Successful extracorporeal membrane oxygenation treatment of catecholamine-induced cardiomyopathy-associated pheochromocytoma: a case report

The main mechanism of Takotsubo cardiomyopathy (TCM) is catecholamine-induced acute myocardial stunning. Pheochromocytoma, a catecholamine-secreting tumor, can cause several cardiovascular complications, including hypertensive crisis, myocardial infarction, toxic myocarditis, and TCM. A 29-year-old woman presented to our hospital with general weakness, vomiting, dyspnea, and chest pain. The patient was nullipara, 28 weeks' gestation, and had a cachexic morphology. Her cardiac enzyme levels were elevated and bedside echocardiography showed apical akinesia, suggesting TCM. The next day, she could not feel the fetal movement, and an emergency cesarean section was performed. After delivery, the patient experienced cardiac arrest and was transferred to the intensive care unit for cardiopulmonary resuscitation (CPR). Spontaneous circulation returned after 28 minutes of CPR, but cardiogenic shock continued, and extracorporeal membrane oxygenation (ECMO) was initiated. On the third day of ECMO maintenance, left ventricular ejection fraction improved and blood pressure stabilized. On the eighth day after ECMO insertion, it was removed. However, complications of the left leg vessels occurred, and several surgeries and interventions were performed. A left adrenal gland mass was found on computed tomography and was removed while repairing the leg vessels. Pheochromocytoma was diagnosed and left adrenalectomy was performed.

Artificial intelligence-enhanced 12-lead electrocardiography for identifying atrial fibrillation during sinus rhythm (AIAFib) trial: protocol for a multicenter retrospective study

Introduction

Atrial fibrillation (AF) is the most common arrhythmia, contributing significantly to morbidity and mortality. In a previous study, we developed a deep neural network for predicting paroxysmal atrial fibrillation (PAF) during sinus rhythm (SR) using digital data from standard 12-lead electrocardiography (ECG). The primary aim of this study is to validate an existing artificial intelligence (AI)-enhanced ECG algorithm for predicting PAF in a multicenter tertiary hospital. The secondary objective is to investigate whether the AI-enhanced ECG is associated with AF-related clinical outcomes.

Methods and analysis

We will conduct a retrospective cohort study of more than 50,000 12-lead ECGs from November 1, 2012, to December 31, 2021, at 10 Korean University Hospitals. Data will be collected from patient records, including baseline demographics, comorbidities, laboratory findings, echocardiographic findings, hospitalizations, and related procedural outcomes, such as AF ablation and mortality. De-identification of ECG data through data encryption and anonymization will be conducted and the data will be analyzed using the AI algorithm previously developed for AF prediction. An area under the receiver operating characteristic curve will be created to test and validate the datasets and assess the AI-enabled ECGs acquired during the sinus rhythm to determine whether AF is present. Kaplan-Meier survival functions will be used to estimate the time to hospitalization, AF-related procedure outcomes, and mortality, with log-rank tests to compare patients with low and high risk of AF by AI. Multivariate Cox proportional hazards regression will estimate the effect of AI-enhanced ECG multimorbidity on clinical outcomes after stratifying patients by AF probability by AI.

Discussion

This study will advance PAF prediction based on AI-enhanced ECGs. This approach is a novel method for risk stratification and emphasizes shared decision-making for early detection and management of patients with newly diagnosed AF. The results may revolutionize PAF management and unveil the wider potential of AI in predicting and managing cardiovascular diseases.

Ethics and dissemination

The study findings will be published in peer-reviewed publications and disseminated at national and international conferences and through social media. This study was approved by the institutional review boards of all participating university hospitals. Data extraction, storage, and management were approved by the data review committees of all institutions.

Clinical Trial Registration

[cris.nih.go.kr], identifier (KCT0007881).

Natural Variations in the Benthic Environment and Bacterial Communities of Coastal Sediments around Aquaculture Farms in South Korea

The aim of this study was to examine the possible seasonal variations in the nutrients (dissolved inorganic nitrogen-DIN and phosphorus) and benthic bacterial communities in marine aquaculture surrounding sediments. The study areas were Geoje, Tongyeong, and Changwon bays in Korea, which are famous for oysters (Magallana gigas), Halocynthia roretzi, and warty sea squirt (Styela clava) farming, respectively. The study sites included semi-enclosed coastal areas with a low seawater exchange rate. Subtidal sediment samples were collected seasonally from the area surrounding the aquacultures between April and December 2020. Seasonal variations in nutrients were observed, with the highest concentration of DIN in August. For phosphorus, site-specific variations were also observed. To investigate the variations in benthic bacterial communities, the advanced technique of 16S rRNA gene amplicon sequencing was applied, and the results indicated a seasonal variation pattern and predominance of Proteobacteria (59.39-69.73%), followed by Bacteroidetes (6.55-12.85%) and Chloroflexi (2.04-4.50%). This study provides a reference for future studies on natural variations in the benthic environment and bacterial communities in the areas surrounding aquacultures.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12088-023-01067-8.

Impact of multivessel versus single-vessel disease on the association between low diastolic blood pressure and mortality after acute myocardial infarction with revascularization

BACKGROUND

Previous studies demonstrated a J-shaped relationship between low diastolic blood pressure (DBP) and adverse clinical outcomes in patients with acute myocardial infarction (AMI) that was sensitive to revascularization. Hypothesized herein, was that this relationship differs between patients with multivessel disease (MVD) and those with single-vessel disease due to differing degrees of myocardial ischemic burden.

METHODS

Among 9,983 AMI patients from the Korea Acute Myocardial Infarction Registry database who underwent percutaneous coronary intervention and were followed up for a median duration of 3.2 years, average on-treatment DBP was calculated at admission, discharge, and every scheduled visit and divided into these parameters: < 70 mmHg, 70-74 mmHg, 75-79 mmHg, and ≥ 80 mmHg. The relationship between average on-treatment DBP and clinical outcomes including all-cause death, cardiovascular (CV) death, non-CV death, and hospitalization for heart failure was analyzed using the Cox regression models adjusted for clinical covariates.

RESULTS

In patients with MVD, all-cause death (hazard ratio [HR]: 1.47; 95% confidence interval [CI]: 1.06-2.04, p = 0.012) and CV death (HR: 1.59; 95% CI: 1.02-2.46, p = 0.027) were significantly increased in patients with a DBP < 70 mmHg, showing a J-shaped relationship. However, these findings were not significant for single-vessel disease. On a sensitivity analysis excluding subjects with a baseline SBP < 120 mmHg, an increased risk of a low DBP < 70 mmHg remained in MVD.

CONCLUSIONS

The J-shaped relationship between low DBP and adverse clinical outcomes in AMI patients who underwent revascularization persisted in MVD, which has a high ischemic burden. These high-risk patients require cautious treatment.

Simultaneous Occurrence of Immune-Mediated Thrombocytopenia and Myocarditis After mRNA-1273 COVID-19 Vaccination: A Case Report

With the global spread of severe acute respiratory syndrome coronavirus 2, several vaccines were developed; messenger RNA (mRNA) vaccines have recently been widely used worldwide. However, the incidence of myocarditis following mRNA vaccination is increasing; although the cause of myocarditis has not yet been clearly identified, it is presumed to be caused by a problem in the innate immune system. Immune-mediated thrombocytopenia (ITP) after vaccination is rare but has been reported and is also assumed to occur by the same mechanism. We report the first case of simultaneous myocarditis and ITP after mRNA vaccination. A 38-year-old woman presented with chest pain, mild dyspnea, and sweating after vaccination with mRNA-1273 vaccine (Moderna) 4 days prior to admission. Upon admission to the emergency department, cardiac enzymes were elevated; blood test performed 5 months ago showed normal platelet count, but severe thrombocytopenia was observed upon admission. After administration of intravenous immunoglobulin, the platelet count improved; subsequently, myocarditis was observed on endomyocardial biopsy. Thus, myocarditis and ITP were judged to have occurred simultaneously due to the expression of the innate immune system markers after mRNA vaccination. The patient was discharged on day 6 of admission.

Acute Physiological Response of Live-Fire Simulation Activities Affecting Cardiovascular Health in Live-Fire Instructors: A Randomized Controlled Simulation Study

OBJECTIVES

This study aimed to assess acute physiological response of fire suppression simulation affecting cardiovascular health during repeated bouts of simulation.

METHODS

Fifteen live-fire instructors were randomly divided into three groups according to fire suppression simulation frequency. Vital signs, biomarkers, and heart rate variability (HRV) were measured before and after simulation.

RESULTS

Vital signs increased immediately after fire simulation and returned to the normal range after 2 h. Most biomarker levels were changed within the normal ranges 72 h after the simulation training. However, one of the HRV frequency domains, high frequency power, was severely suppressed after 1 h and tended to recover after 2 h of simulation (P < 0.05).

CONCLUSIONS

Vital signs and their biomarkers were changed within the normal range regardless of the number of bouts of fire suppression simulations. HRV could be used to assess the effects of fire suppression simulation on cardiovascular health.

The Effects of Single Nucleotide Polymorphisms in Korean Patients with Early-onset Atrial Fibrillation after Catheter Ablation

BACKGROUND

This study evaluated the status of single nucleotide polymorphisms (SNPs) in Korean patients with early-onset (< 40 years old) atrial fibrillation (AF) and their effects on the outcome after catheter ablation.

METHODS

A total of 89 patients (35.7 ± 3.7 years, 81 males) with drug-refractory AF (paroxysmal 64.0%) who underwent catheter ablation were included in this study. Sixteen SNPs, including rs13376333, rs10465885, rs10033464, rs2200733, rs17042171, rs6843082, rs7193343, rs2106261, rs17570669, rs853445, rs11708996, rs6800541, rs251253, rs3807989, rs11047543, and rs3825214, were genotyped. Serial 48-hour Holter monitoring was conducted to detect AF recurrences during long-term follow up.

RESULTS

Wild-type genotypes of rs11047543 (GG; 26/69 [37.7%] vs. GA; 13/18 [72.2%] vs. AA; 0/0 [0%], P = 0.009) and rs7193343 (CC; 0/7 [0%] vs. CT; 22/40 [55.0%] vs. TT; 18/41 [43.9%], P = 0.025) and the homozygous variant of rs3825214 (AA; 16/31 [51.6%] vs. AG; 22/43 [51.2%] vs. GG; 2/13 [15.4%], P = 0.056) were significantly associated with a lower rate of late recurrence. When the patients were assigned to four groups according to the number of risk alleles (n = 0-3), there were significant differences in recurrence rate (n = 0; 0/3 vs. n = 1; 2/13 [15.4%] vs. n = 2; 24/52 [46.2%] vs. n = 3; 13/17 [76.5%], P = 0.003). When correcting for multiple variables, rs11047543 (hazard ratio [HR], 2.723; 95% confidence interval [CI], 1.358-5.461; P = 0.005) and the number of risk alleles (HR, 2.901; 95% CI, 1.612-5.219; P < 0.001) were significantly associated with recurrence of AF after catheter ablation.

CONCLUSION

Polymorphisms on rs7193343 closest to ZFHX3 (16q22), rs3825214 near to TBX5 (12q24), and rs11047543 near to SOX5 (12p12) modulate the risk for AF recurrence after catheter ablation. The number of risk alleles of these 3 SNPs was an independent predictor of recurrence during long-term follow up in Korean patients with early-onset AF.

Comparison between linear and focal ablation of complex fractionated atrial electrograms in patients with non-paroxysmal atrial fibrillation: a prospective randomized trial

AIMS

Findings regarding efficacy of substrate modification for non-paroxysmal atrial fibrillation (AF) are inconsistent. We prospectively compared clinical outcomes of complex fractionated atrial electrogram (CFAE)-guided focal ablation (CFA) and CFAE-guided linear ablation (CLA) in patients with non-paroxysmal AF.

METHODS AND RESULTS

We randomized 150 patients with non-paroxysmal AF into CFA and CLA groups in a 1:1 ratio. Complex fractionated atrial electrogram distribution was evaluated using an automated algorithm of a three-dimensional mapping system. After pulmonary vein isolation (PVI), CFAE-guided ablation was performed in the left atrium and then in the right atrium (RA). When compared with conventional CFA, CLA was performed based on conventional lines, with additional lines. Atrial fibrillation was not induced after PVI alone or with cavotricuspid isthmus ablation in 20.7% of patients. To achieve the endpoint, additional CFAE-guided RA ablation was required in 42.7% and 36.0% of patients undergoing CFA and CLA, respectively (P = 0.403). Atrial fibrillation was terminated during CFAE-guided ablation in 72.9% and 75.0% of patients undergoing CFA and CLA, respectively (P = 0.792). Termination of atrial tachycardia (AT) or non-inducibility of AF/AT was achieved in 61.3% and 68.0% of patients undergoing CFA and CLA, respectively (P = 0.393). The CLA group showed decreased 1-year freedom from AF/AT recurrence (60.0%, CFA vs. 47.3%, CLA; log rank P = 0.085), but no significant difference throughout the follow-up (22.2 ± 21.0 months) (67.1%, CFA vs. 68.9%, CLA; log rank P = 0.298).

CONCLUSION

Long-term efficacy of CFAE-guided ablation was unaffected by the ablation technique in patients with non-paroxysmal AF.

Atrial Substrate Underlies the Recurrence after Catheter Ablation in Patients with Atrial Fibrillation

Prediction of recurrences after catheter ablation of atrial fibrillation (AF) remains challenging. We sought to investigate the long-term outcomes after AF catheter ablation. A total of 2221 consecutive patients who underwent catheter ablation for symptomatic AF were included in this study (mean age 55 ± 11 years, 20.3% women, and 59.0% paroxysmal AF). Extensive ablation, in addition to circumferential pulmonary vein isolation, was more often accomplished in patients with non-paroxysmal AF than in those with paroxysmal AF (87.4% vs. 25.3%, p < 0.001). During a median follow-up of 54 months, sinus rhythm (SR) was maintained in 67.1% after index procedure. After redo procedures in 418 patients, 83.3% exhibited SR maintenance. Recurrence rates were similar for single and multiple procedures (17.4% vs. 16.7%, p = 0.765). Subanalysis showed that the extent of late gadolinium enhancement (LGE), as assessed by cardiac magnetic resonance, is greater in patients with recurrence than in those without recurrence (36.2 ± 23.9% vs. 21.8 ± 13.7%, p < 0.001). Cox-regression analysis revealed that non-paroxysmal AF (hazard ratio (HR) 2.238, 95% confidence interval (CI) 1.905–2.629, p < 0.001), overweight (HR 1.314, 95% CI 1.107–1.559, p = 0.020), left atrium dimension ≥ 45 mm (HR 1.284, 95% CI 1.085–1.518, p = 0.004), AF duration (HR 1.020 per year, 95% CI 1.006–1.034, p = 0.004), and LGE ≥ 25% (HR 1.726, 95% CI 1.330–2.239, p < 0.001) are significantly associated with AF recurrence after catheter ablation. This study showed that repeated catheter ablation improves the clinical outcomes of patients with non-paroxysmal AF, suggesting that AF substrate based on LGE may underpin the mechanism of recurrence after catheter ablation.

Lack of prognostic significance for major adverse cardiac events of soluble suppression of tumorigenicity 2 levels in patients with ST-segment elevation myocardial infarction

BACKGROUND

Elevation of soluble suppression of tumorigenicity 2 (sST2) is associated with cardiac fibrosis and hypertrophy. Under investigation herein, was whether sST2 level is associated with major adverse cardiac events (MACE) and left ventricular (LV) remodeling after primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI).

METHODS

In total, this study included 184 patients who underwent successful primary PCI. A subsequent guideline-based medical follow-up was included (61.4 ± 11.8 years old, 85% male, 21% with Killip class ≥ I). sST2 concentration correlations with echocardiographic, angiographic, laboratory parameters, and clinical outcomes in STEMI patients were evaluated.

RESULTS

The median sST2 level was 60.3 ng/mL; 6 (3.2%) deaths occurred within 1 year. The sST2 level correlated with LV ejection fraction (LVEF) changes from baseline to 6 months (r= -0.273; p = 0.006) after adjustment for echocardiographic parameters including wall motions score index (WMSI). Recovery of LVEF at 6 months was highest in the tertile 1 group (Δ6 months - baseline LVEF; tertile 1, p = 0.001; tertile 2, p = 0.319; tertile 3, p = 0.205). The decrease in WMSI at 6 months was greater in the tertiles 1 and 2 groups than in the tertile 3 group (Δ6 months - baseline WMSI; tertile 1, p = 0.001; tertile 2, p = 0.013; tertile 3, p = 0.055). There was no association between sST2 levels and short-term (log rank p = 0.598) and long-term (p = 0.596) MACE.

CONCLUSIONS

sST2 concentration have predictive value for LV remodeling on echocardiography in patients with STEMI who underwent primary PCI. However, sST2 concentration was not associated with short-term and long-term MACE.

The extent of complex fractionated atrial electrograms in the left atrium reflects age-related electrical remodeling in patients with persistent atrial fibrillation

BACKGROUNDS

Alterations in the atrial structure and function associated with aging result in electric remodeling of the left atrium (LA) in patients with persistent atrial fibrillation (AF). We performed this study to evaluate the influence of age on electric remodeling as assessed by the extent of complex fractionated atrial electrograms (CFAEs) in the LA.

METHODS

A total of 122 patients (mean age, 55.9 ± 10.4 years; range, 31-79; 106 males) who underwent catheter ablation for drug-refractory persistent AF were included in the study. The extent of CFAE was measured by CFAE area and its index (CFAE area/LA surface area × 100) using three-dimensional automated software of NavX system.

RESULTS

The mean value of CFAE extent was significantly different among age groups; the CFAE area decreased significantly with increasing age (30 seconds [43.2 ± 14.5 mm2] vs 40 seconds [28.6 ± 6.0 mm2] vs 50 seconds [22.8 ± 3.4 mm2] vs 60 seconds [15.3 ± 2.6 mm2] vs 70 seconds [10.3 ± 3.2 mm2]; P = .010). A similar significant decrease was observed in the CFAE area index (30 seconds [22.9 ± 7.4] vs 40 seconds [14.9 ± 3.4] vs 50 seconds [10.4 ± 1.6] vs 60 seconds [6.9 ± 1.2] vs 70 seconds [4.6 ± 1.4]; P = .002). Age had a significantly negative correlation with the CFAE area (r = -0.322, P < .001) and CFAE area index (r = -0.357, P < .001).

CONCLUSIONS

Increasing age is associated with electric remodeling in the LA characterized by a decrease in the extent of CFAE area and its index.

P3453Gender difference in impact of ischemic heart disease on long-term outcome in patients with heart failure reduced ejection fraction

Background

Ischemic heart disease (IHD) is a major underlying etiology in patients with heart failure (HF). Although the impact of IHD on HF is evolving, there is a lack of understanding of how IHD affects long-term clinical outcomes and uncertainty about the role of IHD in determining the risk of clinical outcomes by gender.

Purpose

This study aims to evaluate the gender difference in impact of IHD on long-term clinical outcomes in patients with heart failure reduced ejection fraction (HFrEF).

Methods

Study data were obtained from the nationwide registry which is a prospective multicenter cohort and included patients who were hospitalized for HF composed of 3,200 patients. A total of 1,638 patients with HFrEF were classified into gender (women 704 and men 934). The primary outcome was all-cause death during follow-up and the composite clinical events of all-cause death and HF readmission during follow-up were also obtained. HF readmission was defined as re-hospitalization because of HF exacerbation.

Results

133 women (18.9%) were died and 168 men (18.0%) were died during follow-up (median 489 days; inter-quartile range, 162–947 days). As underlying cause of HF, IHD did not show significant difference between genders. Women with HFrEF combined with IHD had significantly lower cumulative survival rate than women without IHD at long-term follow-up (74.8% vs. 84.9%, Log Rank p=0.001, Figure 1). However, men with HFrEF combined with IHD had no significant difference in survival rate compared with men without IHD (79.3% vs. 83.8%, Log Rank p=0.067). After adjustment for confounding factors, Cox regression analysis showed that IHD had a 1.43-fold increased risk for all-cause mortality independently only in women. (odds ratio 1.43, 95% confidence interval 1.058–1.929, p=0.020). On the contrary to the death-free survival rates, there were significant differences in composite clinical events-free survival rates between patients with HFrEF combined with IHD and HFrEF without IHD in both genders.

Figure 1

Conclusions

IHD as predisposing cause of HF was an important risk factor for long-term mortality in women with HFrEF. Clinician need to aware of gender-based characteristics in patients with HF and should manage and monitor them appropriately and gender-specifically. Women with HF caused by IHD also should be treated more meticulously to avoid a poor prognosis.

Acknowledgement/Funding

None

P2860The effects of single nucleotide polymorphisms in Korean patients with early-onset lone atrial fibrillation after catheter ablation

Background

The status of SNPs among patients with extremely early-onset lone AF and the association with outcome of catheter ablation has not been evaluated before. This study evaluated the status of single nucleotide polymorphisms (SNPs) in Korean patients with early-onset (<40 years old) lone AF and effects on the outcome after catheter ablation.

Methods

A total of 89 consecutive patients (mean age 35.7±3.7 years, 81 males) with drug-refractory AF (paroxysmal 64.0%) who underwent catheter ablation were included. Sixteen SNPs including rs13376333, rs10465885, rs10033464, rs2200733, rs17042171, rs6843082, rs7193343, rs2106261, rs17570669, rs853445, rs11708996, rs6800541, rs251253, rs3807989, rs11047543 and rs3825214 were genotyped. Serial 48-day Holter electrocardiographic recordings were acquired to detect AF recurrences during long-term follow up.

Results

Wild type of rs7193343 [CC; 0/7 (0%) vs. CT; 22/40 (55.0%) vs. TT; 18/41 (43.9%), p=0.025] and rs11047543 [GG; 26/69 (37.7%) vs. GA; 13/18 (72.2%) vs. AA; 0/0, p=0.009] and homozygous variant of rs3825214 [AA; 16/31 (51.6%) vs. AG; 22/43 (51.2%) vs. GG; 2/13 (15.4%), p=0.05] were significantly associated with lower rate of late recurrence. When the patients were assigned to four groups according to the number of risk alleles (n=0–3), Kaplan-Meier survival analysis showed incremental prognostic value according to the number of variant alleles (p=0.002) (Figure 1).

Figure 1

Conclusions

Polymorphisms on rs7193343, rs3825214 and rs11047543 modulate the risk for AF recurrence after catheter ablation during long term follow up in Korean patients with early-onset lone AF.

Acknowledgement/Funding

Korean Society of Cardiology

Long-Term Clinical Comparison of Procedural End Points After Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation: Elimination of Nonpulmonary Vein Triggers Versus Noninducibility

BACKGROUND

Pulmonary vein isolation (PVI) is effective for maintenance of sinus rhythm in 50% to 75% of patients with paroxysmal atrial fibrillation, and it is not uncommon for patients to require additional ablation after PVI. We prospectively evaluated the relative effectiveness of 2 post-PVI ablation strategies in paroxysmal atrial fibrillation.

METHODS AND RESULTS

A total of 500 patients (mean age, 55.7±11.0 years; 74.6% male) were randomly assigned to undergo ablation by 2 different strategies after PVI: (1) elimination of non-PV triggers (group A, n=250) or (2) stepwise substrate modification including complex fractionated atrial electrogram or linear ablation until noninducibility of atrial tachyarrhythmia was achieved (group B, n=250). During a median follow-up of 26.0 months, 75 (32.2%) patients experienced at least 1 episode of recurrent atrial tachyarrhythmia after the single procedure in group A compared with 105 (43.8%) patients in group B (P value in log-rank test of Kaplan-Meier analysis: 0.012). Competing risk analysis showed that the cumulative incidence of atrial tachycardia was significantly higher in group B compared with group A (P=0.007). With the exception of total ablation time, there were no significant differences in fluoroscopic time or procedure-related complications between the 2 groups.

CONCLUSIONS

Elimination of triggers as an end point of ablation in patients with paroxysmal atrial fibrillation decreased long-term recurrence of atrial tachyarrhythmia compared with a noninducibility approach achieved by additional empirical ablation. The post-PVI trigger test is thus a better end point of ablation for paroxysmal atrial fibrillation.

Long-term clinical outcomes of catheter ablation in patients with atrial fibrillation predisposing to tachycardia-bradycardia syndrome: a long pause predicts implantation of a permanent pacemaker

Background

There is a controversy as to whether catheter ablation should be the first-line therapy for tachycardia-bradycardia syndrome (TBS) in patients with atrial fibrillation (AF).

Methods

We aimed to investigate long-term clinical outcomes of catheter ablation in patients with TBS and AF. Among 145 consecutive patients who underwent catheter ablation of AF with TBS, 121 patients were studied.

Results

Among 121 patients, 11 (9.1%) received implantation of a permanent pacemaker during a mean 21 months after ablation. Length of pause on termination of AF was significantly greater in patients who received pacemaker implantation after ablation than those who underwent ablation only (7.9 ± 3.5 vs. 5.1 ± 2.1 s, p < 0.001). Using a multivariate model, a long pause of 6.3 s or longer after termination of AF was associated with the requirement to implant a permanent pacemaker after ablation (HR 1.332, 95% CI 1.115-1.591, p = 0.002).

Conclusion

This study suggests that, in patients with AF predisposing to TBS, long pause on termination of AF predicts the need to implant a permanent pacemaker after catheter ablation.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0834-0) contains supplementary material, which is available to authorized users.

Bursting Fracture of Balloon-Expandable Stent and Pseudoaneurysm Formation in the Left Common Iliac Artery and Endovascular Treatment With Graft Stent

Purpose:

To report successful endovascular treatment of a previously implanted balloon-expandable stent bursting fracture with concomitant large pseudoaneurysm formation in the left common iliac artery (LCIA).

Case Report:

A 72-year-old man had been previously treated with balloon-expandable stents for severe stenotic lesion in the LCIA and left external iliac artery. Seven years later, the patient complained pain in both lower legs and back. Angiography demonstrated a 3.5-cm-sized pseudoaneurysm in the LCIA with embedded metal fragments around the lesion. An endovascular treatment was selected using a limb extension graft for endovascular aortic aneurysm repair. The device was successfully deployed, and no endoleak was observed. At 1-month follow-up, computed tomography scan confirmed patency of the implanted stent graft devices in the LCIA and the absence of any endoleak.

Conclusion:

Endovascular approach using a limb extension graft stent for endovascular aortic aneurysm repair can be used for treating stent fracture-related pseudoaneurysm in the common iliac artery.

Gender-related Difference in Clinical Outcome of the Patient with Atrial Fibrillation after Radiofrequency Catheter Ablation

Background and Objectives

Previous studies provided controversial result about gender differences in the clinical outcome after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). We assessed pure difference after adjustment of referral bias.

Methods

The clinical outcomes including freedom from AF/atrial tachycardia (AT) recurrence after RFCA were compared between women and men in 1:1 confounding factor matching with age, AF type, periods since diagnosis (±12 months), and procedure era (±12 months). Subgroup analysis was performed in categories defined by AF type and age of 55 (mean menopausal age of Asian women).

Results

Total 1,875 patients with AF underwent 2,307 RFCA between January 1998 and May 2014 in a single center. Total 367 women (19.6%, 59±10 years) who had undergone first ablation were included. Women had larger left atrial diameter index (26±4 vs. 23±4 mm/m²; p<0.001) and higher peri-procedural complications (9.2% vs. 4.9%; p=0.030) compared to men. The freedom from AF/AT recurrence after RFCA was not different between both groups (71% vs. 76%; log-rank p=0.131, mean follow-up of 55 months). Women with non-paroxysmal AF (PAF) had significantly worse outcome (54% vs. 69%; p=0.014), especially in subgroup with age ≤55 (48% vs. 71%; p=0.010). In multivariate analysis, female gender was an independent predictor of recurrence in subgroup with non-PAF and age ≤55 (hazard ratio [HR], 2.539; 95% confidence interval [CI], 1.112–5.801; p=0.027).

Conclusions

The clinical outcome after RFCA was not different between both genders regardless of referral bias. However, the gender difference became evident in patients under 55 years with non-PAF.

Ethanol Infusion in the Vein of Marshall in a Patient with Persistent Atrial Fibrillation

We report the case of a 64-year-old male with persistent atrial fibrillation (AF) terminated by ethanol infusion into vein of Marshall as add-on therapy. Three-dimensional automated complex fractionated atrial electrogram (CFAE) during AF revealed clustering of CFAE at perimitral isthmus (PMI) and its unipolar mapping showed rotor-like activation, which was suggested to be critical in the perpetuation of AF. AF was organized to atrial tachycardia (AT) by 100% ethanol infusion in the vein of Marshall. Adjunctive radiofrequency ablation at PMI successfully terminated AT and led to bidirectional block of PMI.

Feasibility and accuracy of a new mobile electrocardiography device, ER-2000(®), in the diagnosis of arrhythmia

BACKGROUND

We performed this study to evaluate the feasibility and accuracy of a new mobile electrocardiography (ECG) device, ER-2000(®), in detecting cardiac arrhythmia, by comparing it to a 12-lead ECG used as the gold standard.

METHODS

Mode 1 of ER-2000(®) was recorded using three electrodes with cables attached to the anterior chest wall, and mode 2 was recorded using the side chest channel and finger channel. Standard 12-lead ECG was used to record with a speed of 25 mm/s, simultaneously.

RESULTS

Seventeen patients with complaints of palpitation were enrolled. Twelve-lead ECG revealed normal sinus rhythm in three patients, sinus tachycardia in one, atrial fibrillation (AF) in two, atrial tachycardia (AT) in one, first degree atrioventricular block in one, pacing rhythm in two patients who underwent permanent pacemaker implantation, AF with intermittent ventricular pacing in one, complete right bundle branch block in one, J-wave elevation in one, narrow QRS tachycardia in one, atrial premature beat (APB) in one, ventricular premature beat (VPB) in one, and narrow QRS tachycardia with intermittent aberrant conduction in one. Rhythm diagnosis obtained by the two different modes of ER-2000(®) was correlated with that obtained by the 12-lead ECG in all patients except in one in whom ER-2000(®) showed one APB while 12-lead ECG showed sinus rhythm. R-R interval was accurately recorded despite the detailed morphology of QRS, and T-wave was somewhat modified with the use of ER-2000(®). A pacing blip detected by 12-lead ECG was not detected by ER-2000(®) despite a similar wide QRS duration in the paced QRS.

CONCLUSIONS

A rhythm strip obtained using ER-2000(®) is accurate in diagnosing arrhythmia, despite some differences in the detailed morphology of the QRS and T-wave, and the pacing spike compared to those obtained by the 12-lead ECG.

Unusual polymorphic ventricular tachycardia originating from the pulmonary artery

We report a case about a 27-year-old healthy young male who developed syncope during exercise, which was subsequently identified to be attributable to non-sustained polymorphic ventricular tachycardia (VT). Occurrence of polymorphic VT was neither related to a prolonged QT interval nor a fixed short coupling interval. Standard examinations including echocardiography, coronary angiography, isoproterenol infusion study, and cardiac MRI showed no structural heart disease. On the electrophysiology study, activation mapping revealed that a discrete potential preceded the premature ventricular complex (PVC) triggered polymorphic VT, which was recorded just above the pulmonary valve. After radiofrequency ablation at this area, PVC and polymorphic VT disappeared and did not recur after a 2 month follow up.

Spinal cord injury after conducting transcatheter arterial chemoembolization for costal metastasis of hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) has been used widely to treat patients with unresectable hepatocellular carcinoma. However, this method can induce various adverse events caused by necrosis of the tumor itself or damage to nontumor tissues. In particular, neurologic side effects such as cerebral infarction and paraplegia, although rare, may cause severe sequelae and permanent disability. Detailed information regarding the treatment process and prognosis associated with this procedure is not yet available. We experienced a case of paraplegia that occurred after conducting TACE through the intercostal artery to treat hepatocellular carcinoma that had metastasized to the rib. In this case, TACE was attempted to relieve severe bone pain, which had persisted even after palliative radiotherapy. A sudden impairment of sensory and motor functions after TACE developed in the trunk below the level of the sternum and in both lower extremities. The patient subsequently received steroid pulse therapy along with supportive care and continuous rehabilitation. At the time of discharge the patient had recovered sufficiently to enable him to walk by himself, although some paresthesia and spasticity remained.

Successful retrieval of a fractured and entrapped 0.035-inch terumo wire in the femoral artery using biopsy forceps

A 0.035-inch guide wire fracture and entrapment in a peripheral artery is a very rare complication, but when it does occur it may lead to life-threatening complications, such as perforation, thrombus formation, embolization, and subsequent limb ischemia. We describe our experience of successfully retrieving a fractured 0.035-inch Terumo guide wire in the external iliac artery using a biopsy forcep.

Tool Contact Acceleration Feedback for Telerobotic Surgery

Minimally invasive telerobotic surgical systems enable surgeons to perform complicated procedures without large incisions. Unfortunately, these systems typically do not provide the surgeon with sensory feedback aside from stereoscopic vision. We have, thus, developed VerroTouch, a sensing and actuating device that can be added to Intuitive Surgical's existing da Vinci S Surgical System to provide auditory and vibrotactile feedback of tool contact accelerations. These cues let the surgeon feel and hear contact with rough textures as well as the making and breaking of contact with objects and other tools. To evaluate the merits of this approach, we had 11 surgeons use an augmented da Vinci S to perform three in vitro manipulation tasks under four different feedback conditions: with no acceleration feedback, with audio feedback, with haptic feedback, and with both audio and haptic. Subjects expressed a significant preference for the inclusion of tool contact acceleration feedback, although they disagreed over which sensory modality was best. Other survey responses and qualitative written comments indicate that the feedback may have improved the subject's concentration and situational awareness by strengthening the connection between the surgeon and the surgical instruments. Analysis of quantitative task metrics shows that the feedback neither improves nor impedes the performance of the chosen tasks.

Cause of Chest Pain in a Patient with Previous Myocardial Infarction: Look Outside the Heart for Extracardiac Mass

We report a case of thymic carcinoma that was initially detected by echocardiography in an 80-year-old male who visited the emergency room for chest pain and had a history of myocardial infarction and percutaneous coronary intervention. Transthoracic echocardiography showed a huge extracardiac mass that was located in the anterior mediastinum and was diagnosed as a thymic carcinoma by biopsy.

The current state of robot assisted radical prostatectomy

AIM

The introduction of robotics in the operating room made its first major impact in the arena of prostate cancer. Robot assisted radical prostatectomy (RARP) is the most commonly performed surgery for prostate cancer in the United States.

METHODS

In this review article, we discuss the history of robotic prostatectomy as well as the benefits and drawbacks of the robotic surgical platform. Our University of Pennsylvania technique is described. Patient selection, peri-operative factors, oncological data, and functional outcomes specific to RARP are addressed.

RESULTS

While cost remains a valid criticism to the robotic technique, some of the additional expenditure is offset by improved convalescence, fewer medical complications, and decreased morbidity. Data with follow up approaching 10 years demonstrates equal if not superior outcomes with respect to continence, sexual and oncological factors.

CONCLUSION

The diligent efforts of many have led to the rapid evolution of robot assisted radical prostatectomy. There is a renewed interest in the anatomy, oncological outcomes, and functional consequences of prostatectomy. With technological advances occurring at an accelerating rate, the advances in surgery should be very exciting indeed.

Sublingual grass pollen immunotherapy is associated with increases in sublingual Foxp3-expressing cells and elevated allergen-specific immunoglobulin G4, immunoglobulin A and serum inhibitory activity for immunoglobulin E-facilitated allergen binding to B cells

BACKGROUND

The mechanisms of sublingual immunotherapy (SLIT) are less well understood than those of subcutaneous immunotherapy (SCIT).

OBJECTIVES

To determine the effects of grass-pollen SLIT on oral mucosal immune cells, local regulatory cytokines, serum allergen-specific antibody subclasses and B cell IgE-facilitated allergen binding (IgE-FAB).

METHODS

Biopsies from the sublingual mucosa of up to 14 SLIT-treated atopics, nine placebo-treated atopics and eight normal controls were examined for myeloid dendritic cells (mDCs) (CD1c), plasmacytoid dendritic cells (CD303), mast cells (AA1), T cells (CD3) and Foxp3 using immunofluorescence microscopy. IL-10 and TGF-beta mRNA expression were identified by in situ hybridization. Allergen-specific IgG and IgA subclasses and serum inhibitory activity for binding of allergen-IgE complexes to B cells (IgE-FAB) were measured before, during and on the completion of SLIT.

RESULTS

Foxp3(+) cells were increased in the oral epithelium of SLIT- vs. placebo-treated atopics (P=0.04). Greater numbers of subepithelial mDCs were present in placebo-treated, but not in SLIT-treated, atopics compared with normal controls (P=0.05). There were fewer subepithelial mast cells and greater epithelial T cells in SLIT- compared with placebo-treated atopics (P=0.1 for both). IgG(1) and IgG(4) were increased following SLIT (P<0.001). Peak seasonal IgA(1) and IgA(2) were increased during SLIT (P<0.05). There was a time-dependent increase in serum inhibitory activity for IgE-FAB in SLIT-treated atopics.

CONCLUSIONS

SLIT with grass pollen extract is associated with increased Foxp3(+) cells in the sublingual epithelium and systemic humoral changes as observed previously for SCIT.

Phenylephrine hypertrophy, Ca2+-ATPase (SERCA2), and Ca2+ signaling in neonatal rat cardiac myocytes

We endeavored to use a basic and well-controlled experimental system to characterize the extent and time sequence of sarco(endo)plasmic reticulum Ca(2+)-ATPase (SERCA) involvement in the development of cardiac hypertrophy, including transcription, protein expression, Ca(2+) transport, and cytoplasmic Ca(2+) signaling. To this end, hypertrophy of neonatal rat cardiac myocytes in culture was obtained after adrenergic activation with phenylephrine (PE). Micrographic assessment of myocyte size, rise of [(14)C]phenylalanine incorporation and total protein expression, and increased transcription of atrial natriuretic factor demonstrated unambiguously the occurrence of hypertrophy. An early and prominent feature of hypertrophy was a reduction of the SERCA2 transcript, as determined by RT-PCR with reference to a stable marker such as glyceraldehyde-3-phosphate dehydrogenase. Reduction of Ca(2+)-ATPase protein levels and Ca(2+) transport activity to approximately 50% of control values followed with some delay, evidently as a consequence of a primary effect on transcription. Cytosolic Ca(2+) signaling kinetics, measured with a Ca(2+)-sensitive dye after electrical stimuli, were significantly altered in hypertrophic myocytes. However, the effect of PE hypertrophy on cytosolic Ca(2+) signaling kinetics was less prominent than observed in myocytes subjected to drastic SERCA2 downregulation with small interfering RNA or inhibition with thapsigargin (10 nM). We conclude that SERCA2 undergoes significant downregulation after hypertrophic stimuli, possibly due to lack of SERCA gene involvement by the hypertrophy transcriptional program. The consequence of SERCA2 downregulation on Ca(2+) signaling is partially compensated by alternate Ca(2+) transport mechanisms. These alterations may contribute to a gradual onset of functional failure in long-term hypertrophy.

Ecological modeling for water quality management of Kwangyang Bay, Korea

This study estimated the appropriate pollutant load reduction from point sources in Kwangyang Bay, Korea, using an eco-hydrodynamic model. The total chemical oxygen demand (COD), nitrogen (TN), and phosphorus (TP) loads from rivers and ditches that provide input to the bay were approximately 2.8x10(4), 2.5x10(4), and 5.9x10(2) kg day-1, respectively. Wastewater discharge from industrial complexes was the greatest contributor to pollutant loads in the inner part of the bay. COD values in the inner part of the bay were greater than 3.0 mg l-1, and exceeded Korean seawater quality grade III limits. A residual current was simulated, using a hydrodynamic model, to have a slightly complicated pattern in the inner part of the bay, ranging from 0.001 to 8 cm s-1. In the outer part of the bay, the simulated current flowed out to the South Sea with a southward flow at a maximum of 15 cm s-1. The results of the ecological model simulation of COD levels showed high concentrations, exceeding 4 mg l-1, in the southwest of the Myodo, an area of wastewater discharge, and lower levels, approaching less than 1 mg l-1, closer to the outer part of the bay. Engineering countermeasures to reduce the organic and inorganic material loads from point sources by more than 45% were required to keep the COD levels below 2 mg l-1.

Laparoscopic radical prostatectomy: review and assessment of an emerging technique

BACKGROUND

Several recent reports have affirmed the feasibility of the laparoscopic approach for radical prostatectomy. In this review, we discuss the morbidities associated with this technique and compare outcomes and convalescence with standard open radical prostatectomy.

METHODS

We reviewed all currently published data on laparoscopic radical prostatectomy and our series of 45 robotic-assisted radical prostatectomies and compared them to several landmark series of open retropubic and perineal radical prostatectomies.

RESULTS

Although the initial series reported long operating times, these times have been significantly reduced in more recent series. Data on blood loss, convalescence, impotence, and incontinence rates have also been promising.

CONCLUSIONS

Although follow-up has been short thus far, laparoscopic radical prostatectomy has been shown to be similar to open radical prostatectomy in several areas.

Hematopoietic effect of ginsenoside Rg3 in ICR mouse primary cultures and its application to a biological response modifier

Ginsenoside Rg3, which is obtained as a by-product during the steaming of red ginseng, at 300 microg/ml enhanced the proliferation of the total spleen and bone marrow (BM) cells in both the cyclophosphamide (CYC)-treated and non-CYC-treated groups.

Nitrification of high strength ammonia wastewater and nitrite accumulation characteristics

Biological nitrogen removal via the nitrite pathway in wastewater treatment is very important in saving the cost of aeration and as an electron donor for denitrification. Wastewater nitrification and nitrite accumulation were carried out in a biofilm airlift reactor with autotrophic nitrifying biofilm. The biofilm reactor showed almost complete nitrification and most of the oxidized ammonium was present as nitrite at the ammonium load of 1.5 to 3.5 kg N/m3 x d. Nitrite accumulation was stably achieved by the selective inhibition of nitrite oxidizers with free ammonia and dissolved oxygen limitation. Stable 100% conversion to nitrite could also be achieved even under the absence of free ammonia inhibition on nitrite oxidizers. Batch ammonium oxidation and nitrite oxidation with nitrite accumulating nitrifying biofilm showed that nitrite oxidation was completely inhibited when free ammonia is higher than 0.2 mg N/L. However, nitrite oxidation activity was recovered as soon as the free ammonia concentration was below the threshold level when dissolved oxygen concentration was not the limiting factor. Fluorescence in situ hybridization analysis of cryosectioned nitrite accumulating nitrifying biofilm showed that the beta-subclass of Proteobacteria, where ammonia oxidizers belong, was distributed outside the biofilm whereas the alpha-subclass of Proteobacteria, where nitrite oxidizers belong, was found mainly in the inner part of the biofilm. It is likely that dissolved oxygen deficiency or limitation in the inner part of the nitrifying biofilm, where nitrite oxidizers exist, is responsible for the complete shut down of the nitrite oxidizers activity under the absence of free ammonia inhibition.

Intraoperative mild hypothermia does not increase the plasma concentration of stress hormones during neurosurgery

PURPOSE

To determine how mild hypothermia (34 degrees C) affects the hemodynamic and the stress hormonal responses intraoperatively and during extubation in patients undergoing cerebral aneurysm surgery.

METHODS

After induction, anesthesia was maintained with 1.2% isoflurane and 50% nitrous oxide. For the normothermia and the hypothermia groups, the body temperature was maintained at 36.9 +/- 0.3 degrees C and 34.2 +/- 0.2 degrees C respectively up to the recovery room. Hemodynamic changes were recorded continuously. Stress hormones comprising epinephrine, norepinephrine, ADH, ACTH, and cortisol were measured at the awake control, intraoperative, and extubation periods.

RESULTS

Vital signs of the intraoperative and postextubation time periods were not significantly different between the normothermia and hypothermia groups except for a statistically lower pulse rate intraoperatively in the hypothermia group (P <0.05). In the control awake state, all five hormonal concentrations were similar between the two groups. Intraoperatively, all of the hormonal levels tended to be lower in the hypothermia group compared to the normothermia group, but only the epinephrine level decreased sufficiently to reach statistical significance (P <0.05). During extubation, all stress hormone concentrations, except norepinephrine, were lower in the hypothermia group (epinephrine: P <0.05; ADH: P <0.05; ACTH: P <0.05; cortisol: P <0.05).

CONCLUSIONS

Our data suggest that intraoperative mild hypothermia neither significantly affects the blood pressure response nor increases the concentrations of stress hormones intraoperatively. Furthermore, mild hypothermia significantly decreased the plasma concentrations of stress hormones during the extubation period.

Long-term effects of ureteroscopic laser lithotripsy on glomerular filtration rate in the face of mild to moderate renal insufficiency

BACKGROUND AND PURPOSE

Ureteroscopic laser treatment of calculi in the upper urinary tract was examined in regard to its effect on renal function in the setting of mild renal insufficiency. Percutaneous nephrolithotomy (PCNL) and SWL have been previously shown not to adversely affect the glomerular filtration rate (GFR) in renal insufficiency, but to our knowledge, the effect of ureteroscopic laser lithotripsy on GFR has not been previously reported.

PATIENTS AND METHODS

A retrospective review of all cases of ureteroscopic laser lithotripsy at our institution was performed. A total of 18 patients with a baseline serum creatinine of > or = 1.5 mg/dL were found. The mean follow-up after treatment was 18.0 months (range 4-39 months). The change in the reciprocal of serum creatinine was used as an indicator of change in the GFR. Deterioration of 20% was considered significant.

RESULTS

The overall mean change in treated patients was a 5.9% improvement. Patients with a preoperative creatinine of < 2.0 mg/dL improved 7.6% and those with creatinine of > or = 2.0 mg/dL increased 3.9%. Other factors such as the size of the stone, location of the stone, and total joules used during treatment were not significant.

CONCLUSION

This examination suggests that ureteroscopic laser lithotripsy has no ill effects on renal function in the face of mild to moderate renal insufficiency.

Flail aortic valve and acute aortic regurgitation due to spontaneous localized intimal tear of ascending aorta

This report describes the transesophageal echocardiographic findings of acute severe aortic regurgitation resulting from localized transverse intimal tear of ascending thoracic aorta which could not be suspected as a cause of flail aortic valve preoperatively. In patients with chest pain and acute aortic regurgitation associated with flail aortic valve, localized intimal tear of aorta should be considered as a possible cause of flail aortic valve.

Experience with endoluminal ultrasonography in the urinary tract

Ultrasonography has been an invaluable tool in the field of urology for its noninvasiveness, safety, and relatively low cost. However, examination of the ureter with ultrasound is difficult because of the distance of the transducer from the ureter and because of intervening structures such as nonconductive bowel gas. As smaller probes have become available, attempts have been made to apply them to endoluminal use. Endoluminal ultrasonography has been employed in urology to examine the proper placement of injected collagen, diagnose urethral diverticula, diagnose and stage upper tract transitional-cell carcinoma, locate crossing vessels to guide endopyelotomy, diagnose submucosal calculi, and examine the severity and length of ureteral strictures.

Muc1 mucins on the cell surface are adhesion sites for Pseudomonas aeruginosa

Recently, we cloned and characterized a full-length cDNA of the hamster Muc1 gene, the expression of which appears to be associated with secretory cell differentiation (Park HR, Hyun SW, and Kim KC. Am J Respir Cell Mol Biol 15: 237-244, 1996). The role of Muc1 mucins in the airway, however, is unknown. In this study, we investigated whether cell surface mucins are adhesion sites for Pseudomonas aeruginosa. Chinese hamster ovary (CHO) cells not normally expressing Muc1 mucin were stably transfected with the hamster Muc1 cDNA, and binding to P. aeruginosa was examined. Our results showed that 1) stably transfected CHO cells expressed both Muc1 mRNA and Muc1 mucins based on Northern and Western blot analyses, 2) Muc1 mucins present on the cell surface were degraded by neutrophil elastase, and 3) expression of Muc1 mucins on the cell surface resulted in a significant increase in adhesion of P. aeruginosa that was completely abolished by either proteolytic cleavage with neutrophil elastase or deletion of the extracellular domain by mutation. We conclude that Muc1 mucins expressed on the surface of CHO cells serve as adhesion sites for P. aeruginosa, suggesting a possible role for these glycoproteins in the early stage of airway infection and providing a model system for studying epithelial cell responses to bacterial adhesion that leads to airway inflammation in general and cystic fibrosis in particular.

The effects of morphine on blood-brain barrier disruption caused by intracarotid injection of hyperosmolar mannitol in rats

This study was performed to evaluate whether morphine could alter the degree of disruption of the blood-brain barrier (BBB) caused by hyperosmolar mannitol. Under isoflurane anesthesia, rats in a control group were infused with 25% mannitol into the internal carotid artery before measuring the transfer coefficient (Ki) of (14)C-alpha-aminoisobutyric acid. Infusion of morphine 3 mg/kg in the small-dose morphine group and 10 mg/kg in the large-dose morphine group was completed, 10 min before administering mannitol. There were no statistical differences in systemic blood pressures between these three groups of animals. In the control group, the Ki of the ipsilateral cortex where mannitol was injected, increased to 4.6 times that of the contralateral cortex (19.5 +/- 8.5 vs 4.2 +/- 1.2 microL. g(-1). min(-1), P < 0.002). The Ki of the ipsilateral cortex of the small-dose morphine group was 13.5 +/- 7.6 microL. g(-1). min(-1). The Ki of the ipsilateral cortex of the large-dose morphine group was 9.2 +/- 4.5 microL. g(-1). min(-1) and was smaller than that of control animals (P < 0.05). There was no significant difference in the Ki of the contralateral cortex among the three groups. In conclusion, morphine attenuated BBB disruption induced by hyperosmolar solution without significant effects on systemic blood pressure.

IMPLICATIONS

Our study suggests that morphine may be effective in reducing the blood-brain barrier disruption by hyperosmolar mannitol without significant effects on systemic blood pressure.

Identification and characterization of high molecular-mass mucin-like glycoproteins in the plasma membrane of airway epithelial cells

A previous lectin binding study demonstrated the presence of high molecular-mass mucin-like glycoproteins (HMGP) on the surface of hamster tracheal surface epithelial (HTSE) secretory cells (Proc. Natl. Acad. Sci. USA 1987;84:9304). In the present study, we intended to isolate and characterize these HMGP from the plasma membrane of the primary HTSE cells and then to determine whether or not these membrane HMGP are Muc-1 mucins, a type of mucins originally discovered on the surface of some carcinomas. A subcellular fraction enriched with the plasma membrane was obtained using a sucrose density gradient centrifugation. This fraction contained high molecular-mass glycoconjugates which were excluded from Sepharose CL-4B gel. Biochemical characterization of these glycoconjugates revealed the following characteristics: (1) susceptibility to both pronase and mild alkaline treatments, but totally resistant to proteoglycan-digesting enzymes; (2) partitioning in the detergent phase of Triton X-114 and resistance to digestion by phosphatidylinositol phospholipase C or D; (3) a buoyant density of 1.5 g/ml based on CsCl density gradient centrifugation; (4) polydispersity in terms of both size and charge density; and (5) lack of immunoreactivity with an anti-Muc-1 mucin antibody. We conclude that the plasma membrane of HTSE cells at confluence contains HMGP, which seem to be the integral membrane proteins but different from Muc-1 mucins, and that these membrane HMGP appear to share some similarities with secreted mucins in terms of size and charge.

Transesophageal echocardiographic identification of left upper pulmonary venous obstruction caused by compression by spontaneous pseudoaneurysm of the descending thoracic aorta

Pseudoaneurysm of the aorta usually occurs as a complication of nonpenetrating trauma or deceleration injuries. Spontaneous pseudoaneurysm of the aorta is, however, extremely rare. Pulmonary veins can be affected in this situation because of the anatomic proximity. However, it is often overlooked during clinical examination, during routine echocardiography, and even at invasive angiography. This report describes the importance of transesophageal echocardiography in the detection of pulmonary vein compression, which is not suspected during other noninvasive and invasive diagnostic tests, in a patient with spontaneous pseudoaneurysm of the descending thoracic aorta.