Results of circulatory support for postoperative cardiogenic shock

Over the last 5 years, 15 patients received ventricular assist devices (VADs) (Group 1) and 5 received percutaneous cardiopulmonary support (CPS) (Group 2) while in postoperative cardiogenic shock. Group 1 consisted of 8 men and 7 women ranging in age from 22 to 73 years (average age, 55 years). Nine of these patients underwent surgery for valve replacement, 5 for coronary artery bypass grafting, and 1 for closure of a ventricular septal rupture. The duration of VAD support ranged from 6 h to 9 days (mean, 3.9 days). Group 2 consisted of 4 men and 1 woman ranging in age from 49 to 68 years (average age, 57 years). One of these patients underwent surgery for valve replacement, 1 for coronary artery bypass grafting, 2 for replacement of a thoracic aneurysm, and 1 for left ventricular aneurysmectomy. The duration of CPS ranged from 4 h to 8 days (mean, 2.8 days). In Group 1, 13 patients were weaned from the VADs and 8 survived. Bleeding occurred in 5 patients, renal failure in 4, infection in 3, cardiac failure in 4, cerebral infarction in 1, perioperative myocardial infarction in 1, arrhythmia in 1, and ileus in 1. In Group 2, 4 patients were weaned from the CPS and 3 survived. Bleeding occurred in 3 patients, renal failure in 2, CNS injury in 2, and cardiopulmonary failure in 1. The 8 survivors in Group 1 have been followed for 2 to 56 months (mean, 28.7 months). Five patients were in NYHA class I, 2 were in class II and 1 was in class III.(ABSTRACT TRUNCATED AT 250 WORDS)

Ectopic gastric mucosa in the upper esophagus: detection and radiographic findings

PURPOSE

To detect and characterize the appearance of islands of ectopic gastric mucosa in the upper esophagus at routine examination of the upper gastrointestinal (GI) tract.

MATERIALS AND METHODS

Well-distended upper esophagus was documented with spot radiographs obtained with routine double-contrast examination performed after administration of high-density barium in nine patients. Detected lesions were confirmed by means of endoscopy and biopsy.

RESULTS

Twelve lesions were detected. Radiographic findings were characterized by either a discrete, shallow depression surrounded by a subtle, rimlike elevation on double-contrast images or by a pair of small indentations on the same wall on full-column, single-contrast images at the level of the thoracic inlet. Endoscopic examination revealed well-circumscribed areas of reddish mucosa located 15-26 cm from the incisors.

CONCLUSION

Ectopic gastric mucosa in the upper esophagus is easily demonstrated at routine examination of the upper GI tract. Diagnosis can be based on location and characteristic radiographic appearance.

[Breast sarcoidosis: 2 case reports and a review of 19 literature]

Case 1. A 40-year-old Japanese female with a 11 years history of sarcoidosis. Biopsy of a 0.5 cm-sized right breast nodule showed sarcoid granuloma. About two years later she had had bloody galactorrhoea and biopsy of an apparently normal site of the breast revealed periductal sarcoid granuloma and duct papillomatosis. Case 2. A 63-year-old Japanese female in whom biopsy of a 1 cm-sized right breast nodule revealed sarcoid granuloma. BHL, lung, eyes, muscle, lymph nodes and skin lesions were subsequently detected and the last two were histologically confirmed as sarcoidosis. After nine months all lesions disappeared. Some problems presented in the literature such as periductal sarcoid granuloma formation, latent sarcoidosis in the grossly normal breast and coexistent breast cancer are discussed briefly.

[Surgical treatment of infective endocarditis]

Since 1976, 37 patients have undergone valve replacement for infective endocarditis at our institute. Twenty patients required surgery during the active stage and 17 in the inactive stage. The former group consisted of 17 native and three prosthetic valve endocarditis, and all patients in the latter group had native valve endocarditis. Eighteen patients had AVRs, 15 had MVRs and four had DVRs. Congestive heart failure was the indication for surgery in 80% of the active and 100% of the inactive group. There were nine early deaths (45%) and one late death in the active group, and one early (6%) and one late death in the inactive group. Operative mortality in the active group, however, has recently been reduced to 30% for the 10 patients operated upon in the past two years. Two patients with active endocarditis were complicated by rupture of cerebral mycotic aneurysms postoperatively and resulted in one early and one late death, respectively. It is suggested that timely surgical intervention according to the hemodynamic state of the patients is essential in reducing early mortality in infective endocarditis. Attention should be paid to cerebral mycotic aneurysm as one of the problems affecting on postoperative mortality and morbidity.

Neuropathology of late cortical cerebellar atrophy in Japan: distribution of cerebellar change on an autopsy case and review of Japanese cases

We report a Japanese autopsy case of late cortical cerebellar atrophy. The patient had showed clinically transient remission during thyrotropin-releasing hormone therapy. Our case suggests that thyrotropin-releasing hormone therapy is worth trying as a treatment of late cortical cerebellar atrophy. Neuropathological examination showed diffuse cerebellar cortical lesions and absence of neuronal loss in the dorsomedial part of the inferior olives. We studied qualitatively the detailed distribution of the cerebellar cortical lesions in 6 sections of the right cerebellum. The cerebellar lesions were more conspicuous in the most lateral hemisphere than in the vermis. We also reviewed 7 Japanese autopsy cases of late cortical cerebellar atrophy.

Effect of PSK, a protein-bound polysaccharide preparation, on liver tumors of Syrian hamsters induced by Thorotrast injection

The contrast medium Thorotrast, an agent well known to be carcinogenic, was injected into 400 congeneic Syrian hamsters. The resulting incidence of malignant hepatic tumors such as cholangiocarcinoma, hepatocellular carcinoma and hemangiosarcoma, was significantly higher in the male experimental group than in the control group, and the 50% survival period in the male group was shortened by about 100 days (P < 0.01). However administration of the antitumor drug PSK (Polysaccharide Kureha), a protein bound-polysaccharide extracted from basidiomycete fungi, prevented this carcinogenic effect. The incidence of malignant hepatic tumors in the experimental group was 22.5% compared with 2.8% in the control group (P < 0.01) and 10.5% in the PSK-treated group (P < 0.01). PSK also increased the 50% survival period by 61 days (P < 0.01).

[A case of partial anomalous pulmonary venous connection to the high superior vena cava with intact atrial septum]

A 16-year-old female with partial anomalous pulmonary venous connection to the high superior vena cava underwent a successful correction using only autologous pericardium. Right upper pulmonary venous blood returned to the left atrium via the superior vena cava and the constructed atrial septal defect. The right atrium received blood from the brachiocephalic vein through the conduit. The azygos vein was not identified. Post-operative examination revealed that there were no pressure gradients across the superior vena cava and the conduit. She was discharged from the hospital on the 14th post-operative day.

Protection against ocular and cutaneous infection with herpes simplex virus type 1 by intragastric immunization with live virus

Intragastric administration of live herpes simplex virus type 1 (HSV-1) was assessed for the induction of humoral immune responses and for protection against ocular and cutaneous challenge with virus. Mice showed no clinical abnormalities following intragastric inoculation with three different strains of virus (Miyama + GC, SC16, and P2C6, a thymidine kinase-defective mutant). Replication of virus was not detected in the oesophagus, superior cervical ganglia or coeliac ganglia of such animals and latent infection was not detected in these ganglia at later times after inoculation. Induction of a mucosal immune response was indicated by the presence of antibody (mainly IgG or IgA)-secreting cells in Peyer's patches. Intragastric immunization gave protection to some extent against ocular challenge and to a greater extent against cutaneous challenge with HSV-1. Following the latter challenge, particularly after intragastric immunization with strains SC16 and Miyama, the establishment of latency was almost completely prevented.

Circulatory support for patients experiencing postcardiotomy cardiogenic shock: analysis of risk factors for death and long-term follow-up

Over the last 5 years, 12 patients received ventricular assist devices (VADs) while in postcardiotomy cardiogenic shock. There were 7 male and 5 female patients ranging in age from 22 to 73 years (average age, 54). Eight patients underwent surgery for valve replacements, 3 for coronary artery bypass graftings, and 1 for closure of a ventricular septal rupture. The duration of VAD support ranged from 6 h to 9 days (mean, 4.2 days). Ten patients were weaned from the VADs, and 6 survived. Univariate analysis indicated that renal failure, infection, and heart failure had a negative impact on those patients who survived. Multivariate analysis indicated that heart failure, renal failure, and preoperative left ventricular ejection fraction were the most important predictors of hospital death. The 6 survivors were followed for 4 to 42 months (mean, 25 months); 5 were in New York Heart Association (NYHA) Class I, and 1 was in Class II. The cardiac functions in 5 patients who lived over 1 year were assessed by echocardiography. Preoperative and postoperative UCG revealed that ejection fraction and mean velocity of circumferential fiber shortening increased significantly (p < 0.01). Also, the left ventricular diastolic and systolic dimensions decreased significantly (p < 0.05). However, the patients did not show further changes in these parameters during exercise. Eight patients who had double valve replacements were observed for comparison (control group). In the control group, exercise improved cardiac output and mean velocity of circumferential fiber shortening (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic performance of the biventricular bypass system operated in an independent variable rate mode

The present study was undertaken to determine whether a biventricular bypass system operated in an independent variable rate (VR) mode can maintain the entire circulation. Two pusher-plate pumps which incorporated the Hall effect position sensors were used to bypass the right and left ventricles in 10 sheep under fibrillation. The flow distributions of the pump output to the carotid and renal arteries were investigated every 6 h using ultrasonic blood flow meters for 24 h in 5 animals, and the controllability of the VR mode was evaluated in 5 long-term experiments. The carotid artery flow ratio to the pump output decreased significantly from 4.7 +/- 0.8% before the bypass to 2.7 +/- 0.9% after 24 h. However, the renal artery flow ratio did not change throughout the experiments. In the long-term experiments, the animals were kept alive from 3 to 48 days (mean 15.6 days). The mean pump output had been maintained at more than 90 ml/min/kg for the first 7 days. After the surgery, the pump driving conditions were not readjusted in any experiment. The results indicate that the biventricular bypass system operated in the independent VR mode automatically maintains the entire circulation at a satisfactory level.

Angiokeratoma of the clitoris: a subtype of angiokeratoma vulvae

A 24-year-old married woman had an angiokeratoma of the vulva measuring 3 x 3 x 4 mm localized at the clitoris. The nodule was noticed when she was pregnant with her first child. This tumor grew with occasional tenderness and bleeding during pregnancy, but its size did not change after delivery. The growth of this tumor might be attributable to an increase in venous pressure or serum progesterone levels; therefore this disorder might be classified as a subtype of angiokeratoma of the vulva. This is the first case of angiokeratoma localized at the clitoris.

Efficacy of oral administration of live herpes simplex virus type 1 as a vaccine

Mice given herpes simplex virus type 1 (HSV-1) (Miyama +GC strain) intragastrically via a stainless-steel cannula were rendered immune to subsequent lethal intraperitoneal (i.p.) challenge with HSV-1. The orally administered HSV-1 was completely inactivated in the stomach within a few minutes of inoculation. However, systemic immunity was established 14 days after oral inoculation with the virus and retained for up to 6 months. The mechanisms of establishing systemic immunity were investigated by means of adoptive transfer comparisons. When splenic cells from HSV-1-immunized mice were transplanted into nonimmunized mice, all of the recipient mice survived after a lethal i.p. challenge with the virus. Immunity was not established in antithymocyte serum-treated mice or by transfer of serum from immunized to nonimmunized mice. In addition, all HSV-1-immunized mice died after lethal challenge with HSV-2 and influenza virus A. These findings suggest that the immunity was virus specific, with T lymphocytes playing a major role in its establishment. The present study therefore supports the possibility of oral immunization with live HSV-1 as a vaccine.

Mechanical circulatory support with a centrifugal pump after open heart surgery

Since December 1988, a centrifugal ventricular assist device (VAD) was used to support the circulation in 5 patients who could not be weaned from cardiopulmonary bypass (CPB) or developed cardiogenic shock after removal from CPB. Three patients required a left VAD, one needed a right VAD. One patient had biventricular support using a centrifugal left VAD and a diaphragm type right VAD. The duration of the centrifugal VAD support ranged from 6 to 136 (mean 72)h. All patients were weaned from the VAD, but only 2 patients were discharged from the hospital. Two patients died of multiple organ failure, and one died of cardiogenic shock caused by intractable arrhythmia. Infection occurred in all non-survivors, and 2 of them developed renal failure. We conclude that the centrifugal VAD is effective to recover a failing ventricle. The factors related to the unsuccessful recovery were delayed start of the VAD support and major complications such as infection as infection and renal failure.

[Main pulmonary artery injury caused by golf-swing]

A 87-year-old man suddenly complained of dyspnea and fell into shock just after tee-shot. UCG revealed a large amount of pericardial effusion and good wall motion of the heart. Enhanced CT scan didn't prove any intimal flaps in the aorta. With cardiopulmonary bypass stand-by, we opened the pericardium and found a small laceration in the main pulmonary artery. The site of the laceration corresponded to a hard and sharp pericardial reflection ridge. We speculated that the difference of deceleration power between body and the heart resulted in pendulous or torsional motion of his heart. Supposedly the mutual actions between sharp pericardial reflection ridge and strange motion of the heart injured his main pulmonary artery.

[MRI of brain abscesses]

Four cases of brain abscess were examined on 1.5T MR and their findings were evaluated retrospectively. Preoperative cases had relatively characteristic findings, such as 1) peripheral edema producing hypointensity on T1-weighted images (T1WI) and hyperintensity on T2-weighted images (T2WI); 2) central necrosis with abscess fluid hypointense relative to white matter on T1WI and hyperintense on T2WI; 3) abscess rim iso- to hypointense on T2WI. Gd-DTPA enhanced T1WI carried further information; comparison of iso- to hypointense rim on T2WI (abscess rim) and enhanced area by Gd-DTPA on T1WI suggested that the former represented zone of macrophage infiltration.

[Repetitive rhythmic spikes in epileptic children]

Repetitive rhythmic spikes (RRSs') sometimes appear periodically for 0.2-2.0 seconds at localized in epileptic children. We selected 11 patients (male 6, female 5) with RRSs for this study. Ages were 3-15 years (average 10.7 years). We counted the number of spikes which were recorded on the scalp EEG. The duration of RRSs and the differences of amplitude between large and small spikes on monopolar montages were examined. We also studied the appearance of spikes under different recording conditions; waking and sleep stages, photic stimulation and hyperventilation. Furthermore, we made two dimensional joint-dot plotting for the interval between repetitive spikes. RRSs were classified into two groups. In the first group, joint-dots of RRSs were locally observed between 0.2-0.8 sec. In the second, they were disseminated between 0.2-2.0 sec. In two groups, spikes were mainly observed in the sleep EEG (stage 1). The average number of spikes in the first group was 18.7/min, and that in the second was 25.7/min. The average difference of the amplitude between large and small spikes was 103 microV in the first group, and 88 microV in the second group. The average duration of spikes was 54.2 msec in the first group and 62.4 msec in the second group. From these results, it was assumed that some of spikes in the first group occurred in the surface of the cortex and that some of spikes in the second group were projected from the deep region in the cortex.

Development of the E4T electrohydraulic total artificial heart

A completely implantable total artificial heart (TAH) is being developed based on many years of research performed at the Cleveland Clinic Foundation and Nimbus, Inc. The pumping unit consists of biolized surface-treated pusher plate blood pumps powered by an interventricular electrohydraulic energy converter. A variable volume device references the back side of the pusher plates to lung pressure. Electrical power is supplied by a transcutaneous energy transmission system, integrated with a wearable external battery pack. An implanted internal battery provides back-up power. System design and optimization efforts have resulted in a compact pumping unit package and an overall TAH that meets anatomic, physiologic, and engineering requirements. Overall pumping unit basic dimensions are 98 mm diameter and 80 mm thick. The blood pumps have a truncated conical shape and are separated by a thin interventricular septum 21 mm thick. Theoretical stroke volume is 64 ml, and maximum stroke length is 13.2 mm. Normal pump operation is at 90% of full stroke, which yields a net output of 53 ml, with valve regurgitation taken into account.

[Intracranial multiple granuloma preceded by rheumatic disease--a case report]

In 1980, a 38-year-old man had remittent fever, swelling and arthralgia of the knee, ankle and wrist joints, as well as visual disturbance due to bilateral iritis. On his admission to our hospital, his laboratory data showed neutrophilia, normocytic normochromic anemia, hepatomegaly, hepatocellular damage, and a strongly positive RA test. All the microbiological examinations were negative. Thirty mg of prednisolone improved his symptoms and abnormal laboratory findings. Due to persistent mild arthralgia, he had continued to take 5-10 mg of prednisolone and analgesics until 1985 when he was readmitted to our hospital. In 1983, he began to complain of a steady pain around his left eye, and he sometimes had double vision. In 1985, he began to complain of decreasing left visual acuity and sensory disturbance in his left face in addition to pain in and around the eye. On his 2nd admission to our hospital, the neurological examination revealed involvement of the 2nd and 3rd cranial nerves and the 1st branch of the 5th cranial nerves of the left side. Laboratory data showed a positive RA test with RAHA titer at 1:320 and IgM at 216 mg/dl, but he had no joint deformities. The computed tomography (CT) of the brain demonstrated a high density mass of his left cavernous sinus extending to the left orbital apex. The prescription of the high dose of prednisolone (100 mg/day) relieved ophthalmic pain and improved visual acuity and neurological involvement within a week. Prednisolone was then gradually decreased to 10 mg. In 1986, he had partial and complex partial seizures.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mesenteric hematoma; a pediatric case]

A 3-Year-old girl was admitted to National Beppu Hospital due to abdominal mass. US examination revealed cystic mass with multiple scattered nonreverberatory echoes in right upper abdomen. CT examination revealed almost homogeneous mass (29-31 H.U.) with a few internal components (36-42 H.U.). US and CT were useful methods for diagnosis of mesenteric hematoma.

Suppression of actively induced and passively transferred experimental allergic neuritis by cyclosporin A

The effect of cyclosporin A (CyA) on experimental allergic neuritis (EAN) was examined. CyA suppressed the development of actively induced EAN. The earlier treatment with CyA was begun, the more effective was its effect. CyA was effective even after the development of clinical signs. In actively induced EAN, cessation of CyA treatment lead to the development of EAN. However, in passively induced EAN, it did not. We could not find any differences in the distribution of infiltrating T cell subsets between the control group and the CyA-treated group.