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Multicystic mesothelioma is a well recognized but rare serosal tumor which mainly arises from the peritoneum in women and is considered as a benign lesion. This is the second case report of pericardial multicystic mesothelioma, which took a fatal clinical course. A 63-year-old man presented with pitting edema, shortness of breath, and hoarseness. Radiological investigations revealed solid and cystic tumor of the pericardium which was continuously extending into the mediastinum and the liver. Pericardial biopsy showed micro-cystic tumor lined by single layer of mesothelial cells without atypia, and the diagnosis was multicystic mesothelioma. Curative surgery could not be performed, and three years and four months later, the patient died because of the direct compression of the heart by the tumor. At autopsy, the tumor was found to be directly extending into the right pleural cavity and the right lung, besides the mediastinum and the liver. Neither malignant transformation nor metastatic tumor was identified.

A 78-year-old man was referred to our department with a one-week history of dyspnea and coughing. A chest X-ray showed massive left pleural effusion. Computed tomography revealed diffuse irregular thickening of the left pleura similar to malignant mesothelioma and multiple nodules in both lungs. The patient died of respiratory failure nine days after hospitalization. An autopsy revealed metastasis to the pleura and lungs from urothelial carcinoma of the left kidney.

Esophageal complications occur after hematopoietic stem cell transplantation (HSCT). There are, however, only limited reports on the etiology or management of esophageal complications. Here, we report the occurrence of intramucosal hematoma presenting continuous esophageal hemorrhage in a 34 year-old man following the second peripheral blood stem cell transplantation for acute myeloid leukemia. His hematemesis started 2 months after HSCT and was repeated in supportive care. On day 156, he underwent total esophagectomy as a result of uncontrollable massive hematemesis. Histopathological testings of the resected esophagus confirmed intramucosal hematoma as a cause of hematemesis. This case highlights intramucosal hematoma as one of the important etiologies of esophageal complications following HSCT.

Background Gastric cancer (GC) is a common cancer globally. miRNA-21 (miR-21) appears to be important in the tumourigenesis of almost all types of human cancer. However its precise localization in GC has yet to be clarified. We thus examined miR-21 localization in GC and revealed its clinicopathological importance. Methods Tissue arrays of 469 GCs from 454 patients were examined for miR-21 using in situ hybridization (ISH). The positivity was evaluated separately in tumour cells and stromal cells. Conventional sections of 10 GCs were also stained. Eight cases were examined by quantitative RT-PCR (qRT-PCR). Results miR-21 was highly expressed in tumour cells of 44% of cases and in cancer stroma of 51% of cases. miR-21 of tumour cells was not related to clinicopathological factors, whereas stromal miR-21 was related to many factors including tumour stage, size, and nodal metastasis. Stromal miR-21 gradually increased during tumour progression. ISH of whole sections showed stronger stromal positivity in invasive areas with desmoplastic reaction. Cancer stroma also showed higher miR-21 expression than tumour and non-tumourous tissue in the qRT-PCR study. Conclusion Stromal miR-21 is closely related to tumour progression in GC. Stromal miR-21 of tumours might be a target of treatment.

We report the case of a 58-year-old man who underwent emergency one-stage hybrid repair for multiple thoracic aortic aneurysms involving giant arch and ruptured descending aortic aneurysms. Retrograde thoracic endovascular aortic repair for the ruptured descending aortic aneurysm was first performed to stabilize the hemodynamics. Then, a total arch replacement with an open stent graft, which was inserted into the previous stent graft of the descending aorta in a sutureless telescoped fashion, was performed without any technical problems. This procedure may be one useful therapeutic option for multiple thoracic aortic aneurysms, especially for emergency cases requiring one-stage repair.

BACKGROUND Inflammatory cytokines may play an important role in the pathogenesis of atherosclerosis and heart failure. We have previously demonstrated that long-term treatment with interleukin (IL)-1beta in the coronary artery and myocardium promotes coronary arteriosclerosis and impairs cardiac function, respectively. The cytokines in pericardial fluid may reflect the extent of coronary atherosclerosis and may also directly promote the atherosclerotic process. This study was designed to examine the significance of cytokine concentrations in pericardial fluid of patients with cardiovascular disease. METHODS We measured concentrations of 10 major cytokines in the pericardial fluid of 56 consecutive patients obtained during open heart surgery, 27 with ischemic heart disease (IHD group), 21 with valvular heart disease (VHD group) and eight with congenital heart disease (CHD group). RESULTS The pericardial concentrations of IL-1beta (pg/ml) were significantly higher in the IHD group (60 +/- 15) than in the VHD (29 +/- 5) or the CHD group (26 +/- 4) (P < 0.05 both). There was no significant difference in pericardial concentrations of other cytokines among the three groups. In the IHD group, the IL-1beta concentrations were significantly elevated in patients who had undergone emergency operations or in those with unstable angina. CONCLUSIONS These results suggest that pericardial concentrations of IL-1beta may reflect the extent of ischemic heart disease and that elevated IL-1beta concentrations in pericardial fluid may also directly promote the process of coronary atherosclerosis.

Phosphodiesterase III inhibitors, which have both positive inotropic and vasodilatory effects, occasionally cause hypotension due to afterload reduction and possibly due to preload reduction caused by the increase in vascular capacitance.Six open-chest adult mongrel dogs were used to compare the effects on left ventricular contractility, afterload, and vascular capacitance of the phosphodiesterase III inhibitor, olprinone, with those of dobutamine using a right-heart-bypass model. Contractility and afterload were evaluated by the left ventricular pressure-volume relations with the use of a conductance catheter to derive the end-systolic elastance (Ees) and the effective arterial elastance (Ea). Vascular capacitance change was evaluated by reservoir volume change under a constant bypass flow (80 ml/kg per minute).Ees increased significantly both with dobutamine (7.6 +/- 2.8 to 14.3 +/- 4.8 mmHg/ml, p0.05) and with olprinone (7.6 +/- 2.9 to 11.5 +/- 4.2 mmHg/ml, p0.05). Ea did not change with dobutamine (14.4 +/- 3.5 to 14.5 +/- 3.6 mmHg/ml, p = 0.9), whereas it decreased with olprinone (14.0 +/- 4.1 to 11.4 +/- 3.8 mmHg/ml, p = 0.093). Reservoir volume increased after the infusion of dobutamine (-94.0 +/- 39.8 ml), and decreased after the infusion of olprinone (-114.0 +/- 62.3 ml). The difference was statistically significant (p = 0.007). The reservoir volume change indicated that vascular capacitance decreased with dobutamine, and increased with olprinone.Pre- and afterload reduction of olprinone combined with the positive inotropic effect are useful in treating congestive heart failure and managing low cardiac output syndrome after cardiac surgery.

The aim of this study was to compare the long-term results with the Carpentier-Edwards pericardial bioprosthesis, a second-generation bioprosthesis, and the Hancock porcine valve in the aortic and mitral position. Long-term results of isolated valve replacement with the Carpentier-Edwards pericardial bioprosthesis (73 valves in the aortic position and 73 valves in the mitral position) were compared with those with the Hancock porcine bioprosthesis (41 valves in the aortic and 124 valves in the mitral position). In the aortic position, the mean follow-up period was 8.2±4.0 years with the Carpentier-Edwards pericardial bioprosthesis and 9.9±4.4 years with the Hancock porcine bioprosthesis. In the mitral position, the mean follow-up period was 7.5±4.3 years with the Carpentier-Edwards pericardial bioprosthesis and 10.0±5.3 years with the Hancock porcine bioprosthesis. The results showed that the mean age at implantation was significantly higher in patients with a Carpentier-Edwards pericardial bioprosthesis (58±13 years in the aortic and 51±15 years in the mitral) than in those with a Hancock bioprosthesis (42±13 years in the aortic and 45±10 years in the mitral). In the aortic position, actuarial freedom from structural deterioration of the Carpentier-Edwards pericardial bioprosthesis was significantly better (85±6% at 13 years) than that with the Hancock bioprosthesis (40±10%,P

Objective: We evaluated long-term results of surgical correction of congenital cardiac anomalies in infancy.Methods: We reviewed cases of 856 patients who underwent complete correction of major cardiac anomalies in the first year of life during last 24 years at our institution, and analyzed results. Surgery involved ventricular septal defect (n=453), tetralogy of Fallot (n=92), atrioventricular canal defect (n=93), and complete transposition of the great arteries (n=218).Results: Operative mortality was 2.2% in ventricular septal defect, 0% in tetralogy of Fallot, 8.6% in atrioventricular canal defect, and 4.1% in complete transposition of the great arteries. Freedom from reoperation at 20 years was 96.5±2.0% and actuarial survival was 94.2±1.3% in ventricular septal defect. Freedom from reoperation at 15 years was 90.5±3.9% in tetralogy of Fallot and 86.6±4.4% in atrioventricular canal defect. Actuarial survival at 15 years was 97.8±1.6% in tetralogy of Fallot, 85.7±3.7% in atrioventricular canal defect, and 89.9±2.2% in complete transposition of the great arteries. Actuarial survival in complete transposition of the great arteries was significantly better in arterial than in atrial switch operations.Conclusions: Total correction of ventricular septal defect, tetralogy of Fallot, atrioventricular canal defect, and complete transposition of the great arteries in infancy was conducted safely, but the incidence of reoperation in late follow-up must be reduced.

Background . The effects of pulsatile flow on endothelium-derived nitric oxide-mediated vasodilation are not fully elucidated in an in vivo model. Methods . A left ventricular assist device was established in 10 anesthetized dogs with a centrifugal pump and an air-driven pneumatic pump. The systemic circulation was subjected to step changes in the frequency of pulse (0, 30, 60, and 120 bpm with a fixed pulse pressure of 50 mm Hg), and in the amplitude of pulse (0, 20, and 50 mm Hg with a fixed pulse rate of 120 bpm). Hemodynamic variables and calculated total systemic vascular resistance were compared before and after the administration of N G -Nitro-L-arginine Methyl Ester (L-NAME) (20 mg/kg). Plasma NO 2− /NO 3− concentration levels were also measured. Results . Total systemic vascular resistance significantly decreased while plasma NO 2− /NO 3− concentration increased in response to the rise in both pulse rate and pulse pressure. However, L-NAME significantly diminished these effects of pulsatile flow. Conclusions . Both the frequency and the amplitude of pulse wave in the systemic circulation are significant independent stimuli for endothelium-derived nitric oxide-mediated vasodilation in vivo.

The effects of quenching rate after a solution treatment on strength and fracture toughness of a 6061 aluminum alloy have been investigated, varying the width of PFZ layer and coarse secondary phase particles at grain boundaries by changing the quenching rate utilizing both water quenching and air-cooling. In-situ observation of the fracture toughness tests was also performed to investigate the effects of such microstructural parameters on crack initiation and propagation behaviors. By decreasing the quenching rate, the width of the PFZ layer increases from about 40 to 310 nm, and density and size of the coarse particles increase at the grain boundaries. Mechanical properties such as tensile strength, 0.2% proof stress, elongation, fracture toughness and crack propagation resistance are decreased simultaneously. Especially, the effects of quenching rate on the strength and the crack propagation resistance are remarkable. Such degradation of the mechanical properties is attributed to expansion of the PFZ layer with decreases in quenching rate. It causes localization of plastic deformation, and consequently, transition of fracture mechanisms from grain interior ductile fracture to grain boundary ductile fracture at the PFZ layers. In-situ SEM observation reveals that the effects of the coarse particles at grain boundaries are much less effective than those of the PFZ.

The conductance catheter is widely used for the continuous measurement of the left ventricular (LV) pressure - volume loops. Cyclical change of the right ventricular (RV) volume may alter the parallel conductance volume, thereby affecting the LV mechanical parameters. Using 8 open-chest adult mongrel dogs, multiple LV pressure - volume loops were obtained by 2 methods: first with a vena cava occlusion (VCO) method, which involved RV volume alteration, and second with a right-heart-bypass (RHB) preparation, which decompressed the right ventricle completely. The slope of the end-systolic pressure - volume relation (Ees), the end-systolic volume associated with the end-systolic pressure of 100 mmHg (V100,es), stiffness constant (β), and the end-diastolic volume associated with the end-diastolic pressure of 9 mmHg (V9,ed) were calculated from each loop. There was minimal influence from RV volume alteration on systolic-phase indices [Ees (VCO method, 6.37±1.91 mmHg/ml; RHB preparation, 6.60±1.66 mmHg/ml; p=0.356), and V100,es (VCO method, 18.4±9.3 ml; RHB preparation, 17.8±9.0 ml; p=0.681)], but there was a significant influence on diastolic-phase indices [β (VCO method, 0.0599±0.0152; RHB preparation, 0.0839±0.0150; p=0.007), and V9,ed (VCO method, 35.6±11.3 ml; RHB preparation, 31.9±12.3 ml; p=0.001)]. The increase in the RV volume in the diastolic phase increased the parallel conductance volume, causing overestimation of the LV diastolic volume measured by the conductance catheter. (Jpn Circ J 2001; 65: 749 - 752)

Although protein arginine methyltransferase 5 (PRMT5) has been implicated in various cancers, its expression pattern in lung adenocarcinoma cell lines and tissues has not been elucidated enough. In this study, microarray analysis of 40 non-small-cell lung carcinoma cell lines showed that PRMT5 was a candidate histone methyltransferase gene that correlated with epithelial-mesenchymal transition. Immunocytochemical analysis of these cell lines indicated that the expression of PRMT5 was localized to the cytoplasm of E-cadherin-low and vimentin-high cell lines, whereas it was predominant in the nucleus and faint in the cytoplasm of E-cadherin-high and vimentin-low cell lines. Immunohistochemical analysis of lung adenocarcinoma cases (n = 130) revealed that the expression of PRMT5 was high in the cytoplasm of 47 cases (36%) and the nuclei of 34 cases (26%). The marked cytoplasmic expression of PRMT5 was frequently observed in high-grade subtypes (1 of 17 low grade, 21 of 81 intermediate grade, and 25 of 32 high grade; P < .0001) such as solid adenocarcinoma with the low expression of thyroid transcription factor 1 (the master regulator of lung) and low expression of cytokeratin 7 and E-cadherin (2 markers for bronchial epithelial differentiation), whereas the high nuclear expression of PRMT5 was frequently noted in adenocarcinoma in situ, a low-grade subtype (6 of 17 low grade, 25 of 81 intermediate grade, and 3 of 32 high grade; P = .0444). The cytoplasmic expression of PRMT5 correlated with a poor prognosis (P = .0089). We herein highlighted the importance of PRMT5 expression, especially its cytoplasmic expression, in the process of epithelial-mesenchymal transition and loss of the bronchial epithelial phenotype of lung adenocarcinoma.

To evaluate the pump function of the ventricle, a parameter which (i) incorporates systolic and diastolic function and (ii) separates the heart from preload and afterload is needed. This study utilized ejection fraction (EF), calculated from the end-systolic (ES) and end-diastolic (ED) pressure-volume relationship (PVR) using an arbitrary set of loading conditions. Ten isolated canine hearts with a balloon placed inside the left ventricle were used to determine the ESPVR and EDPVR. An end-diastolic volume (EDV) at a pressure of 15 mmHg and an end-systolic volume (ESV) at 70 mmHg were obtained from the EDPVR and ESPVR, respectively. EF was calculated as (EDV-ESV)/EDV. With low-dose (8 microg/min) and high-dose (40 microg/min) dobutamine infusion, the EF increased from 0.25+/-0.16 to 0.33+/-0.13 and 0.57+/-0.08 (p

Objective: An arterial switch operation is considered a good alternative for the repair of double-outlet right ventricle (DORV) with atrioventricular concordance connection and subpulmonary ventricular septal defect (VSD) when intraventricular rerouting is not feasible. The clinical results of an arterial switch operation with ventricular septal defect closure for this anomaly were studied. Methods: Between 1986 and 1997, 27 patients ranging from 10 days to 5 years of age (mean 0.4 years) underwent an arterial switch operation with ventricular septal defect closure for the correction of double outlet right ventricle with subpulmonary VSD. The 50% rule was used to define doubleoutlet right ventricle. Arch anomalies were associated in nine cases, and were corrected either previously or simultaneously. A subarterial muscle resection was performed in 14 without any subsequent stenosis of the ventricular outflow tract. The relationship of the great arteries was mostly anteroposterior in 15 and mostly side by side in 12. The left coronary artery (main trunk or circumflex artery) courses behind the pulmonary artery in 15/27 (six/15 in the anteroposterior relation and ten/12 in the side by side relation). The Lecompte maneuver was used to reconstruct the pulmonary artery in all but five cases with a side by side relationship of the great arteries. Results: There was one operative death (3.7%) and three late deaths. The actuarial survival rate was 83 ∠ 8% at 9 years. Right ventricular outflow tract obstruction including peripheral pulmonary stenosis developed in seven cases operated on in the early era. The reoperation free rate was 46 ∠ 20% at 9 years. Conclusion: Although double-outlet right ventricle with subpulmonary VSD has complex features, including an aortic arch obstruction and coronary artery anomalies, an optimal definitive surgical repair using an arterial switch operation can be performed safely with a thorough understanding of this variable anomaly. The prevention of right ventricular outflow tract obstruction at the time of an arterial switch operation may thus help improve the rate of late morbidity. © 1999 Elsevier Science B.V. All rights reserved.

Background . Retrograde cerebral perfusion (RCP) is a simple technique and is expected to provide cerebral protection. However, its optimum management and limitations remain unclear. Transcranial Doppler has been used to monitor cerebral perfusion. Using this Doppler technique, we compared cerebral blood flow for RCP with that for selective cerebral perfusion. Methods . Thirty-two consecutive patients underwent elective surgical repair of an aortic aneurysm involving the aortic arch at Kyushu University Hospital. Retrograde cerebral perfusion was used in 15 patients and selective cerebral perfusion, in 17 patients. Continuous measurement of middle cerebral artery blood flow velocities was performed by transcranial Doppler technique. Results . Retrograde middle cerebral artery blood flow velocities during RCP could be measured in only 3 patients, whereas middle cerebral artery blood flow velocities during selective cerebral perfusion could be measured in all but 1 woman. The increase in middle cerebral artery blood flow velocities after RCP was significantly greater than that after selective cerebral perfusion. Conclusions . The measurement of middle cerebral artery blood flow velocities with transcranial Doppler technique is practicable during selective cerebral perfusion but difficult during RCP. The increase in middle cerebral artery blood flow velocities after RCP indicates reactive hyperemia and reflects the critical decrease in cerebral blood flow during this type of perfusion.

No method has been available to assess the right ventricular (RV) pressure-volume relation in the operating room or intensive care unit. Left ventricular cross-sectional area measured by echocardiography using the technology of automated border detection has been used to construct left ventricular pressure-area (P-A) loops. In the human right ventricle, however, this approach has not been validated.We recorded RV P-A loops in 14 patients in the intensive care unit using transesophageal echocardiography. Multiple RV P-A loops were obtained by reducing preload with intravenous nitroglycerin, thereby elucidating the end-systolic P-A relation.With an incremental dose of dobutamine, the slope of the RV end-systolic P-A relation increased (from 4.56+/-2.42 to 7.34+/-3.62 mm Hg/cm2, p0.01), with no change in the x-axis intercept, which implied increased contractility. Furthermore, in the operating room we validated the use of RV cross-sectional area as a surrogate for RV volume by demonstrating the close correlation between the stroke area (maximal RV area minus minimal RV area) and stroke volume (r = 0.962; p0.0001).Transesophageal echocardiography with automated border detection is a promising tool for elucidating RV function through the analysis of RV P-A loops.

Lazaroid, a series of 21-aminosteroids, has been shown to reduce free-radical-mediated injury after ischemia and reperfusion. Recent in vitro studies have demonstrated that, among the various compounds studied, the most efficient agent was U74500A. The question is whether these findings apply to the whole heart experiencing ischemia-reperfusion injury. In this study we compared the myocardial protective effects of U74006F, the only clinical candidate, and U74500A.An isolated rabbit heart preparation perfused with the blood from a support rabbit was used. All hearts were divided into three groups according to the administration of U74500A (4 mg/kg, group A; n = 7), U74006F (4 mg/kg, group F; n = 7), or solvent (group S; n = 7) to the donor rabbit before preservation. After 24 hours of preservation with University of Wisconsin solution at 0 degrees C, all hearts were perfused with cross-circulated blood for 60 minutes with the Langendorff mode followed by 40 minutes in the working mode.After 10 minutes of reperfusion the serum lipid peroxide levels were significantly (p0.05) lower in group A (0.62+/-0.31 nmol/mL) than those in group S (2.1+/-1.3 nmol/mL) and group F (1.0+/-0.6 nmol/mL). The aortic flow rate at 10 mm Hg of left atrial pressure was significantly higher in group A (164+/-37 mL/min) than that of other groups (71+/-28 mL/min in group S and 97+/-28 mL/min in group F). There were no significant differences in high-energy phosphate levels after reperfusion among the three groups.These data imply that U74500A inhibits lipid peroxidation and prevents ischemia-reperfusion injury more efficiently than U74006F.

We report a successful case of extracorporeal membrane oxygenation (ECMO) support for a 7-year-old girl with acute fulminant myocarditis, and describe the pitfalls and management of ECMO. The problem with ECMO is that it may not reduce the afterload of the left ventricle (LV), and may be associated with increased LV wall stress and deteriorating pulmonary congestion. It is important for ECMO management to find the best balance between flow support and LV afterload.

Objective: Amrinone, a selective phosphodiesterase III inhibitor, is reported to have a potent inotropic effect on the left ventricle, but the effects of this drug on right ventricular contractility in the clinical setting are unknown. The concept of ventricular/arterial coupling was applied to investigate the effects of amrinone on right ventricular contractility and afterload with transesophageal echocardiography. Methods and Results: The study was performed in the intensive care unit with 11 patients who had undergone cardiac operations. Right ventricular cross-sectional area was measured with transesophageal echocardiography equipped with a capability of automated border detection as a surrogate for right ventricular volume. Multiple pressure-area loops were obtained by reducing preload to measure end-systolic elastance and effective arterial elastance. External work and pressure-volume area were also measured to calculate the efficiency of energy transfer from pressure-volume area to external work. Nitroprusside (0.3 to 0.5 μg · kg –1 · min –1 ) and amrinone (1 mg · kg –1 intravenously followed by 10 μg · kg –1 · min –1 ) were administered. With nitroprusside infusion, end-systolic elastance and effective arterial elastance remained unchanged (end-systolic elastance, 4.73 ± 2.18 mm Hg/cm 2 to 4.65 ± 2.09 mm Hg/cm 2 ; effective arterial elastance, 8.05 ± 3.84 mm Hg/cm 2 to 7.70 ± 3.64 mm Hg/cm 2 ). In contrast, amrinone reduced afterload (effective arterial elastance, 8.82 ± 3.99 mm Hg/cm 2 to 7.05 ± 4.01 mm Hg/cm 2 , p = 0.004) and enhanced contractility (end-systolic elastance, 4.47 ± 1.79 mm Hg/cm 2 to 6.56 ± 2.22 mm Hg/cm 2 , p = 0.007). Consequently, amrinone decreased the ventricular/arterial coupling ratio (effective arterial elastance/end-systolic elastance, 2.40 ± 1.45 to 1.16 ± 0.63, p = 0.009) and improved the efficiency of energy transfer (external work/pressure-volume area, 0.44 ± 0.15 to 0.54 ± 0.15, p = 0.013). Conclusions: Right ventricular pressure-area relations obtained with transesophageal echocardiography could successfully separate the simultaneous change in right ventricular systolic mechanics and afterload caused by amrinone. Amrinone caused enhancement of right ventricular contractility and afterload reduction. (J Thorac Cardiovasc Surg 1998;116:139-47)

Tachycardia-induced cardiomyopathy is an unusual cardiac disease that is life-threatening if tachycardia is not controlled. We report a 12-year-old boy who suffered from ectopic left atrial tachyarrhythmia that was refractory to medications and caused tachycardia-induced cardiomyopathy with severe heart failure. The patient required a left ventricular assist device (ABIOMED BVS5000 [ABIOMED Inc, Danvers, MA]) as a bridge to recovery. Tachycardia was finally controlled with flecainide while the patient was on left ventricular assist device support. The device was successfully explanted after 28 days of support. The temporary use of a left ventricular assist device was necessary to maintain a good hemodynamic status during the treatment of pharmacological refractory tachycardia, and it allowed a successful bridge to recovery.

We report on the case of a 70-year-old woman who presented dyspnea. Contrast-enhanced computed tomography of the chest revealed the compression of the lower part of the trachea and left main bronchus by an aneurysm of the ascending aorta and aortic arch. Although we performed a replacement of the ascending aorta and aortic arch, we were unable to relieve the stenosis of the trachea and bronchus. By the suspension of the posterior wall of the native aneurysm, we were able to successfully relieve the compression and alleviate the respiratory insufficiency.

In the clinical setting, surgery for aortic regurgitation after ascending aortic replacement is performed in a patient that underwent ascending aortic replacement due to acute aortic dissection (Stanford A). The 1st step is to determine preoperatively whether only surgery for aortic regurgitation should be performed or whether surgery should be performed for both aortic regurgitation and residual aortic dilatation. This decision should be based on the patient's general condition. Also, the possibility of preservation of the native aortic valve should be considered. Staged re-sternotomy using an inferior T-shaped mini-sternotomy is useful for a retrosternal giant aneurysm of the thoracic aorta in combined surgery on both the aortic valve and aortic aneurysm. Steady cardiac and cerebral protection is important for obtaining good results. Postoperative intensive critical care and careful follow-up in the outpatient clinic are also important. In conclusion, it is important for surgeons to become proficient in surgery for aortic valve regurgitation after ascending aortic replacement, because more of these patients will be encountered in the future.

For the purpose of examining the clinical applicability of a newly developed surgical sealant, animal experiments were performed, and clinical trial was followed. In animal experiments, several animal models, including carotid artery anastomosis model and coronary artery bypass grafting model were undertaken. In each model, complete hemostasis of the anastomoses using four simple interrupted sutures, was obtained. In addition, elastomeric property of the sealant prevented thinning of the arterial wall. The clinical trial performed in patients with thoracic aortic surgery showed significantly better hemostasis even under heparinized condition. Based on these excellent results, clinical usage of the sealant was approved.

OBJECTIVES: This study aimed to review the safety of a reusable sealing instrument, BiClamp®, as an alternative to the mechanical stapler for interlobar fissure division in pulmonary lobectomy. METHODS: A retrospective review was conducted of 95 patients who underwent pulmonary lobectomy performed by a single surgeon between November 2005 and March 2010. The patients were divided into two groups according to the period before and after introduction of the BiClamp®: 29 patients who underwent fissure division with staples only (staple group) and 66 patients who underwent the same procedure mainly with the instrument (BiClamp® group). RESULTS: There were 60 (63.2%) male and 35 (36.8%) female patients, with a mean ± SD age of 67.5 ± 10.8 years. Comparison of the characteristics of the two groups revealed that the BiClamp® group included significantly more cases of lobectomy by video-assisted thoracic surgery and far fewer completely lobulated lungs; 6 of 66 patients (9.1%) compared with 9 of 29 (31.0%) of the staple group. Except for 18 patients who underwent division using staples owing to thick parenchyma of the interlobar fissure, we attempted to divide the fissure of 42 patients in the BiClamp® group. Solo use of the BiClamp® was possible for 25 of 60 patients (41.7%) with an incomplete fissure. Eight patients (13.3%) needed one staple cartridge in combination with BiClamp®, five (8.3%) needed two cartridges and four (6.7%) patients needed three (combined use). In most cases, except for right upper or middle lobectomy, the division of the interlobar fissure could be performed by sole use of the BiClamp®. Incidence rates of prolonged air leakage and pneumonia were not significantly different between the two groups (respectively, 6.9 and 3.4% in the staple group vs 10.6 and 9.1% in the BiClamp® group). CONCLUSIONS: The study results demonstrate that the division of the interlobar fissure in pulmonary lobectomy with BiClamp® is safe and feasible in most cases. While the results point out the limitation that division of the right upper or middle lobe may still be a challenge, they show the potential benefit of staple reduction. Less use of staples results in reduced medical costs and carbon dioxide emission, contributing to ‘ecosurgery’, which ultimately conserves the global environment.

Background: The lazaroid U74500A is a 21-aminosteroid that inhibits lipid peroxidation and attenuates ischemia-reperfusion injury. We examined the effect of U74500A on heart preservation with the use of a clinically relevant canine orthotopic heart transplantation model. Methods and results: Six donor dogs (group L) were pretreated intravenously with U74500A (10 mg/kg), and the dogs without pretreatment served as a control (group C, n = 6). The donor heart was preserved in cold University of Wisconsin solution for 24 hours. The heart was then transplanted orthotopically. Myocardial biopsy was performed to measure the adenosine triphosphate level at the end of ischemia. Before reperfusion, recipients in group L received another dose of U74500A (10 mg/kg) intravenously. After 3 hours of reperfusion, left ventricular function was evaluated by left ventricular pressure-volume relations with the use of a Millar catheter and conductance catheter, thereby deriving the slope of the end-systolic pressure-volume relation, the slope of the stroke work–end-diastolic volume relation, and the slope of the maximum dP/dt–end-diastolic volume relation. At the same time, serum creatine kinase MB isoenzyme and lipid peroxide levels were measured. The slopes of the end-systolic pressure-volume relation, the stroke work–end-diastolic volume relation, and the maximum dP/dt–end-diastolic volume relation for group L were significantly higher than those for group C. The adenosine triphosphate levels for group L were significantly higher than those for group C. Serum creatine kinase MB isoenzyme and lipid peroxide levels for group L were significantly lower than those for group C. Conclusions: Inhibition of lipid peroxidation by the administration of U74500A was effective for 24-hour canine cardiac preservation. These results indicate that U74500A is a promising agent for heart allograft preservation. (J THORAC CARDIOVASC SURG 1996;112:1017-26)

Lazaroid, an inhibitor of iron-mediated lipid peroxidation, has been shown to reduce free radical-mediated injury after ischemia and reperfusion. We thus examined the efficacy of pretreatment with lazaroid (U74500A) in enhancing functional recovery after 24-hr heart preservation. An isolated rabbit heart model perfused with the blood from a support rabbit was used. Before preservation, either U74500A (4 mg/kg, group L ; n=6) or solvent (group S ; n=7) was given to the donor rabbit. After 24-hr preservation with UW solution at 0°C, all hearts were perfused with cross-circulated blood for 60 min with the Langendorff mode followed by 40 min of the working mode. In group S, ventricular fibrillation (Vf) after reperfusion was observed in all hearts, whereas no Vf was observed in the U74500A-pretreated group. In group L, the serum creatine phosphokinase ; its isozyme, troponin-T ; and serum lipid peroxide levels after 10 min of reperfusion were all significantly (P

We have recently demonstrated that fasudil, a Rho-kinase inhibitor, is effective in suppressing coronary artery spasm in patients with vasospastic angina. Thus, blockade of Rho-kinase may provide a novel therapeutic strategy to treat ischemic coronary syndrome caused by the spasm. Severe coronary artery spasm still remains a life-threatening serious complication of coronary artery bypass grafting (CABG). In this study, we examined the inhibitory effect of fasudil in patients with intractable severe coronary spasm after CABG. Three patients who underwent CABG showed severe myocardial ischemia resistant to intensive therapy with intravenous conventional vasodilators, including isosorbide dinitrate (ISDN), diltiazem, and nicorandil. Coronary angiography revealed severe coronary spasm in native coronary arteries and/or bypass arterial grafts in all patients. Since intracoronary and/or intragraft administration of ISDN was ineffective to resolve the spasm, we then administered fasudil (1.5 mg/min for 15 minutes) into the spastic arteries. Fasudil successfully resolved the spasm and improved myocardial ischemia in all patients without any systemic adverse effects. In conclusion, the treatment with fasudil may be useful to treat intractable and otherwise fatal coronary spasm resistant to intensive conventional vasodilator therapy after CABG.

Here, we report a 28-year-old woman who transiently showed lactate dehydrogenase (LDH)-linked immunoglobulin during postpartum thyroiditis. She demonstrated high levels of serum LDH (794 IU/l) and thyroid hormones 7 months after delivery. Electrophoretic isoenzyme analysis of LDH showed an abnormal broadband caused by LDH-linked immunoglobulin (IgG-κ). Transient thyrotoxicosis due to postpartum thyroiditis improved without any specific treatment, and elevated serum concentration of LDH decreased to the normal level (395 IU/l) with disappearance of LDH-linked IgG. LDH-linked immunoglobulin may also appear at the postpartum period., Internal Medicine, vol.43(7), pp.575-577; 2004

Capillary hemangiomas are often seen on the skin, mucosa, liver and other organs, but they are very rare in the lung. We report 3 cases of capillary hemangioma of the lung that presented as ground glass opacities(GGO) by computed tomography( CT). Mixed GGO was observed in 2 cases that increased in size after the follow-up period. The remaining case involved a pure GGO that was stable in size. They were suspected to be bronchioloalveolar carcinoma( BAC) based on the CT findings, and video assisted thoracoscopic surgery was performed in all 3 cases. It is difficult to distinguish capillary hemangioma from other malignant diseases such as BAC based on CT findings. As high resolution CT becomes more widely used, GGOs are becoming more frequently detected. When GGOs are detected by CT, capillary hemangiomas should be included in the differential diagnosis. Intraoperatively, an important surgical finding for capillary hemangiomas is that they became impalpable after repeated palpation. This surgical finding can be useful when identifying the region for biopsy and resection.

Primary malignant cardiac tumors occur extremely rarely. Among these, leiomyosarcomas are exceptionally rare. We described a case of left atrial leiomyosarcoma in which surgical intervention was followed by adjuvant radiation therapy. A 74-year-old male was admitted for dyspnea. Chest X-ray showed severe pulmonary congestion. Echocardiography revealed large tumor in the left atrium. Emergency operation was performed. The tumor invaded the left atrial wall and the mitral valve, and the lesion was resected as extensively as possible. Postoperative pathologic examination confirmed leiomyosarcoma. He underwent adjuvant radiotherapy postoperatively. However, early local recurrence was recognized. He died due to sudden circulatory collapse in 8th postoperative month. As cardiac leiomyosarcomas have extremely poor prognosis, complete resection and effective postoperative adjuvant therapy are necessary.

Ejection fraction is a major determinant of morbidity and mortality for patients with ischemic heart disease. Patients with an ejection fraction of 0.40 or less are generally recognized as having a poorer prognosis than those patients with an ejection fraction of 0.50 or better and remain a heterogeneous group. It would be useful if patients with a favorable surgical prognosis could be identified preoperatively. Fifty-five patients who underwent coronary artery bypass grafting and had an ejection fraction less than 0.40 (mean of 0.23 ± 0.07 standard deviation) were studied by catheter measurement of pulmonary arterial pressure and radionuclide left ventriculography. Heart rate, systemic blood pressure, pulmonary artery pressures, cardiac output, and ejection fraction were measured, at rest, after nitroglycerin was given intravenously and with supine bicycle exercise. Forty-seven patients who had follow-up longer than 4 years were divided into two groups according to their life status (alive or dead) 4 years after operation. Measured variables of exercise stress tests and clinical characteristics were entered into factor analysis to obtain a cardiac function factor score for predicting the life status after 4 years. The cardiac function factor score was highly loaded by stroke index (rest, nitroglycerin), cardiac index (exercise), systemic vascular resistance index (exercise), and history of congestive heart failure. The cardiac function factor provided a predictive value superior to that of any individual variable. By dividing the patients into two groups by cardiac function factor score, the actuarial 5-year survival was 72% versus 17% for good and poor prognosis groups, respectively (p < 0.0001). Preoperative exercise stress testing data integrated by factor analysis provide a predictive tool for patients with a low ejection fraction.

To clarify the involvement of polyclonal activation of autoimmune reaction in organ-specific autoimmune diseases, we investigated the prevalence of nonthyroid specific autoantibodies in 50 patients with autoimmune thyroid diseases (22 patients with Graves' disease and 28 with Hashimoto's disease) and in 50 age- and sex-matched controls. None of the 100 subjects had any clinical manifestations or laboratory data indicating any other immunological, infectious, hepatic, or malignant diseases. The prevalence of positive antibodies to nucleus, smooth muscle, and single-stranded DNA in the patients (26%, 36%, and 34%, respectively) was higher than that in the control group (8%, 4%, and 4%, respectively), although neither group was positive for autoantibodies against double-stranded DNA, extractable nuclear antigen, SS-A, SS-B, mitochondria, or rheumatoid factor. Furthermore, 66% of the patients had at least one autoantibody to nucleus, smooth muscle, or single-stranded DNA. In conclusion, patients with autoimmune thyroid diseases show high prevalence of autoantibody against not only thyroid-specific, but also nonthyroid-specific antigens. These results are consistent with the concept that immune reaction of patients with organ-specific autoimmune diseases may be polyclonally accelerated to the production of antibodies against both organ and nonorgan specific autoantigens.

We have experienced a case of left atrial (LA) myxoma with rapid progression of congestive heart failure and ensuing multiple organ insufficiency. After the tumor excision, the hemodynamic derangement was totally corrected and the patient dramatically recovered from kidney, liver, and lung insufficiency. Specifically, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), and central venous pressure (CVP) significantly decreased in the intensive care unit. Administration of prostaglandin E1 (PGE1) was effective in treating residual pulmonary hypertension.

This study aimed to clarify claudin-6 expression patterns in cancers.We surveyed claudin-6 expression by immunohistochemistry using tissue microarray in 860 tumours, including germ cell tumours and major carcinomas. Claudin-6 was expressed consistently in germ cell tumours (28 of 28, 100%), whereas only 64 (8%) of 832 non-germ cell tumours demonstrated claudin-6 expression. Further immunohistochemical study in full tissue sections demonstrated diffuse claudin-6 staining in all seminomas (n=14), embryonal carcinomas (n=10), yolk sac tumours (n=12) and mononuclear trophoblastic cells of choriocarcinomas (n=3), and focal staining in immature epithelial components of immature teratomas (n=6). Additionally, because alpha-fetoprotein (AFP)-producing gastric adenocarcinomas and pulmonary high-grade fetal adenocarcinomas were among the claudin-6 expressing non-germ cell tumours in the microarray studies, we predicted that claudin-6 may be a biomarker for them and studied additional tumours in full sections, which showed claudin-6 expression in AFP-producing gastric adenocarcinomas (18 of 20, 90%) and pulmonary high-grade fetal adenocarcinomas (four of five, 80%). Only one of 11 hepatoblastomas demonstrated focal claudin-6 staining.This study demonstrated that claudin-6 is a novel diagnostic marker for primitive germ cell tumours and is also expressed frequently in some cancers with a primitive phenotype.

Total arch replacement for extended distal arch aneurysm has been known to have a poor outcome because of a limited view on the distal side. An open stent-grafting technique has been employed in many institutions, but several complications have been reported. Specifically, embolism of the distal artery from aneurysm debris and injury to the aortic wall are serious complications. Therefore, we have developed and tested a new sheathless stent-grafting system. We use a small-sized sheath (12 Fr) as an inner cylinder and a stainless-steel Z-shaped stent (Gianturco:William Cook Europe A/S) in the distal part of the graft. This system is deployed by releasing 3-0 polypropylene suture after inserting the full-length graft. The major advantages of this system, compared with other devices, include flexibility, less invasiveness to the aortic wall and low potential for graft migration. This new system may be feasible and clinically effective in the surgical treatment of extended distal arch aneurysm.

We have performed a simple and uniform technique for reconstruction of artificial chordae in patients with anterior mitral prolapse since 1994. In this study, we investigated the long-term clinical and echocardiographic results of chordae replacement with Gore-Tex sutures for anterior mitral leaflet prolapse.A pair of Gore-Tex sutures is passed through a small autologous pericardium and tied on one side of the pericardium. Double-armed mattress stitches on the side without a knot are passed through the head of the papillary muscle and another small pericardium and then tied down. Using this simple technique, 2 pairs of artificial chordae are made. The length of the artificial chordae is determined during the leak test. Chordal replacement with this technique was performed in 30 patients (mean age, 59.3 years) with anterior mitral leaflet prolapse. Echocardiography was performed annually in these patients. Follow-up ranged from 0.2~16.2( 8.0±5.1) years.There were no hospital deaths. Twenty-one patients had no mitral regurgitation( MR) and the others had trivial or mild MR. There were 2 reoperations and 4 cases with recurrent moderate MR in this series. Kaplan-Meier survival and freedom from reoperation at 15 years were 84% and 93%,respectively. Overall, freedom from recurrent moderate or severe MR at 15 years was 81%.Our simple chordae replacement technique with Gore-Tex sutures for anterior mitral prolapse, results in good long-term durability. To avoid recurrence of regurgitation, intraoperative complete repair is essential.

Although a severely calcified ascending aorta is encountered infrequently, it presents formidable problems during cardiac surgery. We describe a case of severe aortic valve stenosis and coronary artery disease combined with a severely calcified ascending aorta. The patient was an 80-year-old man with a calcified ascending aorta. He successfully underwent an aortic valve replacement and a single coronary artery bypass graft (CABG) using a saphenous vein graft with the proximal end connected on a Dacron patch, which was used for aortoplasty of the calcified plate along the aortotomy. These procedures were performed under moderate hypothermia with aortic clamping. This patch aortoplasty can be a useful alternative in cases that require aortotomy and proximal anastomoses of a CABG on a calcified ascending aorta.