanamine (NOC18), an NO donor, induced the relaxation of endothelium-denuded helical segments of rat aorta which were contracted by norepinephrine. NO-dependent relaxation of arterial specimens was enhanced by lowering oxygen concentration in the medium with concomitant increase in their cGMP levels. Anoxia induced the relaxation of the aorta by some NO-enhanceable and methylene blue-insensitive mechanism. These results suggested that local concentrations of oxygen might play important roles in the regulation of NO-dependent GC activity and vascular tonus of resistance arteries.

[A surgical case of cardiac malignant lymphoma in right atrium].

We reported a case of malignant lymphoma originating from the right atrium. The patient was a 71-year-old man who had no symptoms associated with heart failure and arrhythmias. At the time of admission the patient was suggested the presence of a tumor in the right atrium by an echocardiogram accidentally. Coronary angiography revealed a feeding artery to a tumor. Although cytological confirmation was not obtained, diagnostic extirpation of tumor was performed under cardiopulmonary bypass. The histological diagnosis was malignant lymphoma of B-cell origin. His postoperative course was uneventful and no recurrence had been observed one year postoperatively without chemotherapy.

Marked elevation of brain natriuretic peptide levels in pericardial fluid is closely associated with left ventricular dysfunction.

OBJECTIVES: The purpose of this study was to investigate whether atrial and brain natriuretic peptides (ANP and BNP, respectively) represent autocrine/paracrine factors and are accumulated in pericardial fluid. BACKGROUND: ANP and BNP, systemic hormones produced by the heart, have elevated circulating levels in patients with heart failure. Recent evidence suggests that the heart itself is one of the target organs for these peptides. METHODS: With an immunoreactive radiometric assay, we measured the concentrations of these peptides in plasma and pericardial fluid simultaneously in 28 patients during coronary artery bypass graft surgery. RESULTS: The pericardial levels of BNP were markedly elevated in patients with impaired left ventricular function. We investigated the correlation of ANP and BNP levels in plasma or pericardial fluid with left ventricular hemodynamic variables. None of the hemodynamic variables correlated with ANP levels in plasma or pericardial fluid. Both plasma and pericardial fluid levels of BNP were significantly related to left ventricular end-diastolic and systolic volume indexes (LVEDVI and LVESVI, respectively). In addition, BNP pericardial fluid levels had closer relations with LVEDVI (r = 0.679, p < 0.0001) and LVESVI (r = 0.686, p < 0.0001) than did BNP plasma levels (LVEDVI: r = 0.567, p = 0.0017; LVESVI: r = 0.607, p = 0.0010). BNP levels in pericardial fluid but not in plasma correlated with left ventricular end-diastolic pressure (r = 0.495, p = 0.0074). CONCLUSIONS: BNP levels in pericardial fluid served as more sensitive and accurate indicators of left ventricular dysfunction than did BNP levels in plasma. Thus, BNP may be secreted from the heart into the pericardial space in response to left ventricular dysfunction, and it may have a pathophysiologic role in heart failure as an autocrine/paracrine factor.

Marked elevation of vascular endothelial growth factor and basic fibroblast growth factor in pericardial fluid of patients with angina pectoris.

Although we reported that basic fibroblast growth factor (bFGF) levels in pericardial fluid of patients with unstable angina are apparently increased, it was unclear whether vascular endothelial growth factor (VEGF) is also increased in patients with myocardial ischemia. Using an enzyme-linked immunosorbent assay, we measured the concentrations of VEGF and bFGF in pericardial fluid of 51 patients with open heart surgery. Patients were divided into group A (n=10) with class III unstable angina (Braunwald's classification), group B (n=24) with class I or II unstable angina or stable angina and group C (n=17) with non-ischemic heart disease. The VEGF level in pericardial fluid in group A was 83+/-7 pg/ml, being significantly (p<0.001) higher than the 27+/-3 pg/ml in group B and the 28+/-5 pg/ml in group C. The concentrations of bFGF in pericardial fluid in groups A and B were 1461+/-579 and 1224+/-161 pg/ml, respectively, significantly (p<0.05) higher than the 292+/-97 pg/ml in group C. The level of VEGF in pericardial fluid was increased only in patients with severe rest angina within 2 days before emergency coronary artery bypass graft surgery (CABG), while bFGF was increased in all patients undergoing CABG for coronary artery disease. Thus VEGF and bFGF may play important roles in mediating collateral growth in humans.

Clinical application of transluminal endovascular graft placement for aortic aneurysms.

BACKGROUND: In recent years, transluminal endovascular graft placement techniques have been developed for the treatment of aortic aneurysms. We report our initial clinical experience with endovascular graft placement using a graft developed in our laboratory. METHODS: The procedure was performed in 20 patients with a diagnosed aortic aneurysm. The graft is constructed from a Dacron cylinder, and the surface of the graft is supported with multiple rings of extraflexible wire. After the compactly folded graft is delivered through the sheath to the predetermined target point, the graft is deployed and then pressed against the vessel by balloon inflation. Straight graft insertion was attempted in 10 patients, bifurcated graft insertion in 8, and branched graft insertion in 2. RESULTS: Graft placement was successful in 19 of the patients and unsuccessful in 1. There were no cases of graft migration, aneurysm rupture, or graft destruction during a mean follow-up period of 9 months. CONCLUSIONS: Initial clinical results demonstrated the efficacy and safety of endovascular graft placement using this graft.

Elevated basic fibroblast growth factor in pericardial fluid of patients with unstable angina.

BACKGROUND: Collateral growth is induced by chemical signals from the ischemic myocardium. We hypothesized that angiogenic growth factors are produced by cardiac tissue; they are diffusible, more concentrated in pericardial fluids, and are increased by myocardial ischemia. METHODS AND RESULTS: With the use of an enzyme-linked immunosorbent assay, we measured the concentrations of basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) in pericardial fluids of 12 patients with unstable angina (group 1) and of 8 patients with nonischemic heart diseases (group 2). The levels of protein in pericardial fluids were quite comparable between the two groups (34 +/- 2 versus 32 +/- 4 mg/mL). The concentration of bFGF in pericardial fluids in group 1 was 2036 +/- 357 pg/mL, significantly (P < .001) higher than the 289 +/- 72 pg/mL in group 2. The amount of bFGF per milligram of protein was also significantly (P < .05) higher in group 1 than in group 2 (67 +/- 15 versus 12 +/- 4 pg/mg). The concentration of VEGF in pericandial fluids tended to be higher in group 1, but the difference was statistically insignificant (39 +/- 7 versus 22 +/- 6 pg/mL). The amount of VEGF per milligram of protein was 1.2 +/- 0.3 pg/mg in group 1, similar to the 0.8 +/- 0.4 pg/mg in group 2. CONCLUSIONS: This finding provides new evidence that bFGF plays an important role in mediating collateral growth in humans.

Transesophageal echocardiography in the diagnosis of thoracic saccular aortic aneurysm. The value of transesophageal echocardiography during the course of treatment.

Transesophageal echocardiography (TEE) was performed in 17 cases of aortic aneurysms referred to our hospital for further examination and treatment. All 17 cases were treated surgically and TEE was performed as a preoperative examination. In nine of the 17 cases, there were already some signs of bleeding upon admission and in all of these nine cases, rupture of the aneurysm was confirmed during surgery. Measurement on cross-sectional TEE imaging disclosed large aneurysmal diameters in eight of these nine cases, suggesting a close relationship between diameter and rupture. Moreover, observation of the lesions by TEE suggested a relationship between the risk of rupture and morphological characteristics of the thrombus. In seven of the nine bleeding cases, TEE imaging revealed destructive features of the aneurysmal thrombus, such as exfoliation from the aortic wall and/or tearing-off, suggesting expansion of the aortic diameter. Detailed findings of the aneurysm and thrombus on TEE corresponded with surgical findings. Thus, we concluded that TEE is a useful method of obtaining information about aortic aneurysms not only as a preoperative examination but also as an independent examination to determine treatment options and prognosis.

[Results of surgical treatment of aortic dissections].

From January 1989 to September 1993, 59 consecutive patients (35 males and 24 females, mean age 59.6 years old) underwent surgical repair of aortic dissection on the cardiovascular surgical unit at Takeda Hospital. The type of aortic dissection were classified according to Stanford University criteria. Twenty-two patients had acute type A (Ac-A), 10 had chronic type A (Ch-A), 4 had acute type B (Ac-B), and 23 had chronic type B (Ch-B) dissection. Seventeen dissections (29%) in the entire group of 59 cases had ruptured (including cardiac tamponade, pleural effusion and hemoptysis etc.). Ischemia of lower extremity occurred in 7 patients and ischemia of visceral organs in 3 patients. Type A dissection were approached via a median sternotomy and cardiopulmonary bypass with systemic hypothermia. Type B dissections were approached through a left postrolateral thoracotomy. Left heart bypass (left atrial-femoral in 8 cases) and partial cardiopulmonary bypass (femoral-femoral in 12 cases) generally were utilized. Resection of intimal tear and replacement of aorta with vascular grafts (including aortic arch in 19 cases) were performed in most patients and primary closure of the intimal tear was performed in 9 cases using GRF. The over-all operative mortality rate was 36% (8/22) for Ac-A, 20% (2/10) for Ch-A, 25% (1/4) for Ac-B, 22% (5/23) for Ch-B. Main causes of operative death was perioperative brain damage. It is necessary to improve the operative mortality for Ac-A dissections (especially in replacement of aortic arch and arch vessels). Further researches are needed regarding optimal methods of the cerebral protection during reconstruction of aortic arch.

[Introduction of intra-aortic balloon pumping catheter through left subclavian artery guided by trans-esophageal echocardiography].

It is very difficult to insert an intra-aortic balloon pumping catheter into the descending aorta through the subclavian artery by the blind technique. But the technique with the guidance by trans-esophageal echocardiography to introduce the balloon into the descending aorta was simple and useful.

[The pitfalls in the clinical diagnosis of dissecting aortic aneurysm].

It is sometimes very difficult to diagnose dissecting aortic aneurysms (DAA), particularly in its early stage, due to manifold signs and symptoms. The purpose of this study is to clarify the reasons for such erroneous diagnoses. A total of 41 patients with DAA were referred to our hospitals for further examination and/or surgery from April 1986 to August 1989. In 18 of these patients, the diagnostic possibility of an underlying DAA was overlooked by the referring physicians. Among these 18 patients, 2 were mistakenly diagnosed as uncomplicated myocardial infarction (MI), one as pneumonia, 2 as cerebral infarction, 6 as acute abdominal disease, one as cholelithiasis, 5 as thrombosis of the lower extremities, and one as malignant metastasis to the pericardium. The following is the detail: In 2 cases thought to be uncomplicated MI, an expanding dissecting ascending aorta had crushed the lumen of the left coronary artery, causing MI, in turn, wasting clinical treatment and consuming precious time. In one case, enlargement of the descending aorta on the chest radiography was overlooked and the patient's symptoms were mistakenly attributed to pneumonia. In 2 cases in which symptoms of cerebral ischemia were thought to be attributed to cerebral thrombosis, the real cause turned out to be occlusion of the brachiocephalic artery following aortic dissection. Among 6 cases which were initially considered to have only acute abdominal disease, 3 presented with symptoms and signs of ileus, and their exploratory laparotomies yielded no positive findings.(ABSTRACT TRUNCATED AT 250 WORDS)

[Doppler echographic evaluation of pressure gradients of Björk-Shiley valve in the aortic position at rest and with exercise].

Pressure gradient across the Björk-Shiley (B-S) valve in the aortic position was assessed by Doppler echocardiography at rest and with exercise. There was close correlation between peak pressure gradient and area index which is a ratio of geometric orifice area (cm2) to body surface area (BSA) (m2). The correlation coefficient was -0.70 at rest and -0.86 with exercise. High peak pressure gradients with exercise were observed in the patients with 19 mm size (71 mmHg) and 21 mm size (107 mmHg). To avoid residual left ventricular outflow obstruction with exercise, it is considered advisable to use a #19 B-S valve in patients with BSA smaller than 1.1 m2, a #21 B-S valve in patients with BSA smaller than 1.4 m2, a #23 B-S valve in patients with BSA smaller than 1.8 m2, and a #25 B-S valve in patients with BSA smaller than 2.3 m2. If proper size of B-S valve cannot be inserted, aortic or aortic-mitral patch annuloplasty or the use of bileaflet valve are recommended as procedures of choice for small aortic annulus.

[Definitive myocardial blood flow evaluated by contrast echocardiography: experimental and A-C bypass flow studies].

We evaluated the feasibility of a new method for calculating definitive myocardial flow using contrast echocardiography in canine experiments and in patients who had undergone ACBG surgery. The principle for calculating flow was based on Kety-Schmidt method using time-intensity curve analysis between the epicardial and endocardial aspect. Inlet and outlet flows were hypothesized at the epicardium and endocardium, respectively. Analysis of time-contrast-intensity curves between the epicardium and endocardium, the difference of the area to the saturated point between epicardium and pericardium (A), and the saturated value (H) theoretically lead to the equation: Flow = 100 x (H/A) (Kety-Schmidt) in a 100-gram myocardium. No factors of intensity and time were included. Using this equation, the flow in 7 experimental canine and the flow of 9 patients who had ACBG surgery were compared to the electromagnetic flow. In the canine experiments, the left circumflex coronary artery was dissected free and was connected with contrast injector, a magnetic flowmeter and pneumatic occluder, proximal to distal in this order. Flow was controlled either by the occluder or drugs (papaverin and dipyridamole). Manually-agitated contrast media were injected rapidly (1 ml/2.5 sec), and M-mode echocardiographic recordings were densitometrically translated into time-intensity curves. Thirty-eight trials in 7 dogs showed close correlations (r = 0.901) between the electromagnetic flow and contrast echo flow. For the patients with ACBG, M-mode contrast echo recordings were made using transesophageal echo during the operations with contrast injections via the bypass grafts. Analysis of time-intensity curves was made and recorded in the same way as during the experiments.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical features of aortic dissection with early thrombosis of the false lumen].

There are cases of dissecting aortic aneurysm in which thrombotic formation occurs in the false lumen at an early stage, preventing dissection of the vessel wall and enlargement of the aneurysm. We studied such early thrombotic obliteration of false lumina in 12 (28.6%) of 42 patients with dissecting aortic aneurysm who underwent transesophageal two-dimensional echocardiography in the acute phase from June 1986 to October 1989. It was the first employment of a transesophageal approach at our hospital. In this study, we examined the clinical profiles of these patients as well as the usefulness of transesophageal two-dimensional echocardiography in establishing the diagnosis of dissecting aortic aneurysm and characterizing the disease. The patients were classified as Type I (2 patients) and Type III (10 patients; 6 Type IIIa and 4 Type IIIb) according to DeBakey's classification. The minimum and mean intervals from the onset of symptoms to transesophageal two-dimensional echocardiography were 1.5 hours and a mean of 38.2 hours, respectively. These results indicated that thrombotic obliteration of the false lumen had already occurred at a very early stage in some patients. The maximum diameter of the descending aorta was mean 37.6 mm with only 2 patients having that of 40 mm or more. Since left intrapleural hemorrhage was observed in these 2 patients (1 received emergent replacement of the descending aorta), enlargement of the aortic diameter may be indicative of unpredictable outcome, even in patients with early thrombotic obliteration of the false lumen. The long-term clinical course was favorable in all patients, including those who were treated surgically, over a mean follow-up period of 14.5 months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transesophageal Doppler echocardiography in the diagnosis of atrial septal defect].

To assess the usefulness of transesophageal Doppler echocardiography (TEE) in diagnosing atrial septal defect (ASD), we studied eight cases with secundum type ASD, in which the diagnosis was confirmed by cardiac catheterization and surgery. In all cases, TEE provided clear images of the interatrial septum with its defect. Shunt flow through the defect was observed by color Doppler technique, and its velocity was measured using the FFT mode. In two cases, right-to-left shunt blood flow was detected. Two types of probes were used in this study, a lateral scanning probe and a longitudinal scanning probe. The scanning plane of the former was perpendicular to the axis of the probe, and that of the latter was parallel to it. The two probes facilitated the measurement of the two right-angled dimensions, with which we could calculate the defect area, assuming the defect to be an ellipse. The volume of a left-to-right shunt was obtained by multiplying the defect area by the integration of flow velocity against time. Shunt volume per cardiac cycle obtained by this method correlated well with that obtained by the Fick's method during cardiac catheterization. In six cases without a right-to-left shunt, the coefficient of correlation was 0.98, and in all eight cases it was reduced to 0.72. Thus, we concluded that TEE is useful for diagnosing and evaluating ASD.