Thoracoscopic sympathectomy for hyperhidrosis palmaris: a periareolar approach

Severe hyperhidrosis palmaris represents a disabling problem for many patients. Thoracoscopic techniques that involve dissection and removal of the upper thoracic sympathetic chain are believed to result in the lowest incidence of recurrent symptoms. However, aside from an axillary incision, an additional upper anterior chest wall approach is usually required. Over the past 2 years, we have used a periareolar incision in eight patients to improve postoperative cosmesis for this benign condition.

Evolution of the Fontan procedure in a single center

BACKGROUND

Surgical approaches to single ventricle variants include staged, fenestrated, and completed Fontan operations. This study compares outcomes with these modifications of the Fontan operation at a single center.

METHODS

Preoperative risk factors and operative results were analyzed by multivariate techniques in 129 patients undergoing modified Fontan operations since March 1988.

RESULTS

Overall early and late mortality was 5.4% and 0.8%, respectively. Before 1993, completed Fontan operation using right atrial to pulmonary artery anastomosis without fenestration was performed in the majority of patients (44 of 58; 76%). During this period, 10 of 17 patients at high risk had completed Fontan with three takedowns. In 1994, the staged hemi-Fontan and modified Fontan with a lateral tunnel anastomosis and with or without small fenestration (2.5 to 4 mm) were introduced. The majority of patients at high risk during this period underwent hemi-Fontan followed by fenestrated Fontan with no takedowns. Late atrial dysrhythmias occurred in 6 patients (4.7%), generally with larger fenestrations or right atrial to pulmonary anastomoses. Three patients (2.3%) had a stroke, 2 with large (> or = 4 mm) fenestrations. Of 38 fenestrations, 32 (84%) closed spontaneously by 1 year. No protein-losing enteropathy occurred. Most patients (118 of 121) were in New York Heart Association class I/II 4.5 years postoperatively. By multivariate analysis, only Down's syndrome (p < 0.001) predicted early mortality, whereas both Down's syndrome and a systemic right ventricle decreased late survival (p < 0.006).

CONCLUSIONS

Proper selection of patients for modifications of the Fontan procedure resulted in excellent early and late survival with a low incidence of atrial dysrhythmia and stroke. Midterm functional outcomes were excellent.

Correlation of plasma adrenomedullin to myocardial preservation during open-heart surgery

Adrenomedullin (ADM) is a vasoactive peptide with potent dilatory effects. We studied whether perioperative myocardial injury could be altered by the presence of ADM. Blood samples from 19 children with congenital heart disease undergoing surgical repair were collected at six time points: preoperative, on cardiopulmonary bypass (CPB), and 0, 3, 6, and 12 hours after CPB. Blood levels of ADM (pg/ml) and troponin-I (Tn-I; ng/ml), a specific marker of myocardial injury, were measured. Patients were divided into three groups based on their 12-hour Tn-I levels (I, < 10, n = 6; II, 10-25, n = 6; III, >25, n = 7). Preoperative Tn-I levels were within the normal range for all patients. Preoperative ADM levels in group I (with little or no evidence of myocardial injury) were significantly greater than those of either group II or III (242.7 +/- 15.4 vs 83.8 +/- 18 and 85.2 +/- 5.5, respectively; p < or = 0.0001 for each). The 12-hour ADM levels in group I remained significantly lower than preoperative levels (242.7 +/- 15.4 vs 197.4 +/- 11.6, p < or = 0.03) but higher than in the other groups. In group III, ADM increased at the 12-hour time point (159.2 +/- 6.5, p < or = 0.0001 vs baseline). Higher preoperative ADM levels are associated with lower levels of myocardial injury (as assessed by troponin-I release) during congenital heart surgery.

Requirements for mini-exon inclusion in potato invertase mRNAs provides evidence for exon-scanning interactions in plants

Invertases are responsible for the breakdown of sucrose to fructose and glucose. In all but one plant invertase gene, the second exon is only 9 nt in length and encodes three amino acids of a five-amino-acid sequence that is highly conserved in all invertases of plant origin. Sequences responsible for normal splicing (inclusion) of exon 2 have been investigated in vivo using the potato invertase, invGF gene. The upstream intron 1 is required for inclusion whereas the downstream intron 2 is not. Mutations within intron 1 have identified two sequence elements that are needed for inclusion: a putative branchpoint sequence and an adjacent U-rich region. Both are recognized plant intron splicing signals. The branchpoint sequence lies further upstream from the 3' splice site of intron 1 than is normally seen in plant introns. All dicotyledonous plant invertase genes contain this arrangement of sequence elements: a distal branchpoint sequence and adjacent, downstream U-rich region. Intron 1 sequences upstream of the branchpoint and sequences in exons 1, 2, or 3 do not determine inclusion, suggesting that intron or exon splicing enhancer elements seen in vertebrate mini-exon systems are absent. In addition, mutation of the 3' and 5' splice sites flanking the mini-exon cause skipping of the mini-exon, suggesting that both splice sites are required. The branchpoint/U-rich sequence is able to promote splicing of mini-exons of 6, 3, and 1 nt in length and of a chicken cTNT mini-exon of 6 nt. These sequence elements therefore act as a splicing enhancer and appear to function via interactions between factors bound at the branchpoint/U-rich region and at the 5' splice site of intron 2, activating removal of this intron followed by removal of intron 1. This first example of splicing of a plant mini-exon to be analyzed demonstrates that particular arrangement of standard plant intron splicing signals can drive constitutive splicing of a mini-exon.

Primary mediastinal nonseminomatous germ cell tumors: the influence of postchemotherapy pathology on long-term survival after surgery

OBJECTIVES

The treatment of nonseminomatous germ cell tumors with cisplatin-based chemotherapy followed by aggressive surgical resection of residual disease is one of the most successful models for multimodality cancer therapy. We reviewed the case histories of 91 patients treated at our institution from 1981 to 1998 with primary mediastinal nonseminomatous germ cell tumors to evaluate variables that may influence survival after surgery.

METHODS

Twelve of the 91 patients did not undergo postchemotherapy resection because of progressive disease. Seventy-nine of them underwent 82 thoracic surgical procedures and are the basis of this review. The majority (71/75) had elevated serum tumor markers, 75% (n = 50) of which returned to normal levels after first- or second-line chemotherapy.

RESULTS

There were 3 operative deaths and 1 late death, attributed to pulmonary complications. Twenty-four patients died of recurrent disease and 3 of leukemia, for an overall survival of 61% after an average follow-up of 48 months. The pathologic findings of complete tumor necrosis (n = 19) and benign teratoma (n = 28) in the surgical specimen predicted excellent and good long-term survival, respectively, which was statistically better than that of patients having persistent nonseminomatous germ cell tumors (n = 24) or carcinomatous/sarcomatous degeneration (n = 8).

CONCLUSIONS

Primary nonseminomatous germ cell tumors of the mediastinum can be cured with a multimodality therapy, particularly in the subset of patients with postchemotherapy pathologic findings of tumor necrosis and teratoma. Survival is poor but possible in patients with unfavorable pathologic findings after chemotherapy, currently justifying an aggressive surgical approach in patients with otherwise operable disease.

Valved bovine jugular venous conduits for right ventricular to pulmonary artery reconstruction

Various valved and nonvalved external right ventricle (RV) to pulmonary artery (PA) conduits have been used to palliate congenital heart anomalies. The ideal conduit has not been found. Reasons for conduit failures include stenosis, thrombosis, calcification of the valve or graft wall, and development of an obstructive peel. We evaluated valved and nonvalved conduits constructed from a glutaraldehyde preserved segment of bovine jugular vein. Bovine jugular conduits (n = 31), 10-13 mm in diameter, were implanted into weight-matched adult mongrel dogs using a standard closed heart technique. Valved conduits (VC, n = 17) were stented at the valve annulus with a Gore-Tex ring, whereas the nonvalved conduits (NC, n = 14) were stented at their midpoint. The proximal PA was tightly banded to 3 mm with a ligature. Cardiac output (CO) and hemodynamic gradients were measured at the time of insertion and 8 months postoperatively. Pulmonary artery angiograms were used to assess bovine jugular conduit regurgitation. All xenografts were evaluated by gross and histologic exam. Two dogs had conduits placed but died for reasons unrelated to the conduit before evaluation. Valved conduit leaflets showed thickening, insignificant thrombus deposition in the base of one or more cusps, and a mild degree of regurgitation as assessed by angiograms. Examination of the NC showed mild conduit thickening and a moderate-to-severe degree of regurgitation as assessed by angiograms. There was a significant difference observed in pulmonary outflow gradients between the VC (11 +/- 2 mm Hg) and NC (17 +/- 2 mm Hg) (p < 0.05), although neither group developed a hemodynamically significant gradient. On gross examination, VC ventricles displayed significantly less evidence of volume and pressure overload compared with the NC ventricle. Valved conduits demonstrated significantly less obstruction and regurgitation. The potential clinical advantages of bovine jugular conduits are their availability, potential durability evidenced by lack of early calcification, and the advantage of not requiring a proximal extension for the RV anastomosis. The presence of a durable and functional xenograft valve in valved conduits may prevent postoperative sequelae in some patients.

RNase P RNAs from some Archaea are catalytically active

The RNA subunits of RNase Ps of Archaea and eukaryotes have been thought to depend fundamentally on protein for activity, unlike those of Bacteria that are capable of efficient catalysis in the absence of protein. Although the eukaryotic RNase P RNAs are quite different than those of Bacteria in both sequence and structure, the archaeal RNAs generally contain the sequences and structures of the bacterial, phylogenetically conserved catalytic core. A spectrum of archaeal RNase P RNAs were therefore tested for activity in a wide range of conditions. Many remain inactive in ionically extreme conditions, but catalytic activity could be detected from those of the methanobacteria, thermococci, and halobacteria. Chimeric holoenzymes, reconstituted from the Methanobacterium RNase P RNA and the Bacillus subtilis RNase P protein subunits, were functional at low ionic strength. The properties of the archaeal RNase P RNAs (high ionic-strength requirement, low affinity for substrate, and catalytic reconstitution by bacterial RNase P protein) are similar to synthetic RNase P RNAs that contain all of the catalytic core of the bacterial RNA but lack phylogenetically variable, stabilizing elements.

Splicing-independent processing of plant box C/D and box H/ACA small nucleolar RNAs

Small nucleolar RNAs (snoRNAs) are involved in various aspects of ribosome biogenesis and rRNA maturation. Plants have a unique organisation of snoRNA genes where multiple, different genes are tightly clustered at a number of different loci. The maize gene clusters studied here include genes from both of the two major classes of snoRNAs (box C/D and box H/ACA) and are transcribed as a polycistronic pre-snoRNA transcript from an upstream promoter. In contrast to vertebrate and yeast intron-encoded snoRNAs, which are processed from debranched introns by exonuclease activity, the particular organisation of plant snoRNA genes suggests a different mode of expression and processing. Here we show that single and multiple plant snoRNAs can be processed from both non-intronic and intronic transcripts such that processing is splicing-independent and requires endonucleolytic activity. Processing of these different snoRNAs from the same polycistronic transcript suggests that the processing machineries needed by each class are not spatially separated in the nucleolus/nucleus.

Detection of Ob-receptor in human adrenal neoplasms and effect of leptin on adrenal cell proliferation

Leptin, a hormone mainly secreted from adipose tissue, communicates a metabolic signal to the adrenal gland. Ob-Receptor (Ob-R) expression was reported in rat, mice and human adrenal glands. This study intended to investigate possible differences in the Ob-R expression and distribution of Ob-R protein in human adrenal tumors as compared to normal adrenal tissue. Proliferative effects of leptin were analyzed in the human adrenocortical carcinoma cell line (NCI-H295). The full length Ob-R mRNA and the isoforms B219.1 and B219.3 could be demonstrated by RT-PCR in all adrenal tumors (n=8), the tumor cell line (NCI-H295) and normal tissue. In contrast the Ob-R isoform B219.2 was absent in the carcinoma cell line and in most of the adrenal tumors (n=5), whereas it was present in normal adrenals. The Ob-R protein could be demonstrated in benign and malignant adrenocortical tumors. Pheochromocytomas showed only a weak immunostaining with the human Ob-R antibody. Human leptin did not affect the proliferation or variability of adrenal tumor cells as demonstrated by [3H]-thymidine assay and WST-1 test. In conclusion, although functional leptin receptors are expressed in human adrenal tumors, leptin does not regulate tumor cell proliferation.

Neuropsychology and the self-concept

The biological basis of the self is discussed in relation to neuropsychological findings in cases with focal brain injury. This material demonstrates that the self is deposited at an early phase in the process of object realization and distributes into the private space of imagery and the external space of object perception. A disruption or truncation of this process results in an erosion of the self that is similar across the different perceptual modalities. From the pattern of pathological breakdown, it is concluded that the self is a categorical, relational entity that achieves autonomy in the context of an act of cognition that is fully derived, i.e., actualizes completely. The autonomy depends on the completeness of this derivation. The preliminary locus of the self in the mental state entails a holistic or multimodal phase of potential before perceptual individuation. The relation of the self-concept to antecedent phases in the microgenesis of a cognition, the relation to feeling, personal history, and the immediate past, points to a limbic transition in the outward development of the mental state.

The Ribonuclease P Database

Ribonuclease P is responsible for the 5'-maturation of tRNA precursors. Ribonuclease P is a ribonucleoprotein, and in bacteria (and some Archaea) the RNA subunit alone is catalytically active in vitro, i.e. it is a ribozyme. The Ribonuclease P Database is a compilation of ribonuclease P sequences, sequence alignments, secondary structures, three-dimensional models and accessory information, available via the World Wide Web at the following URL: http://www.mbio.ncsu.edu/RNaseP/home .html

Stem-loop structure in the 5' region of potato virus X genome required for plus-strand RNA accumulation

Computer-generated thermodynamic predictions and solution structure probing indicated two stem-loop structures, stem-loop 1 (SL1; nt 32-106) and stem-loop 2 (SL2; nt 143-183), within the 5' 230 nt of potato virus X (PVX) RNA. Because the existence of SL1 was further supported by covariation analysis of several PVX strains, the functional significance of this structure was investigated by site-directed mutational analysis in a tobacco protoplast system. In general, mutations that reduced genomic plus-strand RNA accumulation similarly affected coat protein accumulation, indicating that subgenomic plus-strand RNA was also affected. In contrast, minus-strand RNA levels remained relatively unchanged. Mutational analysis of the stem C (SC) region of SL1 indicated that pairing was more important than sequence, which was consistent with the covariation analysis. Alterations that increased length and stability of either SC or stem D (SD) were deleterious to plus-strand RNA accumulation. The formation of internal loop C between SC and SD, as well as specific nucleotides within this loop, were also required. Several modifications were made to the terminal GAAA tetraloop, a motif known for enhanced RNA stability. Both GANA and GAAG motifs resulted in wild-type levels of RNA accumulation. However, a UUCG tetraloop was detrimental, indicating that the sequence of this element was important beyond just providing stabilization of the structure. These data indicate that multiple features of SL1 are critical for accumulation of PVX plus-strand RNA.

Donor cardiac troponin T: a marker to predict heart transplant rejection

BACKGROUND

Noninvasive methodologies have shown poor sensitivity in predicting rejection when compared to serial endomyocardial biopsies. We studied the potential role of donor blood troponin T (Tn-T) as a marker for predicting heart transplant rejection.

METHODS

Blood cardiac Tn-T was measured from 16 heart donors. Transplant rejection and cardiac function in the recipients were monitored for 1 year.

RESULTS

When data were analyzed based on donor blood Tn-T levels, 6 patients who received hearts from donors with low Tn-T (<0.45+/-0.1 ng/mL) showed no rejection, and patients whose hearts came from donors with higher Tn-T (6.01+/-0.81 ng/mL) developed episodes of high-grade rejection (3A) within 38.5+/-2.1 days after transplantation. Eight patients who received hearts from donors with intermediate levels of Tn-T (3.57+/-0.55 ng/mL) showed mild rejection (grade 1). All recipients had qualitatively normal left ventricular systolic function by serial echocardiography. The mean donor ischemic time was 169+/-47 minutes.

CONCLUSIONS

The quality of the donor heart is an important prognostic factor in heart transplantation. It may be possible to identify severely damaged donor organs before transplantation and avoid their use or to develop more aggressive strategies for reducing recurrent acute rejection episodes in high-risk patients.

A role for neural cell adhesion molecule in the formation of the avian inner ear

The inner ear forms by a series of folds within an ectodermal placode. Previous work has shown that changes in surrounding tissues play a more prominent role in invagination than changes in the cytoskeleton of the primordium. Interference with the integrity of the extracellular matrix causes abnormalities in the folding process, primarily related to abnormalities in the paraxial mesoderm which lies ventral to the placode. In this study, the role of the neural cell adhesion molecule (N-CAM) was investigated, based on the expression of this component of the plasmalemma at the time the otic placode begins to fold. Microinjection of blocking antibodies to N-CAM into the paraxial mesoderm adjacent to the otic placode resulted in two major classes of defects, detachment of the primordium from the neural tube and interference with formation of the folds. Microinjection of saline, control immunoglobulin, or antibody against cytoplasmic domain had no effect. These defects correlate with the pattern of N-CAM expression at the time of injection, along the neural ectoderm and otic epithelium and the mesenchyme cells ventral to the primordium. It seems likely that N-CAM is playing a role in heterophilic associations rather than through the homophilic binding domain during formation of the otic vesicle.

Fundamentals of process neuropsychology

An examination of the whole-to-part transition over phases, from potential to actual in the specification of a concrete entity, as in the momentary mind/brain state, reveals patterns of change that can be considered a first approximation to the foundational laws of cognition. These laws, which amount to a theory of universal change, apply as well to the becoming or actualization of non-cognitive entities. Thus, the thesis is advanced that the mental and the physical actualize a generic process and that a theory of this process, process monism, is a metaphysics of the antecedents of occasions of fact or the laws of change that deliver objects. The commonality of the mental and the physical lies in the conceptuality of the duration of becoming and its continuity with the duration of the conscious present. The before/after relation that characterizes the phase-transitions in a non-cognitive entity is the seed of the past/present relation in consciousness. The connectedness of past and present arises as a feeling of the relation of antecedent phases imminent in a concrete particular. The theory rejects as regressive the elimination of consciousness by a reduction to the material, or the reverse, in idealism, as well as an emergence of consciousness from material states. A deep current of connectedness runs from the nature of conscious phenomena to the categories of existence at the level of the atom.

Studies of the neuronal transdifferentiation process in cultured human pheochromocytoma cells: effects of steroids with differing functional groups on catecholamine content and cell morphology

The neuronal differentiation of adrenal pheochromocytoma cells from human subjects was studied in vitro for periods of up to 65 days. Changes with time in culture were observed in both intracellular catecholamine content (progressive decreases in epinephrine, norepinephrine, and dopamine, except for a possible transient early increase in the latter) and in morphology (increases in neurite outgrowth) of cells cultured in control medium; supplementation of cultures with nerve growth factor resulted in a substantial increase in neurite formation. The effects on these changes of the presence in the culture medium of various steroids were examined. The addition of 11-oxygenated steroids (aldosterone, corticosterone, cortisol, or dexamethasone) at 10(-5) M concentrations caused at least 2.5-fold increases in mean intracellular dopamine and norepinephrine levels; with dexamethasone, 9-10-fold increases were observed. Intracellular epinephrine content was also enhanced by 11,17-oxygenated steroids (dexamethasone and cortisol), but not by the other 11-oxygenated compounds studied. These two 11,17-oxygenated glucocorticoids also inhibited the morphologic changes seen with extended periods in culture, decreasing the outgrowth of neurite projections and causing cells to attain a vacuolated and granular appearance; the presence of dexamethasone strongly inhibited the morphologic changes induced by nerve growth factor. 11-Deoxy steroid intermediates (pregnenolone, 11-deoxycorticosterone, and 11-deoxycortisol) had little or no effect on catecholamine content or on morphology. Preliminary observations suggest that C-18 and C-19 sex steroid hormones (17 beta-estradiol and testosterone) may have morphologic effects opposite to those of the 11-oxygenated compounds, showing a slight stimulatory influence on the formation of neurite projections, but no significant effect on catecholamine content.

Recurrent aortic coarctation: is surgical repair still the gold standard?

OBJECTIVE

We reviewed our experience with surgical repair compared with balloon aortoplasty of recurrent coarctations of the aorta.

METHODS

This is a retrospective review of 1 institution's 27-year experience with surgical repair of recurrent aortic coarctation. A thorough chart review was performed of all pediatric patients undergoing surgical repair for recurrent aortic coarctation (n = 56) from January 1970 through July 1996.

RESULTS

The vast majority of recoarctations were repaired with a prosthetic patch technique, with a greater than 96% success rate. No deaths or major complications occurred in the 56 patients. Although a direct comparison with balloon aortoplasty cannot be done, we have reviewed the data available in the literature and found higher complication rates and lower success rates than we obtained in our series.

CONCLUSIONS

Although the treatment of aortic coarctation has improved significantly during the past decades, persistent hypertension after repairs at an older age and recurrent coarctation after repairs in neonates occur in all institutions. Surgeons have not agreed on the optimal approach to primary coarctation repair, and invasive cardiologists have challenged operative intervention for both recurrent and primary coarctation. This study demonstrates that surgical repair of recurrent coarctation of the aorta can be performed safely and with excellent results. We believe it is still the gold standard in the management of recurrent coarctation of the aorta.

Evolutionary variation in bacterial RNase P RNAs

Sequences encoding RNase P RNAs from representatives of the last remaining classical phyla of Bacteria have been determined, completing a general phylogenetic survey of RNase P RNA sequence and structure. This broad sampling of RNase P RNAs allows some refinement of the secondary structure, and reveals patterns in the evolutionary variation of sequences and secondary structures. Although the sequences range from 100 to <25% identical to one another, and although only 40 of the nucleotides are invariant, there is considerable conservation of the underlying core of the RNA sequence. RNase P RNAs, like group I intron RNAs but unlike ribosomal RNAs, transfer RNAs or other highly conserved RNAs, are quite variable in secondary structure outside of this conserved structural core. Conservative regions of the RNA evolve by substitution of apparently interchangeable alternative structures, rather than the insertion and deletion of helical elements that occurs in the more variable regions of the RNA. In a remarkable case of convergent molecular evolution, most of the unusual structural elements of type B RNase P RNAs of the low G+C Gram-positive Bacteria have evolved independently in Thermomicrobium roseum , a member of the green non-sulfur Bacteria.

Dispensation of emergency contraceptive pills in Michigan Title X clinics

OBJECTIVES

Emergency contraceptive pill dispensation was estimated in Michigan Title X family planning programs.

METHODS

Logistic regression and tobit estimation models were used to predict whether and to what extent emergency contraceptive pills are dispensed.

RESULTS

Of the 53 programs studies, 32 dispensed emergency contraceptive pills, averaging fewer than one client per month. Total dispensation was skewed toward a few programs, and the contribution of health departments to this total was small. Emergency contraceptive pill services appeared to be randomly distributed across programs, although most dispenser reported having provided the pills for less than 12 months.

CONCLUSIONS

Recent policy advances should lead to more consistent emergency contraceptive pill dispensation in Title X programs.

Effect of modified ultrafiltration in high-risk patients undergoing operations for congenital heart disease

BACKGROUND

Modified ultrafiltration (MUF) after cardiopulmonary bypass (CPB) in children decreases body water, removes inflammatory mediators, improves hemodynamics, and decreases transfusion requirements. The optimal target population for MUF needs to be defined. This prospective, randomized study attempted to identify the best candidates for MUF during operations for congenital heart disease.

METHODS

Informed consent was obtained from 100 consecutive patients with complex congenital heart disease undergoing operations with CPB. They were randomized into a control group (n = 50) of conventional ultrafiltration during bypass and an experimental group using dilutional ultrafiltration during bypass and venovenous modified ultrafiltration after bypass (MUF group, n = 50). Postoperative arterial oxygenation, duration of ventilatory support, transfusion requirements, hematocrit, chest tube output, and time to chest tube removal were compared between the groups stratified by age and weight, CPB technique, existence of preoperative pulmonary hypertension, and diagnosis.

RESULTS

There were no MUF-related complications. In patients with preoperative pulmonary hypertension, MUF significantly improved postoperative oxygenation (445 +/- 129 mm Hg versus control: 307 +/- 113 mm Hg, p = 0.002), shortened ventilatory support (42.9 +/- 29.5 hours versus control: 162.4 +/- 131.2 hours, p = 0.0005), decreased blood transfusion (red blood cells: 16.2 +/- 18.2 mL/kg versus control: 41.4 +/- 27.8 mL/kg, p = 0.01; coagulation factors: 5.3. +/- 6.9 mL/kg versus control: 32.3 +/- 15.5 mL/kg, p = 0.01), and led to earlier chest tube removal. In neonates (< or =30 days), MUF significantly reduced transfusion of coagulation factors (5.4 +/- 5.0 mL/kg versus control: 39.9 +/- 25.8 mL/kg, p = 0.007), and duration of ventilatory support (59.3 +/- 36.2 hours versus 242.1 +/- 143.1 hours, p = 0.0009). In patients with prolonged CPB (>120 minutes), MUF significantly reduced the duration of ventilatory support (44.7 +/- 37.0 hours versus 128.7 +/- 133.4 hours, p = 0.002). No significant differences were observed between MUF and control patients for any parameter in the presence of ventricular septal defect without pulmonary hypertension, tetralogy of Fallot, or aortic stenosis.

CONCLUSIONS

Modified ultrafiltration after CPB is safe and decreases the need for homologous blood transfusion, the duration of ventilatory support, and chest tube placement in selected patients with complex congenital heart disease. The optimal use of MUF includes patients with preoperative pulmonary hypertension, neonates, and patients who require prolonged CPB.

Monocusp valve and transannular patch reconstruction of the right ventricular outflow tract: an experimental study

Repair of congenital right ventricular outflow tract obstruction often requires reconstruction with a transannular patch to alleviate pulmonary stenosis. Post repair pulmonary insufficiency with right ventricular dilatation and volume overload may result and lead to acute or progressive right heart failure. The use of a monocusp valve has been proposed as a means to prevent this problem. Fresh pericardium is well known to fail clinically, leading to pulmonary insufficiency limiting mid- and long-term results. In a chronic dog model (147 +/- 34 days), three valve types were evaluated: 1) polytetrafluoroethylene (PTFE; n = 9), 2) fresh pericardium (PERI; n = 6), and glutaraldehyde fixed pericardium (GLU; n = 6). Hemodynamics, angiography, and echocardiography were performed at implantation and sacrifice. Gross and microscopic pathology were evaluated. No significant differences were found among the three groups with regard to stenosis as evaluated by echocardiography, measured right ventricular wall thickness, and hemodynamic pressure gradients across the valve. By echocardiography, both PTFE (1 of 9) and GLU (0 of 6) showed less regurgitation than PERI (5 of 6) (p < 0.05). This was confirmed by angiography. PTFE showed less neo-intimal hyperplasia, less thrombus formation, and less calcification than GLU or PERI (p = NS). The PTFE monocusp developed no prohibitive gradients, no early pathologic deterioration, and maintained competence compared with the GLU and PERI groups. Although continued investigation of long-term durability and competence of the PTFE monocusp valve is warranted, both PTFE and GLU values seem to demonstrate less regurgitation than the PERI monocusp valve in an adult dog model of right ventricular outflow tract reconstruction.

Adrenomedullin in patients at high risk for pulmonary hypertension

BACKGROUND

Adrenomedullin is a newly identified peptide with profound hypotensive effects. We investigated perioperative adrenomedullin levels among patients with congenital heart disease with and without pulmonary hypertension.

METHODS

Levels of plasma adrenomedullin, endothelin-1, and nitric oxide metabolites were measured in three groups: (1) low pulmonary flow (n=11); (2) high flow/low pulmonary arterial pressure (less than 60% systemic pressure) (n=9); and (3) high flow/high pressure (n=10). Samples were obtained preoperatively, on and off pump, and 3, 6, and 12 hours after bypass.

RESULTS

Adrenomedullin levels were highest in the low pulmonary flow group (189.7+/-15 pg/mL low flow versus 103.1+/-9.5 pg/mL high flow/low pulmonary and 139+/-17.5 pg/mL high flow/high pressure at 12 hours; p < or = 0.05). The arterial pressure/systemic pressure remained significantly lower in the high flow/low pulmonary pressure compared with the high flow/high pressure group (0.37+/-0.08 versus 0.62+/-0.11; p < 0.005). Perioperative endothelin-1 and nitric oxide levels remained low in the low pulmonary flow group but increased progressively in both high flow groups.

CONCLUSIONS

Circulating plasma adrenomedullin appears to affect baseline vascular tone in patients with intact endothelial function. It may interact with nitric oxide and endothelin-1 to help regulate blood pressure perioperatively in patients with congenital heart disease.