[Treatment of a massive tracheal bleeding with percutaneous cardiopulmonary support].

A 69-year-old woman was admitted to our hospital with heart failure. Echocardiography demonstrated severe mitral valve regurgitation due to chordae rupture of the posterior mitral leaflet. Although she was intubated and ventilation was initiated, her condition did not improve. On the 17th hospital day, she was scheduled to undergo mitral valve plasty. After induction of anesthesia, massive bleeding occurred from the tracheal granuloma (diameter, 3 cm), which had developed at the tip of the tracheal tube, and the airway was obstructed. Emergency percutaneous cardiopulmonary support (PCPS) was then introduced. Thereafter, endoscopic hemostasis was performed, followed by the excision of the granulation tissue using a gastric fiberscope. After excising the tissue, the patient could be ventilated; therefore, she was weaned from PCPS. The maximum PCPS flow was 4.0 l/min, and it was conducted for a 210-minutes duration. Her respiratory condition improved, and she was weaned from the ventilator 3 days after surgery. Mitral valve plasty was performed 55 days after the first operation, and she was discharged from the hospital in good health.

[Reoperation due to failure of a Freestyle bioprosthesis].

We report re-do aortic valve and ascending aorta replacements by using the valve-on-valve technique for primary tissue failure of a Freestyle bioprosthesis. A 74-year-old male, who had had a 25 mm Freestyle bioprosthetic valve implanted by the sub-coronary method 5 years previously for aortic valve regurgitation due to congenital bicuspid valve, was referred to our hospital for dyspnea and palpitation. He presented with heart failure secondary to aortic regurgitation due to primary tissue failure, and computed tomography demonstrated an enlarged ascending aorta (5 cm in diameter). The operative findings revealed that the Freestyle bioprosthetic valve had a leaflet tear at the left coronary cusp. We replaced the degenerated Freestyle bioprosthesis with a 19 mm Mosaic aortic bioprosthesis by using the valve-on-valve technique, and ascending aorta replacement was performed simultaneously. This technique can be useful for re-do surgery for degenerated stentless valves to avoid potential risks of complete excision of the bioprosthesis.

[Unruptured aneurysm of the sinus of Valsalva associated with right ventricular outflow tract stenosis; report of a case].

A 51-year-old female was referred to our hospital for heart murmur and was diagnosed with right ventricular outflow stenosis by echocardiography. Six years later, follow-up echocardiogram revealed that the stenosis was caused by an aneurysm of the sinus of Valsalva (2 cm in diameter) originated from the right coronary sinus. Resection and patch closure of the aneurysm were carried out under complete cardiopulmonary bypass. The aneurysm was not associated with ventricular septal defect and was categorized as Sakakibara-Konno type I. Postoperative state was uneventful. Systolic murmur disappeared and pressure difference in the right ventricular outflow was normalized.

[Multiple acute aortic dissection; report of a case].

A 60-year-old woman has been followed under the diagnosis of De Bakey type Illb acute aortic dissection. She developed sudden backache, and the diagnosis based on the emergent computed tomography (CT) was De Bakey type I dissection. At the operation, previous De Bakey type Illb dissection was far from the new dissection observed in the ascending aorta and arch aorta. We replaced the ascending aorta and aortic arch with woven Dacron graft (arch first technique) under retrograde cerebral perfusion. Since the residual dissection (De Bakey type III) in the multiple aortic dissection has tendency to dilate fast, intensive follow-up of the patient would be necessary.

[Modified Komeda-David operation for postinfarction ventricular septal perforation].

The infarct exclusion technique with a xeno-pericardial patch which Komeda and associates firstly reported in 1990 is one of the best procedure to close ventricular septal perforation. A large patch can protect the perforation and the surrounding weak tissue from the internal left ventricular pressure. However, suturing this large patch to the left ventricular wall through the small incision is not technically easy because of the patch design in the ventricle. We modified the design of the patch. This round shaped bovine pericardial patch was sutured continuously to the left ventricular wall. Then, excessive part of the patch was trimmed to make a corn shape. Finally, the corn shaped patch fit the left ventricular wall naturally.

[Superior result of ketone body ratio in normothermic cardiopulmonary bypass].

UNLABELLED: Nineteen patients undergoing aortocoronary bypass surgery were divided into two groups according to the perfusion temperature, either normothermia (36 degrees C) or hypothermia (30 degrees C). The hepatic blood flow was measured at three points before, during and after cardiopulmonary bypass. Arterial and hepatic venous ketone body ratios (AKBR, HKBR) and hepatic venous saturation (ShvO2) were measured throughout the surgery. RESULTS: Hepatic blood flow in both groups was identical before, during, and after the CPB. The significantly lower ShvO2 levels were observed during the CPB in the normothermic group. The both AKBR and HKBR in the hypothermic group decreased severely after the initiation of CPB (p < 0.01). However, the reduction in AKBR and HKBR was less severe in the normothermic group. CONCLUSIONS: Normothermic CPB provides adequate liver perfusion and results in a better hepatic metabolism than hypothermic cardiopulmonary bypass.

Right ventricular dynamic cardiomyoplasty for the univentricular heart with pulmonary hypertension.

OBJECTIVES: We conducted an acute experimental study to test the feasibility of dynamic cardiomyoplasty in a setting of modified Fontan procedure for univentricular heart with pulmonary hypertension to obtain a possible proxy for high-risk Fontan candidates. METHODS: After electrical preconditioning of the left latissimuss dorsi for 6 weeks in 8 dogs, the right ventricular cavity was totally obliterated with concomittent closure of the tricuspid valve and right pulmonary artery. Modified Fontan circulation was established with the aortic homograft anastomosed between the right atrium and pulmonary trunk, incorporated with a pericardial pouch as a compression chamber (neoright ventricle) fixed onto the epicardial surface of the ventricle. After cardiopulmonary bypass termination, a latissimus dorsi was applied to wrap the pericardial pouch and ventricle clockwise and stimulated with a trained-pulse (25 Hz) at 1:1 synchronization ratio with cardiac beats. RESULTS: Profound right heart failure was noted during Fontan circulation in increased pulmonary vascular resistance (11 +/- 3.2 Wood units), whereas graft pacing showed significant augmentation of systolic pulmonary pressure by 54 +/- 12%, the mean pulmonary flow by 68 +/- 23%, and aortic pressure by 23 +/- 5% at a physiological range of central venous pressure (13.2 +/- 0.7 mmHg). Right heart function curve analysis confirmed marked augmentation of right heart performance, restoring almost normal pulmonary circulation. These functional benefits were sustained up to 4 hours in 4 animals until experiments were terminated. CONCLUSIONS: Dynamic cardiomyoplasty in a modified Fontan procedure is a viable surgical option for univentricular heart, not a Fontan candidate.

Non-ionic detergent Tween 80 modulates VP-16 resistance in classical multidrug resistant K562 cells via enhancement of VP-16 influx.

The non-ionic detergent Tween 80, which is used as a solvent for lipophilic drugs such as VP-16 and Taxotere, was found to reverse VP-16 resistance of the P-glycoprotein-associated multidrug resistance phenotype via increasing VP-16 influx. In adriamycin-resistant human chronic myelogenous leukemia K562 cells (K562/ADM), which overexpress mdr1 mRNA, the accumulation of VP-16 was only about 10% that in wild-type K562 cells. Tween 80 enhanced VP-16 accumulation in K562/ADM cells but did not influence VP-16 accumulation in parental K562 cells. VP-16 efflux was rapid and similar in both sensitive and resistant cell lines and was not blocked by Tween 80 or verapamil. Under glucose-free conditions, VP-16 accumulation in K562/ADM cells was only half of that in K562 cells. Tween 80 increased VP-16 accumulation in K562/ADM cells in glucose-free medium. In growth inhibition assay, Tween 80 reversed K562/ADM sensitivity to VP-16 without cell damage. Taken together, Tween 80 reverses VP-16 sensitivity in multidrug-resistant K562 cells by increasing influx, which is considered to be the primary mechanism of VP-16 resistance in K562/ADM cells.

Pilot study of continuous low-dose 5-fluorouracil and cisplatin (FP regimen) for the treatment of metastatic breast cancer.

Background. The effect of low-dose 5-fluorouracil (FU) and cisplatin therapy (FP regimen) against metastatic breast cancer was investigated. Methods. A pilot study of the FP regimen was performed in 11 patients with metastatic breast carcinoma who had previously received chemotherapy, including adriamycin, and/or hormonal therapy. Their median age was 56 years (range, 48-72 years). Visceral metastases were present in all patients. FU, at a dose of 170 mg/m(2) per day, was administered for 28 days by continuous intravenous infusion. Cisplatin (7 mg/m(2) per day) was given intravenously on days 1-5, 8-12, 15-19, and 22-26. After a 2-week interval, this treatment was repeated. Results. Of the 11 patients assessable for tumor response to the FP regimen, 4 patients (36%; 95% confidence intervals [CI], 8%-64%) achieved an objective response, with 1 showing a complete response and 3 showing a partial response. Median time to progression was 6.5 months (range, 4-25 months). The median survival time from the initiation of the FP regimen was 11 months (range, 3-25 months). Gastrointestinal and hematologic toxicity was mild. Conclusion. The FP regimen is promising for and has acceptable tolerance in patients with metastatic breast carcinoma refractory to previous anthracycline-containing chemotherapy.

The role of a staged approach for high-risk Fontan candidates.

The preoperative risk characteristics and surgical outcome were reviewed in 24 patients who underwent a one-stage Fontan procedure (One-stage Group) and in 16 patients who underwent bidirectional cavopulmonary shunt as an interim procedure prior to a subsequent Fontan procedure (Two-stage Group) to clarify the role of the staged approach for high-risk Fontan candidates. There were 2 hospital deaths after the one-stage Fontan, and another 2 after the takedown of the fenestrated Fontan to BCPS in patients considered to be less than ideal candidate because of the presence of 3 or more risk factors. In contrast, among the total of 16 patients in the Two-stage Group who had significantly more risk factors than those in One-stage Group (2.8 +/- 1.4, vs 1.1 +/- 1.2 p < 0.001), 14 patients survived after bidirectional cavopulmonary shunt, and a subsequent Fontan procedure was accomplished in 12 patients of these 14, with 2 operative deaths after the takedown to bidirectional cavopulmonary shunt. The rate of final Fontan completion in the Two-stage Group (10/16, 62.5%) was considered to be reasonable, considering the fact that this patient group essentially includes non-Fontan candidates. Additionally, in the category of high-risk with 3 or more risk factors, the rate of successful Fontan completion was higher in the Two-stage Group than in the One-stage Group (50% vs 25%). In the survivors of the Two-stage Group, the average number of risk factor decreased from 2.7 +/- 1.3 (range 0 to 5) to 1.0 +/- 1.0 (range 0 to 4) after bidirectional cavopulmonary shunt with concomitant procedures (i.e., extended pulmonary artery reconstruction in 8, and repair of atrioventricular valve regurgitation in 4), predominantly due to improved Fontan candidacy, relating to pulmonary and/or ventricular characteristics, and eliminated anatomical risks. In conclusion, the two-stage approach with bidirectional cavopulmonary shunt accompanied by concomitant repair of associated anomaly may be useful to lower the risk enough to allow subsequent Fontan completion in high-risk patients.

[Multi-drug resistant breast cancer responding to chemotherapy with docetaxel (taxotere: TXT)].

The patient was a fifty-five year old female who had stage IVb advanced breast cancer with hypoxia due to bilateral pulmonary metastases and lymphangitis. The cancer was adriamycin (ADM) and multi-drug resistant. We administered docetaxel (taxotere: TXT) 60 mg/m2 every 3 weeks. After 2 courses, the pulmonary metastases had become remarkably reduced in size and hypoxia was reduced and performance status (PS) improved. Major toxic defects were grade-4 neutropenia and hair loss. The patient could be discharged from the hospital without O2 inhalation and enjoyed a better quality of life (QOL). This chemotherapy is thought to be effective against ADM and multi-drug resistant breast cancer.

[Clinical outcomes in low grade follicular lymphoma].

Twenty-six patients with follicular small-cleaved lymphoma (FSCL) and 16 patients with follicular mixed lymphoma (FML) were treated at the Nichidai Itabashi Hospital between 1981 and 1995. The 5-year overall survival rate was 74.3% and 70.0% for the FSCL and FML patients, respectively. Of the patients with stage III-IV FSCL, 9 were assigned to a "watchful waiting" follow-up course and 13 were treated with a single alkylating agent or CHOP therapy. The 5-year failure-free survival rate was 66.7% and 33.0%, respectively. Of the patients with stage II-IV FML, 6 were treated with CHOP or MACOP-B protocol. The complete response rate for this group was only 33.3%, and none of the patients were in remission for more than 2 years. Histological transformation into diffuse aggressive lymphoma was observed in 7 patients, with the median time from diagnosis to transformation at 50 months. Three of those patients were successfully treated with intensive chemotherapy after transformation.

[Merocyanine 540-mediated photodynamic therapy inhibits P-glycoprotein (P-gp) activity in adriamycin-resistant K562 cells].

The photosensitizing dye merocyanine 540 (MC540) has been used in preclinical models and in a phase I clinical trial in the U.S.A. for the extracorporeal purging of autologous bone marrow grafts contaminated with leukemia or lymphoma. In this communication, we report MC540-mediated photodynamic therapy (PDT) was effective in purging leukemic cells expressing P-gp. When K562 and K562/ADM were exposed to MC540 (15 micrograms/ml) and white light (145.8 kJ/m2), the concentration of K562 and K 562/ADR was reduced by 1.8 and 3.0 log, respectively. Using flow cytometry and confocal laser scan microscopy, MC540 and calcein-AM were bound intracellularly and effluxed by P-gp in K562/ADM. In K562/ADM, calcein-AM efflux was inhibited by P-gp modulator, cyclosporin A (5 microM) and verapamil (15 micrograms/ml). In contrast, MC540 efflux was inhibited by cyclosporin A but not verapamil. Furthermore, MC540-mediated PDT inhibited efflux of calcein-AM and MC540, and induced the accumulation of dyes in K562/ADM. We conclude that MC540 is a substrate of P-gp and that MC540-mediated PDT is useful for purging MDR cells through inhibition of P-gp activity.

Effect of dietary magnesium level on nephrocalcinosis and growth in rats.

We studied the extent of kidney calcification by varying dietary levels of Mg, based on pathological examinations and calcium (Ca) and magnesium (Mg) balance tests. AIN-76 diets containing varying levels of Mg--0.3 (-M), 1.3 (1/20M), 2.4 (1/10M), 9.2 (1/5M), 19 (control), 38 (2M), 102 (5M), and 187 (10M) mmol/kg diet--were fed to 3-week-old male Fischer-344 rats for 14d. Although the magnitude of abnormality was highest in kidney of rats fed the -M diet, the damage was normalized as the dietary level of Mg increased, with increasing serum Mg concentration and urinary excretion of Mg. We found almost no deposition of Ca in rats fed the 10M diet. The mechanism by which the high dietary Mg induces these effects most likely involves a competition between Mg and Ca for reabsorption in proximal and/or distal tubules, since these diets increased the urinary excretion of Ca. However, these high Mg diets decreased food intake and body weight gain compared with the control diet, although these indices were not decreased in rats fed the 2M diet. The results suggest that a dietary magnesium level approximately twice the normal level effectively reduces kidney calcification while maintaining normal growth in rats.

Bioavailability of magnesium contained in roasted and ground soybean (kinako) as evaluated by serum and bone magnesium contents, kidney calcification, and magnesium absorption.

The bioavailability of roasted and ground soybean (kinako) magnesium (Mg) in Fischer 344 strain male rats with respect to serum Mg level, bone Mg contents, kidney calcification, and Mg absorption was evaluated. Four-week-old male rats were divided into four groups of six rats each. The four groups were the control (20SC), Mg-deficient diet (1/3 Mg20SC), 20SCK diet, and 20SCDK diet. The 20SCK and 20SCDK diets were prepared to contain amounts of Mg equal to that in the 20SC diet with kinako or defatted kinako as the Mg source, respectively. After a 4-week experimental period, rats were decapitated and blood serum, right femur, and right kidney were collected, and Mg, calcium (Ca), and phosphorus (P) concentration in those tissues were determined. The Mg balance was also investigated. The serum Mg concentration in the 1/3 Mg20SC group was half the level in the 20SC group, and the serum Ca concentration was higher than in the 20SC group, indicating apparent hypercalcemia. Serum Mg and Ca concentrations in the 20SCK and 20SCDK groups did not significantly differ from those in the 20SC group. Femur Mg concentration in the 1/3 Mg20SC group was lower than in the 20SC group. Femur Mg concentrations in the 20SCK and 20SCDK groups were lower than in the 20SC group, but significantly higher than in the 1/3 Mg20SC group. The kidney Ca concentrations in the 20SCK and 20SCDK groups were significantly higher than those in the 20SC and 1/3 Mg20SC groups, and there was also kidney calcification. These results indicated that kinako and defatted kinako Mg were used effectively as a serum and femur Mg source, but that kinako and defatted kinako carry a risk of kidney calcification when used as the only Mg source.

[A case report of aortic valve replacement following ruptured aneurysm of the sinus of Valsalva with bicuspid valve].

Only three cases of the combination of bicuspid aortic valve and ruptured aneurysm of the sinus of Valsalva, associated with previously repaired coarctation of aorta, have been reported. A twenty-year-old man with a sudden onset of CHF due to ruptured aneurysm of the sinus of Valsalva underwent intracardiac repair by direct closure of the sinus Valsalva in combination with patch closure of a subarterial VSD. Although, no AR was detected preoperatively, massive regurgitation occurred after the repair due to subsequent failure of aortic valve coaptation in the present of the bicuspid aortic valve, which was not diagnosed preoperatively. Aortic valve replacement with SJM 25 mm was successfully performed.

[Successful treatment with intermittent administration of etoposide for an adult case with recurrent hemophagocytic syndrome, developed in association with chronic EB virus infection related lymphoid hyperplasia in the small intestine].

A 28-year-old man complaining of melena accompanied by high grade fever was previously operated on for two small ulcerative, infiltrative lesions of the small bowel at another hospital in April, 1992. In the resected small intestines an immunohistochemical study was positive for EBV encoded RNA (EBER). It is assumed that Epstein-Barr (EB) virus infection has contributed to the small bowel lesions. In March, 1993, he was diagnosed as having chronic EB virus infection. In October, 1993, he was transferred to our hospital for further examination of high grade fever, rapidly worsening thrombocytemia and severe liver disfunction. Mature histiocytes with hemophagocytosis were detected in the bone marrow and he was diagnosed as having hemophagocytic syndrome (HPS) due to reactivation of chronic EB virus infection. Although treatment by corticosteroids, acyclovir and gamma globulin was not effective administration of etoposide induced remission of the disease. In December, 1993 and January, 1994 HPS recurred, but etoposide was again effective in alleviating the disease. To prevent recurrence of HPS after we discharge the patient, intermittent administration of small doses of etoposide was started. Since then HPS has not recurred, and the drug was eventually discontinued in November, 1995. Our case suggested that Etoposide could change the fulminant course of EB virus-associated HPS and that it is effective to sustained remission.

Configuration of linear dynamic cardiomyoplasty for hypoplastic right ventricle.

BACKGROUND: The purpose of this study is to determine feasibility of linear dynamic cardiomyoplasty with a briefly preconditioned latissimus dorsi in the experimental model simulating patch enlargement of the hypoplastic right ventricle. METHODS: In 8 mongrel dogs, a diminished right ventricular chamber was reconstructed with an extended pericardial patch. A left latissimus dorsi, preconditioned for 2 weeks (2 Hz) after a previous 2-week vascular delay period, was placed on the patch, with the muscle fiber oriented in parallel to the right ventricular long axis. RESULTS: Graft pacing with trained-pulses of 25 Hz at a 1:1 ratio showed significant augmentation of pulmonary flow and pressure (158% +/- 21%, 156% +/- 14%, respectively), contributing to restoring right ventricular function comparable with preoperative control, which was also confirmed by the right ventricular function curve and pressure-volume relationship analyzes. Continuous pacing was performed in 4 animals for 7 hours without evidence of muscle fatigue, implying feasibility of "working conditioning" after minimum preconditioning for this type of right heart assist. CONCLUSIONS: Linear latissimus dorsi myoplasty can restore normal right ventricular performance at a physiologic preload, and may provide a surgical option for the hypoplastic right ventricle.

[A surgical case report--rare association of tetralogy of Fallot with cor triatriatum, unroofed coronary sinus and persistent left superior vena cava].

We experienced the rare association of Tetralogy of Fallot with cor triatriatum, unroofed coronary sinus and persistent left superior vena cava. Only one case of this association has ever been reported in the literature. We successfully performed a total correction which consisted of a resection of the intra-left atrial fibrous membrane, reconstruction of the LSVC return pathway to the right atrium with PTFE graft, atrial partition with a bovine pericardial patch and the conotruncal repair for Tetralogy of Fallot. Cardiac catheterization 6 months after operation demonstrated the smooth drainage from LSVC into the right atrium without pressure gradient. His postoperative course has been uneventful.

Bioavailability of magnesium contained in purple laver (Asakusa-Nori) by rats with scarce magnesium, being evaluated from serum magnesium, kidney calcification, and bone magnesium contents.

An experiment was designed to evaluate the bioavailability of purple laver (Asakusa-Nori, Porphyra tenera Kjellman) magnesium (Mg) in Mg-scarcity Fischer 344 male rats from serum Mg level, kidney calcification and bone Mg contents. Male rats of 4 weeks of age were divided into four groups of six rats. The four groups were control (20SC), Mg-restricted (-Mg20SC), -Mg20SC plus purple laver (-Mg20SCP), and 20SC plus purple laver (20SCP) group respectively. To -Mg20SC, 1/10 Mg of the 20SC diet was added. -Mg20SCP diet purple laver as a Mg source. 20SCP diet was designed to contain double amount of Mg. After a 3-week experimental period, rats were decapitated. Blood serum, right kidney, and right femur were collected and Mg, calcium (Ca), phosphorus (P) were determined. Serum Mg concentration of the -Mg20SC was 1/3 of the 20SC, indicating apparent hypomagnesemia. Serum P also showed lowered concentration. On the other hand, the serum Ca indicated higher value than the other groups, indicating hypercalcemia. Addition of purple laver to -Mg20SC diet resulted in a normal serum Mg, Ca, and P level. The Mg-scarcity (-Mg20SC) rats accumulated much amount of kidney Ca. Whereas, there was no significant difference in kidney Ca between control (20SC) group and purple laver-supplemented (-Mg20SCP) rat group. The -Mg20SC rats showed lowered ash content and reduced Mg and P concentrations in the femur. Purple laver supplementation increased the ash, Mg, and P. All of the results indicated that the purple laver Mg was used as a Mg source.(ABSTRACT TRUNCATED AT 250 WORDS)