Complete transection of the left hepatic duct due to blunt abdominal trauma

A 21-year-old man was transferred to our hospital after a traffic accident. He had chief complaint of right upper abdominal pain. Abdominal computed tomography scan at admission showed fluid collection in the abdominal cavity and linear low density area in the hepatic hilus including segment V of the liver. Operative findings revealed a hepatic laceration extending from the boundary between segment IV and segment V to the hepatic hilus, and a completely transection of the left hepatic duct near the caudate lobe without ischemic change and contusion. The bile duct of the caudate lobe communicated with the left hepatic bile duct at the distal portion of the torn wedge, and was not injured. The transected bile duct was primarily repaired with an interrupted end-to-end anastomosis using a retrograde transhepatic bile duct tube (RTBD tube) as stent. Intra- and postoperative cholangiography via the tube revealed no leakage or narrowing. He is in good health for 60 months after surgery. The case illustrates the condition of the transectional wedges for end-to-end anastomosis, and the usefulness of RTBD tube for the anastomotic stent and the diagnosis of bile leakage after anastomosis.

Protective effects of BQ-123, an ETA receptor antagonist, against leukotoxin-induced injury in rat lungs

We tested the hypothesis that BQ-123, a novel endothelin type A (ETA) receptor antagonist, protects the lung against leukotoxin 9,10-epoxy-12-octadecenoate (Lx), which causes acute lung injury in animals. In isolated rat lungs perfused with Earle's balanced salt solution, BQ-123 suppressed the Lx-induced increase in wet lung weight, wet lung weight/dry lung weight, the effluent perfusate lactic dehydrogenase activity, and effluent perfusate and lung tissue ET-1 levels. BQ-123 also significantly attenuated the Lx-induced increase of the pulmonary capillary filtration coefficient. Thus our experimental results indicate that the ETA receptor antagonist, BQ-123, protects against Lx-induced experimental lung vascular injury.

Gene expression of TGF-alpha, EGF and IL-6 in cultured renal tubular cells and renal cell carcinoma

BACKGROUND

Renal cell carcinoma (RCC) is thought to arise from the renal tubular cells (RTC). Assuming that proliferating RTC imply a premalignant change of RTC into RCC, messenger RNA expressions of growth factors in cultured RTC were compared to both cultured and frozen noncultured RCC.

METHODS

The expression of transforming growth factor-alpha (TGF-alpha), epidermal growth factor (EGF), EGF receptor (EGFR) and interleukin-6 (IL-6) were studied in surgically obtained RCC (n = 17), cultured RCC (n = 10), and autologous cultured RTC (n = 15). Quantitation of the PCR product was performed using a computer image analyzer which evaluated the intensity of each cytokine relative to beta-actin.

RESULTS

TGF-alpha, EGFR and IL-6 were detected in most of the cultured RTC, and both cultured and noncultured RCC were also expressed at high levels. In contrast to a high positivity of TGF-alpha, EGF was not strongly positive in all specimens.

CONCLUSIONS

Our results show that there is a predominant autocrine production of TGF-alpha in RCC and RTC, suggesting that TGF-alpha plays a distinct role in the proliferation of these cells. These studies also indicate that the mechanisms of proliferation and cytokine production of RCC and RTC are similar.

[Mitochondrial dysfunction in acute lung injury caused by endothelial-1 and leukotoxin]

We studied whether endothelin-1 (ET-1) and leukotoxin (Lx), which have a different effects on vascular tone in isolated perfused rat lungs, also have different effects on mitochondrial function in edematous lung injury. Lung mitochondria were extracted from isolated perfused rat lungs exposed to each mediator. In lungs exposed to 0.5 nmol of ET-1, lung wet weight increased with a markedly elevated perfusion pressure but with no increase in the release of lactate dehydrogenase (LDH), an index of cell damage, into the perfusate. Neither mitochondrial respiration rate no ATP content in the lung tissue differed from those of untreated lungs. In contrast, in lungs treated with 30 mumol of Lx, lung wet weight markedly increased despite a small elevation of perfusion pressure; release of LDH into the perfusate increased, and the mitochondrial respiration rate in state 3 adn 4 significantly decreased while the ATP content in the lung tissue was less than in untreated lungs. We also examined cellular and mitochondrial damage in hydrostatic lung edema caused by raising an outflow reservoir. Mitochondrial respiration was not suppressed, and perfusate LDH activity was not increased, although lung wet weight increased as much as it did after the treatment described above. These results indicate that lung mitochondrial function is differentially affected by ET-1 and Lx, and they suggest that abnormalities in energy production by lung mitochondria are related to permeability edema.

Complement-mediated killing of porphyromonas gingivalis 381 by the immunoglobulin G induced by recombinant 40-kDa outer membrane protein

Porphyromonas gingivalis has been implicated as an important pathogen in severe adult periodontitis. We have previously cloned a 40-kDa outer membrane protein from P. gingivalis 381 and succeeded in producing sufficient quantities of the recombinant protein (r40-kDa OMP). r40-kDa OMP has been the subject of considerable interest to us as a possible vaccine candidate. To understand the role of anti-r40-kDa OMP antibody in the host defense mechanisms against P. gingivalis, we examined the involvement of a rabbit antibody against r40-kDa OMP (r40-kDa OMP Ab) to an in vitro complement-mediated bactericidal assay for P. gingivalis 381. By measuring the absorbance values in order to assay the surviving bacteria, we found significant anti-P. gingivalis activity of r40-kDa OMP Ab when guinea pig complement was present. Using affinity-purified immunoglobulin G of r40-kDa OMP Ab (IgG-r40-kDa OMP), we demonstrated that the IgG contributed to anti-P. gingivalis activity in the antibody-complement system. This was effected by measuring the incorporation of tritiated thymidine into newly synthesized nucleic acids. Finally, we confirmed the cell lysis of P. gingivalis 381 exposed to IgG-r40-kDa OMP in the presence of complement sources in a radioactive bactericidal assay using bacteria labeled with [14C]sodium acetate. Assembling the data from experiments using component-deficient complements, we concluded that IgG-r40-kDa OMP was related to the killing of P. gingivalis 381 by mediation in the complement activated through both the classical and the alternative pathways.

Accumulation of deletions and point mutations in mitochondrial genome in degenerative diseases

Accumulation of various mutations in the mitochondrial genome is proposed as an important contributor to aging and degenerative diseases. Extensive fragmentation of mtDNA was detected in association with increased 8-hydroxydeoxyguanosine content in the heart mitochondrial DNA (mtDNA) from a patient with premature aging and mitochondrial cardiomyopathy, who carried a mutation within the mitochondrial tRNA(Asp) gene. This result suggests that damage to mtDNA by hydroxyl radical and accumulation of deleted mtDNA can be accelerated by a specific mitochondrial genotype. Similarly, extensive fragmentation of mtDNA was also detected in cultured cells exposed to a high oxygen concentration atmosphere, implying that mtDNA is vulnerable to reactive oxygen species. To clarify the role of point mutations accumulated in mtDNA, we examined the sequence heterogeneity of mtDNA in the skeletal muscle of a MELAS patient who carried a mutation within the mitochondrial tRNA(leu)(UUR) gene. The analysis revealed that the frequency of mutant clones in the MELAS muscle was significantly higher than those in an age-matched control muscle and a control placenta. Some of these nucleotide substitutions were missense and nonsense mutations, which potentially have deleterious effects on the mitochondrial function. The frequency of nucleotide substitutions in the striatum of three patients with Parkinson's disease was also significantly higher than that in control tissues. We also observed increased protein modification by 4-hydroxy-2-nonenal, a lipid peroxidation by-product, in Parkinson's disease. These results suggests that a vicious cycle contributes to the progression of degenerative process. In this cycle, first a primary mitochondrial mutation(s) induces a mitochondrial respiratory defect, which increases the leakage of reactive oxygen species (ROS) from the respiratory chain. Then the ROS would trigger accumulation of secondary mtDNA mutations in postmitotic cells, leading to further aggravation of mitochondrial respiratory defects and increased production of ROS and lipid peroxides from mitochondria, and thus resulting in degeneration of cellular components.

New jet irrigation bipolar system

Irrigation bipolar systems are particularly useful for the washout of hematomas in subarachnoid hemorrhage during the acute stage of surgery and for preventing adherence of tissue to the bipolar tips during coagulation. These systems have become essential tools, and numerous improvements have been made to them. First, regarding the flow volume, both the interval of droplets and the size of individual water droplets can be adjusted. Second, this system is equipped with two major functions. The first is a preirrigation function, in which a small amount of irrigation water flows before operation of the bipolar coagulation. This wets the bipolar tips, eliminating any heat remaining from the previous use. Another function is postirrigation; after the coagulation has stopped, continuous irrigation is quickly provided to achieve a standby state by cooling down the tissue and the tips of the bipolar forceps. By using both of these functions, mild coagulation without adherence of burned tissue and clots to the bipolar forceps and minimization of residual heat during frequent use can be achieved. This article describes the new jet irrigation bipolar system and the use of an actual system that combines jet irrigation functions with the new cooling functions.

Patients with renal cysts associated with renal cell carcinoma and the clinical implications of cyst puncture: a study of 223 cases

OBJECTIVES

To clarify the association between renal cysts and renal cell carcinoma (RCC), we analyzed patient demographics, types of cystic disease, and modes of cyst-tumor coexistence along with the results of cyst puncture.

METHODS

A total of 507 hospitals provided information regarding clinical experiences with RCC and cyst puncture over a 2-year period.

RESULTS

Renal cysts were identified by preoperative imaging in 223 (4%) of 5721 patients with RCC. Histologic examination revealed cystic RCC in 56 patients (25%) and RCC associated with cystic diseases in 167 (75%). Cystic disease included simple cysts in 72 patients (32%), acquired cystic disease of the kidney (ACDK) in 62 (28%), multilocular renal cysts in 20 (9%), polycystic kidney in 3 (1%), and unspecified or miscellaneous in 10. Cyst puncture performed in 47 (21%) of 223 patients demonstrated bloody fluid in 20 cases and nonbloody fluid in 27. Cytologic analysis of cystic fluid obtained from 37 patients revealed a malignancy in 5 (14%), accounting for 25% of the bloody and 4.8% of nonbloody specimens. Cytology failed to detect RCC in ACDK and multilocular cysts but was positive in cases of cystic RCC and solitary cysts. Four of 5 cytology-positive cases comprised those of tumor in cyst and cyst within tumor.

CONCLUSIONS

Simple cysts and ACDK accounted for 60% of the renal cysts associated with RCC. Cystic RCC was involved in 25% of cases. Positive cytology may be expected in select cases, including those with close cyst-tumor relationships and those involving bloody cyst fluid. However, negative cytology does not exclude RCC.

[Histopathological prognostic factors in 146 patients with renal cell carcinoma: comparison between incidental and non-incidental cases]

To characterize the prognostic factors among pathological structural pattern, cell type, infiltration, and incidental or non-incidental renal cell carcinoma (RCC), we reviewed the records of 146 patients with RCC who underwent nephrectomy at our institute. The patients were 26 to 86 years old (mean age 58). The men-to-women ratio was 3.2:1. The tumor originated in the right kidney in 83 patients and in the left in 63. The solid pattern was associated with poorer survival than other patterns (p < 0.01). Spindle or pleomorphic cell type had poorer survival than common type (p < 0.01). The number of incidentally discovered RCC has increased since 1986, and survival is better than in non-incidental RCC, because of smaller tumor size, low stage tumor (stages 1, 2; 83.6%), and fewer papillary or solid type. In addition, there were no spindle or pleomorphic cell type, grade 3 or INF gamma-positive case. Survival is good even when the tumor is large.

Effect of herbimycin A on renal cancer cell growth

We investigated the effect of herbimycin A on the monolayer growth of 4 human renal cell carcinoma (RCC) cell lines and a normal renal tubular cell line (RTC 13) using MTT [3-(4,5-dimethylthiszol-2,5-diphenyl tetrazolium bromide)] assay. Herbimycin A induced remarkable growth inhibition in each RCC cell line tested, without any morphological changes of the cells. At the concentration of 500 ng/ml, herbimycin A caused more than a 30% growth inhibition in all RCC cells (p < 0.005 vs RTC 13), while less than 7% growth inhibition was observed in RTC 13 at the same herbimycin A concentration. The cell cycle was estimated by analysing DNA (deoxyribonucleic acid) content using a FACS. A DNA histogram of RCC cells treated at herbimycin A showed a block in the cell cycle at the S and G2M phases. However, little effect by herbimycin A on RTC 13 cells was observed. Our results suggest that protein tyrosine kinases inhibitors, like herbimycin A, may offer a new treatment option for RCC patients.

Polymerase chain reaction and an outer membrane protein gene probe for the detection of Porphyromonas gingivalis

A sensitivity assay for Porphyromonas gingivalis based upon the polymerase chain reaction (PCR) was developed. A 426-bp sequence, including a DraI-HincII DNA fragment (278 bp) encoding the 40-kDa outer membrane protein of the P. gingivalis gene was amplified. PCR products were obtained from chromosomal DNAs of the P. gingivalis strains tested but not from those of other oral microorganisms. The lower limit of template DNA detection was 10 pg with 30 cycles and 100 fg with 40 cycles of PCR by agarose gel electrophoresis. The PCR products were hybridized with DraI-HincII DNA fragment internal to the PCR primers regions used. The lower limit of hybridization detection was 10 pg and 10 fg of template DNA with 30 and 40 cycles of PCR, respectively. These results demonstrated the simplicity, rapidity and specificity of the procedure, as well as the use of the DraI-HincII DNA fragment in the identification of P. gingivalis.

An upregulation of interleukin-2 receptor, transferrin receptor expression and cytokine production mediated by hemin in human peripheral blood mononuclear cells

BACKGROUND

We previously reported that hemin-induced mitogenicity in mouse splenocytes was potentiated up to two-fold by interleukin (IL)-2, and the combination of hemin and IL-2 was also effective in inducing cytotoxicity for NK-resistant target cells. The purpose of this study was to investigate the effects of hemin both on expression of membrane surface receptors and on production of cytokine in human peripheral blood mononuclear cells (PBMC).

METHODS

Human PBMC were obtained from 16 healthy volunteers. We analyzed hemin-mediated surface phenotypes of cells using flow cytometry, and levels of tumor necrosis factor (TNF)-alpha and interferon (IFN)-gamma in the culture-supernatant of cells by ELISA system.

RESULTS

Hemin induced increased expression of both transferrin receptor and IL-2 receptor (CD25) on PBMC in a dose-dependent manner. When the combination of hemin (30 mumol/L) and IL-2 (100 U/mL) was added to the culture of PBMC, the population of double positive cells was increased up to 70.4%. These effects of hemin were enhanced by the addition of catalase in the culture. Treatment with hemin plus IL-2 effectively enhanced the production of TNF-alpha and IFN-gamma in PBMC.

CONCLUSION

Hemin upregulated both IL-2 receptor and transferrin receptor expression, and stimulated TNF-alpha and IFN-gamma production in PBMC. IL-2 cooperated with hemin in eliciting these effects.

Reevaluation of enzyme-linked immunosorbent assay with ultraviolet-treated polystyrene microtiter plates for measurement of antibodies to dsDNA

We reevaluated the efficacy of enzyme-linked immunosorbent assay (ELISA) with ultraviolet (UV)-treated polystyrene microtiter plates (UV-ELISA) for the detection of human serum anti-dsDNA antibodies. The subjects consisted of 38 patients with systemic lupus erythematosus (SLE). The titers of IgG serum anti-dsDNA antibodies by UV-ELISA were significantly (p < 0.01) higher in sera from 26 active SLE patients than in those from 12 inactive SLE patients. ELISA with poly-L-lysine coated microtiter plates (PLL-ELISA) revealed the similar results. However, the background ratio was only 1.0 +/- 0.9% by UV-ELISA, which was significantly (p < 0.01) lower than that by PLL-ELISA (16.8 +/- 10.8%). These results demonstrated the efficacy of ELISA with UV-treated polystyrene microtiter plates for the measurement of human serum anti-dsDNA antibodies in patients with SLE.

Role of ceramide in stimulation of the transcription of cytosolic phospholipase A2 and cyclooxygenase 2

Several lines of evidence have implicated lipid second messengers in the signaling pathways evoked by tumor necrosis factor (TNF). In a previous study, we characterized TNF-resistant sublines derived from murine fibrosarcoma L929 cells. and demonstrated that TNF stimulation of arachidonate metabolism via cytosolic phospholipase A2, (cPLA2) was one of the pathways responsible for the killing of L929 cells. On the other hand, the sphingomyelin cycle, which generates ceramide, is also recognized as a pathway that participates in the apoptosis in certain types of cells. In this study, we evaluated the role of ceramide in TNF-signaling in L929 cells. L929 cells generated ceramide in response to TNF, whereas the TNF-resistant sublines did not. The addition of an exogenous cell-permeable ceramide analogue resulted in the elevated expression of cPLA2 and cyclooxygenase 2 mRNAs in the cells. These results suggest the role of ceramide to amplify the magnitude of signals generated through the PLA2 pathway.

Hepatocyte growth factor (HGF)-induced cell migration is negatively modulated by epidermal growth factor through tyrosine phosphorylation of the HGF receptor

Hepatocyte growth factor (HGF) stimulated cell migration of human gastric carcinoma cell lines MKN1, MKN7, and MKN28. Epidermal growth factor (EGF) also stimulated the cell migration of these three cell lines. In MKN7 cells, HGF-stimulated cell migration was rather reduced in the presence of EGF, whereas such an observation was not made with MKN1 and MKN28 cells. Therefore, we compared the effect of EGF on HGF-stimulated HGF receptor phosphorylation in these cell lines. HGF induced a rapid tyrosine phosphorylation of the HGF receptor in all these cell lines. In MKN7 cells, the increased phosphorylation was further enhanced by EGF, although EGF alone did not affect tyrosine phosphorylation of the HGF receptor. In MKN1 and MKN28 cells, EGF did not influence tyrosine phosphorylation of the HGF receptor, whether HGF was present or not. The data presented here suggest that EGF negatively modulates the cellular response to HGF by increasing tyrosine phosphorylation of the HGF receptor in certain types of epithelial cells, e.g., MKN7 cells.

Studies on the mechanism of early onset macular degeneration in cynomolgus (Macaca fascicularis) monkeys. I. Abnormal concentrations of two proteins in the retina

Cynomolgus (Macaca fascicularis) monkeys from three families, which showed symptoms of early onset macular degeneration was studied. Two proteins, albumin and glyceraldehyde 3-phosphate dehydrogenase, were found to have markedly altered concentrations in whole retina of the monkeys with early onset macular degeneration, compared with normal controls. SDS-polyacrylamide gel patterns detected a 40-70% increase in the concentration of albumin and about 65% decrease in the concentration of glyceraldehyde 3-phosphate dehydrogenase in these affected retinas. There was however no significant difference in the relative concentrations of albumin in the plasma samples of affected and normal monkeys belonging to the three families studied and to an unrelated family. These initial findings suggest that degradative as well as antioxidant enzymes might be involved in the mechanisms leading to macular degeneration. In addition, the results also correlate with a possible role of these two proteins in H2O2 toxicity and appear to indicate that oxidative stress is significant in the etiology of early onset macular degeneration.

Effect of danazol on the immunocompetent cells in the eutopic endometrium in patients with endometriosis: a multicenter cooperative study

OBJECTIVE

To assess the effects of danazol on immunocompetent cells, human leukocyte antigen (HLA) expression, and adhesion molecules in the eutopic endometrium of patients with endometriosis.

DESIGN

Antigens were localized immunohistochemically in the endometria, before treatment and during treatment (2 months later).

PARTICIPANTS

Ten patients with laparoscopically proven endometriosis who consented to participate in this study were treated with 400 mg/d of danazol for 4 months. Forty-two infertile patients without endometriosis or adenomyosis served as controls.

RESULTS

Immunohistochemical analysis revealed significantly increased expression of the T cell subsets, macrophages, adhesion molecules, and HLA antigens in eutopic endometrium in patients with endometriosis compared with the infertile group. Treatment with danazol reduced the number of cells in T cell subsets, adhesion molecules, or HLA antigen expression, especially of gamma delta T cells, to 39.5% of the pretreatment value in patients with endometriosis.

CONCLUSIONS

Danazol had an immunomodulatory effect on the autoimmune response in endometrium associated with endometriosis.

Different apoptotic pathways mediated by Fas and the tumor-necrosis-factor receptor. Cytosolic phospholipase A2 is not involved in Fas-mediated apoptosis

Fas is a cell-surface receptor that belongs to the tumor-necrosis factor (TNF)/nerve growth factor receptor family. Fas can transduce an apoptotic signal through the death domain in the cytoplasmic region, which has similarity with the corresponding region of the TNF type-I receptor. Here, we expressed human Fas in mouse L929 cells or its subline (C12), which express extremely low levels of cytosolic phospholipase A2 (cPLA2). L929 cells were sensitive to the cytotoxic activity of TNF, while C12 cells were resistant. Cross-linking of human Fas with anti-(human Fas antibody) Ig killed both L929 transformants and C12 transformants expressing human Fas. Various inhibitors of the arachidonate metabolism significantly inhibited the TNF-induced cytotoxicity in L929 cells, but they did not have any effect on Fas-mediated apoptosis. These results indicated that cPLA2 is required for TNF-induced apoptosis, whereas it is dispensable for Fas-mediated apoptosis, and suggested that the TNF receptor and Fas use different signaling pathways for apoptosis.

Analysis of phosducin as a candidate gene for retinopathies

Phosducin, a retina-expressed gene mapped to chromosome 1q25-32.1, was analyzed as a candidate gene for retinopathies. The phosducin gene was cloned and characterized, and PCR primers were designed. Eighty-three patients with various retinopathies and 45 control subjects (24 American, 21 Japanese) were analyzed for mutations in the phosducin gene by PCR, denaturing gradient gel electrophoresis (DGGE), and sequencing. A heterozygous sequence variant changing a glycine to arginine at codon 178 was found in one Usher syndrome type II (USH2) patient, while the other USH2 patients did not show any coding sequence variant. A heterozygous sequence variant changing an asparagine to lysine at codon 174 was found in a patient with a severe retinal degeneration in the category of diseases known as acute zonal occult outer retinopathy (AZOOR). Three non-coding sequence variants were found. Two of these were always present together and found in 20.8% of American and 2.4% of Japanese control subjects, reflecting a difference in population pools. In conclusion, the phosducin gene did not show mutations consistent with it being the causative gene for USH2, but its possible pathogenicity in AZOOR or other retinopathies remains an open question which may be answered by further analysis.

[Bucillamin induced lung injury in rheumatoid arthritis]

Thirteen cases with rheumatoid arthritis who experienced lung injury during the treatment with bucillamine (Bc), about whom the questionnaires were answered by the physicians and whose X-ray films could be rechecked, were studied. Nine cases out of the 13 showed patchy mottled infiltrates in the bilateral center sparing the periphery, and the other 4 showed diffuse infiltrates. In these 9, serum gamma-globulin level decreased when lung injury appeared. The gamma-globulin level before the start of Bc administration, the level when lung injury appeared, the gamma-globulin decrease, and its ratio to the level before Bc were 1790 +/- 661 mg/dl, 1297 +/- 666 mg/dl, 459 +/- 320 mg/dl and 29.1 +/- 18.0%, respectively. In 5 out of the 9, gamma-globulin level reincreased when they recovered from the injury: 2 out of the 5 showed the reincrease even after steroid therapy. The data were obtained only from 2 out of the 4 with diffuse pattern in X-ray, and the decrease and the decrease ratio were 200 mg/dl (5.8%) in 1, and 49 mg/dl (3.6%) in the other. The characteristics of Bc-induced lung injury might be mottled infiltrates in the center appearing concurrently with serum immunoglobulin decrease.

Arterial reconstruction of the posterior segment after central bisegmentectomy and caudate lobectomy

A 71 year old woman was admitted with jaundice and found to have a tumor originating from the cystic and common hepatic ducts, which infiltrated the origins of the right bile duct and duct of Spiegel. The tumor was also shown to encase the right hepatic artery. A central bisegmentectomy with concurrent caudate lobectomy was performed using the right gastroepiploic artery for reconstruction of the posterior segmental branch of the right hepatic artery. Celiac angiography conducted 3 weeks postoperatively confirmed the patency of the hepatic segmental arterial anastomosis. The patient had an uneventful recovery with no evidence of liver failure, and was discharged home thirty-two days. Tumors infiltrating the right hepatic artery, which have traditionally been treated with extensive liver resection, can be managed with hepatic segmentectomy and reconstruction of the segmental hepatic artery.

[Left ventricular pseudoaneurysm recognized 9 years after mitral valve replacement and repeated heart failure of 3 years duration: a case report]

A 66-year-old woman had suffered from repeated heart failure beginning 6 years after mitral valve replacement. Left ventricular pseudoaneurysm was discovered 9 years after the replacement, while no evidence including histology was obtained for the cause of the pseudoaneurysm except the mitral valve replacement. The progression of aortic valve stenosis and the formation of the pseudoaneurysm may have contributed to the onset of congestive heart failure. Surgical treatment was successful. Although left ventricular pseudoaneurysm after mitral valve replacement is rare, careful echocardiographic examination is necessary for detecting such a complication in patients after surgery.

Exercise beta-methyl iodophenyl acid (BMIPP) and resting thalium delayed single photon emission computed tomography (SPECT) in the assessment of ischemia and viability

To clarify the significance of exercise BMIPP (beta-methyl iodophenyl pentadecanoic acid) and resting T1 delayed single photon emission computed tomography (SPECT) in the assessment of ischemia and viability, we studied maximal exercise-loading BMIPP SPECT following rest-injected T1 3 h SPECT in 11 control subjects, 20 patients with effort angina and 38 patients with old myocardial infarction. The left ventricular wall on ECT was divided into 9 segments. BMIPP and T1 uptake were scored as 0 = normal, 1 = reduced, 2 = severely reduced, or 3 = absent. Discordance was defined as when segments with a reduced BMIPP uptake had a better resting T1 uptake. Significant coronary artery stenosis was defined as stenosis of 75% or greater on coronary arteriogram. Left ventricular wall motion was assessed as either normokinesis, hypokinesis, severe hypokinesis, akinesis or dyskinesis on left ventriculogram. When discordance was considered to be a marker of ischemia, the sensitivity and specificity in effort angina and control subjects were 95.2% and 84.6% for patients and 83.9% and 94.4% for diseased vessels, respectively. There were no differences between the sensitivity and specificity in left anterior descending artery (LAD), left circumflex artery (LCx) and right coronary artery (RCA) lesions (83.3%, 95.5% in LAD, 83.3%, 95.5% in LCx, 85.7%, 92.6% in RCA, respectively). All of the patients with old myocardial infarction had reduced exercise BMIPP uptake in infarcted regions. In old myocardial infarction, 35 patients had segments with discordant uptake. Discordance was observed in 75 (91.5%) of 82 segments with hypokinesis, and in 24 (92.3%) of 26 segments with severe hypokinesis. Even among the 36 segments with akinesis or dyskinesis, 25 (69.0%) had discordant uptake. When discordance in the infarcted region was considered to be a marker of viability, regions with severe asynergy showed a high possibility of viability. Thus, discordant uptake on exercise BMIPP and resting T1 delayed SPECT may be a useful marker of ischemia in effort angina and of viability in old myocardial infarction.