[Patent foramen ovale presented hypoxemia with cardiac sarcoidosis].

A 53-year-old woman with a double, double, double (DDD) pacemaker due to complete atrioventricular block was admitted to our hospital with a diagnosis of congestive heart failure. At the time of admission, she was in a hypoxic state with cyanosis and clubbed finger. The ultrasonic cardiogram showed a severe degree of tricuspid valve regurgitation and a thin left ventricular septal wall. Transesophageal echocardiography revealed a patent foramen ovale (PFO) with continuous right to left shunt flow. She was diagnosed with cardiac sarcoidosis with hypoxemia caused by PFO. PFO closure and tricuspid valve annuloplasty (DeVega method) were performed. Following surgery, the patient's hypoxemia improved and the cyanosis disappeared. The patient was discharged 37 days after the operation.

Mange caused by Sarcoptes scabiei (Acari: Sarcoptidae) in wild raccoon dogs, Nyctereutes procyonoides, in Kanagawa Prefecture, Japan.

Parasitological and histopathological examinations were performed in 25 raccoon dogs (Nyctereutes procyonoides) obtained in Kanagawa Prefecture, Japan, all of which were found to be heavily infected with Sarcoptes scabiei. The mites detected on these raccoon dogs were morphologically indistinguishable from the human species, and no Demodex mites were detected. Histopathological examinations showed prominent hyperkeratosis and acanthosis with eczema, and numerous burrows containing mites were observed in the epidermis. The enzootic dermatitis of wild raccoon dogs in recent years was clearly demonstrated to be caused by S. scabiei in the present study.

[A case of a left atrial primary malignant fibrous histiocytoma].

Primary malignant fibrous histiocytoma (MFH) of the heart is very rere. We report a case of a primary intracardiac MFH. A 50-year-old woman underwent an operation for congestive heart failure due to left atrial (LA) tumor. Cardiac echocardiogram showed the tumor attached to the septal wall and posterior wall of LA. We extendedly resected the tumor with septal and partially posterior wall and reconstructed there with pericardial substitute. Pathological diagnosis was MFH. Although she did well postoperatively, cardiac echocardiogram showed a recurrent tumor in the LA at 10 days after operation. She developed respiratory failure, and chest and abdominal CT demonstrated metabolism to the lung, liver and bladder at post operative 47 days. At 77 days after operation, she expired. The prognosis of MFH is poor despite surgery. We recommend extended surgery, if the LA tumor had wide base attached to the septal or posterior wall.

Successful restoration of the trapezius muscle using pedicle latissimus dorsi. A case report.

Reconstruction of the trapezius muscle using a pedicle latissimus dorsi flap was performed in a 27-year-old man with a large synovial sarcoma in his shoulder girdle. Size and location of the tumor required combined resection of surrounding muscles, including the trapezius, levator scapulae, and rhomboid major and minor. Thus, an extensive defect of the suspending muscles of the scapula was created after accomplishing an adequate resection of the tumor. The flap was performed to restore the trapezius functionally because there were no adjacent muscles available. The transferred muscle compensated for loss of the trapezius, thereby recovering excellent shoulder function. Although an opportunity of its application is thought to occur infrequently, the pedicle latissimus dorsi can activate scapular motion successfully in the absence of the levator scapulae. The technique may be extended to salvage failed conventional reconstruction after spinal accessory nerve palsy.

[The effect of intraoperative high-dose tranexamic acid on blood loss after operation for acute aortic dissection].

The effect of high dose tranexamic acid on blood loss after operations for acute aortic dissection was evaluated. Twenty-eight patients undergoing emergent operations for acute aortic dissection were studied. There were two groups, group T with 13 patients (group T) who were given 7 g of tranexamic acid after induction of anesthesia and 3 g of it after CPB and group C with 15 patients who did not receive tranexamic acid. There was a tendency that group T had less bleeding during operation and after operation (559.6 +/- 865.8 ml in group T and 805.8 +/- 442.9 ml in group C, 1719.2 +/- 1008.7 ml in group T and 3547.7 +/- 4580.1 ml in group C, respectively), but there was no significant difference between two groups. The removal of drainage tubes after operation was significantly earlier in group T (5.0 +/- 2.3 post operative day in group T and 8.1 +/- 5.2 post operative day in group C; p < 0.05). FDP and D-dimer level as measures of fibrinolytic activity were elevated at pre- and postoperative period in both groups, but they tended to be lower in group T at postoperative period. One patient required reexploration because of excessive bleeding and no mediastinal infection was reported in group T, whereas 4 patients underwent reexploration and 2 patients developed mediastinitis in group C. There were 5 hospital death (33.3%) in group C and 2 (15.4%) in group T. High dose of tranexamic acid seems to control fibrinolytic activity, thereby reducing blood loss and requirements, which may contribute to lower morbidity and mortality in operations for acute aortic dissection.

[A case of radical operation for right-sided infective endocarditis due to Pseudomonas aeruginosa concurrent with VSD in the elderly person].

The case is a 60-year-old male. He was seen at this department because of a slight fever of less than 37.5 degrees C from half a year earlier. Echocardiography revealed vegetations under the tricuspid valve and pulmonary valve, and on scintigraphy of the pulmonary blood flow he was diagnosed with multiple pulmonary infarction. Causative bacteria were not identified by blood culture on admission. As the intraoperative findings, vegetations were seen attached to the area from the septal cusp to the anterior cusp in the tricuspid valve. With the pulmonary valve, a part of the valvular cusp was perforated. After closing VSD with a patch, the vegetations attached to the valvular cusps were excised and the tricuspid valve was reconstructed. As for the pulmonary valve, valve replacement was performed because of the destructive degeneration of the valvular cusp. Pseudomonas aeruginosa was detected on culture of the tissue of the valvular cusp resected during operation. Post operative course was uneventful. The patient was discharged on the 21st postoperative day.

[CABG performed for LMT orifice stenosis 15 years after AVR in a case of aortitis syndrome].

The case is a 54-year-old female at age 39 years, she underwent aortic valve replacement (AVR) for aortic valve regurgitation (AR) due to aortitis syndrome at a certain hospital. At the 15th year after AVR she was diagnosed with unstable angina due to LMT orifice stenosis and underwent CABG at this hospital. A distal side of anastomosis was performed on the LAD branch seg 6, an artificial vascular patch was placed for the proximal side of anastomosis to prevent inflammation of the aortic wall from spreading to the proximal side of anastomosis. On the postoperative cardiac catheter examination, the graft was found to be patent well. In the case of CABG complicated with aortitis syndrome, stenosis and obstruction of the proximal side of anastomosis long time after surgery pose a problem. However, the method so as to perform a proximal anastomosis by placing an artificial vascular patch on the aortic wall is considered to be one of the useful means which can avoid such a problem.

Occurrence of high ratio of males after introduction of minocycline in a colony of Leptotrombidium fletcheri infected with Orientia tsutsugamushi.

In colonies of Leptotrombidium fletcheri mites infected with Orientia tsutsugamushi (Ot), the agent of scrub typhus, males rarely appear. In the present study, the development of a high ratio of males was observed after introduction of minocycline (MC). A high dose of MC was injected subcutaneously into a mouse, and by feeding unfed larvae from an infected mite colony on this mouse, the Ot in the mites were successfully killed. Of a total of 130 unfed larvae attached to the mouse, 29 developed into females; of these, 9 laid an average of 112.4 eggs/female. Unfed larvae in the succeeding generations were attached to untreated mice. All adults in the P and F1 generation were females, and males started to appear at the F2 generation. The ratio of males to females was 332:7, 108:13, 263:61 and 71:9 at the F2, F3, F4 and F5 generations, respectively. These data suggest that Ot in the ovary or gonad may suppress the development of males.

Resuscitation of Vibrio cholerae O1 strain TSI-4 from a viable but nonculturable state by heat shock.

Vibrio cholerae strain TSI-4 was incubated in an M9 salt solution at 15 degrees C for more than 100 days. The plate counts showed no viable cells on day 30, but a broth culture from that day showed the growth of bacteria. However, after 35 days the bacteria entered the nonculturable state, based on the assessment of both the plate counts and broth culture. A portion of the culture was heated at 45 degrees C for 1 min in a water bath and subsequently plated onto a nutrient agar plate. More than 1000 colonies were recovered after this heat-shock treatment. The recovered cells showed the same chromosomal DNA pattern in the restriction map and the same outer membrane protein pattern in SDS-PAGE. Recovery of viable cells by heat-shock was achieved in cultures grown on M9 salt but not from cultures grown in phosphate-buffered saline. This suggests that the presence of NH4Cl in the M9 salt solution may support the growth of the bacteria in a low nutrient medium, while also playing an important role in resuscitation.

Seasonal development of Leptotrombidium akamushi (Acari: Trombiculidae) under field temperatures.

Engorged larvae of Leptotrombidium akamushi (Brumpt), a vector of scrub typhus, were reared in small plastic containers placed on the ground and fed fresh eggs of the collembolan Sinella curviseta Brook. Engorged larvae obtained in October developed into deutonymphs through protonymphs approximately 1 mo before winter and became dormant in the cold winter season (approximately 3 mo). Most deutonymphs developed into tritonymphs in April and adults in May. Females began laying eggs in mid-June and the numbers of unfed larvae showed a peak in August. The mites reared from July rapidly developed into adults by August, and laid eggs in September. Larvae were most abundant in October, and adults became dormant in the winter. The same adults laid eggs from early May to late June and, upon hatching, the larval population peaked in early July of the 2nd summer. Most larvae died before the 2nd winter. Eggs hatched approximately 3 wk after oviposition and longevity of unfed larvae was 2 mo. Because of this very short incubation period, L. akamushi larvae occur in the summer, whereas L. pallidum Nagayo, Miyagawa, Mitamura & Tamiya, and L. scutellare Nagayo, Miyagawa, Mitamura, Tamiya & Tenjin occur in the autumn, although 3 species lay eggs from May to August.

[Reconstruction of pulmonary trunk in pulmonary atresia and tetralogy of Fallot utilizing autologous tissue].

Establishment of right ventricular-pulmonary arterial continuity with autologous tissue, avoiding the use of prosthetic conduit, is presented. From February 1992 through March 1993, 22 patients with pulmonary atresia and tetralogy of Fallot underwent reparative operation at The Heart institute of Japan. In 20 patients out of the 22 patients, the right ventricular-pulmonary arterial continuity was successfully established with either direct anastomosis or insertion of tailored autologous pericardial tube. The morphology of the right ventricular-pulmonary arterial discontinuity comprised of valvular and infundibular atresia in seven, truncal atresia in nine, and failed extracardiac conduit in four. In patients with relatively short distance between right ventricle and pulmonary artery, the pulmonary artery was retracted and anastomosed directly to the cranial margin of the ventriculotomy incision to serve as a smooth floor made of autologous tissue. In patients with long distance, tailored autologous pericardial tube was interposed between right ventricle and pulmonary artery instead of using prosthetic conduit. Both techniques were completed by mono- or bicuspid anterior patch made of equine pericardial conduit. There were no early and late deaths. Postoperative catheterization data showed satisfactory reduction of right ventricular pressure with the right-to-left ventricular systolic pressure ratio ranging from 0.42 to 0.69 (average 0.52) in direct anastomosis group and 0.43 to 0.48 (average 0.45) in autologous pericardial tube group, and the pressure gradient across right ventricular outflow tract ranged from 1 to 15 (average 8) mmHg and 1 to 15 (average 5.8), respectively. The distributing frequency of late complication, mainly conduit obstruction, of prosthetic materials prompted us to use autologous tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of transposition of the great arteries with intact ventricular septum associated with left ventricular outflow obstruction].

Thirteen patients have undergone surgical treatment for transposition of the great arteries (TGA) with intact ventricular septum (IVS) associated with left ventricular outflow obstruction (LVOTO) in our institute. Ages at operation ranged from three months to six years (mean 9.2 +/- 4.7 months). Of these patients, seven had dynamic type LVOTO (group I), and six had organic LVOTO (group II). Preoperative left ventricular end-diastolic volume was significantly smaller in group II (78 +/- 13% of normal) than control group (135 +/- 53% of normal). Preoperative pressure gradient between the pulmonary artery and left ventricle was significantly greater in group II (55.8 +/- 3.2 mmHg) than group I (35.2 +/- 3.9 mmHg). In group I, II patients underwent two-stage ASO, the other 5 patients underwent Senning operation. The reason for the Senning operation were era before introduction of ASO in our institute (1983) or unsuccessful training of the left ventricle. In group II, all but one patient underwent Senning operation, the other underwent a successful Fontan operation with Damus anastomosis because of too small left ventricle (LVEDV: 49% of normal). Techniques to correct LVOTO at the definitive operation included ventriculotomy (n = 4) and pulmonary valvotomy (n = 2). One patients in group II underwent a Fontan operation with Damus anastomosis due to an underdeveloped left ventricle (LVEDV: 49% of normal). There was no early or late death. The postoperative pressure gradients disappeared or reduced to trivial levels in all patients. At present no LVOTO has developed in any of the patients.

The measurement of swimming velocity of Vibrio cholerae and Pseudomonas aeruginosa using the video tracking methods.

The swimming velocities of two monotrichous flagellated bacteria were measured by a computer-assisted video tracking method. Tracing the moving path of the individual bacterium revealed that the bacterial cell did not swim continuously in a straight direction, but frequently changed swimming direction and velocity. The average swimming velocities calculated from the 3-sec path were 75.4 +/- 9.4 microns/sec in four strains of Vibrio cholerae and 51.3 +/- 8.4 microns/sec in five strains of Pseudomonas aeruginosa. These results suggest that V. cholerae swim faster than P. aeruginosa at 30 C in nutrient broth. This method is useful for a detailed analysis of bacterial movement and moving patterns in different environmental conditions.

Granulocyte colony-stimulating factor does not enhance phagocytosis or microbicidal activity of human mature polymorphonuclear neutrophils in vitro.

The direct effects of human granulocyte colony-stimulating factor (hG-CSF) on mature polymorphonuclear neutrophils (PMNs) in vitro were studied with regard to chemotaxis, superoxide production, and phagocytosis and microbicidal activity against the following viable microorganisms: Staphylococcus aureus, serum-resistant Pseudomonas aeruginosa, and Candida albicans. Recombinant hG-CSF (rhG-CSF) acted as a chemoattractant for human PMNs in a dose-dependent manner. The chemotactic response of PMNs to N-formyl-methionyl-leucyl-phenylalanine (FMLP) was not enhanced by rhG-CSF at any of the concentrations used. rhG-CSF did not induce the generation of superoxide by itself. However, rhG-CSF was able to prime human PMNs and to enhance O2- release stimulated by FMLP in a dose-dependent manner. rhg-CSF did not enhance phagocytosis or killing of the three species of microorganisms by normal PMNs. With PMNs obtained from patients who had hematological disorders or solid tumors, no enhancement of the microbicidal activity was observed in most cases. Microbial killing mediated by PMNs depended on the ratio of PMNs to target organisms. We concluded from these facts that the most important effect of rhG-CSF was to increase the number of the peripheral PMNs and not to enhance the functions of mature PMNs.

[Reoperation after surgical repair of atrioventricular canal defect].

Among 114 survivors who underwent total repair of atrioventricular canal defect between 1981 and 1993, 19 patients underwent reoperation for the occurrence and progression of mitral valve insufficiency (18 patients), thrombosed prosthetic valve (1 patient), and subaortic stenosis (4 patients) on one or two occasions after operation. There were 7 males and 12 females with ages at reoperation ranging from 3 months to 13.8 years (mean, 3.8 years), and was no operative but one late death. At reoperation, reparative procedures involving the readjustment of previously repaired mitral cleft and annuloplasty were successfully achieved in 6 patients who had no additional abnormalities of subvalvar apparatus. Twelve patients, who were associated with additional valvar and subvalvar lesions, needed a prosthetic valve replacement. We emphasized that surgical technique based on precise knowledge of each individual mitral and submitral anatomy is indispensable to achieve good surgical results. When the anatomy involves submitral abnormalities, careful postoperative follow-up should be recommended to take measures of the progression of mitral valve regurgitation.

[Reoperations of extracardiac valved conduit for congenital cardiac defects].

Fifteen of 223 patients who have had extracardiac conduit repair at the Heart Institute of Japan from January, 1970, to April, 1991, have required conduits replacement because of conduit obstruction or infection. The main causes of obstruction were degeneration of the prosthetic valve and proliferative pseudo-intima in the conduit. The interval between initial conduit repair and conduit replacement was 2.2 to 18.3 years (mean 10.5 +/- 4.4). The average pressure gradient through the conduit decreased from 74.7 +/- 42.0 mmHg preoperatively to 12.3 +/- 7.1 mmHg postoperatively (p < 0.05). There was no early and late death. We concluded that xeno-pericardial roll conduits were superior to others and that conduit replacement procedure following the extracardiac conduit repair was safe and effective.

Characterisation of the external surfaces of Pseudomonas aeruginosa isolated from human blood and respiratory tract.

The surface structures of the cell envelopes of 16 clinical isolates of Pseudomonas aeruginosa were examined by electronmicroscopy with the new fixation technique of freeze-substitution. Two types of structures were observed among the organisms. In one group of strains, mostly isolated from blood, a dense fibrous layer c. 30 nm thick was found around the outer-membrane surface, whereas no such structure was observed in the other group of isolates, most of which were from sputum. Lipopolysaccharides extracted from the isolates with a dense fibrous layer were found by SDS-PAGE to have long O-polysaccharide chains, whereas strains without such a layer mostly had lipopolysaccharides that lacked high mol. wt. O-polysaccharide chains.