Granulocyte phagocytic function is impaired during cardiopulmonary bypass

BACKGROUND

The presence of impaired phagocytic function of the reticuloendothelial system after cardiac operations using cardiopulmonary bypass remains controversial.

METHODS

In this study, the phagocytic function of granulocytes in 14 patients undergoing cardiac operations with cardiopulmonary bypass was examined using a chemiluminescence method. Seven patients with abdominal aortic aneurysms served as controls. Electron microscopy also was employed to evaluate morphologic changes.

RESULTS

The 14 cardiac patients showed impaired phagocytic function from immediately after operation until 12 hours after the operation. This phagocytic function recovered within 24 hours. The 7 control patients showed no change in phagocytic function during or after the operation. Scanning electron microscopic examination of the cardiac patients' granulocytes revealed the loss of villi on cell surfaces immediately after operation. However, these villi were restored within 24 hours after the operation.

CONCLUSIONS

The phagocytic function of granulocytes was impaired in the early postoperative period in patients undergoing cardiopulmonary bypass, and this was probably due to the loss of villi on granulocyte surfaces.

[Usefulness of scheduled IABP for CABG]

We examined the usefulness of intra-aortic balloon pumping (IABP) before the coronary arterial bypass grafting (IABP) before the coronary arterial bypass grafting (CABG) in patients with severe ischemic heart disease. Left main trunk (LMT) disease, unstable angina and low ejection fraction (less than 40%) were indications for scheduled IABP. Eleven patients underwent IABP before CABG surgery (the scheduled IABP group), and five patients didn't before CABG surgery (the unscheduled IAPB group). Analysis comprised the duration of IABP and mortality. There were no significant differences between the two groups in age, pre-operational cardiac index, ejection fraction, aorta clamp time or total perfusion time. IABP application times were significantly longer in the unscheduled IABP group than in the scheduled IABP group (p < 0.05). No death occurred in the scheduled group, but three patients in the unscheduled group died (p < 0.05). No complications were observed due to IABP in any patient of either group. We conclude that scheduled IABP is useful for patients with severe ischemic heart disease.

[A case of pulmonary sarcoma with a differential diagnosis from preoperative pulmonary thromboembolism]

Primary sarcoma of pulmonary artery is a rare tumor. A 46-year-old man was hospitalized because of dyspnea and hemoptysis. Pulmonary thromboembolism was suspected by chest X-ray, scintigraphy, and CT. But the mass had a to-and-fro movement above the pulmonary valve on pulmonary arterial cineangiography. We strongly suspected that it was primary neoplasm of pulmonary artery. The pulmonary artery was opened under cardiopulmonary bypass. The tumor arised pulmonary trunk and extended peripherally. The tumor was surgically removed as complete as possible, though a proxymal balloon embolectomy was unsuccessful. The histological finding was malignant fibrous histiocytoma of the pulmonary artery.

[A case report of open heart surgery in an infant with MNMS caused by femoral arterial cannulation during cardiopulmonary bypass]

We report a case of myonephropathic metabolic syndrome (MNMS) and compartment syndrome caused by femoral arterial cannulation during long-term cardiopulmonary bypass. A boy who had been diagnosed with truncus arteriosus type 1 and who subsequently underwent a Rastelli operation at age 3 months had a second Rastelli operation at age 6 years due to graft stenosis (pressure gradient 82 mmHg between RV and PA). MNMS and compartment syndrome occurred postoperatively due to long-term femoral arterial cannulation during cardiopulmonary bypass. However, acute renal failure was successfully managed with CAPD. The patient recovered from acute renal failure 40 days postoperatively. CAPD is considered useful for postoperative acute renal failure in infants. We conclude that retrograde insertion of the cannula should be changed to anterograde insertion at an earlier time, or else the cannula should be inserted via the prosthetic graft.

[Thoracoscopic closure of patent ductus arteriosus for children: two case report]

We reported thoracoscopic closure of patent ductus arteriosus (TCPDA) performed on two children. All of two patients had no residual shunt postoperatively. Postoperative pain was less than left thoracotomy procedure. In addition TCPDA had merits cosmetically. We concluded that TCPDA was less invasive and safety procedure compared with conventional procedure.

Effect of cardioplegic arrest and reperfusion on coronary reserve and autoregulation

BACKGROUND

The effects of cardioplegic arrest and reperfusion on the coronary vasculature remain to be characterized. This study was designed to investigate changes in coronary reserve and autoregulation after hypothermic cardioplegic arrest and reperfusion.

METHODS

Isolated rabbit hearts were perfused in a retrograde manner with Krebs-Henseleit bicarbonate buffer solution at a pressure of 80 cm H2O. Baseline measurements were performed for (1) coronary flow; (2) vasodilatory response to 5-hydroxytryptamine (10(-7) mol/L) and nitroglycerin (10(-4) mol/L); (3) autoregulatory capacity, quantified as closed-loop gains; and (4) isovolemic left ventricular function. Hearts were then subjected to cardioplegic arrest for 90 minutes. Twenty minutes after reperfusion, measurements were repeated.

RESULTS

Coronary flow decreased significantly after reperfusion (6.2 +/- 1.1 versus 5.3 +/- 1.1 mL.min-1.g-1; p < 0.01). The response to 5-hydroxytryptamine as percentage increase of flow decreased significantly after reperfusion (134.0% +/- 12.0% versus 109.1% +/- 6.8%; p < 0.01). However, there was no significant change in the response to nitroglycerin after reperfusion (121.3% +/- 17.6% versus 136.6% +/- 13.3%). The closed-loop gain demonstrated negative values before arrest but became positive after reperfusion, indicating loss of autoregulation after reperfusion. There was no significant change in left ventricular function.

CONCLUSIONS

The coronary flow reserve in response to 5-hydroxytryptamine and autoregulation were impaired after cardioplegic arrest and reperfusion, whereas nitroglycerin-induced vasodilatory response and left ventricular function were preserved.

[Postoperative immunological capacity after coronary artery bypass grafting in a patient with chronic hemodialysis: comparison with data from patients without chronic hemodialysis]

Recently, coronary artery bypass grafting (CABG) has been performed safely in patients maintained on hemodialysis. However, the postoperative immunological capacity of patients undergoing CABG during chronic hemodialysis has not been fully investigated. Recently we performed CABG in a patient undergoing chronic hemodialysis and measured the immunological parameters. The WBC count, the populations of lymphocytes, OKT 4-positive cells, and OKT 8-positive cells, and NK activity were determined, and the lymphocyte stimulation test (using PHA) was performed before and after cardiopulmonary bypass, then, 1, 3, and 6 days after CABG. We compared these data with those from 17 patients without chronic hemodialysis. The immunological capacity after CABG in the patient with chronic hemodialysis was similar to that of patients without chronic hemodialysis. We suggest that CABG in patients with chronic hemodialysis is a safe operation with regard to the immunological capacity.

Differential display and cloning of shear stress-responsive messenger RNAs in human endothelial cells

To investigate the effect of shear stress on endothelial gene expression, we performed differential display of mRNAs from cultured human umbilical vein endothelial cells either incubated under static conditions or exposed to shear stress (15 dynes/cm2) for 6 h in a flow-chamber. Around 4% of the total number of mRNAs detected were either up- or down-regulated by shear stress. DNA sequencing of some of these shear stress-responsive mRNAs revealed homology of several clones to known gene sequences and many other clones for unknown genes. Known genes, including those for human laminin B1 chain, H(+)-ATP synthase coupling factor 6, lysyl oxidase, myosin light chain kinase, and interleukin-8 receptor, were upregulated by shear stress, while the gene encoding NADH dehydrogenase was down-regulated. The present results suggest that shear stress can change the expression of numerous genes in endothelial cells, far more than reported to date, and that mRNA differential display is quite useful for cloning known and unknown shear stress-responsive genes.

[Early and late results of pericardiectomy for constrictive pericarditis]

Seven patients (4 males and 3 females: age 1 to 71 years old) who underwent operations for constrictive pericarditis from 1980 were reviewed. The median sternotomy approach was used without cardiopulmonary bypass. The pericardial flap was excised just anterior to both phrenic nerves. The postoperative hemodynamic improvement was good, especially in cardiac index (from 2.30 to 3.30 l/min/m2). Two patients were operative death. One was metastasis to pericardium from gastric cancer and another was multiple organ failure due to sepsis. Long-term survival was 3 to 13 years. One patient was dead at nine years after operation. Others were in New York Heart Association Class 1 or 2 in the long-term period after surgery. We conclude that our method can lead to good cardiac functional results and long-term good results. Our report wishes to emphasize early diagnosis and operation.

[Significance of systemic inflammatory response syndrome at cardiopulmonary bypass]

Systemic Inflammatory Response Syndrome (SIRS) is a new concept of entry criteria for sepsis. This concept, when applied to area of Multiple Organ Failure (MOF), is considered to be a preparatory state for MOF. To study the significance of SIRS state at cardiac surgery, we measured the body temperature, white blood cell count, respiratory rate and heart rate of 18 patients who underwent elective cardiac surgery, from the 1st post-operative day to the 7th post-operative day. We also measured Interleukin-6 and 8 (IL-6 and IL-8) to understand the relationship between the SIRS state and inflammatory cytokines just after cardiopulmonary bypass (CPB), at the 1st, 3rd and 6th postoperative day. The result was as follows: Patients with CPB more than 120 minutes have more frequency and longer duration of SIRS than patients with CPB less than 120 minutes. Serum levels of IL-8 at SIRS state were revealed statistically higher than at non-SIRS case. Duration of SIRS state was related to CPB time and serum levels of IL-6 and IL-8 just after CPB. We concluded that SIRS state is an indication for anti-cytokine therapy to prevent MOF, and it is important to shorten CPB time in order to decrease the duration of SIRS.

[An approach to the emergency surgery for arch and/or ascending aortic aneurysm]

The outcome of emergency surgery for the aortic arch aneurysm and/or dissecting aneurysm is worse than that of elective surgery. To decide the future strategy of the emergency surgery for these disease, 11 patients with emergency surgery (= group E: 8 for aortic dissection and 3 for rupture of the aortic arch aneurysm, age; 61 +/- 13 SD) were compared with 12 patients who had elective surgery (= group S: 5 for aortic dissection and 7 for aortic arch aneurysm, age; 69 +/- 3 SD). Ascending aorta replacement was performed in 7 cases in group E v.s. 1 in group S, aortic arch replacement in 2 v.s. 5, ascending aorta and aortic arch replacement in 1 v.s. 4 and patch replacement of the aortic wall in 1 v.s. 2, respectively. Selective cerebral perfusion (SCP) upon the cardiopulmonary bypass (CPB) was used in 45% (5/11) in group E. v.s. in 92% (11/12) in group S, p < 0.05. CPB time, aortic clamp time and SCP time were not significantly different between E group and S group. Postoperative cardiac failure, respiratory failure, renal failure, brain injury and infection occurred at insignificant rates between both groups. Thirty-day and 3-year survivorships were 73% in group E, while in group S they were 92% and 75%, respectively. In group E there were 2 cases which had aortic wall injury due to the aortic clamp used during the surgery. We recommend the use of selective cerebral perfusion and open distal anastomosis in emergency surgery for aortic arch aneurysm and/or Stanford type A aortic dissection.

Surgical repair of a coronary sinus diverticulum not associated with Wolff-Parkinson-White syndrome

Diverticulum of the coronary sinus is rare. A 58-year-old man without Wolff-Parkinson-White syndrome underwent repair of a coronary sinus diverticulum accompanies by mitral regurgitation. The coronary sinus diverticulum had been identified 6 years earlier and had enlarged over time. At surgery, the neck of the diverticulum was closed, and the mitral valve replaced with a CarboMedics prosthetic valve (diameter, 29 mm). This the first case report of the surgical repair of a coronary sinus diverticulum not associated with Wolff-Parkinson-White syndrome.

Diagnostic significance of thrombin-antithrombin III complex (TAT) and D-dimer in patients with deep venous thrombosis

Thrombin-antithrombin III (TAT) and D-dimer were measured in 50 patients suspected of deep venous thrombosis (DVT) to assess the usefulness of these indicators in the diagnosis of DVT. DVT was diagnosed by ultrasonography (compression method and Doppler imaging). In patients who were negative for DVT (Group A), TAT was 3.8 +/- 2.36 micrograms/L (mean +/- SD) and D-dimer was 0.7 +/- 0.69 micrograms/ml, whereas in patients diagnosed with DVT (Group B), TAT was 20.4 +/- 19.10 micrograms/L (p < 0.001) and D-dimer was 9.0 +/- 9.21 micrograms/ml (p < 0.001). Thus, Group B had significantly higher levels of both markers. Moreover, 19 of the 23 cases in Group B had acute DVT, with symptoms appearing within 2 weeks of onset. When the cutoff for a positive diagnosis of DVT was set at TAT of 7.0 micrograms/L or more and D-dimer of 3.0 micrograms/ml or more, sensitivity was 84%, specificity was 96%, and accuracy was 90%. Based on these results, we concluded that TAT and D-dimer are extremely useful in screening for acute DVT.

[Surgical treatment for ruptured aneurysm of distal arch or aortic arch: report of three cases]

We experienced three cases of surgery for ruptured aneurysm of the distal aortic arch (2 cases) or aortic arch (1 case). A 59-year-old man who was diagnosed as distal arch aneurysm ruptured to the pericardial cavity underwent graft replacement of the aneurysm and reconstruction of a left subclavian artery under selective cerebral perfusion (SCP). This patient had left hemiplegia postoperatively. A 73-year-old man who was diagnosed as an aneurysm of distal arch and descending aorta ruptured to left pleural cavity underwent graft replacement of the aneurysm and reconstruction of a left subclavian artery under SCP, and died of severe left ventricular failure possibly due to preoperative myocardial ischemia. A 70-year-old man who was diagnosed as a saccular aneurysm of aortic arch ruptured to mediastinum underwent resection of the aneurysm and patch plasty of the aorta under SCP. The postoperative course was uneventful. We discussed the approach to aneurysm, adjunctive method and surgical precedures from standpoint of our ruptured three cases.

Effects of the mycelial extract of cultured Cordyceps sinensis on in vivo hepatic energy metabolism in the mouse

Mice were given the extract of cultured Cordyceps sinensis (Cs) (200 mg/kg daily, p.o.) for 3 weeks. In vivo phosphorus-31 nuclear magnetic resonance (NMR) spectra of the liver were acquired at weekly intervals using a surface coil. From 1 to 3 weeks, a consistent increase in the ATP/inorganic phosphate ratio, which represents the high energy state, was observed in the Cs extract-treated mice. The intracellular pH of the Cs extract-treated mice was not significantly different from that of the control mice. No steatosis, necrosis, inflammation or fibrosis were observed in the liver specimens from Cs extract-treated mice.

[Influence of cardiopulmonary bypass on biological response]

To investigate the influence of cardiopulmonary bypass (CPB) on biological response, we measured the serum level of tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), and granulocyte elastase (GEL) in 24 patients who underwent elective cardiac surgery and 32 patients who underwent elective gastroenterological surgery. All patients were alive. The serum level of GEL in cardiac patients was significantly higher than that in gastroenterological patients on the 1st and the 3rd postoperative day (P = 0.00008, P = 0.00097 respectively). In addition. there was a significant relationship between CPB time and the serum level of GEL immediately after CPB (r = 0.53, P = 0. 007). That is a reason why higher level of serum GEL in cardiac surgery is due to the bacterial translocation. TNF-alpha and IL-1beta were detected in only :3 patients who underwent over 250 minutes CPB. It is most important to shorten the CPB time in order to decrease the serum GEL and lessen the biological response surgery.

[Clinical evaluation of patients with cardiopulmonary bypass by plasma granulocyte elastase]

To evaluate the role of granulocyte elastase (GEL) at cardiopulmonary bypass (CPB), the plasma GEL level was measured in 24 patients who underwent elective cardiac surgery and 47 patients who underwent elective gastroenterological surgery. The cardiac surgical patients were divided into two groups: 5 patients with CPB less than 120 minutes (HL group), and 19 patients with CPB more than 120 minutes (HH group). The patients with gastro-enterological surgery were also divided into two groups: 15 patients with postoperative complications (GC group), and 32 patients without postoperative complications (GU group). All the patients of GU, HL and HH groups were alive. Two patients of GC group died because of multiple organ failure (MOF). The serum levels of GEL in both the HH group and the GC group remained higher than in the GU group at 6 postoperative day (POD). The high serum level of IL-8 gave rise to high serum level of GEL in the HH group, even after cardiac surgery. We assumed that anti-cytokine therapy and aggressive administration of Ulinastatin are useful against postoperative complications and that careful management is need after long CPB.

Efficacy of benidipine hydrochloride on myocardial ischemia and reperfusion

The efficacy of benidipine hydrochloride in preventing myocardial ischemia and reperfusion injury was evaluated in isolated rabbit hearts (n = 28). Isovolumic left ventricular function, coronary flow, creatine phosphokinase (CPK) release, and myocardial water content were measured after ischemia during both normothermia (37 degrees C; Group I) and hypothermia (23 degrees C; Group II). After baseline measurements, hearts were induced to arrest by chilled cardioplegic solution. Each group was divided into two subgroups, depending upon whether benidipine hydrochloride (10(-9) mole/liter) was added in the cardioplegia (A, without benidipine; B, with benidipine). After 30 min of ischemia for Group I and 180 min for Group II (which added another cardioplegia every 30 min), hearts were reperfused. Measurements the same as those at baseline were carried out every 15 or 30 min for up to 60 min. Benidipine-treated hearts started beating in a shorter time than did control hearts (Group I-B, 38.7 +/- 3.7 sec vs Group I-A, 59.9 +/- 5.6; Group II-B, 36.7 +/- 2.0 vs Group II-A, 47.8 +/- 3.3). The percentage of recovery of left ventricular developed pressure after 60 min of reperfusion was significantly better in benidipine groups (P < 0.05). With respect to changes in coronary flow and CPK release after reperfusion, benidipine groups were preserved extremely well. We conclude that the addition of benidipine hydrochloride to cardioplegic solution significantly improves ventricular function after myocardial ischemia and reperfusion.

Clinical significance of no-reflow phenomenon observed on angiography after successful treatment of acute myocardial infarction with percutaneous transluminal coronary angioplasty

The clinical significance of the angiographic no-reflow phenomenon was evaluated in 93 patients with acute myocardial infarction treated by percutaneous transluminal coronary angioplasty (PTCA). On the basis of the post-PTCA angiograms, patients were divided into three groups: normal angiogram (group 1, n = 65), slight no-reflow (group 2, n = 13), and severe no-reflow (group 3, n = 15). Regional wall motion in the chronic phase was depressed in groups 2 and 3 compared with group 1. The proportion of the area of the transmural infarction to that of the total infarction determined by scintigraphy was higher in groups 2 and 3 than in group 1. A significantly higher incidence of myocardial rupture and of death resulting from cardiac causes was observed in group 3 compared with group 1. The severity of this phenomenon immediately after an emergency PTCA correlated well with the severity of myocardial damage, with patients having severe no-reflow showing the poorest prognosis.

[Clinical analysis of the surgical therapy of DeBakey type I acute aortic dissection]

We investigated relation of operative mortality with factors such as during from onset to operation, cardiac tamponade, age (more than 70 years old), aortic regurgitation, and shock. Fourteen patients underwent emergent surgery for DeBakey type I acute aortic dissection. These patients were the basis for this reports. Operative mortality was 43% (6/14). Although not statistically significant, there was a trend toward preoperative cardiac tamponade, namely the patients with preoperative tamponade had a poor prognosis. Causes of death were as follows, two patients related to the residual false lumen, two patients to surgical procedure, one patients to ischemic heart and one to mis-swallowing after operation. Among two patients who related to the residual false lumen, one died of rupture of the descending aorta that the clamping was performed during operation and the other occlusion of superior mesenteric artery 43 days after operation. Causes of deaths in patients in relation with surgical procedure were brain death and postoperative bleeding in 1 each. We concluded that the residual false lumen is a risk factor in the peri-operative stage.

Focused-ion-beam digging of biological specimens

The focused ion beam (FIB) technique has been applied for digging damageable biological specimens of human hair and the housefly eye. Sharp cross-sections have been formed for these specimens and their cross-sectional structures have been observed in scanning ion microscope (SIM) images. The applicability of FIB has been confirmed for these biological specimens.

Flow stimulates ICAM-1 expression time and shear stress dependently in cultured human endothelial cells

Human umbilical vein endothelial cells were subjected to controlled levels of shear stress in a flow-loading apparatus, and changes in the expression of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1) were measured by flow cytometry. Application of shear stress (15 dynes/cm2) increased the cell surface expression of ICAM-1 2.7 times the control level 4 hr after the onset of flow, while it caused no change in VCAM-1 expression. The increase of ICAM-1 expression by shear stress was time- and force-dependent and reversible. Flow loading using perfusates with different viscosity revealed that the increase in ICAM-1 was shear-stress- rather than shear-rate-dependent. Reverse transcriptase/polymerase chain reaction analysis showed upregulation of ICAM-1 mRNA levels by shear stress, whose time course closely paralleled that of the cell surface protein. These results suggest that shear stress generated by blood flow acts as a regulator of cell adhesion molecule expression on vascular endothelial cells.