[Stomach cancer mortality and nutrition intake in northern Japan--especially on relation to sodium chloride]

There is a big difference on the stomach cancer (SC) mortality between the north-western and the north-eastern parts of Honshu (mainland of Japan) although not much differences on cerebrovascular disease (CVD) mortality can be observed between these two areas while both of these diseases are said to be related to high-salted diets. The relation between diet and age-adjusted mortality of SC and CVD in northern Honshu was examined here, based on the results of the nutrition survey carried out by prefecture office (1971-87, 6 prefectures, total of 18 data sets). The results are summarized as follows: 1. There are no significant differences on salt intake between the north-western and the north-eastern parts of Honshu. 2. Intake of milk and dairy products is negatively related to SC. 3. Intake of animal protein is negatively related to CVD.

[Quantitative assessment of myocardial viability following coronary artery bypass grafting using exercise thallium-201 myocardial single photon emission computed tomography and left ventricular regional wall motion]

Using exercise thallium-201 myocardial single photon emission computed tomography (SPECT) and % radial shortening (%RS), 58 patients were evaluated before and after coronary artery bypass grafting (CABG) to quantitatively assess myocardial viability and the effect of CABG. The patient was classified, according to redistribution pattern, as group I with only complete redistribution (20 cases) and group II with including incomplete redistribution (22 cases) and group III with no redistribution (16 cases). 1. Group I was expected complete improvement of ischemic myocardium after CABG but regional left ventricular wall motion was unchanged (sigma i%RS: 142.5 +/- 54.7----138.4 +/- 39.6, sigma a%RS: 201.2 +/- 51.1----238.2 +/- 68.2). 2. Group II was expected to diminish ischemic size after CABG and left ventricular regional wall motion was significantly improved (sigma i%RS: 68.8 +/- 25.9----154.9 +/- 42.6 p less than 0.01, sigma a%RS: 108.4 +/- 62.3----178.9 +/- 77.6, p less than 0.05). 3. Group III was no significant change of ischemic size and left ventricular wall motion after CABG (sigma i%RS: 67.8 +/- 24.1----83.9 +/- 19.2, sigma a%RS: 86.0 +/- 29.0----94.0 +/- 33.9). The present study suggests that quantitative assessment of myocardial viability using exercise thallium-201 myocardial SPECT and %radial shortening was useful method to determine the indication and to assess the effect of CABG.

[Modified Fontan operation of single ventricle with D-TGA]

An 8-year-old boy who had previously received two systemic pulmonary shunts, underwent successfully direct anastomosis between SVC and right pulmonary artery (bidirectional Glenn shunt), and proximal side of SVC and main pulmonary artery. Post operative course was uneventful with pleural effusion during a shot period. Post operative right atrial pressure was 9/5 mmHg without evidence of live swelling.

De Vega's annuloplasty for acquired tricuspid disease: early and late results in 110 patients

From January 1978 through February 1989, 110 tricuspid annuloplasties (De Vega's procedure) were performed in association with mitral and combined mitral and aortic valve disease. Preoperatively, 106 (96%) of 110 patients were in New York Heart Association functional class III or IV. There were seven early deaths (6.3%), and 3 patients, 2 with mitral lesions and 1 with a combined lesion, died during a follow-up period of 3 to 52 months (mean follow-up, 22 months). Four patients (3.6%) required reoperation because of biological mitral valve failure at 5 to 8 years after tricuspid annuloplasty (mean period, 6.6 years). Twenty-three (62%) of 37 randomly selected patients evaluated by echocardiography and 14 (70%) of 20 patients evaluated by right ventriculography showed complete disappearance of tricuspid regurgitation after tricuspid annuloplasty in 1 to 18 months (mean period, 3.3 months). Seventy-seven (96%) of the survivors were in functional class I or II after tricuspid annuloplasty. The actuarial survival rate for the TAP series including early deaths was 85.8% +/- 7.4% at 10 years and the actuarial rate of freedom from reoperation on the tricuspid valve was 96.7% +/- 1.4%. Our surgical experience indicates that the De Vega's annuloplasty, as the method of first choice, is a simple, reliable procedure and resulted in improvement in 90% of patients with moderate to severe functional tricuspid regurgitation.

[Effectiveness of the bidirectional Glenn shunt for the univentricular heart]

Two cases underwent a modified Fontan operation with simultaneous superior vena cava-right pulmonary artery end-to-side anastomosis, which we called "bidirectional Glenn shunt". This anastomosis seems to be so effective for reduction of right arterial volume loading, and could proved life-saving in the case with the acute obstruction at the site of the right atriopulmonary artery anastomosis immediately after surgery.

[A case of left ventricular pseudoaneurysm with severe cardiac failure and premature ventricular beats]

A surgically successful case of left ventricular pseudoaneurysm 10 years after an acute myocardial infarction was reported. A 63-year-old man had an acute inferior myocardial infarction 10 years ago. Recently congestive heart failure and premature ventricular beats developed. He was diagnosed as a left ventricular pseudoaneurysm by echocardiogram, CT scan, and left ventriculogram. After the operation, the symptoms diminished and improvement of left ventricular function was observed. A brief review of the literature is given.

[The treatment of accompanied organ failure after thoracic and cardiovascular surgery with mechanical organ-supports]

Five hundred and thirty-three patients have been treated after thoracic and cardiovascular surgery in our ICU during the last four years. Cardiac failure was shown in 150 cases, respiratory failure in 132 cases, renal failure in 76 cases, and hepatic failure in 84 cases. The appropriate mechanical organ-supports (MOS) were applied in the following cases: intra-aortic balloon pumping (IABP) in 48 cases, veno-arterial bypass (VAB) in 18 cases, left ventricular assist device (LVAD) in 1 case, respirator in 132 cases, continuous hemofiltration (CHF) in 44 cases, hemodialysis (HD) in 13 cases, peritoneal dialysis (PD) in 21 cases, Continuous intensive peritoneal dialysis (CIPD) in 7 cases, and plasma exchange (PEx) in 22 cases. The results of MOS6 which required exocorporeal circulation were not satisfactory, especially CHF (mortality rate 75.0%), HD (76.9%), and VAB (100%). Though, the results of IABP (35.4%) and CIPD (14.3%) were significantly better. The main cause of early death (within 6 post-operative days) was low output syndrome (LOS) (63.6%). However, that of late death (beyond 14 post-operative days) was sepsis (66.7%). Therefore, it is important for the survival of these patients to control LOS during the early post operative period and then to concentrate on the prevention of infection.

[A case report of surgical treatment of dissecting aneurysm of the thoracic aorta (DeBakey IIIb) with chronic renal failure]

The patient has been receiving hemodialysis (H.D.) for chronic renal failure due to polycystic kidney since last February. He suddenly had back pain and short of breath February 8, 1988. He was pointed out to have hypertension and cardiomegaly on chest roentgenogram. He was transferred to our hospital, and suspected dissecting aneurysm. Magnetic resonance imaging was useful for the diagnosis of the dissecting aneurysm and may have a potential advantage in following up the residual false lumen. The patient underwent graft inclusion technique for dissecting aneurysm of the thoracic aorta of type IIIb with an aid of partial femoro-femoral bypass. The water and electrolytes balances were controlled by GI therapy and hemoconcentrator during operation. Since serum potassium level was gradually increasing up to 7.8 mEq/l inducing arrhythmias with coronary arterial spasm postoperatively, H.D. was instituted. The induction of H.D. was easily performed with satisfactory results. Heparin was not used while blood coagulation profiles tended to be low in early postoperative period. He returned to his work this August.

[Implications of preoperative angiography and coronary artery bypass grafting for patients with combined coronary artery and great vessels diseases]

Preoperative coronary angiography showed that the significant coronary artery disease (CAD) was present in 47% of patients with thoracic aortic aneurysm (TAA), abdominal aortic aneurysm (AAA), or aortoiliac occlusive disease (A.I). Fifty-seven patients underwent the both coronary artery and great vessel diseases on the simultaneous or sequential stage. As CAD, 13 patients had one vessel disease (VD), 18 had two-VD, 26 had three-VD and 4 of them had left main trunk lesions. As great vessel diseases, 23 patients had A-I, 20 had AAA, 8 had TAA, 5 had TAA+AAA, and 1 had TAA+A-I. There were 4 early deaths (7%) in 57 patients, and 4 (3%) in total 120 coronary and great vessel's operative procedures. The 5-year survival rates were 57.4 +/- 15.5% for TAA, 87.1 +/- 8.5% for AAA and 63.9 +/- 11.1% for A-I, which were not significantly different from those of patients without CAD, respectively except for TAA. The present data suggest that preoperative coronary angiography and CABG in the selected patients may have the beneficial effects on survival and quality of life.

Wada-Cutter heart valve: overall experience at the Sapporo Medical College

We performed cardiac valve replacement using the Wada-Cutter valve in 124 patients during the 9 years between 1966 and 1974: aortic valve replacement in 48, mitral valve replacement in 56, tricuspid valve replacement in 9, and multiple valve replacement in 11. Sixteen patients died within 30 days after operation, and 34 died in the late postoperative period, with a cumulative mortality rate of 40.3%. Postoperative complications included valve thrombosis in 9 patients, thromboembolism in 4, and mechanical valve failure in 5. The Wada-Cutter valve, first described at the Annual Meeting of The Society of Thoracic Surgeons on January 27, 1967, in a discussion on the paper by Cooley and colleagues on mitral valve replacement with a discoid valve, attracted attention for its unique design. Four of the Wada-Cutter valves were incorporated in Liotia's total artificial heart, which was implanted clinically for the first time in Cooley's second-stage heart transplantation. It may not only claim to be the origin of today's most popular tilting-disc heart valves but also has some original concepts with regard to bileaflet and tricuspid tilting-disc heart valves. However, at that time, cardiac valve replacement with this prosthesis resulted in a high incidence of thrombosis without systemic anticoagulation and in mechanical valve failure due to hinge wear of the Teflon occluder. For these reasons, its clinical use was discontinued in 1974. If Pyrolite carbon had been adopted in construction of the valve when it first became available, the valve design could have been useful even today.

[Long-term results of cardiac valve replacement: a 10- to 25-year retrospective study]

A total of 149 patients who underwent cardiac valve replacement between January, 1964 and June, 1979 in our institution have been survived more than 10 years postoperatively. The prosthetic valves primary employed in this series were both mechanical valve such as Starr-Edwards, Smeloff-Cutter, Wada-Cutter, Lillehei-Kaster valves and biological valve such as Hancock valve. Of these, 69 patients (46%) implanted with Starr-Edwards or Wada-Cutter valve were not anticoagulated postoperatively, and 52 (53%) underwent reoperation mainly for valve-related complications or aggravated other valve lesions during the follow-up period. One hundred and thirteen patients were confirmed to be alive at the end of June, 1989, with the follow-up period of 10 to 25 years. Of these, 98 patients (87%) are in the NYHA I or II at the present time. Other twenty-two patients were dead and fourteen were lost to follow-up over 10 years after operation. Although cardiac valve replacement may improve the longevity and the quality of life, available prosthetic valves were not ideal both in material and design. The increased risk of thrombogenesis of mechanical valve and the limited durability of biological valve necessitated re-replacement in the long-term period. Therefore, in addition to selection of the appropriate valve prosthesis, and optimal prevention of valve-related complications, early diagnosis and treatment of these complications are important to improve the long-term results of cardiac valve replacement.

[Evaluation of left ventricular function in the patients with aortic regurgitation following aortic valve replacement by radionuclide cardiography]

Twenty patients undergoing AVR were subjected to this study and divided into the early and the late groups. 6 healthy adults were dealt as the control group. The EF, PER, 1/3 EF, TPE were compared among these three groups both at rest and during exercise. The detailed responses to the exercise were measured by %delta between at rest and during exercise. Furthermore, the LV function in the filling period were examined by the 1/3 FF and RFR at rest. This study suggests that although the left ventricular function and contractile reserve to the exercise remained insufficient in the early postoperative phase, nearly complete recovery of the reserve could be obtained in the later phase, while the left ventricular function in the rapid filling period was significantly decreased in both early and late postoperative phase.

[Successful right pneumonectomy in pulmonary aspergilloma]

Right extrapleural pneumonectomy was performed on a 50-year-old male with aspergilloma suffering from severe hemoptysis. The post operative course was uneventful and he was discharged on the 30th day following operation. Aspergilloma is a potentially life threatening disease with large hemoptysis. So surgery is the only choice for treatment. We discussed the preoperative and postoperative problems including selection of the operative techniques for pulmonary aspergilloma.

[Total graft replacement of the thoracoabdominal aorta with reconstruction of visceral branches, intercostal and lumbar arteries in expanding chronic dissecting aneurysms of the thoracoabdominal aorta]

Four patients with expanding chronic dissecting thoracoabdominal aneurysm underwent total replacement of the thoracoabdominal aorta with reconstruction of all visceral branches, intercostal and lumbar arteries with the aid of femoro-femoral bypass. During aortic cross-clamping, selective celiac and both renal arteries perfusion was performed to prevent the organ ischemia. Somatosensory evoked potentials monitoring or spinal cord evoked potentials monitoring was also performed to detect the spinal cord ischemia. Surgical technique employed in this series was direct anastomosis of onlay patch graft to the normal true lumen from which visceral branches and intercostal and lumbar arteries arise. The celiac artery and left renal artery arise from the false lumen in some cases were reconstructed with graft interposition or direct anastomosis to an opening made in the onlay patch graft. All patients survived the operation, and are leading normal life late in the postoperative period except one who developed partial paraplegia. Total graft replacement of the thoracoabdominal aorta may be a valid technique for the treatment of expanding aneurysms of the dissecting thoracoabdominal aorta.

[Quantitative analysis of myocardial revascularization on left ventricular diastolic function]

To evaluate the effects of myocardial revascularization on left ventricular diastolic function, we studied three groups of subjects. Group I consisted of 10 patients without any previous myocardial infarction. Group II consisted of 10 patients with previous myocardial infarction. The control group consisted of 8 normal subjects, all with no evidence of cardiac disease as determined by cardiac catheterization. Left ventricular diastolic function was assessed by maximum negative dp/dt, constant T, diastolic compliance and 1/3 fractional filling before and after surgical revascularization. (1) Constant T, maximum negative dp/dt and diastolic compliance: There was no significant difference among groups I, II and the control group preoperatively, and the variables were not improved postoperatively. (2) 1/3 fractional filling: 1/3 fractional fillings in groups I and II were significantly lower (p less than 0.05, p less than 0.01) than the control group preoperatively, and it was significantly improved in group I, but unchanged in group II postoperatively. In conclusion, myocardial revascularization improves left ventricular diastolic function in the patients without previous myocardial infarction. The effects of myocardial revascularization, however, in the patients with prior myocardial infarction do not bring about an enhancement of left ventricular diastolic function.

[Surgical management of acquired tricuspid valve disease--the effects and comparison of tricuspid annuloplasty (De Vega) and tricuspid valve replacement]

A total of 92 patients with tricuspid valvular disease (TR) had surgical repair of DeVega's annuloplasty in 80 patients (87%) and of valve replacement in 12 patients (13%) from January, 1978, to March, 1988. All of those patients were diagnosed by cardiac catheterization and angiogram, clinical findings and in recent cases, pulsed and color Doppler echocardiography were applied. Eighty-nine of 92 patients (97%) were in NYHA class III or IV before operation. There were 7 early death (8.5%) with DeVega procedure and one death (8.3%) in TVR and late deaths were noted in 3 patients (3.6%) (DeVega's procedure) and one (8.3%) in TVR. Two patients after DeVega procedure at 5 and 6 years were required re-operation of TVR because of recurrent mitral valvular disease. Seventy-seven of 80 survivors were in NYHA class I or II postoperatively. Twenty-seven randomized selected patients after DeVega's annuloplasty were investigated by pulsed and color Doppler echocardiography, 17 of them (63%) had no regurgitation and the remaining 10 patient had mild to moderate regurgitation. This study suggests that DeVega's annuloplasty has a simple and reliable procedure in patients with functional TR and results in excellent hemodynamic and functional effects postoperatively.

A case of a right coronary artery to left ventricle fistula observed over twenty years

Since the natural history of a coronary artery to left ventricle fistula is not well known, a case of such a fistula in 36-year-old female patient, followed for 20 years is presented. Two-dimensional echocardiography performed as a follow-up examination revealed enlargement of the right coronary artery and the right Valsalva sinus. Two-dimensional color flow mapping showed the jet flow to the apex from the base of the left ventricle only during the diastolic phase. An aortogram confirmed that enlargement of both the right coronary artery and the right Valsalva sinus had occurred during the 20 years. The shunt flow ratio was about 50%. The Symbas procedure, closing of the coronary artery fistula by arteriotomy directly over the site of the fistula, was performed with the aid of extracorporeal circulation. Our findings indicate that enlargement of the shunted coronary artery and its Valsalva sinus can occur gradually where there is a relatively large shunt flow. Therefore, early surgical treatment is recommended in cases like this one.

[Clinical evaluation of low cardiac output syndrome following adult open heart surgery]

Between April, 1984 and December, 1988, 450 adult patients underwent open heart surgery for the valvular heart disease (VHD) and ischemic heart disease (IHD) in our institution. As the postoperative complication, LOS was observed in 33 patients with VHD (14.2%), and in 27 patients with IHD (12.4%) with no significant difference between the two groups. Treatment for LOS employed in this series consisted of pharmacological therapy in 11 patients, IABP in 42, IABP+veno-arterial bypass (VAB) in 5, right heart bypass (RHB)+IABP in 1 and left ventricular assist device (LVAD)+IABP in 1. All patients who were treated by the pharmacological therapy were alive and were discharged. Eighty-one % of the patients who were assisted with IABP were able to weaned off IABP, and 57% of the patients were alive and were discharged. All patients who were assisted with IABP+VAB died of LOS within 3 days after the operation. One patients who was assisted with RHB+IABP for pulmonary hypertension after emergency re-MVR and the other patient with LVAD+IABP for LOS after emergency CABG were able to be weaned off the assisted circulation and were discharged from the hospital. The salvage rate of patients with IHD by mechanical assisted circulation was generally higher than that of patients with VHD. Because of the limitation of IABP or VAB effect on the hemodynamic, LVAD directly assisted cardiac function would be indicated for severe LOS following open heart surgery without delay.

Double exposure speckle technique for imaging system analysis and use in rod lens arrays

New double exposure speckle techniques for imaging system analysis are developed and their feasibility is experimentally examined. Using a single convex lens as the test lens, the MTF of the lens is obtained from the measured visibility of Young's fringes which have been produced by Fourier transforming a double exposure specklegram recorded through the test lens. By using conventional optical filtering techniques the spatial variations in the imaging quality are visualized for GRIN rod lens arrays.

Surgical treatment of aneurysms of the transverse aortic arch

Over the past four years, 21 patients have been operated for aneurysms of the thoracic aorta requiring aortic arch reconstruction. The causes of the aneurysms were dissecting aneurysms of the aorta (type A) in 16 patients and atherosclerosis in 5 patients. To prevent cerebral ischemia during operation, selective cerebral perfusion (SCP) (600 ml/min at 25 degrees C) was employed in 11 patients and hypothermic circulatory arrest (HCA) at 15 degrees C in 10 patients. There were three early deaths (14.3%) in the series. There were no serious neurologic complications in either group. The present data suggests that both selective cerebral perfusion SCP and HCA are useful methods for cerebral protection during resection of aortic arch aneurysms, although the latter method has the limitation of restricted cerebral arrest time.

[Comparative analysis of mechanical and biological prosthetic valves after isolated valve replacement--cooperative study on total 1281 patients]

A total of 1281 patients (594 aortic and 687 mitral) received 734 mechanical valves (320 Björk-Shiley, 283 SJM and 131 Omniscience) and 547 biological (259 ionescu-Shiley, 227 Hancock, and 61 Carpentier-Edwards) were analyzed for postoperative valve dysfunction and thromboembolism. The actuarial survival rates (free from late cardiac deaths and valve-related deaths) were 88.6% (11 years) for mechanical mitral and 86.0% (11 years) for biological mitral valves, and 91.7% (16 years) and 88.5% (12 years), for mechanical and biological aortic valves, respectively. There were no significant differences among these groups. Actuarial rates of freedom from valve-related events were 88.7% (11 years) and 51.7%, for mechanical and biological mitral valves, respectively. There was significant difference between the two types of valves in over 7 years after surgery. In contrast, there were no significant differences between mechanical and biological aortic valves. Actuarial rates of freedom from valve dysfunction were 97.6% (11 years) for mechanical and 56.5% (12 years) for biological mitral valves. The net 12 year results showed no significant differences between the two types of mitral prosthetic valves, but a significantly increased rate of valve dysfunction in the biological mitral valves compared with the mechanical in over 6 years of the study. Concerning AVR, there were no significant differences in the incidence of valve dysfunction between mechanical and biological aortic valves. Actuarial rates of freedom thromboembolism were 92.3% (11 years) and 93.8% (11 years) for mechanical and biological mitral valves, respectively. There were no significant differences between the two types of mitral prosthetic valves.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diltiazem blood cardioplegia in patients of severe valvular heart disease]

This study was undertaken to analyze the effect of diltiazem blood cardioplegia (D-BCP) in patients of valvular heart disease with severe left ventricular dysfunction (EF = 56.3%, FS = 26.0%, CI = 2.241/min/m3), they were satisfied with NYHA functional class 3 and 4, also cardiothoracic ratio over 65%. By negative choronotropic action of D, the heart rates in D added group tend to be less than those of D free group 4 to 16 hours postoperatively, although that may diminish the incidence of ventricular arrhythmia postoperatively. D-BCP improved better functional recovery (mPAWP-LVSWI relation) during the early postoperative period than those seen in preoperatively. The pulmonary vascular resistance index of D added group showed significantly lower levels than those in the preoperative period, 0 to 16 hours after surgery. Consequently, D-BCP might be safe and provide superior protection for severe valvular heart disease.