[Surgery in acute bacterial endocarditis. Restraints--possibilities]

The limitations and possibilities of surgery in acute infective endocarditis depend on the indication, haemodynamic or bacteriological, the site of infection, aortic or mitral, and whether affecting a native or prosthetic valve. The common possibility of conserving the mitral valve in acute endocarditis is an additional therapeutic option. Similarly, the use of aortic homografts has improved the results in aortic endocarditis. Surgical principles have therefore evolved with conservative mitral valve surgery and "biological" aortic valve replacement. Techniques in prosthetic valve endocarditis have not surgery and earlier extra-anatomical procedures to avoid multiple recurrence with use of homografts or Danielson's technique for the aortic orifice. There have been fewer innovations for recurrent endocarditis on mitral valve prostheses. Irrespective of the site or type of endocarditis, the precocity of surgical treatment is an essential prognostic factor.

High prevalence of thyroid autoantibodies in a prospective series of patients with chronic hepatitis C before interferon therapy

After describing two cases of Hashimoto's thyroiditis associated with chronic hepatitis C, we set up a prospective study to assess the prevalence of thyroid autoantibodies (thyroglobulin and thyroid microsomal autoantibodies) in 72 chronic hepatitis C patients (43 men and 29 women; mean age = 51 +/- 2.1 yr) before interferon therapy admitted between January and December 1991 to our liver unit. Thyroid autoantibodies were systematically assayed in 60 chronic HBsAg-positive patients (34 men and 26 women; mean age = 50 +/- 2.2 yr), who served as controls. Antibody to hepatitis C virus was detected with a second-generation enzyme immunoassay and then confirmed with a recombinant immunoblot assay and a supplemental enzyme immunoassay using two beads. In chronic hepatitis C patients, no men had thyroid autoantibodies. Nine of 29 women (31%) had thyroid autoantibodies. Among them, six (20.7%) had high titers of thyroid autoantibodies, and two had hypothyroidism. In all nine of these women, hepatitis C virus viremia was detected on nested polymerase chain reaction (with primers located in the 5' untranslated region). One year later, titers of thyroid autoantibodies had increased in one patient. Three other patients progressed to hypothyroidism. We judged four of 29 patients (13.8%) to have Hashimoto's thyroiditis on the basis of their high titers of thyroid autoantibodies and biological features of hypothyroidism. In the control group, only one man had thyroid microsome autoantibodies, at a very low titer (1:100). The association between chronic hepatitis C and presence of thyroid autoantibodies is clearly confirmed (p = 0.021) by this study.

Genetic and biochemical analysis of Salmonella typhimurium FliI, a flagellar protein related to the catalytic subunit of the F0F1 ATPase and to virulence proteins of mammalian and plant pathogens

FliI is a Salmonella typhimurium protein that is needed for flagellar assembly and may be involved in a specialized protein export pathway that proceeds without signal peptide cleavage. FliI shows extensive sequence similarity to the catalytic beta subunit of the F0F1 ATPase (A. P. Volger, M. Homma, V. M. Irikura, and R. M. Macnab, J. Bacteriol. 173:3564-3572, 1991). It is even more similar to the Spa47 protein of Shigella flexneri (M. M. Venkatesan, J. M. Buysse, and E. V. Oaks, J. Bacteriol. 174:1990-2001, 1992) and the HrpB6 protein of Xanthomonas campestris (S. Fenselau, I. Balbo, and U. Bonas, Mol. Plant-Microbe Interact. 5:390-396, 1992), which are believed to play a role in the export of virulence proteins. Site-directed mutagenesis of residues in FliI that correspond to catalytically important residues in the F1 beta subunit resulted in loss of flagellation, supporting the hypothesis that FliI is an ATPase. FliI was overproduced and purified almost to homogeneity. It demonstrated ATP binding but not hydrolysis. An antibody raised against FliI permitted detection of the protein in wild-type cells and an estimate of about 1,500 subunits per cell. An antibody directed against the F1 beta subunit of Escherichia coli cross-reacted with FliI, confirming that the proteins are structurally related. The relationship between three proteins involved in flagellar assembly (FliI, FlhA, and FliP) and homologs in a variety of virulence systems is discussed.

Neural Networks and Nonlinear Adaptive Filtering: Unifying Concepts and New Algorithms

The paper proposes a general framework that encompasses the training of neural networks and the adaptation of filters. We show that neural networks can be considered as general nonlinear filters that can be trained adaptively, that is, that can undergo continual training with a possibly infinite number of time-ordered examples. We introduce the canonical form of a neural network. This canonical form permits a unified presentation of network architectures and of gradient-based training algorithms for both feedforward networks (transversal filters) and feedback networks (recursive filters). We show that several algorithms used classically in linear adaptive filtering, and some algorithms suggested by other authors for training neural networks, are special cases in a general classification of training algorithms for feedback networks.

Computational Diversity in a Formal Model of the Insect Olfactory Macroglomerulus

We present a model of the specialist olfactory system of selected moth species and the cockroach. The model is built in a semirandom fashion, constrained by biological (physiological and anatomical) data. We propose a classification of the response patterns of individual neurons, based on the temporal aspects of the observed responses. Among the observations made in our simulations a number relate to data about olfactory information processing reported in the literature; others may serve as predictions and as guidelines for further investigations. We discuss the effect of the stochastic parameters of the model on the observed model behavior and on the ability of the model to extract features of the input stimulation. We conclude that a formal network, built with random connectivity, can suffice to reproduce and to explain many aspects of olfactory information processing at the first level of the specialist olfactory system of insects.

Aortic dissection: anatomic types and surgical approaches

Our classification system of acute dissection of the aorta is based on the site of the main intimal tear: Type A: on the ascending aorta; type B: on the transverse aortic arch; type C: on the descending aorta. The extension of the dissecting process is classified as "antegrade" or "retrograde". Acute dissection involving the ascending aorta is an absolute surgical urgency. Any delay in referring the patient to a proper surgical institution or to the operating room increases the risk of death. Fifty per cent of patients, indeed, either untreated or medically supported, die within 48 hours after the onset of symptoms. Surgical therapy is mainly aimed at preventing the patient from dying from intrapericardial rupture of the aorta or from acute massive aortic regurgitation. In type A, it is necessary to replace the ascending aorta with a bloodtight Dacron prosthesis after resecting the entry site, if possible. Downstream, joining the two dissected cylinders by two running sutures and the aid of GRF glue, seals the false lumen. Upstream, the reconstruction of the aortic root and the resuspension of the aortic valve, also by means of running sutures and GRF glue, suppress the aortic valve insufficiency in 90% patients. However, in case of pre-existing annulo-aortic ectasia, the ascending aorta must be replaced by a composite tube according to the Bentail technique. The use of GRF glue since the beginning of 1977, has dramatically improved the immediate and long-term results, accounting for a hospital mortality rate of 10%, in patients less than 65 years old. In type B, resecting the entry site requires that the transverse arch be partially or totally replaced. It is, therefore, mandatory to protect the Central Nervous System. In our experience this is best achieved by perfusing the carotid arteries with cold blood (6 degrees C) during circulatory arrest at moderate core hypothermia (28 degrees C). With this technique of "Cerebroplegia", the hospital mortality rate has been lowered to 28%, higher, though, than in patients undergoing isolated replacement of the ascending aorta. In type C, only the dissections demonstrating symptoms of major complications (rupture or deleterious ischemia) require urgent surgical treatment. In the remaining cases, medical treatment, based on permanent and accurate control of the patient's blood pressure, lead to a good long-term survival rate. Close survey at regular intervals, by means of CT scan or MNR is mandatory to detect any aneurysmal evolution, which may require surgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Coronary surgery can be an alternative to heart transplantation in selected patients with end-stage ischemic heart disease

Patients with ischemic heart disease (IHD) low ejection fraction (EF), and congestive heart failure (CHF), are usually referred for orthotopic heart transplantation (OHT). This study reports our experience with coronary artery bypass grafting (CABG) in patients initially referred for OHT, and suggests guidelines to facilitate the choice of procedure (OHT or CABG). Between January 1990 and December 1991, 32 patients with IHD, proposed for OHT, underwent CABG 31/32 patients were male, the mean age was 58 +/- 12 years (40 to 70). Congestive heart failure was present in all patients and was the main symptom. The mean EF was 23 (14 to 31%), mean cardiac index (CI) 2.4 l/min per m2 (1.6 to 3.1 l/min per m2), mean pulmonary artery mean pressure (MPAP) 26 (20 to 37 mmHg) and mean pulmonary wedge pressure 16 (12 to 22 mmHg). Every patients underwent a myocardial viability study by thallium scintigraphy (n = 32) and/or by positron emission tomography (n = 10). The perioperative mortality was 9.3% (3/32). All long-term survivors (n = 27) are in NYHA Class II with a complete follow-up (mean 18 +/- 6 months). Ejection fraction control either by angiography (n = 15) or by single photon emission computed tomography (n = 12) showed an increase of up to 38% (22%-46%). Three determinant factors influenced the choice of CABG. 1) CI > 21/min per m2, 2) MPAP < 35 mmHg. 3) Detection of myocardial viability.(ABSTRACT TRUNCATED AT 250 WORDS)

Specification and implementation of a digital Hopfield-type associative memory with on-chip training

The definition of the requirements for the design of a neural network associative memory, with on-chip training, in standard digital CMOS technology is addressed. Various learning rules that can be integrated in silicon and the associative memory properties of the resulting networks are investigated. The relationships between the architecture of the circuit and the learning rule are studied in order to minimize the extra circuitry required for the implementation of training. A 64-neuron associative memory with on-chip training has been manufactured, and its future extensions are outlined. Beyond the application to the specific circuit described, the general methodology for determining the accuracy requirements can be applied to other circuits and to other autoassociative memory architectures.

Total orthotopic heart transplantation: an alternative to the standard technique

An alternative technique of total orthotopic heart transplantation is described. Complete excision of the recipient's atria is undertaken. Ventricular as well as atrial orthotopic transplantation is performed.

Valve extension with glutaraldehyde-preserved autologous pericardium. Results in mitral valve repair

Preliminary experimental studies in our laboratory have shown that autologous pericardium treated with glutaraldehyde prevents late deterioration and calcification of the tissue. For this reason, glutaraldehyde-treated autologous pericardium has been used in a series of 64 patients who underwent operations for leaflet extension of the mitral valve between 1980 and 1989. Ages ranged from 2.5 to 60 years (mean 19 +/- 15). The causes of mitral valve insufficiency were rheumatic fever (69%), bacterial endocarditis (17%), congenital (8%), endomyocardial fibrosis (4.5%), and trauma (1.5%). The autologous tissue was fixed in a 0.62% glutaraldehyde solution for 15 minutes and rinsed in saline for an additional 15 minutes. Patching techniques varied depending on the site and the extent of the lesion. Associated mitral valve repair techniques (Carpentier's techniques) were mandatory in all patients. The period of follow-up extended from 6 months to 9 years (mean 3.1 +/- 2.5 years). There were no operative deaths in this series, and there was one late death (2%). In the six patients (12%) who underwent reoperation, there has been no case of calcification of the pericardial patch. Postoperative mitral valve function was assessed by bidimensional color Doppler echocardiographic techniques. Mitral valve insufficiency was trivial or absent in 80% of the patients. This experience permits us to conclude that leaflet extension is a simple and safe technique in valve reconstruction, allowing repair of mitral valves that otherwise would need to be replaced. It permits use of an adult-size prosthetic ring in children. Glutaraldehyde-treated autologous pericardium is the material of choice for this type of repair.

Intra-operative transoesophageal echocardiography after mitral repair--specific conditions and pitfalls

The aim of this study was to determine the specific conditions and pitfalls of immediate assessment of the reconstructed mitral valve in open chest patients. Sixty-two patients had a mitral reconstruction controlled by transoesophageal echocardiography and colour Doppler (TEE) from the moment when cardiac activity restarted under extracorporeal circulation (ECC), until complete rewarming of the patient and weaning off the by-pass. The following conditions altered the imaging quality: (1) dried probe in the oesophagus or air bubbles, (2) non-aspirated air from the stomach, (3) small or empty left atria, (4) invagination of the left atrial appendage, (5) trapped air in the posterior pericardium, (6) spontaneous contrast. Transient mitral regurgitation disappeared completely in 12/62 patients: five had temporary impairment of LV function, two had reduced filling of the heart, one had left ventricular outflow obstruction exacerbated by isoproterenol and nitroglycerin, two had ventricular ectopic rhythms, and two epicardial pacing. Only one of the 62 patients had persistent significant MR which required a second run of ECC. We conclude that mitral regurgitation after mitral valve repair is closely related to the quality of LV function. A decision to reoperate should eliminate the possible pitfalls, and take into consideration the specific conditions of immediate postoperative cardiac function.

Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch

Profound hypothermia associated with circulatory arrest is the commonest method of cerebral protection during operations on the aortic arch. This technique allows a limited time to perform the aortic repair, however. It also necessitates prolonged cardiopulmonary bypass to rewarm the patient. This may be the cause of coagulation disorders or infection. Selective perfusion of the carotid arteries can also be used. When the perfusion is derived from the main arterial line, however, the repair of the aorta requires that the vessel be crossclamped, and cannot be performed in an "open, bloodless" manner. To avoid the disadvantages of both techniques, we have developed a new technique of cerebral protection. After a regular cardiopulmonary bypass has been established, the carotid arteries are cannulated and perfused with blood cooled at 6 degrees to 12 degrees C, through a separate heat exchanger, while the core temperature is maintained at moderate hypothermia (25 degrees to 28 degrees C, rectal). To perform the "open" distal repair, the cardiopulmonary bypass is discontinued while the carotid perfusion is maintained (250 to 350 ml/min). When the distal repair is completed, cardiopulmonary bypass is resumed and the carotid perfusion is discontinued. Between 1984 and June 1989, 54 patients (mean age 55 years) were operated on with this method (45 elective operations, 9 emergency procedures). Mean duration of cardiopulmonary bypass was 121 minutes (65 to 248), and mean duration of circulatory arrest was 22 minutes (10 to 51). The electroencephalogram, routinely recorded, showed return of the cerebral activity after a mean time of 12 minutes and normal activity after a mean time of 66 minutes. There was no intraoperative death. Hospital mortality rate was 13% (7/54). One death was related to neurologic disorders. All patients but one awakened normally within 8 hours after operation. Two patients (4.3%) experienced a transient neurologic episode (lateral hemianopia) 9 and 11 days postoperatively. There was no hemorrhagic complication (24-hour average blood loss: 840 +/- 540 ml). In our experience the technique of "cold cerebroplegia" has been demonstrated to provide excellent cerebral protection. It requires no prolonged cardiopulmonary bypass and does not limit the time necessary to perform the aortic repair. It may be considered as a safe alternative to profound hypothermia associated with circulatory arrest.

Interaction between roxithromycin and cyclosporin in heart transplant patients

Cyclosporin is an immunosuppressive agent commonly used in transplant patients. It is actively metabolised by the cytochrome P450 system and interactions with drugs metabolised by the same system are predictable. This is particularly relevant since cyclosporin has a low therapeutic index and its renal toxicity is concentration-related. Roxithromycin, a new, well-tolerated macrolide with a weak interactive profile, uses the same isoenzyme of the P450 system as cyclosporin. To evaluate its interaction potential in clinical practice, 8 heart transplant recipients treated with cyclosporin for at least 1 month received roxithromycin for 11 days (150 mg twice daily). Bi-weekly controls of plasma cyclosporin concentrations and creatinine levels were carried out before, during and after roxithromycin treatment. A slight nonsignificant rise in cyclosporin concentrations was observed, but creatinine levels remained stable during roxithromycin treatment. Values of cyclosporin concentrations diminished after withdrawal of roxithromycin. Cyclosporin dosage adjustment was not necessary. There was a minor pharmacokinetic interaction, which can be considered safe for the usual therapeutic dosage of roxithromycin used.

The native mitochondrial F1-inhibitor protein complex carries out uni- and multisite ATP hydrolysis

The rate of ATP hydrolysis under multi- and unisite conditions was determined in the native F1-inhibitor protein complex of bovine heart mitochondria (Adolfsen, R., MacClung, J.A., and Moudrianakis, E.N. (1975) Biochemistry 14, 1727-1735). Aurovertin was used to distinguish between hydrolytic activity catalyzed by the F1-ATPase or the F1-inhibitor protein (F1.I) complex. We found that incubation of aurovertin with the F1.I complex, prior to the addition of substrate, results in a stimulation of the hydrolytic activity from 1 to 8-10 mumol min-1 mg-1. The addition of aurovertin to a F1.I complex simultaneously with ATP results in a 30% inhibition with respect to the untreated F1.I. In contrast, if the F1.I complex is activated up to a hydrolytic activity of 80 mumol min-1 mg-1, aurovertin inhibits the enzyme in a manner similar to that described for F1-ATPase devoid of the inhibitor protein. The native F1.I complex catalyzes the hydrolysis of ATP under conditions for single catalytic site, liberating 0.16-0.18 mol of Pi/mol of enzyme. Preincubation with aurovertin before the addition of substrate had no effect under these conditions. On the other hand, if the F1.I ATPase was allowed to hydrolyze ATP at a single catalytic site, catalysis was inhibited by 98% by aurovertin. In F1-ATPase, the hydrolysis of [gamma-32P]ATP bound to the first catalytic site is promoted by the addition of excess ATP, in the presence or absence of aurovertin. Under conditions for single site catalysis, hydrolysis of [gamma-32P]ATP in the F1.I complex was not promoted by excess ATP. We conclude that the endogenous inhibitor protein regulates catalysis by promoting the entrapment of adenine nucleotides at the high affinity catalytic site, thus hindering cooperative ATP hydrolysis.

[Enoximone in the hemodynamic evaluation before heart transplantation. A new test]

A better selection of patients referred for cardiac transplantation should lead to better surgical results. The presence of severe and irreversible pulmonary hypertension is an important factor and its pretransplantation assessment requires pharmacodynamic testing with vasodilators and dobutamine. The aim of this study of 10 patients in congestive cardiac failure referred for cardiac transplantation was to evaluate enoximone in this indication by comparing it with sodium nitroprussiate (3 micrograms/kg/mn). Intravenous enoximone (total dose of 1.5 mg/kg) increased the cardiac index (+49%; p less than 0.01), slightly reduced the mean systemic blood pressure (-8%; p less than 0.05) whilst inducing a greater reduction in systemic arterial resistances (-36%; p less than 0.01); the fall in mean blood pressure was less than with sodium nitroprussiate (-23%; p less than 0.01). Myocardial oxygen consumption (rate-pressure product) did not increase in contrast to the effect of dobutamine (+21%; p less than 0.01). There was a significant reduction in pulmonary arteriolar resistances (p less than 0.01) with all three drugs but the interpretation of this response and its prognostic significance in patients with a low cardiac output and persistent pulmonary hypertension are discutable even when pulmonary arteriolar resistances are less than 6 Wood units. The value of using an inotropic agent such as Dobutamine or Enoximone is to unmask fixed pulmonary hypertension which may be missed in patients with low cardiac output even with vasodilator drugs, and also to mimic the haemodynamic result of transplantation. In this indication Enoximone may be used like Dobutamine but with the advantage of not increasing myocardial oxygen consumption and being probably less arrhythmogenic.

Kinking of the pulmonary artery: a treatable cause of acute right ventricular failure after heart transplantation

Kinking of the pulmonary artery has been reported only once as a cause of acute right ventricular failure after heart transplantation. We report two cases of kinking of the pulmonary artery encountered during a 3-year period (120 heart transplants). An analysis of the causes of this complication and a diagnostic and therapeutic approach are presented.

[Effect of hypertension on the renal and cardiac functions of patients with heart transplantation]

To evaluate the incidence, risk factors and effects of systemic hypertension on renal function and left ventricular hypertrophy after heart transplantation, 85 recipients under triple drug low low dosage immunosuppressive therapy were studied. After a mean follow-up of 12.5 +/- 8.7 months, high incidence of hypertension was observed in 67% of the patient and 71% had developed de novo hypertension. None of the pre-transplant nor post-transplant cardiovascular risk factors were significantly associated with post-transplant hypertension. Faster deterioration of renal function, as assessed by intraindividual variations of serum creatinine values, was demonstrated in hypertensive patients and appeared as an early indicator of cyclosporine nephrotoxicity in patients at risk for hypertension. [table: see text] Serial (early, intermediate, late) echocardiographic evaluations demonstrated early increase in left ventricular mass and in fractional shortening in both hypertensive and normotensive heart transplant recipients with sustained enhanced contractility in hypertensive patients. [table: see text] Further studies will help to determine the exact relationship between cyclosporine dosages and hypertension, and their respective roles in the development of renal insufficiency and left ventricular hypertrophy after heart transplantation.

Valve repair with Carpentier techniques. The second decade

Among 206 consecutive patients having undergone mitral valve repair with a prosthetic ring between 1972 and 1979 in our institution, the 195 patients (94.5%) who survived the operation were studied to assess the long-term function of this method of repair. Patients' ages ranged from 18 to 79 years (mean age 48.7 years). Mitral valve insufficiency was due to degenerative disease in 113 patients (58%), rheumatic disease in 74 (38%), ischemia and other causes in eight patients (4%). A total of 188 patients (9.7%) were in New York Heart Association class III or IV preoperatively and 94 (48%) had atrial fibrillation. The patients were divided into three functional groups: type I (normal leaflet motion), 35 patients (18%); type II (leaflet prolapse), 147 patients (75%); and type III (restricted leaflet motion), 13 patients (7%). The techniques included prosthetic ring annuloplasty (185 patients), leaflet resection (158 patients), chordal shortening (89 patients), leaflet mobilization (10 patients) and papillary muscle reimplantation (2 patients). Long-term follow-up was available in 189 patients (96.8%), for a rate of 2316 patients per year. The 15-year actuarial and valve-related survival rates were 72.4% and 82.8%, respectively. At 15 years, 93.9% of the patients were free from thromboembolism, 96.6% free from endocarditis, 95.6% free from anticoagulant-related hemorrhage, and 87.38% free from reoperation. Actuarial rate of freedom from reoperation was higher in the group with degenerative disease (92.7%) than in the group with rheumatic disease (76.12%). Among the 157 survivors, 117 (74%) were in New York Heart Association class I and class II and 105 (66%) were in sinus rhythm. Doppler echocardiographic studies showed normal ventricular contractility in 134 patients (84.5%), absence of mitral regurgitation in 112 (74%), trivial regurgitation in 27 (17%), and significant regurgitation in 4 patients (2.5%).