Midterm results of conservative repair of the incompetent bicuspid aortic valve

AIM

Repair of the bicuspid aortic valve is not generally considered the treatment of choice. Our success with this procedure leads us to report our immediate and mid-term

RESULTS

METHODS

From August 1993 to December 2000, 19 patients with aortic regurgitation due to congenital aortic valve underwent aortic valve repair (17 men and 2 women with a mean age of 42+/-17 years; range, 16 to 70 years). The mean preoperative aortic regurgitation grade was 3.1+/-0.8 on a scale of 1 to 4. Mean preoperative New York Heart Association functional class was 1.9+/-0.8. Fourteen patients had pure aortic regurgitation, 2 also had infectious endocarditis, 1 had angina pectoris, and 2 had an ascending aortic aneurysm.

RESULTS

There was 1 hospital death (5.2%), and 1 patient required re-operation due to recurrent infectious endocarditis. Mean aortic regurgitation grade at discharge was 1.1+/-0.9, and functional class was 1.1+/-0.2. All patients were followed for a mean duration of 40+/-23 months (range, 0.5 to 84 months). There was 1 late death, and two patients required aortic valve replacement. The 5-year survival rate was 90+/-7%. The 1- and 5-year re-operation-free rates were 87+/-12% and 76+/-23%.

CONCLUSIONS

Bicuspid aortic valve repair is a safe procedure with good early postoperative

RESULTS

However midterm results are not satisfactory. Re-operation is a promising alternative and progress aortic regurgitation were complications. Bicuspid aortic valve repair to valve replacement that requires additional study to individualize treatment.

[Aortic valve repair with minimal access "J" sternotomy]

Recently many cardiovascular operations have been performed with minimally invasive cardiac surgery (MICS). It is reported that MICS is superior to standard full sternotomy in regard to cosmetic and post-operative recovery. In our institution, aortic valve repair operations have been performed to aortic valve insufficiency. This time, we performed aortic valve repair by minimal access "J" sternotomy. A 63-year-old male with degenerative aortic regurgitation underwent aortic valve repair by MICS. He had experienced dyspnea on exertion 7 days before admission. Preoperative transthoracic echocardiogram showed the grade of aortic regurgitation (AR) was severe. Surgery was successful and the grade of AR became trivial. This combined procedure have merits for patients because of freedom from anticoagulation and small incision. Such combined surgery may be indicated in the treatment in a subset of patients with degenerative AR.

Selection of surgical methods for infected infrarenal abdominal aortic aneurysms

BACKGROUND

There is no standard treatment for patients with infected abdominal aortic aneurysm (AAA). To determine the basis for selection of a surgical method, we reviewed our experiences with all patients who underwent surgery for infected infrarenal AAA.

METHODS

Between 1993 and 2000, 6 patients with infected infrarenal AAA underwent surgery. Extra-anatomic bypass grafting was performed in 2 of 3 patients with infection extending into the retroperitoneum. In situ grafting was performed in 3 patients with localized infection and in 1 patient with extended infection.

RESULTS

Severe peritonitis occurred in 2 patients with extended infection in the early postoperative phase. One patient, who had undergone in situ grafting, died of sepsis. The other patient, who had undergone extra-anatomic bypass grafting, was treated by continuous irrigation with an electrolyzed strong acid aqueous solution (ESAAS). He recovered gradually and was discharged. After a follow-up period with a mean of 40 months (range: 17-102 months), all 5 patients who survived surgery are alive and asymptomatic.

CONCLUSIONS

It was suggested that the method used for revascularization should be selected based on the degree of diffusion of infection. For a patient with extended infection, postoperative continuous irrigation with ESAAS appears to be effective in eradicating retroperitoneal infection.

[Redo coronary artery bypass grafting using the patent left internal thoracic artery graft as an in flow with composite internal thoracic artery Y grafting; report of a case]

In redo coronary artery bypass grafting (CABG), graft selection and revascularization methods are major problems. We experienced a redo-CABG with occluded previous vein grafts. These grafts were to the circumflex artery and right coronary artery. We conducted operation using cardiopulmonary bypass. We at this operation, chose right internal thoracic artery (RITA) as a conduit and anastomosed it to the side of functioning left internal thoracic artery (LITA) graft, and then diogonal branch, posterolateral branch, and atrioventricular branch were revascularized with the RITA. Post operative course was uneventful. Internal thoracic artery (ITA) is superior to vein graft and other arterial graft as to long term patency. We believe composite Y graft with the use of bilateral ITA can be one of the revascularization strategy in redo CABG.

Evaluation of ppk-specified polyphosphate as a mercury remedial tool

To evaluate the utility of polyphosphate kinase gene (ppk)-specified polyphosphate in mercury remediation, a fusion plasmid, pMK27, with ppk from Klebsiella aerogenes and mercury transport genes, merT and merP, from Pseudomonas K-62, was constructed. The transcription and translation of ppk, merT and merP were found to be mercury-inducible. The ppk-specified polyphosphate was identified in cells preinduced by Hg2+, but not in cells without mercury induction, suggesting that the synthesis of polyphosphate is regulated by merR. The hypersensitive phenotype to Hg2+, shown by bacteria with pMRD141, which contains merT and merP, was almost completely restored to its original levels when the ppk was introduced into the plasmid, suggesting that the Hg2+-toxicity was reduced by the polyphosphate, probably via chelation formation. Bacteria with pMK27 accumulated approximately 6-fold more mercury than the bacteria with cloning vector, pUC119. These results clearly demonstrate that the polyphosphate is capable of retaining mercury in the cells without taxing the cells. Based on the results obtained in the present study, the fusion plasmid pMK27 may serve as a strategy for mercury remediation.

Enamel matrix derivative (EMDOGAIN) rapidly stimulates phosphorylation of the MAP kinase family and nuclear accumulation of smad2 in both oral epithelial and fibroblastic human cells

In our previous study, we demonstrated that porcine enamel matrix derivative (EMD) induces p21WAF1/cip1 within 8 hours and subsequently arrests the cell cycle of human oral epithelial cells in G1 phase. In contrast, EMD markedly stimulates the proliferation of gingival fibroblasts without inducing p21WAF1/cip1. To investigate the mechanism of how EMD produces these differential effects, we have focused on the initial response of these two cell types to EMD. In epithelial cell cultures, EMD stimulated cytoskeletal actin polymerization within 30 min and promoted cell adhesion in our experimental system. EMD failed to stimulate either intracellular Ca2+ mobilization or cAMP production in either cell type. In both epithelial and fibroblastic cells, EMD (25-100 microgram/ml) rapidly produced dose-dependent phosphorylation of the mitogen-activated protein kinase (MAPK) family: extracellular signal response kinase (ERK), p38-MAPK (p38-K), and c-Jun-terminal kinase/stress-activated protein kinase (JNK). However, neither inhibitors of MEK (ERK kinase) nor p38-K could block EMD's anti-proliferative action on epithelial cells. On the other hand, EMD rapidly stimulated translocation of smad2 into the nucleus in both cell types. Spurred by this finding, we assayed for TGF-beta1, a ligand for one receptor associated with smad2 activation, and detected significant levels in EMD preparations. The sum of these pharmacological findings indicates that EMD contains at least one bioactive factor, which is most probably TGF-beta1 (or TGF-beta-like substances). In conjunction with the similarities in the differential growth-modulating actions between EMD and what is known for TGF-beta, we suggest that TGF-beta might act as the principal growth regulating agent of oral fibroblastic and epithelial cell types in EMD despite being present in only low levels.

Survival of a subarachnoid hemorrhage patient who presented with prehospital cardiopulmonary arrest: case report and review of the literature

A 63-year-old woman was admitted to the intensive care unit after resuscitation from prehospital cardiopulmonary arrest (CPA). A brain CT scan revealed a subarachnoid hemorrhage (SAH), which was considered to be the cause of the CPA. The patient recovered neurologically after admission, and the elevated intracranial pressure (ICP) was controlled by inducing mild hypothermia. The day after admission, cerebral angiography revealed a ruptured cerebral aneurysm. The aneurysm was successfully treated with detachable coils by an endovascular technique. Mild hypothermia was continued for 3 days, and the patient was gradually rewarmed. After rehabilitation, the patient was discharged to her home with severe disability. Although aneurysmal SAH is one of the most common causes of CPA, survival of SAH patients after CPA is rare. This case illustrates the ability and possibility of multidisciplinary treatment, including the use of endovascular techniques and mild hypothermia, to improve the outcome of SAH patients with CPA who have been considered to be inoperable and untreatable.

8,16,24,32,40,48-Hexamethoxy[2.6]metacyclophane-1,9,17,25,33,41-hexayne: a novel near-planar ammonium-selective ionophore

The titled cyclophane (cyclic [6]metaphenylacetylene) with six methoxy groups inside the cavity has a nearly planar carbon framework, forms open-channel structures in the crystal, and exhibits an ammonium-selective ionophoric property in spite of the considerably large cavity.

High-performance liquid chromatographic method to analyze picomole levels of glutathione, cysteine and cysteinylglycine and its application to pre-cancerous rat livers

A HPLC-based method for quantifying glutathione, cysteine and cysteine-containing peptide is described. N-(2,4-Dinitrophenylaminoethyl)maleimide was synthesized from ethylenediamine, 2,4-dinitrochlorobenzene and maleic anhydride. The maleimide was reacted at 40 degrees C and pH 5.8 for 10 min with thiol compounds such as glutathione or cysteine. An aliquot of the reaction mixtures was applied to a reversed-phase column (4.6 x 150 mm) of HPLC. When glutathione and cysteine were simultaneously assayed, the column was eluted with a gradient of acetonitrile in potassium phosphate (pH 7.0). The derivatives were monitored at 350 nm. Good liner relationships existed between peak area and concentration of glutathione or cysteine from 10 pmol to 2 nmol. The recovery tests from rat liver homogenate were 99.7+/-2.2% for glutathione and 104.9+/-3.8% for cysteine. By this method gamma-glutamylcysteine, cysteinylglycine, and homocysteine could be also quantified. The determination limits of glutathione, cysteine and other thiol compounds were 5 pmol. The method is simple: a sample solution is mixed with the labelling reagent and an aliquot of the reaction mixture is applied to a standard HPLC. The hepatic levels of cysteine and glutathione in pre-cancerous rats were determined by this method. The cysteine level in pre-cancerous livers was extremely elevated in comparison to that of the control groups, while no difference was observed in the glutathione contents between the pre-cancerous and control groups.

Isolated abducens nerve paresis associated with incomplete Horner's syndrome caused by petrous apex fracture--case report and anatomical study

A 17-year-old male presented with a wound on the right temporal region, oozing hemorrhagic necrotic brain tissue and cerebrospinal fluid, following a fall. Computed tomography showed temporoparietal and petrous apex fractures on the right. Neurological examination revealed abducens nerve paresis, ptosis, and myosis on the right side. The patient was treated surgically for the removal of the free bony fragments at the fracture site and to close the dural tear. The abducens nerve paresis, ptosis, and myosis persisted at the 3rd monthly postoperative follow-up examination. The anatomy of the abducens nerve at the petroclival region was studied in four cadaveric heads. Two silicone-injected heads were used for microsurgical dissections and two for histological sections. The abducens nerve has three different angulations in the petroclival region, located at the dural entrance porus, the petrous apex, and the lateral wall of the cavernous segment of the internal carotid artery. The abducens nerve had fine anastomoses with the trigeminal nerve and the periarterial sympathetic plexus. There were fibrous connections extending inside the venous space of the petroclival area. The abducens nerve seems to be vulnerable to damage in the petroclival region, either directly by trauma to its dural porus and petrous apex or indirectly by stretching of the nerve through the nervous and/or fibrous connections. Concurrent functional loss of the abducens nerve and the periarterial sympathetic plexus clinically manifested as incomplete Horner's syndrome in our patient.

Spontaneous thrombosis of intracavernous internal carotid artery aneurysm and parent artery occlusion in patients with positive balloon test occlusion--two case reports

Two patients with giant intracavernous internal carotid artery (ICA) aneurysms were intolerant to balloon test occlusion of the ICA, and later developed spontaneous thrombosis of the aneurysm and the parent ICA without ischemic sequelae. Case 1: A 60-year-old female with a giant right intracavernous ICA aneurysm presented with right abducens nerve paresis. An unsuccessful extracranial-to-intracranial bypass graft operation was complicated by transient postoperative ophthalmoplegia. The patient did not tolerate balloon test occlusion of the right ICA after attempted bypass surgery, and was treated conservatively. The patient presented with acute onset of headache 3 years later. Case 2: A 50-year-old female with a giant right intracavernous ICA aneurysm presented with right abducens nerve paresis. The patient was managed conservatively after a positive balloon test occlusion of the right ICA. The patient suffered transient hypopituitarism and acute onset of headache 2 years later. Spontaneous thrombosis of the aneurysms and occlusion of the parent ICA were found in both patients. Neither had major hemispheric infarcts, but the first patient had asymptomatic infarcts, which were presumed to be thromboembolic in nature. Patients with intracavernous ICA aneurysms who have positive balloon test occlusions appear to develop tolerance to spontaneous and gradual occlusion of the ICA without significant sequelae. However, these patients have an increased risk of developing embolic infarctions. The role for anticoagulation and repeat hemodynamic tests remains unclear.

Expression of cementum-derived attachment protein in bovine tooth germ during cementogenesis

Cementum-derived attachment protein (CAP) is a 56 kDa collagenous protein that promotes attachment of mesenchymal cells. Previous studies have shown that the presence of CAP is restricted to cementum in adult human tissues. In this study, we report generation of a monoclonal antibody against CAP and its use for the investigation of CAP in developing bovine tooth germs. Mice were immunized with CAP purified from bovine cementum, and a monoclonal antibody, 3G9, was produced. Immunohistochemical staining of bovine tooth germ at root forming stage using 3G9 antibody showed that the tissue distribution of CAP expression was limited to cementum matrix and cementoblasts during cementogenesis. Alveolar bone did not stain with the 3G9 antibody, whereas anti-type I collagen stained positively. CAP was purified from bovine tooth germs with immunoaffinity purification using the 3G9 antibody. Examination of the immunoaffinity-purified fraction showed that CAP existed in tooth germ as a 65 kDa protein. The protein was susceptible to bacterial collagenase. To investigate the possible biological function of CAP during cementogenesis, we isolated dental follicle cells from the bovine tooth germ, and showed that they adhered to surfaces containing CAP. These data demonstrate that CAP is expressed by bovine cementoblasts as a 65 kDa protein and that the CAP may have a function in cementogenesis.

Postischemic hypothermia attenuates apoptotic cell death in transient focal ischemia in rats

Hypothermia confers potent neuroprotection against ischemic injury. Attenuation of apoptosis by hypothermia can be one of the responsible mechanisms. In this study, in situ DNA nick-end labeling (TUNEL) and immunostaining of Bax protein were performed to evaluate the effect of postischemic hypothermia on apoptotic cell death, employing rodent transient focal ischemia. Animals received 1 hour of transient focal ischemia. Brain temperature was maintained at 37.5 +/- 0.5 degrees C during ischemia. Immediately after reperfusion, animals were assigned to either a normothermic or hypothermic group. In hypothermia, animals were cooled and brain temperature was lowered to 34.5 +/- 1.0 degrees C. Prolonged hypothermia was maintained for 16 hours and animals rewarmed. In both groups, TUNEL and immunostaining of Bax was performed. In normothermia, the number of TUNEL positive cells reached the peak at 2 days after ischemia and decreased gradually. In hypothermia, the peak was shifted to 3 days after ischemia. The number of TUNEL positive cells in hypothermia was persistently below that of normothermia. Similarly, in hypothermia, immunostaining of Bax showed attenuated immunoreactivity compared with that in normothermia. In conclusion, postischemic hypothermia reduced both the number of TUNEL positive cells and immunoreactivity of Bax, which may be one of the responsible mechanisms with which hypothermia exerts neuroprotection.

A giant internal carotid-posterior communicating artery aneurysm presenting with atypical trigeminal neuralgia and facial nerve palsy in a patient with autosomal dominant polycystic kidney disease: a case report

BACKGROUND

In cases of internal carotid-posterior communicating artery (IC-PC) aneurysm, involvement of the trigeminal nerve at its root is rare, and facial nerve palsy is even more unusual.

CASE REPORT

A large, unruptured IC-PC aneurysm was detected in a 56-year-old man with autosomal dominant polycystic kidney disease (ADPKD), but surgery was not performed because of mild renal dysfunction. Two months later, a sudden, severe headache suggested a subarachnoid hemorrhage, which was ruled out by computed tomography and lumbar puncture. Neurological examination revealed complete oculomotor palsy, atypical trigeminal neuralgia, and facial palsy with gustatory disturbance. Magnetic resonance (MR) imaging revealed a partially thrombosed giant aneurysm that directly compressed the trigeminal nerve root, reached the internal auditory canal, and was adjacent to the facial nerve. The neck of the aneurysm was successfully clipped via a subtemporal transtentorial approach. The postoperative course was uneventful, and all neurological symptoms had resolved within 3 months.

CONCLUSIONS

We believe that the prosopalgia in this case was atypical trigeminal neuralgia due to direct compression of the trigeminal nerve root by the aneurysmal sac. A contributory cause was stretching of the oculomotor nerve, which contains sensory afferent inhibitory fibers derived from the ophthalmic branch of the trigeminal nerve. The facial palsy was of peripheral type and was accompanied by gustatory disturbance. This is the first reported case of facial palsy caused by an IC-PC aneurysm and also a very rare case of an IC-PC aneurysm clipped by a subtemporal transtentorial approach.

[Biodistribution of hypoxic marker, 99mTc-HL91 (4,9-diaza-3,3,10,10-tetramethyldodecan-2,11-dione dioxime)]

99mTc-HL91 (4,9-diaza-3,3,10,10-tetramethyldodecan-2,11-dione dioxime) was developed as a hypoxic marker. Athymic mice bearing human tumors were administered with 99mTc-HL91 to evaluate it from the clinical point view. The tumor was visualized clearly 4 hours after injection. The biodistribution study revealed that 99mTc-HL91 was accumulated in the liver (tissue-to-blood ratio (T/B) = 11.5) and kidney (2.25) with higher than in the tumor (1.01). Oxygen condition of the tumor and muscle was measured by using the probe. 99mTc-HL91 uptake of tumors with PO2 (tumor-to-muscle ratio) under 0.55 was higher than that with 0.55 or higher PO2. Oxygen condition of tumors with 1.0 or higher uptake (tumor-to-blood ratio) was lower than that with the lower uptake. Autoradiography of tumor sections indicated that 99mTc-HL91 was scarcely accumulated in the necrotic and viable areas while strong radioactivity was observed in the border zone (speculated to be hypoxic condition). Our experimental results suggest that the 99mTc-HL91 scintigraphy may be useful for evaluating oxygenation status of some tumors in non-abdominal region.

Method to improve cosmetic outcome following craniotomy

This technical note describes a simple method for reducing the dead space created by craniotome due to the loss of bone dust and improving the cosmetic outcome following a craniotomy. After drilling the burr holes for the craniotomy, the bone between the holes is drilled away in a standard fashion except that multiple regions of about 1 cm in length are left intact. These intact regions are broken using a periosteal elevator and fixed like a bridge when the bone is replaced. The resulting bone flap is readily returned to its original position without making the dead space created by regular craniotomy. The amount of the dead space caused by losing the bone dust is reduced and a good cosmetic recovery is obtained. This technique is useful for both craniotomy and facial bone surgery, which requires cosmetic results.

Aortic valve repair in dominant aortic regurgitation

OBJECTIVE

We studied immediate and mid-term results after aortic valve repair.

METHODS

Immediate and mid-term results were studied in 63 patients undergoing aortic valve repair, calculating survival and reoperation free rates.

RESULTS

Subjects were 49 men and 14 women aged 15 to 76 years (mean: 53 +/- 17 years). Mean preoperative aortic regurgitation grading of 1 to 4 was 3.2 +/- 0.7. Mean preoperative New York Heart Association functional class was 1.9 +/- 0.8. Two in-hospital deaths occurred. (3.2%) Mean aortic regurgitation grade at discharge was 1.3 +/- 0.8 (p < 0.0001; vs preoperative grade) and functional class was 1.1 +/- 0.2 (p < 0.0001; vs preoperative class),--significantly improved. Overall follow-up was 98.4%, and mean follow-up continued 41.4 +/- 22.1 months. Mean functional class at follow-up was 1.2 +/- 0.4 (n = 49), improved from preoperative class (p < 0.0001). Mean aortic regurgitation grading at follow-up was 1.8 +/- 0.8 (n = 41), improved from preoperative grading (p < 0.0001). Five-year survival was 95.1 +/- 2.8%. One-year reoperation freedom was 96.6 +/- 2.4% and 5-year 77.9 +/- 6.9%.

CONCLUSIONS

Survival after surgery was good, while reoperation was comparable to other reports but less satisfactory compared to reoperation freedom after aortic valve replacement. Based on reoperative findings, a change in indication was made. We believe technical refinements could improve postoperative results.

Removal of anterior clinoid process for basilar tip aneurysm: clinical and cadaveric analysis

The difficulty in the operation for basilar tip aneurysm is the restriction in surgical working space. To resolve this problem, aggressive skull base surgery has been reported, but these techniques are not prevalent. Pterional and subtemporal approaches are commonly used for basilar tip aneurysms. In an attempt to increase the surgical working space during the pterional approach, the anterior clinoid process and the roof of the optic nerve were removed extradurally to increase the mobilization of the intracranial internal carotid artery and optic nerve. The effects of removing the anterior clinoid process and microanatomy in the perioptic area were analyzed by cadaveric procedures in 10 cases (20 sides). With this procedure, the internal carotid artery can be retracted medially with a spatula 6.1 +/- 0.8 mm (mean +/- SD). The length and the area of dural fold in the bone defect region in the optic canal roof are 2.1 mm and 13.6 mm. In 10 clinical cases, this procedure allowed enough space to approach the basilar tip aneurysm without disturbing the internal carotid artery blood flow. The clinical outcome was satisfactory.

Cerebral microaneurysms found incidentally during aneurysm surgery

Not uncommonly, cerebral microaneurysms are found incidentally during surgery for another previously diagnosed cerebral aneurysm(s). The frequency and angiographic characteristics of such incidental microaneurysms are retrospectively summarized. Seventeen patients were identified as harboring incidental microaneurysms, comprising 4.9% of the whole series. The middle cerebral artery (MCA) was the most frequent location (seven cases, 41%) of these microaneurysms. There was a tendency for MCA microaneurysms to be contiguous to a previously known, larger aneurysm at the same location. Neurosurgeons as well as interventional neuroradiologists should be aware of the possible presence of these incidental microaneurysms while treating patients with a cerebral aneurysm(s). Although the actual clinical implications of these incidental microaneurysms have not been elucidated, the few additional risks to patients already surgically exposed for the treatment of another aneurysm, along with the possible benefit of preventing their rupture and growth, would justify the surgical treatment of these microaneurysms.

Expression of the neural RNA-binding protein Musashi1 in human gliomas

Tumor cells arising from a particular tissue may exhibit the same gene expression patterns as their precursor cells. To test this proposition, we have analyzed the expression of a neural RNA-binding protein, Musashi1, in primary human central nervous system (CNS) tumors. In rodents, Musashi1 is expressed predominantly in proliferating multipotent neural precursor cells, but not in newly generated postmitotic neurons. The expression of Musashi1 is downregulated with the successive progression of neurogenesis. In normal adult human tissues, we detected low levels of Musashi1 expression in brain and testis by RT-PCR analysis. In an RNA panel of 32 cancer tissues and cell lines, elevated expression of Musashi1 was seen in all five malignant gliomas studied, in contrast to the slight expression seen in other tumor cells, including those in several melanomas and a prostate cancer. Western blot analysis showed strong Musashi1 expression in malignant gliomas compared with nonneoplastic brain tissue. Glioblastomas, the most malignant form of glioma, showed higher Musashi1 expression than less malignant gliomas by immunohistochemical analysis. Tumors with strong Musashi1 expression tended to have high proliferative activity. Thus, the expression of Musashi1 correlated with the grade of the malignancy and proliferative activity in gliomas. These results suggest that primary CNS tumors may share gene expression patterns with primitive, undifferentiated CNS cells and that Musashi1 may be a useful marker for the diagnosis of CNS tumors.