Direct hemoperfusion using polymyxin-B immobilized fiber for septic shock after cardiac surgery.

BACKGROUND: The factors contributing to the efficacy and outcome of direct hemoperfusion using polymyxin-B immobilized fiber (PMX-DHP) after cardiac surgery were investigated. METHODS AND RESULTS: In 23 patients who received PMX-DHP for shock related to infection after cardiac surgery, there were no differences in the pre- and intraoperative clinical data of survivors (n=14) and non-survivors (n=9). Before the PMX-DHP treatment, the clinical assessment values of the survivors and non-survivors, respectively, showed the following significant differences: sepsis-related organ failure assessment score, 9.46+/-2.84 vs 12.89+/-3.37 (P<0.05); number of failed organs, 1.8+/-0.9 vs 3.1+/-1.1 (P<0.05); partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio, 194+/-118 vs 102+/-29 (P<0.05); and total bilirubin, 2.7+/-2.8 vs 8.7+/-6.5 mg/dl (P<0.05). The systolic blood pressure and catecholamine index in the survivors improved significantly 12 h after PMX-DHP treatment, from 83+/-19 mmHg to 118+/-14 mmHg (P<0.01), and from 20.7+/-11.5 to 14.9+/-8.0 (P<0.05). Conversely, in the non-survivors, only the systolic blood pressure improved significantly, from 74+/-17 mmHg to 118+/-33 mmHg (P<0.001). CONCLUSIONS: Prompt initiation of PMX-DHP with drug treatment during the postoperative course of patients with septic shock caused by systemic inflammatory response syndrome related to infection and who are refractory to vasopressor treatment, can improve the disease state before multiple organ failure develops.

Early initiation of polymyxin B-immobilized fiber therapy effective for septic shock after aortic replacement.

A 76-year-old female underwent ascending aorta and partial arch replacement. She developed septic shock on postoperative day 6. She was administered dopamine, 10 microg x kg(-1) x min(-1); dobutamine, 5 microg x kg(-1) x min(-1); and norepinephrine, 0.3 microg x kg(-1) x min(-1). However, the blood pressure was 74/40 mmHg. Direct hemoperfusion using polymyxin B-immobilized fiber (PMX-DHP) was started; 3 h later, the blood pressure increased to 118/54 mmHg. Norepinephrine was stopped, and dopamine and dobutamine doses were decreased to 5 microg x kg(-1) x min(-1) 3 and 12 h after completing PMX-DHP, respectively. In suspected septic shock, early PMX-DHP simultaneously with drug treatment facilitates hemodynamic improvement.

Chronic stage left ventricular aneurysm and thrombus after myocardial infarction.

A 60-year-old man had acute myocardial infarction 13 years ago. After percutaneous coronary intervention, the follow-up left ventriculography (8 years ago) showed dyskinesia in the anterolateral and apical segments of the wall. Following this, there was no change in the clinical symptom. After 6 years the patient discontinued aspirin without seeking medical advice. In this year, a thrombus was found in the left ventricle, and thrombectomy was performed. Left ventricular aneurysm has always been a risk for thrombogenesis in any stage, and a periodic follow-up including an echocardiogram and anticoagulation therapy is necessary.

Right atrial separation effect for chronic atrial fibrillation with atrial septal defect: report of four cases.

We operated on 56 adults diagnosed with atrial septal defect (ASD) between 1990 and 2004. Of these, eight had complications of atrial fibrillation (AF) in the preoperative period. After 1998, right atrial separation was performed in four cases. Marked improvement was noted in three out of the four cases. The right atrial separation procedure was a simple, easy, and effective method for the treatment of chronic AF associated with ASD.

A sewing needle completely buried in the myocardium removed under extracorporeal circulation.

A 14-year-old boy had a needle accidentally inserted through his chest wall. Chest X-ray showed a needle-shaped metallic density localized in the cardiac silhouette. An echocardiography indicated the needle had passed through the interventricular septum, and its eye and point had reached the right and left ventricle, respectively. Surgical removal of the needle was performed. The needle could not be observed from the heart surface, and was recognized in a dent 5 mm on the right side from the left anterior descending branch (LAD). The needle was easily removed under extracorporeal circulation, and he was discharged ten days after the operation.

Tricuspid pouch can cause systemic embolization in adulthood.

A 63-year-old-man with significant left hemiplegia was admitted to hospital. He had experienced a transient cerebral ischemic attack 10 years ago. Computed tomography revealed hypodensity along the right lateral ventricle, which corresponded to the left paralysis. Echocardiography and left ventricular angiography revealed an aneurysm of the membranous septum (AMS) without a ventricular septal defect (VSD). Therefore, the embolism was thought to be of cardiac origin, but surgery revealed that it was not caused by AMS. The aneurysm was created when the septal leaflet of tricupid valve formed a giant capsule during the process of natural closure of the VSD. It was a large pouch, 2.0 cm in diameter, adjacent to the septal leaflet. Anomalies of the tricuspid valve, including pouches, can resemble AMS.

A novel method of removing artifacts because of metallic dental restorations in 3-D CT images of jaw bone.

CT images, especially in a three-dimensional (3-D) mode, give valuable information for oral implant surgery. However, image quality is often severely compromised by artifacts originating from metallic dental restorations, and an effective solution for artifacts is being sought. This study attempts to substitute the damaged areas of the jaw bone images with dental cast model images obtained by CT. The position of the dental cast images was registered to that of the jaw bone images using a devised interface that is composed of an occlusal bite made of self-curing acrylic resin and a marker plate made of gypsum. The patient adapted this interface, and CT images of the stomatognathic system were filmed. On the other hand, this interface was placed between the upper and lower cast models and filmed by CT together with the cast models. The position of the marker plate imaged with the dental casts was registered to those adapted by the patient. The error of registration was examined to be 0.25 mm, which was satisfactory for clinical application. The damaged region in the cranial bone images as an obstacle for implant surgery was removed and substituted with the trimmed images of the dental cast. In the method developed here, the images around the metallic compounds severely damaged by artifacts were successfully reconstructed, and the stomatognathic system images became clear, and this is useful for implant surgery.

Surgical treatment for complications of acute myocardial infarction.

OBJECTIVE: We report the results of surgical repair for postinfarction left ventricular free wall rupture (LVFR) and ventricular septal perforation (VSP) complicating acute myocardial infarction. METHODS: We experienced 14 LVFRs and 10 VSPs from January 1991 to December 2002. The mean age of patients with LVFR was 74+/-8.1 years. There were 6 oozing cardiac ruptures and 8 blowout cardiac ruptures. An intraaortic balloon pump (IABP) was inserted in 8 patients, and percutaneous cardiopulmonary support (PCPS) was inserted in 5 patients. The mean age of patients with VSP was 72+/-5.1 years. The rupture was located within the anterior septum in 8 patients and within the posterior septum in 2 patients. All patients required IABP, and one of them needed PCPS. We employed a sutureless technique in 8 patients, direct closure in 5 patients, and infarct exclusion in 1 patient with LVFR. Infarct exclusion was conducted in 9 patients, and the da Silva technique was used in 1 patient with VSP. RESULTS: The patient survival rate of LVFR was 36% (blowout 13%; oozing 67%). Residual shunt occurred in 4 patients with VSP postoperatively. The overall survival rate for VSP was 70%. CONCLUSION: The operative prognosis of blowout cardiac rupture was poor. Good results were obtained with the infarct exclusion technique for patients with VSP. Although some patients had postoperative residual shunts, the infarct exclusion technique was generally a safe and excellent procedure.

The safety and feasibility of the local implantation of autologous bone marrow cells for ischemic heart disease.

BACKGROUND AND AIMS: Local autologous bone marrow cell implantation (BMCI) can induce therapeutic angiogenesis. We evaluated the safety and feasibility of this treatment for ischemic heart disease. METHODS: The safety of BMCI was preclinically confirmed in dogs by giving a direct injection of either 2 x 10(7) bone marrow cells (n = 4) suspended in 0.1 mL phosphate-buffered saline (PBS), or 0.1 ml PBS only (n = 4, PBS group), into the myocardium of the left ventricle at six points. Electrocardiograph (ECG), echocardiography, and systemic biochemistry indexes were recorded 1, 7, 30, and 240 days after treatment, and histological change was examined 240 days after treatment. We also evaluated the clinical safety and feasibility of BMCI in six patients with ischemic heart disease, who were given BMCI treatment in combination with coronary artery bypass grafting (CABG), by recording Holter ECG, echocardiography, computed tomography, and systemic biochemistry indexes in the acute and chronic phases after treatment. RESULTS: No significant changes in systemic biochemistry indexes were found after BMCI treatment in comparison with control groups, in either the experimental investigation or the clinical trial. No cardiac damage related to BMCI was detected by ECG or echocardiography, and histological examination showed minimal fibrotic change within the myocardium after BMCI or PBS injection in the dogs. Local calcification was not detected on histological slices 240 days after treatment in the dogs, or on computed tomography 1 year after treatment in the patients. CONCLUSIONS: BMCI treatment appears to be a safe and feasible method of inducing angiogenesis to treat ischemic heart disease

CD117+ stem cells play a key role in therapeutic angiogenesis induced by bone marrow cell implantation.

Therapeutic angiogenesis can be induced by the implantation of bone marrow mononuclear cells. We investigated the roles of mature mononuclear cell and stem cell fractions in bone marrow in this treatment. Although CD34 is the most popular marker for stem cell selection for inducing therapeutic angiogenesis, we separated CD117-positive cells (CD117+) from mature bone marrow mononuclear cells [CD117-negative cells (CD117-)] from mice using the antibody to the stem cell receptor, because some of the bone marrow stem cells that express CD117+ and CD34- might generate angiogenic cytokines and differentiate into endothelial cells. The angiogenic potency of CD117+ and CD117- cells was investigated in vitro and in vivo. Significantly higher levels of VEGF were secreted from the CD117+ cells than from the CD117- cells (P < 0.001). Most of the CD117- cells died, but the CD117+ cells grew well and differentiated into endothelial cells within 14 days of culture. The CD117+ cells survived and were incorporated in microvessels within 14 days of being implanted into the ischemic hindlimbs of mice, but the CD117- cells did not. The microvessel density and blood perfusion of the ischemic hindlimbs were significantly higher in the CD117+ cell-implanted mice than in the CD117- cell-implanted mice (P < 0.01). The microvessel density in ischemic hindlimbs was also significantly higher in the CD117+ cell-implanted mice than in the total bone marrow cell-implanted mice (P < 0.05). Thus CD117+ stem cells play a key role in the therapeutic angiogenesis induced by bone marrow cell implantation.

Improvement of cardiac function by bone marrow cell implantation in a rat hypoperfusion heart model.

BACKGROUND: Local bone marrow cell implantation can induce angiogenesis. In the present study we investigated whether angiogenesis induced by bone marrow cell implantation improves deteriorated cardiac function in a rat heart model of hypoperfusion. METHODS: A hypoperfusion heart model was created in Dark Agouti rats by ligating the left anterior descending artery placed against a copper wire (phi275 microm), then pulling out the wire immediately. The left ventricular (LV) anterior wall was injected directly at six points, each with 1 x 10(7) bone marrow cells in 10 microL of phosphate-buffered saline or with phosphate-buffered saline only, respectively. Echocardiography was performed to evaluate the cardiac function 7, 30, 60, and 90 days after treatment. Microvessel density and blood flow in the LV anterior wall were estimated 60 days after treatment. RESULTS: Both the increase of LV end-systolic diameter and the decrease of percent of fractional shortening caused by myocardial ischemia were attenuated effectively by bone marrow cell implantation treatment. Bone marrow cell implantation treatment also increased the levels of angiopoietin-1 and vascular endothelial growth factor in the LV anterior wall. The microvessel density, blood flow, and thickness of the LV anterior wall significantly also increased after bone marrow cell implantation treatment compared with those after phosphate-buffered saline injection. CONCLUSIONS: The local implantation of autologous bone marrow cells induced angiogenesis and improved the perfusion of ischemic myocardium, thereby preventing LV remodeling and improving deteriorated cardiac function caused by myocardial hypoperfusion.

Autologous bone marrow cell implantation as therapeutic angiogenesis for ischemic hindlimb in diabetic rat model.

The angiogenic effect induced by autologous bone marrow cell implantation (BMCI) was examined in the ischemic hindlimbs of diabetic and nondiabetic rats. Diabetes mellitus was induced by the systemic administration of streptozotocin. We investigated the production of angiogenic factors and endothelial differentiation from bone marrow cells and the native recovery of blood flow in the ischemic hindlimbs. To observe the angiogenic effect induced by BMCI treatment, 6 x 10(7) bone marrow cells were injected intramuscularly at six points into the ischemic limbs, and regional perfusion recovery was evaluated with colored microspheres 2 wk later. No difference was found between diabetic and nondiabetic rats in the release of angiogenic factors or endothelial differentiation from bone marrow cells in vitro. The levels of nitric oxide in plasma were significantly lower, and native perfusion recovery in the ischemic hindlimbs was significantly slower in the diabetic rats than in the nondiabetic rats. However, although perfusion recovery was achieved in the ischemic hindlimbs, there was no significant increase in systemic VEGF after BMCI treatment in either the diabetic or nondiabetic rats. Therefore, therapeutic angiogenesis induced by BMCI could be a safe and effective treatment for ischemic limb disease in diabetic patients.

Angiogenesis induced by the injection of peripheral leukocytes and platelets.

BACKGROUND: Peripheral leukocytes and platelets (LAPs) contain many kinds of cells with the ability to secrete several growth factors and cytokines. We attempted to induce therapeutic angiogenesis by injecting self-LAPs into a rat ischemic hindlimb model. MATERIALS AND METHODS: Supernatants from cultured LAPs were used for the endothelial cell (EC) proliferation assay, and LAPs were used in a cornea model to evaluate angiogenic potency. LAPs were injected directly into the male Dark Agouti rat ischemic hindlimb model, after which a microangiogram was done and the capillary/muscle fiber ratio was examined histologically. ELISA revealed the levels of contributing growth factors and cytokines present in the ischemic muscles. RESULTS: The EC proliferation assay showed that the supernatants of LAPs accelerated proliferation and that the LAPs induced angiogenesis in the cornea model. The microangiograms and histological evaluation revealed that angiogenesis was induced more effectively in the rats injected with LAPs (LAP group) than in the those injected with phosphate-buffered saline (PBS group). The levels of basic fibroblast growth factor (bFGF) in the ischemia, PBS, and LAP groups were significantly increased compared to those in the sham group. The level of interleukin-1beta (IL-1beta) in the LAP group was significantly more elevated than in the other groups. CONCLUSIONS: The injection of self-LAPs induced angiogenesis in a rat ischemic hindlimb model. Ischemia caused an elevation in the level of bFGF and also in IL-1beta derived from LAPs, which contributed to angiogenesis. This is a novel, yet simple and safe method of inducing therapeutic angiogenesis.