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Toxoplasma is a common parasite worldwide that mainly affects the brain, lungs and eyes. Although toxoplasmic encephalitis is a lethal disease without treatment, past case reports show most patients with systemic lupus erythematosus who developed toxoplasmic encephalitis were misdiagnosed and treated as neuropsychiatric systemic lupus erythematosus, which led to unfavorable outcomes. We herein describe a case of disseminated toxoplasmosis affecting all the above organs with atypical symptoms, which developed with exacerbation of systemic lupus erythematosus. She had initially manifested with retinochoroiditis without vitritis, mild cognitive impairment and an isolated lung mass. These are completely different from the classic symptoms of toxoplasmosis that have been reported in patients with HIV infection and/or those after hematopoietic transplantation. Our case, together with previously reported cases, suggests the manifestation of toxoplasmosis that develops in systemic lupus erythematosus patients can be different from that seen in conventional cases and varies between individual patients. Our case highlights both the difficulty in and the importance of diagnosing toxoplasmosis in patients with systemic lupus erythematosus and provides helpful information to identify this rare, devastating, yet treatable disease.

We have routinely applied an extra-strong graduated compression stocking to cesarean section patients to reduce the incidence of spinal anesthesia hypotension. Because bupivacaine has recently become available in Japan, we compared the incidence of spinal hypotension using either 2.0 ml of hyperbaric 0.3% dibucaine or 0.5% bupivacaine. There were 98 full-term parturients wearing the stocking who received 2.0 ml injection of dibucaine or bupivacaine for elective cesarean section. When systolic blood pressure decreased to 90-100 mm Hg or to less than 70% of the pre-anesthesia value, ephedrine was injected intravenously. There was no significant difference in systolic blood pressure or heart rate during spinal anesthesia between the dibucaine and bupivacaine groups. Although the demographic data and various data related to anesthesia or surgery were similar in the groups, the fluid volume and the dose and incidence of ephedrine injection during anesthesia showed significant differences: the mean dose was 3.6 and 1.5 mg and the incidence was 41% and 19% in the dibucaine and bupivacaine groups, respectively. Spinal anesthesia using bupivacaine results in a lower incidence of spinal hypotension compared with dibucaine and, in combination with fitting the extra-strong stockings onto both legs, is clinically useful for cesarean sections.

Because a standard type of graduated compression stocking is not effective for the prevention of spinal anesthesia hypothension during cesarean section, we have used an extra-strong type of graduated compression stocking. This study examined whether the extra-strong stocking reduces usage of vasopressor agents. Forty-eight and 47 full term parturients were fitted with the standard stocking and the extra-strong stocking, respectively. Spinal anesthesia was performed by injecting 2.0 ml 0.3% dibucaine hyperbaric solution. When systolic blood pressure decreased to 90-100 mmHg or to less than 70% of the pre-anesthesia value, ephedrine was injected. There was no significant difference in systolic blood pressure or heart rate during spinal anesthesia between the groups. The mean dose of ephedrine injected during anesthesia was 12.2 and 4.3 mg, and the incidence of ephedrine injected was 85 and 49%, in the standard and extra-strong stocking groups, respectively. The extra-strong stocking group showed significantly lower values. Fitting the extra-strong stocking on both legs for cesarean sections undergoing spinal anesthesia reduced usage of vasopressor agents, suggesting a promising use of this stocking for non-invasive prophylaxis.

We experienced 2 effective cases of nifekalant hydrochloride. One patient was 76-year-old female who underwent emergent coronary artery bypass grafting (CABG) because of unstable angina pectoris (AP) and ventricular fibrillation (Vf). Her cardiac function had been decreased preoperatively due to old myocardial infarction (OMI). One day after CABG, she revealed sustained ventricular tachycardia (VT) and Vf. Although administrations of neither lidocaine hydrochloride nor magnesium sulfate were effective, nifekalant hydrochloride finally stopped the life-threatening arrhythmia without hypotension. Another patient was 77-year-old male who underwent CABG and Dor operation. His cardiac function also had been decreased due to OMI. He revealed VT attack at midnight 3 days after operation. VT attack still appeared at next 2 midnight under lidocaine hydrochloride infusion, but finally it has disappeared after starting a drip infusion of nifekalant hydrochloride. Nifekalant hydrochloride is quite useful as a new therapeutic strategy for uncontrollable VT and Vf and for the patient who has a reduced left ventricular function because it has an inotropic effect.

Summary: A 12-year-old female patient presented with unilateral sensorineural hearing loss. Distortion-product otoacoustic emission testing failed to reveal any measurable emissions in the affected side. MR imaging did not reveal labyrinthine malformation. Three-dimensional Fourier transformation–constructive interference in steady-state MR images showed a thin cochlear branch. We speculated that mumps infection or developmental malformation caused the unilateral sensorineural hearing loss.

The type of renal dysplasia resulting from obstructive uropathy depends on the completeness of the obstruction and its timing with respect to the stage of glomerulogenesis at the time of the obstruction. The authors created a successful obstructive uropathy model in the female fetal lamb to demonstrate the differing pathogenesis of renal dysplasia.Female fetal lambs at 60 and 90 days' gestation had their urethra and urachus ligated transabdominally and were delivered by cesarean section at 145 days (full term). Kidney length and cortical thickness were measured, and samples were examined histologically. In the lambs operated on at 90 days, the urine was collected at delivery and Na and CI were measured and compared with the results obtained from normal full-term lambs.Seven of 10 female lambs had hydronephrosis or dysplastic kidneys. The cortext to kidney length ratio was 10+/-3% in the 90-days hydronephrotic group versus 29+/-6% in the controls (P.001). Morphologically, the 90-day model had dilatation of the collecting tubules with normal glomerular numbers. The 60-day model had tubular cysts with fibromuscular cuffing and reduced glomerular numbers. The fetal urine Na was 47+/-3.3 mmol/L in controls versus 78+/-24 mmol/L in the hydropnephrotic lambs (P.05). The urine CI in these lambs was 38+/-8.6 mmol/L in controls versus 55+/-14.5 mmol/L in the hydronephrotic lambs (P.05).An obstructive uropathy model was created in female fetal lambs. There were no dysplastic changes in the kidneys in lambs operated on at 90 days' gestation, but there were definite dysplastic changes in those operated on at 60 days. Concentrations of Na and CI in the fetal urine are higher than normal in the 90-day model.

BACKGROUND AND PURPOSE: In childhood-onset moyamoya disease, the angiographic disease process of stenoocclusive lesions is progressive, and cerebral infarctions often develop as a result of ischemia. Our purpose was to determine how the severity of stenoocclusive lesions in the anterior and posterior circulations affects the distribution of cerebral infarction in patients with childhood-onset moyamoya disease. METHODS: In 69 patients with childhood-onset moyamoya disease, angiograms were reviewed for stenoocclusive lesions, and CT scans, MR images, or both were reviewed for the sites and extent of cerebral infarction. The relationship between the angiographic and CT/MR findings was examined. RESULTS: The prevalence and degree of stenoocclusive lesions of the posterior cerebral artery (PCA) significantly correlated with the extent of lesions around the terminal portion of the internal carotid artery (ICA). The prevalence of infarction significantly correlated with the degree of stenoocclusive changes of both the ICA and PCA. Infarctions tended to be distributed in the anterior borderzone in less-advanced cases, while in more advanced cases lesions were additionally found posteriorly in the territory of the middle cerebral artery, the posterior borderzone, and the PCA territory. CONCLUSION: Our results indicate that progressive changes of the anterior and posterior circulations are associated with the distribution of cerebral infarction, culminating in a patchily disseminated or honeycomb pattern of infarction on CT and MR studies in late stages of the disease.

Mitral valve aneurysm is defined as a localized protrusion of the valve with a different radius from that of the remaining portion of the valve. The medical records and pathological findings of seven patients with mitral valve aneurysm [aged 48-69 years (mean 64), 4 males] and the pathological findings of other 29 Japanese cases were reviewed. All seven patients were diagnosed pathologically as infective endocarditis, but two patients had no documentation of clinical symptoms suggestive of infective endocarditis (latent infective endocarditis). The underlying lesion of the heart was aortic valve disease and/or fibrosal degeneration of the mitral valve. Only 29 of 36 Japanese case reports stated a precise description of the valve pathology. Of these 29 cases, 23 were associated with infective endocarditis, two with rheumatic valvular disease with fusion and/or shrinkage of the chordae tendineae, three with mitral valve prolapse or myxomatous degeneration of the mitral valve, and one with aortitis syndrome. Neovascularization was described in eight cases. Neovascularization with thick wall should be considered as post-inflammatory vascularization. This review indicates that patients with latent infective endocarditis and mitral valve aneurysm should be considered as potential candidates for valve surgery.

The purpose of this study was to retrospectively evaluate the outcome of refractory infected mediastinitis managed primarily with mobilization of pectoral muscle flaps and omental transposition. From January 1992 to December 1995, infected mediastinitis occurred in 11 (2.5%) of 447 consecutive patients. All patients required sternal debridement. The wound was thoroughly irrigated with a solution of 0.5% povidone-iodine in physiological saline after debridement and then the defect was repaired. Reconstruction of the chest wall was attained using pectoral muscle flaps in seven patients and pectoral muscle flaps and omental transposition in four. Antibiotic therapy was provided for 6 weeks or more according to the regimen in North America. No hospital deaths occurred after surgery. Significant early complications occurred in four patients. The reasons for the prolonged hospitalization were a recurrent wound infection, prosthetic valve endocarditis and saphenous vein graft pseudoaneurysm formation caused by Methicillin-resistant Staphylococcus aureus (MRSA) and Methicillin-resistant Staphylococcus epidermidis (MRSE). Length of stay in ICU after surgical treatment was range 1 to 140 days (an average of 11 +/- 3 days in 9 patients without complications in ICU). Duration between surgical treatment and discharge was range 47 to 300 days (an average of 58 +/- 8 days in 7 patients without significant early complications). At the time of this report, the patients are doing well with no signs of recurrence of infection. The mean follow-up was 28.8 months (range 8 to 48 months). We conclude that single-stage mobilization of pectoral muscle flaps together with omental transposition is very usefull for managing refractory infected mediastinitis. But careful follow-up is needed after this procedure in case of MRSA-caused mediastinitis because of its tendency to recur.

We analyzed the risk of mitral valve re-replacement (re-MVR) in patients over 70-year-old. Surgical and late follow-up results were compared between 14 elderly patients over 70-year-old (group I) and 23 patients aged from 60 to 69-year-old (group II) who underwent re-MVR due to primary tissue failure (PTF). Donation of autologous blood and a rate of replaced valve prosthesis (mechanical/biological) were different between the two groups. There were no differences in the other factors such as clinical profile, preoperative organ function, operative characteristics, post operative relating factors. No operative death occurred in both groups. There was one hospital death in group I (a hospital mortality rate of 7.1%). The cause of death was related to massive cerebral infarction due to anticoagulant-related thromboembolic event. 4-64 months after re-MVR, the improvement of a NYHA function class was I-II in the two groups. With improvement in myocardial protection and intraoperative strategies, the operative risk in patients undergoing re-MVR over 70-year-old has been markedly reduced. Surgical results in aged patients were satisfactory and age alone is not a contraindication for this operation. The re-MVR in aged patients should be done at the early stage of PTF before progress of cardiac failure.

To assess the clinical, angiographic and early follow-up findings of young patients suffering an acute myocardial infarction, in comparison with older patients with infarction, in the thrombolytic era.A retrospective analysis of the medical records of 46 patients40 years-old (group I) at the time of an acute myocardial infarction was compared with that of 46 older patients, randomly selected, presenting with this syndrome between february, 1991 and february, 1996 (group II). In both groups a comparison was conducted regarding the proportions of gender, risk factors, type of infarction (Q vs non-Q), left ventricular function, coronary anatomy and early mortality (1 month). The medical treatment was comparable for both groups, including the utilization of thrombolytics.The groups were discriminated only by: higher prevalence of smoking, of angiographically normal coronary arteries, and of non-critical (75% reduction of luminal diameter) coronary stenosis in group I; in the older group a higher proportion of patients had multivessel disease. Although not reaching statistical significance, a trend was observed to a more benign early course of the infarction in the patients less than40 years-old.The present findings are similar to those described in the pre-thrombolytic era, for young patients suffering an acute myocardial infarction.

A 17-year-old woman was found to have ectopic atrial tachycardia by her physician. Echocardiography and cardiac catheterization revealed findings resembling dilated cardiomyopathy at the time of initial presentation. The tachycardia was controlled with atenolol only at a dose of 50 mg/day. However, at the age of 22, the presence of ectopic atrial tachycardia was once again confirmed. We successfully performed catheter ablation for persistent ectopic atrial tachycardia. Serial echocardiographic findings showed the left ventricular dimension and function appeared to return to normal 1 year postablation. However, despite pharmacologic control and catheter ablation therapy, histopathology revealed myocardial fibrosis presumably representing permanent damage of the heart secondary to tachycardia 1 year postablation.

A 41-year-old Japanese woman complained of a gradually enlarging swelling of her left cheek for seven months. She was diagnosed with osteopetrosis by standard skeletal radiographs, and her cheek swelling was diagnosed as maxillary osteomyelitis secondary to osteopetrosis. She underwent a left partial maxillectomy, and her post-operative course was stable with no complications. A literature review is also presented.

The pathogenesis of nonrheumatic calcification of the mitral valve was investigated by analyzing the clinical and echocardiographic characteristics of patients with mitral valvular calcification without any findings suggestive of rheumatic heart disease or infective endocarditis. Calcification of the mitral valve was observed in nine patients, who all had calcified stenotic (aortic valve area1 cm2) bicuspid aortic valve. Calcification of the mitral valve was localized to the basal portion of ventricular aspect of the anterior mitral leaflet and contiguous to that of the aortic valve. Mobility and thickness of the mitral leaflet was normal except for the calcified portion. Calcification of the mitral valve was not contiguous to posterior mitral annular calcification nor was related to direction of aortic regurgitant flow. In patients with calcified stenotic bicuspid aortic valve, calcification of the mitral valve was not associated with location of the two aortic cusps, aortic valve area, aortic valvular peak pressure gradient, direction of the left ventricular outflow, end-diastolic left ventricular outflow tract dimension, end-diastolic dimension of the aortic annulus, incidence of aortic regurgitation, calcification of the aortic arch, or risk factors of atherosclerosis. Six patients with mitral valvular calcification had aortic valve replacement. Preoperative coronary angiogram of these patients was normal. Calcification of the aortic valve was on the ventricular and aortic aspects. The calcification of the aortic valve, anterior mitral ring, or anterior mitral leaflet was not rheumatic in these six patients. Rheumatic disease, risk factors of atherosclerosis, mechanical stress by left ventricular outflow or aortic regurgitant flow, or mitral annular calcification did not appear to be related to mitral valvular calcification. The distribution of aortic and mitral valvular calcification suggested that the calcification of the mitral valve was due to progression of calcification of the bicuspid aortic valve.

A 71-year-old woman with active aortic prosthetic endocarditis due to Methicillin-resistant Staphylococcus epidermidis (MRSE) and subannular mycotic aneurysm and paravalvular leakage and acute mitral regurgitation underwent emergent surgical treatment. The mycotic aneurysm was closed using a prosthetic patch after surgical debridement. Re-aortic valve replacement with a 21-mm Hancock II prosthesis was performed at the paraannular position by utilizing the patch. Mitral valve was also replaced with a 27-mm Hancock II prosthesis. Antibiotic therapy was provided by vancomycin combined with rifampicin and gentamicin. The following regimen was given, vancomycin 1 g i.v. q12h for 6 weeks plus gentamicin 80 mg/day i.v. for 4 weeks plus rifampicin 450 mg/day orally for 6 weeks. Vancomycin and gentamicin doses were modified appropriately according to the monitored serum levels in the patient with renal failure. Postoperative course was uneventful. The patient is doing well 11 months after surgery and no recurrence of infection has been seen. We conclude that prompt surgical removal of the infected sources and appropriate antibiotic therapy based on the bacteriology may be the only curative treatment for uncontrolled infection at the active phase of MRSE prosthetic endocarditis.

Third mitral valve replacement (3rd MVR) have become more frequent as use of replacement procedures has become more widespread. However, little information exists to clearly document the determinants of 3rd MVR. To evaluate backgrounds and risks and complications of 3rd MVR, we reviewed data on 10 patients (6 male and 4 female, age averaged 58 +/- 8 years) who underwent 3rd MVR because of prosthetic valve malfunction during December 1986-May 1995. This represented 7.1% of total number of reoperations for valve surgery (10/140) during that period. The incremental effect of the 3rd MVR on hospital mortality and mobidity was studied by comparing first mitral valve replacement (1st MVR) and second mitral valve replacement (2nd MVR) and 3rd MVR. After an interval of 134 +/- 23 months, 3rd MVR was undertaken for congestive heart failure due to primary tissue failure in 65%, paravalvular leakage in 20%, prosthetic valve endocarditis in 15%. One patient died at 11 days postoperatively, for a mortality rate of 10%. Cause of death was related to multiple organ failure due to low cardiac output syndrome. The surgical risk of 2nd MVR and 3rd MVR is higher than that of 1st MVR, but there is no conclusive evidence that the difference between 2nd MVR and 3rd MVR is statistically significant. With improvement intraoperative strategies, the operative risk in patients undergoing 3rd MVR has been markedly reduced.

To solve the problem of diagnosing apocrine carcinoma (APCA) through distinguishing it from benign apocrine metaplasia with atypia (APMA).The study group consisted of five histologically confirmed cases of uncommon infiltrating apocrine carcinoma and a case of noninfiltrating apocrine carcinoma of the breast by aspiration biopsy cytology. The control group consisted of 103 cases of benign apocrine metaplasia with no atypia (APMN), 4 cases of APMA and 34 cases of common-type adenocarcinoma that were encountered in 662 breast aspirations from 1988 to 1992 at Hekinan Municipal Hospital.In APCA the average age of patients (65 +/- 17.7 SD)(mean +/- SD) was more than 20 years older than APMA, and APCA generally measuredor = 2 cm or more in diameter as compared toor = 2 cm in APMA lesions. In APCA the apocrine cells had high cellularity, with the cells occur singly and with syncytia in the background. Numerous degenerated apocrine cells and characteristic cell detritus were found. APCA was also characterized by apocrine cells with more marked nuclear abnormalities, including hyperchromasia and irregular nuclear shape, frequently with irregular nucleoli; more nuclei measureor = 12 micron in diameter than in APMA. These findings, however, were present only to a mild degree in APMA, if at all. APMA may coexist with APCA.If APMA is diagnosed, an open biopsy should be performed to distinguish it from APCA.

Factors involved in the progression of senile aortic valve calcification were evaluated by analyzing the clinical and echocardiographic characteristics of patients older than 69 years with senile aortic valve calcification. The patients were divided into three groups; group 1: 46 male and 40 female patients with calcification of one cusp and almost normal pliability of three cusps, group 2: 48 males and 55 female patients with calcification of two or three cusps, mildly reduced pliability of calcified cusps, and aortic valve area (AVA)or = 2.0 cm2, group 3: 26 male and 31 female patients with calcification of two or three cusps, significantly reduced pliability of calcified cusps, and AVAor = 1.5 cm2. There were no significant differences in age, weight, height, left ventricular dimension, or left ventricular wall thickness between these three groups. For male patients, the end-diastolic maximum left ventricular outflow tract dimensions (LVOT) in groups 1, 2, and 3 were 20 +/- 2 mm, 19 +/- 2 mm (p0.01 vs group 1), and 17 +/- 3 mm (p0.001 vs group 1, p0.01 vs group 2), respectively. For female patients, the LVOTs of groups 1, 2, and 3 were 18 +/- 2 mm, 16 +/- 2 mm (p0.001 vs group 1), and 16 +/- 2 mm (p0.001 vs group 1), respectively. Reduction in LVOT was not associated with left ventricular hypertrophy or decrease in dimension of aortic annulus. In female patients, the frequency of mitral annular calcification of group 3 was 61% [p0.05 vs group 1 (35%), p0.01 vs group 2 (25%)].(ABSTRACT TRUNCATED AT 250 WORDS)

We experienced aortic valve replacement for 18 patients (4 male and 14 female, ranging from 40 to 81 years old, mean 64 years old) with small aortic annulus with new small prosthesis. Medtronic Hall 20 A (MH 20 A). The average body surface area was 1.47 m2 (range 1.28 to 1.81 m2). One patient was died of lung cancer at 3 months postoperatively. One nonstructural dysfunction and one low cardiac output syndrome was noted during operation. Sixteen survivors with MH 20 A, showed satisfactory clinical results, except for minor thromboembolism, in 2 patients. The MH 20 A had the same function as that of MH 21 A, already reported. We concluded that aortic valve replacement by Medtronic Hall 20 A prosthesis was usefull for the patient with small aortic annulus.

A 61-year-old female admitted with the diagnosis of both coronary ostial stenosisthe severe calcified aorta due to Takayasu's arteritis. She underwent coronary artery bypass grafting successfully, using the right internal thoracic artery to RCAthe left internal thoracic artery to LAD, without cardiopulmonary bypass. Coronary artery bypass grafting without cardiopulmonary bypass is one of the useful surgical technique for the patient with the severe calcified aorta due to Takayasu's arteritis.

Coronary ostial stenosis with otherwise normal coronary vessels occurs in patients with syphilis or Takayasu's aortitis. Iatrogenic ostial stenosis may develop as a complication of coronary angiography or after coronary perfusion at the time of cardiac surgery. Isolated ostial stenosis in the absence of these factors has been reported infrequently and its unique clinical and angiographic profile has been noted recently. Hence, it is proposed that this type of isolated ostial stenosis may represent a clinical entity distinct from the usual atherosclerotic coronary disease. We report the case of a middle-aged woman with this type of isolated coronary ostial stenosis. A 55-year-old female was admitted with the complaint of exertional chest pain, which had appeared 2 months admission and which had gradually become more frequent. The ECG on admission was normal. She had no coronary risk factor. Treadmill exercise test was stopped at stage 2 of Bruce protocol because ischemic S-T segment depression appeared in II, III, aVF, V4-V6 and she complained of a chest pain. Coronary angiography showed a 90% stenosis of the left coronary ostium with normal distal vessels. The right coronary artery was normal. A coronary artery bypass graft to the left anterior descending branch was performed uneventfully and the patient remains asymptomatic.

To investigate the relationship between distribution of human leukocyte antigen alleles and susceptibility to primary biliary cirrhosis among Japanese, we performed serological typing and human leukocyte antigen DP genotyping in 47 Japanese patients with primary biliary cirrhosis. Serologically, the frequency of human leukocyte antigen DQ3 was significantly higher in the patients than in healthy controls, whereas frequency of DR52 was significantly lower in the patients. Human leukocyte antigen DP genotyping using the polymerase chain reaction-restriction-fragment-length polymorphism method showed that the frequency of human leukocyte antigen DPB1*0501 (85.1%) was significantly higher in patients than in healthy controls but that the frequency of DPB1*0402 was significantly lower in patients. The positive association of human leukocyte antigen DPB1*0501 with primary biliary cirrhosis was stronger than that of serological human leukocyte antigen DQ3, which can be explained by its linkage to DPB1*0501. In addition, three of seven DPB1*0501-negative patients had DPB1*0202, suggesting that the human leukocyte antigen DPB1 amino-acid chain plays an important role in the immunogenesis of primary biliary cirrhosis among Japanese patients. Comparative analysis of amino acid sequences from DPB1 alleles indicated that a Leu at position 35 of the DPB1 chain likely contributes to the susceptibility to primary biliary cirrhosis among the Japanese.

From March 1986 to September 1991, the right gastroepiploic artery has been used for coronary artery bypass grafting in 200 patients (171 male and 29 female patients, mean age 58 years, range 6 to 80 years. They were followed up from 6 to 70 months with a mean of 27 months. There were 16 reoperations and 176 patients had triple vessel or left main disease. The gastroepiploic artery (182 in situ and 18 free grafts) was anastomosed to 11 anterior descending, 3 diagonal, 26 circumflex, and 160 right coronary arteries. The internal thoracic artery was concomitantly used in 192 patients. The mean number of distal anastomoses was 2.3 with arterial grafts and 3.3 including additional saphenous vein grafts. Postoperative angiography was performed in 152 patients within 6 months after the operation (mean 2 months) and after the operation second angiograms were done sequentially 1 to 5 years (mean 2 years) after the operation in 40 patients. There were 6 early and 4 late deaths. A new Q wave was noted in 4 patients. Duration of the operation and postoperative complications did not increase with the use of the gastroepiploic artery. Relief of angina was noted in 186 patients. Gastroepiploic artery graft patency was 95% (144/152) in the early postoperative period and 95% (38/40) in the late postoperative period. Percutaneous transluminal coronary angioplasty was done successfully through the in situ gastroepiploic artery graft for anastomotic stenosis in four cases. In stress myocardial scintiscans, performed sequentially preoperatively and in the immediate, 1-year, and 2-year postoperative periods in 11 patients, washout rate of the gastroepiploic artery-grafted area improved from 35% +/- 10% to 45% +/- 15% (p0.05) and was maintained to 43% +/- 6% and 48% +/- 9% at respective periods. In conclusion, the gastroepiploic artery is a suitable conduit for coronary artery bypass grafting in terms of low surgical risk, high patency rate, and excellent patient outcome.

An 80-yr-old female presented with obstructive jaundice. Endoscopic retrograde cholangiopancreatography showed a carcinoma in the middle extrahepatic bile duct, and a biliary endoprosthesis was inserted. Exfoliative cytology of the bile and forceps biopsy of the tumor revealed a papillary adenocarcinoma. Surgical resection could not be done because of her cardiovascular complications, and neither chemotherapy nor radiotherapy was administered. Stents were exchanged and cleaned 21 times because of occlusion and cholangitis. Subsequent serial cholangiogram showed a slow growth of the papillary tumor, but local invasion to the adjacent organs or distant metastasis was not observed. The patient survived for 7 yr and 6 months after insertion of the biliary endoprosthesis.

To clarify the clinical usefulness of a second generation antibody to hepatitis C virus (anti-HCV-2), we tested the anti-HCV-2 by enzyme immunosorbent assay (Imucheck HCV Ab) in comparison to the first generation antibody (anti-HCV-1). Serum samples were obtained from the patients with acute hepatitis, chronic liver diseases, alcoholic liver disease and autoimmune liver diseases. Furthermore, both antibodies were tested in serum samples from individuals in a hyperendemic area of non-A, non-B hepatitis. Anti-HCV-2 was detected earlier than anti-HCV-1 in acute type C hepatitis. The prevalence of anti-HCV-2 was higher than that of anti-HCV-1 in acute and chronic non-A, non-B liver diseases. However, prevalence of anti-HCV-2 was not increased in patients with non-viral liver disease such as pure alcoholic liver disease and autoimmune liver diseases. The HCV-infection rate was increased to about 40% by detection of anti-HCV-2 in individuals in hyperendemic area of non-A, non-B hepatitis. Thus, the assay of anti-HCV-2 is very useful to detect actual HCV infection. The accuracy and sensitivity of anti-HCV-2 were higher than those of anti-HCV-1.

A 19 year-old girl with an unusual type of coarctation of the aorta terminating in complete obstruction is presented. At the age of 5 years, she was diagnosed by aortography to have coarctation of the aorta of type IV C according to Edward's classification. No surgical treatment was performed at that time because her growth was good and she didn't have hypertension. During the follow-up period, marked hypertension developed, and she was readmitted. The aortogram revealed a bicuspid aortic valve and total obstruction of the descending thoracic aorta at the site where coarctation was noticed previously. The abdominal aorta distal from the obstruction site was filled through rich collateral circulation. As these angiographic interval changes are very rare, we discussed the genesis of obstruction and operative indication by reviewing the literature.

Aortic calcification was evaluated preoperatively by computed tomography (CT) in 136 of 275 candidates for coronary artery bypass surgery (age range, 30-80) years (mean 60.2 years), including 110 men and 26 women), from April 1989 to March 1991. Calcification in the mid-ascending aortic wall was detected in 20 (14.7%) cases, calcification in all regions of the aorta was more common in patients older than 60 years (22.5%, n = 71), than younger (6.2%, n = 65) (p less than 0.01). Atherosclerosis of the ascending aorta was identified intraoperatively in 25 (18.3%) cases. Practically, the specificity of CT findings was excellent (98.3%), but the sensitivity was less satisfactory (72.0%) due to the presence of atherosclerosis without calcification. In cases of arteriosclerosis of the ascending aorta, great care was taken to prevent embolism secondary to a dislodged atheromatous plaque. The "aortic no-touch technique", with in situ internal thoracic artery and right gastroepiploic artery anastomosis under ventricular fibrillation, was performed in 6 cases, a single aortic cross-clamp was applied in 19 cases, and conventional methods were employed when the ascending aorta was normal or the "no-touch" or "single-clamp" procedure could not be used (control, 111 cases). No neurologic complications occurred in the "no-touch" group, while 2 cerebral infarctions occurred in the single-clamp group (10.5%) and the control group (1.8%) respectively. These differences between groups was not significant. Patients with a calcified ascending aorta are at higher risk for neurologic complications of coronary bypass. The risk can be decreased by minimizing surgical trauma to the ascending aorta by the use of "no-touch" techniques.

After aorto-coronary bypass grafts surgery plasma level of myosin light chain I, determined with monoclonal antibodies to myosin light chain I (LC-I), were studied in 12 patients (pts) without electrocardiographical perioperative myocardial infarction. Rest 201Tl myocardial images were collected before and after surgery. LC-I increased and reached peak levels (15 +/- 7 ng/ml) at 91 +/- 29 minutes after the aortic declamp. From peak levels LC-I rapidly decreased with fast half-time disappearance (1.4 +/- 0.9 hours). In 5 pts of 12 pts LC-I recovered to normal range and MB reached maximum levels (34 +/- 23 IU/L) at 18 +/- 9 hours after declamp. In 4 pts 201Tl images showed improvement and in one 201Tl images showed no changes. In 7 pts of 12 pts LC-I decreased to minimum levels (2.7 +/- 0.6 ng/ml) at 12 +/- 6 hours and then gradually increased to peak levels (5.6 +/- 0.9 ng/ml) on day 3 +/- 0.9. MB reached maximum level (61 +/- 20 IU/L) at 3.2 +/- 1 hours. In 201Tl images 3 pts showed suspected new lesion, 2 pts showed no changes and 2 pts showed improvement. No correlation was noted between peak LC-I level and duration of aortic declamp. No significant relation was suspected between early LC-I peak and irreversible myocardial cell injury. From close relationship between aortic declamp and appearance of LC-I peak, it was concluded that LC-I, accumulated during aortic clamp, was washed out by aortic declamp. Relation was suspected between early LC-I peak and myocardial injury during myocardial protection.(ABSTRACT TRUNCATED AT 250 WORDS)

The nephrotic syndrome is often accompanied by hyperlipidemia associated with an increased risk of accelerated atherosclerosis. The present study was undertaken to evaluate the effects of pravastatin, a novel competitive inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A reductase, on the serum lipids and apolipoproteins in patients with this syndrome and marked hyperlipidemia. Eleven adult patients received 10 mg of pravastatin twice daily for 4 to 8 weeks. The total serum cholesterol decreased from 426 +/- 44 to 309 +/- 18 mg/dl (-27.4%, mean +/- S.E.; p less than 0.01) following administration of pravastatin. The serum triglyceride decreased from 332 +/- 122 to 229 +/- 50 mg/dl (-30.9%), although this change was not significant. Despite the fact that the HDL cholesterol level was barely changed (51 +/- 7 to 51 +/- 6 mg/dl), the LDL cholesterol fell from 313 +/- 30 to 211 +/- 16 mg/dl (-32.5%; p less than 0.005), and the LDL to HDL cholesterol ratio fell from 7.57 +/- 1.59 to 4.94 +/- 0.88 (-34.8%; p less than 0.05). These changes caused the atherogenic index to decline from 9.6 +/- 2.4 to 6.1 +/- 1.2 (-36.5%; p less than 0.05). No significant alterations could be found among apolipoproteins A-1, A-2, B, C-2, C-3, and E. During the present study period, pravastatin was well tolerated and did not affect the serum protein, albumin, serum urea nitrogen, creatinine levels, or urine protein excretion. Also, there were no serious adverse effects. Pravastatin appears to be effective for treating patients with hyperlipidemia of the nephrotic syndrome.

Between June 1983 and July 1989, 25 consecutive chronic dialysis patients with medically refractory angina pectoris underwent revascularization, either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) (21 males and 4 females, mean age of 57 +/- 10 years, and mean duration of dialysis of 3.7 +/- 5.0 years). Patients with single-vessel disease and/or mildly calcified lesions received PTCA (n = 15), while those with multi-vessel disease and/or severely calcified lesions received CABG (n = 10). As controls for PTCA-treated dialysis patients, 208 non-dialysis patients who received initial PTCA in 1988 were used. The mean number of diseased vessels was 2.7 +/- 0.7 for CABG group, and 1.5 +/- 0.8 for PTCA group (p0.01). In both groups, 80% of patients were successfully revascularized. In CABG group, however, 7 of 10 patients had major complications including 2 hospital deaths, while no complications occurred in the PTCA group. During the follow-up period after CABG (35 +/- 30 months), recurrent angina developed in one patient, who was successfully treated with PTCA. In the PTCA group, angiographic success was initially obtained in 16 of 21 lesions (76%), which was significantly lower than that in the control group (92%, p0.05). Follow-up angiography revealed restenosis in 6 of 16 lesions with successful PTCA (38%), similar to that observed in the control group (32%, p = ns). A second PTCA was successful in 5 of 6 patients with restenosis, however, 4/5 patients developed recurrent angina. Three of 4 patients with a second episode of restenosis underwent a third PTCA, and angina recurred in 2.(ABSTRACT TRUNCATED AT 250 WORDS)

The cases of acute pulmonary thromboembolism after coronary artery bypass surgery have been rarely reported in Japan. We, however, experienced 2 cases of them and lost them against intensive therapy. In Mitsui Memorial Hospital, 6 cases of pulmonary thromboembolism had been diagnosed in 1990 (0.074% in admission patients), four of the cases had occurred following surgical procedures. Its manifestations are deceivingly nonspecific and are difficult to distinguish perioperative myocardial infarction, pericardial tamponade, and pneumothorax, especially in postoperative states. We would like to emphasize that acute pulmonary thromboembolism is getting important problems also in Japan.

Studies on the transfer into the fetus and the milk were performed after administration of 14C-Z-103 and 65Zn-Z-103 (catena-(S)-[mu-[N alpha-(3-aminopropionyl)histidinato(2-)-N1,N2,O:N tau]- zinc], CAS 107667-60-7) to rats. After oral administration of 14C-Z-103 to pregnant rats, the transfer of radioactivity to the fetus was studied by means of whole body autoradiography (ARG) and measurement of radioactivity in the fetus. The concentration of radioactivity in the fetus was approximately the same as those in the blood and the placenta of the maternal animal. The transfer of radioactivity into the milk was demonstrated after administration of 14C-Z-103 to lactating rats. Radioactivity in the fetus and milk are considered to be due to metabolites of L-carnosine of Z-103, such as amino acid or protein. The distribution of radioactivity in the fetus was also observed after administration of 65Zn-Z-103 to pregnant rats. However, after administration of non-radioactive Z-103 to pregnant rats, the zinc level in the fetus was found to be almost the same level as that in the fetus of the untreated rats. The transfer of radioactivity to the milk was studied after administration of 65Zn-Z-103 to the lactating rats, and it was seen that the concentration of radioactive zinc in the milk was much lower than the endogenous level of zinc in the milk at any of the time points investigated.(ABSTRACT TRUNCATED AT 250 WORDS)

Imipenem/cilastatin sodium (IPM/CS) was administered to a total of 67 patients with severe infections complicating hematological disorders and solid tumors. Fifty patients are included in the present analysis of efficacy and 64 in that of safety. 1. Out of 31 patients with hematological disorders, responses were excellent in 10 patients, good in 10 patients, and the efficacy rate was 64.5%. Out of 19 patients with solid tumors, responses were excellent in 8 patients, good in 8 patients and the efficacy rate was 84.2%. 2. For patients whose responses to other antibiotics had been poor, the efficacy rate was 59.3% in the group with hematological disorders and 62.5% in the group with solid tumors. 3. The relationship between the neutrophil count and efficacy was studied in the patients with hematological disorders. The efficacy rate for 8 patients whose neutrophil counts were 500/mm3 or less was 75.0%. 4. For the patients with hematological disorders, the efficacy rate for patients from whom causative organisms were isolated was 70.0% and that for patients for whom they were unknown was 61.9%. 5. Adverse reactions were observed in 3 patients and abnormal laboratory test results in 2 patients. However, they were mild and disappeared after discontinuation of this drug. From these results, IPM/CS is considered to be a useful antibiotic for the treatment of severe infections complicating hematological disorders and solid tumors.

A 70-year-old woman was admitted for evaluation of hepatosplenomegaly, fever and elevated serum LDH levels. A biopsy specimen of the liver revealed histiocytic proliferation at the portal triad, and a mild degree of hepatitis. A bone marrow biopsy specimen showed proliferation of histiocytes with minimal immaturity and atypism, and haemophagocytosis by the proliferated histiocytes. Fever, hepatosplenomegaly and elevation of LDH levels all disappeared spontaneously, and presumptive diagnosis of benign reticulosis with haemophagocytosis was made. One year later, fever, hepatosplenomegaly and elevation of LDH levels redeveloped, and the liver and bone marrow biopsy specimen showed proliferation of unequivocally malignant histiocytes. The patient died as a result of disseminated intravascular coagulation with shock 20 d later. We concluded that, in this case, malignant histiocytosis first presented as benign haemophagocytic reticulosis and, 1 year later, there was a typical malignant presentation.

A case of the elder PDA with aneurysm of the main pulmonary artery is reported. The patient was a 59-year-old female who had been suffering from severe heart failure. The PDA was closed directly from inside of the pulmonary artery using balloon catheter under usual cardiopulmonary bypass with limited circulatory arrest, and the aneurysm was repaired by aneurysmorrhaphy. The postoperative course was uneventful and she was discharged after 34 postoperative days. The pathological finding of the aneurysm of the main pulmonary artery is a cystic mucoid degeneration like a finding of Marfan syndrome. The etiology of the aneurysm of the main pulmonary artery seems to be extended Ao-PA shunt besides somewhat congenital change of the pulmonary artery.

A case of Romano-Ward syndrome effectively treated by both propranolol and atrial pacing is reported. A 33 year-old female, who had experienced syncopal episodes since she was 20 years old, had a family history showing her son with QTc 0.46. Her QT-U interval and QTc were both 0.6 second when propranolol was not administered. It shortened to 0.28 second and 0.39 respectively under exercise stress testing, and also shortened to 0.41 second and 0.43 respectively when left satellite ganglion block was used. Electrophysiologic study demonstrated that both sinus and atrioventricular nodal functions were normal, but the refractory periods of right and left ventricle differed significantly, and nonsustained ventricular tachycardia was induced. Her QT-U and QTc intervals shortened to 0.37 seconds and 0.43 respectively through both the treatment of 80 bpm atrial pacing, and the administration of 80mg propranolol. She has never experienced a syncopal episode.

For 10 adult cases of Ebstein's anomaly, tricuspid valve supraannular imposition (TVSI) without excision of native tricuspid valve were performed and its late results (6 mo. to 11.5 y, mean 6.8 years) were investigated. All cases showed the severe low output syndrome after the surgery. But the postoperative recovery of the cardiac function was smooth and there was no early death nor A-V block. Both the A-V conduction and the RV subvalvular structures were preserved in TVSI and it contributed to the postoperative good contractility of RV. In two cases, the serious postoperative ventricular tachycardia or ventricular fibrillation were experienced, one case required open cardiac massage and 6 hours long assist circulation in the other. In late stage, one patient died 9 years after the TVSI from the failure of the bioprosthetic mitral valve which had been implanted simultaneously, and the other 9 survivors returned to the class I of NYHA classification. LVDd and DS obtained by echocardiography showed significant enlargement; 29 +/- 4.5 mm and 19 +/- 4.1 mm before operation to 42 +/- 3.1 mm and 29 +/- 5.8 mm in late stage respectively. EF showed the tendency of slight decrease from the preoperative supernormal value to the normal range. RVD showed significant decrease after the surgery (58 +/- 4.2 mm to 37 +/- 4.1 mm). Bioprosthetic valve failure in tricuspid position was not experienced. PAC or PVC were seen quite often and 8 of 9 cases received medication for arrhythmia even in late stage.(ABSTRACT TRUNCATED AT 250 WORDS)

The long term (10 to 15 years) results of coronary artery bypass grafting (CABG) were studied in 20 patients. The duration of follow-up was ranged from 130 to 170 months with mean 146.4 months. Ten out of 20 patients underwent coronary angiography (CAG), which disclosed that the late patency of saphenous vein (SV) grafts was 68.8% (11/16), but 54.5% (6/11) of patent SV grafts showed atherosclerotic changes such as irregularity and localized narrowing. On the other hand, internal thoracic artery (ITA) grafts were all patent without any atherosclerotic luminal changes. We recognized that ITA grafts were superior to SV grafts from an angiographic standpoint of view in the long term in Japan.

We successfully performed craniotomy and mitral valve replacement on a patient with bacterial endocarditis and ruptured intracranial aneurysm. A 15-year-old woman with fever and heart murmur was admitted to another hospital. Infective endocarditis and mitral valve regurgitation was diagnosed and treated with antibiotics. About one month after admission the patient suddenly showed severe headache and hemiparesis. Brain CT demonstrated intracerebral and subarachnoidal hemorrhage. The patient was unconscious when transferred to Mitsui Memorial Hospital where cerebral angiography showed anterior cerebral aneurysm and echocardiography showed mitral valve vegetation. We judged the necessary mitral valve replacement could be delayed until the aneurysm had been stabilized. We therefore began treatment using a different antibiotic but, in spite of this, 10 days later the aneurysm had enlarged dramatically. As conservative treatment was ineffective, a clipping operation was done to prevent re-rupture at the time of mitral valve replacement which could not be delayed much longer. 10 days later, cerebral 4 vessel study was done which showed no abnormality. Mitral valve replacement was then done and the patient was discharged in good health 64 days after the valve replacement.

A case of bioprosthetic mitral valvular dysfunction accompanied by mitral stenosis due to pannus is reported. A 69-year-old woman, whose mitral valve had been replaced with a Hancock bioprosthetic valve in June 1979, underwent the second mitral valve replacement in September 1988 because of valvular dysfunction. The ring and cusps of this Hancock valve was partially covered with hard and milky white pannus which resulted in mitral stenosis. The tear of cusp was observed at the point of contact with pannus, which resulted in mitral regurgitation. Histologically, pannus was consisted of two-layered structure, fibrin and collagen fiber, which demonstrated this over-growth was based on thrombus. Main causes of bioprosthetic valve dysfunction are calcification and tear of cusps. But, valvular dysfunction due to pannus-formation described in this case has been experienced very rarely.

Anti-HCV was tested in serial serum samples of 20 patients with non-A, non-B post-transfusion hepatitis (NANB-PTH) who had been followed for more than 3 years after the onset. The rate of chronicity of disease was significantly higher in anti-HCV positive patients (12 out of 14, 85.7%) than in anti-HCV negative patients (group 1) (1 out of 6 patients, 14.3%). Among 14 anti-HCV positive patients, 7 lost anti-HCV during the follow-up period (group 2) and 6 of these 7 patients revealed normalization of liver dysfunction before or after the disappearance of anti-HCV. To the contrary, remaining 7 patients whose anti-HCV sustained positive (group 3) did show persistent abnormal liver function tests. Anti-HCV titer was significantly higher in group 3 than in group 2 at the point of 1 year after PTH. The titration of anti-HCV at 1 year after the onset of PTH was thought to be useful for estimating the prognosis of patients with post-transfusion hepatitis type C.

The prevalence of hepatitis C virus (HCV) infection in patients with long-term hemodialysis (HD) in Japan was assessed using an Ortho HCV Antibody ELISA TEST system. Out of 51 patients, 48 of whom had a history of blood transfusions, 15 (29%) were positive for anti-HCV. This figure is much higher than that in other countries (1-20%), and the difference may reflect a select population. Six (33%) of 18 HD patients with chronic hepatic disease were anti-HCV positive. On the other hand, the prevalence of hepatitis B virus (HBV) markers was 39% (20/51), and 7 (35%) of these 20 with HBV markers were also positive for HCV. The prevalence of anti-HCV showed no relation to the duration of HD treatment. Although a correlation between the prevalence and the blood units transfused was not demonstrated, anti-HCV positive patients had received blood transfusions amounting to significantly more units than those given to negative patients. Anti-HCV was detected in approximately one-third of patients with long-term HD, indicating a lower prevalence of HCV infection as compared to that of HBV infection, and patients with hepatitis of type C accounted for about one-third of HD patients with chronic hepatic disease.

Left ventricular free wall rupture secondary to acute myocardial infarction is almost invariably fatal. This report is the case presentation of a successful repair of left ventricular free wall rupture. A 55-year-old man, with a diagnosis of acute infero-lateral myocardial infarction, was transferred from another hospital to our CCU having recurrent chest pain on the fourth day after infarction. Shortly after admission, he lost his consciousness and fell into cardiogenic shock. Echocardiography showed a large pericardial fluid. He was immediately transferred to the operating room with the diagnosis of the heart rupture. After opening the pericardium containing 200 cc of blood, cardiac tamponade was relieved. The posterolateral portion of the left ventricle was found to be bluishly discolored, with a 8 mm-long tear of epicardium. Using cardiopulmonary bypass, the tear was closed with Teflon-reinforced sutures. The post-operative course was uneventful.

This is a report of the management of a patient with chronic idiopathic thrombocytopenic purpura (ITP) and ischemic heart disease. High-dose transvenous gamma-globulin therapy (400 mg/kg/day for five days) was started five days prior to operation, yielding an increase in platelet count from 5.8 X 10(4)/mm3 to 12.8 X 10(4)/mm3. Platelet transfusion was used at the end of cardiopulmonary bypass and on the first postoperative day. There were no problems with hemostasis during the operative procedure and the postoperative course was uneventful. We prefer high-dose transvenous gamma-globulin therapy for ITP prior to open heart surgery as a treatment of choice.