[Ross procedure with aortic replacement for aortic stenosis with ascending aortic aneurysm: report of a case].

Bicuspid aortic valve (BAV) is a common congenital heart disease, and it is well known to be a risk factor for ascending aortic dilatation and dissection. We here report a case of 34-year-old woman who underwent Ross procedure with ascending aortic replacement under the diagnosis of subaortic stenosis and ascending aortic aneurysm. She was pointed out to have heart murmur soon after the birth diagnosed as patent ductus arteriosus. The ductus was ligated when she was 3-years-old, however, heart murmur remained. Further examinations revealed that she also had aortic stenosis with BAV. During her 20-year-follow-up, subaortic stenosis and ascending aorta ectasia were also progressed. Pathological examinations of resected ascending aortic wall showed mucoid degeneration and laceration of collagen fibers, suggesting the fragility of dilated aortic wall with BAV.

Ultrasonic measurement of vascular scaffold elasticity using catheter system.

Characterization of grafted vascular scaffold is essential for evaluating its biocompatibility, maturity and structural intensity. Quantitative elastic modulus measurement of vascular scaffold powerfully assists its characterization because the mechanical property is closely related with the biocompatibility, maturity and structural intensity of the vascular scaffold. We have presented an in vitro or in vivo measurement system for the tissue-engineered vessel before and after grafting in the previous study, we present a novel and modified method for in vivo assessment and follow-up of the vascular scaffold in this study. The measured quantitative elastic modulus is converted into the regeneration score for in vivo assessment. The effectiveness of the proposed evaluation method was validated by in vivo experimental data using canines.

[First successful clinical application of tissue engineered blood vessel].

With this tissue engineering (TE) technique, the peripheral pulmonary artery was successfully reconstructed, using the patient's own venous cells in a 4-year-old girl, 2 years after Fontan procedure. A 4-year-old girl was given a diagnosis of single right ventricle, double-outlet right ventricle and pulmonary atresia. She underwent left modified Blalock-Taussig shunt at a month old, pulmonary artery angioplasty at a year and 3 months old, and bidirectional cavopulmonary shunt at 2 years and a month old. She underwent again pulmonary artery angioplasty and Fontan operation at 3 years and 3 months. An angiographical examination 7 months after the operation revealed total occlusion of the right intermediate pulmonary artery. TE technique using autologous cells was indicated. The application of this procedure was approved by the ethical committee in Tokyo Women's Medical University. The patient's parents were thoroughly informed and signed a consent form. Approximately 2 cm of the peripheral vein was explanted under sterile conditions. The tissue was minced, placed in tissue culture dishes and cultured at 37 degrees C, 100% humidity and a 5% CO2 atmosphere for almost a month. The number of cells substantially increased to reach 12 millions for almost a month. The culture medium was changed every 3 days. The polymer tube that served as a scaffold for cells was composed of the copolymer of PCL-PLA (50:50) with reinforcement by woven PGA. The polymer conduit, 10 mm in diameter, 20 mm in length and 1 mm in thickness, was designated to biodegradate within 8 weeks. The number of seeded cells was approximately a million/cm2. The graft transplantation was performed 10 days after seeding cells. The occlusive right intermediate pulmonary artery was reconstructed with the TE vessel graft under extracorporeal circulation with a pump-oxygenator. The patient followed a satisfactory postoperative course. The postoperative angiography demonstrated that the graft was not constricted and dilated but that it preserved good patency. Long-term follow-up are necessary. We plan to continue to use the TE technique using autologous cells in the low pressure system like venous or pulmonary circulation. Because our results even in early experimental phase were valuable and promising, we believe that the TE approach may play an important role in the near future as an another alternative, together with transplantation and artificial organ, especially in the field of cardiovascular surgery that mostly needs replants.

[A case report of ross operation and ventricular septal defect closure following correction of type A interruption by modified Blalock-Park, pulmonary artery banding and patent ductus arteriosus division].

A 2-year-old boy who had undergone a correction of a type A interruption using a modified Blalock-Park operation, pulmonary artery banding and the division of a patent ductus arteriosus, underwent a Ross operation and closure of ventricular septal defect (VSD). Although a pre-operative echo cardiogram revealed a bicuspid aortic valve, and a Doppler echocardiogram showed only 10 mmHg of pressure gradient across the aortic valve, Ross procedure was performed as a procedure accompanying the closure of a total conus VSD. The total conus VSD was closed with a Dacron patch using pledget mattress sutures. In addition, a running suture was applied over the denuded aortic root and the cranial margin to achieve water tight closure. An aortic root replacement procedure was our first choice for the Ross operation. After both coronary buttons were re-implanted into pulmonary sinuses, a pulmonary artery autograft was wrapped around by the remaining aortic wall for reinforcement to prevent future dilatation. The main pulmonary artery was reconstructed using a bicuspid pericardial valve conduit with a diameter of 24 mm. A post-operative echocardiogram showed no neoaortic valve regurgitation, good coaptation of tri-leaflets, mild regurgitation of pericardial valve and good cardiac performance.

[Current status of tissue engineering for therapeutic use].

During the past three decades, significant advances have been made in the field of transplantation. However, clinical obstacles such as donor scarcity, cost, infection and life-long immunosuppression(especially within the pediatric age group) have become the major limitations for organ transplantation. This article discusses the recent progresses as well as the remaining challenges in tissue engineering that may enable such technology to replace organ transplantation. Additionally, we describe a practical method for tissue engineering in the field of cardiovascular surgery.

Tissue-engineered vascular autograft: inferior vena cava replacement in a dog model.

Tissue-engineered vascular autografts (TEVAs) were made by seeding 4-6 x 10(6) of mixed cells obtained from femoral veins of mongrel dogs onto tube-shaped biodegradable polymer scaffolds composed of a polyglycolid acid (PGA) nonwoven fabric sheet and a copolymer of L-lactide and caprolactone (n = 4). After 7 days, the inferior vena cavas (IVCs) of the same dogs were replaced with TEVAs. After 3, 4, 5, and 6 months, angiographies were performed, and the dogs were sacrificed. The implanted TEVAs were examined both grossly and immunohistologically. The implanted TEVAs showed no evidence of stenosis or dilatation. No thrombus was found inside the TEVAs, even without any anticoagulation therapy. Remnants of the polymer scaffolds were not observed in all specimens, and the overall gross appearance similar to that of native IVCs. Immunohistological staining revealed the presence of factor VIII positive nucleated cells at the luminal surface of the TEVAs. In addition, lesions were observed where alpha-smooth muscle actin and desmin positive cells existed. Implanted TEVAs contained a sufficient amount of extracellular matrix, and showed neither occlusion nor aneurysmal formation. In addition, endothelial cells were found to line the luminal surface of each TEVA. These results strongly suggest that "ideal" venous grafts with antithrombogenicity can be produced.

[Cryopreservation of vascular mixed cell for tissue engineering in cardiovascular surgery].

Tissue engineering (TE) is a new discipline that offers the potential to create replacement structures from autologous cells and biodegradable polymer scaffold. Various vascular and valvular grafts have been tried to create with this TE approach. In clinical use of this technique, harvested and cultured cells have to keep viability until implantation as tissue engineered tissue. But few research for cryopreservation of vascular mixed cells has been performed. So, we investigated the proper method for cryopreservation of vascular mixed cells harvested from femoral artery and vein of dogs. Cells were cultured and divide into three groups, A: cryopreserving in 5% dimethylsulfoxide (DMSO), hydroxyethyl starch (HES), and fetal bovine serum (FBS) with -80 degrees C freezer; B: cryopreserving in 10% DMSO and FBS with programmed freezer; C: control (continuous culture in media). After rapid thawing at 40 degrees C, group A showed higher viability than group B with flow cytometry. The results means that vascular mixed cells can be successfully cryopreserved in the DMSO/HES mixture simply and inexpensively, without rate controlled freezing.

Vomeronasal epithelial cells of human fetuses contain immunoreactivity for G proteins, Go(alpha) and Gi(alpha 2).

Two G protein subfamilies, Go(alpha) and Gi(alpha 2), were identified and localized immunohistochemically in the vomeronasal organ (VNO) of 5-month-old human fetuses. Immunoreactivity for Go(alpha) and Gi(alpha 2) was present in a subset of vomeronasal epithelial cells. Prominent immunoreactivity was observed in apical processes and their apical terminals facing onto the vomeronasal lumen. Nerve fibers associated with the VNO exhibited intense immunoreactivity for Go(alpha) and weak immunoreactivity for Gi(alpha 2). Since Go(alpha) and Gi(alpha 2) are characteristically expressed and coupled with putative pheromone receptors in rodent vomeronasal receptor neurons, the present results suggest the possibility that vomeronasal epithelial cells containing Go(alpha) and Gi(alpha 2) in human fetuses are chemosensory neurons.

Complete resection of cardiac leiomyosarcoma extending into the pulmonary trunk and right pulmonary artery.

A cardiac leimyosarcoma is an extremely rare tumor. We report a case of complete resection of a cardiac leiomyosarcoma extending into the pulmonary trunk and the right pulmonary artery using the Freestyle bioprosthesis (Medtronic, Inc, Minneapolis, MN) and Xenomedica graft (Baxter Healthcare Corp, Horw, Switzerland). Extensive resection and reconstructive surgery with the addition of radiotherapy prolonged the patient's life.

[A surgical case of papillary muscle reconstruction and double-CABGs for mitral regurgitation due to ruptured papillary muscle after myocardial infarction].

A 76-year-old female patient underwent papillary muscle reconstruction, and d-CABGs a month after the onset of myocardial infarction. Posterior papillary muscle (PPM) was recognized to be ruptured partially, its stump was sewn to original PPM. An ePTFE suture (CV 5) was placed from anterior mitral leaflet to anterior papillary muscle in attempt to reinforce PPM-repair. Carpentier-Edwards ring was inserted and d-CABGs (LITA to LAD and GEA to RCA) were performed, simultaneously. Postoperative examination revealed no regurgitation and no stenosis of bypass grafts during follow-up period of 5 months after the procedure. Papillary muscle reconstruction was effective procedure for MR due to the ruptured papillary muscle.

[A successful case of simultaneous operation of aortic arch aneurysm and left lung cancer].

We report a simultaneous operated case of a 73-year-old man with aortic arch aneurysm and squamous cell carcinoma of the lung. Via median sternotomy, aneurysmectomy and graft replacement was performed under hypothermic circulatory arrest and selective brain perfusion. After changing the position, left upper lobectomy with lymph node dissection was performed via left posterolateral thoracotomy. In spite of using cardiopulmonary bypass, hemostasis was easy, and there was no complication through intra-operative to post-operative course. The cases of simultaneous operation of thoracic aortic aneurysm and lung cancer are rare, and only 3 cases have been reported in Japan. Under careful selection of the patients, simultaneous operations can be performed safely.

[Curative report of two cases with MRSA mediastinitis after cardiovascular surgery, treated by new irrigation technique (intermittent mass-irrigation technique)].

We experienced a 42-year-old patient who underwent aortic valve replacement and a 63-year-old patient who underwent coronary artery bypass grafting with mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA). They were successfully treated with the intermittent mass-irrigation technique. The irrigation device consistent of a irrigation tube which placed in upper half of mediastinum and three suction tubes which placed in lower half. We dripped the wash composed of 0.03-0.05% of Povidone-Iodine with 1,000 ml of physiological saline, for 3 to 5 times a day by condition. After each wash, we cross clamped the drainage tubes and filled mediastinum with 0.5 grams of vancomycin hydrochloride dissolved in 100 ml of physiological saline, dripped from irrigation tube, for 30 minutes. After 9-day irrigation in the former case and 16-day irrigation in the latter case, the culture of drainage turned negative. We presumed that this new method is effective for mediastinitis after cardiovascular surgery.

Three-dimensional imaging and osteometry of adult human skulls using helical computed tomography.

To make a digital image database of human craniology, we optimized the three-dimensional (3-D) images of 29 dried human skull specimens by helical computed tomography (CT). For the verification of the quantitative exactitude of these image data, we manually measured nine items of direct distances between standard anthropologic points on each skull and the corresponding distances projected on the CT monitor by specifying the respective points. The results obtained by the two methods of manual and CT measurements were compared and statistically analyzed. The CT measurements were so exact that the lower limit of correlation coefficients (95% of the confidence interval) between the two results was more than 0.8 in six items; i.e., maximal cranial length and breadth, minimal frontal breadth, bizygomatic breadth, distance between ectomolares and nasion-basion length. In contrast, the CT results were less well correlated with the manual measurements of three items; i.e., distance between bilateral mastoidales, total facial height, and nasal breadth. We concluded that the qualitative representation of 3-D CT images was adequate, although some quantitative data may be incorrect. The inaccuracy is suspected to be due to the difficulty in specifying the standard points on the CT images, and due to the differences in measurement procedures between the direct and projected distances.

Cimetidine reduces impairment of cellular immunity after cardiac operations with cardiopulmonary bypass.

OBJECTIVE: Depressive effects of cardiopulmonary bypass on cell-mediated immune responses may lead to postoperative infectious complications. We previously reported that cimetidine reduced postbypass depression of the cytotoxic activity of natural killer cells. This study evaluated cimetidine as an agent to preserve cellular immunity after cardiac operations. METHODS: In a prospective randomized study, 20 patients were divided into two groups of equal size. Cimetidine-group patients received 400 mg of cimetidine intravenously before bypass and a 33 mg/hr intravenous infusion of cimetidine after the operation, continuing until the fifth postoperative day. Control-group patients received conventional perioperative therapy. Lymphocyte subsets, natural killer cell activity, percentage of CD56+CD16+ (percentage of natural killer cells), and percentage of CD11b+CD8+ (percentage of suppressor T lymphocytes) were measured perioperatively. RESULTS: Although temporary postoperative reductions in percentages of CD3+, CD4+, and CD56+CD16+ cells were observed in both groups, CD8+ percentages on postoperative day 1 and CD11b+CD8+ percentages on postoperative days 1 and 3 in the cimetidine group were significantly lower compared with those in the control group (p = 0.01,p = 0.004, andp = 0.02, respectively). Temporary postoperative reduction of natural killer cell activity was also observed in both groups, but the natural killer cell activity on postoperative day 1 in the cimetidine group (17.1%) was significantly higher (p = 0.02) than that in the control group (8.20%). CONCLUSIONS: Cimetidine counteracts depressive effects of cardiopulmonary bypass on cell-mediated immunity and may possibly reduce postoperative susceptibility to infection.

[Morphological studies on lower margins of nasal aperture in the skull of Hokkaido Japanese].

It is well-known that the lower margins of nasal aperture in the human skull may be classified into the following four types, i.e., Forma anthropina, Forma infantilis, Fossae praenasales and Clivus nasoalveolaris, and that the rates of appearance of these four types differ with races. In the present study we made morphological studies on the lower margins of nasal aperture of 465 Hokkaido Japanese skulls, 463 skulls with symmetrical nasal aperture and 2 skulls with asymmetrical one, and compared the findings with those of all races in the world, especially of the Japanese, Ainu, Moyoro Man, Hamanaka Site Man and Eskimo. Forma anthropina was found in 330 skulls (71.27 +/- 2.10%) among the 463, marking the highest rate. Forma infantilis, found in 74 skulls (15.98 +/- 1.70%) among the 463, marked the second highest rate. Fossae praenasales, found in 42 skulls (9.07 +/- 1.33%) among the 463, marked the third highest rate. These 42 cases of Fossae praenasales were further classified into three types, i.e., sub-Forma infantilis, 17 (40.48%), typical Fossae prenasales, 23 (54.76%) and sub-Clivus nasoalveolaris, 2 (4.76%). Clivus nasoalveolaris, found in 17 skulls (3.67 +/- 0.87%) among the 463, marked the lowest rate. As a whole, the rates of the four types in the Hokkaido Japanese were close to those in the other groups of the Japanese in Kinai and Hokkaido (Ito).

[A successful mitral valve replacement for a 13-year-old girl with mitral stenosis and pulmonary hypertension after renal transplantation].

Mitral valve replacement was successfully performed in a 13-year-old girl due to severely calcified mitral valve stenosis and pulmonary hypertension who had undergone renal transplantation from her father at the age of 8 years old. Although, percutaneous transluminal mitral commissurotomy had been performed for four times until January 1996, severe mitral stenosis could be relieved and she was transported to our hospital in emergency for respiratory failure caused by pulmonary edema. Then we decided to perform mitral valve replacement. The operation was done successfully using trans-septal superior approach with SJMHP 19 mmM. the blood cyclosporin levels were monitored and controlled within normal limits. This is the first successful case of pediatric open heart surgery after renal transplantation to our knowledge.

[Studies on the foramen vesalius in the Japanese juvenile and adult skulls].

Foramen Vesalius is known to be an inconstant foramen, which appears in the anteriomedial side of the foramen ovale. The foramen Vesalius is classified into the open type and the closed type. We studied the frequencies and the types of foramen Vesalius in Japanese by examining 20 juvenile skulls from 3 months to 8 years old and 400 adult skulls from 18 to 91 years old. Of the 20 juvenile skulls, 11 skulls (55.00%) had foramen Vesalius. Of the 400 adult skulls, 87 skulls (21.75%) had foramen Vesalius; 69 (21.50%) in 321 male and 18 (22.78%) in 79 female skulls. No remarkable differences were observed in the ratio between the male and the female, and between the left side and the right side. Among the 69 adult male skulls, the foramen Vesalius was bilateral in 52 skulls (75.36%) and unilateral in 17 (24.64%); among the 18 adult female skulls, it was bilateral in 13 (72.22%) and unilateral in 5 (27.78%). The ratio of the closed type was slightly higher than that of the open type in both sexes and in both sides; however, no remarkable differences were observed. The skulls with one foramen Vesalius were most frequent; those with two followed it and those with 3 foramen Vesalius were least frequent. No remarkable differences were observed in the number of foramen Vesalius between the sexes and the sides.

Central projections of primary afferent fibers from the rat trigeminal nerve labeled with isolectin B4-HRP.

The central projections of unmyelinated primary afferent fibers from the rat trigeminal nerve were investigated using retrograde and transganglionic transport of isolectin B4-horseradish peroxidase (B4-HRP). After the injection of a small amount of the tracer into various areas of the facial dermis and oral mucosa, small neuronal somata were retrogradely labeled in the trigeminal ganglion. Clearly delineated transganglionic labeling was observed exclusively in lamina II of the medullary and upper cervical dorsal horn. Its distribution showed a somatotopic organization. Fibers from the oral mucosa terminated in the region 0-1.7 mm caudal to the obex, whereas those from the facial skin terminated in the region from 1.3 mm caudal to the obex through the second cervical segment. In each of these two terminal regions, the rostral areas in the periphery were represented more rostrally than the caudal areas, and the dorsal areas in the periphery were represented more ventrolaterally than the ventral areas.

The fusion of ossification centres in the cartilaginous and membranous parts of the occipital squama in human fetuses.

The process of fusion of the ossification centres in the occipital squama is described in human fetal skulls. During the 3rd fetal month, irregular ossification centres appear in the membranous tissue behind the cartilaginous supraoccipital bone plate. The centres rapidly develop to form a meshwork of bony trabeculae which cover the external surface of the supraoccipital plate and then fuse with the primary interparietal part along its lateral edges. In the 4th fetal month, similar irregular ossification centres appear on the internal surface of the supraoccipital plate. After the 5th month, these ossification centres fuse with the root of the secondary interparietal part in the midline. They occasionally fuse with the lateral portion of the primary interparietal part in the early 5th month. These show that the external and internal surfaces of the supraoccipital part are covered with a thin sheet of bone ossified in membrane, which is periosteal ossification, while the main portion of this part develops in cartilage.