Distance between mitral anulus and papillary muscles: anatomic study in normal human hearts

BACKGROUND

Preservation of the annulo-papillary muscle continuity in mitral valve replacement is important. Even in patients who require excision of the mitral apparatus, the continuity can be restored. However, there is no guide to the proper length for the resuspension.

METHODS

In 57 normal cadaveric hearts, the distance from the tip of the papillary muscle to its corresponding mitral anulus was directly measured.

RESULTS

The distance from the tip of the anterolateral papillary muscle to the left trigone (10-o'clock position: D10) and to the point between the anterior and the middle scallops of the mural leaflet (8-o'clock position: D8) was 23.5 +/- 3.7 mm and 23.2 +/- 3.6 mm, respectively. The distance from the tip of the posteromedial papillary muscle to the right trigone (2-o'clock position: D2) and to the point between the middle and the posterior scallops of the mural leaflet (4-o'clock position: D4) was 23.5 +/- 4.0 mm and 23.5 +/- 3.9 mm, respectively. There was no statistically significant difference among the 4 distances (P =.96). Each distance was significantly longer than the corresponding chordae tendineae (D10 vs the anterior main chorda: 17.2 +/- 3.9 mm, D8 vs the anterior cleft chorda: 14.5 +/- 3.2 mm, D2 vs the posterior main chorda: 17.9 +/- 4.3 mm, and D4 vs the posterior cleft chorda: 14.9 +/- 3.2 mm, respectively; P =.0001). The mean distance had a significant correlation with the mitral annular diameter (r = 0.31, P =.019).

CONCLUSIONS

In normal hearts, the annulo-papillary muscle distances of the mitral apparatus are similar in 2-, 4-, 8-, and 10-o'clock positions and correlate with the mitral annular diameter.

Aortic valve replacement for aortic regurgitation in a patient with primary antiphospholipid syndrome

A 42-year-old woman with the diagnosis of aortic regurgitation was admitted to hospital for surgical treatment. Ten years ago, primary antiphospholipid syndrome had been diagnosed, and she had a history of recurrent spontaneous abortions and deep vein thrombosis. She was suffering from moderate exertional dyspnea and chest pain. Catheter investigation revealed progressive dilatation of the left ventricle and a deterioration of the ejection fraction. The aortic valve was excised and replaced with a mechanical valve. A specimen of the aortic valve showed localized thickening and shrinkage of the midportion and base of each cusp, with vegetation on the surface. These localized, specific findings suggest that another mechanism may be involved in the cardiac valve pathology in patients with primary antiphospholipid syndrome. No hemostatic or thromboembolic problems were encountered after the surgery, and her postoperative course was uneventful.

Regulation of lens fiber cell differentiation by transcription factor c-Maf

To elucidate the regulatory mechanisms underlying lens development, we searched for members of the large Maf family, which are expressed in the mouse lens, and found three, c-Maf, MafB, and Nrl. Of these, the earliest factor expressed in the lens was c-Maf. The expression of c-Maf was most prominent in lens fiber cells and persisted throughout lens development. To examine the functional contribution of c-Maf to lens development, we isolated genomic clones encompassing the murine c-maf gene and carried out its targeted disruption. Insertion of the beta-galactosidase (lacZ) gene into the c-maf locus allowed visualization of c-Maf accumulation in heterozygous mutant mice by staining for LacZ activity. Homozygous mutant embryos and newborns lacked normal lenses. Histological examination of these mice revealed defective differentiation of lens fiber cells. The expression of crystallin genes was severely impaired in the c-maf-null mutant mouse lens. These results demonstrate that c-Maf is an indispensable regulator of lens differentiation during murine development.

A case of anomalous origin of the pulmonary arteries: right pulmonary artery from the descending aorta and the left pulmonary artery from the ascending aorta

A 3-month-old girl classified as having persistent truncus arteriosus underwent surgical correction of the anomalous origin of the pulmonary arteries; the right pulmonary artery from the descending aorta and the left pulmonary artery from the ascending aorta. The patient died on the fourth postoperative day. The definite diagnosis and choice of surgical strategies should be further examined.

A simple distraction device for finger lengthening

A simple, light distraction device was developed for digital lengthening. Materials for this device are one piece of 1.5-mm K-wire, two five-hole miniplates, one one-hole miniplate, two bolts and nuts, and a nonabsorbable suture or surgical wire. These components are easily obtainable, and the device can be assembled easily for each patient during surgery. The principle of distraction using this device is unique: A distal bone segment is pulled straight forward by a suture or surgical wire. This minimizes scar formation on the finger. Finger elongation using commercially available distraction devices needs two transfixations of K-wires, two each for the proximal and distal bone segments, which create scars where the K-wires move. The authors report a clinical application in which their distraction device was used.

Dephosphorylation of specific proteins during induction of senescence in immortal human fibroblasts expressing thermolabile SV40 T antigen

Particular protein kinase inhibitors block a senescence-like phenomenon in SVts8 cells induced by a shift up in temperature. We characterized cellular proteins with affinity chromatography using one such inhibitor as a ligand. Two proteins of 56 and 100 kDa were found to be dephosphorylated specifically, probably due to induction of a protein phosphatase activity(s).

Reverse U-shaped split temporalis musculofascial flap in cranial base reconstruction

To extend the versatility and range of the temporalis muscle, a new type of temporalis musculofascial flap was developed. This was achieved by dividing the muscle into two portions--anterior and posterior-while maintaining vascular communication between the deep and the middle temporal arteries. This flap is reverse U-shaped with one of the arms of the "U" corresponding to a pedicle, which supplies the blood, and the other corresponding to the recipient region. The bottom of the U corresponds to continuity between the anterior and posterior portions of the muscle, which contains the vascular communication. In two patients with meningioma, the flap was applied to occupy the extradural dead space combined with a pericranial flap to prevent leakage of cerebral spinal fluid to the dural defect. The reverse U-shaped split temporalis musculofascial flap has some advantages for intracranial reconstruction: sufficient rotational arc, adequate thickness, and rich vascularity. A reverse U-shaped split temporalis musculofascial flap is useful and of benefit, especially for reconstruction at the region of the anterior midline skull base.

Coronary artery bypass grafting in a case with severe aortic atheromatosis associated with abdominal aortic aneurysm

A 69-year-old man with coronary artery disease associated with abdominal aortic aneurysm underwent a one-stage operation utilizing a low-flow cardiopulmonary bypass. Ordinary cardiopulmonary bypass was abandoned as a result of severe atheromatous finding in the entire aorta. However, coronary artery bypass grafting without cardiopulmonary bypass was hazardous as a result of heart enlargement and deteriorating function. Therefore, the abdominal aortic aneurysm was first replaced with a bifurcated graft. Coronary artery bypass grafting with two arterial grafts was then performed successfully on the beating heart with the support of a low-flow cardiopulmonary bypass connected to the bifurcated graft.

[Valve replacement in children]

Between May 1979 and September 1998, 202 children underwent surgical treatment for valvular heart disease. Of these 23, who ranged in age from 25 days to 15 years, underwent valve replacement, including 1 reoperation. The valve replacement consisted of the aortic valve in 5 patients, the mitral valve in 3, the tricuspid valves in 9, including 5 systemic atrioventricular valves for atrioventricular discordance, the pulmonary valve in 6, 5 bioprostheses and 18 mechanical prostheses. There were 4 operative deaths, 1 hospital death and 3 late deaths. At the 10-years follow-up, the actual survival rate was 67.8%, the event free rate was 76.1% and the freedom from reoperation rate was 86.2%. Valve re-replacement was performed in only 1 patient due to a thrombosed tricuspid valve. These results suggest that there is a small risk of major complications and reoperation in children who undergo valve replacement, whether a bioprosthetic valve or a mechanical valve. The long-term results of younger patients should be followed more closely according to their growth.

The introduction of dominant-negative p53 mutants suppresses temperature shift-induced senescence in immortal human fibroblasts expressing a thermolabile SV40 large T antigen

Immortal human fibroblasts, SVts8 cells, which express a heat-labile SV40 large T antigen, induces a senescence-like phenomenon in response to upward shift in temperature. Cells with arrested division show strong induction of senescence-associated beta-galactosidase. We examined how p53 and pRB are involved in this phenomenon since they are major targets of the T antigen. Transfection of cells with plasmids encoding the wild-type T antigen or human papilloma virus type 16 E6/E7 proteins completely abolished the arrest in cell division, a plasmid encoding the E6 protein suppressed it markedly, while a plasmid encoding E7 had no effect. Plasmids encoding dominant-negative p53 mutants also suppressed the arrest in cell division to various degrees. Upon temperature shift, p21 mRNA was upregulated 10-fold in SVts8 cells, but only slightly in clones expressing the wild-type T antigen or dominant-negative p53 mutants. These data demonstrate that p53 plays a major role in this senescence-like phenomenon.

High origin of the right coronary artery with congenital heart disease

We encountered a case of anomalous high origin of the right coronary artery associated with ventricular septal defect and patent ductus arteriosus. The right coronary artery originated from the distal part of the ascending aorta resulting in unsuccessful induction of cardiac arrest by cardioplegia. We describe this rare case with anomalous origin of the right coronary artery.

Early and mid-term outcomes of cardiac and thoracic aortic surgery in over-75-year-olds with postoperative quality of life assessment

The early and mid-term outcomes of cardiac and thoracic aortic surgery were reviewed in seventy-two consecutive patients aged 75 years and older, together with assessment of postoperative quality of life. Twenty-six patients had ischemic heart disease, twenty had valvular heart disease, one had congenital heart disease, and twenty-five had thoracic aortic aneurysm. Twenty-five (34.7%) required an emergency operation. There were 6 early deaths (8.3%) and 11 late deaths (17.2%), of which the emergency cases had higher mortality of 5 early deaths (20.0%) and 3 late deaths (15.0%). In particular, most cases with a ruptured thoracic aortic aneurysm died eventually from various complications including neurological dysfunction. The others with a non-ruptured aneurysm also had atherosclerotic aortic or arterial lesions which caused a lethal cerebrovascular accident or ischemic heart disease. The quality of life of 51 of 53 survivors was assessed using the Rosser and Watts index being based on disability and distress scores. The response was satisfactory--the disability score was 2.6 +/- 1.9 and the distress score was 1.4 +/- 0.4. The patients with a thoracic aortic aneurysm had worse quality of life scores than those of the ischemic heart disease or valvular heart disease patient-groups because of various perioperative complications. Our experiences demonstrate that the results including the postoperative quality of life following cardiac and aortic surgery in the elderly is satisfactory except for emergency cases. The results would prompt us to operate, if possible, electively in their stable conditions, even on elderly over-75-year-olds.

Single-stage surgery for distal aortic arch aneurysm and infrarenal abdominal aortic aneurysm through anterolateral approach

A 58-year-old man with a distal aortic arch aneurysm (DAA) associated with an infrarenal abdominal aortic aneurysm (AAA) successfully underwent a single-stage replacement of the aneurysms. A left anterolateral thoracotomy was used for replacement of the DAA, which was performed using profound hypothermic circulatory arrest and continuous retrograde cerebral perfusion. An extraperitoneal approach in conjunction with a lateral abdominal incision was employed for replacement of the AAA. The combination of an anterolateral thoracotomy and a lateral abdominal incision is useful in combined surgery for DAA and AAA.

Enzymatic synthesis of fructose 1,6-Diphosphate with ATP regeneration in a batch reactor and a semibatch reactor using purified enzymes of Bacillus stearothermophilus

The enzymatic synthesis of fructose 1,6-diphosphate (FDP), an important glycolytic intermediate whose applications in the field of medicine have generated a great deal of interest, was performed in a batch reactor and a semibatch reactor. Using the batch reactor, FDP was first synthesized from glucose by three enzymatic reactions and the ATP consumed was regenerated simultaneously using conjugated enzymes, all of which were purified from crude cell extract of thermophilic Bacillus stearothermophilus. The results of the experiments performed using several enzyme concentrations suggest the existence of an optimum concentration for each enzyme at which the maximum FDP yield can be attained. Since the thermal decomposition of acetyl phosphate reduced the yield of FDP in the batch reactor, the use of a semibatch reactor in which acetyl phosphate was fed continuously was examined. The yield of FDP was improved but the time required to complete the reaction was longer, resulting in a lower productivity of FDP. The yields observed in the two reactors using various enzyme and substrate concentrations were in good agreement with the theoretical predictions calculated based on differential equations derived for the system using the rate equations and the kinetic parameters determined previously. This means that these equations can be used for the analysis of the experimental results as well as for determining the optimum experimental conditions.

Theoretical investigation of fructose 1,6-diphosphate production and simultaneous ATP regeneration by conjugated enzymes in an ultrafiltration hollow-fiber reactor

The performance of an ultrafiltration hollow-fiber reactor, in which enzymatic synthesis of fructose 1,6-diphosphate (FDP) from glucose and enzymatic ATP regeneration are performed simultaneously, was analyzed theoretically. The reaction system consists of three-step synthetic reactions catalyzed by glucokinase (GK), phosphoglucose isomerase and phosphofructokinase, and the ATP regeneration reaction catalyzed by acetate kinase. Based on a simple analytical model developed previously in which the liquid flowing in a tube was assumed to be plug flow and the radial concentration gradients in the tubes and shell side space were both neglected, a computer program was developed to calculate the concentration profiles of all the components along the flow direction in the tubes and shell side space of the reactor. From the FDP concentrations at the reactor outlet calculated under various operational conditions, reactor performances such as the FDP yield and the ATP recycle number were determined. The calculation showed the interesting phenomenon that under some conditions the FDP yield was higher when GK concentration was lower.

Peptide synthesis catalyzed by organic solvent-stable protease from Pseudomonas aeruginosa PST-01 in monophasic aqueous-organic solvent systems

The equilibrium yields of the peptide Cbz-Arg-Leu-NH2 synthesized from Cbz-Arg and Leu-NH2 using the PST-01 protease in the presence of organic solvents were investigated under various conditions. The equilibrium yields depended little on the concentration of the carboxyl component, but significantly on the concentration of the nucleophile. The optimum temperature and pH for a high equilibrium yield were 30 degrees C and greater than 5.0, respectively. Under optimum conditions the equilibrium yields were 71.6% and 87.7% in the presence of 50% (v/v) DMF and 60% (v/v) DMSO, respectively. Furthermore, the PST-01 protease also catalyzed the syntheses of the dipeptides Cbz-Lys-Leu-NH2, Cbz-Ala-Leu-NH2, Cbz-Ala-Phe-NH2, Cbz-Arg-Leu-NH2, and Cbz-Lys-Phe-NH2 with equilibrium yields of more than 60% in the presence of 50% (v/v) DMF and 50 mM sodium phosphate buffer (pH 7.0).

Enzymatic production of fructose 1,6-diphosphate using crude cell extract of Bacillus stearothermophilus

The enzymatic production of fructose 1,6-diphosphate (FDP) from glucose was performed in a batch reactor and a semibatch reactor using the crude cell extract of Bacillus stearothermophilus which contains all four enzymes required for the synthesis. The experimental results of the yield and the time courses of FDP production obtained using various enzyme concentrations were in good agreement with the theoretical predictions calculated based on the differential equations including the rate equations of the four enzymes, which were determined using the purified enzymes of B. stearothermophilus.

Purification and characterization of organic solvent-stable protease from organic solvent-tolerant Pseudomonas aeruginosa PST-01

An organic solvent-stable protease (PST-01 protease) in a culture broth of organic solvent-tolerant Pseudomonas aeruginosa PST-01 was purified by successive hydrophobic interaction chromatography using Butyl-Toyopearl gels. The purified enzyme was homogeneous as determined by SDS-polyacrylamide gel electrophoresis. PST-01 protease had a molecular mass of 38 kDa. The optimum temperature and pH for casein hydrolysis were 55 degrees C and 8.5, respectively. PST-01 protease was stable at pH 8-12 and below 50 degrees C and was determined to be a metalloprotease which was inhibited by EDTA, 1,10-phenanthroline, and phosphoramidon. PST-01 protease inhibited by EDTA was reactivated completely by the addition of zinc or cobalt ions. The stability of PST-01 protease in solutions containing water-soluble organic solvents or alcohols was higher than that in the absence of organic solvent. Furthermore, in general, PST-01 protease was more stable than commercially available proteases, namely, subtilisin Carlsberg, thermolysin, and alpha-chymotrypsin, in the presence of water-soluble organic solvents or alcohols.

Purification and characterization of lipase from Rhizopus chinensis cells

Lipase from Rhizopus chinensis cells was purified and characterized. The molecular mass of purified lipase was 28.4 kDa and the optimal temperature and pH for its activity were 37 degrees C and 5.5, respectively. Purified lipase exhibited high hydrolytic activity against fatty acid methyl esters such as methyl caprylate, methyl laurate, and methyl palmitate. Freeze-dried lipase catalyzed the transesterification between olive oil and methyl laurate in n-hexane.

DNA topoisomerase inhibitors induce reversible senescence in normal human fibroblasts

Inhibitors of DNA topoisomerases I and II induced arrest in cell division in normal human fibroblasts depending on cell divisions. Arrested cells showed morphology similar to those of normally senesced cells and strongly induced senescence-associated beta-galactosidase. In these cells, p16ink4a was upregulated, whereas p21waf1 or p53 was not altered. Upon removal of the inhibitors, the cells resumed growth but their cumulative population doublings were reduced dose dependently. Accelerated telomere shortening was not observed in the arrested cells. These results suggest that DNA topoisomerase inhibitors are efficient and reversible inducers of premature senescence in normal human cells.

[Clinical features in patients with delayed endolymphatic hydrops]

We report clinical features in patients with delayed endolymphatic hydrops (DEH) with juvenile unilateral deafness. Among 23 patients with DEH, 15 cases were diagnosed as ipsilateral DEH and 8 cases as contralateral DEH. The distribution of onset age showed two peaks at ages of < 30 years and > 40 years. In 80% of the ipsilateral DEH cases, the onset of episodic vertigo was at younger ages. On the other hand, in 75% of the contralateral DEH cases, the onset of fluctuation hearing loss of the contralateral ear was at older ages. Ispilateral DEH and Meniere's disease may show different pathophysiologies. The incidence of dominant negative summating potential in the better-hearing ear was 20% in the ispilateral DEH cases and 60% in the contralateral DEH cases. It is suggested that endolymphatic hydrops is in the better-hearing ear of contralateral DEH.

Monitoring of regional cerebral oxygenation by near-infrared spectroscopy during continuous retrograde cerebral perfusion for aortic arch surgery

OBJECTIVE

To assess the value of monitoring of regional cerebral oxygen saturation (rSO2) during aortic arch surgery using continuous retrograde cerebral perfusion (CRCP) in conjunction with profound hypothermic circulatory arrest (HCA).

METHODS

The rSO2 of 12 consecutive patients was monitored non-invasively using near-infrared spectroscopy (NIRS) and the data were analyzed statistically.

RESULTS

The mean duration of HCA with CRCP was 62-/+14.1 min. The mean CRCP flow rate was 226+/-163 ml/min. Surgical outcomes were favorable with only a single hospital death (8.3%). However, the rSO2 decreased gradually in all patients during HCA, even combined with CRCP, and fell to 46+/-8.7% on average. It did not change so greatly before HCA and returned finally to its initial level at the end of re-warming. Only one patient developed a permanent neurologic deficit; this patient showed the greatest decrease of rSO2 from 56% to 29% after the longest HCA of 88 min. Two parameters, End-rSO2 (the ratio of post- to pre-HCA rSO2) and delta-rSO2 (the rate of decrease from preto post-HCA rSO2) were obtained since the initial values of rSO2 before surgery differed. There were linear correlations between the CRCP flow rate and each of these two parameters. A multiple regression analysis also revealed a linear equation relating the parameters, which allowed prediction of the safe duration of HCA in different conditions of CRCP and a more favorable adjustment of the CRCP condition in each patient.

CONCLUSIONS

The study suggests that the combination of HCA and CRCP has a limit of safe duration in spite of its potential usefulness for brain protection, and that rSO2 monitored by NIRS is useful in testing for adequate brain protection. It is hoped that monitoring of rSO2 can facilitate prediction of the safe duration of HCA with CRCP and a more favorable adjustment of CRCP.