P3632Prognostic impact of aortic valve stenosis in patients with acute myocardial infarction

Background

Aortic valve stenosis (AS) is associated with the presence and severity of coronary artery disease independently of clinical risk factors, which leads to increased cardiovascular mortality. However, the prevalence of AS and its prognostic value among patients with acute myocardial infarction (AMI) remain unknown.

Purpose

The purpose of this study was to investigate the prevalence and prognostic impact of AS in AMI patients.

Methods

We studied 2,803 AMI patients using data from Mie ACS registry, a prospective and multicenter registry. Patients were divided into subgroups according to the presence and severity of AS based on maximal aortic flow rate by Doppler echocardiography before hospital discharge: non-AS <2.0 m/s, 2.0 m/s≤mild AS <3.0 m/s, 3.0 m/s≤moderate AS <4.0m/s and severe AS≥4.0 m/s. The primary outcome was defined as 2-year all-cause mortality.

Results

AS was detected in 79 patients (2.8%) including 49 mild AS, 23 moderate AS and 6 severe AS. AS patients were significantly older (79.9±9.8 versus 68.3±12.6 years), and higher killip classification than non-AS patients (P<0.01, respectively). However, left ventricular ejection fraction, and prevalence of primary PCI was similar between the 2 groups. During the follow-up periods (median 725 days), 333 (11.9%) patients experienced all-cause death. AS patients demonstrated the higher all-cause mortality rate compared to that of non-AS patients during follow up (47.3% versus 11.3%, P<0.0001, chi square). Kaplan-Meier curves showed that the probability of all-cause mortality was significantly higher among AS patients than non-AS patients, and was highest among moderate and severe AS (See figure A and B). Cox regression analyses for all-cause mortality demonstrated that the severity of AS was the strongest and independent poor prognostic factor (HR 1.71, 95% CI 1.30–2.24, P<0.001, See table).

Cox hazard regression analysis Hazard ratio 95% Confidential interval P-value Severity of aortic valve stenosis 1.71 1.30–2.24 <0.001 Killip classification 1.63 1.46–1.82 <0.001 Age 1.07 1.06–1.09 <0.001 Serum creatinine level 1.05 1.03–1.08 <0.001 Max CPK level 1.00 1.00–1.01 <0.001 Left ventricular ejection fraction 0.96 0.95–0.97 <0.001 Primary percutaneous coronary intervention 0.67 0.47–0.96 0.03 CPK suggests creatinine phosphokinase.

All cause mortality

Conclusions

The presence of AS of any severity contributes to worsening of patients' prognosis following AMI independently of other known risk factors.

Acknowledgement/Funding

None

[Exposure for harvesting gastroepiploic artery graft]

We present out technique for harvesting the gastroepiploic artery (GEA). We use a Universal Stabilizer Arm and an assistant attachment to push the liver against the diaphragm, giving en enough working space to harvest the graft. Between January and December 2007, 99 isolated coronary artery bypass grafting (CABG)s were performed, and in 36 (36.4%) patients the GEA was harvested using this technique. The mean operation time was 251.1 +/- 40.5 minutes and the mean number of distal anastomosis was 3.6 +/- 0.8. The early patency rate of the GEA graft was 95%. Combined use of a Universal Stabilizer Arm and an assistant attachment provide good exposure for harvesting the GEA.

[Delayed surgery for traumatic rupture of the aortic arch with an isolated left vertebral artery; report of a case]

Although traumatic rupture of the thoracic aorta has been considered a surgical emergency, we report here an example of successful delayed surgery for acute traumatic rupture of the aortic arch with an isolated left vertebral artery in an 18-year-old woman. The patient was.admitted to the intensive care unit with hemothorax and, rib fractures, and a decision was made to treat the aortic injury conservatively until the patient was stabilized. She underwent surgery after 3 months of observation. After the isolated left vertebral artery had been anastomosed to the left carotid artery, total arch replacement was performed. Delayed surgery for aortic rupture as a treatment choice may be of benefit in selected cases of complex trauma.

[Assessment of proximal aortic anastomosis device in coronary artery bypass grafting]

The aim of this study was to assess the feasibility and safety of a new proximal anastomotic device (PAD) "Enclose II" in coronary artery bypass grafting (CABG). PAD enables the construction of a proximal aortic anastomosis without the use of partial clamp of the ascending aorta, thus reduces the incidence of adverse perioperative neurologic injury related to atheroembolic events. This device was used in 41 off-pump CABG and 11 on-pump beating heart CABG patients for performing 46 radial artery (RA) and 9 vein anastomoses to the aorta. The subjects were 43 males and 9 females, with a mean age of 63.6 years. Thirteen (25%) patients had severe atherosclerotic cerebrovascular lesions preoperatively. The mean flow in the RA graft was 52.4 +/- 26.9 ml/min and that of saphenous vein graft (SVG) was 61.1 +/- 31.9 ml/min. Angiography showed all grafts patent. There was no procedure-related adverse events or cerebrovascular complication. Enclose II device can be a valuable tool to perform RA and vein anastomoses in CABG.

[Clinical evaluation of landiolol hydrochloride, an ultra short-acting beta-blocker]

Postoperative supraventricular tachyarrhythmia (SVT) remains the most common complication of cardiovascular surgery. Current guidelines recommend treatment with beta-blockers in prevention and management of postoperative atrial fibrillation after cardiac surgery. Landiolol hydrochloride is a newly developed ultra short-acting selective beta1-blocker with a half-life of approximately 4 minutes. We investigated its effects on the cardiac function as well as on postoperative SVT. Landiolol hydrochloride had a sufficient therapeutic effect without apparent side effect. After its administration cardiac index decreased, whereas stroke volume increased. Pulmonary artery wedge pressure, pulmonary artery pressure, and central venous pressure remained unchanged. Its main effect proved to be decrease in heart rate.

[On-pump beating coronary artery bypass grafting with axillary cannulation in the presence of atherosclerotic lesions in the ascending aorta]

A 72-year-old man was admitted to our hospital for dyspnea and chest pain. Coronary artery bypass grafting (CABG) was scheduled because of severe stenosis of the left main trunk. Computed tomography showed severe atherosclerotic lesions in the whole aorta, especially in the ascending aorta. Although off-pump CABG was thought to be the 1st choice, we determined that it would be difficult to establish a cardiac support device due to atherosclerotic lesions in case of sudden deterioration. We performed on-pump beating CABG with axillary cannulation with an 8 mm tube graft. Postoperatively, we recognized no symptoms of stroke, and the patient was discharged on the 12th postoperative day. Axillary cannulation using a side graft was useful in the presence of atherosclerotic lesions in the ascending aorta.

[Early results of new style aortosaphenous vein graft connector in coronary artery bypass grafting]

We retrospectively studied early clinical results of PAS-Port (PP) system. Fifty patients who underwent coronary artery bypass surgery with saphenous vein graft (SVG) from April 2004 to May 2005 were enrolled in this study. PP was tried for 36 SVGs in 32 patients. In 2 patients, SVG 4.0 mm in diameter could not be loaded into the device. In other 2 patients, anastomosis with PP was failed and followed by hand-sewing under aortic clamp or with Heartstring. Anastomosis with PP was successfully completed for 34 SVGs in 30 patients (group P) and conventional hand-sewing was performed for 23 SVGs in 20 patients (group C). The target vessels for SVG were similar between the 2 groups. No complication occurred in the use of PP. Postoperative angiography before discharge was performed for 31 SVGs in 27 patients (90.0%) in group P and 20 SVGs in 17 patients (85.0%) in group C. The patency rate of SVG was 96.8% in group P and 100% in group C. In conclusion, early results of PP were satisfactory compared with those of conventional hand-sewing. Severely sclerotic aorta and oversized SVG should be excluded because of possibility for incomplete deployment of the inner flange in PP.

[Extracardiac rupture of aneurysm of the noncoronary sinus of valsalva: report of a case]

A 78-year-old female was admitted to our hospital because of sudden onset of chest pain and general fatigue. A chest X-ray showed marked cardiomegaly and computed tomography (CT) revealed pericardial effusion with left pleural effusion. Upon admission to CCU, she suddenly lost consciousness and was intubated. Echocardiography confirmed increase in the amount of the pericardial effusion, which was drained at CCU. By an emergent operation, ruptured aneurysm of the noncoronary sinus of Valsalva to the pericardial space was confirmed upon opening the chest and patch plasty of the sinus of Valsalva was performed. The postoperative course was uneventful, and she was discharged on the 24th postoperative day. Extracardiac rupture of aneurysm of the sinus of Valsalva is extremely rare, and the emergent operation is indispensable.

[Off-pump versus conventional coronary artery bypass grafting in octogenarians]

Coronary artery bypass grafting (CABG) in elderly patients is becoming increasingly common. From January 1996 to February 2002, 836 patients underwent CABG in our hospital, of whom 33 patients (3.9%) were aged 80 years or older. We evaluated the clinical and short-term results of 7 cases of off-pump CABG (OPCAB) and 26 cases of conventional CABG (C-CABG). Mean patient age and preoperative risk factors were similar in both groups. The OPCAB group had significantly decreased operation time (218 versus 281 minutes, p<0.05), and the number of distal anastomoses was significantly fewer in the OPCAB group than in the C-CABG group (1.9 versus 3.8, p<0.05). The frequency of complete revascularization in C-CABG was significantly higher than that of the OPCAB group (84.6% versus 42.9%, p<0.05), and there were no differences in the incidence of major postoperative complications between the groups. There was no hospital death in either group. Cumulative cardiac event free rates were 75% at 1 year and 75% at 3 years in the OPCAB group and 100% at 1 year and 84.6% at 3 years in the C-CABG group (p<0.05). In conclusion, CABG is safe and effective for myocardial revascularization in octogenarians. Except for high-risk cases, complete revascularization with OPCAB or C-CABG should be performed, because favorable outcomes can be expected even in the elderly patients.

[Prosthetic valve endocarditis complicated with cardiogenic shock and disseminated intravascular coagulation; report of a case]

A 67-year-old man, who had been performed aortic and mitral valve replacement 3 years before, was admitted because of appetite loss, general fatigue and anemia. Although transthoracic echocadiogram showed no evidence of prosthetic valves failure, the patient fell in profound shock. He needed endotracheal intubation and inotropic support. Transesophageal echocadiogram revealed vegetation formation on the prosthetic mitral valve and massive periprosthetic valve leakage. The diagnosis of prosthetic valve endocarditis was established. Blood examination showed severe disseminated intravascular coagulation (DIC). The patient underwent re-mitral valve replacement and recovered well from shock and DIC.

Aortic valve replacement for aortic stenosis with a small aortic annulus in a patient having Werner's syndrome and liver cirrhosis

Werner's syndrome is a rare genetic disease characterized by premature aging and scleroderma-like involvement of the skin. We report a case of aortic valve replacement for severely calcified aortic valve stenosis with a small annulus in a patient suffering from Werner's syndrome and liver cirrhosis

Simultaneous mitral valve replacement and bypass grafting for mycotic aneurysm of the femoral artery during the active phase of infective endocarditis: a case report

A 52-year-old woman with a 3-week history of fever and cough was diagnosed as having bacterial endocarditis with vegetation and severe mitral valve insufficiency by echocardiography. Blood culture revealed Streptococcus mitis. After antibiotic treatment for 3 weeks, the patient noticed swelling with pain in her left groin. Computed tomography revealed an occluded aneurysm in the left common femoral artery. Simultaneous surgical treatments of mitral valve replacement and bypass grafting using a saphenous vein following resection of the mycotic femoral arterial aneurysm were performed. Pathohistological examination of surgical specimens revealed acute inflammatory findings, but no microorganisms were found, probably because of the preoperative antibiotic therapy. Her postoperative course was uneventful, and there was no recurrence of mycotic aneurysms in a period of 10 months after the operation. Prompt recognition and urgent simultaneous surgical treatments for mycotic aneurysms complicated with infective endocarditis were effective.

Subtotal thoracic aortic replacement as reoperation for ruptured aortic dissection: report of a case

We report successful repair of a ruptured chronic aortic dissection in a 63-year-old female who had undergone end-to-end anastomosis for acute type A dissection 8 years before. The patient had hypotension with back pain and cough. A computed tomogram revealed a large chronic aortic dissection (Stanford type A) and complete atelectasis of the left lung due to hemothorax. The brachiocephalic artery was also dissected and aneurysmal. Emergency surgery was performed. Subtotal thoracic aortic replacement with reconstruction of 4 cervical vessels was carried out using hypothermic circulatory arrest with selective cerebral perfusion via a redo-sternotomy and a left anterolateral thoracotomy. The patient was discharged from the hospital without any sequelae.

New type of stable Q balls in gauge-mediated supersymmetry breaking

We obtain a new type of a stable Q ball in the context of gauge-mediated supersymmetry breaking in the minimal supersymmetric standard model. It is a so-called gravity-mediation type of Q ball, but stable against the decay into nucleons, since the energy per unit charge is equal to gravitino mass m(3/2), which can be smaller than nucleon mass in the gauge-mediation mechanism. We consider the cosmological consequences in this new Q-ball scenario, and find that this new type of Q ball can be considered as the dark matter and the source for the baryon number of the universe simultaneously.

Rupture of a giant saccular aneurysm of coronary arteriovenous fistulas

A 58-year-old Japanese woman was admitted to our hospital because of chest pain. A continuous murmur was detected at the left parasternal area. Electrocardiogram showed ST elevation in leads V2, V3 and V4. Chest computed tomography and echocardiography demonstrated pericardial effusion and a large mass which was adjacent to the pulmonary artery. An abnormal blood flow was detected in the mass by Doppler echocardiography. Coronary angiography confirmed that the mass was a giant aneurysm of coronary arteriovenous fistula arising from both the left and right coronary arteries. This patient had no symptoms until rupture of the fistula. Rupture of a coronary arteriovenous fistula is very rare but can be a cause of chest pain and pericardial effusion.

[Analysis of prevalent Orientia tsutsugamushi in Aichi Prefecture]

Orientia tsutsugamushi was isolated from one of 8 patients' sera in Aichi Prefecture, and was identified to have the same antigenicity with the KN-2 strain (KN-2 like) based on the reactivity with 13 types of strain-specific or cross-reactive monoclonal antibodies to Karp, Gilliam, and Kato strains. Four isolates from 4 unfed larvae and adult of Leptotrombidium pallidum were also classified as the KN-3 like strains. Using indirect immunofluorescence, sera from 20 patients with tsutsugamushi disease were tested for reactivity with KN-1, KN-2, KN-3, and GJ-1 strains, isolated from patients in Gifu Prefecture. Fifteen sera showed the highest titer against KN-2 strain in Immunogloburin M (IgM). Of the other 5, three were higher for KN-3 strain in IgM, and two were KN-1 or GJ-1, respectively. These results suggested that KN-2 like strains were prevalent in the region where the number of patients has been ranked the highest in Aichi Prefecture. KN-1, KN-3, and GJ-1 like strains were also existed in this area. KN-3 like strain was likely to be distributed in another area. Aichi Prefecture.

[Surgical treatment of a ruptured saccular aneurysm associated with bilateral coronary arteries-pulmonary artery fistulas: a case report]

We reported a successful operative case of ruptured coronary artery saccular aneurysm associated with bilateral coronary arteries-pulmonary artery fistulas. A 57-year-old woman, had been treated with hemodialysis due to chronic renal failure, suffered from acute heart failure with chest pain suddenly. Echocardiograph showed moderate pericardial effusion. A saccular coronary artery aneurysm with bilateral coronary arteries-pulmonary artery fistulas revealed by coronary angiogram. Ligation of coronary artery fistula, closure of orifice of draining artery to pulmonary artery and aneurysmorrhaphy were performed emergently. Post operative angiogram revealed complete disappearance of the fistulas.

[Surgical results of emergent coronary artery bypass grafting]

During a period of past five years, 57 patients underwent emergent coronary artery bypass grafting at our hospital. The reason for performing emergent CABG were unstable angina pectoris in 38 patients and acute myocardial infarction in 19 patients. Five patients died postoperatively. Mortality rate was higher in the patients with AMI (15.8%) than in the patients with UAP (5.3%). Among 19 patients after AMI, 7 patients were in cardiogenic shock preoperatively, and two of them died after operation. Though the surgical results for AMI with cardio-genic shock is discouraging, complete revascularization can be performed safely for the patients with UAP and uncomplicated AMI. It appears that optimal timing of the patients with left main shock syndrome should be guided by the relative presence of an element of ischemia or necrosis.

The long-term survival rates of patients after repair of abdominal aortic aneurysms

This study was undertaken to examine the long-term survival rates of patients following abdominal aortic aneurysm (AAA) repair in comparison with an age-matched normal population, and to determine by multivariate analysis the factors influencing long-term survival. Of 125 patients who underwent AAA repair prior to July 1986, 13 died during hospitalization. Of these 13 patients, 6 who suffered aneurysmal rupture all died within 30 days. The survival rate of patients with ruptured aortic aneurysms was significantly lower than that of those with nonruptured aneurysms. Of the 112 patients surviving hospitalization, 85 died within 0.48 to 24 years after their operation. The long-term survival rate of patients who had suffered a preoperative cardiovascular event was significantly lower than that of those who had not suffered a preoperative cardiovascular event. The actual survival rate was significantly lower than the expected survival rate. According to a multivariate analysis, the significant predictors of late survival were age, aneurysmal rupture, and chronic renal failure in all the patients, and age, chronic renal failure, and pre- and postoperative cardiovascular events in patients who did not die in hospital. These findings indicate the importance of improving immediate perioperative management of ruptured AAA and that cardiovascular events should be prevented, or treated during long-term follow-up.

Immunoglobulin G (IgG) subclass and IgE responses in human paragonimiases caused by three different species

In 40 cases of human paragonimiases caused by Paragonimus westermani (20 cases), P. miyazakii (10 cases), and P. skrjabini (10 cases), responses of serum immunoglobulin G (IgG), IgG subclasses, and IgE were analyzed by immunoblotting with crude antigens prepared from egg, 4-week-old juvenile, and adult forms of P. westermani. The 32- and 35-kDa proteins in the adult extracts showed specific reactions regardless of the causative species (39 of 40 cases; 98%). Sera of patients infected with P. westermani and P. miyazakii reacted strongly with the 28-, 46-, and 94-kDa proteins of egg extracts, while those from patients infected with P. skrjabini reacted faintly. No sera from patients with other trematodiases (0 of 15 cases), cestodiases (0 of 20 cases), or lung cancer (0 of 5 cases) or from healthy controls (0 of 10 individuals) showed positive reactions. Analysis by IgG subclass revealed that IgG4 (33 of 40 cases; 83%) and IgG1 (29 of 40 cases; 73%) antibodies in the patient sera recognized the 32- and 35-kDa proteins predominantly. IgG3 reaction was found in 50% (10 of 20 cases) and 30% (3 of 10 cases) of the sera of patients infected with P. westermani and P. miyazakii, respectively. In an IgE immunoblot, 83% (33 of 40 cases) of the sera from paragonimiasis patients reacted with the 32- and 35-kDa proteins while no sera from patients with heterologous diseases and healthy controls showed a positive reaction. Both 32- and 35-kDa proteins in adult extracts of P. westermani were highly reliable for serodiagnosis of human paragonimiases.

Kinetics and collagenolytic role of eosinophils in chronic gastric ulcer in the rat

An association between eosinophils and tissue damage has been observed in numerous disorders. However, few reports have addressed the role of infiltrating eosinophils in gastric ulcer healing. The aim of this study was to investigate the kinetics and role of eosinophils infiltrating experimental chronic gastric ulcers in the rat. We developed a monoclonal antibody against human matrix metalloproteinase 1 (MMP1) purified from conditioned culture medium of human skin fibroblasts. Acetic acid-induced gastric ulcers were resected from rats on days 1, 3, 5, 10, 20, 40, and 180 after the days of induction (day 0). Tissue specimens were immunostained with this antibody and examined with an electron microscope. Few eosinophils were observed in the granulation tissue until day 20. By days 40 and 180, MMP1-positive eosinophils had increased in the granulation tissue of open ulcers. Azan staining revealed dispersed collagen fibers around infiltrating eosinophils. In contrast, scars demonstrated few eosinophils in fibrous tissue on days 40 and 180. Eosinophils which express MMP1 infiltrate granulation tissue at the chronic stage of gastric ulceration. The results suggest that eosinophils may play a role in tissue remodeling and deterioration of ulceration.

Virulence in mice of Orientia tsutsugamushi isolated from patients in a new endemic area in Japan

Four strains of Orientia tsutsugamushi (KN-1, KN-2, KN-3 and GJ-1) isolated from patients in an area of Gifu Prefecture, Japan, in which tsutsugamushi disease is newly endemic, were examined for their virulence in mice. Among these, KN-1 (identified as Kawasaki type), GJ-1 (identified as Kuroki type) and KN-2 strains were found to be non-lethal for BALB/c mice as well as CH3/HeJ mice, even with high doses (10(6) x being the 50% mouse infectious dose). On the other hand, the KN-3 strain was found to be sufficiently virulent to kill BALB/c mice. Among the prototype strains (Gilliam, Karp and Kato), the Karp and Kato strains exhibited high virulence to mice, while the Gilliam strain killed only a susceptible strain of mouse. BALB/c mice infected with KN-1 and KN-2 strains showed significant splenomegaly and moderate ascites accumulation in the first week of infection, while these symptoms became prominent during the second week of infection using KN-3, Karp and Kato strains. After infection with the GJ-1 strain, these symptoms were not observed. Antibody responses induced by infections with highly virulent strains were lower than that with low or intermediate virulent strains.

Demonstration of antigenic and genotypic variation in Orientia tsutsugamushi which were isolated in Japan, and their classification into type and subtype

A total of 40 strains of Orientia tsutsugamushi (34 isolates from patients and trombiculid mites in Japan, and 6 prototype strains of antigenic variants) were examined for classification based on the reactivities with type-specific monoclonal antibodies in indirect immunofluorescence tests, and on the restriction fragment length polymorphism of a polymerase chain reaction (PCR)-amplified 56-kilodalton type-specific antigenic protein gene. By these methods, several antigenic and genotypic variants were found among the strains, and these variants were classified into types and further into subtypes. These results suggest that there are many variants in O. tsutsugamushi, and the methods used here seem to be useful for the systematic classification of the numerous variants. A strain which may be a new type distinguishable from those identified previously was also found in this study. Furthermore, variety in the degree of pathogenicity in mice related to type and/or subtype classification were observed.

Apoptosis of lymphocytes in mice induced by infection with Rickettsia tsutsugamushi

Histological examinations of mice infected with either a lethal (Karp) or a self-limitating (Gilliam) strain of Rickettsia tsutsugamushi were performed. Tingible body macrophages in the spleen and necrotizing lymphadenitis in regional lymph nodes were prominent only in the former. Apoptotic legions in the lymphocytes of these organs were clearly demonstrated by histochemical and electron microscopical examinations.

[Studies on tsutsugamushi disease in Gifu prefecture. 6. Correlation between number of patients and meteorological elements]

The correlations between numbers of tsutsugamushi disease patients and meteorological elements were analyzed for 11 years from 1982 to 1992 in Gifu Prefecture, Japan by using regression analysis. The number of patients in early winter was closely correlated independently to both the mean of the minimum temperatures from 11th May to 31st July and the mean of the maximum temperatures in November in the same year. Regression coefficients (R2) were 0.689 and 0.560, respectively. On this basis, an equation for prediction of the number of patients in early winter was designed as follows: N = [e (j - 17.6) + 2.3(v - 13)] x j x v/156 (prediction formula 1) N:predicted number of patients in early winter j:the mean of the minimum temperature from 11th May to 31st July v: the mean of the maximum temperature in November e:the base of the natural logarithm (= 2.718...) The number of patients in early winter was also closely correlated to j in an equation of the fifth degree (R2 = 0.930). N = 22.524656384 j5 - 2218.23705 j4 + 87272.992 j3 - 1714734.329 j2 + 16825634.235 j - 65963810.254 Based on these formulas, the temperature in early summer has a significant effect upon the prevalence of tsutsugamushi disease in early winter.

[Syphilitic thoracic aortic aneurysm with destruction of vertebral body, producing numbness of lower extremities and paraplegia]

Numbness and paraplegia are uncommon complaints in patient with thoracic aortic aneurysm (TAA). The patient was a 64-year-old man. He suffered numbness and gait disturbance (paraplegia). The blood examination showed no positive findings except a Wassermann was positive. Roentgen examination of the chest showed two abnormal shadows like tumors. The CT and MRI revealed destruction of the vertebral bodies and TAAs adjacent to the spinal cord. After the graft replacement was performed, numbness and paraplegia disappeared. This suggests that in our patient the TAAs destruct the vertebral body and produce pressure on the spinal cord, causing numbness and paraplegia. We experienced a rare case of the syphilitic TAA producing bone destruction, numbness and paraplegia.

[Oozing type left ventricular rupture: report of three cases]

Two cases of postinfarction oozing type left ventricular rupture and a case of oozing type left ventricular rupture due to catheter perforation for left ventriculography are reported. The technique used to repair the rupture is fibrin glue-oxycellulose fixation method. The post operative course of three cases were uneventful. But left ventricular aneurysm remained in two cases.

[A left subclavian arterial aneurysm caused by fibromuscular dysplasia: a case report]

A 70-year-old man complained left supraclavicular pulsatile tumor. Angiography and CT revealed the left subclavian arterial aneurysm that was just behind the clavicle. The aneurysm was resected through a cross-clavicle incision and an 8 mm Hemashield graft was implanted. The pathological study showed change of fibromuscular dysplasia. The post-operative course was uneventful.

Transmission of Rickettsia tsutsugamushi strains among humans, wild rodents, and trombiculid mites in an area of Japan in which tsutsugamushi disease is newly endemic

Thirty-two newly isolated strains of Rickettsia tsutsugamushi, 14 from patients with tsutsugamushi disease, 12 from wild rodents, and 6 from trombiculid mites parasitizing rodents in Gifu Prefecture, Japan, were examined for reactivities to 12 monoclonal antibodies by an indirect fluorescent-antibody test to classify their antigenicities. All of the isolates could be classified into one of six groups (KN-1, KN-2, KN-3, GJ-1, R158, and R161) according to their reactivities to the monoclonal antibodies. The KN-1 and GJ-1 strains that are prevalent among patients from Gifu Prefecture had the same reactivities as the Kawasaki and Kuroki strains, respectively, which have been isolated and are prevalent in the Miyazaki and Kagoshima prefectures in southwest Japan. The isolates from patients were different in serotype from those from rodents and mites (Leptotrombidium pallidum). The KN-2 and KN-3 strains were most prevalent among patients and among rodents and mites, respectively. No close similarity between KN-2 and other strains tested was observed. KN-3 is only a minor contributor to diseases in patients in Gifu Prefecture; however, it was proven that the same strain was prevalent in Niigata Prefecture in northern Japan. Thus, Gifu Prefecture is an area where southern, northern, and local strains are found. We hypothesize that humans are prone to infection with KN-2, GJ-1 (very similar to Kuroki), and KN-1 (very similar to Kawasaki), probably by infestation with Leptotrombidium scutellare. While both L. scutellare and L. pallidum parasitize wild rodents and may carry any rickettsial strain, the most virulent strain, KN-3, is predominant among wild rodents. Antigenic analysis using monoclonal antibodies to R. tsutsugamushi should be useful for epidemiological studies of infection with this organism.

[Two case reports of recurrent mediastinitis with chronic mediastinal fistula successfully treated with muscle flap re-transposition]

We experienced two cases of recurrent poststernotomy mediastinitis with chronic mediastinal fistula. Both cases had already received muscle flaps for post operative mediastinitis. However, chronic mediastinal fistula appeared after nine months in the first case, and eleven months in the second case. We removed the infected tissue and the predgets, which were used on the ascending aorta. Then closed the wound by the muscle flap closure. The chronic fistula were closed, and the functional and cosmetic results were excellent.

[An operative case of aortic valve regurgitation due to blunt trauma to the chest]

While a 70-year-old man was riding a motorcycle, he was hit by car on his chest on October 19, 1990. Medical check-up at the emergency room of another hospital was negative. However, he fell in to dyspnea on the night of next day which progressed to develop signs of orthopnea. He revisited the hospital where he was found to have aortic regurgitation and subsequent congestive heart failure after medical examination including echocardiography and was referred to our hospital 7 days after the accident. He was operated upon the following day. On opening the pericardium, about 100 ml of reddish black fluid was accumulated. The appearance of the heart was normal except for black discoloration of the epicardial fat pad at the base of the aorta. Opening the ascending aorta transversely, the right coronary cusp was found to be perforated. The aortic valve was considered preferable to replace than to repair. The aortic valve was replaced with a St. Jude Medical valve. His recovery was uneventful and he has been well thereafter.

[A case of surgical repair for combined septal perforation and cardiac rupture after myocardial infarction]

The successful surgical repair of the combination of septal perforation and cardiac rupture after myocardial infarction was underwent on a 73-year-old man. Complete correction could be performed under the fibrillated heart state employing cardiopulmonary bypass, resulted in the early postsurgical cardiac performance.

[Results of surgical repair by muscle flap closure for poststernotomy mediastinitis]

Between 1984 and 1991, 30 patients developed poststernotomy mediastinitis after cardiac or mediastinal operations. Sixteen of these patients were treated with debridement and open drainage or primary closure following mediastinal irrigation (drainage group). Fourteen patients were treated with debridement, and delayed or primary wound closure by the technique of pectoral or rectus abdominus muscle flap mobilization (muscle flap group). The purpose of this study was to compare the results of the different treatment of poststernotomy mediastinitis. Although the pre- and perioperative profile, complications and risk factors for mediastinal infection were the same, the mortality of muscle flap group was significantly lower than that of drainage group (Fisher exact probability test, p < 0.05). Pulmonary function of the patients who received muscle flap mobilization did not decrease from the function before surgery, despite the defect of sternal bony stabilization. We conclude that muscle flap mobilization may be a superior method as the treatment for poststernotomy mediastinitis after cardiac operations, and may not decrease respiratory function of the patients.

[Studies on tsutsugamushi diseases in Gifu Prefecture. 5. Characterization of monoclonal antibodies to prototype strains of Rickettsia tsutsugamushi and immunological grouping of newly isolated strains using the antibodies]

We characterized 8 monoclonal antibodies (MAbs) to Karp, Kato, and Gilliam strains of Rickettsia tsutsugamushi, and analysed 17 isolates from patients with Tsutsugamushi disease using these MAbs. These were divided into 3 strain-specific (Kp/D11, Kt/2D9, and Gi/E4) and 5 cross-reactive MAbs (Kp/1F11, Kp/1C10, Kp/C6, Kt/3B2, and Kt/3C2). All MAbs recognized characteristic protein antigens using the indirect fluorescent-antibody test (IFA) and proteinase K treatment. Analysis by polyacrylamide gel electrophoresis and immunoblotting techniques revealed that Kato-specific MAb Kt/2D9 recognized a polypeptide with a molecular mass of 54 kilodalton (kDa) of the homologous strain, and cross-reactive MAbs Kp/1F11, Kp/C6, and Kt/3B2 recognized those of 46-47 kDa, 46-47 KDa, and 60 kDa, respectively to the homologous and heterologous strains. MAbs Kp/1C10 which exhibited a high IFA titer against the Karp strain and only low titers against heterologous strains recognized only the 110 kDa polypeptide of the homologous strain. MAb Kt/3C2 which reacted with both Karp and Kato strains recognized a 54 to 56 kDa polypeptide band of the two prototype strains as well as several other polypeptides, however, each molecular mass was present in only one of two strains. Testing by the plaque reduction technique showed another characteristic of MAb Kt/3C2 to neutralize both Karp and Kato Strains. Fourteen isolated strains from patients in the south and west regions of Gifu Prefecture, the Shimokoshi stain isolated in Niigata Prefecture, and Kawasaki and Kuroki stains isolated in Miyazaki Prefecture were examined for reactivities to 8 MAbs by IFA to classify their antigenicities. No isolated strains reacted with Karp-specific Kp/D11, Kato-specific Kt/2D9, or Gilliam-specific Gi/E4.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of tricuspid pouch associated with ventricular septal defect and functional left ventricular-right atrial communication]

We reported a 60-year-old woman with tricuspid pouch associated with ventricular septal defect and subsequent left ventricular-right atrial communication. Preoperative angiographic findings suggested the presence of membranous septal aneurysm, ventricular and atrial septal defects, and tricuspid insufficiency. However, at operation, besides perimembranous inlet type ventricular septal defect, a pouch, 1.5 cm in diameter was found in the adjacent part to the septal leaflet within the anterior one of the tricuspid valve. The ventricular septal defect was closed with a patch. From these findings, it is speculated that the tricuspid pouch was formed by the effect of jet stream through the ventricular septal defect.

How effective is the agar plate method for Strongyloides stercoralis?

The sensitivity of the agar plate method for the diagnosis of Strongyloides stercoralis was studied experimentally. Results demonstrated that this method was sensitive enough to detect S. stercoralis even when only a few worms were present.

[Significance of detection of specific IgE in Anisakis-related diseases]

Anisakis larvae which parasitize sea fishes sometimes cause not only anisakiasis but also such allergic reactions as mackerel-induced urticaria. We prepared AlaSTAT by using excretory/secretory antigens from Anisakis larvae to detect specific IgE in various patients groups. The AlaSTAT positive rate was 87.5% in gastric anisakiasis patients who were endoscopically diagnosed, while it was 66.7% in patients who had acute abdominal pain but no larva detected. Ascariasis in the common bile duct was 0%. The positive rate in mackerel-induced urticaria patients was 75.0%, while it was 8.3% and 10.0% in patients with urticaria of unknown origin and normal controls, respectively. Based on these data, the detection of specific IgE using AlaSTAT is useful in elucidating the cause of urticaria or acute abdominal pain, such as Anisakis.

A modified agar plate method for detection of Strongyloides stercoralis

The agar plate method is a new technique with high detection rates for coprological diagnosis of human strongyloidiasis. This report details modifications of the technique and establishes a standardized procedure. We recommend that all plates should be carefully observed using a microscope because macroscopic observation can lead to false negative results. It is also advisable to pour formalin solution directly into microscopically positive dishes to collect worms by sedimentation. This procedure enables one to observe worms otherwise hidden. Sealing dishes with adhesive tape prevents larvae from crawling out of the dishes, eliminating any possibility in the reduction of detection rates, and greatly improves the safety conditions for the technician performing the procedure. We consider the agar plate method to be superior to the filter paper method in detecting Strongyloides, and we believe that it will eventually become the technique of choice.

[A case report of a patient repeatedly infected with Ancylostoma duodenale, probably from himself through his artificial anus, and resistant against a single dose of pyrantel pamoate]

A 88 year old Japanese male was repeatedly infected with Ancyclostoma duodenale. He underwent an artificial anus operation about 55 years ago. He appeared to be infected with hookworm earlier than in 1977 and developed severe anemia. Though he was treated with pyrantel pamoate and mebendazole several times, reinfections developed in each time. A possible origin for his reinfections was his own feces defecated through his artificial anus. Unsanitary handling of the anus and the feces exposed himself to oral or percutaneous infection. Besides, a single dose of pyrantel pamoate, usually very effective against Ancylostoma duodenale, was not so effective in this patient. Therefore, we prescribed multiple doses of pyrantel pamoate, and followed by a single dose of mebendazole. However, reinfections still persisted because of his unsanitary behavior.

The critical role of blood from HLA-homozygous donors in fatal transfusion-associated graft-versus-host disease in immunocompetent patients

Fatal transfusion-associated graft-versus-host disease developed in a 69-year-old woman with colon cancer who underwent elective hemicolectomy. During the perioperative period, she was transfused with 4 units of nonirradiated fresh whole blood less than 6 hours after the blood was donated by family members. She was immunocompetent and was not treated with any immunosuppressive agents such as corticosteroids, chemotherapy, or irradiation therapy. The implicated donor was thought to be her daughter, who was homozygous for an HLA haplotype that was shared with the recipient: A24, Bw52, CBL, DR2. This is the most common haplotype in the Japanese population. This case and others in the Japanese literature indicate that the transfusion of fresh, nonirradiated blood that contains immunocompetent lymphocytes and peripheral hematopoietic precursor cells from HLA-homozygous donors can be lethal to the recipient.

[Studies on tsutsugamushi disease in Gifu prefecture. 4. Survey results in Ena and Takayama City, and the summary of the studies in the prefecture]

Investigations of trombiculid mites and Rickettsia tsutsugamushi in wild rodents were made in Ena (Nov. 1988) and Takayama (May 1989) City. In the former area where no patient has been reported so far, Leptotrombidium pallidum (63.9%) was most predominant and no L. scutellare was found. A Karp-related rickettsia (11.1%) was isolated from wild rodents and 30% of them had antibody to R. tsutsugamushi (anti-Karp was prominent). The latter area where patients were reported in spring as well as in autumn, L. pallidum (22.4%) was one of the dominant species in spring. Karp-related strains were isolated from 37.5% of wild rodents. And the antibody possession rate was 50.0%. These data reconfirmed our hypothesis that the majority of patients in autumn were infected by L. scutellare and a part by L. pallidum. In spring in Takayama area, the vector was L. pallidum which possessed Karp-related strain(s).

T-cell-dependent accumulation of eosinophils in the lung and its inhibition by monoclonal anti-interleukin-5

The transnasal administration of an extract of the parasite Ascaris suum to C57BL/6 mice for 3 weeks produced marked eosinophilia in the bronchoalveolar lavage (BAL) fluid. The oral administration of ciclosporin significantly suppressed the pulmonary eosinophilia. Athymic C57BL/6-nu/nu mice failed to develop pulmonary eosinophilia. These data indicate that the pulmonary eosinophilia caused by this parasite extract is T-cell-dependent. Genetically mast-cell-deficient (WB x C57BL/6) F1-W/Wv (W/Wv) mice developed marked eosinophilia in the BAL, which shows that mast cells are not necessary in the formation of lung eosinophilia in this model. Monoclonal antimurine interleukin-5 injected intraperitoneally clearly inhibited the infiltration of eosinophils in the lung, suggesting that T-cell-derived interleukin-5 is essential.