[Urgent coronary reoperation under the beating heart via the left thoracotomy]

An 80-year-old female, who had received coronary artery bypass grafting (CABG) 12 years ago was admitted to our hospital because of unstable angina. The vein grafts to the left anterior descending artery (LAD) and circumflex artery (Cx) were both occluded. Chest computerized tomography showed a severely calcified aorta. An intra-aortic balloon pump was inserted and an urgent reoperation was performed. The patient was positioned for an anterolateral left thoracotomy. The chest was entered through the forth intercostal space. The pericardium was opened parallel to the phrenic nerve. Femorofemoral bypass was instituted. Anastomosis of the saphenous vein graft and the diagonal branch and anastomosis of a second saphenous vein to the old SVG just proximal to the anastomotic site of Cx were performed under a beating heart. Proximal anastomosis of the two saphenous veins and the left subclavian artery was then performed. The patient had an uncomplicated postoperative recovery. A postoperative angiogram showed that the new SVG anastomosed to the diagonal branch was patent while the other new SVG anastomosed to the old SVG/Cx was occluded. The patient was discharged and is now free from angina.

[Evaluation of coronary artery bypass grafts with magnetic resonance imaging]

Currently, the efficacy of magnetic resonance imaging (MRI) for evaluating coronary artery disease has been reported. In this study, we have evaluated the usefulness and the problems of MRI for evaluating the patency of coronary artery bypass grafts. Thirty-five patients who received coronary artery bypass grafting (CABG) were evaluated by using MRI for determining the graft patency compared with conventional coronary angiography. There were 30 men and 5 women. The mean age was 61.2 years (range 45 to 75). The 35 patients had a total of 92 grafts (28 internal thoracic artery, 7 gastroeploic artery and 57 saphenous vein grafts). Magnetic resonance coronary angiogram (MRCA) was performed with SIGNA HORIZON 1.5 T (GE Inc.) by using 2D-FASTCARD sequence. All patients underwent imaging in the transverse and coronal planes, most had imaging in the sagittal plane, and a few had in the oblique plane. By using MRCA, 82 of 90 grafts were diagnosed correctly as patent, and 1 of 2 grafts were diagnosed correctly as occluded. Thirty-four of 40 LAD grafts (85%), 20 of 22 RCA grafts (91%) and 29 of 30 Cx grafts (97%) were correctly evaluated. The efficacy of MRCA for evaluating the patency of coronary artery bypass grafts was recognized. But the sternal wire (stainless steel) and hemoclip interfere with the interpretation and reduce the sensitivity. Higher sensitivity may be obtained by changing the material of the sternal wires and hemoclips at coronary surgery.

[Beneficial effects of continuous hemodiafiltration after cardiac surgery in patients with chronic renal failure]

From December 1993 to June 1996, fourteen patients with chronic renal failure (CRF) were underwent cardiac surgery. Thirteen of them had coronary artery bypass grafting (CABG) and one patient had aortic valve replacement. We employed continuous hemodiafiltration (CHDF) with or without peritoneal dialysis in eleven cases in the early postoperative course of open heart surgery. In these cases, the usefulness of CHDF were examined. CHDF was started after 16.9 +/- 13.7 hours of surgery, and continued for 31.9 +/- 18.0 hours. We adjusted blood flow as 80 ml/min, perfusate flow of hemofilter as 500 ml/hr, and the activated clotting time (ACT) as 150-200 seconds with heparin or nafamostat mesilate. No hemorrhagic tendency was observed. Mean serum creatinine level before and after 24 hours of CHDF was 5.6 +/- 2.2 and 5.6 +/- 2.1 mg/dl respectively, and it was not elevated. The average removal volume was 2,223 +/- 1,256 ml for the first 24 hours, and pulmonary wedge pressure was decreased from 9.0 +/- 2.3 to 6.4 +/- 3.0 mmHg (p < 0.05). However, there was no significant change at cardiac output before and after CHDF. Total dose of dopamine and dobutamine were unchanged. No significant change were noted at systemic vascular resistance and pulmonary vascular resistance. We conclude that CHDF allows an adequate removal of fluid and waste products without deleterious effects on hemodynamics even in patients after cardiac surgery. CHDF is a safe and effective alternative in patients with CRF after cardiac surgery.

Studies on the metabolism and disposition of the new retinoid 4-[(5,6,7,8-tetrahydro-5,5,8,8-tetramethyl-2-naphthyl)carbamoyl]benzoic acid. 5th communication: factors affecting percutaneous absorption in rats

4-[(5,6,7,8-Tetrahydro-5,5,8,8-tetramethyl-2-naphthyl)carbamoyl] benzoic acid (CAS 94497-51-5, Am-80) is a new synthetic retinoid which has been shown to have a potent topical antipsoriatic activity. Factors affecting the percutaneous absorption of Am-80 were studied with the intention of obtaining information for toxicity and clinical investigations. The percutaneous absorption of radioactivity was compared after topical application of 0.1% 14C-Am-80 ointment to female rats by simple application (SA), occlusive dressing technique (ODT), and application using lint (AUL). After single topical application to normal skin female rats, the percutaneous absorption of radioactivity was very low with no significant differences in the extent of absorption among the three application methods. In the stripped skin female rats, a distinct increase of the percutaneous absorption was observed indicating that it was markedly affected by the lack of the stratum corneum. Compared with the single dosing, a considerable increase of percutaneous absorption was observed following repetitive topical application once daily for 4 or 7 days to the normal skin female rats. The extent of increase was highest in ODT rats followed by SA rats, but was relatively low in AUL rats. The effects of concentration, dose and application area of 14C-Am-80 ointment on the percutaneous absorption of radioactivity were studied following topical application of 0.002%-0.008% 14C-Am-80 ointment to normal skin male rats by ODT to areas of 72 cm2/kg-360 cm2/kg (5%-25% of the body surface area) at ointment doses of 2g/kg-8 g/kg. When the application area and the amount of ointment applied were fixed at 144 cm2/kg (10% of the body surface area) and 2 g/kg, respectively, the amount of radioactivity absorbed increased in proportion to the 14C-Am-80 concentration in the ointment, whereas the rate of percutaneous absorption, expressed as the percent of dose, was nearly constant. When the 14C-Am-80 concentration in the ointment and the amount of ointment applied were fixed at 0.08% and 2 g/kg, respectively, both the amount of radioactivity absorbed and the rate of percutaneous absorption markedly increased with an increase in the application area. When the concentration of 14C-Am-80 in the ointment was set at 0.008% and the application area at 72 cm2/kg, 144 cm2/kg or 288 cm2/kg (5%, 10% or 20% of the body surface area), the amount of radioactivity absorbed increased as the amount of ointment applied increased for areas of the same, though the rate of percutaneous absorption remained almost constant. When the 14C-Am-80 concentration in the ointment was fixed at 0.008%, the amount of radioactivity absorbed increased markedly about 20-fold with 4-fold simultaneous increases in both the application area (from 72 cm2/kg to 288 cm2/kg) and the amount of ointment applied (from 2 g/kg to 8 g/kg).

Regulation of voltage-gated ion channels during ascidian embryogenesis

In the proto-chordate Halocynthia roretzi, a voltage-activated sodium current undergoes a change in kinetics within 48 h of fertilization. Molecular cloning and microinjection of antisense DNA into single cells suggest that the kinetic changes are due to the increased expression of a neural-specific sodium channel gene, TuNa I. TuNa I gene transcription is first induced in late-stage gastrulae, preceding the appearance of the rapidly inactivating sodium current unique to alpha 4-2 derived neural cells. In cleavage-arrested and intact embryos, cell interactions between specific animal and vegetal blastomeres are required for induction of TuNa I gene expression. By contrast, another sodium channel gene, TuNa II, is mainly expressed in neural cells of the alpha 4-1 lineage. In this lineage, cells of endoderm, notochord and muscle develop. TuNa II gene transcription occurs in isolated alpha 4-1 blastomeres without interacting with other lineage cells. Thus, there are two distinct neural cell lineages in the ascidian tadpole: one is similar to the ectoderm-derived neural tissue controlled by a mechanism reminiscent of the neural induction in the vertebrate, the other is the lineage of posterior neural tube in which motor neurons develop in close association with the notochord or muscle lineage.

[Coronary artery bypass grafting under the beating heart in a patient with insufficient cardiopulmonary bypass]

Coronary artery bypass grafting in a 64-year-old male with a severe calcified ascending aorta was performed under the beating heart, because of insufficient cardiopulmonary bypass. The patient suffered inferior and anterolateral myocardial infarction with moderate mitral regurgitation. Computerized tomography showed a severely calcified ascending aorta. During the operation, cardiopulmonary bypass was conducted with femoral arterial cannulation and bicaval cannulation. Adequate perfusion flow, however, could not be achieved. Anastomoses of left internal thoracic artery-left anterior descending artery and right gastroepiploic artery-right coronary artery were performed under a beating heart supported by cardiopulmonary bypass. The patient made an uneventful recovery and postoperative angiography revealed patent grafts. Mitral regurgitation remained unchanged, but the postoperative lifestyle has been stable for the last 15 months.

[Three cases of coronary to pulmonary arterial fistulae combined with valvular disease]

Three cases of coronary to pulmonary arterial fistulae (CAF) combined with valvular disease are reported. The first case was 53-year-old male admitted with mitral stenosis (MS) and left atrium thrombus. CAF originating from both coronary artery and draining to pulmonary artery were found by coronary angiography. Open mitral comissurotomy (OMC), thrombectory and ligation of CAF were performed. Case 2 was 52-year-old female suffered from CHF due to MS. Abnormal communication from left coronary artery to pulmonary artery was demonstrated. OMC and ligation of CAF were performed. Case 3 was 65-year-old male with combined valvular disease. MS, aortic regurgitation and CAF from right coronary artery to pulmonary artery were revealed. Mitral and aortic valve replacement and ligation of CAF were done. Diffusion of coronary angiography increase chance to reveal coronary artery fistulas during examination of acquired cardiac disease. Coronary artery fistulas draining into pulmonary artery were completely ligated by double ligation at both the arising point from coronary artery and the draining point to pulmonary trunk.

[Indication and result of hypothermic fibrillatory arrest in coronary artery bypass grafting]

Currently, cardioplegic arrest is used for almost all coronary artery bypass grafting (CABG). However, there are some cases in which aortic occlusion or the cardioplegic infusion is not desirable. In this paper, we discussed the indications and the usefulness of hypothermic fibrillatory arrest for CABG. From April 1992 to March 1995, CABG with hypothermic fibrillatory arrest was performed in 6 patients (3.9% of total CABG cases). The reasons of employing hypothermic ventricular fibrillation were as follows; calcified ascending aorta in 2 patients, coronary aneurysm associated with Behçet's decrease in 1, revascularization to the totally obstructed branches with poor left ventricular function in 2, and collateral circulation from bronchial artery with total obstruction of left main trunk in 1. The age range was 48 to 68 years with a mean of 59.0 +/- 7.8 years. Five patients had a history of myocardial infarction and 2 of them had a left ventricular ejection function less than 0.25. Surgical procedures consisted of elective ventricular fibrillation without aortic cross-clamp, systemic hypothermia and local pericardial cooling, left atrial or pulmonary artery venting, and local vessel isolation during distal anastomosis. Average number of grafts was 2.0 +/- 0.6, and 5 left internal thoracic arteries, 2 gastroepiploic arteries and 5 saphenous vein were used. Mean duration of ventricular fibrillation was 74.0 +/- 17.5 min. Postoperative angiography confirmed all bypasses patent. Only 1 patient, whose preoperative left ventricular ejection function was 0.20, died of heart failure 5 months after the operation. All other patients survived asymptomatically. Hypothermic fibrillatory arrest is useful and reliable technique in coronary artery bypass grafting when aortic occlusion or cardioplegic arrest is not desirable.

Cysteine protease of Porphyromonas gingivalis 381 enhances binding of fimbriae to cultured human fibroblasts and matrix proteins

It has been shown that Porphyromonas gingivalis 381, a suspected periodontopathogen, possesses fimbriae on its cell surface. The organism is also known to produce proteases which can degrade the host cell surface matrix proteins. In this study, we investigated the effect of protease on the binding of the purified P. gingivalis fimbriae to cultured fibroblasts or matrix proteins. A protease that can hydrolyze benzoyl-L-arginine p-nitroanilide was obtained from P. gingivalis 381 cells by sonication in phosphate-buffered 0.2% Triton X-100 and was purified by column chromatography. The molecular size of the protease was estimated to be 55 kDa by gel filtration or 47 kDa by sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis. The enzyme activity was markedly inhibited by sulfhydryl reagents, antipain, and leupeptin. The protease degraded various host proteins, including collagen and fibronectin, and cleaved the COOH terminus of the arginine residue in peptides such as benzoyl-L-arginine p-nitroanilide. However, P. gingivalis fimbriae were not degraded by protease activity. The enzyme activity was enhanced in the presence of reducing agents or CaCl2. When cultured fibroblasts were partially treated with the protease, the binding of the purified P. gingivalis fimbriae to the fibroblast monolayer was increased significantly. However, this enhancing effect was suppressed upon the addition of antipain and leupeptin. Similarly, binding of the fimbriae to the collagen or fibronectin immobilized on the microtiter wells was also enhanced. Addition of these host matrix proteins efficiently inhibited the binding of fimbriae to the fibroblast monolayer. The binding assay of fimbriae using dipeptidyl ligand affinity column chromatography demonstrated a clear interaction between fimbriae and the arginine residue. Taken together, these results indicate that the P. gingivalis protease at least partially degrades the host matrix proteins, which, in turn, may lead to an increased exposure of the cryptic ligands that can result in enhanced fimbria-mediated binding of this organism to periodontal tissues.

Strategy for breast conserving treatment--analysis of recurrence and prognosis after breast cosnserving treatment

Two hundred and four patients with small breast cancer (T < or = 3.0 cm. N0 or N1a) were given breast conserving treatment (radiation group: 101, non-radiation group: 103) during the period from Feb. 1988 to Jan. 1995. Survival analysis of breast conserving treatment radiation group versus non-radiation group revealed the following: 1) Breast conserving treatment had a good prognosis, and a 5-year overall survival rate of 96.2%. 2) There was no significant difference of 5-year overall, disease-free and ipsilateral breast disease-free survival rate between the radiation group and non-radiation group. 3) Surgical margin involvement was the most significant risk factor in local recurrence after breast conserving treatment, and non-radiation was a possible risk factor. 4) Local recurrence was a significant risk factor for distant metastases after breast conserving treatment the same as node positive. These results suggested as follows: 1) Lumpectomy with a clear margin and radiation is the best choice for small breast cancer (T < or = 3.0 cm, N0 or N1a). 2) Adjuvant therapy after surgical treatment is necessary for local recurrence.

[A study on the maternal plasma C21 steroids concentration during pregnancy]

During pregnancy, C21 steroids such as progesterone (P4), and cortisol (F), have been reported to be closely involved in uterine contraction. To clarify the association between changes in steroid hormones and the onset of delivery, we measured the concentrations of six C21 steroids in maternal blood by high performance liquid chromatography. Changes in each steroid hormone were evaluated by analysis of variance during pregnancy. Pregnenolone, a source of C21 steroids, gradually increased during pregnancy. P4 and 17P4, its metabolite, reached a peak 3 weeks before delivery and noticeably decreased thereafter. Accompanying a decrease in P4 and 17P4, 20P4 and F, its metabolite, were noticeably increased. The association among these steroid hormones was also evaluated. The correlation between P4 and F was reversed after 3 weeks before delivery. These results suggest that steroid hormones in the maternal blood begin to change dynamically about 3 weeks before delivery. In particular, a decrease in P4 and an increase in F seem to be closely related to the onset of delivery.

Observation of enhanced backscattering from a plane mirror viewed through polymer-film-dispersed liquid crystals

We report experimental results on enhanced backscattering from a plane mirror that is viewed through polymer-film-dispersed nematic liquid crystals. The distribution of the averaged intensity of the light reflected from the mirror placed behind the polymer film is investigated with an image-processing system when a Gaussian beam wave is incident. The enhanced light peak is observed in an incident beam direction, the result of which is predicted by a theory based on the circular Gaussian statistic random-phase-screen model. We pay attention to the enhancement dependence on parameters such as the distance between the polymer film and the flat mirror. The observed result is similar to a previous study by Jakeman et al. in which a random diffusive glass plate was used as a random-phase screen [J. Phys. D 21, 32 (1988)].

[Coronary artery bypass grafting in a patient with a single coronary artery]

Coronary artery bypass grafting in a patient with a single coronary artery is reported. A 61-year-old male who had chest pain and palpitation was transferred to our hospital. His ECG showed ischemic change, and CPK rose to a high level. Emergency coronary angiography revealed a type L II A (Lipton's criteria) single coronary artery and atherosclerotic stenosis on three major branches. He underwent CABG of LAD using LITA, #3 and #14 using saphenous vein grafts. Post operative angiography confirmed patent grafts, and the patient was free from symptoms.

Serum-soluble interleukin-2 receptor levels before and after surgical treatment for Graves' disease

Serum-soluble interleukin-2 receptor (ssIL-2R) is released from its specific affinity membrane receptor on activated T lymphocytes and is detected as a form of the alpha-chain of IL-2R in the peripheral blood. We measured the ssIL-2R levels by enzyme-linked immunosorbent assay in 29 healthy subjects and 39 patients with Graves' disease who were given antithyroid drugs to prepare them for surgical treatment. The preoperative ssIL-2R levels in Graves' patients were significantly higher than those in the healthy controls (681 +/- 387 vs 369 +/- 149 U/ml); in particular, the preoperative levels in hyperthyroid patients were significantly higher than those in euthyroid patients. On the 5th day after thyroid resection, their ssIL-2R levels (560 +/- 296 U/ml) were significantly lower than the preoperative levels. There were no correlations between the preoperative ssIL-2R levels and the immunological parameters such as thyroglobulin antibody, microsomal antibody, and thyroid-stimulating hormone receptor antibody. Thus, we conclude that ssIL-2R levels can be decreased by surgical resection of goiter in Graves' patients whose hyperthyroid status does not respond to the administration of antithyroid drugs, and this may be a useful indicator of immunological status after surgical treatment of Graves' disease.

[The mechanism of beta-receptor desensitization in human myometrial culture cell]

Beta-adrenoceptor desensitization is considered to be primarily due to phosphorylation of receptors by protein kinase A (PKA) and beta-adrenaline receptor kinase (beta-ARK) and sequestration of receptors themselves. But in the human uterine muscle, the desensitization mechanism has been evaluated only as a phenomenon, and there are few studies on its mechanism. We evaluated cAMP production by beta-agonist and changes in the number of beta-receptors in cultured human myometrial cells. Uterine muscle cell were obtained from patients with benign disease before menopause and cultured. 1) At the confluent stage, dl-Isoproterenol Hydrochloride (ISP) was added under various conditions, and the intracellular cAMP concentration was determined by EIA. 2) After the addition of ISP (10(-6) M), plates were incubated at 37 degrees C, and beta-AR on the cell membrane surface (S beta-AR) and total beta-AR (T beta-AR) was measured in a binding assay with 125I-pindolol. The production of cAMP dose-dependently increased 30 minutes after the addition of ISP at 10(-6) M or higher, but rapidly decreased thereafter. T beta-AR was similar in the cells treated with ISP (10(-6) M) and the untreated cells. On the other hand, S beta-AR decreased by about 50% in the ISP treated cells. These result suggest the desensitization of beta-AR in human uterine muscle, and the involvement of the sequestration mechanism as its cause.

[A case report of surgical repair of a ruptured aneurysm of the sinus Valsalva in an aged person with cardiac cachexia]

A 71-year-old woman underwent surgical repair of a ruptured aneurysm of the sinus Valsalva. She had an aneurysm of the right coronary sinus ruptured into the right atrium. There was no VSD. The patient suffered from heart failure for 38 years and went into cardiac cachexia. Direct closure from the right atrium was performed and the patient has resumed full physical activities. As far as we know, this is one of the oldest patients who underwent successful surgery for this disease in this country.

[Coronary artery bypass grafting in a patient with right aortic arch associated with retroesophageal anomalous left subclavian artery]

A rare case of coronary artery bypass grafting in a patient with right aortic arch was presented. A 62-year-old man was admitted to our hospital with angina pectoris. Coronary angiography revealed total obstruction of left anterior descending artery and jeopardized collateral from right coronary artery. Aortography disclosed right aortic arch associated with retroesophageal anomalous left subclavian artery. As the symptom of neither the vascular ring nor the subclavian steal syndrome was recognized, left internal thoracic artery along with the saphenous vein was used for bypass conduit. The patient is doing well without any troubles 7 months after the operation. Attention should be made to use left internal thoracic artery in a patient with right aortic arch.

[Intraocular penetration of oral levofloxacin in rabbits]

The intraocular penetration of levofloxacin was studied in albino and pigmented rabbits after oral administration of 14C-levofloxacin at a dose of 20 mg/kg. The radioactivity of the eyeball of albino rabbits in the autoradiogram was much higher at 1 hr than at 2 or 6 hr after administration. On the other hand, the distribution of radioactivity in pigmented rabbits was similar at 1, 2, and 6 hr after administration. The radioactivity levels in melanin-containing tissues such as the iris-ciliary body and the choroid-retina were significantly higher in pigmented rabbits than in albino rabbits 2 hr after oral administration. The radioactivity levels in the ocular tissues without melanin except for the cornea were similar in albino and pigmented rabbits. These results indicate that the intraocular pharmacokinetics of levofloxacin are markedly affected by its affinity for melanin.

Neural expression of a sodium channel gene requires cell-specific interactions

In the protochordate Halocynthia roretzi, voltage-activated sodium current undergoes a change in kinetics within 48 hr of fertilization. Molecular cloning and microinjection of antisense DNA into single cells suggest that the kinetic changes are due to the increased expression of a putative neural-specific sodium channel gene, TuNa I. TuNa I gene transcription is first induced in late stage gastrulae, preceding the appearance of the rapidly inactivating sodium current unique to neural cells. In cleavage-arrested and intact embryos, cell interactions between specific animal and vegetal blastomeres are required for induction of TuNa I gene expression. Our results implicate cell contact, prior to neurulation, as a mechanism for selectively activating the TuNa I gene expressed in cells of the neural lineage.

[Intra-arterial infusion chemotherapy for recurrent breast cancer via an implantable system--the second report]

Intra-arterial infusion chemotherapy via an implantable port catheter has been applied in 16 patients with locally recurrent breast cancer. The regimen consisted of induction and subsequent maintenance: intra-arterial infusion of epirubicin (EPI). Non-responders were entered into the second-line regimen consisting of Methotrexate and 5-FU (MF). The results were as follows: 1) The response rate (CR+PR) of EPI to locoregional lesions was 50%, and the median duration of response was 5.7 months. 2) The response rate and the duration of response of MF were 25% and 3 months, respectively. 3) Patients with ER-rith, no previous therapy and a long disease-free interval tended to have a high rate of response to intra-arterial infusion therapy. 4) Improvements of QOL, such as intractable pain, infection and severe lymphedema were recognized in 68.6% of the cases. In more than half of the cases, these treatments were carried out in an outpatient clinic. 5) Leucopenia and catheter or portal problems were encountered in 68.6% and 25.0%, respectively. We conclude that intra-arterial infusion chemotherapy via implantable system is a promising modality with regard to therapeutic effect and improvement of quality of life.