Cepharanthin, a multidrug resistant modifier, is a substrate for P-glycoprotein

P-glycoprotein modulators are respected to be multidrug resistance reversing agents in cancer chemotherapy. Some calcium channel blockers, calmodulin inhibitors or immunosuppressive agents have been used in clinical studies, although the dose of these drugs required to test in vitro experimental data might cause potent pharmacological effects which are not desirable in patients. By using LLC-GA5-COL150 cells that express P-glycoprotein specifically on the apical membranes, we examined the transport of anticancer drugs mediated by P-glycoprotein. Cepharanthin, a biscoclaurine alkaloid, potently inhibits the transport of vinblastine and daunorubicin, both commonly used anticancer agents. The 50% inhibitory concentration of cepharanthin on daunorubicin transport was 2.06 microM. Combined inhibitory effects on daunorubicin transport were observed when cepharanthin was used together with cyclosporin A, a potent immunosuppressive agent and P-glycoprotein modulator. Cepharanthin itself was transported by P-glycoprotein. Transcellular transport of cepharanthin across LLC-GA5-COL150 cell monolayers was saturable when its concentration was under 5 microM, and the transport was inhibited by P-glycoprotein modulators. These results indicate that cepharanthin can reverse multidrug resistance, and proper combination with other P-glycoprotein modulators could potentiate its inhibitory effect on expelling the anticancer drugs out of the cell via P-glycoprotein.

[Surgical treatment for total anomalous pulmonary venous connection of Darling type Ib and IIb, using SVC-appendage anastomosis and pedicled right atrial flap]

A eight-day-old girl with total anomalous pulmonary venous connection of type I b + IIb underwent a total correction. Right atrium (RA) was entered through a vertical incision. Atrial septal defect (ASD) in the caudal aspect of fossa ovalis was enlarged by cutting the primum tissue. RA flap was sutured to ASD and intracardiac orifice margin of SVC to create a roof of pulmonary venous channel. SVC just cranial to entrance of common pulmonary vein was oversewn. Anastomosis between the cephalad SVC and opened right atrial appendage was made. Postoperative angiography showed wide PV channel and SVC channel.

Multidrug resistance-associated protein-mediated multidrug resistance modulated by cyclosporin A in a human bladder cancer cell line

A doxorubicin-resistant subline (5637/DR5.5) from human bladder cancer cells (5637) was induced by stepwise increase in the doxorubicin concentration. 5637/DR5.5 cells were cross-resistant to vinblastine and etoposide but not to mitomycin C and cisplatin. We analyzed the mdr1, MRP (multidrug resistance-associated protein), and DNA topoisomerase II gene expression using the reverse transcription polymerase chain reaction assay (RT-PCR) and investigated possible differences in the accumulation and efflux of radiolabeled daunorubicin. 5637/DR5.5 cells do not express the mdr1 gene, but the expression levels of MRP are markedly higher than in drug-sensitive 5637 cells. The intracellular accumulation of radiolabeled daunorubicin was markedly decreased in the 5637/DR5.5 cells in comparison with the parent cells. This reduced drug accumulation was associated with an enhanced drug efflux, but was reversed when cells were incubated with cyclosporin A. Cyclosporin A at the concentration of 5 microM caused 3.4-fold enhancement of daunorubicin-sensitivity in the 5637/DR5.5 cells. On the other hand, there was no difference in DNA-topoisomerase II activity between the parent and resistant cells. The resistance of the 5637/DR5.5 cells is therefore associated with an enhanced drug efflux mediated by the MRP gene overexpression, as distinct from P-glycoprotein, and is modulated by cyclosporin A.

c-Myc and cyclin D3 (CcnD3) genes are independent targets for glucocorticoid inhibition of lymphoid cell proliferation

Glucocorticoids inhibit the expression of critical cell cycle-regulatory genes. The G1 cyclin gene CcnD3, which encodes cyclin D3, is inhibited by dexamethasone in P1798 murine T lymphoma cells. Glucocorticoids also inhibit expression of the catalytic partner of cyclin D3, Cdk4. Inhibition of these two genes results in a decrease in the ability to phosphorylate the Rb-1 tumor suppressor gene product. Stable transformation with SV40 T antigen expression vectors prevents glucocorticoid-mediated cell cycle arrest, which is consistent with the conclusion that glucocorticoids inhibit Rb-1 phosphorylation. Overexpression of cyclin D3 suffices to restore Rb-kinase activity in glucocorticoid-treated cells. Nevertheless, overexpression of cyclin D3 does not prevent glucocorticoid inhibition of cell proliferation. Cells transformed with Cdk4 expression vectors, with or without cyclin D3 expression vectors, also undergo G0 arrest in the presence of dexamethasone. Glucocorticoids inhibit c-Myc expression in lymphoid cells, and transient expression of c-Myc protein attenuates the lytic response in glucocorticoid-treated human leukemia cells (R. Thulasi, D. V. Harbour, and E. B. Thompson, J. Biol. Chem., 268: 18306-16312, 1993). However, P1798 cells stably transfected with c-Myc expression vectors are sensitive to glucocorticoid-mediated G0 arrest. Such transformants withdraw from the cell cycle when treated with dexamethasone. P1798 cells were transformed so as to express both c-Myc protein and cyclin D3 in the presence of glucocorticoids. These Myc/D3 cells continue to proliferate in the presence of dexamethasone, and virtually all of these cells are capable of entering S phase in the presence of the steroid. Rapid apoptotic cell death occurs when wild-type P1798 cells are treated with dexamethasone in serum-free medium. Myc-transformed and cyclin D3-transformed cells also die rapidly when treated with glucocorticoids in the absence of serum. T antigen transformants are resistant to glucocorticoid-mediated apoptosis in serum-free medium. Double transformants that express both cyclin D3 and c-Myc are also resistant to apoptosis in the presence of dexamethasone. We conclude that inhibition of both CcnD3 and c-Myc genes is critical to glucocorticoid-mediated G0 arrest. Furthermore, those genes that convey resistance to growth arrest also convey resistance to cell death.

[A case report of prosthetic valve replacement for malfunction of the Hancock valve in mitral position associated with recurrent peptic ulcer and renal dysfunction]

A 62-year-old woman was admitted with malfunction of the Hancock valve in mitral position. She had been suffering from gastroduodenal ulcer for about ten years. She couldn't take warfarin after 5 years later of the initial operation due to recurrent gastrointestinal bleeding. Judging from her age and renal dysfunction, we preferred mechanical valve to avoid the risks for the reoperation. After confirming the healed ulcer with administering omeprazole, we performed prosthetic valve replacement with SJM 29 M successfully. Postoperative course was uneventful and recurrence of the ulcer was not observed.

[Reoperation for coarctation of the aorta and interrupted aortic arch]

This report presented four patients who underwent surgery for restenosis after repair of coarctation of the aorta (CoA) or interrupted aortic arch (IAA) at our institution between January 1980 and October 1994. Case #1 underwent primary repair for IAA, VSD, and PDA consisting of aortic arch reconstruction using a EPTFE (expanded polytetrafluoroethylene) graft of 10 mm in diameter at the age of four years. After 17 years, pressure gradient of 58 mmHg between the ascending aorta and the descending aorta prompted the reoperation. Case #2 underwent primary repair for CoA, VSD, and PDA consisting of a bypass between the ascending aorta and the descending aorta with an EPTFE graft of 11 mm in diameter at the age of three years. After 13 years, he had reoperation because of pressure gradient of 64 mmHg. Case #3 had pressure gradient of 20 mmHg between the upper and lower limb at the hospital discharge following patch angioplasty for CoA at five years of age. He underwent unsuccessful percutaneous transluminal balloon angioplasty at age 12 and had reoperation at age 15. Case #4 underwent subclavian flap angioplasty as the first stage operation for CoA, VSD, and PDA at 1 month after birth. About 9 months after the initial operation, the pressure gradient between the upper and lower limb had reached 40 to 50 mmHg, and the patient had reoperation at the age of 1 year. The reoperation method for cases #1, #2 and #3 consisted of bypass grafting from the left subclavian artery to the descending aorta under a simple cross clamping of the thoracic aorta.(ABSTRACT TRUNCATED AT 250 WORDS)

A gene outside the human MHC related to classical HLA class I genes

By presenting antigenic peptides to T lymphocytes, major histocompatibility complex (MHC) class I molecules play important roles in the human immune system. Knowledge is limited on the evolutionary history of human MHC class I-related molecules. An expressed class I gene, MR1, has now been identified on human chromosome 1q25, outside the MHC. In contrast to other known human divergent class I genes, MR1 encodes peptide-binding domains similar to those encoded by human leukocyte antigen (HLA) class I genes on chromosome 6 and by nonmammalian classical MHC class I genes. This gene may thus contribute to understanding the evolution of the MHC.

Differences in urease activity in live Helicobacter pylori cultured from patients with gastroduodenal diseases

AIM

To develop a reliable method for measuring urease activity in live bacteria, and to determine whether there are any differences in urease activity among the Helicobacter pylori strains involved in gastroduodenal disease.

DESIGN

The stability of the method was examined in the first phase of the study, and in a second phase the mean urease activity in clinical isolates from different groups of patients was compared.

MATERIALS AND METHODS

To assess the stability and reliability of the method, we assessed the relationship between bacterial proliferation and urease activity, the relationship between the number of bacteria and the optical density, and differences in urease activity among bacterial generations. Ten of the 3-day-old colonies in the third generation were suspended in phosphate-buffered saline, and urease activity was measured as 10(5) colony-forming units/ml bacteria.

RESULTS

The assay system appeared to be effective, because the urease activity of live bacteria in the logarithmic growth period was constant, the number of bacteria and the optical density showed a linear correlation on a bilogarithmic graph and there was no significant difference in urease activity over three generations. With this method, urease activity varied from 0.192 to 80.42 mIU/10(5) colony-forming units of bacteria/ml. There was no significant difference in the mean urease activity of live bacteria from controls, gastric ulcer patients and duodenal ulcer patients. However, the mean urease activity in bacteria from cancer patients was significantly higher than that of controls or duodenal ulcer patients.

CONCLUSIONS

H. pylori strains derived from cancer patients, which have relatively high levels of urease activity, might easily colonize the stomach and lead to much mucosal damage during the long course of H. pylori infection.

Spatial ventricular gradient in patients with Wolff-Parkinson-White syndrome in comparison with normal subjects: vectorcardiographic evidence for significant repolarization changes due to preexcitation

We investigated the use of the spatial ventricular gradient (VG) from vectorcardiogram (VCG) to determine whether significant repolarization differences were present in patients with WPW syndrome compared with normal subjects and also examined which VG parameter (i.e., elevation, azimuth, and magnitude) reflected the differences in repolarization properties during preexcitation. VG was calculated in 49 patients of Wolff-Parkinson-White (WPW) syndrome (group A: left-sided accessory pathway, n = 29; group B: right-sided, n = 20). Group N consisted of 607 normal subjects. In group A, the azimuth of VG was significantly (p < 0.01) greater than in groups B and N. In group B, the elevation of VG was significantly (p < 0.01) greater than in groups A and N. There were no significant differences in the magnitude of VG among groups. QRS duration was significantly (p < 0.01) related with the elevation of VG in group B. These findings suggested that VG is useful for spatial evaluation of repolarization abnormalities during preexcitation, which are related to the site of the accessory pathway.

Immunogenetic analysis of the human leukocyte antigen DQA1 locus in patients with duodenal ulcer or chronic atrophic gastritis harbouring Helicobacter pylori

AIM

To examine the human leukocyte antigen (HLA)-DQA1 locus in patients harbouring Helicobacter pylori with chronic atrophic gastritis or duodenal ulcer as part of an investigation into immunogenetic differences in the host.

SUBJECTS AND METHODS

We examined 116 patients harbouring H. pylori (55 patients with chronic atrophic gastritis, 61 with duodenal ulcers) and 28 H. pylori-negative healthy controls for HLA-DQA1 genotypes. H. pylori infection was determined by culturing biopsy samples from the gastric body and antrum and by enzyme-linked immunosorbent assay. HLA-DQA1 typing was carried out by the polymerase chain reaction-restriction fragment length polymorphism method.

RESULTS

The allele frequency of DQA1*0102 was significantly higher in H. pylori-negative controls (0.250) than in H. pylori-positive duodenal ulcer patients (0.090). In contrast, the allele frequency of DQA1*0301 was significantly lower in H. pylori-negative controls (0.214) than in H. pylori-positive duodenal ulcer patients (0.418).

CONCLUSION

These results suggest that there are genetic differences in the HLA-DQA1 locus between H. pylori-positive duodenal ulcer patients and H. pylori-negative healthy controls.

Effects of suprachiasmatic lesions on circadian rhythms of blood pressure, heart rate and locomotor activity in the rat

To determine whether the circadian rhythms in blood pressure (BP), heart rate (HR) and locomotor activity are controlled by an internal biological clock located in the suprachiasmatic nucleus (SCN), we continuously measured these parameters in SCN-lesioned rats using a newly developed implantable radiotelemetry device and a computerized data collecting system. Although SCN-lesioned rats showed a weak but significant 24-h periodicity in BP and HR under light-dark (LD) cycles, BP, HR and locomotor activity became completely aperiodic under constant dark (DD) conditions. The amount of locomotor activity was significantly reduced in SCN-lesioned rats compared to that in intact rats. BP tended to be higher in SCN-lesioned rats, but the differences were significant only in the comparison of systolic blood pressure (SBP) under LD and DD (p < 0.05) and of mean blood pressure (MBP) under LD (p < 0.05). HR in SCN-lesioned rats was significantly lower under LD (p < 0.05), but not under DD. The standard deviation and the variation coefficient of MBP, as indices of short-term variability of this parameter, were significantly larger in SCN-lesioned rats than in intact rats, while those of HR and locomotor activity did not differ significantly between SCN-lesioned and intact rats. These results indicate that the SCN is important not only for generating circadian rhythms of BP, HR and locomotor activity, but also for buffering the short-term variability of BP in rats.

A proton pump inhibitor, E3810, has antibacterial activity through binding to Helicobacter pylori

Helicobacter pylori infection is causally related to atrophic gastritis, and it may also be associated with peptic ulcer and gastric carcinoma. Eradication of H.pylori is recommended in patients with such diseases, especially in those with peptic ulcer. A new potent proton pump inhibitor, E3810, had an antibacterial effect on H. pylori, as has been reported for omeprazole and lansoprazole, two other proton pump inhibitors. The minimum inhibitory concentration of E3810 was 1.57-3.13 micrograms/ml, lower than that of omeprazole or lansoprazole. To clarify the mechanism of the antibacterial effect of E3810, we analyzed the characteristics of E3810 binding to H. pylori. Scatchard plot analysis of this binding showed a curvilinear profile, indicating the presence of several molecules with different affinities to E3810 on H. pylori. The binding capacity of E3810 to H. pylori was calculated to be about 2 x 10(6) sites/cell. These results suggested that E3810 has an antibacterial effect against H. pylori and that the effect may be mediated through direct binding to H. pylori.

Transvaginal pulsed and color Doppler sonography for the evaluation of adenomyosis

In an earlier paper, we reported our scoring system for the diagnosis of adenomyosis by gray scale transvaginal sonography. In this study we evaluated 44 benign uterine masses (adenomyosis and myomas) and seven uterine malignancies. We used transvaginal color and pulsed Doppler imaging to determine whether this technique is useful to differentiate adenomyosis from uterine malignancies. The peak systolic velocity and the resistive index of intratumoral vessels were studied. The differences in these parameters for adenomyosis and uterine malignancies were statistically significant. Our results suggest that this technique is useful to differentiate adenomyosis from uterine malignancies.

[A case report of bentall type operation for annuloaortic ectasia with anomalous origin of the right coronary artery complicated by aortic dissection]

A 49-year-old woman of Marfan's syndrome, who had undergone replacement of the thoracoabdominal aorta for Stanford B type aortic dissection at 47 years of age, developed Stanford A type aortic dissection with annulo-aortic ectasia and aortic regurgitation. At the time of operation, anomalous origin of the right coronary artery from the left sinus of Valsalva and near site of the left coronary orifice were found. Then, composite graft replacement of the ascending aorta and aortic valve, in which a single graft of 16 mm in diameter was interposed between the coronary ostia and composite graft, was performed. Anomalous origin of the right coronary artery from the left sinus of Valsalva is a rare congenital abnormality. It is a matter how to reconstruct the coronary circulation for this type of operation. This technique was useful to reconstruct the aortic root even when an anomalous origin of the coronary artery existed.

Lansoprazole treatment of Helicobacter pylori-positive peptic ulcers

Forty-nine patients with Helicobacter pylori (Hp)-positive gastric ulcer (GU) and 39 patients with Hp-positive duodenal ulcer (DU) were studied. Before the trial and every 3 or 4 weeks, phenol red dye spraying endoscopy, the rapid urease test, biopsy specimen histology, and culture were performed to assess the ulcer stage and to detect Hp. Patients were divided into three groups: group I received lansoprazole 30 mg/d; Group II received dual therapy of lansoprazole 30 mg/day and amoxicillin (AMPC) 1 g/day or clarithromycin (CAM) 400 mg/day; and Group III received combination therapy of lansoprazole 30 mg/day, AMPC 1 g/day, or CAM 400 mg/day, and metronidazole 500 mg/day. Patients with GU received lansoprazole for 8 weeks and patients with DU received lansoprazole for 6 weeks. The other agents were administered for 2 weeks at the beginning of the trial. There were no differences in ulcer healing among the three treatment groups in patients with GU or DU, but there were significant differences in the eradication of Hp. No side effects were observed in any of the patients. We conclude that combination therapy is likely to be most effective and is harmless for Hp-persistent patients with peptic ulcer.

QRST time integral values in 12-lead electrocardiograms before and after radiofrequency catheter ablation in patients with Wolff-Parkinson-White syndrome

OBJECTIVES

We investigated the usefulness of QRST values obtained from 12-lead electrocardiograms (ECGs) for identification of repolarization abnormalities before and after radiofrequency ablation in patients with Wolff-Parkinson-White syndrome.

BACKGROUND

Marked T wave abnormalities often appear after ablation and have been attributed to a continuation of repolarization abnormalities present before ablation (cardiac memory). However, to our knowledge repolarization properties before and after ablation have not been assessed quantitatively.

METHODS

We calculated the ECG QRST values from 53 patients with Wolff-Parkinson-White syndrome and compared these values before, immediately after and 1 day and 1 week after successful ablation in 25 patients.

RESULTS

QRST values were abnormally high in lead V1 in 7 of 28 patients with a left-sided accessory pathway and abnormally low in leads III and aVF and high in lead aVL in 12, 9 and 10 of 20 patients, respectively, with a right-sided accessory pathway. Preexisting QRST abnormalities were still present immediately and 1 day after ablation but were usually absent by 1 week after ablation. QRST values before, immediately after and 1 day after ablation were not significantly different in any lead. In 14 patients with ablation of a left-sided accessory pathway, QRST values before, immediately after and 1 day after ablation in lead V1 and immediately after ablation in leads I, aVR and V2 were significantly different from QRST values in those leads 1 week after ablation. In six patients with ablation of a right-sided accessory pathway, QRST values before, immediately after and 1 day after ablation in leads III, aVL and aVF and immediately after ablation in lead II were significantly different from QRST values in those leads 1 week after ablation.

CONCLUSIONS

Electrocardiographic QRST values may provide useful quantitative information with respect to repolarization properties before and after ablation in patients with Wolff-Parkinson-White syndrome that is otherwise difficult to obtain by conventional ECG analysis.

[Bypass grafting of left subclavian artery to descending thoracic aorta for relative stenosis of bypass graft after total correction for type A IAA with VSD]

A 4-year-old child underwent one-stage total correction for type A IAA with VSD in 1975 as the first successful case in Japan. At age 21, a gradual rise in her upper limb pressure to 190 mmHg prompted repeat catheterization, which showed a pressure gradient across the EPTFE graft of 58 mmHg. Under general anesthesia in the right lateral position, the patient's left thorax was reopened. The EPTFE graft had undergone patchy calcific degeneration and was significantly hardened. An 18-mm Toray graft preclotted with fibrin glue was anastomosed to the left subclavian artery in side-to-end fashion. Its distal end was anastomosed to the descending aorta distal to the EPTFE bypass during a 20-minute aortic occlusion. The postoperative recovery was uneventful and the pressure gradient between the upper and lower limbs fell to 0 at discharge. We chose this method for reoperation of type A IAA and CoA because of the reduced need for dissection and better effectiveness.

Establishment and characterization of IRTA17 and IRTA21, two novel acute non-lymphocytic leukaemia cell lines with t(16;21) translocation

The t(16;21)(p11;q22) translocation is an infrequent chromosomal abnormality, but seems specific to acute non-lymphocytic leukaemia (ANLL). We established two cell lines with t(16;21)(p11;q22) from the bone marrow of a patient with ANL in relapse. Their morphological, karyotypic, immunohistochemical and genetic features are examined. Although both cell lines show monocytoid features morphologically, they express only CD13 (My7) and CD34, and neither expressed monocytoid or lymphoid markers. Reverse transcription-polymerase chain reaction showed that both cell lines expressed a similar TLS-ERG chimaeric mRNA as a result of the t(16;21)(p11;q22) translocation. As far as we know, there is no report of a leukaemia cell line with t(16;21). These cell lines represent a useful tool for leukaemia research.

Cloning and characterization of MST, a novel (putative) serine/threonine kinase with SH3 domain

Protein kinases play a key role in cell growth regulation. We have isolated a cDNA fragment of the MST gene from the MKN28 gastric cancer cell line cDNA pool by degenerate polymerase chain reaction. MST-cDNAs were cloned from the human brain cDNA library. Nucleotide sequence analysis indicated that the MST gene encodes a novel putative non-receptor type of serine/threonine kinase with Src homology 3 (SH3) domain, two leucine zipper domains and proline rich domain. The deduced amino acid sequence corresponding to a part of kinase domain and leucine zipper domains of MST (amino acid codons 244-461) is almost identical to the published partial amino acid sequence of MLK2. MST is the first non-receptor type of serine/threonine kinase containing SH3 domain, leucine zipper domain and proline rich domain other than PTK1/Sprk. The MST gene was moderately expressed in brain, skeletal muscle and testis as a 3.8 kb mRNA, and the MST gene has been mapped to human chromosome 19q13.1-q13.2.

[Stanford type A acute aortic dissection involving an aberrant right subclavian artery--a successful operative case]

A 64-year-old woman was admitted with chest (pain) and back pain. We found aortic dissecting area from ascending aorta to aortic arch and thoracic descending aorta by enhanced computed tomography. She was diagnosed Stanford type A acute aortic dissection. Emergent operation was performed on Jan. 20th, 1994. During operation, we found an aberrant right subclavian artery from Jan. 20th, 1994. During operation, we found an aberrant right subclavian artery from descending aorta. Using non-clamping selective cerebral perfusion, we could succeed this operation. As far as we know, this is the first report in Japanese literatures.

[Plasma concentration of cytosine arabinoside (Ara-C) in the elderly patients with hematological malignancy treated by Ara-C or cytarabine ocfosfate (SPAC)]

Plasma concentration of cytosine arabinoside (Ara-C) was determined in elderly patients with myelodysplastic syndromes or acute myelocytic leukemia who were treated with subcutaneous injection of Ara-C (Ara-C s.c.; 10 mg/m2/12 hr, 14-21 days), continuous drip infusion of Ara-C (Ara-C d.i.v.; 20 mg/m2/day, 24 hr 14 days) and/or oral administration of cytarabine ocfosfate (SPAC) (SPAC p.o.; 100 mg-300 mg/body/day, 14 days) by radioimmunoassay. In the Ara-C s.c. patients, the peak plasma level (Cmax) of Ara-C was 103 ng/ml and the time to reach Cmax was 15 min. The elimination half-like (t1/2) was 25 min and no accumulation was detected after 14 days of consecutive Ara-C s.c. administrations. In the SPAC p.o. patients, Cmax of Ara-C was 3-8 ng/ml and it took 3-5 days to reach Cmax. The plasma concentration level of Ara-C remains almost at the Cmax level during the SPAC p.o. administration and it remained higher than 0.32 ng/ml for as long as 15 days after the end of administration. In a Ara-C d.i.v. patient, plasma level of Ara-C was detected 4-7 ng/ml during the administration (day 7 through day 14). In all patients bone marrow suppression was observed after chemotherapy regardless of regimen, and there was no significant difference between nadir peripheral cell blood counts of Ara-C s.c. patients and SPAC p.o. patients.

[A case of acute dissecting aortic aneurysm associated with congenital bicuspid aortic valve]

The congenital bicuspid aortic valve is recognized as a cause of aortic dissection. But in Japan, the case of aortic dissection associated with bicuspid aortic valve is rare. A 66-year-old man was referred to our hospital with a diagnosis of acute Stanford A type dissecting aneurysm associated with stenotic bicuspid aortic valve. The chest computed tomography showed thrombosis of the pseudo lumen. An operation consisting of aortic valve replacement and graft replacement of the aneurysm was performed on emergency basis because of remarkable dilation of the ascending aorta. He has been doing well after the operation and discharged from the hospital on the 46th postoperative day. It is though to be important to follow up with special concern about possible dilation of sinus of Valsalva due to intrinsic weakness of the aortic wall.