Adipocyte-derived plasma protein, adiponectin, suppresses lipid accumulation and class A scavenger receptor expression in human monocyte-derived macrophages

BACKGROUND

Excessive lipid accumulation in macrophages plays an important role in the development of atherosclerosis. Recently, we discovered an adipocyte-specific plasma protein, adiponectin, that is decreased in patients with coronary artery disease. We previously demonstrated that adiponectin acts as a modulator for proinflammatory stimuli and inhibits monocyte adhesion to endothelial cells. The present study investigated the effects of adiponectin on lipid accumulation in human monocyte-derived macrophages.

METHODS AND RESULTS

Human monocytes were differentiated into macrophages by incubation in human type AB serum for 7 days, and the effects of adiponectin were investigated at different time intervals. Treatment with physiological concentrations of adiponectin reduced intracellular cholesteryl ester content, as determined using the enzymatic, fluorometric method. The adiponectin-treated macrophages contained fewer lipid droplets stained by oil red O. Adiponectin suppressed the expression of the class A macrophage scavenger receptor (MSR) at both mRNA and protein levels by Northern and immunoblot analyses, respectively, without affecting the expression of CD36, which was quantified by flow cytometry. Adiponectin reduced the class A MSR promoter activity, as measured by luciferase reporter assay. Adiponectin treatment dose-dependently decreased class A MSR ligand binding and uptake activities. The mRNA level of lipoprotein lipase as a marker of macrophage differentiation was decreased by adiponectin treatment, but that of apolipoprotein E was not altered. Adiponectin was detected around macrophages in the human injured aorta by immunohistochemistry.

CONCLUSIONS

The adipocyte-derived plasma protein adiponectin suppressed macrophage-to-foam cell transformation, suggesting that adiponectin may act as a modulator for macrophage-to-foam cell transformation.

Airway rescue with the intubating laryngeal mask in a patient with an unexpectedly large epiglottic cyst

We report the successful use of the intubating laryngeal mask airway for rescue and intubation in an anaesthetised patient with an unexpectedly large epiglottic cyst. This case illustrates that airway rescue and intubation with the intubating laryngeal mask is possible and preoperative airway assessment does not always provide reliable information about airway management.

Effects of a thromboxane receptor antagonist (NT-126) and a thromboxane synthase inhibitor (OKY-O46) on protamine-induced circulatory changes in dogs

OBJECTIVE

To examine whether a thromboxane receptor antagonist, NT-126, or a thromboxane synthase inhibitor, OKY-046, prevents circulatory changes caused by protamine reversal of heparin and to evaluate the significance of thromboxane generation in the phenomena.

DESIGN

Prospective, randomized, controlled, animal study.

SETTING

A university research laboratory.

PARTICIPANTS

Twenty-four adult mongrel dogs.

INTERVENTIONS

According to the pretreatments, the animals were divided into 3 groups (n = 8 in each): (1) control (normal saline); (2) NT-126, 0.01 mg/kg; and (3) OKY-046, 1 mg/kg. Under general anesthesia, all animals were anticoagulated with intravenous heparin, 200 IU/kg, 5 minutes before the pretreatment. Five minutes after the pretreatment, protamine sulfate, 2 mg/kg, was administered intravenously over 10 seconds. Hemodynamic variables were recorded repeatedly until 60 minutes after the protamine. Plasma thromboxane B2 level was determined at baseline and 10 minutes after protamine injection.

MEASUREMENTS AND MAIN RESULTS

The average values of mean arterial blood pressure and mean pulmonary artery pressure among the 3 groups in each period and values in each group over the study period were not significantly different. There was weak correlation between maximum percent increases in systolic pulmonary artery pressure or maximum percent decreases in systolic arterial blood pressure for 5 minutes after the protamine versus percent increases in plasma thromboxane B2 level.

CONCLUSION

Neither NT-126 nor OKY-046 appears to be effective in preventing protamine-induced circulatory changes in this dog model, suggesting that thromboxane generation alone is not responsible for the phenomena.

Haemodynamic responses to the intubating laryngeal mask and timing of removal

We determined (a) the haemodynamic responses to intubating laryngeal mask (ILM) airway insertion/intubation and removal in anaesthetized patients, and (b) whether the timing of ILM removal influences these responses. One-hundred and twenty patients without cardiovascular disease were studied. ILM airway insertion/intubation was 5 min after induction with propofol 2 mg kg(-1) and maintenance of anaesthesia with sevoflurane 2% in oxygen 33% and nitrous oxide. Patients were randomly assigned for removal of the intubating laryngeal mask airway at 1, 3 and 5 min after successful intubation. Systolic and diastolic arterial pressures and heart rate were recorded preinduction (baseline), before ILM airway insertion/intubation, at 1-min intervals after insertion/intubation, and at 1-min intervals for 5 min after ILM removal. ILM insertion was successful at the first attempt in all patients, but 46 patients required more than one intubation attempt. Compared with baseline values, there were no increases in systolic or diastolic arterial pressure, but there was an increase in heart rate 1 min after ILM insertion/intubation (9%, P<0.001) and 1 min after ILM removal (8%, P<0.01). There was a significant increase in systolic and diastolic pressures and heart rate 1 min after ILM insertion/intubation (30%, 31% and 15%; all: P<0.002) compared with before ILM insertion/intubation values and 1 min after ILM removal (9%, 8% and 7%; all P<0.05) compared with 1 min after ILM insertion/intubation values. Removal of the ILM 1 min after successful intubation resulted in higher arterial pressure compared with removal at 3 min (systolic arterial pressure 10% higher for 1 min, P = 0.01) and 5 min (systolic arterial pressure 10-23% higher for 3 min, P<0.01; diastolic arterial pressure 10-20% higher for 4 min, P>0.02), but there were no differences in heart rate between groups. Systolic and diastolic arterial pressures were greater if more than one intubation attempt was required. Early removal or multiple intubation attempts did not exceed baseline haemodynamic values. We conclude that ILM insertion/intubation and removal in anaesthetized patients produces little or no haemodynamic response, even if multiple intubation attempts are required. The timing of removal exerts a small, but clinically unimportant influence on these responses.

Reduction in standard MAC and MAC for intubation after clonidine premedication in children

We examined the relative effects of different doses of oral clonidine on the MAC for endotracheal intubation (MACEI) and the MAC for skin incision (MAC) in children. We studied 90 children (15 in each group) (age range 2-8 yr, weight 10-27 kg, height 89-124 cm) who received one of three preanaesthetic medications: placebo (control), oral clonidine 2 micrograms kg-1, or oral clonidine 4 micrograms kg-1 100 min before anaesthesia. Anaesthesia was induced and maintained with sevoflurane in oxygen and air without i.v. anesthetics and neuromuscular relaxants. The end-tidal sevoflurane concentration was kept constant for > or = 15 min before tracheal intubation or skin incision. MACs were determined using Dixon's 'up-and-down method'. Mean (SD) MACEIs of sevoflurane were 2.9 (0.1)%, 2.5 (0.1)% and 1.9 (0.1)% (P < 0.05), and MACs were 2.3 (0.1)%, 1.8 (0.1)% and 1.3 (0.1)% (P < 0.05), respectively, in control, clonidine 2 micrograms kg-1 and clonidine 4 micrograms kg-1 groups. The MACEIs and MACs decreased dose-dependently. The MACEI/MAC ratio (1.4) was not affected by clonidine.

Adiponectin, an adipocyte-derived plasma protein, inhibits endothelial NF-kappaB signaling through a cAMP-dependent pathway

BACKGROUND

Among the many adipocyte-derived endocrine factors, we found an adipocyte-derived plasma protein, adiponectin, that was decreased in obesity. We recently demonstrated that adiponectin inhibited tumor necrosis factor-alpha (TNF-alpha)-induced expression of endothelial adhesion molecules and that plasma adiponectin level was reduced in patients with coronary artery disease (CIRCULATION: 1999;100:2473-2476). However, the intracellular signal by which adiponectin suppressed adhesion molecule expression was not elucidated. The present study investigated the mechanism of modulation for endothelial function by adiponectin.

METHODS AND RESULTS

The interaction between adiponectin and human aortic endothelial cells (HAECs) was estimated by cell ELISA using biotinylated adiponectin. HAECs were preincubated for 18 hours with 50 microg/mL of adiponectin, then exposed to TNF-alpha (10 U/mL) or vehicle for the times indicated. NF-kappaB-DNA binding activity was determined by electrophoretic mobility shift assays. TNF-alpha-inducible phosphorylation signals were detected by immunoblotting. Adiponectin specifically bound to HAECs in a saturable manner and inhibited TNF-alpha-induced mRNA expression of monocyte adhesion molecules without affecting the interaction between TNF-alpha and its receptors. Adiponectin suppressed TNF-alpha-induced IkappaB-alpha phosphorylation and subsequent NF-kappaB activation without affecting other TNF-alpha-mediated phosphorylation signals, including Jun N-terminal kinase, p38 kinase, and Akt kinase. This inhibitory effect of adiponectin is accompanied by cAMP accumulation and is blocked by either adenylate cyclase inhibitor or protein kinase A (PKA) inhibitor.

CONCLUSIONS

These observations raise the possibility that adiponectin, which is naturally present in the blood stream, modulates the inflammatory response of endothelial cells through cross talk between cAMP-PKA and NF-kappaB signaling pathways.

Adiponectin, a new member of the family of soluble defense collagens, negatively regulates the growth of myelomonocytic progenitors and the functions of macrophages

We investigated the functions of adiponectin, an adipocyte-specific secretory protein and a new member of the family of soluble defense collagens, in hematopoiesis and immune responses. Adiponectin suppressed colony formation from colony-forming units (CFU)-granulocyte-macrophage, CFU-macrophage, and CFU-granulocyte, whereas it had no effect on that of burst-forming units-erythroid or mixed erythroid-myeloid CFU. In addition, adiponectin inhibited proliferation of 4 of 9 myeloid cell lines but did not suppress proliferation of erythroid or lymphoid cell lines except for one cell line. These results suggest that adiponectin predominantly inhibits proliferation of myelomonocytic lineage cells. At least one mechanism of the growth inhibition is induction of apoptosis because treatment of acute myelomonocytic leukemia lines with adiponectin induced the appearance of subdiploid peaks and oligonucleosomal DNA fragmentation. Aside from inhibiting growth of myelomonocytic progenitors, adiponectin suppressed mature macrophage functions. Treatment of cultured macrophages with adiponectin significantly inhibited their phagocytic activity and their lipopolysaccharide-induced production of tumor necrosis factor alpha. Suppression of phagocytosis by adiponectin is mediated by one of the complement C1q receptors, C1qRp, because this function was completely abrogated by the addition of an anti-C1qRp monoclonal antibody. These observations suggest that adiponectin is an important negative regulator in hematopoiesis and immune systems and raise the possibility that it may be involved in ending inflammatory responses through its inhibitory functions. (Blood. 2000;96:1723-1732)

The awakening concentration of sevoflurane in children

Sevoflurane is frequently used as a rapidly acting drug for the induction of anesthesia. We investigated the awakening concentration (MAC-awake) of sevoflurane in ASA physical status I children (age range 2-10 yr). We also investigated the effects of two different doses of clonidine (2 and 4 microg/kg) on the MAC-awake of sevoflurane. Subjects were randomly divided into three groups and received placebo (n = 24), clonidine 2 microg/kg (n = 17), or clonidine 4 microg/kg (n = 22) orally, 100 min before the induction of anesthesia. Sedation scores were estimated, by using a five-point scale, after entry into the operating room, and anesthesia was induced and maintained with sevoflurane in oxygen and balanced nitrogen, without an additional anesthetic. After surgery, end-tidal sevoflurane was decreased stepwise by 0.2% at 15-min intervals, a standardized verbal command was played to the patients, and the MAC-awake was determined. The MAC-awake of sevoflurane alone was 0. 78% +/- 0.24% (mean +/- SD), which decreased to 0.36% +/- 0.09% and 0.36% +/- 0.16% (both P <0.0001, compared with the control group) after premedication with the small and large doses of clonidine, respectively. The lack of any dose-response relationship might be explained by a plateau effect.

IMPLICATIONS

The awakening concentration of sevoflurane in unpremedicated children was 0.78%. Oral clonidine premedication at a dose of 2 microg/kg reduced the awakening concentration to 0.36%. However, an additional decrease in this value was not observed after the administration of the larger dose of clonidine premedication (4 microg/kg).

Aquaporin adipose, a putative glycerol channel in adipocytes

Adipose tissue is a major site of glycerol production in response to energy balance. However, molecular basis of glycerol release from adipocytes has not yet been elucidated. We recently cloned a novel member of the aquaporin family, aquaporin adipose (AQPap), which has glycerol permeability. The current study was designed to examine the hypothesis that AQPap serves as a glycerol channel in adipocytes. Adipose tissue expressed AQPap mRNA in high abundance, but not the mRNAs for the other aquaglyceroporins, AQP3 and AQP9, indicating that AQPap is the only known aquaglyceroporin expressed in adipose tissue. Glycerol release from 3T3-L1 cells was increased during differentiation in parallel with AQPap mRNA levels and suppressed by mercury ion, which inhibits the function of AQPs, supporting AQPap functions as a glycerol channel in adipocytes. Fasting increased and refeeding suppressed adipose AQPap mRNA levels in accordance with plasma glycerol levels and oppositely to plasma insulin levels in mice. Insulin dose-dependently suppressed AQPap mRNA expression in 3T3-L1 cells. AQPap mRNA levels and adipose glycerol concentrations measured by the microdialysis technique were increased in obese mice with insulin resistance. Accordingly, negative regulation of AQPap expression by insulin was impaired in the insulin-resistant state. Exposure of epinephrine translocated AQPap protein from perinuclear cytoplasm to the plasma membrane in 3T3-L1 adipocytes. These results strongly suggest that AQPap plays an important role in glycerol release from adipocytes.

Segmental cervical spine movement with the intubating laryngeal mask during manual in-line stabilization in patients with cervical pathology undergoing cervical spine surgery

We quantified the extent and distribution of segmental cervical movement produced by the intubating laryngeal mask (ILM) during manual in-line stabilization in 20 anesthetized patients with cervical pathology undergoing cervical spine surgery. All patients had neurological symptoms preoperatively. The ILM was inserted with the head and neck in the neutral position. Intubation was facilitated by transillumination of the neck with a lightwand. Cervical movement was recorded with single-frame lateral radiographic images taken 1) immediately before induction (baseline); 2) during ILM insertion (insertion); 3) when transillumination was first seen at the cricothyroid membrane (intubation A); 4) when the tube was being advanced into the trachea (intubation B); and 5) during ILM removal (removal). Radiographic images were digitized and the degree of flexion/extension and posterior movement measured for the occiput (C0) through to C5. During ILM insertion, C0-5 were flexed by an average of 1-1.6 degrees (all P < 0.05). During intubation A/B, C0-4 were flexed by an average of 1.4-3.0 degrees (all P < 0.01), but C5 was unchanged. During ILM removal, C0-3 were flexed by an average of 1 degree (all: P < 0.05), but C3-5 were unchanged. During insertion and intubation A/B, C2-5 were displaced posteriorly by an average of 0.5-1.0 mm (all: P < 0.05). During removal, there was no change at C1-5. Neurological symptoms improved in all patients. We conclude that the ILM produces segmental movement of the cervical spine despite manual in-line stabilization in patients with cervical spine pathology undergoing cervical spine surgery. This motion is in the opposite direction to direct laryngoscopy, suggesting that different approaches to airway management may be more appropriate depending on the nature of the cervical instability.

IMPLICATIONS

The intubating laryngeal mask produces segmental movement of the cervical spine, despite manual in-line stabilization in patients with cervical spine pathology undergoing cervical spine surgery. This motion is in the opposite direction to direct laryngoscopy, suggesting that different approaches to airway management may be more appropriate depending on the nature of the cervical instability.

Genomic structure and mutations in adipose-specific gene, adiponectin

BACKGROUND

Adiponectin is a collagen-like plasma protein specifically synthesized in adipose tissue. Plasma adiponectin concentrations are decreased in obesity whereas it is adipose-specific.

OBJECTIVE

To clarify the significance of the genetic variations in adiponectin gene on its plasma concentrations and obesity.

SUBJECTS

Two hundred and nineteen unrelated adult Japanese subjects (123 men and 96 women, age: 20-83 y, BMI: 16-43 kg/m2) including 77 obese subjects (BMI>26.4 kg/m2).

MEASUREMENT

Human adiponectin gene was isolated from PAC DNA pools. Mutations in the adiponectin gene were screened by direct sequencing or restriction-fragment polymorphism. The levels of plasma adiponectin were determined by the enzyme-linked immunosorbent assay (ELISA).

RESULTS

Adiponectin gene spanned 17 kb on chromosome 3q27, consisting of three exons and two introns. Within 2.1 kb of the 5'-flanking region, there were two octamer elements present in the promoter of adipsin. Two nucleotide changes were identified. One was a polymorphism (G/T) occurring in exon 2, and the other was a missense mutation (R112C) in exon 3. The mean plasma adiponectin levels of the subjects carrying G allele were low (G/G: 4.5 microg/ml; G/T: 5.9 microg/ml; and T/T: 6.3 microg/ml), but were not statistically significant. The allelic frequency between the obese and the non-obese showed no significant difference. The subject carrying R112C mutation showed markedly low concentration of plasma adiponectin.

CONCLUSION

Two nucleotide changes have been identified in the adiponectin gene. G/T polymorphism in exon 2 was associated with neither plasma adiponectin concentrations nor the presence of obesity. A subject carrying missense mutation (R112C) showed markedly low plasma adiponectin concentration.

[Early and late results of combined valvular and coronary artery operations]

A total of 122 patients with ischemic heart disease underwent valvular surgery. Thirty-nine had combined CABG and aortic valve surgery (included Bentall method), 72 had CABG and mitral valve operations, and 8 patients had CABG and double or triple valve operations. Only 3 patients for ruptured papillary muscle due to acute myocardial infarction had isolated mitral valve replacement. Early mortality was 5.1% AV, 2.8% MV and 12.5% DTV in the combined groups and 0% in the valve only group. The grafts patency rate was 93.5%. Univariate analysis of risk factors selected in the dialysis patients and the patients age older than 65 years as the strongest predictors for early death. At the mean follow up period of 5.4 +/- 4.8 year after surgery, the 5-year all death free rates were 57.9 +/- 9.6% AV, 69.6 +/- 5.8% MV and 75.0 +/- 15.3% DTV. The 5-year cardiac death free rates were 73.8 +/- 9.0% AV, 77.5 +/- 5.4% MD and 75.0 +/- 15.3% DTV.

Identification of a GPI-anchored type HDL-binding protein on human macrophages

To identify the HDL3-binding proteins on human macrophages, we examined the involvement of GPI-anchored protein in the binding of HDL3, and tried to purify HDL3-binding protein. From membrane fractions of macrophages, we obtained 80- and 130-kDa HDL3-binding proteins by ligand blotting. Treatment of macrophages with phosphatidylinositol-specific phospholipase C (PI-PLC) significantly decreased the specific HDL3-binding in a dose-dependent manner. Furthermore, treatment with mannosamine, which blocks GPI-anchor formation, decreased specific HDL3-binding in a dose-dependent manner. PI-PLC treatment released from the cells the proteins with an M(r) of 80 kDa, which could also bind HDL3. PI-PLC as well as mannosamine treatment markedly reduced cholesterol efflux from macrophages in association with the decreased HDL-binding. Using HDL3-affinity chromatography, we purified 80-kDa GPI-anchored type HDL3-binding protein. In summary, we demonstrate the implication of 80-kDa GPI-anchored protein in the binding of HDL3 to human macrophages, which might have some role in reverse cholesterol transport.

Plasma concentrations of a novel, adipose-specific protein, adiponectin, in type 2 diabetic patients

Adiponectin is a novel, adipose-specific protein abundantly present in the circulation, and it has antiatherogenic properties. We analyzed the plasma adiponectin concentrations in age- and body mass index (BMI)-matched nondiabetic and type 2 diabetic subjects with and without coronary artery disease (CAD). Plasma levels of adiponectin in the diabetic subjects without CAD were lower than those in nondiabetic subjects (6.6+/-0.4 versus 7.9+/-0.5 microg/mL in men, 7.6+/-0.7 versus 11.7+/-1.0 microg/mL in women; P<0.001). The plasma adiponectin concentrations of diabetic patients with CAD were lower than those of diabetic patients without CAD (4.0+/-0.4 versus 6.6+/-0.4 microg/mL, P<0.001 in men; 6.3+/-0.8 versus 7.6+/-0. 7 microg/mL in women). In contrast, plasma levels of leptin did not differ between diabetic patients with and without CAD. The presence of microangiopathy did not affect the plasma adiponectin levels in diabetic patients. Significant, univariate, inverse correlations were observed between adiponectin levels and fasting plasma insulin (r=-0.18, P<0.01) and glucose (r=-0.26, P<0.001) levels. In multivariate analysis, plasma insulin did not independently affect the plasma adiponectin levels. BMI, serum triglyceride concentration, and the presence of diabetes or CAD remained significantly related to plasma adiponectin concentrations. Weight reduction significantly elevated plasma adiponectin levels in the diabetic subjects as well as the nondiabetic subjects. These results suggest that the decreased plasma adiponectin concentrations in diabetes may be an indicator of macroangiopathy.

Tracheal intubation with the Macintosh laryngoscope versus intubating laryngeal mask airway in adults with normal airways

We tested the hypothesis that haemodynamic changes to intubation and postoperative pharyngolaryngeal morbidity are similar for blind intubating laryngeal mask (ILM)-guided compared with laryngoscope-guided tracheal intubation in adults with normal airways. We also compared intubation success rates and airway complications. One-hundred and fifty paralysed, anaesthetized adult patients undergoing elective surgery were randomly assigned to one of three equal-sized groups: 1. blind intubation via the ILM using a straight, silicone tube; 2. intubation with a Macintosh laryngoscope using a straight silicone tube and 3. intubation with a Macintosh laryngoscope using a polyvinyl chloride tube (controls). A standard sequence of adjusting manoeuvres was followed if intubation was difficult. The number of adjusting manoeuvres and intubation attempts, time to intubation, intubation success rate (first attempt and within 3 min), haemodynamic changes (pre-induction, post-induction, post-intubation), oesophageal intubation, mucosal trauma (blood detected), hypoxia (SpO2 < 95%) and postoperative pharyngolaryngeal morbidity (double-blinded) were documented. Time to successful intubation was longer (57 vs 35 s), and more intubation attempts were required in the ILM group (P < 0.0001). The intubation success rate was 100% (all first attempt) for the laryngoscope groups and 94% (56% first attempt) for the ILM group. There were no significant differences in heart rate or blood pressure among groups. Oesophageal intubation (26 v 0%) and mucosal trauma (19 v 2%) were more common in the ILM group. Hypoxia and postoperative pharyngolaryngeal morbidity were similar among groups. Blind intubation through the ILM offers no advantages over the Macintosh laryngoscope for adult patients requiring intubation for elective surgery with normal airways, but it is a feasible alternative.

Surgical angioplasty of ruptured left anterior descending coronary artery without cardiopulmonary bypass

We report a case of successful off-pump surgical angioplasty in the left anterior descending coronary artery using a saphenous vein patch. A 49-year-old male with left main disease and severe cerebrovascular stenosis underwent off-pump bypass to the left anterior descending artery. Postoperative angiography showed anastomotic stenosis where balloon angioplasty was performed. However, it resulted in coronary perforation complicated with epicardial tamponade, and emergency off-pump surgical angioplasty was performed. This case demonstrated that coronary arterial rupture could be managed by surgical angioplasty without cardiopulmonary bypass when coronary artery perforation occurred.

Localization of CD9, an enhancer protein for proheparin-binding epidermal growth factor-like growth factor, in human atherosclerotic plaques: possible involvement of juxtacrine growth mechanism on smooth muscle cell proliferation

Heparin-binding epidermal growth factor (EGF)-like growth factor (HB-EGF), a member of the EGF family, has a potent mitogenic activity for vascular smooth muscle cells (SMCs). We previously reported that HB-EGF is involved in atherogenesis of human aorta and coronary arteries. ProHB-EGF (the membrane-anchored form of HB-EGF) has also been demonstrated to possess a mitogenic activity, which is approximately 30-fold increased when coexpressed with CD9 in mouse L cells. Thus, in the process of atherogenesis, CD9 may be involved in the proliferation of SMCs. We immunohistochemically investigated the localization of CD9 and proHB-EGF in the human aorta and coronary arteries. In normal aorta and coronary arteries, CD9 immunostaining was virtually negative, whereas proHB-EGF immunostaining was positive, especially in the arteries of babies. In contrast, in atherosclerotic lesions, some intimal SMCs were strongly positive for CD9 and proHB-EGF immunostaining. The juxtacrine growth activities of human aortic SMCs were inhibited in vitro by adding neutralization antibodies for CD9 or adding the specific inhibitor of HB-EGF. Besides, coexpressed CD9 and proHB-EGF cells markedly incorporated [(3)H]thymidine into the SMCs. CD9 is localized immunohistochemically in the SMCs of the atherosclerotic aorta and coronary arteries. CD9, when coexpressed with proHB-EGF, enhances proHB-EGF activities for SMC growth in a so-called juxtacrine manner in vitro and may be involved in atherogenesis.

A comparison of blind and lightwand-guided tracheal intubation through the intubating laryngeal mask

We have tested the hypothesis that intubation success rates, haemodynamic changes, airway complications and postoperative pharyngolaryngeal morbidity differ between blind and lightwand-guided intubation through the intubating laryngeal mask airway. One hundred and twenty paralysed anasthetised adult patients (ASA I-II, no known or predicted difficult airways) were assigned in a random manner to one of two equal-sized groups. In the blind group, patients were intubated blindly through the intubating laryngeal mask airway. In the lightwand group, patients were intubated through the intubating laryngeal mask airway assisted by transillumination of the neck with a lightwand. A standard sequence of adjusting manoeuvres was followed if resistance occurred during intubation or if transillumination was incorrect. The number of adjusting manoeuvres, time to intubation, intubation success rates, haemodynamic changes (pre-induction, pre-intubation, postintubation), oesophageal intubation, mucosal trauma (blood detected), hypoxia (oxygen saturation < 95%) and postoperative pharyngolaryngeal morbidity (double-blinded) were documented. Overall intubation success was similar (blind, 93%; lightwand, 100%), but time to successful intubation was significantly shorter (67 vs. 46 s, p = 0. 027) and the number of adjusting manoeuvres was significantly fewer (p = 0.024) in the lightwand group. There were no significant differences in blood pressure or heart rate between the groups at any time. Oesophageal intubation occurred more frequently in the blind group (18 vs. 0%, p = 0.002). The incidence and severity of mucosal injury, sore throat and hoarseness were similar between the groups. We conclude that lightwand-guided intubation through the intubating laryngeal mask is superior to the blind technique.

An adipocyte-derived plasma protein, adiponectin, adheres to injured vascular walls

Adipose tissue secretes a variety of proteins into the bloodstream. We have previously reported a novel cDNA, apM1 (adipose most abundant gene transcript 1), which is specifically and abundantly expressed in adipose tissue [1]. Primary structure analysis predicted that the apM1 gene product possesses significant homology to collagens VIII, X and complement factor C1q, and we named it adiponectin. In the current study, we analyzed characteristics of adiponectin in vitro and in vivo. Adiponectin protein was proved to be secreted into the medium when the cDNA was transfected to COS cells. Anti-adiponectin cross-reactivities were abundantly detected in the human plasma. In solid-phase binding assays, adiponectin specifically bound to collagen types I, III and V, which are present in vascular intima. Immunohistochemical analysis revealed that adiponectin was detected in the walls of the catheter-injured vessels but not in the intact vascular walls. These data suggest that adiponectin is a plasma protein produced by adipose tissue and accumulates in vascular walls when the endothelial barrier is injured.

Novel modulator for endothelial adhesion molecules: adipocyte-derived plasma protein adiponectin

BACKGROUND

Among the many adipocyte-derived endocrine factors, we recently found an adipocyte-specific secretory protein, adiponectin, which was decreased in obesity. Although obesity is associated with increased cardiovascular mortality and morbidity, the molecular basis for the link between obesity and vascular disease has not been fully clarified. The present study investigated whether adiponectin could modulate endothelial function and relate to coronary disease.

METHODS AND RESULTS

For the in vitro study, human aortic endothelial cells (HAECs) were preincubated for 18 hours with the indicated amount of adiponectin, then exposed to tumor necrosis factor-alpha (TNF-alpha) (10 U/mL) or vehicle for the times indicated. The adhesion of human monocytic cell line THP-1 cells to HAECs was determined by adhesion assay. The surface expression of vascular cell adhesion molecule-1 (VCAM-1), endothelial-leukocyte adhesion molecule-1 (E-selectin), and intracellular adhesion molecule-1 (ICAM-1) was measured by cell ELISA. Physiological concentrations of adiponectin dose-dependently inhibited TNF-alpha-induced THP-1 adhesion and expression of VCAM-1, E-selectin, and ICAM-1 on HAECs. For the in vivo study, the concentrations of adiponectin in human plasma were determined by a sandwich ELISA system that we recently developed. Plasma adiponectin concentrations were significantly lower in patients with coronary artery disease than those in age- and body mass index-adjusted control subjects.

CONCLUSIONS

These observations suggest that adiponectin modulates endothelial inflammatory response and that the measurement of plasma adiponectin levels may be helpful in assessment of CAD risk.

Plasma concentrations of lidocaine and its principal metabolites during continuous epidural infusion of lidocaine with or without epinephrine

BACKGROUND AND OBJECTIVES

The purpose of this study was to evaluate the effect of epinephrine on the absorption of lidocaine and the accumulation of active metabolites of lidocaine during continuous epidural anesthesia.

METHODS

Lidocaine was administered as an initial bolus of 5 mg/kg of 2% lidocaine solution followed by continuous infusion at 2.5 mg/kg/h. Patients in group I (n = 10) received lidocaine alone and patients in group II (n = 10) received lidocaine + epinephrine (5 pg/mL). Concentrations of lidocaine and its active metabolites, monoethylglycinexylidide (MEGX) and glycinexylidide (GX), were measured in plasma samples obtained after 15 minutes, 30 minutes, and 1, 2, and 3 hours of infusion using high-performance liquid chromatography with ultraviolet detection.

RESULTS

Plasma lidocaine concentrations were higher in group I for the first 30 minutes; however, after 1 hour the levels were the same. Plasma MEGX and GX increased continuously in both groups. MEGX levels the were significantly higher in group I, but there was no significant difference in the sum of lidocaine + MEGX after 2 hours. There was no significant difference in GX levels between the two groups.

CONCLUSIONS

With respect to continuous epidural administration, addition of epinephrine to lidocaine solutions is ineffective after 2 hours for reducing the potential for systemic toxicity, because the sum of the plasma concentrations of lidocaine and its principal active metabolite, MEGX, are unaffected.

Dural closure with nonpenetrating clips prevents meningoneural adhesions: an experimental study in dogs

OBJECTIVE

Meningospinal and cranial dural adhesions were compared in a canine model, after duraplasty using nonpenetrating clips or penetrating needles and sutures.

METHODS

Fourteen dogs underwent bilateral craniotomies and duraplasties, with implantation of dural prostheses (DuraGuard; Biovascular Corp., Minneapolis, MN), using either 6-0 silk sutures or titanium clips (DuraClose; Surgical Dynamics, Norwalk, CT). Fourteen other dogs underwent L3-L4 laminectomies; three longitudinal dural incisions were closed with 6-0 silk sutures, 6-0 polyglactin 910 (Vicryl) sutures, or clips. Groups of eight dogs (four cranially treated and four spinally treated) were killed 6, 12, 24, and 52 weeks after surgery, and specimens were collected for study after perfusion and fixation (two cranial and two spinal dural reconstructions at 52 wk). Evaluations included assessment of the appearance of approximated dural margins and responses to clips, sutures, and dural prostheses (inflammation, foreign body reaction, fibrosis, and severity of meningospinal/meningocerebral adhesions). Data were evaluated using the Wilcoxon signed-rank and McNemar tests.

RESULTS

Duraplasties with clips displayed significantly less extensive acute and chronic inflammation, foreign body reaction, and meningoneural adhesions than did repairs with needles and sutures.

CONCLUSION

This report is the first long-term experimental study comparing two fundamentally different methods for dural repair in a relevant animal model.

[Management of patient with acute myocardial infarction due to left main trunk obstruction]

Between April 1995 and March 1998, we experienced 13 cases of Acute Myocardial Infarction due to Left Main Trunk Obstruction (LMT-AMI). Two cases died before emergent intervention. Eight cases underwent emergent intervention (Plain Old Balloon Angioplasty (POBA) in five cases, Stenting in 3 cases); 2 cases died of acute occlusion of POBA site, 1 case survived by only POBA, and the other 5 cases underwent following Coronary Artery Bypass Grafting (CABG). 3 cases underwent only CABG with stable hemodynamics condition by Intraaortic balloon pumping (IABP) support. In a result, seven of eight CABG cases survived. Emergent stenting made the hemodynamics before CABG stable, and six-month's follow up angiogram showed occluded bypass grafts and patent stented sites in two of three cases. The combination therapy of emergent stenting and CABG will have to be evaluated in future.

Bleeding from a tear in the gastric mucosa caused by transoesophageal echocardiography during cardiac surgery: effective haemostasis by endoscopic argon plasma coagulation

We present an unusual complication of transoesophageal echocardiography (TOE) during cardiac surgery. Although the patient had no oesophageal or gastrointestinal disease, a gastric mucosal tear of approximately 2 cm long occurred in the mucosa just distal to the gastrooesophageal junction caused by the TOE probe. Bleeding from the tear was stopped using endoscopic argon plasma coagulation.

[Reoperative off-pump subclavian-coronary artery bypass grafting in an elderly patient with left internal thoracic artery stenosis]

A 80-year-old Japanese female was diagnosed to have angina pectoris and admitted to our hospital. She had been operated on with mitral valve replacement and coronary artery bypass grafting to right and circumflex coronary artery 4 years before. The coronary angiogram showed significant stenosis with severe calcification in the left anterior descending coronary artery, and it was unsuitable for catheter intervention. The patient also had stenotic left internal thoracic artery and multiple cerebral infarction, but successful off-pump subclavian-coronary artery bypass grafting using saphenous vein graft through small thoracotomy was performed without new neurological deficit. This procedure is useful for patients with left internal thoracic artery unsuitable for MIDCABG, due to quality, size, or injury during preparation.

Protective effect of JTV519, a new 1,4-benzothiazepine derivative, on prolonged myocardial preservation

BACKGROUND

JTV519 is know to protect cardiomyocytes from calcium overloading-induced damage. The aim of this study was to investigate the potential protective effect of JTV519 on myocardium subjected to prolonged ischemia and the underlying mechanism of such protection. The effect of JTV519 was also compared with that of diltiazem, a 1,5-benzothiazepine derivative.

METHODS

Isolated rat hearts were randomly divided into three groups. Control hearts were arrested with histidine-tryptophan-ketoglutarat (HTK) cardioplegic solution alone. In the JTV519 group of hearts, cardiac arrest was achieved with JTV519 (10(-3) mmol/L) in the HTK solution. Hearts in the diltiazem group were arrested with diltiazem (0.5 mmol/L) in the HTK solution. All the hearts were then subjected to 6-hour storage in HTK solution at 4 degrees C.

RESULTS

After a 30-minute reperfusion, the left ventricular developed pressure in the JTV519 and diltiazem groups were improved significantly compared with the control group. There was a significantly lower left ventricular end-diastolic pressure level and higher recovery of coronary flow in the JTV519 group than in the control group. The postischemic intracellular calcium concentration was attenuated by adding JTV519 or diltiazem to HTK cardioplegia.

CONCLUSION

As an adjunct to cardioplegia, JTV519 showed a significant protective effect on myocardium undergoing 6 hours of ischemia. The beneficial protective effects of JTV519 are correlated with its ability to inhibit the postischemic rise in intracellular calcium.

Paradoxical decrease of an adipose-specific protein, adiponectin, in obesity

We isolated the human adipose-specific and most abundant gene transcript, apM1 (Maeda, K., et al., Biochem. Biophys. Res. Commun. 221, 286-289, 1996). The apM1 gene product was a kind of soluble matrix protein, which we named adiponectin. To quantitate the plasma adiponectin concentration, we have produced monoclonal and polyclonal antibodies for human adiponectin and developed an enzyme-linked immunosorbent assay (ELISA) system. Adiponectin was abundantly present in the plasma of healthy volunteers in the range from 1.9 to 17.0 mg/ml. Plasma concentrations of adiponectin in obese subjects were significantly lower than those in non-obese subjects, although adiponectin is secreted only from adipose tissue. The ELISA system developed in this study will be useful for elucidating the physiological and pathophysiological role of adiponectin in humans.

Role of adipocytokines on the pathogenesis of atherosclerosis in visceral obesity

Obesity which is defined as accumulation of excess body fat, is a major cause of atherosclerotic vascular disease in industrial countries. Recent advances in the biology of adipose tissue have revealed that adipose tissue is not simply an energy storage organ but it also secretes a variety of molecules which affect the metabolism of the whole body. Through a systematic search of active genes in adipose tissue, we found that adipose tissue, especially visceral fat expressed numerous genes for secretory proteins (about 30% of total genes analyzed). Among them, plasminogen activator-1 (PAI-1), which is a regulator of the fibrinolytic system, was overexpressed in the visceral fat in an animal model of obesity. Plasma levels of PAI-1 were closely correlated with visceral fat adiposity. Thus, PAI-1 secreted from visceral fat may play some role in thrombotic vascular disease in visceral obesity. Adiponectin, a novel adipose-specific gene product, which has a matrix-like structure, is abundantly present in the bloodstream. Dysregulated secretion of adiponectin may be related to vascular disease in obesity. Biologically active molecules secreted from adipose tissue (adipocytokines) may have important roles in the development of atherosclerotic disease in obesity.

[Coronary artery bypass grafting for cases which were not amenable to preoperative left ventriculogram]

We evaluated the coronary artery bypass grafting (CABG) for the cases which were not amenable to preoperative left ventriculograms (LVG). Between June 1970 and March 1996, we had 2045 cases of isolated CABG, and 52 cases of which were not amenable to preoperative LVG. The reasons of no preoperative LVG were during cardiopulmonary resuscitation (CPR) in 4 cases, shock state in 14, NYHA class IV or CCS class IV in 26, angina attack after coronary angiography in 3 and so on. Preoperative diagnoses were acute myocardial infarction in 28, angina after infarction in 13, unstable angina in 9 and effort angina in 2. Preoperative conditions were reoperation in 6, insertion of intra-aortic balloon pumping in 46, chronic renal failure in 15 (hemodialysis in 4) and arrhythmia (VT or Vf) in 12. Concerning the coronary lesions, left main trunk and triple vessel diseases occupied 75% of all. Surgical deaths were 5 cases (9.6%) and hospital deaths were 4 cases (7.7%). The all cases which needed preoperative CPR were died with brain injury. The result of the cases which were not amenable to preoperative LVG were worse than the cases with ischemic cardiomyopathies. In conclusion, no preoperative LVG is one of the highest risk factors of all.

[Central venous access via the distal femoral vein using ultrasound-guidance]

We used a new method for central venous (CV) access via the distal femoral vein using ultrasound guidance in two cases. In the first case, because of multiple catheter punctures for hemodialysis previously, femoral catheter placement was impossible using a standard landmark technique. In the second case of laryngoplasty, it was also impossible to place a CV catheter at usual groin sites because of extensive mycosis. In these two cases, we attempted CV catheterization via the distal femoral vein at the femur (10 cm from the inguinal ligament) by using ultrasound guidance. In both cases the catheter placement was easy and took a short time. No complication due to puncture and catheterization was observed. CV access via the femoral vein in the groin has been the first-choice for the patients undergoing neuro- or neck-surgery. However, the femoral CV catheters at inguinal site has been associated with higher incidence of catheter infection than the subclavian or internal jugular vein. These methods have a potential for decrease in catheter infection rate. These two case reports suggest that the CV catheterization at distal femoral site by ultrasound-guidance is useful as a new method of CV access.

[A combination of reoperation for pseudoaneurysm following the Cabrol procedure and total aortic arch replacement in a patient with Marfan syndrome--a case with an aberrant right subclavian artery]

A 44-year-old male with Marfan's syndrome had undergone an initial operation for DeBakey type I acute aortic dissection with annulo-aortic ectasia. He had undergone replacement of the ascending aorta and aortic valve with a composite graft and reconstruction of the coronary artery by the Cabrol procedure. At 5 years after the initial surgery he experienced chest pain and was subsequently examined. Computed tomography revealed a pseudoaneurysm in the ascending aorta and the residual aortic dissection. The maximum diameter of the pseudoaneurysm was 85 mm and the maximum diameter of the aortic arch was 55 mm. The aortic arch was associated with an aberrant right subclavian artery. Angiography revealed that the pseudoaneurysm was caused by leakage at the coronary ostium-graft anastomoses. We repaired the anastomoses and performed total aortic arch replacement with reconstruction of four arch branches. The postoperative course was uneventful without any complications. We report this case because there have been few reports regarding arch replacement in cases with an aberrant right subclavian artery.

Calcium channel blockers attenuate cardiovascular responses to tracheal extubation in hypertensive patients

PURPOSE

Hypertensive patients exhibit exaggerated cardiovascular responses to tracheal extubation. This study was undertaken to examine the inhibitory effects of calcium channel blockers, nicardipine and diltiazem, on haemodynamic changes after tracheal extubation.

METHODS

Sixty hypertensive patients (ASA physical status II) undergoing elective orthopaedic (upper and lower extremity) surgery received, in a randomized, double-blind manner, 30 micrograms.kg-1 nicardipine, 0.2 mg.kg-1 diltiazem or saline (as a control) (n = 20 of each) i.v. before tracheal extubation. Changes in heart rate (HR), mean arterial pressure (MAP) and rate-pressure product (RPP) were measured before and after tracheal extubation.

RESULTS

The HR, MAP and RPP increased after tracheal extubation in the control group (P < 0.05). The increases in these haemodynamic variables were attenuated with nicardipine or diltiazem. The inhibitory effects of diltiazem on these cardiovascular responses to tracheal extubation were greater than those of nicardipine (HR; 86 +/- 7 vs 101 +/- 10, RPP; 11,437 +/- 1,575 vs 14,675 +/- 2,874, mean +/- SD, P < 0.05).

CONCLUSION

Compared with nicardipine, administration of diltiazem produced greater attenuating the circulatory responses to tracheal extubation in hypertensive patients.

High concentration of glucose induces the expression of intercellular adhesion molecule-1 in human umbilical vein endothelial cells

Atherosclerosis is known to be accelerated in patients with diabetes mellitus. We have examined the effect of glucose on the expression of intercellular adhesion molecule-1 (ICAM-1) in cultured human umbilical vein endothelial cells (HUVEC) and the adhesion of cells of monocyte-like cell line, THP-1, to HUVEC. HUVEC exposed to a high glucose concentration (16.7 mM) showed a 1.4-fold increase in the adhesion of THP-1 cells and a 1.3-fold increase in cell surface expression of ICAM-1 after 6 h exposure compared with those cultured in medium with a low glucose concentration (5.6 mM). ICAM-1 expression began to increase after 3 h exposure, was maximal at 6 h and gradually decreased afterwards. At 16.7 mM, raffinose stimulation produced a significantly lower expression of ICAM-1 on HUVEC than glucose, furthermore it caused a significantly lower expression than low glucose stimulation (5.6 mM). We conclude that a high concentration of glucose can induce ICAM-1 in endothelial cells and that this effect may play an important role in atherogenesis in patients with diabetes mellitus.

Lipoprotein(a) enhances the expression of intercellular adhesion molecule-1 in cultured human umbilical vein endothelial cells

BACKGROUND

We reported an increase in serum lipoprotein(a) [Lp(a)] levels in patients with thromboangiitis obliterans, suggesting that Lp(a) could also contribute to the pathogenesis of cardiovascular diseases by a mechanism different from atherosclerosis. Adhesion molecules were shown to contribute to the development of not only atherosclerotic but also inflammatory vascular diseases.

METHODS AND RESULTS

We evaluated the effect of Lp(a) on the expression of intercellular adhesion molecule (ICAM)-1, vascular cell adhesion molecule (VCAM)-1, and E-selectin in human umbilical vein endothelial cells by a cell ELISA. Lp(a) dramatically enhanced the levels of ICAM-1 in a dose-dependent manner. A discernible increase in ICAM-1 expression was observed at a physiological concentration of 0.26 mmol cholesterol/L Lp(a) after 48-hour incubation. A 1.8-fold increase in ICAM-1 expression was observed 48 hours after the addition of Lp(a) (1.04 mmol cholesterol/L). Northern blot analysis demonstrated that the amount of ICAM-1 mRNA was increased after treatment with Lp(a). In contrast to ICAM-1, the expression of VCAM-1 and E-selectin was not significantly affected by Lp(a). Lp(a-) [apolipoprotein(a)- removed Lp(a) by reduction with dithiothreitol] and LDL had no significant effect on the expression of ICAM-1. In contrast, recombinant apolipoprotein(a) protein alone significantly enhanced ICAM-1 expression. Lp(a) decreased the level of active transforming growth factor (TGF)-beta in the conditioned medium. Furthermore, recombinant TGF-beta significantly decreased the Lp(a)-induced ICAM-1 expression. These findings suggested that Lp(a) may enhance the ICAM-1 expression by decreasing active TGF-beta level.

CONCLUSIONS

Lp(a) could contribute to the development of cardiovascular diseases by enhancing the expression of ICAM-1 in endothelial cells.

Troglitazone suppresses intimal formation following balloon injury in insulin-resistant Zucker fatty rats

Troglitazone, a thiazolidinedione derivative, overcomes insulin resistance through promoting insulin receptor function. However, the effect of the resultant enhancement of insulin action on the regulation of cellular proliferation remains unknown. We investigated the effect of troglitazone on intimal proliferation after balloon injury in insulin-resistant Zucker fatty rats. Troglitazone markedly decreased blood glucose and triglyceride levels at the therapeutic dosage. The area of neointima significantly decreased in treated animals 2 weeks after operation, as compared with the untreated control animals (0.0526 +/- 0.0292 and 0.115 +/- 0.0354 mm2, respectively). The ratio of neointimal to medial area in treated rats (0.75 +/- 0.26) decreased by as much as 53% compared with untreated rats (1.40 +/- 0.05). We next examined DNA synthesis in cultured smooth muscle cells (SMCs) derived from non-insulin-resistant rats, to assess whether troglitazone suppresses the proliferation of vascular SMCs independent of metabolic effects. The result showed that troglitazone decreased [methyl-3H]thymidine incorporation into DNA. In conclusion, treatment with troglitazone in Zucker fatty rats resulted in a reduction in neointima formation after balloon injury, and also corrected hypertriglyceridemia and hyperglycemia. In addition, in vitro studies revealed that the anti-proliferative effect of troglitazone stems from its direct action on DNA synthesis rather than any accompanying metabolic changes. Therefore, troglitazone seems to be applicable in preventing atherosclerosis in patients with insulin resistance.

Troglitazone enhances glucose uptake and inhibits mitogen-activated protein kinase in human aortic smooth muscle cells

The thiazolidinedione analogue troglitazone is an antidiabetic agent that improves insulin resistance in rodents and humans. Although coronary artery disease is common in patients with the insulin resistance syndrome, the effects of troglitazone on smooth muscle cells (SMC) have not been fully elucidated. We therefore examined the effects of troglitazone on cell growth and glucose uptake in human aortic SMC. Mitogen-activated protein (MAP) kinase activity and glucose transporter (Glut) 1 mRNA levels were also studied. In the absence of troglitazone, insulin (10(-7) M) caused a 2-fold increase of DNA synthesis in SMC and troglitazone suppressed the increase of DNA synthesis in a dose-dependent manner. This growth suppression was accompanied by inhibition of MAP kinase activity. On the other hand, troglitazone significantly increased Glut 1 mRNA and enhanced glucose uptake in SMC. These results suggest that troglitazone affects the insulin signaling pathways in SMC and suppresses growth while promoting glucose uptake. Our findings support the application of troglitazone as an inhibitor of SMC proliferation in patients with insulin resistance.

Role of membrane-anchored heparin-binding epidermal growth factor-like growth factor and CD9 on macrophages

Heparin-binding epidermal-growth-factor-like growth factor (HB-EGF) is a potent mitogen for smooth-muscle cells (SMCs) belonging to the EGF family. We have previously determined that HB-EGF is expressed in macrophages and SMCs of human atherosclerotic lesions and that its membrane-anchored precursor, proHB-EGF, also has a juxtacrine mitogenic activity which is markedly enhanced by CD9, a surface marker of lymphohaemopoietic cells. Therefore, when both proHB-EGF and CD9 are expressed on macrophages, they may strongly promote the development of atherosclerosis. In the present study we have investigated the changes in proHB-EGF and CD9 in THP-1 cells during differentiation into macrophages and by the addition of oxidized low-density lipoproteins (OxLDL) and assessed juxtacrine growth activity of THP-1 macrophages for human aortic SMCs. HB-EGF and CD9 at both the mRNA and the protein level were up-regulated after differentiation into macrophages, and further expression of HB-EGF was induced by the addition of OxLDL or lysophosphatidylcholine. Juxtacrine induction by formalin-fixed growth was suppressed to control levels by an inhibitor of HB-EGF and was partially decreased by anti-CD9 antibodies. These results suggest that co-expression of proHB-EGF and CD9 on macrophages plays an important role in the development of atherosclerosis by a juxtacrine mechanism.

[Implantation of the Novacor left ventricular assist device in a patient with dilated cardiomyopathy]

The Novacor left ventricular assist device has been widely applied as a bridge to heart transplantation. The patient, a 29-year-old, male had severe left ventricular failure due to dilated cardiomyopathy. The heart failure had progressively worsened and showed severely reduced wall motion of the left ventricle with fraction shortening of 0.03. His cardiac catheterization data with 7 r of dopamine infusion was as follows; RA(12), RV46/9EDP(12), PA(w)(31), cardiac Index 1.73 l/min/cm2. Novacor implantation was performed on March 11th, 1996. After the implantation the patient was extubated on day 3 and recovered rapidly. No complications, such as bleeding or thromboembolic episodes were seen. The patient was flown to the USA for cardiac transplantation on 24th, September, 1996. During the 11-hour flight from Narita to Los Angeles, he experienced no adverse effects. The patient underwent a successful cardiac transplant at UCLA Medical Center. His post-operative course was uneventful. We believe that either chronic circulatory support or the bridge to transplant using Novacor LVAS will be a significant breakthrough for the treatment of Japanese patients with severely deteriorated cardiomyopathy.

Characteristics of coronary artery disease and lipoprotein abnormalities in patients with heterozygous familial hypercholesterolemia associated with diabetes mellitus or impaired glucose tolerance

Familial hypercholesterolemia (FH) is a genetic disorder characterized by high levels of serum low density lipoprotein (LDL) cholesterol and premature coronary atherosclerosis. In order to elucidate the influence of abnormal glucose metabolism on the development of coronary artery disease (CAD) in FH patients, we examined the prevalence of CAD and characteristics of lipoprotein abnormalities in patients with heterozygous FH who were accompanied by diabetes mellitus (DM) or impaired glucose tolerance (IGT). The subjects of the present study were 150 patients with heterozygous FH, all over 40 years of age. Oral glucose tolerance tests demonstrated that 15 patients had DM and 27 had IGT. The combination of DM or IGT with FH was associated with a further increase in the prevalence of CAD (DM:IGT:normal glucose tolerance (N), 87:59:43%). Furthermore, the prevalence of the stenoses in the distal coronary arteries was significantly higher in the DM group than in the N group, while there was no significant difference in the prevalence of proximal and middle lesions. Serum triglyceride levels were significantly higher in the DM and IGT groups than in the N group (P < 0.01, DM versus N group; P < 0.01, IGT versus N group), while total cholesterol levels were not significantly different. When lipoproteins were analyzed by polyacrylamide gel electrophoresis, the frequency of midband appearance, which implies an increase in remnant lipoproteins, was significantly higher in the DM and IGT groups than in the N group (DM:IGT:N, 87:72:29%, P < 0.01, DM versus N group; P < 0.01, IGT versus N group). Ultracentrifugation analysis of lipoproteins revealed that intermediate density lipoprotein cholesterol was increased in DM and IGT groups compared with the N group. These data suggest that abnormal glucose metabolism may accelerate the development of CAD in FH patients due to an increase in atherogenic remnant lipoproteins in addition to high concentration of LDL. Special attention should be paid in the treatment of FH patients with impaired glucose metabolism, to avoid the advancement of coronary atherosclerosis.