[Surgery for ventricular septal defect with aortic regurgitation]

Twenty-two patients (mean age of 12.9 years) with ventricular septal defect (VSD) associated with aortic regurgitation (AR) were treated surgically. Sixteen patients had subpulmonic VSD and six had infracristal VSD. Fourteen patients with subpulmonic VSD underwent VSD closure alone. VSD was closed by pulling up the inferior rim to the pulmonary valve thus support the prolapse aortic cusp. AR improved in two and has remained stable in eleven for 0.5 to 12.7 years (mean 4.4 years). Aortic valve replacement (AVR) was necessary in an adult patient later. Plication of the aortic valve was effective in a young patient but ineffective in an adult patient. In infracristal VSD, AVR was necessary in two adult patients. In a young patient, AR improved by plication. Direct VSD closure ceased progression of AR in three patients. The long-term follow-up shows that VSD closure with our technique has been sufficient to arrest progression of AR in subpulmonic VSD. Early closure of VSD should be emphasized to prevent aortic valve prolapse and regurgitation.

Epithelioid cell melanomas have greater DNA ploidy abnormalities than spindle cell melanomas: cytological evidence for a higher malignant potential of the former

The cellular DNA ploidy of 30 cases of malignant melanoma was measured by 4',6-diamidino-2-phenylindole-DNA (DAPI-DNA) microfluorometry. DNA histograms and DNA index values were compared among melanomas of different cell morphology. Epithelioid cell melanomas often showed greater DNA aneuploidy than spindle cell melanomas in terms of histographic pattern. DNA index values of the former (mean +/- standard error, 1.84 +/- 0.31) were significantly higher than those of the latter (1.55 +/- 0.24; P < 0.05). The DNA index values of mixed-type melanomas were intermediate. These results indicate that the epithelioid cell melanomas have greater DNA ploidy abnormalities which are usually correlated with a greater malignant potential in pigmentary neoplasms. Thus our results confirm clinical evidence that melanoma patients with the epithelioid type of cells have a poorer prognosis than those with the spindle type of cells.

Successful differentiation of Spitz naevus from malignant melanoma by microfluorometric analysis of cellular DNA content

Two cases of presumed Spitz naevus, whose diagnosis on clinical and histological grounds was uncertain, were examined for cellular DNA content using the technique of DAPI-DNA microfluorometry. They were compared with 20 cases, respectively, of clinically and histologically confirmed, Spitz naevus, malignant melanoma and acquired pigmented naevus. The two Spitz naevi showed a diploid pattern in a distribution histogram of cellular DNA content. The pattern was similar to that of confirmed Spitz naevi and of acquired pigmented naevi but different from the aneuploid pattern of malignant melanomas. DNA index values of the two cases were within the range of confirmed Spitz naevi and different from those of malignant melanomas. The DAPI-DNA microfluorometric method thus provided confirmatory evidence for the diagnosis of Spitz naevus. The method appears to reflect sensitively the biological behaviour of tumour cells, and is a useful aid to the diagnosis of uncertain Spitz naevi.

Porokeratosis large skin lesions are susceptible to skin cancer development: histological and cytological explanation for the susceptibility

Porokeratosis (PK), an autosomal dominant inherited skin disorder, is known to develop malignant skin tumors on its skin lesions. Our recent literature survey has revealed that large PK skin lesions are frequently a precursor of malignant changes. In the study, large and small PK skin lesions were investigated in terms of histological features of the epidermis and of the cellular DNA content of epidermal cells. Large PK lesions frequently showed hypertrophic epidermis with many mitotic cells, while small lesions usually presented atrophic epidermis without such mitotic cells. Abnormal cells, like those containing hyperchromatic, large, and/or irregularly shaped nuclei, were present in the epidermis of both large and small lesions with a preponderance in the former over the latter. DNA polyploidy was seen more frequently in large PK lesions than in small ones. DNA index values were significantly higher in large lesions than in small ones. The histological features and DNA ploidy abnormalities probably reflect the higher proliferation and the greater potential for malignant changes of large PK skin lesions. Our study helps to explain the clinical evidence that large PK skin lesions are frequently a precursor of malignant skin tumors.

[Surgical treatment of primary cardiac tumors]

Thirty-four cases of primary cardiac tumors, consisted of 11 men and 23 women, aged between 26 and 80 years have been operated on in our institution. A total of 30 myxomas and four malignant tumors were resected. The clinical presentations included congestive heart failure in 25 patients, tachyarrhythmia in 6, chest pain in 4, and embolism in 10. All 30 myxoma lesions were completely resected, although none of the malignant tumors could be resected completely because of invasion of the tumor to the surrounding tissues. Four patients with malignant tumors died of tumor recurrence within 9 months after operation. Histological diagnosis was rhabdomyosarcoma in two patients, round cell sarcoma in one and malignant fibrous histiocytoma in one. All patients with myxoma survived operation. Follow-up was completed in 28 patients (range 1 month to 15 years, mean 5.5 years): Twenty-four were in New York Heart Association Class I, and the remaining two in Class II. Actuarial survival rate was 89% at 15 years after operation. No recurrent myxoma have been identified clinically or by echocardiography. For malignant primary tumors, more effective adjuvant therapy with aggressive resection will be inevitable to improve long-term prognosis.

[Simultaneous cesarean section and mitral valve replacement for infective endocarditis during pregnancy--a case report]

Infective endocarditis (IE) during pregnancy is uncommon. A 31-week-pregnant, 21-year-old woman suffered from severe mitral regurgitation caused by IE. She fell into heart failure and threatened abortion. Following to cesarean section, an emergent mitral valve replacement with a bioprosthetic valve was successfully performed. Her postoperative recovery was uneventful and she was discharged home 30 days after the operation. Her baby, however, died of intracranial hemorrhage caused by hypoxia 171 days after delivery. A strategy of simultaneous open heart surgery and cesarean section is recommended when emergent open heart surgery is inevitable for the treatment of cardiac diseases in cases with 24 and/or more weeks' gestation.

[Surgical repair of total anomalous pulmonary venous drainage--four adult cases of successful operation]

We have experienced four adult cases of total anomalous pulmonary venous drainage (TAPVD). They were three females and one male, age between 18-51 with a mean of 33.8. In Darling's classification, they constituted of three cases of type Ia and one type IV. Cardiac catheterization revealed 1.71-5.93 with a mean of 3.92 in Qp/Qs and 0.34-0.49 with a mean of 0.38 in Pp/Ps. The pulmonary to systemic resistance ratio (Rp/Rs) was then calculated as 0.02-0.15 with a mean of 0.09. All cases showed short route type of drainage vein in pulmonary arteriography. None of them had stenosis or obstruction in the drainage veins. The operation was composed of anastomosis between the left atrium and the common pulmonary vein, closure of the atrial septal defect (ASD), and ligation of the drainage vein. Gersony-Malm's method was adopted in two cases and the posterior approach in two cases in anastomoses between the left atrium and the common pulmonary vein. Intraatrial approach combined with posterior approach was tried in a case with small left atrium. The mean size of ASD was 43 mm (35-55 mm) in diameter. Patch closure was performed in three cases. Important factors in survival for adult TAPVD are large ASD and short route type drainage vein without stenosis. All of four cases had good results. The operation method is variable and an easier approach must be adopted.

[Open-heart surgery without donor-blood transfusion--a clinical study]

Since October 1987, 80 patients underwent open-heart surgery without donor-blood transfusion. 50 (Group I) out of these 80 cases were selected to be paired with 50 patients (Group II) who underwent open-heart surgery with homologous blood transfusion in the same period. Twelve cases (Group III) underwent open-heart surgery without homologous blood transfusion but were transfused after surgery. To decrease the homologous blood requirements, ultra-filtration system as well as conservation and autotransfusion of autologous blood was employed. Peripheral blood count, blood chemistry for liver and renal function were analyzed and compared among these three groups. Although hematocrit of Group I was lower than that of Group II until the third postoperative day, there was no difference after the seventh postoperative day. The platelet count was more in Group I than in Group II or III on the first and the seventh postoperative day. The level of lactate dehydrogenase was higher in Group II than in Group I. Total bilirubin was more elevated in Group II than in Group I on the first and the fourteenth postoperative day. Direct bilirubin was also higher in Group II than in Group I till fourteenth postoperative day. Five cases in Group II fulfilled the criteria of the serum hepatitis. Blood urea nitrogen and creatinine were less in Group I than in Group II. The duration of the intra-tracheal intubation was shorter in Group I than in Group II or III. There was no difference in postoperative dosage or duration of catecholamines among three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Functional pulmonary atresia: a case report]

A male neonate, two days of age, was admitted with cyanosis and tachypnea. Chest roentgenograms showed massive cardiomegaly and decreased pulmonary vasculatures. Echocardiographic and the right ventriculographic findings were interpreted as showing primary pulmonary atresia with secondary tricuspid incompetence. At a Brock operation, however, there was no resistance in passing the instrument through the pulmonary valve. The baby died twelve hours after surgery. Postmortem examination showed that the tricuspid regurgitation was a cause of the functional pulmonary atresia (FPA). It is important to distinguish FPA from pure pulmonary atresia because conservative therapy is the first choice for the FPA.

[Sudden onset of systemic hypoxia associated with both tricuspid regurgitation and persistent foramen ovale: a case report]

A 33-year-old female who had undergone closure of VSD 20 years before, was hospitalized for sudden onset of dyspnea without history of febrile or traumatic disorder. On admission, she had cyanotic lips and nailbeds but no clubbed finger. Chest x-ray film showed neither lung congestion nor cardiomegaly. Arterial blood gas analysis revealed deep hypoxia (PaO2 = 49.6 mmHg). Echocardiogram clarified massive tricuspid regurgitation (TR) due to chordal rupture of anterior leaflet, small VSD jet stream through the membranous aneurysm and a great deal of R-L shunt on the atrial level through a persistent foramen ovale. Cardiac catheterization data confirmed 35% of R-L shunt. At operation, a torn chordal tendon of anterior leaflet and an adhered septal leaflet to aneurysm of membranous portion of ventricular septum were seen. There were two pledgets, used at the first surgery, at the base of the aneurysm and a couple of tiny holes (VSDs) above and below the pledgets were recognized. Following resection of anterior and posterior leaflet, plication of septal leaflet and closure of VSD, a Xenograft valve (Carpentier-Edwards 29-M) was implanted. Then persistent foramen ovale, 20 x 20 mm in large, was closed directly. Her postoperative course was excellent with disappearance of cyanosis, normalized oxygen saturation in arterial blood and improved activity without dyspnea.

[A case report of cystic adventitial degeneration communicating with the hip joint in the external iliac artery]

Cystic adventitial degeneration is an uncommon cause of arterial obstruction. Its etiology is debated. We report a case in which the left external artery was affected and the cystic mass communicated with the hip joint. The findings of this case support the embryonic theory that the articular synovium and adventitial cysts have the same mesenchymal origin.

[Surgical management of tricuspid regurgitation associated with acquired valvular disease]

The best means of managing tricuspid regurgitation associated with acquired valvular disease is still controversial. During the period from 1978 to 1988, 111 patients who had tricuspid regurgitation along with associated valvular dysfunction were treated in Kagoshima University Hospital. Patients with moderate to severe regurgitation underwent annuloplasty in 61 (Carpentier's in 39, DeVega's in 20, and Kay's method in 2) and valve replacement in 8. Forty-two patients were treated conservatively on the tricuspid valve because of mild regurgitation. We found the results to be less satisfactory with a high incidence of postoperative deaths and residual tricuspid regurgatation in the group treated by annuloplasty with a Carpentier ring than in the other two groups of annuloplasty or in the group of valve replacement. We conclude the modified DeVega's method is the first choice for annuloplasty in patients with mild to moderate regurgitation, and we believe it appropriate to replace the valve in an increasing number of subjects which have severe regurgitation.

Cutaneous malignant lymphoma in an infant

A case of cutaneous malignant lymphoma in a 7-month-old infant is described. The skin was the only apparent organ involved. Immunophenotypic studies revealed that the infiltrate was positive for B4 (CD19), J5 (CD10), and cytoplasmic mu chain, and lambda chain, but negative for B1 (CD20). The significance of these findings is discussed. We believed the tumor was of B-cell origin. The reported cases of cutaneous malignant lymphoma in infancy are briefly reviewed.

[Surgical treatment of descending thoracic aortic aneurysm under temporary bypass with antithrombogenic tube and bio-medicus centrifugal pump]

Four patients with descending thoracic aortic aneurysm were successfully operated on under temporary bypass with an antithrombogenic tube and a Bio-Medicus centrifugal pump. The bypass flow ranged from 1.0 to 2.4 l/min with the mean femoral artery pressure of 50 to 70 mmHg. No complications such as paraplegia, hepatic dysfunction or renal failure were encountered in all the patients. Temporary increment of the serum amylase level occurred in all the patients, but any apparent clinical symptoms were not present. The temporary bypass method with an antithrombogenic tube and a centrifugal pump is useful and reliable for surgical treatment of descending thoracic aortic aneurysm.

The necessity of reoperation for patients with Bjork-Shiley, St Jude Medical, Hancock and Carpentier-Edwards prostheses

The purpose of this study was to determine the criteria of valve selection from the long-term results of Hancock, Carpentier-Edwards, St Jude Medical and Bjork-Shiley prostheses, taking into special account the frequency of reoperation. Reoperations on the Hancock bioprosthesis were performed on six patients for tissue leaflet disruption with an incidence of 2.2 per cent/patient-year. Reoperations on the Carpentier-Edwards bioprosthesis were performed on 24 patients for tissue leaflet disruption in 23 patients and prosthetic valve endocarditis (PVE) in one, with an incidence of 3.8 per cent/patient-year. Reoperations on the Bjork-Shiley prosthesis were performed in two patients for severe hemolysis, with an incidence of 0.32 per cent/patient-year. Reoperations on the St Jude Medical prosthesis were performed on 3 patients, for valve thrombosis in one patient, PVE in one, and hemolysis in one, with an incidence of 0.23 per cent/patient-year. The overall mortality rate was 20 per cent, or 7 patients, and the indications for reoperation affected this. Patients with primary tissue failure had a mortality rate of 10.3 per cent; those with a thrombosed valve, 0 per cent; those with hemolysis, 66.7 per cent; and those with valve infection, 100 per cent. A good chance of survival may be achieved in patients facing prosthetic valve complications by performing reoperation as soon as possible after early detection, since mortality is high following emergency reoperation and in patients with severe symptoms. Currently, we recommend mechanical prostheses for valve replacement except in patients over 70 years old and in younger patients with absolute contraindications to anticoagulative therapy.

[Intravascular hemolysis after prosthetic valve replacement]

Two kinds of mechanical valve, St. Jude Medical (SJM) and Björk-Shiley (B-S), in patients with single valve replacement have been evaluated on a view point of intravascular hemolysis. Cases were consisted of 78 SJM and 32 B-S for the mitral and 12 SJM and 36 B-S for the aortic positions. Serum LDH, indirect bilirubin, GOT, hemoglobin levels and reticulocyte count were pursued in a given schedule, especially on the 21st postoperative day. A follow-up study on cases with abnormally high level of LDH (over 800 W.U.) at the time of hospital discharge was also performed. Paravalvular leakage detectable on the echocardiographical study was denied in all cases. The case with SJM valve replacement on the mitral position revealed a higher level of LDH, GOT and a large count of reticulocyte than those in the B-S valve. Insignificantly was found, however, in the same study with replaced valve on the aortic position. There was no correlation between the severity of hemolysis and the size of prostheses. The level of LDH, remained in high on discharge declined gradually thereafter during postoperative observation. As a whole, the result of this study supports the conventional valve selection and usage in our clinic. The patient with subclinical hemolysis after valve replacement should be placed on a schedule of close observation.

[Experimental study of coronary reactive hyperemia--effects of hypothermia and potassium cardioplegia]

A hyperemic response on dog hearts following myocardial ischemia for 10 minutes has been studied in reference to myocardial protection with cardioplegia and hypothermia. Experimental animals were divided into four groups according to the difference in temperature and with or without cardioplegia during ischemia of the hearts. Group I (n = 7) succumbed to a normothermic ischemia. Group II (n = 6) had normothermic ischemia following infusion of 8 ml/kg of a normothermic cardioplegic solution. Group III (n = 7) had ischemia under moderate hypothermia (28 degrees C). Group IV [n = 7) had hypothermic ischemia following infusion of 8 ml/kg of hypothermic cardioplegic solution. A percent repayment of the flow debts in groups I, II, III, and IV were 234.6 +/- 38.3%, 101.5 +/- 40.8%, 134.5 +/- 50.0% and 112.8 +/- 36.5%, respectively. There was significant difference between group I and group II and IV (p less than 0.001) and group III (p less than 0.02). Peak flow in reactive hyperemia compared with control flow were 605.4 +/- 131.1%, 328.3 +/- 60.2%, 288.8 +/- 79.7% and 282.2 +/- 65.4% in each group I, II, III, and IV, respectively. The value in group I was significantly high in comparison with others (p less than 0.005). Depression of oxygen consumption was observed in groups with hypothermia as well as with cardioplegia. A hyperemic response was low in cardioplegia and/or hypothermia group. These data are suggestive of a beneficial use of cardioplegia and hypothermia on cardiac surgery through the observation of coronary reactive hyperemia after myocardial ischemia.

Function of the transplanted canine heart after prolonged preservation by simple immersion

The purpose of this study was to investigate the maximum limits of a simple topical cooling method with preservation of graft viability following orthotopic transplantation. Coronary vascular washout was performed with cold potassium-verapamil cardioplegia. The heart was then removed, suspended in the same solution, and stored at 4 degrees C. The experimental material was divided into three groups according to the preservation time: 24 h in group I (six animals), 36 h in group II (five animals), and 48 h in group III (three animals). All six animals in group I and four of five animals in group II maintained a stable recipient circulation after transplantation. No animals in group III could be taken off cardiopulmonary bypass. Contraction band injury after transplantation was more frequently observed in the group II grafts than in those of group I. In conclusion, the combination of coronary vascular washout with cold potassium-verapamil cardioplegia and storage at 4 degrees C in the same solution may preserve the canine heart for 24-36 h, as demonstrated by cardiac function immediately after orthotopic transplantation.

Orthotopic transplantation of the canine heart after prolonged preservation by simple immersion

The viability of the heart was assessed following orthotopic transplantation. Following coronary vascular washout with cold potassium-verapamil cardioplegia, the heart was removed, immersed in the same solution, and stored at 4 degrees C for 24 hours in Group I (6 animals), 36 hours in Group II (5 animals), and 48 hours in Group III (3 animals). All six animals in Group I and four of five animals in Group II maintained a stable recipient circulation for the acute phase of 2 hours after transplantation, without cardiopulmonary bypass. For the dogs in Group III, cardiopulmonary bypass was vital. Contraction band injury after transplantation was more frequently observed in the Group II grafts than those of Group I. We conclude that the combination of coronary vascular washout with cold potassium-verapamil cardioplegia and storage at 4 degrees C in the same solution may preserve the canine heart for up to 24 to 36 hours, as demonstrated by post-orthotopic transplantation function.

[A comparative study of experimental models for cardiac preservation through orthotopic transplantation]

Various kinds of models for canine heart preservation were evaluated through orthotopic transplantation. Following warm ischemic (WIT) and preservation times (PT), donor hearts were orthotopically transplanted to recipients and observed for 2 hours. The study was divided into four groups. A heart-lung preparation (Group A) was preserved by coronary perfusion with diluted blood for an hour following 15-minute WIT in A-1 (n = 33), and 2 hours following 30-minute WIT in A-2 (n = 19). Following 30-minute WIT, the heart (Group B) was preserved for an hour by coronary perfusion with diluted blood in B-1 (n = 20), a modified Krebs solution in B-2 (n = 14), and a EL-solution in B-2 (n = 14). Following 30-minute WIT, the heart (Group C) was preserved for 2 hours by a Langendorff's model with coronary perfusion using perfluorochemical in C-1 (n = 5) and Hydroxyethyl starch in C-2 (n = 1). In Group D, electromechanical arrest of the heart and coronary vascular washout were performed in D-1 (n = 8) with K+ cardioplegia, D-2 (n = 8) with K+-verapamil cardioplegia, and D-3 (n = 5) with Collins M-verapamil cardioplegia. The heart was then removed and suspended in the same solution. The graft was preserved at 4 degrees C for 6 hours in D-1 and D-2, and 24 hours in D-3. Fourty-eight % in A-1 and 26% in A-2 were successfully transplanted.(ABSTRACT TRUNCATED AT 250 WORDS)

Potassium-verapamil cardioplegia for myocardial protection: an experimental evaluation through preservation and transplantation

The efficacy of potassium-verapamil cardioplegia for myocardial protection was studied using the canine heart preservation and transplantation system. Coronary vascular washout of the grafts was performed via the aortic root both in Group I (n=8) with 4 degrees C high potassium cardioplegic solution and in Group II (n=8) with 4 degrees C high potassium and 1 mg/L verapamil solution. The heart were immersed into the same solution as used for washout and stored at 4 degrees C for 6 hours, without oxygenation and perfusion. The grafts were transplanted orthotopically under conditions of cardiopulmonary (CP) bypass. Adequate hemodynamics without the support of CP bypass was obtained in all the grafts of Group II during a 2-hour observation period. In contrast, only five out of eight grafts in Group I were able to support the recipient circulation. Contraction bands were more prominently and frequently observed in the histology in Group I. Thus, the combination of coronary vascular washout with cold potassium-verapamil cardioplegia and storage at 4 degrees C with the same solution seems to be effective for myocardial protection of the canine heart in cases of orthotopic transplantation.