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Recurrent aphthous ulceration (RAU) is considered to be an acute inflammatory disease of unknown pathogenesis. Apoptosis may represent an important event in the control of inflammation.The aim of this study was to investigate apoptosis process in RAU using immunohistochemistry.We studied the expression and location of p53, bcl-2 and bax in ulcerated lesions clinically diagnosed as RAU (n = 12) and compared it with that of oral clinically normal mucosa (n = 6) and of other inflammatory chronic disease such as oral fibrous inflammatory hyperplasia (FIH; n = 18).Significant statistically differences (n0.05) in p53 expression were noticed in RAU when compared with normal mucosa. No significant statistically differences (P0.05) were noticed between FIH and RAU. Bcl-2 and bax did not show remarkable differences between groups.Taken together, the data suggest that RAU induces p53 immunoexpression. Therefore, the protein might be related to the aetiopathogenesis of the ulcerated oral lesions.

Oxidation and other modifications of serum low-density lipoprotein (LDL) are associated with the development of atherosclerosis, and a scavenger receptor and CD40 signalling are also known to play important roles in the process. We previously showed that the Src family protein-tyrosine kinase Lyn is physically and/or functionally associated with macrophage type-I and type-II class-A scavenger receptors (MSR-A) and CD40. In this study, we addressed whether Lyn is involved in the build-up of serum lipid levels and in atherosclerotic changes. When fed a normal diet, lyn-deficient mice had serum lipid levels that were no different from those of wild-type mice. By contrast, lyn-deficient mice fed a high-fat diet showed serum lipid levels that were much higher than those seen in wild-type mice. Curiously, however, the lyn-deficient mice fed either diet showed no increase in incidence of atherosclerotic lesions compared with wild-type mice. This may be partly explained by our data showing suppression of proliferation of peritoneal macrophages in response to oxidized LDL in the absence of Lyn, and failure of stimulation of the CD40 pathway in lyn-deficient macrophages to induce expression of monocytic chemoattractant protein-1 (MCP-1), which is related to atherosclerosis. These results suggest that Lyn plays an important role in the metabolism of serum lipids and in the development of atherosclerotic lesions on high-fat diets.

The pathogenic role of hyperlipidemia in long-standing nephrotic syndrome (NS) is known to be responsible for both the progression of glomerulosclerosis and tubulointerstitial injury, especially in focal segmental glomerulosclerosis (FGS).Aggressive lipid lowering treatment by low density lipoprotein (LDL) apheresis (LDL-A) using a dextran sulfate cellulose column to treat patients with steroid-resistant or frequently recurrent severe NS was performed first without fixing the protocol in eight patients with FGS and one with minimal change nephrotic syndrome (MCNS). The period of NS before LDL-A, number and average intervals of LDL-A until the end of the therapy, and the prognosis were investigated. Next, a multicenter study with a fixed protocol of LDL-A treatment was designed in combination with steroid therapy for treatment twice a week for three weeks and weekly for six weeks, and was performed in 17 patients with FGS. The effects on the state of NS in addition to the change of urinary eicosanoid metabolites and remission rates were evaluated.In the preliminary study, along with a rapid improvement of hyperlipidemia, a high incidence of remission was achieved by LDL-A performed at relatively short intervals. In the multicenter study with a fixed protocol, there was a significant decrease of urinary protein (P0.001) and increase of serum albumin (P0.02) as well as a decrease of thromboxane B2 (TXB2) excretion (P0.05) after the treatment. Urinary excretion of TXB2 was significantly reduced after LDL-A (P0.05). The rate of entering into complete or incomplete remission was 71% with a relatively short duration of nephrotic-range proteinuria using the LDL-A therapy in comparison with steroid therapy alone.The rapid improvement of hypercholesterolemia with LDL-A treatment may provide a new approach for a high rate of improvement in the degree of NS in steroid-resistant NS of FGS and MCNS.

We report a case of fatal bowel necrosis possibly caused by pulsatile cardiopulmonary bypass (CPB). An 80-year-old female underwent emergency coronary artery bypass grafting (CABG) for unstable angina. Pulsatile CPB was applied because of stenosis of bilateral carotid and renal arteries. On the third postoperative day, total bowel necrosis due to acute mesenteric ischemia was revealed at emergency laparotomy before her death. Pulsatile CPB may increase the risk of distal embolism of dislodged plaque in cases with severe aortic atheromatosis.

Surgical treatment for congenital aortic regurgitation (AR) with ventricular septal defect (VSD) in pediatric patients carried out between 1979 and 1994 was reviewed. Aortic commissural valvuloplasty (AVP) was performed on prolapsed cusps in 34 patients (mean age 6.3 +/- 3.3 years (range: 2 to 24 years) with AR and VSD. The preoperative grade of AR was 2.6 +/- 0.8 measured angiographically by Sellers' classification. Patients had greater than moderate AR in conjunction with subpulmonary (n = 16), perimembranous (n = 15) or mixed type VSD (n = 3). In total, 25 right coronary cusps (RCC), five non-coronary cusps (NCC) and one left coronary cusp were repaired. In two cases, both RCC and NCC were plicated. One case had bicuspid valve and both cusps were repaired. There were no operative or late deaths. Moreover, the AR grade of the 25 cases has been below mild during a mean of 11.3 years follow up, though seven cases (22%) have developed above moderate AR. The two cases with persistent AR required redo AVP, with one having aortic valve replacement eventually after redo surgery. The operative findings showed cusp perforation on the repair site, or cusp elongation. However, the overall event-free rate analyzed by the Kaplan-Meier method was sufficiently favorable, with 96.6 +/- 3.4% for 5 years and 92.8 +/- 4.9% for 10 years. We conclude that aortic valvuloplasty for aortic regurgitation and VSD in pediatric patients is beneficial, with low mortality and reoperation rates.

From 1981 to 1996, 48 consecutive patients, aged range 1 to 72 years, underwent surgical treatment for infective endocarditis. The infection was in the aortic valve in 10 patients, the mitral valve in 17, the aortic and mitral valves in 7, mixed aortic, mitral and tricuspid valves in one, the tricuspid valve in 9, the pulmonary valve in 3, and the other in 2, thirty-seven patients had native valve endocarditis (NVE) of which 22 cases were in the active stage. Seven cases had active prosthetic valve endocarditis (PVE) and 4 had VSD patch infection. The overall hospital mortality rate was 14.6% (7/48). The hospital mortality rate of NVE was 2.7% (1/37) and that of active NVE was 4.5% (1/22). That of PVE was 71.4% (5/7) and one of 4 cases with VSD patch infection was lost, so the mortality rate of the prosthetic material infection was 54.5% (6/11). Only 1 patient required reoperation for persistent infection. There were 2 late deaths caused by noncardiac disease. Thirty-nine of the total IE patients are now survived. These data demonstrate excellent results in patient with NVE undergoing the surgical treatment at the early phase, and support the premise that patients with active PVE should have also early surgical intervention.

We report a 46-year-old woman who has been suffered from myasthenia gravis and underwent thymomectomy in December 1988. Her myasthenic symptoms improved by treatment with corticosteroid and azathioprine; the latter drug was administrated for more than one year. She noticed weight gain of 10 kg and edema in both legs and feet, which developed acutely in August 1994. Laboratory data showed that she suffered from nephrotic syndrome with a large amount of proteinuria (15 g/day). Renal biopsy revealed that biopsied glomeruli showed early stage of membranous nephropathy associated with acute tubular necrosis. Although therapeutic trials of steroid pulses could not eliminate proteinuria, substitution of cyclophosphamide for azathioprine brought marked improvement of the nephrotic syndrome with disappearance of the urinary protein excretion within 10 days. From reports of similar cases with myasthenia gravis in Japan and in Europe, therapeutic usage of azathioprine in patients with myasthenia gravis associated with thymoma should be cautious for appearance of nephrotic syndrome when azathioprine is continued for more than one year.

We report surgical treatment of double-orifice mitral valve (DOMV) associated with incomplete-type endocardial cushion defect. All three cases had "central type DOMV classified by Cascos" with bridging tissue between two mitral orifices. We closed mitral cleft in the two cases with moderate mitral regurgitation, although we left the bridging tissue. It is thought to be beneficial to leave the bridging tissue undivided to avoid postoperative mitral regurgitation in such cases.

We report successful aortic arch replacement using continuous retrograde cerebral perfusion (CRCP) for the three cases of ruptured distal aortic arch aneurysm (DAAA) into the left lung. All of them, who had preoperative episodes of hemosputum and hemoptysis, were diagnosed rupture of DAAA into the lung with computed tomography, magnetic resonance image, aortography or transesophageal echo. Following urgent graft replacement of the aortic arch or repair of the rupture on the suture line in the previous arch vessel reconstruction was carried out safely through median sternotomy approach. The left upper lobe of lung adherent tightly to the DAAA wall was not dissected to prevent the lung from bleeding, air leakage and infection. All of them, who awoke smoothly after CRCP, did not developed any pulmonary complications and survived uneventually. We concluded that median approach and not tearing lung from DAAA wall might be key-points for successful operation in cases of ruptured DAAA into lung and that CRCP is an safe and useful method to protect brain in such cases.

The clinical significance of the chordae tendinae regarding postoperative left ventricular performance was evaluated in 148 patients with mitral regurgitation or mitral stenosis who underwent either mitral valve replacement using St. Jude Medical valve with complete chordal preservation, or with conventional mitral valve replacement, or valve repair. Mitral valve replacement preserving the autologous chordae tendinae (n = 28) or replacing them with Gore-Tex sutures (n = 16) was performed in 44 patients, 24 with mitral regurgitation and 20 with mitral stenosis. Their hemodynamic parameters were compared to those of patients who underwent conventional mitral valve replacement involving 25 with mitral regurgitation and 28 with mitral stenosis, or who underwent valve repair in 24 with mitral regurgitation, or commissurotomy in 27 patients with mitral stenosis. The LV performance was analyzed by cineangiography in the early (mean 1.2 months), and by multiple gated blood scintigraphy (MUGA), or echocardiography (UCG) in the late postoperative periods (mean 5.4 years) in the three groups of patients. In the mitral regurgitation group, the LV ejection fraction (EF) was unchanged in the chordal preserved group, but it was decreased in the conventional replacement and repair groups. The LV contractility index was better in the chordal preserved than in the conventional group. Both the LVEF by MUGA, and LV fractional shortening (FS) by UCG were significantly higher after chordal preservation or repair than after conventional valve replacement. The chordal preserved group exhibited superior LV performance than the conventional group, especially in those with mitral regurgitation and depressed preoperative left ventricular function (EF0.50). There were no significant difference between the three groups in patients with mitral stenosis. The results support the concept that maintenance of continuity between the mitral annulus and the papillary muscle has a beneficial effect on postoperative left ventricular performance, especially in patients with mitral regurgitation and depressed preoperative left ventricular function, but had no major effect in patients with mitral stenosis.

We report a rare case of coronary artery perforation by a guide wire for percutaneous transluminal coronary angioplasty (PTCA) complicating with postinfarction cardiac rupture (oozing type). The patient had acute myocardial infarction on the extensive anterior wall and developed cardiac rupture followed by serious cardiac tamponade during the emergency PTCA several hours after tissue plasminogen activator (t-PA) given intravenously. The meandering left anterior descending artery (LAD) was found injured by a PTCA guide wire apart from a small oozing-type cardiac rupture near the apex. We repaired urgently the perforated LAD as well as the ruptured left ventricle. It is thus suggested that coronary artery perforation by a PTCA guide wire may occur on meandering coronary arteries and develop a serious hemorrhagic complication, particularly after thrombolytic therapy.

In relation to the aortic arch operation, atherosclerotic lesions in this area was investigated in autopsy specimen. Fifty specimens of the aorta with severe atherosclerotic lesions were chosen from 182 autopsies of patients older than 70 years at Tenri Hospital. The aortic arch and the adjacent aorta were divided into 9 segments (three portions around orifices of the arch tributaries [1-3], the ascending aorta proximal to the branchiocephalic artery [4], the descending aorta distal to the left subclavian artery [5], and 4 portions of the aortic arch which consisted with proximal anterior [6], distal anterior [7], proximal posterior [8], and distal posterior wall [9]) as shown in the figure. The degree of atherosclerosis was scored by Gore-Tejada atherosclerosis index (ASCI). The ASCI of the arch (12.7) was significantly higher than the ascending aorta (5.3). (p0.05). Among 9 segments of the aortic arch, the ASCIs of the anterior wall of the distal arch (25.1), the aorta distal to the left subclavian artery (17.3), the arch around the orifice of the brachiocephalic artery (17.1) were significantly higher. The ulcerative plaques were predominantly found at the anterior wall of the distal arch (36%). On the other hand, the calcified plaques were predominantly found around the orifice of the brachiocephalic artery (26%). Ten specimens demonstrated significant stenosis at the orifice of the left subclavian artery. From this autopsy study, the degree of atherosclerotic lesion was predominant at the anterior wall of the distal aortic arch and at around the orifice of the brachiocephalic artery.(ABSTRACT TRUNCATED AT 250 WORDS)

From April 1979 to October 1993, 126 adult patients underwent reoperative cardiac valve surgery. Patients were divided into two groups: 53 patients who underwent surgery before January 1990 (group 1) and 73 patients who underwent surgery after January 1990 (group 2). After January 1990, a clinical strategy for reducing homologous blood transfusions was implemented, including the use of predonation of autologous blood in the operating room, reduced heparin doses, an elevated threshold of indication for blood transfusion, and autotransfusion of shed, drained blood after surgery. In group 1, 44 patients (93.0%) received an average of 3785 +/- 1251 ml of homologous blood transfusions. In group 2, only 26 patients (35.6%) needed homologous blood transfusions and had a smaller amount (2985 +/- 1521 ml) on average. Furthermore, only seven patients needed fresh blood transfusion in group 2.

Bacteriological and clinical studies were carried out on staggered intensive chemotherapy regimen for methicillin-resistant Staphylococcus aureus (MRSA) infections combined with Gram-negative opportunistic pathogens as polymicrobial infections. The regimen consisted of administering ceftazidime (CAZ) 30 minutes after infusion of arbekacin (ABK) and a bolus injection of fosfomycin (FOM). The combination of these drugs strongly inhibited the growth of MRSA and Pseudomonas aeruginosa. By this combination treatment, both of MRSA and P. aeruginosa in mixed culture became more susceptible to killing by macrophages. We evaluated the clinical efficacy and safety of combination of ABK, FOM and CAZ in the treatment of 15 patients with MRSA infections. The total efficacy rate was 80.0% and the bacterial eradication rate of MRSA was 60.0%. It is considered that staggered intensive chemotherapy with ABK, FOM and CAZ is useful for such polymicrobial infections involving MRSA.

The purpose of this study was to examine if anterior chamber tumors could be eliminated by adoptive immunotherapy.Precursor T cells were recovered from lymph nodes draining subconjunctival space or anterior chamber tumors and restimulated in vitro to obtain fully functional tumor-specific CD8+ cytolytic T cells.Subconjunctival space tumor-derived cytolytic T cells eliminated tumors completely when injected simultaneously into the eye with the tumor cells, or when the anterior chamber injection was delayed for up to 3 days. In vitro restimulated cytolytic T cells obtained from lymph nodes draining progressively growing anterior chamber tumors were as effective as those obtained from lymph nodes draining subconjunctival space tumors, indicating that mice with anterior chamber tumors possess precursor cytotoxic T cells with the potential to differentiate into cytolytic T cells capable of eliminating intraocular tumors. By determining the frequency of tumor-specific cytolytic T cells in the effector cell inocula, it was estimated that cures of intraocular tumors are possible when the ratio of cytolytic T cells to tumor cells is less than 1:50, and the total tumor burden at the time of adoptive immunotherapy is less than 80,000 viable tumor cells.It was concluded that terminally differentiated, antigen-specific, cytotoxic T cells injected directly into an intraocular tumor site are capable of eliminating the tumor, and may represent a mode of ocular tumor immunotherapy in the future.

Deep hypothermic circulatory arrest (DHCA) was introduced as an adjunct for operations involving aortic arch lesions in 1970's and has since been widely used. Profound hypothermia protects the brain and other vital organs by reducing metabolic rate. We initiated the use of continuous retrograde cerebral perfusion (CRCP) via the superior vena cava during DHCA in 1987. We studied 15 patients who required DHCA and CRCP during repair or replacement of the aortic arch. CRCP times ranged from 11 to 78 (mean +/- S.D.; 37.3 +/- 21) minutes, and minimal nasopharyngeal temperatures ranged from 13.7 to 25 (17.7 +/- 2.6) degrees C. Two patients died one month postoperatively due to preoperative disease. Three patients, who were in shock preoperatively due to cardiac tamponade, developed acute renal failure postoperatively. The remaining patients were weaned from the respirator by the 2nd postoperative day. No patient had CRCP-related complications. During CRCP, the partial pressure of oxygen (PO2), saturation of oxygen (SO2), and oxygen content significantly decreased (p0.001), and the partial pressure of carbon dioxide (PCO2) and CO2 content significantly increased (p0.001) between retrogradely perfused blood and blood draining from the arch vessels. These results most probably reflected that the aerobic metabolism of the brain was maintained by CRCP while the central nervous system was maintained in a hypothermic state, with oxygen and substrate availability, wash-out of metabolites, and buffering capacity and oncotic pressure of the blood maintained. This technique offers the potentials of sufficient metabolic support to the brain during DHCA and prolonged safe time limits of DHCA.

The in vitro production of granulocyte/macrophage colony stimulating factor (GM-CSF) by mononuclear cells from the peripheral blood of patients with bronchial asthma (BA) was examined by enzyme-linked immunosorbent assay (ELISA). In 3 of 12 cases studied, mononuclear cells from BA patients produced GM-CSF without stimulation. And in 5 of 12 cases studied, mononuclear cells from BA patients produced GM-CSF in response to IL-2. Mononuclear cells from patients with other diseases (n = 13) and healthy volunteers (n = 6) did not release any detectable (or = 7.5 pg/ml) GM-CSF. The culture media of mononuclear cells from BA patients showed activities for stimulating the proliferation and survival of eosinophils, and these activities were partially inhibited by anti-GM-CSF antibodies. GM-CSF production by mononuclear cells from BA patients treated with prednisolone was lower than that of mononuclear cells from untreated BA patients. And prednisolone showed a reduction in the GM-CSF production from mononuclear cells in response to IL-2. These results suggest that GM-CSF production by mononuclear cells may play a role in the pathogenesis of BA.

DBA/2-derived P815 tumor cells form progressively growing tumors when injected into the anterior chamber (AC) of normal BALB/c eyes. By contrast, P815 cells injected into the subconjunctival (SCon) space of BALB/c mice are promptly rejected. Despite these very different outcomes, both AC and SCon tumors elicit an equal clonal expansion of tumor-specific precursor cytotoxic T cells (pTc) within the draining cervical lymph nodes. Moreover, tumor-specific pTc migrate systemically and infiltrate both AC and SCon tumor-containing eyes. The present study explores the hypothesis that pTc generated in response to AC P815 tumors are less efficient "killers" than their SCon counterparts. To address this issue pTc were restimulated in vitro in the presence of exogenous lymphokines to initiate the terminal differentiation of pTc into fully functional cytotoxic T cells (Tc). Then an assay was developed to evaluate the capacity of AC and SCon CD8+ Tc to eliminate P815 tumor cells growing in vitro, i.e., achieve a "cure." This assay established the day tumor cells were completely eliminated (cure), as well as the rate of tumor cell removal. Using this approach it has been learned that pTc harvested from AC and SCon tumor-bearing mice have the same potential for eliminating P815 tumor cells in vitro. Moreover, the efficiency of achieving an in vitro tumor "cure" was found to be remarkably enhanced if exogenous lymphokines, as a surrogate source of T cell "help," were included in the cultures at the time effector lymphocytes were added to the proliferating tumor target cells. This latter finding emphasizes the need for sustained availability of helper factors in order to maximize the efficiency with which Tc can eliminate tumor cells. We interpret the results to mean that successful rejection of tumors in vivo is likely to turn upon (a) arrival of tumor-specific pTc at the tumor site, (b) delivery of "help" that promotes the terminal conversion of these cells into Tc, and (c) sustained presence of "help" which promotes the efficiency of immune elimination of tumor cells. Since equally large numbers of P815-specific pTc enter AC and SCon tumor sites in BALB/c mice, the failure of rejection in the former may be due to an inability of the host to provide immediate and sustained local T cell help. Implications of these studies for the development of immunotherapies for intraocular tumors are discussed.

The postoperative regional left ventricular motion of 22 patients with a diagnosis of mitral regurgitation, and who underwent mitral valve replacement with preservation of chordae tendineae, were retrospectively analyzed by cineangiography in the early postoperative period and by multiple-gated cardiac blood pool scintigraphy in the mid-to-late postoperative period. The operation consisted of the division of the anterior leaflet into anterior and posterior segments, the shifting and reattachment of the divided segments to the mitral ring of the respective commissural areas, and the use of a low-profile bileaflet prosthetic valve. Control groups consisted of 28 patients with mitral regurgitation who underwent mitral valve replacement with a conventional technique and 16 patients who underwent mitral valve repair. Compared with the conventional mitral valve replacement group, the radial shortening of the left ventricle of the chordae-preserved mitral valve replacement group was greater at the apical septal, inferoapical, anterobasal, and anterolateral portions, whereas the radial shortening of the repair group was greater than that of the chordae-preserved group only at the inferolateral portion. The ejection fraction of the whole left ventricle was statistically greater in the chordae-preserved group, and also regional ejection fraction of the chordae-preserved mitral valve replacement group was greater at the apical septal, inferoapical, inferolateral, anterobasal, and anterolateral portions than that of the conventional mitral valve replacement group at these portions. On the other hand, the postoperative regional and global motion was identical to that of the mitral valve repair group except at the inferolateral portion. The result of this study supports a concept that maintenance of continuity between the mitral anulus and the papillary muscle has a beneficial effect on postoperative left ventricular performance.

We conducted a multiple-center joint study on the effects of recombinant human erythropoietin (rEPO) for predialysis patients. rEPO was intravenously administered to 42 predialysis patients (13 males and 29 females) with hematocrit (Ht) levels of less than 30%. The subjects were divided into group A (28 cases) in which rEPO was administered twice a week, and group B (14 cases) with rEPO administration once a week. The initial administration dosage was 6000IU/week. The Ht levels were 22.6 +/- 3.3% for group A and 23.2 +/- 2.7% for group B before the administration of rEPO, and increased to 31.0 +/- 4.0% and 27.7 +/- 3.7% respectively twelve weeks after initiating administration. The levels of effective improvement on anemia included 'markedly effective' in 17 cases (80.9%) and 'effective' in 2 cases (9.5%) in group A, and 'markedly effective' in 5 cases (41.7%) and 'effective' in 3 cases (25.0%) in group B. No significant change was seen in serum creatinine (Cr) levels during the study period. In the evaluation of renal function by reciprocal serum creatinine (1/Cr), a consistent tendency was not recognized; thus, suggesting that the rEPO administration had no effect on the renal function. No variation of blood pressure was seen. As far as side effects were concerned, headache and heavy headedness were recognized in four cases. There were, however, no cases in which the severity of the side effects dictated the discontinuation of the rEPO administration. In conclusion, rEPO was judged to be a safe and effective treatment for the anemia of predialysis patients.

The lymphocyte subunits and subsets of 12 patients with Vogt-Koyanagi-Harada disease (VKH disease) were characterized using two-color flow cytometry techniques, both in cerebrospinal fluid (CSF) and in peripheral blood (PB). Soluble interleukin-2 receptor (sIL-2R) levels and interleukin-6 (IL-6) levels were also measured. The percentage of T cells was significantly higher in CSF than in PB (P less than 0.01), but the percentage of B cells was decreased in CSF (P less than 0.05). As for T-cell subsets, the percentage of helper T cells was especially high in CSF (P less than 0.01). Also, the ratio of helper T cells/suppressor T cells was significantly larger in CSF than in PB. These data suggest that helper T cells play an important role in the early stages of VKH disease. sIL-2R and IL-6 levels were not elevated in CSF of patients with VKH disease. The level of sIL-2R in serum also was not elevated.

A 5-year-old girl presented infected tricuspid valve related to a residual ventricular septal defect. Antibiotic therapy produced a satisfactory initial improvement. However, subsequent deterioration with uncontrolled infection, in spite of alterations of the antibiotic regime, necessitated surgical intervention. Because the lesion was localized to the anterior leaflet of the tricuspid valve, partial excision of this leaflet and patch was undergone with a sustained clinical improvement with minimum residual valvular incompetence. This experience supports the concept that tricuspid valvuloplasty is the method of choice in the treatment of patient with regional right-sided infective endocarditis.

Between 1987 to 1990, six patients underwent replacement of the ascending aorta and aortic valve with a composite graft which was not wrapped with aneurysmal aortic wall; annuloaortic ectasia in 4, aortitis with acute onset of aortic regurgitation in 1, and acute aortic dissection with aortic regurgitation in 1. In 2 patients, "open aortic anastomosis" under deep hypothermic systemic circulatory arrest and retrograde cerebral perfusion was utilized for distal anastomosis of the graft to the resected aortic arch. Three patients required no transfusion. One patient with annuloaortic ectasia and severely dilated left ventricle died from ventricular fibrillation in ICU. One patient with aortitis died from stroke due to occlusion of bilateral carotid arteries 3 years postoperatively. The other 4 patients are alive and favorable. It is our belief that this technique still maintains simplicity and facilitates the secured anastomosis and minimized bleeding.

A case of delayed hemolytic transfusion reaction (DHTR) caused by blood transfusions after open heart surgery was reported in a 61-year-old woman. She had undergone mitral annuloplasty 8 years before. She underwent the 2nd mitral and tricuspid annuloplasty for recurrent mitral and tricuspid regurgitation in 1988. After the reoperation, she developed severe hemolytic anemia with fever. The anti-Jka antibody was detected in her serum by the blood antibody screening test. She was diagnosed to have a DHTR. She was treated conservatively and recovered.

A rare case of left atrial myxoma associated with ruptured chordae tendineae is presented. The patient was 70-year-old woman, and was diagnosed to have a left atrial myxoma. The myxoma was extirpated together with the atrial septum from which tumor developed. After removal of the myxoma, a ruptured strut chordae tendineae of anterior leaflet was also detected and resutured to the original papillary muscle. The cause of the torn chordae is presumed to be so-called "wrecking ball effect", and to be myxomatous degeneration of the valve.

Recently we replaced the ascending aorta and aortic arch in 8 patients with aneurysm or dissection, using profound hypothermic circulatory arrest with retrograde cerebral perfusion. There were no operative deaths. Open aortic anastomosis facilitated repair of the aortic arch without clamping the arch tributaries, and embolism due to particulate debris from clamping of the arch vessels was eliminated. Retrograde cerebral perfusion during profound hypothermic circulatory arrest is a simplified technique that may protect the brain. This method offers advantages over previously described methods, particularly in obviating dissection of the arch tributaries and the clamping thereof, and in protecting the central nervous system.

We report a case of 47-year-old woman with an isolated deficiency of adrenocorticotropic hormone. She was admitted complaining of fatigue and frequent loss of consciousness. The patient developed severe hyponatremia (100 mEq/l) after five days of the admission. Her plasma renin activity and plasma aldosterone concentration were low though she was dehydrated. After the treatment of dehydration, plasma osmolality was low but high plasma antidiuretic hormone (ADH) level sustained. Both high urinary sodium excretion and low urinary aldosterone excretion still remained after one month of replacement therapy with prednisolone. But, glomerular filtration rate and a response of urinary volume to acute water loading were normalized. These results suggested that severe hyponatremia of the patient was caused by an inappropriate secretion of ADH and suppression of renin-aldosterone system. We consider the suppression of renin-aldosterone system was partially independent of an inappropriate secretion of ADH.

The efficacy, safety, and pharmacokinetics of carvedilol were investigated in an open trial performed on six patients with hypertension and chronic renal failure requiring hemodialysis. The plasma level of unchanged carvedilol after a single dose of 10 mg reached a peak 1-5 h after administration both on days with and without hemodialysis. The drug was gradually metabolized thereafter and had almost disappeared from the plasma after 24 h. Blood pressure was lowered by carvedilol both on days with and without hemodialysis. No carvedilol passed through the dialysis membrane. During the 4-week administration period of carvedilol at 10 mg/day, assessment of plasma samples taken just prior to early morning administration demonstrated no drug accumulation. Blood pressure was well controlled during the administration period. Tolerance to the antihypertensive effect was not observed. Heart rate was not significantly changed at any time. There were no side effects in any of the patients during the trial, and laboratory parameters remained unchanged. These results indicate that carvedilol is a safe and effective antihypertensive agent for use in patients on chronic hemodialysis.

A total of 20 patients underwent mitral valve replacement (MVR) with preservation of the papillary muscles (PM) and chordae tendineae (CT) with the object of maintaining left ventricular contractility and decreasing the risk of left ventricular rupture after surgery. The patients comprised of 8 males and 12 females whose ages ranged from 33 to 67 years. In 8 patients, the posterior leaflet was left in place and in 12, the CT to the anterior leaflet were also preserved by excision of the central portion and reattachment of the rest of the leaflet to the appropriate commissural regions. St. Jude Medical valves were exclusively employed as a substitute. Reasons for MVR were isolated MR in 12 cases, MRs in 5 and MSr in 3. There were one operative, one hospital and one late death respectively. Postoperative C.I. increased from 2.65 +/- 0.48 to 3.8 +/- 0.75 ml/min./M2 and LVEF increased from 55.1 +/- 11.4 to 63.4 +/- 13.4%. The area method showed marked improvement of segmental wall motion in anterolateral regions. Chordal shortening also disclosed improvement in long axis. Preservation of papillary muscles and chordae tendineae during MVR has been found to have a beneficial effect on postoperative left ventricular contractility.

The percentage and absolute numbers of thymos-dependent (T) and thymos-independent (B) peripheral blood lymphocytes, the in vitro response of lymphocytes to phytohemagglutinin (PHA), and the sensitization with 2,4dinitrochlorobenzene (DNCB) was studied in 26 patients with hyperthyroidism due to Graves' disease. The results showed a normal percentage of both T and B cells and increased absoluted numbers of total lymphocytes in patients compared with 30 healthy controls. The in vitro response to PHA was normal in most patients with the exception of 5 of them who showed an impaired response. All patients developed a reaction of delayed hypersensitivity to DNCB. Our study indicated that there is no general abnormality in cell-mediated immunity in Graves' disease.

An atypical huge patent ductus arteriosus (PDA) associated with extreme pulmonary hypertension in a 6-month old female infant was reported. The left 3rd intercostal thoracotomy revealed huge PDA which has an appearance of pulmonary-ductus-descending aorta-trunk (PDDT) on the left side. The right side of the ductus continued to the aortic arch without demarcation between the ductus and the aorta. The median sternotomy clarified the ascending aorta, normal aortic arch, and main pulmonary artery. However, the top of the main pulmonary artery seemed to be fused with the aortic arch. The diagnosis of distal type of aortopulmonary window with wide communication was made and the total circulatory arrest with deep hypothermia and the intracavitary patching for separation of systemic and pulmonary blood flow seemed to be required for the complete repair. Total repair was decided to be postponed one week later and the chest was closed. The patient died of multi-organ failure originating from acute respiratory failure 23 days after exploratory thoracotomy without being repaired. Postmortem examination revealed a huge PDA freely communicating with the ascending aorta and the aortic arch. This is a report of an atypical huge PDA rarely seen and the conventional division or ligation is unfeasible. The circulatory arrest with deep hypothermia and intracavitary patching are obligatory for the surgical repair.