Liver-related safety assessment of green tea extracts in humans: a systematic review of randomized controlled trials.

There remain liver-related safety concerns, regarding potential hepatotoxicity in humans, induced by green tea intake, despite being supposedly beneficial. Although many randomized controlled trials (RCTs) of green tea extracts have been reported in the literature, the systematic reviews published to date were only based on subjective assessment of case reports. To more objectively examine the liver-related safety of green tea intake, we conducted a systematic review of published RCTs. A systematic literature search was conducted using three databases (PubMed, EMBASE and Cochrane Central Register of Controlled Trials) in December 2013 to identify RCTs of green tea extracts. Data on liver-related adverse events, including laboratory test abnormalities, were abstracted from the identified articles. Methodological quality of RCTs was assessed. After excluding duplicates, 561 titles and abstracts and 119 full-text articles were screened, and finally 34 trials were identified. Of these, liver-related adverse events were reported in four trials; these adverse events involved seven subjects (eight events) in the green tea intervention group and one subject (one event) in the control group. The summary odds ratio, estimated using a meta-analysis method for sparse event data, for intervention compared with placebo was 2.1 (95% confidence interval: 0.5-9.8). The few events reported in both groups were elevations of liver enzymes. Most were mild, and no serious liver-related adverse events were reported. Results of this review, although not conclusive, suggest that liver-related adverse events after intake of green tea extracts are expected to be rare.

[Redo-operation for the cusp perforation 5 years after aortic valve replacement with stentless bioprosthesis; report of a case].

A 31-year-old male presented with increase of aortic valve regurgitation 5 years after implantation of Prima Plus Stentless bioprosthesis in a bicuspid aortic valve. He underwent redo aortic valve replacement with a mechanical valve concomitant with replacement of the ascending aorta. Pathological examination of the explanted stentless valve presented no inflammatory cell infiltration. The prosthetic valve regurgitation was considered to be due to small injury at the 1st operation.

[Surgical treatment for ischemic heart disease].

BACKGROUND: Surgical treatment for ischemic heart disease (IHD) has changed after the administration of off-pump coronary artery bypass grafting (CABG) [OPCAB] and left ventricular restoration (LVR). We studied the development of the treatment and the surgical results. PATIENTS AND METHODS: Since May 2000 when the indication for OPCAB and LVR was defined, surgical treatment for IHD has been performed in 1,251 patients. The age ranged from 32 to 91 (mean 66 +/- 10) years and there were 977 men and 274 women. The elective operation was 1,130 and emergency 121. Definite indication for OPCAB was calcified ascending aorta, significant cerebrovascular disease, hemorrhagic tendency, and single vessel lesion. Conventional CABG (C-CAB) was the first choice and morbidity and surgical results were examined. RESULTS: OPCAB was performed in 297 (29.9%) and combined operation with CABG was required in 258 patients (20.6%). In elective operation, hospital mortality was one in OPCAB and one in C-CAB. In OPCAB and C-CAB, stroke was none and one, and mediastinitis was 0 and 0, respectively. CONCLUSION: The technique for OPCAB is necessary for CABG; however, it is not appropriate to persist with only OPCAB for CABG. Combined operation is often required with CABG and it is essential to perform precise C-CAB.

[Acute pulmonary embolism after cesarean section; report of a case].

We present a case of acute pulmonary embolism (APE) after cesarean section. A cesarean section was performed on a 27-year old woman with normal course. However, one day after operation, she suddenly developed syncope and dyspnea. Soon after the symptom, she developed hypotension 60 mmHg. As a result of various examinations, her illness was diagnosed as APE with right ventricular dysfunction after cesarean section. She was consulted to our hospital for treatment. Soon after her arrival, we treated her for both APE and cardiogenic shock. The combined with antithrombotic therapy using heparin sodium, was successfully treated the patient from cardiogenic shock due to APE with right ventricular dysfunction after cesarean section.

Autophagic degeneration as a possible mechanism of myocardial cell death in dilated cardiomyopathy.

In failing hearts, cardiomyocytes degenerate and interstitial fibrosis, which indicates cardiomyocyte loss, becomes more prominent in the myocardium. However, the precise mechanism of cardiomyocyte degeneration that leads to cell death is still unclear, although it is presumed that lysosomal function and autophagy play an important role because lysosomal activity increases under stress such as hypoxia. Myocardium that had been resected during partial left ventriculectomy performed in patients with dilated cardiomyopathy (DCM) was examined. Under light microscopy, some cardiomyocytes had a marked scarcity of myofibrils and had prominent cytoplasmic vacuolization. Atrophic and degenerated cardiomyocytes were often observed adjacent to replacement fibrotic tissue. Immunohistochemistry showed positivity for lysosome-associated membrane protein and a lysosomal catheptic enzyme in vacuoles of various sizes in the cardiomyocytes and these lysosomal markers were markedly increased in atrophic and degenerated cardiomyocytes. Electron microscopy revealed that degenerated cardiomyocytes had many vacuoles containing intracellular organelles, such as mitochondria, and were considered to be autophagic vacuoles. In DCM hearts, autophagy appeared to be associated not only with degradation of damaged intracellular organelles but also with progressive destruction of cardiomyocytes. It is possible that autophagic degeneration is one of the mechanisms of myocardial cell death.

Enterovirus RNA replication in cases of dilated cardiomyopathy: light microscopic in situ hybridization and virological analyses of myocardial specimens obtained at partial left ventriculectomy.

OBJECTIVE: Recently, attention has been focused on enteroviral infection of the heart in the genesis of dilated cardiomyopathy (DCM). To determine the location of enteroviral RNA in the myocardium, we performed light microscopic in situ hybridization (ISH) and virological analyses of myocardial specimens obtained at partial left ventriculectomy (PLV). METHODS: Posterolateral walls of the left ventricle from 26 DCM patients were examined. Myocardial specimens were tested for the presence of enteroviral genomes by polymerase chain reaction (PCR). We selected two age-matched groups (10 patients each) in which enteroviruses were either present (EV-plus group) or not (EV-minus group). For both groups, we examined in situ localization of enteroviral RNA in the myocardium by ISH. RESULTS: In PCR studies, both sense and antisense enteroviral RNA were detected in the myocardium of seven patients in the EV-plus group. The presence of this RNA indicates active viral replication in the myocardium. Five of seven patients who exhibited both sense and antisense enteroviral RNA died early after surgery. On ISH, three patients had evidence of active replication of enteroviral genomes. Viral genomes were present in myocardial lesions, especially in endocardial sites. Viral signals were found in degenerating myocardial cells, interstitial inflammatory cells, and endothelial cells of small vessels. These positive signals were not detected in the myocardium of the EV-negative group. CONCLUSIONS: We detected both sense and antisense enteroviral RNA in various myocardial lesions. This suggests that active enteroviral replication plays a role in the development of myocardial lesions in DCM patients. Active viral replication appears to be a prognostic factor for DCM after PLV. Further study of active viral replication in myocardial lesions will provide information useful for evaluating different therapeutic strategies for DCM.

Myocardial inflammatory cell infiltrates in cases of dilated cardiomyopathy as a determinant of outcome following partial left ventriculectomy.

Partial left ventriculectomy (PLV) can be used to treat refractory congestive heart failure caused by dilated cardiomyopathy (DCM). In order to understand the relationship between the underlying myocardial injury and early clinical outcomes after PLV, histopathologic, immunohistochemical and virologic studies of the resected myocardium were performed. The posterolateral left ventricular walls from 27 patients with idiopathic DCM were examined. Cardiomyocyte diameter, degree of myocardial fibrosis, degree of cardiomyocyte degeneration, and degree of inflammatory cell infiltration were compared with mortality rates. Polymerase chain reaction was performed to detect enterovirus genome in the myocardium. Some patients had inflammatory cell infiltrates with focal accumulations of lymphocytes and macrophages, including both cytotoxic/suppressor T-cells and helper/inducer T-cells. The number of inflammatory cells (activated lymphocytes plus macrophages/mm2) was significantly greater in patients who died of cardiac insufficiency after surgery (27.8 +/- 5.7; n = 7) than in the survivors (11.1 +/- 2.5; n = 15). There was no significant difference in the degree of myocardial fibrosis, cardiomyocyte diameter or degree of cardiomyocyte degeneration between the 2 groups. Enterovirus genome was detected in the myocardium of 9 (38%) of 24 patients examined and 5 of these enterovirus-positive hearts had severe inflammatory cell infiltrates (37.9 +/- 2.5/mm2). Early survival in patients undergoing PLV for DCM is significantly affected by the degree of myocardial inflammation, so patients with more severe or ongoing inflammation may have poor clinical outcomes. Chronic myocarditis may play an important role in the etiology and pathophysiology of idiopathic DCM.

Left ventriculoplasty for ischemic cardiomyopathy.

OBJECTIVE: In order to treat ischemic cardiomyopathy, which is defined as non-aneurysmal diffuse akinetic left ventricle with chronic heart failure following myocardial infarction, the mid-term effect of the endoventricular circular patch plasty (EVCPP) was studied. MATERIALS AND METHODS: EVCPP has been performed on 54 patients (46 men and eight women with a mean age of 61 years) during 4 years from March 1997 to December 2000. Thirty-two patients (59%) were NYHA class III and 22 patients (41%) were class IV. Nine patients (17%) had mild angina pectoris before the operation but others had no chest pain. Single, double, triple, and left main disease were noted in six, 13, 32, and three patients, respectively. Mean left ventricular ejection fraction was 23.3 +/- 6.3% (6--30%). Coronary artery bypass grafting was concomitantly undergone by 51 patients (94%) and mitral valve reconstruction was done on 19 patients (35%). RESULTS: Two patients (3.7%) needed an intra-aortic balloon pump to wean from cardiopulmonary bypass. Seven patients (12.9%) died in the hospital. Among them, two patients (4.4%) out of 45 patients who underwent elective operation died of stroke and heart failure. Five patients (55.5%) out of nine patients who required emergency operation died of heart failure and multiorgan failure. Late death occurred in six patients (11.1%) due to arrhythmia and heart failure in each of three patients. Out of 41 survivors, 38 patients returned to NYHA class I or II and three patients to class III. Out of 50 patients who underwent left ventricular study before and after operation, ejection fraction increased from 22.8 +/- 6.6 to 36.2 +/- 8.0% and mean left ventricular end-diastolic volume and left ventricular end-systolic volume indices reduced from 152.8 +/- 24.6 to 105.0 +/- 36.5 and from 113.6 +/- 45.7 to 66.4 +/- 28.4 ml/m(2), respectively. Mean pulmonary wedge pressure decreased from 19.1 +/- 8.8 to 14.9 +/- 6.8 mmHg. One-, 2-, and 3-year actuarial survival rates were 87.9, 82.7 and 77.2%, respectively. CONCLUSION: Left ventriculoplasty using EVCPP is effective to exclude the akinetic LV segment, and left ventricular function and clinical status improve in patients with ischemic cardiomyopathy.

Left ventricle restoration in patients with non-ischemic dilated cardiomyopathy: risk factors and predictors of outcome and change of mid-term ventricular function.

OBJECTIVE: The partial left ventriculectomy (PLV) for end-stage dilated cardiomyopathy (DCM) which worked in some patients has been reported, although the hospital mortality is high. To reduce hospital mortality, we selected operative procedures of left ventricular (LV) restoration to improve the operative results. We analyzed the risk factors and predictors of outcome, and the mid-term changes of the LV function were determined. PATIENTS AND METHODS: Between December 1996 and September 2000, 74 patients with non-ischemic DCM received LV restoration. The age ranged from 14 to 76 years (mean, 49.0+/-14.0 years), and there were 63 men and 11 women. The etiology of the DCM was idiopathic DCM in 49 patients, and dilated hypertrophic cardiomyopathy in seven patients and others in 18. The preoperative New York Heart Association (NYHA) functional class was 29 in class III and 45 in class IV, in which 32 patients depended on inotropic support. PLV or septal anterior ventricular exclusion (SAVE) was selected depending on the akinetic lesion of the LV based on the intraoperative echo-test. Fifty-six patients received elective operations, and emergency operations were performed in 18 patients. The risk factors and predictors of outcome were analyzed in 74 patients, and in 35 patients who survived more than 1 year after receiving LV restoration, the mid-term cardiac function was examined by cardiac echogram and catheterization. RESULTS: PLV was performed in 62 patients and SAVE in 12 patients. Concomitant mitral surgery was performed in 66 patients (89%) and tricuspid annuloplasty in 42 patients (57%). There were 15 hospital deaths and 13 patients died after discharge from the hospital (cardiac deaths in nine and non-cardiac deaths in four). In the 46 late survivors, the NYHA class was I or II in 42 patients and III in four patients. Selection of the procedure of LV restoration (P<0.01), elective operation (P<0.05), and the preoperative volume of LV (endodiastolic volume index of <180 ml/m(2); P<0.05) were risk factors and predictors influencing hospital and late death. After the operation, the LV function improved significantly and the improvement was maintained at the mid-term period; the LV ejection fraction was 31.8+/-7.9% (P<0.01) at 1 year from 23.0+/-7.3% preoperatively, left ventricular diastolic diameter was 62.8+/-10.9 (P<0.01) from 81.7+/-8.2 mm and the LV endosystolic volume index was 88.5+/-45.8 (P<0.05) from 162.6+/-41.6 ml/m(2). CONCLUSIONS: The operative results improved with the selection of the procedures, with elective operation, and mitral plasty for less cardiac dilatation. The mid-term results of clinical status and LV function showed the effectiveness of the operation.

[Left ventriculoplasty for non-ischemic cardiomyopathy with severe heart failure in 70 patients].

OBJECTIVES: Treatment of cardiac failure due to non-ischemic cardiomyopathy by left ventriculoplasty using partial left ventriculectomy (Batista operation) or septal anterior ventricular exclusion was evaluated. METHODS: Left ventriculoplasty was performed in 70 patients (59 men and 11 women with a mean age of 51 years) from December 1996 to June 2000. Preoperative New York Heart Association (NYHA) functional class was IV in 43 patients including 29 receiving inotropic support, and class III in 27 patients. Nineteen patients required emergency surgery because of on-going shock and 51 patients were operated electively. Combined cardiac procedures were mitral valve reconstruction in 62 patients (45 replacements, 17 repairs), tricuspid annuloplasty in 37, and aortic valve replacement in 4. The initial 24 patients underwent typical Batista operation regardless of myocardial viability. The other 46 patients underwent selective ventriculoplasty to excise or exclude the weakest part according to the findings of the intraoperative echo-guided volume reduction test. RESULTS: The intraaortic balloon pump was used in 12 patients and the left ventricular assist device in 2 patients. Three (5.9%) of the 51 patients who underwent elective operation and 12 (63.2%) of the 19 patients with emergency operation died in the hospital, giving an overall hospital mortality of 21.4% (15/70). Hospital mortality was reduced from 33.3% (8/24) in the initial 24 patients to 15.2% (7/46) in the recent 46 patients with the volume reduction test. Mean ejection fraction increased from 22.2 +/- 6.7% to 29.6 +/- 6.0%. Diastolic dimension decreased from 81.1 +/- 9.5 to 69.8 +/- 19.2 mm. End-diastolic and systolic volume indices decreased from 199.0 +/- 47.9 to 124.1 +/- 34.9 ml/m2 and from 154.0 +/- 41.2 to 89.3 +/- 31.7 ml/m2, respectively, at one postoperative month in the 55 hospital survivors. The mean pulmonary capillary wedge pressure decreased from 25.6 +/- 7.8 to 13.6 +/- 4.5 mmHg. Serum brain natriuretic peptide decreased from 999 +/- 647 preoperatively to 547 +/- 362 pg/ml one month after the operation. Thirteen patients (18.6%) died in the late period mainly due to heart failure. Among the 42 survivors, 37 patients returned to NYHA functional class I-II, and cardiac events were rare after one postoperative year. Actuarial survivals at 3 years in elective and emergency operations were 71.9% and 33.3%, respectively. CONCLUSIONS: Left ventriculoplasty is acceptably safe for elective operation and clinical improvement can be obtained by proper surgical procedures and careful postoperative medical treatment.

A double fistula, broncho-cavitary-cutaneous communication caused by cancer invasion.

Pulmonary infection with cavitation causes severe respiratory symptoms if the cavity has a communication with main bronchus, through which fluid flows out into trachea. In this report a young male with lung cancer invading an adjacent pre-existent fungus cavitary lesion is presented. Cancer invasion led to broncho-cavitary communication and caused massive intrabronchial aspiration. Subsequently, the cancer destroyed the thoracic wall, and a cavitary-cutaneous fistula developed which relieved symptoms as if treated with open drainage.

Intraoperative coronary artery imaging with infrared camera in off-pump CABG.

To achieve high quality off-pump coronary artery bypass grafting (CABG), thermal coronary artery imaging using a new generation infrared camera was used and anastomotic status was assessed intraoperatively. In 12 patients who underwent off-pump CABG, 18 grafts (11 internal thoracic, 2 radial, 2 gastroepiploic arteries, and 3 saphenous veins) were evaluated following completion of anastomoses. All grafts were clearly visualized and anastomotic and flow status were observed with local epicardial cooling by CO2 blower in the normothermic heart. Seventeen grafts had no problems and one internal thoracic artery graft showed anastomotic failure that was successfully revised. All grafts were restudied by conventional catheter angiography postoperatively, and all were patent. Intraoperative coronary imaging with a highly sensitive infrared camera is noninvasive and effective for real time evaluation in the operating room. This results in more successful off-pump CABG.

Evaluation of viral infection in the myocardium of patients with idiopathic dilated cardiomyopathy.

OBJECTIVES: The aim of this study was to evaluate the viral etiology of idiopathic dilated cardiomyopathy (DCM). BACKGROUND: The demonstration of enteroviral genome in hearts with DCM has reinforced the importance of enteroviruses in the pathogenesis of DCM. However, there is uncertainty about the character and activity of enteroviruses detected in the myocardium. Recently, the association of hepatitis C virus or adenovirus with DCM has been reported. METHODS: Myocardial specimens from 26 patients with idiopathic DCM, which were obtained at partial left ventriculectomy (PLV), were examined virologically. Strand-specific detection of enteroviral RNA was performed to differentiate active viral replication from latent persistence. Polymerase chain reaction was used to detect genomic sequences of hepatitis C virus, adenovirus, cytomegalovirus, influenza viruses, mumps virus, herpes simplex viruses, varicella-zoster virus and Epstein-Barr virus. RESULTS: Plus-strand enteroviral RNA was detected in 9 (35%) of the 26 patients. Minus-strand enteroviral RNA was determined in seven (78%) of these nine plus-strand RNA-positive patients. Sequence analysis revealed that the enteroviruses detected were coxsackie B viruses, such as coxsackievirus B3 and B4. However, genetic material from other viruses was not detected. Six (86%) of seven minus-strand enteroviral RNA-positive patients died of cardiac insufficiency within the first six months after PLV. CONCLUSIONS: Coxsackie B viruses were seen in hearts with idiopathic DCM. Active viral RNA replication appeared to be present in a significant proportion of these cases. Minus-strand coxsackieviral RNA in the myocardium can be a marker for poor clinical outcome after PLV. There was no evidence of persistent infection by other viruses in hearts with DCM.

Late angiographic result of using the right gastroepiploic artery as a graft.

OBJECTIVE: The angiographic patency of the right gastroepiploic artery graft used for coronary artery bypass grafting was studied during the late (5-10 years) postoperative period. METHODS: Among 936 patients undergoing a gastroepiploic artery graft for coronary artery bypass grafting between 1986 and 1999, postoperative angiographic restudy was conducted on 685 patients within 1 year (mean, 2.2 months), on 102 patients between 1 and 5 years (mean, 2.3 years), and on 52 patients between 5 and 10 years (mean, 7.8 years). RESULTS: The patency rate of the gastroepiploic artery graft was 94%, 88%, and 83% in each restudy group. The cumulative patency rate estimated by the Kaplan-Meier method was 96.6% at 1 month, 91.4% at 1 year, 80.5% at 5 years, and 62.5% at 10 years. Causes of late occlusion were primary anastomotic stenosis and anastomosis to a less critically stenosed coronary artery. Once the gastroepiploic artery was perfectly anastomosed to the coronary artery, which has tight stenosis and good runoff, late patency was good, and new stenosis in both the gastroepiploic artery trunk and the anastomotic site was uncommon. CONCLUSION: The gastroepiploic artery graft can be used effectively for coronary artery bypass for the long term with proper target selection.

[Combined valve and coronary artery bypass surgery].

Between January 1997 and November 1999, 31 patients underwent combined valve and coronary artery bypass grafting (CABG) surgery in our institute. There was no hospital death and clinical symptom improved in all patients after surgery. Mean follow-up was 16.3 months. The actuarial survival rate was 96.8% at 1 year. There were 4 late deaths (CHF in 3, arrhythmia in 1). Tepid blood cardioplegia was effective for those operations. Operation of CABG combined with valve surgery or LV surgery could be safely performed. We therefore considered that complete correction of the lesion with not only CABG but also combined valve surgery or LV surgery was the procedures of choice in patients with complicated lesions.

[Coronary artery bypass grafting without cardiopulmonary bypass in 200 patients].

OBJECTIVES: To evaluate the efficacy of off pump coronary artery bypass grafting (CABG), results in the initial consecutive 200 patients were reviewed. METHODS: Between October 1996 and December 1999, 200 patients underwent CABG without cardiopulmonary bypass. There were 146 men and 54 women aged from 27 to 89 years (mean 68 years). Single, double, triple and left main disease were noted in 94, 55, 33 and 18 patients, respectively, with a mean ejection fraction of 51%. Preoperative complications were previous stroke in 34 patients, chronic renal failure in 22 patients, previous CABG in 18 patients, and aortoiliac aneurysm or occlusive disease in 14 patients. Fifty-five patients (28%) were 75 years or older. Surgical approach was made through a midsternal incision including lower half small sternotomy in 105 patients, left anterior small thoracotomy in 92 and small epigastric incision (gastroepiploic-right coronary anastomosis) in 3. Mean number of distal anastomoses was 1.3 (range 1-4). Anastomosis was performed in 189 left anterior descending, 13 diagonal, 27 circumflex and 41 right coronary arteries. The conduits were 174 internal thoracic, 10 internal thoracic-inferior epigastric composite, 22 right gastroepiploic and 5 radial arteries, and 50 saphenous vein grafts. Four patients underwent combined off pump CABG and transmyocardial laser revascularization, and 36 patients underwent hybrid (off pump CABG and angioplasty) revascularization. RESULTS: Four patients (2.0%) died in the hospital due to intestinal necrosis in 2 patients, postoperative aortic dissection in one, and multiorgan failure with stroke in one. No serious ventricular tachyarrhythmia or use of intraaortic balloon pump occurred. Perioperative myocardial infarction was noted in one patient. Stroke occurred in 4 patients (2.0%) but 3 patients recovered in a short period. Three-year survival and cardiac event free rate were 90.3% and 81.1% by the Kaplan-Meier method. Postoperative angiographic study showed excellent patent graft in 92% of grafts (192/209), stenosed (> or = 50%) graft in 5% (10/209) and occlusion in 3% (7/209). CONCLUSIONS: Off pump CABG can be performed safely and effectively in both high risk and low risk patients with coronary artery disease. Refinement of surgical technique and equipment will make this procedure more useful.

[Surgery for idiopathic cardiomyopathy].

Among the patients with idiopathic cardiomyopathy, those with dilated cardiomyopathy were surgically treated. Initial 18 patients were treated with partial left ventriculectomy(PLV) and thereafter PLV in 26 patients, septal exclusion technique (EVCPP) in 5 patients, or solo-valvular surgery in 12 patients were applied according to the findings of the intraoperative cardiac echogram. The postoperative morbidity and mortality decreased after the selection of the operative procedures. Conclusively, left ventriculoplasty with PLV or EVCPP is a hope for the patients with dilated cardiomyopathy.

Preparation of completely 6-O-desulfated heparin and its ability to enhance activity of basic fibroblast growth factor.

Although regioselective removal of 6-O-sulfate groups of heparin has been undertaken by several researchers, complete 6-O-desulfation with little side reaction has not been attained successfully. In this work, a modified method with a certain silylating reagent, N-methyl-N-(trimethylsilyl)trifluoroacetamide, has been established to produce completely 6-O-desulfated heparin with few other chemical changes. The degrees of 6-O-desulfation were estimated by means of chemical disaccharide analyses and/or (13)C NMR spectra. Although the completely 6-O-desulfated heparin lost about 20% of 2-O-sulfate groups, any other chemical changes and depolymerization were not detected. The completely 6-O-desulfated heparin displayed strong inhibition of COS-1 cell adhesion to basic fibroblast growth factor (bFGF)-coated well in a dose-dependent manner, as was clarified by the competitive cell-adhesion assay. Furthermore, the completely 6-O-desulfated heparin was shown to promote in vitro A31 fibroblast proliferation in a dose-dependent manner in the presence of bFGF. These results suggest that signal transduction through bFGF/bFGF receptor in A31 cells occurs in the absence of 6-O-sulfate groups in heparin. The involvement of 6-O-sulfate group(s) of heparin/heparan sulfate in the promotion of bFGF mitogenic activity was reported by several groups. This discrepancy between our results and those of other groups would be due to the differences in molecular size of heparin/heparan sulfate derivatives and/or cell species used for the assay.

Nontransplant cardiac surgery for end-stage cardiomyopathy.

OBJECTIVE: To treat end-stage cardiomyopathy, we evaluated endoventricular circular patch plasty, partial left ventriculectomy, and valvular reconstruction alone in our 2-year experience. METHODS: Among 86 patients with heart failure evaluated between December 1996 and February 1999, 33 patients with ischemic cardiomyopathy (25 men and 8 women; mean age 61 +/- 7.8 years; New York Heart Association class 3.5 +/- 0.5) were treated with endoventricular circular patch plasty combined with coronary bypass grafting (84%) and mitral reconstruction (36%). The other 53 patients with nonischemic cardiomyopathy (45 men and 8 women; mean age 48 +/- 14.3 years, New York Heart Association class 3.7 +/- 0.5), were treated by left ventricular reduction by partial left ventriculectomy (n = 37) or patch plasty (n = 3) and valve reconstruction alone (n = 13). The first 24 patients (group I) underwent ventriculectomy with or without valve reconstruction; the more recent 29 patients (group II) underwent left ventricular reduction (n = 16) or valve reconstruction alone (n = 13) on the basis of the intraoperative echocardiographic evaluation to observe changes of wall motion and thickness during cardiopulmonary bypass. RESULTS: Ischemic Group: Hospital mortality in elective (n = 26) and emergency (n = 7) operations was 4% and 43%, and 3 patients died in the late postoperative period. Mean New York Heart Association class and ejection fraction improved from 3.5 +/- 0.5 to 1.5 +/- 0.7 and from 23% +/- 7.7% to 36% +/- 8.6%, respectively. Left ventricular end-diastolic and end-systolic volume indexes decreased from 162 +/- 46 mL/m(2) to 110 +/- 39 mL/m(2) and from 130 +/- 47 mL/m(2) to 70 +/- 32 mL/m(2), respectively. Nonischemic Group: In 40 patients with left ventricular reduction, hospital mortality in elective (n = 33) and emergency (n = 7) operations was 6% and 86%, and 5 patients died in the late postoperative period. Mean New York Heart Association class and ejection fraction improved from 3.7 +/- 0.5 to 1.7 +/- 0.6 and from 18% +/- 6.4% to 31% +/- 5.9%. Left ventricular end-diastolic and end-systolic volume indexes decreased from 203 +/- 45 mL/m(2) to 110 +/- 37 mL/m(2) and from 164 +/- 40 mL/m(2) to 79 +/- 33 mL/m(2), respectively. In 13 patients undergoing valve reconstruction alone (12 mitral with or without tricuspid and 1 tricuspid plus left ventricular assist device), hospital mortality in elective (n = 9) and emergency (n = 4) operations was 0% and 50% with no late deaths. Mean New York Heart Association class and ejection fraction improved from 3.6 +/- 0.5 to 2.0 +/- 0.5 and from 22% +/- 6.0% to 30% +/- 14.5%, respectively. Mean left ventricular end-diastolic and end-systolic volume indexes decreased from 170 +/- 34 mL/m(2) to 150 +/- 50 mL/m(2) and from 140 +/- 38 mL/m(2) to 104 +/- 40 mL/m(2), respectively. Overall mortality decreased from 50% in group I to 10% in group II. The survival estimates at 2 years were 77% (confidence limits 57%-88%) in the ischemic group and 63% (confidence limits 47%-75%) in the nonischemic group (no significant difference). The analysis of our data showed that the factors influencing the surgical results for dilated cardiomyopathy were presence of severe mitral regurgitation, preoperative New York Heart Association functional class IV with emergency operation, and operative procedures with randomly performed partial left ventriculectomy without an intraoperative echo test. CONCLUSION: Endoventricular circular patch plasty, partial left ventriculectomy, and solo valve reconstruction can be performed with an acceptably low risk as elective operations. The selection of operative procedures in idiopathic dilated cardiomyopathy and avoidance of emergency surgery improved operative mortality and morbidity. Among patients who survived at least 1 year, there were no late deaths up to 30 months' follow-up.