DOPA cyclohexyl ester, a DOPA antagonist, blocks the depressor responses elicited by microinjections of nicotine into the nucleus tractus solitarii of rats.

Nicotinic cholinergic receptors play a role in cardiovascular regulation in the lower brain stem. Herein, we present evidence that l-3,4-dihydroxyphenylalanine (DOPA), a putative neurotransmitter in the central nervous system, is involved in the depressor response to microinjection of nicotine into the nucleus tractus solitarii (NTS). Microinjection of nicotine into the medial area of the NTS led to decreases in arterial blood pressure and heart rate in anesthetized rats. Mecamylamine, a nicotinic receptor antagonist, microinjected into NTS, blocked the depressor and bradycardic responses to nicotine. Nicotine-induced depressor and bradycardic responses were blocked by DOPA cyclohexyl ester (DOPA CHE), an antagonist for DOPA. DOPA CHE did not modify the action of carbachol on excitatory postsynaptic potential in rat cortical slices. These results suggest that endogenous DOPA is involved in nicotine-induced depressor responses in the NTS of anesthetized rats.

[Delayed traumatic diaphragmatic hernia with strangulated stomach; report of a case].

A 30-year-old male who had suffered from the left hemopneumothorax due to the traffic accident 13 years before was admitted to our hospital suffering from abdominal pain. Computed tomography revealed the stomach was incarcerated through the left central tendon of the left diaphragm. He was diagnosed as delayed traumatic diaphragmatic hernia and emergency operation was performed via thoracic approach. Stomach and omentum, densely adhered to the lung and the chest wall, were strangulated in the left pleural cavity and hardly reducible. Stomach and omentum were reduced through the enlarged hernia and necrotized stomach was totally resected under the subsequent laparotomy. Hernia was closed directly via thoracic approach. A prompt diagnosis is necessary for a case highly suspicious of delayed traumatic diaphragmatic hernias presenting with strangulation.

[Aortic valve replacement in a renal transplant recipient].

A 65-year-old male was admitted to our hospital for surgical treatment of congestive heart failure with aortic regurgitation. He had received renal transplantation 15 years before in the United States, and had been under immunosuppressive regimen with ciclosporin and mycophenolate mofetil. Although the renal allograft function had been gradually deteriorating, and preoperative serum creatinine level was 1.8 mg/dl, and it decreased to 1.5 mg/dl after aortic valve replacement. Cryopreserved aortic allograft was needed for the aortic valve replacement. The reasons are; the patient may need hemodialysis (HD) or retransplantation of the kidney in the future, and the immunosuppressive therapy for kidney will provide good immunologic environment for second allograft, i.e.--aortic valve. He tolerated the operation well and the immunosuppressive agents were continued in the perioperative period. He is now in New York Heart Association (NYHA) class I.

[Secondary left main trunk coronary artery shock syndrome].

A 71-year-old male patient was admitted to our hospital and diagnosed as inferior wall acute myocardial infarction (AMI). Coronary angiogram revealed 3 vessel disease and left main trunk coronary artery (LMT) lesion. Because right coronary artery (RCA) had been recanalised, he was scheduled to operation. On the 6th day after admission, another attack made him fell into secondary LMT shock syndrome and lung edema. Emergency operation was performed and he recovered from heart failure. Here we report the case and added some considerations.

'No-Touch' isolation procedure for ruptured mycotic abdominal aortic aneurysm.

The present study reports a case of the successful surgical repair of a ruptured infra-renal mycotic abdominal aorta with Enterobactor cloacae in a 66-year-old man. During the operative procedure, an extra-anatomic bypass was installed before the laparotomy in order to avoid bacterial contamination. A complete resection of the infected aorta, tapering of the arterial stumps, wrapping of the omentum, and ligation of the aorta and arteries with Teflon tapes was carried out. The patient is alive and well 1 year postsurgery.

[Pronounced progression of interstitial pneumonia in a precious metal worker].

A 43-year-old man who had been engaged in the precious-metal processing industry for 18 years was admitted to our hospital because of shortness of breath on exertion. Chest roentgenograms disclosed ground glass opacities and annular-nodular shadows in the basal area of the right lung field and almost all of the left lung field. A video-assisted thoracoscopic lung biopsy was performed, and histologic examination disclosed usual interstitial pneumonia (UIP). Mineral analysis revealed high modes of silicon and aluminum, two elements consistent with the materials used in the patient's factory. The histopathological findings indicated interstitial pneumonia caused by the inhalation of dust particles. After corticosteroid therapy, computed tomographic scans disclosed that the ground glass opacities had subsided, but that honeycomb shadows remained. A chest roentgenogram taken 2 years earlier demonstrated only minute granular lesions in the basal area of right lung field. The interstitial shadows had progressed significantly over the intervening 2-year span. The findings in this case should be of value to the etiologic study of UIP.

Are Metallic Markers Necessary for Coronary Artery Bypass Grafts? A Study Using X-ray Computed Tomography and Selective Graft Angiography.

Using X-ray computed tomography (CT) and selective graft angiography, the authors studied the necessity of metallic markers in coronary artery bypass grafts on 45 patients (mean age 57.2 years) with 87 saphenous vein grafts. Eight patients had 17 markers. X-ray CT was performed after surgery using an apparatus with a 1-second scanning time. Noncontrast X-ray CT was performed on horizontal sections, at 5-mm intervals, from the lower margin of the aortic arch to the lower left ventricle. A contrast medium was then injected into the antecubital vein (3 ml/second, total 30 ml) in one cross-section at the level of bifurcation of the pulmonary artery. Aortography (60 degrees in the left anterior and oblique positions, 20 ml/second, total 40 ml) was performed concurrently. Selective graft angiography was taken in the same direction, using 4 cm right of the Judkins with reference to the aortographic image and position of five clips on the sternum. Aortography revealed 79 patent and 8 occluded grafts. Selective graft angiography was easily performed even in grafts without markers. A cross-section of the occluded graft could not be seen with X-ray CT. Grafts with markers were often masked by artifacts produced by markers on X-ray CT. The number of observed graft slices (marker-positive grafts) was only 1.2 +/- 1.1 slices, significantly (p < 0.01) lower than marker-negative grafts (4.1 +/- 3.1 slices). In particular, the number of marker-positive right coronary artery grafts was 0.4 +/- 0.9 slices. Four of five right coronary artery grafts were unobservable due to artifacts. In grafts without markers, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of X-ray CT to graft patency were 100%, 85.7%, 98.4%, 100%, and 98.6%, respectively. This study suggests that metallic markers may not be necessary for coronary artery bypass grafts.

Effects of Postoperative Pericardial Effusion on Coronary Artery Bypass Grafts: A Study with X-ray Computed Tomography.

The aim of this study was to evaluate the effects of pericardial effusion on coronary artery bypass grafts and their patency using X-ray computed tomography (CT). Uncontrasted CT of horizontal sections from the lower margin of the aortic arch to the left ventricle was done at 5-mm intervals. In one cross-section of the pulmonary bifurcation level, 30 ml of a contrast media (lohexol 350) was injected at a rate of 3 ml/second into the antecubital vein. All slices of uncontrasted CT were analyzed for the presence or absence of effusion. The severity was expressed as the maximum value of the thickness of effusion. CT was repeated about every 6 months postoperatively under the same conditions. Selective angiography was also performed 7.1 +/- 3.9 months postoperatively. A total of 46 patients (mean age 57 years) underwent CT and angiography. A total of 95 grafts were implanted: 90 saphenous veins and 5 internal thoracic arteries. Selective angiography revealed that 79 grafts were patent and 16 were occluded. The first postoperative CT (at 2.6 +/- 2.1 months) showed the retention of effusion in all patients. The mean maximum value was 1.0 +/- 0.5 cm; there were no significant differences between patent grafts (1.0 +/- 0.5 cm) and occluded grafts (1.0 +/- 0.5 cm). Occlusion was found in 10 grafts by the first CT (2.9 +/- 2.7 months postoperatively) and another 6 grafts by the second CT (11.3 +/- 4.2 months). Thereafter, all grafts were patent. Previously occluded grafts showed no cross-section images on uncontrasted or contrasted CT. Except for two grafts, all patent grafts could be observed even without contrast enhancement. The remaining two grafts were masked with effusion, but patency was confirmed by a contrast media. In conclusion, retention of effusion does not affect the patency of grafts. Occlusion occurs early after surgery, and grafts cannot be imaged on CT. Patent grafts can be observed by uncontrasted CT, as well as contrasted CT, except where a large amount of effusion is present.

[Superimposed infective endocarditis at anterior mitral leaflet in a patient with prolapsed posterior leaflet: report of a case treated with valvuloplasty].

A 64-year-old male patient was referred to our hospital for massive mitral regurgitation after infective endocarditis. Echocardiography revealed vegetation on the atrial surface of the midst of the anterior mitral leaflet. At operation it was found that the anterior leaflet was perforated due to infection, and the posterior leaflet was prolapsed resulting from elongated chordae. Anterior leaflet was patched with autologous pericardium, and posterior leaflet was repaired with rectangler resection. An autologous pericardial strip was sutured to posterior mitral annulus. The patient survived the operation without complication.

[A case of mediastinal liposarcoma surgically removed by bilateral thoracotomy].

A rare case of mediastinal liposarcoma was experienced at our institute. A 64-year-old male patient was accidentally found by chest X-ray photo. The tumor was so gigantic and seemed to involve the descending aorta, therefore, it was removed through bilateral thoracotomy. It was well encapsulated and its malignancy resides in that of low grade to be completely removed. The patient is expected to acquire long term survival.

[A case of invasive thymoma made resectable by preoperative chemotherapy].

A 25-year-old male patient of invasive thymoma was referred to our institute on March'95. He had night coughs and on the annual chest X ray exam a large tumor was found in antero-superior mediastinum. At first his tumor was too large to be resected and left brachiocephalic vein was completely occluded. By needle biopsy it was proved to be thymoma, therefore, preoperative chemotherapy was planned. The tumor responded well to the two courses of ADOC (ADM, CDDP, VCR, CAP) therapy and the tumor seemed to become resectable. In June operation was performed and the tumor was resected completely. It appears that in case of stage Ill invasive thymoma, preoperative chemotherapy is one of the choices although it seems unresectable.

[A case of one stage operation for primary lung cancer and abdominal aortic aneurysm].

A 75-year-old male patient of primary lung cancer associated with abdominal aortic aneurysm was operated successfully in one stage. Right S2, S3 lung cancer was resected first and then aortic aneurysm was replaced with a Dacron graft. Both disease should be operated upon as early as possible. Low dose heparin usage did not disturb the operation. This case is the third reported case of one stage operation in Japan.

[A case of non-small-cell primary lung cancer invading distal aortic arch and left subclavian artery].

A 71-year-old male patient was referred to our institute for abnormal mediastinal shadow. It was proved to be squamous cell carcinoma arising in left S1 + 2 and involving distal aortic arch and left subclavian artery (T4N2M0 Stage IIIB). The cancer responded well to the preoperative induction therapy and it was resected completely with associated resection of distal aortic arch and left subclavian artery. Both arteries were replaced with Dacron grafts. With induction therapy and extended operation, this patient of non small cell T4 primary lung cancer is expected to acquire long term survival.

[A case of recurrent constrictive pericarditis complicated with atrial septal defect].

A case of recurrent constrictive pericarditis complicated with atrial septal defect (ASD) was operated successfully at our institute. ASD was missed at the time of the first operation. The combination of ASD and constrictive pericarditis is rare and this case is the fifth reported one in Japan. Difficulty in diagnosis of ASD and operative procedure for recurrent constrictive pericarditis are described and discussed.

[A case report of Cabrol procedure with zero-porosity graft in a patient of annulo-aortic ectasia with severe aortic regurgitation].

A 63-year-old man was admitted to the hospital for the treatment of annulo-aortic ectasia with severe aortic regurgitation. The aortogram revealed dilatation of the aortic root and severe aortic regurgitation. LVEDVI was 207 ml/m2 but the patient was asymptomatic. Aortic root reconstruction was performed with Cabrol procedure using zero-porosity graft. There was no evidence of bleeding due to this graft and the percent dilatation of this graft was 33%. This zero-porosity graft of knitted Dacron coated with gelatin seems to offer some advantages to the operation. The patient is in stable health today, but perioperative occurrence of VPCs may have owed to diminished LV function caused by severe aortic regurgitation.

Successful removal of a cardiac fibroma in an elderly patient.

Successful removal of a cardiac fibroma of the left ventricular free wall in a 76-year-old male is reported. The rarity of this tumor in the elderly and diagnostic clues are discussed.

[Detection and significance of calcified coronary arteries by computed tomography].

To investigate whether coronary artery disease is detected noninvasively, we correlated calcification on computed tomography (CT) with coronary angiographic (CAG) findings in 90 consecutive patients including 48 with angina pectoris or myocardial infarction. The mean age was 52.2 years and 83% were men. CT scans without contrast enhancement (3 sec scan time) were obtained at 1 cm thickness from the ascending aorta to cardiac apex to identify calcification in coronary arteries. Results; CAG revealed of 50 patients, and stenosis was present more often at calcified vessels on CT. (table; see text) Calcification occurred more often in 2 or 3 vessel disease. However, stenotic segments were not always calcified. We conclude that CT is sensitive for the detection of calcification and an important method for the diagnosis of coronary artery disease.