Extended endocardial repair of postinfarction ventricular septal rupture: new operative technique--modification of the Komeda-David operation

Between January 1992 and November 1992, four consecutive patients (ages 53 to 81 years) underwent early surgical repair of postinfarction ventricular septal ruptures using a new simple operative technique. The principles of the technique are longitudinal incision of the infarcted left anterior ventricular wall, placement of a saccular patch of single equine pericardium that covers the infarcted left ventricular wall, and large buttressed suture closure of the left ventriculotomy. The infarcted septum and infarcted left ventricular wall are completely separated from the left ventricular cavity. In this procedure, the infarcted myocardium is not resected, and left and right ventricular muscles are preserved. This technique is simple and safe for use in the acute phase of myocardial infarction, and it preserves ventricular function after surgery.

Sequential internal mammary artery grafts: clinical and angiographic assessment

Between January 1988 and August 1992, the internal mammary artery was used as a sequential graft to the left anterior descending artery and/or diagonal branch in 34 patients. One patient died in hospital. After surgery all survivors were free from angina for a follow-up of up to 4 years. Recatheterization was performed in 33 patients within 1 year of surgery. Postoperative angiography showed that 65 anastomoses (98%) were patent, but three patent grafts (5%) between the proximal and distal sequential anastomoses showed 'string sign'. It is important to prevent 'string sign' in sequential grafting. It is considered that sequential internal mammary artery grafting should be limited to coronary arteries with severe stenosis that divides anastomosed coronary arteries into two.

Anomalous origin of the left coronary artery from the pulmonary artery. New operative technique

We report a new operative technique for repair of anomalous origin of the left coronary artery from the pulmonary artery. The principles of the proposed technique are left main coronary angioplasty using a transected main pulmonary artery, side-to-side anastomosis of the aorta and newly created left coronary artery, and direct anastomosis of the transected pulmonary artery. No prosthetic material is used in this procedure. Our experience in two adults (a 35-year-old man and a 68-year-old woman) indicated that this technique permits two coronary system repair for any anatomic variation of the left coronary artery without the use of prosthetic material. This is more advantageous in infants.

[Coronary artery bypass grafting surgery without cardiopulmonary bypass]

Improved technique in coronary artery surgery has allowed coronary artery bypass graftings (CABG) to be placed on beating heart. The effects of extracorporeal circulation and cardiac arrest are eliminated. From Jan. 1991 to June, 1992, we performed CABG surgery without cardiopulmonary bypass and cardiac arrest in 15 patients; the age ranged from 47 to 82 years with the mean of 65. Patients who had LAD and/or RCA stenosis were candidate of this procedure in early series. However in recent series, we extended the candidate to three-vessel or LMT stenosis cases who were considered ineligible for standard CABG because of renal failure or poor left ventricular function. Distal anastomoses were performed with interruption of coronary flow. From one to two distal anastomosis to the LAD and/or RCA (mean 1.4/patient) were performed. The ITA was used in all 15 patients. Combined cardiac or vascular operation was performed in 5 patients (AAA repair, TAA repair, carotid endarterectomy or coronary endarterectomy). There were no deaths and no perioperative myocardial infarction. Postoperative angiography were performed in 12 patients with a patency rate of 89%.

Structure of 29-kDa protein from ascidian (Halocynthia roretzi) body wall muscle

Preparations of thin filament from ascidian (Halocynthia roretzi) body wall muscle were found to be contaminated with large amounts of an unknown protein which, when purified, migrated to 29 kDa on SDS-PAGE and was thus named HR-29. To elucidate its physiological function, we have determined the primary structure of HR-29 by peptide and cDNA sequence analysis. Genomic sequence analysis showed that HR-29 is divided to four exons by three introns. It is composed of 251 amino acid residues and the N-terminal Ser is blocked by an acetyl group. The N-terminal domain of 150 residues is hydrophilic, and from residue 36 to 92 there are three similar repeated sequences of 19 residues. The N-terminal domain showed no significant sequence homology with other proteins. On the other hand, the C-terminal domain of 100 residues has homology with those of small heat-shock proteins and alpha-crystallin of lens protein. HR-29 is thought to be a fusion protein of two different origins. Recently alpha B-crystallin was identified in skeletal muscle and suggested to be a myofibril-stabilizing protein [Atomi, T. et al. (1991) J. Biochem. 110, 2360-2364]. Thus, HR-29 may also be a myofibril-stabilizing protein, as suggested by the sequence similarity of the C-terminal domain with alpha-crystallin, although the origin and role of the N-terminal domain are not clear.

Postoperative erythroderma after cardiac operations. The possible role of depressed cell-mediated immunity

Erythroderma as a manifestation of graft-versus-host disease after cardiac operations with blood transfusion may occur more frequently in Japan than in other countries. We have seen this problem in five patients who, after heart operations, died with symptoms and signs characteristic of graft-versus-host disease: cutaneous eruption, fever, diarrhea, leukopenia associated with agranulocytosis, and liver dysfunction. In the three patients seen most recently, skin biopsy showed findings similar to those of graft-versus-host disease after bone marrow transplantation. In addition, immunologic investigation showed remarkable differences in the findings in these patients and in those who did not have a graft-versus-host disease-like syndrome after cardiac operations. In particular, interleukin-2 production in response to mitogen stimulation was markedly diminished after operation in our patients, and the ratio of OKT4+ cells to OKT8+ cells in peripheral blood was low, reflecting increased numbers of OKT8+ cells after the occurrence of symptoms. The results raise the possibility that transient depression of cellular immunity after cardiac operations with blood transfusion may contribute to the occurrence of postoperative acute graft-versus-host disease.

Congenital quadricuspid aortic valve associated with aortic regurgitation

A case of quadricuspid aortic valve is described. The aortic valve consisted of 3 equal-sized and 1 smaller cusps, and a supernumerary cusp located between the right and noncoronary cusps. A right coronary ostium was close to the accessory commissure, and in a lower position. Three fenestrations were found at the supernumerary commissure. Aortic valve replacement was performed successfully with a St. Jude Medical prosthetic valve. On histological examination, the resected cusps showed fibrotic thickening with calcification and no sign of previous inflammatory disease. Quadricuspid aortic valve must be considered a malformation capable of leading to severe valve failure in later life.

Augmentation of interleukin-2 production after cardiac operations in patients treated with erythropoietin

It has been reported recently that cardiac operations can be followed by a transient impairment of cell-mediated immunity. In this study we examined indices of cell-mediated immunity in patients undergoing cardiac operations. Twenty-five of the patients received erythropoietin (200 U/kg) daily for 2 weeks before and after operation, and 30 matched control patients did not receive erythropoietin. On postoperative day 1, the numbers of total T cells and helper/inducer T cells were significantly higher in erythropoietin-treated patients than in control patients. The ability of patients' cells to make interleukin-2 in vitro increased after erythropoietin injection in the preoperative period. By postoperative day 1, erythropoietin-treated patients exhibited a fall in interleukin-2 production that was significantly less than that in control patients; levels increased by day 2 to a mean value twice that of the preoperative baseline and more than four times the corresponding mean level in the control groups, and levels returned to the baseline range by postoperative day 14. Levels of interleukin-2 production in erythropoietin-treated patients were significantly higher than those in control patients at each interval tested through postoperative day 7. These findings indicate that erythropoietin treatment not only augmented levels of circulating erythrocytes but also improved indices of cell-mediated immunity. Although the mechanism responsible for this effect remains to be determined, the finding suggests that erythropoietin might help to ameliorate or prevent the impairment of immune function that can occur after cardiac operations.

[The changes of the cell-mediated immunity in patients with administration of recombinant erythropoietin]

The change of cell-mediated immunity was studied in patients receiving open heart surgery with or without administration of recombinant erythropoietin (rEPO). Group I was not administered rEPO in 30 patients, and Group II was done intravenously with 200U/kg/day of rEPO for 6.4 +/- 2.4 days before operation and also for 7.2 +/- 3.6 days after operation in 20 patients. The ratio of reticulocyte increased in all patients receiving rEPO. In both groups the ratios of OKT3 and OKT4 positive T lymphocytes decreased significantly on postoperative day 1. However, the ratios in patients with rEPO increased more significantly than in those without rEPO. Lymphocyte blast formation which was indicated by PHA-SI (phytohemagglutinin stimulation index) increased after administration of rEPO. The postoperative PHA-SI in both groups showed similar changes. The level of interleukin-2 (IL-2) production increased after the administration similar to PHA-SI change. The level of it decreased on postoperative day 1 and increased on postoperative days 3 and 7. We administered 200U/kg/day of rEPO for 7 days in a patient with postoperative erythroderma after open heart surgery and the level of IL-2 production was found to also increase in patient according with recovery of symptom. In conclusion, our data suggested that the rEPO might effect on not only erythrocyte but also lymphocyte activation.

Modified De Vega's annuloplasty for functional tricuspid regurgitation--early and late results

From 1978 through 1987, 321 patients who had functional tricuspid regurgitation (TR) associated with mitral or combined mitral and aortic valve disease underwent tricuspid annuloplasty with our modification of the original De Vega's annuloplasty technique. The modified De Vega's annuloplasty consisted of two separate semicircular sutures placed around the anterior and lateral aspect of the tricuspid valve. Preoperatively, 229 (71.3%) of the 321 patients were in New York Heart Association functional class III or IV. There were nineteen early deaths (5.9%), and 15 patients died during a follow-up period of 15 to 126 months (mean follow-up, 26 months). Five patients (1.5%) required reoperation because of biological mitral valve failure and recurrence of mitral stenosis. The severity of TR was evaluated by two-dimensional and pulsed Doppler echocardiography, and was classified on a scale of 0 to Grade 3 according to the maximal distance and the flow pattern of the regurgitant signals in the right atrium. Postoperative echocardiographic evaluation of TR was performed in 121 randomly selected patients late after operation. TR reduced to Grade 1 or less in 107 (88.4%) of the 121 patients after operation. Ninety-six percent of the survivors were in New York Heart Association functional class I or II, postoperatively. The actuarial survival rate for the 321 patients with the modified De Vega's annuloplasty including early deaths was 88.2% at 10 years and the actuarial rate of freedom from reoperation on the tricuspid valve was 97.6%. Our surgical experience indicated that the modified De Vega's annuloplasty, as the method of first choice, is a simple, reliable procedure and resulted in reduction of the severity of TR in 88.4% of the patients with functional TR.

Amino acid sequence of polypeptide chain IIB of extracellular hemoglobin from the polychaete Tylorrhynchus heterochaetus

The giant extracellular hemoglobin from the polychaete Tylorrhynchus heterochaetus consists of two types of subunits: a "monomeric" chain (chain I) and a disulfide-bonded trimer of chains IIA, IIB, and IIC. The complete amino acid sequence of chain IIB was determined. This chain has 148 amino acid residues and a molecular weight of 17,236 including a heme group. Of the residues in chain IIB, 74 (50%) and 34 (30%) were found to be identical with those in the corresponding positions in Tylorrhynchus chains IIC and I, respectively (Suzuki, T., Furukohri, T., and Gotoh, T. (1985) J. Biol. Chem. 260, 3145-3154). Marked differences were found between the chains of Tylorrhynchus and Lumbricus in the COOH-terminal regions. Significant differences were predicted between the monomeric chain I and the "trimeric" chains (IIB and IIC) in the hydropathy profiles and alpha-helical contents.

[Experimental study on free muscle transplantation--histological changes and functional recovery of transplanted muscles in relation to the duration of ischemia and denervation]

The purpose of this study was to clarify the influence of temporary ischemia and denervation on the characteristics of transplanted muscles.

MATERIALS AND METHODS

The rectus femoris brevis muscle of white rabbit was used. Under an operating microscope, this muscle was mobilized preserving its feeding vessels, and the innervating nerve was severed at 1 cm proximal to the entrance of the muscle. Six groups were made as follows. Group D: The severed nerve was left as it was. Group S: The nerve was sutured immediately after severance. No treatment was made on the feeding vessels. Group SI: The artery and vein were clamped for 1, 2, 3 and 4 hours (group SI-1, 2, 3 and 4) after nerve repair. The proximal and distal tendon were reattached to their original place in every group. Examination I: Transplanted muscles were examined histologically and histochemically from 48 hours to 6 months. Motor end-plate was one of the targets of observation.

RESULTS

Main patho-histological changes observed on the muscle and motor end-plates at one week were thought due to denervation, and the longer ischemic time caused more severe change in the group SI-3 and 4. Phagocytosis, destruction of muscle fibers and edema in the interstitial tissue were seen in these long ischemic time groups. A few motor end-plates in the group SI-3 and many of them in the group SI-4 were atrophic and their acetylcholinesterase (AChE) activity was low. Reduced nicotinamide-adenine dinucleotide-tetrazolium reductase (NADH-TR) and phosphorylase activity were reduced in all groups at one week. At 3 weeks, muscle atrophy was pronounced and was found earlier in type II fibers than in type I as a result of denervation. Pathological changes such as elongation, atrophy or segmentation and low AChE activity were observed in the motor end-plates of all groups at 3 and 6 weeks. These findings were more pronounced in the group SI-3 and 4. In all groups at 6 weeks, phosphorylase activity was found to be generally low but NADH-TR reaction stained a few regenerated muscle fibers. Although muscle atrophy was still observed at 9 weeks, recovery in size and shape and histochemical reaction was seen in all groups at this stage. These findings became more manifest at 15 weeks and almost normal appearance of muscle fibers was observed at 6 months. Interstitial connective tissue, however, increased, and necrotized muscle fibers were seen extensively in the group SI-3 and 4.(ABSTRACT TRUNCATED AT 400 WORDS)