Microalbuminuria and deterioration of renal function after elective repair of infrarenal abdominal aortic aneurysm.

AIMS: Renal dysfunction affects the prognosis of patients after aortic surgery. However, the factors associated with the postoperative deterioration of renal function has not been clarified precisely. METHOD: We prospectively examined renal function in 80 patients (age: 73 +/- 7 years, 66 males) who required the elective repair of infrarenal abdominal aortic aneurysm (AAA). Serum creatinine (Scr) was measured. 24-h-creatinine clearance (Ccr) and urinary albumin excretion (UAE) were determined. Renal volume and mean renal length were calculated using the data obtained by ultrasonography. 48 patients showed normal UAE (< 30 mg/day), and 24 had microalbuminuria (30-300 mg/day) and 8 had overt proteinuria (> 300 mg/day). Scr were 0.9 +/- 0.4, 1.0 +/- 0.3 and 2.1 +/- 1.3 mg/dl, respectively. RESULTS: On Day 5 after surgery, 12 patients (15%) showed deterioration of renal function as defined either by an increase in Scr (> or = 0.5 mg/dl) or by a decrease in Ccr > or =20%). The acute deterioration of renal function was related to mean renal volume, mean renal length, duration of operation and the use of antibiotics. At Month 12 after surgery, Scr increased in the overt proteinuria group. The deterioration of renal function at Month 12 was found in 8 patients (10%) with microalbuminuria or overt proteinuria, and related to preoperative Ccr, UAE, mean renal volume, mean renal length, smoking status and blood pressure. CONCLUSION: We conclude that the deterioration of renal function occurred in considerable number of patients with AAA after elective operation on acute and chronic phase, although the development of end-stage renal failure is rare. Factors related to the acute and late deterioration appears to be different. UAE and renal size should be measured, even if Scr is in normal range at preoperative observation.

Disappearance of aortic intramural hematoma and its significance to the prognosis.

BACKGROUND: An aortic intramural hematoma (IMH) is a form of aortic dissection (AD). IMHs regress with time or completely disappear in some patients, whereas they progress to overt AD in other patients. The purpose of the present study was to investigate how IMHs change serially during a follow-up period. METHODS AND RESULTS: We analyzed 44 consecutive medically treated patients with IMHs, in whom transesophageal echocardiography (TEE) was performed serially at both 1 and 6 months after the onset. After TEE, the patients were followed with interviews (mean follow-up 1552+/-539 days). IMHs disappeared at 6 months in 21 patients (48%) (disappearance group), whereas IMHs were still demonstrated at 6 months in 20 patients (45%) (persistent group); in the disappearance group, IMHs disappeared at 1 month in 8 patients (18%). In 3 patients (7%) in whom an IMH was demonstrated at 1 month, overt AD occurred until 6 months. The disappearance group was younger than the persistent group (64+/-11 versus 72+/-8 years, P:<0.01), and the maximum diameter of the aorta was smaller in the disappearance group than in the persistent group (33+/-5 versus 42+/-7 mm, P:<0.01). During the long-term follow-up, overt AD occurred at 7 and 11 months in 2 patients, and progressive aortic dilatation that required surgical treatment occurred at 12 and 24 months in 2 of the persistent group patients, whereas neither overt AD nor progressive aortic dilatation occurred in the disappearance group. In the patients in whom overt AD occurred, the maximal aortic diameter was >45 mm and an IMH was demonstrated at 1 month. On the other hand, those with a maximal aortic diameter of <45 mm or a disappeared IMH did not have overt AD. CONCLUSIONS: IMHs disappeared until 1 month in 18% and until 6 months in 48% of patients with IMHs. The disappearance of IMHs was related to the maximum diameter of the aorta and age. Both a disappeared IMH and a maximal aortic diameter of <45 mm suggest a good prognosis.

Prediction of progression or regression of type A aortic intramural hematoma by computed tomography.

BACKGROUND: It has been reported that early surgery should be required for patients with type A aortic intramural hematoma (IMH) because it tends to develop classic aortic dissection or rupture. However, the anatomic features of type A IMH that develops dissection or rupture are unknown. The purpose of this study was to investigate the predictors of progression or regression of type A IMH by computed tomography (CT). METHODS AND RESULTS: Twenty-two consecutive patients with type A IMH were studied by serial CT images. Aortic diameter and aortic wall thickness of the ascending aorta were estimated in CT images at 3 levels on admission and at follow-up (mean 37 days). We defined patients who showed increased maximum aortic wall thickness in the follow-up CT (n=9) or died of rupture (n=1) as the progression group (n=10). The other 12 patients, who all showed decreased maximum wall thickness, were categorized as the regression group. In the progression group, the maximum aortic diameter in the initial CT was significantly greater than that in the regression group (55+/-6 vs 47+/-3 mm, P=0.001). A Cox regression analysis revealed that the maximum aortic diameter was the strongest predictor for progression of type A IMH. We considered the optimal cutoff value to be 50 mm for the maximum aortic diameter to predict progression (positive predictive value 83%, negative predictive value 100%). CONCLUSIONS: Maximum aortic diameter estimated by the initial CT images is predictive for progression of type A IMH.

[Usefulness and safety of the early rehabilitation program for patients with acute aortic dissection].

The usefulness and safety of the early rehabilitation program (2- and 3-week courses) were validated for patients with acute aortic dissection. This program undergone by 42 consecutive patients between 1996 and 1997 was compared to the conventional program undergone by 66 patients between 1993 and 1995, using the prognosis and complications for elderly patients. Mortality rate and morbidity rate were not significantly different between the early and conventional programs. The incidence of intensive care unit (ICU) syndrome in elderly patients was 16% (3 of 19 cases) vs 50% (15 of 30 cases), respectively (p < 0.05). The duration of hospital stays was 26 +/- 7 vs 37 +/- 13 days, respectively (p < 0.05). The early rehabilitation program for patients with acute aortic dissection was safe and useful to prevent complications in elderly patients, and was cost effective.

Effects of antecedent anginal episodes and coronary artery stenosis on left ventricular function during coronary occlusion.

We evaluated the effects of antecedent anginal episodes and coronary artery stenosis on left ventricular function during coronary occlusion and the role of collateral filling in 33 patients with angina pectoris who underwent angioplasty. Wall motion abnormalities were investigated by echocardiography and classified into hypokinesia and akinesia. Collateral filling during angioplasty was evaluated by using a second artery catheter. Akinesia was observed as follows: 24% of the patients had > 30 anginal episodes, 38% had 5 to 30, and 87% of the patients had < 5 (p < 0.01); 12% of patients had a lesion of 99%, 47% had a lesion of 90%, and 83% had a lesion of 75% (p < 0.05). Akinesia was observed in none of the patients with grade 3 collaterals, 57% with grade 2, and 67% with grade 1 or 0 (p < 0.01). These observations suggest that the patients with antecedent frequent anginal episodes and severe coronary stenosis have less left ventricular dysfunction during coronary occlusion. This finding may be the result of more extensive collateral development.

[Reliability of biplane transesophageal color Doppler echocardiography in evaluating mitral valve prolapse: comparison with surgical findings].

The reliability of biplane transesophageal color Doppler echocardiography for the evaluation of mitral valve prolapse was assessed by comparison with surgical findings in 27 patients. The mitral valve prolapse site was classified as the medial, central, and lateral portions of the anterior leaflet, and medial, middle, and lateral scallops of the posterior leaflet. The prolapsed sites were determined by the site of systolic displacement using two-dimensional echocardiography, the site of flow acceleration and the direction of the mitral regurgitant jet using color Doppler echocardiography. The sensitivity of transesophageal echocardiography for detecting prolapse at the medial, central, and lateral portions of the anterior leaflet, and the medial, middle and lateral scallops of the posterior leaflet was 91, 100, 86, 83, 100, and 80%, respectively. The specificity was 100, 100, 96, 100, 89, and 100%, respectively. Biplane transesophageal echocardiography is a reliable method for detecting the site of mitral valve prolapse.

[Quantification of mitral regurgitant stroke volume by the proximal isovelocity surface area method].

Although color Doppler flow mapping has been used to quantitate the severity of mitral regurgitation, this approach has various limitations. Doppler color flow mapping of a proximal isovelocity surface area (PISA), defined by a blue-red aliasing interface, has been shown in vitro to be accurate for estimating volume flow rate across an orifice. Volume flow rate can be calculated as PISA x aliasing velocity. To evaluate the clinical applicability of the PISA method, we compared the regurgitant stroke volume estimated by the PISA method with the conventional pulsed wave Doppler method in 18 patients with mitral regurgitation. The mean systolic aliasing radius was calculated from color overlayed M-mode (Q/M-mode) images. The mitral regurgitant stroke volume calculated by the PISA method correlated well with that calculated by the pulsed Doppler method (r = 0.89, SEE = 6.0 ml). Thus, the color Doppler PISA method can be applicable to calculating the regurgitant volume in patients with mitral regurgitation.

Value of acceleration flow signals proximal to the leaking orifice in assessing the severity of prosthetic mitral valve regurgitation.

To test the value of acceleration flow signals proximal to the leaking orifice in assessing the severity of prosthetic mitral valve regurgitation, 39 consecutive patients undergoing left ventriculography were examined by Doppler color flow imaging. Acceleration flow signals proximal to the regurgitant orifice were detected in 27 of the 31 patients who had prosthetic mitral regurgitation by left ventriculography (sensitivity 87%). All four patients without acceleration flow signals had mild prosthetic mitral regurgitation by angiography. No acceleration flow signals were detected in any patient without prosthetic regurgitation by left ventriculography (specificity 100%). Individual values of the maximal area of acceleration flow signals obtained from three orthogonal planes in seven patients with mild prosthetic mitral regurgitation by angiography ranged from 0 to 17 mm2 (mean 4 +/- 6). In 8 patients with moderate prosthetic mitral regurgitation by angiography, the maximal area of acceleration flow signals ranged from 21 to 58 mm2 (mean 33 +/- 15), whereas the maximal area of acceleration flow signals in 16 patients with severe prosthetic regurgitation ranged from 20 to 173 mm2 (mean 102 +/- 41). The maximal area of the acceleration flow signals from three planes correlated well with the angiographic grade of prosthetic mitral regurgitation. There was a significant difference in the maximal area of acceleration flow signals between mild and moderate (p less than 0.001), moderate and severe (p less than 0.001) and mild and severe (p less than 0.001) prosthetic mitral regurgitation. Thus, measurement of acceleration flow signals by Doppler color flow imaging is useful in assessing the severity of prosthetic mitral regurgitation.

Antitumor activity of D-mannosamine in vitro: different sensitivities among human leukemia cell lines possessing T-cell properties.

D-Mannosamine is toxic to human malignant T-lymphoid cell lines derived from patients with T-cell leukemia. We observed heterogeneity of mannosamine susceptibility among those cell lines. The leukemic T-cell lines, subgrouped according to the degree of mannosamine inhibition on nucleic acid biosyntheses, were: Subgroup 1, HPB-MLT cells; Subgroup 2, CCRF-HSB-2 and HPB-ALL cells; and Subgroup 3, MOLT-4 cells. The most sensitive line, HPB-MLT, originated from the patient with adult T-cell leukemia. The cytotoxicity of mannosamine was potentiated by a fatty acid, sodium oleate, at concentrations that were noncytolytic, and the interaction between the two drugs was synergistic. These results would suggest that mannosamine induces changes in the membrane structure of the leukemia cells. Thus, the primary target of the tumoricidal activity of mannosamine may also be the cellular membranes.