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Right ventricular (RV) failure during the use of a left ventricular assist device (LVAD) is the leading cause of death in circulatory support patients. Previous work, both experimentally and clinically, has shown the difficulties in predicting the behavior of the right ventricle at the start of LVAD. An experimental study has been designed to evaluate RV functional changes during LVAD and its relation to preload changes. The model used adult mongrel pigs (n = 10). Right ventricular functional parameters were measured with a thermodilution RV ejection fraction catheter. The left ventricle was supported by a Nippon Zeon blood pump. Two groups were studied, the first one was the LVAD-off group (n = 5) and the other was the LVAD-on group (n = 5) which was supported by LVAD at maximum flow. Change of cardiac output, mean pulmonary artery pressure (PAP), RV stroke work, and RV ejection fraction in both groups were not significantly different. However, the relationship between right ventricular end-diastolic pressure (RV-EDP) and right ventricular stroke volume (RVSV) was significantly changed at a high level of RV-EDP. When RV-EDP was over 6.5 mm Hg in the LVAD-off group, RVSV decreased to 52.3 +/- 11.5 ml while in the LVAD-on group, RVSV increased to 97.2 +/- 22.0 ml. The change in PAP in the LVAD-on group was lower than in the LVAD-off group. We conclude that, at the volume overload state, LVAD can reduce the afterload of the right ventricle and maintain Frank-Starling's effect, thus having a beneficial effect on right ventricular performance.

Changes in the right ventricular function measured with a thermodilution ejection fraction catheter have been recorded in open-chest normal pigs and pigs with acute right heart failure (RVF) undergoing left ventricular assistance with a pneumatic-sac-type device (LVAD). To produce acute right heart failure, 5 pigs underwent ligation of the right ventricular free wall coronary arteries. Compared with normal pigs, cardiac output in ligated pigs fell by 21% (7.5 +/- 0.5 vs 9.5 +/- 1.2 L/min; p < 0.05) and the right ventricular end diastolic pressure rose (11.4 +/- 2.6 vs 5.7 +/- 3.6 vs mmHg: p < 0.05). With the left ventricular assist device connected, the right atrial pressure was increased to 3, 5, 7, 10 and 12 mmHg by volume loading while maintaining the haematocrit at 35 +/- 6%. The right ventricular stroke work index (RVSWI) increased with volume loading in normal pigs. In RVF pigs, RVSWI increased significantly with the LVAD (59.2 +/- 5.8 vs 23.5 +/- 7.8 mmHg ml/min/kg, p < 0.01), approaching that of normal pigs (62.3 +/- 4.8 mmHg ml/min/kg). Similar changes were observed in the cardiac output and right ventricular stroke volume. These results show that, in this model of open-chest, mild, acute right heart failure, left ventricular assistance allows right ventricular function to return to normal, despite volume overloading, by decreasing right ventricular after load and increasing right ventricular compliance.

The prognosis of 174 patients with cirrhosis during the 1980s (1981-89) was analysed. The estimated survival rates were 87.3% in 3 years and 68.5% in 5 years. During the follow-up period, 58 patients died: 20 of hepatocellular carcinoma (37.7%); 11 of hepatic failure (20.8%); eight of gastrointestinal bleeding (15.1%); and 14 of other causes (26.4%). Multivariate analysis revealed that serum albumin, indocyanine green retention rate at 15 min and white blood cell count were significantly associated with prognosis. The results were also compared to our previous study covering the 1970s (1971-80). The estimated survival rate was significantly improved compared to that during the 1970s (54.3% in 5 years, P < 0.001). In the 1980s, hepatic failure mortality significantly decreased (P < 0.01), and non-liver-related mortality significantly increased (P < 0.05). In summary, the prognosis of cirrhosis has improved in recent years, and changes of death cause and prognostic factors were observed. It was concluded that to evaluate the severity and prognosis of cirrhosis, new indices and appropriate classification were necessary.

Objectives: Forty patients with solitary hepatocellular carcinoma (HCC) smaller than 20 mm in diameter were admitted to our hospitals from March 1986 to December 1989. Of that 40 patients, 17 were treated with hepatectomy, 12 with percutaneous ethanol injection therapy, and 11 with the combination of percutaneous ethanol injection therapy and transcatheter arterial embolization., Method: Following up the patients after their first treatment for 2 months to 6 yr, as of April 30, 1993, we evaluated the effects of hepatectomy, percutaneous ethanol injection therapy, and the combination of percutaneous ethanol injection therapy and transcatheter arterial embolization., Results: Of the 23 patients who did not undergo surgery, eight died from recurrence of HCC and one died from ruptured varices. Of the 14 surviving patients, 10 experienced recurrences during the follow-up period. Of the 17 patients who underwent surgery, one died in hospital and four died from recurrence of carcinoma. Of the remaining 12 patients, nine experienced recurrences. The cumulative survival and recurrence rates were similar in operated and nonoperated patients. There was no significant difference in these rates in patients treated with versus without transcatheter arterial embolization., Conclusion: Our results showed that the efficacy of hepatectomy and the efficacy percutaneous ethanol injection therapy for small solitary HCC were similar. However, percutaneous ethanol injection therapy was safer and less expensive than hepatectomy.

We performed coronary artery bypass grafting with the bilateral internal thoracic artery (ITA), right gastroepiploic artery (RGEA) and inferior epigastric artery (IEA) on a 53-year-old patient who was associated with familiar hypercholesterolemia. The IEA was extended with right ITA as a composite graft and sequentially anastomosed to the right coronary artery and distal branch of the right coronary artery. Both the LITA to the left anterior descending artery and the RGEA to the circumflex artery were used as in situ graft. The postoperative coronary angiogram showed all the graft patient.

To determine whether the extent of myocardial fibrosis in dilated cardiomyopathy could be estimated noninvasively, signal-averaged electrocardiograms were recorded in 32 patients with dilated cardiomyopathy, followed by left ventricular endomyocardial biopsy. The root mean square voltage for the last 40 msec (V40), the duration of the filtered QRS complex (fQRSd) and the duration of low amplitude signals < 40 microV (LAS) were obtained by signal-averaged electrocardiography. The extent of fibrosis in all biopsy samples was measured by the point-counting method. The extent of myocardial fibrosis closely correlated with fQRSd (r = 0.623, p < 0.001), LAS (r = 0.570, p < 0.001), and V40 (r = -0.355, p < 0.05). When fibrosis was classified into intercellular and interfascicular types, the extent of intercellular fibrosis more closely correlated with fQRSd (r = 0.695, p < 0.0001), LAS (r = 0.640, p < 0.0001), and V40 (r = -0.533, p < 0.005). These results suggest that signal-averaged electrocardiograms might be useful for estimation of the extent of myocardial fibrosis, especially intercellular fibrosis in patients with dilated cardiomyopathy.

The authors developed a new intraluminal aortic prosthesis (IA graft) for internal obliteration of Stanford type B dissection. The newly devised intraluminal aortic graft is a self-expandable metallic stent (Gianturco stent) outer-jacketed with a thin open-cell structured microporous film made of segmental polyurethane (0.2 mm thick, 0.1 mm pore size). Through the femoral artery, the intraluminal aortic grafts (14-20 mm diameter-, 4 cm long) were inserted into a 12 Fr catheter sheath by compression, were implanted into the descending thoracic aortas of five mongrel dogs; they were removed at the projected times of death ranging from 1 to 6 months after implantation. Histopathologic examination revealed that an elastic fiber layer had regenerated and that on the inner surface of the graft adherent and proliferating endothelial cells were observed, even at 1 month after graft implantation. Complete epithelialization was observed over the entire inner surface of the graft within 4 months after implantation. This healing process suggests that the intraluminal aortic graft is highly biocompatible and might be stable in chronic use after the obliteration of acute Stanford type B dissections.

We had 18 patients (15 males and 3 females) with lethal midline granuloma (polymorphic reticulosis) in the period from 1981 to 1990. This number was about 5.6% of the total number of patients with malignant head and neck tumors that we encountered during this period. An average of 9.1 months separated the first appearance of disease and the beginning of treatment. Most of the 18 patients underwent both radiation therapy and chemotherapy (COP, CHOP, MACOP-B), but, since their disease had reached an advanced stage, 3 underwent radiation therapy only, 3 underwent chemotherapy only, and 1 received no radical therapy at all. Of the 18 patients, 13 died of the disease. In of 6 of these, the disease was confined to the local lesion. The 5-year cumulative survival rate was 15.7% (Kaplan-Meier). Fourteen autopsy studies revealed that tumor cells had invaded the liver (92.8%), lung (92.8%) and spleen (71.4%) and in all cases it was in leukemic patterns. Fifteen cases were studied for tumor surface marker phenotype, but none was found to be positive for L26, CD43, Leu M1 (CD15), or MAC 387. Five cases were positive for UCHL-1 (CD45RO) and 10 cases were positive for lysozyme. All cases were positive for Ki-1 (CD30).

Objectives: The purpose of this study was to elucidate whether the effectiveness of long-term beta-blocker therapy could be predicted before this therapy is started., Background: Long-term beta-blocker therapy has recently been reported to provide a favorable effect in treatment of congestive heart failure due to dilated cardiomyopathy., Methods: Several measurements including histologic variables before administration of metoprolol were retrospectively compared among 18 good responders (showing improvement of at least one New York Heart Association functional class or an increase in ejection fraction > or = 0.10 12 months after drug administration) and 12 poor responders without such improvement., Results: Although there were no significant differences between the two groups in age, gender, functional class, heart rate, blood pressure, pulmonary capillary wedge pressure, cardiac index, left ventricular end-diastolic dimension and ejection fraction, percent fibrosis estimated by the point-counting method in endomyocardial biopsy specimens was significantly lower in good than in poor responders (7.6 +/- 5.7 vs. 14.2 +/- 9.7%, p < 0.05). Moreover, when the types of fibrosis were classified as interfascicular and intercellular by the dominance of counted points, there were 13 cases of interfascicular fibrosis and 5 cases of intercellular fibrosis in good responders and 1 case of interfascicular fibrosis and 11 cases of intercellular fibrosis in poor responders (p < 0.001, sensitivity 72%, specificity 91%, predictive accuracy 80%). These results suggest that improvement with long-term beta-blocker therapy may be more likely to occur in patients with less myocardial fibrosis, with interfascicular fibrosis the dominant type., Conclusions: The extent and type of fibrosis may be important factors in the prediction of the effectiveness of long-term beta-blocker therapy for dilated cardiomyopathy.

The current report describes a case of extradural angiolipoma with spinal cord compression that was studied by magnetic resonance imaging. In considering the strategy for the surgical management, it is desirable to determine the histologic type of spinal cord tumors before the operation. The literature of spinal angiolipoma is reviewed, and the possibility of using magnetic resonance imaging to define the histologic type of spinal cord tumors before operation is discussed.

We constructed a cDNA library against the plasma obtained from the patient with acute exacerbation of non-A, non-B liver cirrhosis, and immunoscreened this library with the sera obtained from the patients with non-A, non-B chronic liver disease. One positive clone lambda 22C containing about 1.2 kb cDNA insert was isolated from 10(6) clones. Nucleotide sequence determination and subsequent homology search revealed its identity to the tolA gene of Escherichia coli. Anti-tolA antibody was detected in 54.5% of the patients with NANB chronic liver disease whose sera were negative for antibody to hepatitis C virus (anti-C100). In contrast, anti-tolA was detected only of 14.6% patients with anti-C100 positive NANB chronic liver disease, 10.5% with hepatitis B surface antigen-positive chronic liver disease, 7.7% with alcoholic liver disease and 4.2% in normal control, and no positive case in acute hepatitis of etiology and in primary biliary cirrhosis. However, antibody to the core protein of hepatitis C virus (anti-JCC) was detected 50% of the patients whose sera were negative for anti-C100 but positive for anti-tolA. Recently, it has been reported that hepatitis C virus is rich in mutations and has some variants. These results indicated the presence of a common epitope between the tolA protein and some agent related to non-A, non-B hepatitis, especially to anti-C100 negative non-A, non-B hepatitis such as variants of hepatitis C virus which have mutations in C100 coded region.

A continuous lysing and resealing of erythrocytes permitted internalization of inositol hexaphosphate (IHP), a strong allosteric effector of Hb, leading to significant rightward shifts of the HbO2 dissociation curve. Twelve piglets were put on cardiopulmonary bypass (CPB) with the heart beating, cooled to 25 degrees C then rewarmed to 37 degrees C before weaning off CPB. AoP, LV pressure, PAP, and cardiac output (CO) were monitored. Blood samples were taken before CPB, at 25 degrees C, at 30 degrees C, at 37 degrees C and after CPB for assessment of blood gases, arterio-venous difference in O2 content, lactates, P50 (partial pressure of O2 at 50% Hb saturation), and ionogram. Control group I included five pigs where the CPB circuit was primed with Ringer's lactate solution and porcine blood. In group II (n = 5), priming was done with Ringer's lactate solution and IHP loaded erythrocytes. P50 was significantly higher during CPB than before surgery in group II (20%), but not in group I (1%). There was a significant increase in VO2 in group II (6.02 ml/min) compared to group I (4.03 ml/min) (p less than 0.05) after CPB. Hemodynamics improved after CPB in group II (mean AoP 42 mmHg and syst LVP 70 mmHg) compared to group I (AoP 25 mmHg and syst LVP 22.5 mmHg). These preliminary results show that O2 transportation at the end of CPB is enhanced and myocardial function is improved in piglets with the use of IHP erythrocytes.

Alveolar macrophages were obtained from 23 patients and the effects of phorbol myristate acetate (PMA), lipopolysaccharide (LPS), and dexamethasone (DEX) on the proportion of cells with intracellular alpha-1 antichymotrypsin (ACT), and concentrations of ACT in the culture medium were studied in vitro. The alveolar macrophages were obtained by bronchoalveolar lavage at autopsy or from resected lungs at operation and were cultured in suspension for 3 days in medium containing PMA, LPS, DEX, PMA+DEX, or LPS+DEX. Both PMA and LPS significantly increased the percentage of macrophages with intracellular ACT. Dexamethasone did not increase the number of ACT-positive cells and significantly suppressed the increase induced by PMA or LPS, releasing ACT into the culture medium. The release of ACT from macrophages may contribute to the anti-inflammatory effects of corticoids.

A 54-yr-old man with multiple metastatic liver cancer was admitted to our hospital because of melena and intermittent colicky pain on the right upper abdomen. He underwent partial gastrectomy for gastric cancer 3 yr before the admission. Endoscopic examination of the duodenum on the 3rd hospital day showed active bleeding from the papilla of Vater, and diagnosis of hemobilia was done. Transcatheter arterial embolization controlled the bleeding successfully, and no rebleeding occurred until his death due to the advanced cancer 8 months later. We considered that the high vascularity of his metastatic tumor caused hemobilia. To the best of our knowledge, this is the first report of hemobilia by metastatic liver cancer treated successfully with transcatheter arterial embolization.

A case of primary malignant lymphoma of the spleen is presented. The tumor was successfully removed and eight years after the surgery, the patient died without any recurrence of the malignant lymphoma. A review of the literature, with special reference to prognosis is also presented. Long-term follow-up is necessary in patients with primary malignant lymphoma of the spleen who have been curatively operated because the malignant lymphoma of the spleen may in fact be a metastatic lesion from nodal and extranodal lymphomas, or may be a partial lesion from a multicentrically originating lymphoma.

A case of adrenal myelolipoma which was diagnosed preoperatively based on the combined examinations of computed tomography and angiography is presented. Computed tomography revealed a large suprarenal fatty tumor with increased density areas secondary to hemorrhage. Angiography demonstrated that the tumor originated from the adrenal gland.

Seventeen autopsy cases with occlusion of the circle of Willis were examined clinicopathologically. These patients ranged in age from 8 years to 64 years and consisted of 6 males and 11 females. The following results were obtained. 1. Fresh and massive intracerebral hemorrhage was confirmed in 13 of 17 patients and cerebral infarct in 4 of 17 patients. 2. Among these 13 patients, massive hemorrhage was found in basal ganglia, thalamus and hypothalamus of 9 patients, and in thalamus, cerebral peduncle and midbrain of 4 patients. 3. Rupture of the dilated muscular-type arteries was noted in the thalamus and basal ganglia in 2 of 13 patients. Ruptured arteries with organization of the lumen were found in the old hemorrhagic foci in one of them. 4. Overgrown and dilated arteries, branching off from the circle of Willis, were confirmed in 11 patients. These arteries consisted of "perforating" arteries well developed as collateral circulation. 5. No ruture in these arteries of the subarachnoidal spaces was found in 11 patients. In one of them, a small saccular aneurysm was found. These findings strongly suggest that in patients with occlusion of the circle of Willis intracerebral rupture of overgrown "perforating" arteries as collateral circulation may be the main cause of intracranial hemorrhage and intracerebral hemorrhage due to rupture of the arteries may be repeated.

Cases of acute aortic dissection presenting to the First Department of Surgery at Toyama Medical and Pharmaceutical University Hospital were divided into 2 groups according to the presence or absence of complications such as electrocardiographic abnormalities, hepatic or renal dysfunction, intestinal necrosis, and leg ischemia. After hospitalization such complications were completely absent in the "complication-free group", but were present in the "complication group". Fluctuations in serum enzyme activity (CK, LDH, GOT, GPT) were measured, and the 2 groups compared. In the complication-free group, serum CK activity was significantly elevated at 273.3 +/- 154.5 IU/l, reaching a peak on the first day, after which it decreased to normal by the fourth day. In the complication group, fluctuations in the serum enzyme activity levels corresponded to the type of complication, with the fluctuations paralleling changes in the clinical course. Also, CK activity was measured in aortic wall specimens obtained at autopsy, and the CK activity of 585.0 +/- 35.3 IU/g protein demonstrated. From the above it was thought the transient elevation of serum CK activity found in uncomplicated aortic dissection is due to the CK released from the dissected aortic wall into blood.

The cytologic and histochemical characteristics of the tumor cells from medullary thyroid carcinoma and pheochromocytoma are described. In cell samples obtained from medullary thyroid carcinomas, amyloid deposits were detected both intracellularly and extracellularly. Medullary thyroid carcinoma cells, as well as pheochromocytoma cells, showed positive for both argentaffin and argyrophil reactions. The diagnostic significance of intracellular amyloid deposits and of positive silver and chromaffin reactions of the intracytoplasmic granules may be stressed in establishing the cytologic diagnosis of medullary thyroid carcinoma and/or pheochromocytoma.

Previously we reported that malignant histiocytosis presenting as lethal midline granuloma (MH-LMG) showed rapidly progressive course (mean survival 14 months). Because of the same biopsy findings of polymorphic cellular infiltrates (PCI), we considered that MH-LMG and midline malignant reticulosis (MMR) are similar disease. In this paper, we studied 5 cases with MH-LMG showing slow clinical course with more than 5 year survivals, and a similarity found in MH-LMG and MMR in which disseminated and localized disease are present, is discussed. Among clinical data, no abnormality in hematologic findings in MH-LMG with slow clinical course was the only different point from that with progressive course. Biopsy findings of PCI in which atypical histiocytes with positive reactions for lysozyme by immunoperoxidase procedures were present, were identical with those in MH-LMG with progressive course. Autopsy findings justified a diagnosis of MH. MH with slow clinical course seems to be identical with MMR showing localized lesion. Therefore a term MMR should be replaced by a term MH-LMG in the classification of LMG.