Electrocardiographic activity depends on the relative position between intimate persons

Interpersonal space (IPS) refers to the area surrounding the body in which we engage in social interactions while maintaining our comfort. Numerous previous studies have reported the psychological and physiological changes associated with the proximity of two people engaged in face-to-face interaction. Currently, there is limited knowledge about how the relative position between two socially intimate individuals affects their psychological and physiological states. This research measured the subjective discomfort and electrocardiographic responses of participants when standing static at various relative positions. The highest discomfort, lowest heart rate, and highest heart rate variability (HRV; parasympathetic activity index) were observed when the friend stood in the face-to-face position. Interestingly, heart rate also decreased when the friend stood on the right side, although HRV did not change. We interpreted the results as suggesting that the presence of a familiar person elicits the electrocardiographic responses associated with an increase in parasympathetic activity.

Internet usage and the problems about the commute to school in Japanese adolescents

Introduction

As inappropriate Internet usage has been increasing, various problems were observed, particularly in adolescence. For example, excessive Internet use might lead to absenteeism for high school students. This study aimed to examine the association between Internet usage and some difficulties of commute, such as tardy and absence for school in 4th to 9th-grade students.

Methods

Study participants were all students of the 4th-9th grade in Japanese rural public schools and their parents. In 2018 a self-reported survey was conducted. The questionnaire contained items about Internet usage, such as duration and family rules, and the current situation about commuting to school. The parents answered the same questions about their children and also responded to their own Internet usage time. The answers about their commute to school “tardy more than once a week”, “sometimes absent” and “have experience of school absenteeism” were categorized as “school absence”. The duration of Internet use was categorized every 2 hours as “never”, “0-2hrs (reference) ”, “2-4hrs” and “over 6hrs”. Multiple logistic regression analyses were performed to examine the associations between the duration of Internet use and the absence of school adjusting by covariates.

Results

Study participants were 6,031 students and 5,525 guardians participated, and response rates were 87.8%, and 80.5%, respectively. The number of “school absence” case was 429 (7.2%). The “school absence” was significantly associated with the duration of Internet use, and these relationships grew stronger as the period got longer. Odds ratio and 95% confidence interval of “over 6hrs” were 4.1 and 2.9-5.6, respectively. The parents’ own Internet usage time was also associated with their children’s school absence.

Conclusions

The longer students used the Internet, the higher the risk of school absence. Own Internet usage time of parents was also associated with children's commuting to school.

Key messages

Excessive Internet use might induce absenteeism in younger adolescents as well as older adolescents. Few studies have examined the association between Internet use and absenteeism.

Direct gaze enhances interoceptive accuracy

Direct-gaze signals are known to modulate human cognition, including self-awareness. In the present study, we specifically focused on 'bodily' self-awareness and examined whether direct gaze would modulate one's interoceptive accuracy (IAcc)-the ability to accurately monitor internal bodily sensations. While viewing a photograph of a frontal face with a direct gaze, an averted face or a mere white cross as a baseline, participants were required to count their heartbeats without taking their pulse. The results showed higher IAcc in the direct-gaze condition than in the averted-face or baseline condition. This was particularly the case in participants with low IAcc at baseline, indicating that direct gaze enhanced the participants' IAcc. Importantly, their heart rate was not different while viewing the direct gaze and averted face, suggesting that sensitivity to interoceptive signals, rather than physiological arousal, is heightened by direct gaze. These findings demonstrate the role of social signals in our bodily interoceptive processing and support the notion of the social nature of self-awareness.

Automatic facial mimicry in response to dynamic emotional stimuli in five-month-old infants

Human adults automatically mimic others' emotional expressions, which is believed to contribute to sharing emotions with others. Although this behaviour appears fundamental to social reciprocity, little is known about its developmental process. Therefore, we examined whether infants show automatic facial mimicry in response to others' emotional expressions. Facial electromyographic activity over the corrugator supercilii (brow) and zygomaticus major (cheek) of four- to five-month-old infants was measured while they viewed dynamic clips presenting audiovisual, visual and auditory emotions. The audiovisual bimodal emotion stimuli were a display of a laughing/crying facial expression with an emotionally congruent vocalization, whereas the visual/auditory unimodal emotion stimuli displayed those emotional faces/vocalizations paired with a neutral vocalization/face, respectively. Increased activation of the corrugator supercilii muscle in response to audiovisual cries and the zygomaticus major in response to audiovisual laughter were observed between 500 and 1000 ms after stimulus onset, which clearly suggests rapid facial mimicry. By contrast, both visual and auditory unimodal emotion stimuli did not activate the infants' corresponding muscles. These results revealed that automatic facial mimicry is present as early as five months of age, when multimodal emotional information is present.

Liver-related safety assessment of green tea extracts in humans: a systematic review of randomized controlled trials

There remain liver-related safety concerns, regarding potential hepatotoxicity in humans, induced by green tea intake, despite being supposedly beneficial. Although many randomized controlled trials (RCTs) of green tea extracts have been reported in the literature, the systematic reviews published to date were only based on subjective assessment of case reports. To more objectively examine the liver-related safety of green tea intake, we conducted a systematic review of published RCTs. A systematic literature search was conducted using three databases (PubMed, EMBASE and Cochrane Central Register of Controlled Trials) in December 2013 to identify RCTs of green tea extracts. Data on liver-related adverse events, including laboratory test abnormalities, were abstracted from the identified articles. Methodological quality of RCTs was assessed. After excluding duplicates, 561 titles and abstracts and 119 full-text articles were screened, and finally 34 trials were identified. Of these, liver-related adverse events were reported in four trials; these adverse events involved seven subjects (eight events) in the green tea intervention group and one subject (one event) in the control group. The summary odds ratio, estimated using a meta-analysis method for sparse event data, for intervention compared with placebo was 2.1 (95% confidence interval: 0.5-9.8). The few events reported in both groups were elevations of liver enzymes. Most were mild, and no serious liver-related adverse events were reported. Results of this review, although not conclusive, suggest that liver-related adverse events after intake of green tea extracts are expected to be rare.

Orthographic Reading Deficits in Dyslexic Japanese Children: Examining the Transposed-Letter Effect in the Color-Word Stroop Paradigm

In orthographic reading, the transposed-letter effect (TLE) is the perception of a transposed-letter position word such as “cholocate” as the correct word “chocolate.” Although previous studies on dyslexic children using alphabetic languages have reported such orthographic reading deficits, the extent of orthographic reading impairment in dyslexic Japanese children has remained unknown. This study examined the TLE in dyslexic Japanese children using the color-word Stroop paradigm comprising congruent and incongruent Japanese hiragana words with correct and transposed-letter positions. We found that typically developed children exhibited Stroop effects in Japanese hiragana words with both correct and transposed-letter positions, thus indicating the presence of TLE. In contrast, dyslexic children indicated Stroop effects in correct letter positions in Japanese words but not in transposed, which indicated an absence of the TLE. These results suggest that dyslexic Japanese children, similar to dyslexic children using alphabetic languages, may also have a problem with orthographic reading.

Delayed disengagement of attention from snakes in children with autism

In the visual search task, it is well known that detection of a tilted straight line as the target among vertical lines that act as distractors is easier than vice versa, and that detection of a snake image as the target among flower images is easier than vice versa. In this study, the degree of such search asymmetry was compared between 18 children with autism and 14 typically developing (TD) children. The results revealed that compared to TD children, children with autism were disproportionally slow when asked to detect the flower among the snake images, suggesting the possibility that they experienced difficulty of disengaging their attention from the snake images. This delayed disengagement would serve itself as an enhanced attentional bias toward snakes in children with autism that is similar to characteristics of visual search performance in anxiety patients.

Absence of predispositional attentional sensitivity to angry faces in children with autism spectrum disorders

A rapid allocation of attention towards threatening stimuli in the environment is crucial for survival. Angry facial expressions act as threatening stimuli, and capture humans' attention more rapidly than emotionally positive facial expressions - a phenomenon known as the Anger Superiority Effect (ASE). Despite atypical emotional processing, adults with Autism Spectrum Disorders (ASD) have been reported to show ASE similar to typically developed (TD) individuals. One important question is whether the basic process for ASE is intact in individuals with ASD or whether instead they acquire an alternative process that enables ASE. To address this question, we tested the prevalence of ASE in young children with and without ASD using a face-in-the-crowd task. ASE was clearly observed in TD children, whereas ASD children did not show the effect. In contrast to previous reports of ASE in adults or relatively older children with ASD, our results suggest that in ASD basic predispositional mechanisms to allocate attention quickly towards angry faces are not preserved.

Viewing images of snakes accelerates making judgements of their colour in humans: red snake effect as an instance of 'emotional Stroop facilitation'

One of the most prevalent current psychobiological notions about human behaviour and emotion suggests that prioritization of threatening stimuli processing induces deleterious effects on task performance. In order to confirm its relevancy, 108 adults and 25 children were required to name the colour of images of snakes and flowers, using the pictorial emotional Stroop paradigm. When reaction time to answer the colour of each stimulus was measured, its value was found to decrease when snake images were presented when compared with when flower images were presented. Thus, contrary to the expectation from previous emotional Stroop paradigm research, emotions evoked by viewing images of snakes as a biologically relevant threatening stimulus were found to be likely to exert a facilitating rather than interfering effect on making judgements of their colour.

Preliminary evidence that different mechanisms underlie the anger superiority effect in children with and without Autism Spectrum Disorders

Previous studies have demonstrated that angry faces capture humans' attention more rapidly than emotionally positive faces. This phenomenon is referred to as the anger superiority effect (ASE). Despite atypical emotional processing, adults and children with Autism Spectrum Disorders (ASD) have been reported to show ASE as well as typically developed (TD) individuals. So far, however, few studies have clarified whether or not the mechanisms underlying ASE are the same for both TD and ASD individuals. Here, we tested how TD and ASD children process schematic emotional faces during detection by employing a recognition task in combination with a face-in-the-crowd task. Results of the face-in-the-crowd task revealed the prevalence of ASE both in TD and ASD children. However, the results of the recognition task revealed group differences: In TD children, detection of angry faces required more configural face processing and disrupted the processing of local features. In ASD children, on the other hand, it required more feature-based processing rather than configural processing. Despite the small sample sizes, these findings provide preliminary evidence that children with ASD, in contrast to TD children, show quick detection of angry faces by extracting local features in faces.

Intensive exposure to narrative in story books as a possibly effective treatment of social perspective-taking in schoolchildren with autism

One of the major characteristics of autism is impairment of communication and socialization. While such impairment per se has been well documented, research into effective interventions for children with this developmental disorder is still limited. Here we present preliminary evidence for the possibility of improvement of the capability of social perspective-taking in schoolchildren with autism by having intensive experience with narrative, in which they were exposed to narrative in story books read by their parents over a consecutive 5- to 6-day-period. When their capability was evaluated on the basis of a conventional role-taking task, the mean score tended to increase after the exposure as compared to before the exposure, whereas such a change was not recorded in children who did not experience such exposure. These effects were confirmed when the children were retested 4 months later. Although preliminary, the current study represents a step toward the development of more effective social perspective-taking interventions for children with autism.

Estrogen biosynthesis in the gonad of the frog Rana rugosa

In certain species of amphibians gonadal differentiation is influenced by steroid hormones. In the case of the frog Rana rugosa testosterone given to tadpoles reverses sex from female to male, while the opposite reversal - male to female - can be achieved using estradiol-17β. In this study, we investigated whether CYP19 (P450 aromatase), the enzyme responsible for a production of estradiol-17β, was present in the differentiating gonad of R. rugosa. Initially, we immunized rabbits against frog CYP19 peptides and performed immunostaining using specific antibodies purified from that serum. CYP19-reactive signals were observed in gonadal somatic cells of the female, but not male tadpoles at stage (St.) I (the stage prior to phenotypic sex determination in tadpoles of R. rugosa). Immunopositive signals were also produced in ovarian somatic cells froglets at St. XXV (just after the completion of metamorphosis). We also examined the enzymatic activity of CYP19 in the differentiating gonad of R. rugosa. Reverse-phase HPLC (high performance liquid chromatography) analysis revealed that [(3)H]testosterone was converted to [(3)H]estradiol-17β in the gonad of tadpoles at St. I. Interestingly, the rate of conversion was much higher in females than in males. To the best of our knowledge, this is the first report on the biosynthesis of estradiol-17β in the gonad of amphibians, and the co-incident identification of active CYP19 enzyme in the differentiating gonad of R. rugosa. Based on our results, we conclude that estradiol-17β may be involved in ovarian differentiation in this species.

[Redo-operation for the cusp perforation 5 years after aortic valve replacement with stentless bioprosthesis; report of a case]

A 31-year-old male presented with increase of aortic valve regurgitation 5 years after implantation of Prima Plus Stentless bioprosthesis in a bicuspid aortic valve. He underwent redo aortic valve replacement with a mechanical valve concomitant with replacement of the ascending aorta. Pathological examination of the explanted stentless valve presented no inflammatory cell infiltration. The prosthetic valve regurgitation was considered to be due to small injury at the 1st operation.

Structural changes in gonadal basement membranes during sex differentiation in the frog Rana rugosa

Here we report that structural changes in gonadal basement membranes during sex differentiation in the frog Rana rugosa are revealed using an antibody to its laminin component. Immunohistochemical staining indicated that the first sexual dimorphism appeared in testicular cords and ovarian cavities in differentiating gonads of tadpoles at St. 25-3W, three weeks after they reached St. 25. During development, as the testis enlarged, testicular cord partitions appeared to form by invagination of the testicular epithelium. Ovarian cavities also increased in volume. Laminin-positive basement membranes initially surrounded a partial surface of oocytes close to the ovarian cavity, fully covering growing oocytes by St. X. Laminin-reactive signals were present in somatic cells outside seminiferous tubules in the testis and outside oocytes in one-year-old frogs. BrdU-labeling showed that the number of dividing germ cells increased continuously in male gonads but increased in females only up to St. V, declining at St. X and thereafter. The number of dividing germ cells declined when the basement membranes had fully covered the oocytes. Together, these findings suggest that the first sexual dimorphism in the gonad of R. rugosa first appears as a structural change in the basement membranes. Finally, we speculate that the basement membrane on the surface of oocytes may affect their proliferation in this species.

[Surgical treatment for ischemic heart disease]

BACKGROUND

Surgical treatment for ischemic heart disease (IHD) has changed after the administration of off-pump coronary artery bypass grafting (CABG) [OPCAB] and left ventricular restoration (LVR). We studied the development of the treatment and the surgical results.

PATIENTS AND METHODS

Since May 2000 when the indication for OPCAB and LVR was defined, surgical treatment for IHD has been performed in 1,251 patients. The age ranged from 32 to 91 (mean 66 +/- 10) years and there were 977 men and 274 women. The elective operation was 1,130 and emergency 121. Definite indication for OPCAB was calcified ascending aorta, significant cerebrovascular disease, hemorrhagic tendency, and single vessel lesion. Conventional CABG (C-CAB) was the first choice and morbidity and surgical results were examined.

RESULTS

OPCAB was performed in 297 (29.9%) and combined operation with CABG was required in 258 patients (20.6%). In elective operation, hospital mortality was one in OPCAB and one in C-CAB. In OPCAB and C-CAB, stroke was none and one, and mediastinitis was 0 and 0, respectively.

CONCLUSION

The technique for OPCAB is necessary for CABG; however, it is not appropriate to persist with only OPCAB for CABG. Combined operation is often required with CABG and it is essential to perform precise C-CAB.

[Acute pulmonary embolism after cesarean section; report of a case]

We present a case of acute pulmonary embolism (APE) after cesarean section. A cesarean section was performed on a 27-year old woman with normal course. However, one day after operation, she suddenly developed syncope and dyspnea. Soon after the symptom, she developed hypotension 60 mmHg. As a result of various examinations, her illness was diagnosed as APE with right ventricular dysfunction after cesarean section. She was consulted to our hospital for treatment. Soon after her arrival, we treated her for both APE and cardiogenic shock. The combined with antithrombotic therapy using heparin sodium, was successfully treated the patient from cardiogenic shock due to APE with right ventricular dysfunction after cesarean section.

A double fistula, broncho-cavitary-cutaneous communication caused by cancer invasion

Pulmonary infection with cavitation causes severe respiratory symptoms if the cavity has a communication with main bronchus, through which fluid flows out into trachea. In this report a young male with lung cancer invading an adjacent pre-existent fungus cavitary lesion is presented. Cancer invasion led to broncho-cavitary communication and caused massive intrabronchial aspiration. Subsequently, the cancer destroyed the thoracic wall, and a cavitary-cutaneous fistula developed which relieved symptoms as if treated with open drainage.

Autophagic degeneration as a possible mechanism of myocardial cell death in dilated cardiomyopathy

In failing hearts, cardiomyocytes degenerate and interstitial fibrosis, which indicates cardiomyocyte loss, becomes more prominent in the myocardium. However, the precise mechanism of cardiomyocyte degeneration that leads to cell death is still unclear, although it is presumed that lysosomal function and autophagy play an important role because lysosomal activity increases under stress such as hypoxia. Myocardium that had been resected during partial left ventriculectomy performed in patients with dilated cardiomyopathy (DCM) was examined. Under light microscopy, some cardiomyocytes had a marked scarcity of myofibrils and had prominent cytoplasmic vacuolization. Atrophic and degenerated cardiomyocytes were often observed adjacent to replacement fibrotic tissue. Immunohistochemistry showed positivity for lysosome-associated membrane protein and a lysosomal catheptic enzyme in vacuoles of various sizes in the cardiomyocytes and these lysosomal markers were markedly increased in atrophic and degenerated cardiomyocytes. Electron microscopy revealed that degenerated cardiomyocytes had many vacuoles containing intracellular organelles, such as mitochondria, and were considered to be autophagic vacuoles. In DCM hearts, autophagy appeared to be associated not only with degradation of damaged intracellular organelles but also with progressive destruction of cardiomyocytes. It is possible that autophagic degeneration is one of the mechanisms of myocardial cell death.

Myocardial inflammatory cell infiltrates in cases of dilated cardiomyopathy as a determinant of outcome following partial left ventriculectomy

Partial left ventriculectomy (PLV) can be used to treat refractory congestive heart failure caused by dilated cardiomyopathy (DCM). In order to understand the relationship between the underlying myocardial injury and early clinical outcomes after PLV, histopathologic, immunohistochemical and virologic studies of the resected myocardium were performed. The posterolateral left ventricular walls from 27 patients with idiopathic DCM were examined. Cardiomyocyte diameter, degree of myocardial fibrosis, degree of cardiomyocyte degeneration, and degree of inflammatory cell infiltration were compared with mortality rates. Polymerase chain reaction was performed to detect enterovirus genome in the myocardium. Some patients had inflammatory cell infiltrates with focal accumulations of lymphocytes and macrophages, including both cytotoxic/suppressor T-cells and helper/inducer T-cells. The number of inflammatory cells (activated lymphocytes plus macrophages/mm2) was significantly greater in patients who died of cardiac insufficiency after surgery (27.8 +/- 5.7; n = 7) than in the survivors (11.1 +/- 2.5; n = 15). There was no significant difference in the degree of myocardial fibrosis, cardiomyocyte diameter or degree of cardiomyocyte degeneration between the 2 groups. Enterovirus genome was detected in the myocardium of 9 (38%) of 24 patients examined and 5 of these enterovirus-positive hearts had severe inflammatory cell infiltrates (37.9 +/- 2.5/mm2). Early survival in patients undergoing PLV for DCM is significantly affected by the degree of myocardial inflammation, so patients with more severe or ongoing inflammation may have poor clinical outcomes. Chronic myocarditis may play an important role in the etiology and pathophysiology of idiopathic DCM.

Left ventriculoplasty for ischemic cardiomyopathy

OBJECTIVE

In order to treat ischemic cardiomyopathy, which is defined as non-aneurysmal diffuse akinetic left ventricle with chronic heart failure following myocardial infarction, the mid-term effect of the endoventricular circular patch plasty (EVCPP) was studied.

MATERIALS AND METHODS

EVCPP has been performed on 54 patients (46 men and eight women with a mean age of 61 years) during 4 years from March 1997 to December 2000. Thirty-two patients (59%) were NYHA class III and 22 patients (41%) were class IV. Nine patients (17%) had mild angina pectoris before the operation but others had no chest pain. Single, double, triple, and left main disease were noted in six, 13, 32, and three patients, respectively. Mean left ventricular ejection fraction was 23.3 +/- 6.3% (6--30%). Coronary artery bypass grafting was concomitantly undergone by 51 patients (94%) and mitral valve reconstruction was done on 19 patients (35%).

RESULTS

Two patients (3.7%) needed an intra-aortic balloon pump to wean from cardiopulmonary bypass. Seven patients (12.9%) died in the hospital. Among them, two patients (4.4%) out of 45 patients who underwent elective operation died of stroke and heart failure. Five patients (55.5%) out of nine patients who required emergency operation died of heart failure and multiorgan failure. Late death occurred in six patients (11.1%) due to arrhythmia and heart failure in each of three patients. Out of 41 survivors, 38 patients returned to NYHA class I or II and three patients to class III. Out of 50 patients who underwent left ventricular study before and after operation, ejection fraction increased from 22.8 +/- 6.6 to 36.2 +/- 8.0% and mean left ventricular end-diastolic volume and left ventricular end-systolic volume indices reduced from 152.8 +/- 24.6 to 105.0 +/- 36.5 and from 113.6 +/- 45.7 to 66.4 +/- 28.4 ml/m(2), respectively. Mean pulmonary wedge pressure decreased from 19.1 +/- 8.8 to 14.9 +/- 6.8 mmHg. One-, 2-, and 3-year actuarial survival rates were 87.9, 82.7 and 77.2%, respectively.

CONCLUSION

Left ventriculoplasty using EVCPP is effective to exclude the akinetic LV segment, and left ventricular function and clinical status improve in patients with ischemic cardiomyopathy.

Left ventricle restoration in patients with non-ischemic dilated cardiomyopathy: risk factors and predictors of outcome and change of mid-term ventricular function

OBJECTIVE

The partial left ventriculectomy (PLV) for end-stage dilated cardiomyopathy (DCM) which worked in some patients has been reported, although the hospital mortality is high. To reduce hospital mortality, we selected operative procedures of left ventricular (LV) restoration to improve the operative results. We analyzed the risk factors and predictors of outcome, and the mid-term changes of the LV function were determined.

PATIENTS AND METHODS

Between December 1996 and September 2000, 74 patients with non-ischemic DCM received LV restoration. The age ranged from 14 to 76 years (mean, 49.0+/-14.0 years), and there were 63 men and 11 women. The etiology of the DCM was idiopathic DCM in 49 patients, and dilated hypertrophic cardiomyopathy in seven patients and others in 18. The preoperative New York Heart Association (NYHA) functional class was 29 in class III and 45 in class IV, in which 32 patients depended on inotropic support. PLV or septal anterior ventricular exclusion (SAVE) was selected depending on the akinetic lesion of the LV based on the intraoperative echo-test. Fifty-six patients received elective operations, and emergency operations were performed in 18 patients. The risk factors and predictors of outcome were analyzed in 74 patients, and in 35 patients who survived more than 1 year after receiving LV restoration, the mid-term cardiac function was examined by cardiac echogram and catheterization.

RESULTS

PLV was performed in 62 patients and SAVE in 12 patients. Concomitant mitral surgery was performed in 66 patients (89%) and tricuspid annuloplasty in 42 patients (57%). There were 15 hospital deaths and 13 patients died after discharge from the hospital (cardiac deaths in nine and non-cardiac deaths in four). In the 46 late survivors, the NYHA class was I or II in 42 patients and III in four patients. Selection of the procedure of LV restoration (P<0.01), elective operation (P<0.05), and the preoperative volume of LV (endodiastolic volume index of <180 ml/m(2); P<0.05) were risk factors and predictors influencing hospital and late death. After the operation, the LV function improved significantly and the improvement was maintained at the mid-term period; the LV ejection fraction was 31.8+/-7.9% (P<0.01) at 1 year from 23.0+/-7.3% preoperatively, left ventricular diastolic diameter was 62.8+/-10.9 (P<0.01) from 81.7+/-8.2 mm and the LV endosystolic volume index was 88.5+/-45.8 (P<0.05) from 162.6+/-41.6 ml/m(2).

CONCLUSIONS

The operative results improved with the selection of the procedures, with elective operation, and mitral plasty for less cardiac dilatation. The mid-term results of clinical status and LV function showed the effectiveness of the operation.

Enterovirus RNA replication in cases of dilated cardiomyopathy: light microscopic in situ hybridization and virological analyses of myocardial specimens obtained at partial left ventriculectomy

OBJECTIVE

Recently, attention has been focused on enteroviral infection of the heart in the genesis of dilated cardiomyopathy (DCM). To determine the location of enteroviral RNA in the myocardium, we performed light microscopic in situ hybridization (ISH) and virological analyses of myocardial specimens obtained at partial left ventriculectomy (PLV).

METHODS

Posterolateral walls of the left ventricle from 26 DCM patients were examined. Myocardial specimens were tested for the presence of enteroviral genomes by polymerase chain reaction (PCR). We selected two age-matched groups (10 patients each) in which enteroviruses were either present (EV-plus group) or not (EV-minus group). For both groups, we examined in situ localization of enteroviral RNA in the myocardium by ISH.

RESULTS

In PCR studies, both sense and antisense enteroviral RNA were detected in the myocardium of seven patients in the EV-plus group. The presence of this RNA indicates active viral replication in the myocardium. Five of seven patients who exhibited both sense and antisense enteroviral RNA died early after surgery. On ISH, three patients had evidence of active replication of enteroviral genomes. Viral genomes were present in myocardial lesions, especially in endocardial sites. Viral signals were found in degenerating myocardial cells, interstitial inflammatory cells, and endothelial cells of small vessels. These positive signals were not detected in the myocardium of the EV-negative group.

CONCLUSIONS

We detected both sense and antisense enteroviral RNA in various myocardial lesions. This suggests that active enteroviral replication plays a role in the development of myocardial lesions in DCM patients. Active viral replication appears to be a prognostic factor for DCM after PLV. Further study of active viral replication in myocardial lesions will provide information useful for evaluating different therapeutic strategies for DCM.

[Left ventriculoplasty for non-ischemic cardiomyopathy with severe heart failure in 70 patients]

OBJECTIVES

Treatment of cardiac failure due to non-ischemic cardiomyopathy by left ventriculoplasty using partial left ventriculectomy (Batista operation) or septal anterior ventricular exclusion was evaluated.

METHODS

Left ventriculoplasty was performed in 70 patients (59 men and 11 women with a mean age of 51 years) from December 1996 to June 2000. Preoperative New York Heart Association (NYHA) functional class was IV in 43 patients including 29 receiving inotropic support, and class III in 27 patients. Nineteen patients required emergency surgery because of on-going shock and 51 patients were operated electively. Combined cardiac procedures were mitral valve reconstruction in 62 patients (45 replacements, 17 repairs), tricuspid annuloplasty in 37, and aortic valve replacement in 4. The initial 24 patients underwent typical Batista operation regardless of myocardial viability. The other 46 patients underwent selective ventriculoplasty to excise or exclude the weakest part according to the findings of the intraoperative echo-guided volume reduction test.

RESULTS

The intraaortic balloon pump was used in 12 patients and the left ventricular assist device in 2 patients. Three (5.9%) of the 51 patients who underwent elective operation and 12 (63.2%) of the 19 patients with emergency operation died in the hospital, giving an overall hospital mortality of 21.4% (15/70). Hospital mortality was reduced from 33.3% (8/24) in the initial 24 patients to 15.2% (7/46) in the recent 46 patients with the volume reduction test. Mean ejection fraction increased from 22.2 +/- 6.7% to 29.6 +/- 6.0%. Diastolic dimension decreased from 81.1 +/- 9.5 to 69.8 +/- 19.2 mm. End-diastolic and systolic volume indices decreased from 199.0 +/- 47.9 to 124.1 +/- 34.9 ml/m2 and from 154.0 +/- 41.2 to 89.3 +/- 31.7 ml/m2, respectively, at one postoperative month in the 55 hospital survivors. The mean pulmonary capillary wedge pressure decreased from 25.6 +/- 7.8 to 13.6 +/- 4.5 mmHg. Serum brain natriuretic peptide decreased from 999 +/- 647 preoperatively to 547 +/- 362 pg/ml one month after the operation. Thirteen patients (18.6%) died in the late period mainly due to heart failure. Among the 42 survivors, 37 patients returned to NYHA functional class I-II, and cardiac events were rare after one postoperative year. Actuarial survivals at 3 years in elective and emergency operations were 71.9% and 33.3%, respectively.

CONCLUSIONS

Left ventriculoplasty is acceptably safe for elective operation and clinical improvement can be obtained by proper surgical procedures and careful postoperative medical treatment.

Minimally invasive coronary artery revascularization: off-pump bypass grafting and the hybrid procedure

was safe, effective, and suitable especially in patients with high risks for coronary artery bypass grafting.

Evaluation of viral infection in the myocardium of patients with idiopathic dilated cardiomyopathy

OBJECTIVES

The aim of this study was to evaluate the viral etiology of idiopathic dilated cardiomyopathy (DCM).

BACKGROUND

The demonstration of enteroviral genome in hearts with DCM has reinforced the importance of enteroviruses in the pathogenesis of DCM. However, there is uncertainty about the character and activity of enteroviruses detected in the myocardium. Recently, the association of hepatitis C virus or adenovirus with DCM has been reported.

METHODS

Myocardial specimens from 26 patients with idiopathic DCM, which were obtained at partial left ventriculectomy (PLV), were examined virologically. Strand-specific detection of enteroviral RNA was performed to differentiate active viral replication from latent persistence. Polymerase chain reaction was used to detect genomic sequences of hepatitis C virus, adenovirus, cytomegalovirus, influenza viruses, mumps virus, herpes simplex viruses, varicella-zoster virus and Epstein-Barr virus.

RESULTS

Plus-strand enteroviral RNA was detected in 9 (35%) of the 26 patients. Minus-strand enteroviral RNA was determined in seven (78%) of these nine plus-strand RNA-positive patients. Sequence analysis revealed that the enteroviruses detected were coxsackie B viruses, such as coxsackievirus B3 and B4. However, genetic material from other viruses was not detected. Six (86%) of seven minus-strand enteroviral RNA-positive patients died of cardiac insufficiency within the first six months after PLV.

CONCLUSIONS

Coxsackie B viruses were seen in hearts with idiopathic DCM. Active viral RNA replication appeared to be present in a significant proportion of these cases. Minus-strand coxsackieviral RNA in the myocardium can be a marker for poor clinical outcome after PLV. There was no evidence of persistent infection by other viruses in hearts with DCM.

Intraoperative coronary artery imaging with infrared camera in off-pump CABG

To achieve high quality off-pump coronary artery bypass grafting (CABG), thermal coronary artery imaging using a new generation infrared camera was used and anastomotic status was assessed intraoperatively. In 12 patients who underwent off-pump CABG, 18 grafts (11 internal thoracic, 2 radial, 2 gastroepiploic arteries, and 3 saphenous veins) were evaluated following completion of anastomoses. All grafts were clearly visualized and anastomotic and flow status were observed with local epicardial cooling by CO2 blower in the normothermic heart. Seventeen grafts had no problems and one internal thoracic artery graft showed anastomotic failure that was successfully revised. All grafts were restudied by conventional catheter angiography postoperatively, and all were patent. Intraoperative coronary imaging with a highly sensitive infrared camera is noninvasive and effective for real time evaluation in the operating room. This results in more successful off-pump CABG.

Late angiographic result of using the right gastroepiploic artery as a graft

OBJECTIVE

The angiographic patency of the right gastroepiploic artery graft used for coronary artery bypass grafting was studied during the late (5-10 years) postoperative period.

METHODS

Among 936 patients undergoing a gastroepiploic artery graft for coronary artery bypass grafting between 1986 and 1999, postoperative angiographic restudy was conducted on 685 patients within 1 year (mean, 2.2 months), on 102 patients between 1 and 5 years (mean, 2.3 years), and on 52 patients between 5 and 10 years (mean, 7.8 years).

RESULTS

The patency rate of the gastroepiploic artery graft was 94%, 88%, and 83% in each restudy group. The cumulative patency rate estimated by the Kaplan-Meier method was 96.6% at 1 month, 91.4% at 1 year, 80.5% at 5 years, and 62.5% at 10 years. Causes of late occlusion were primary anastomotic stenosis and anastomosis to a less critically stenosed coronary artery. Once the gastroepiploic artery was perfectly anastomosed to the coronary artery, which has tight stenosis and good runoff, late patency was good, and new stenosis in both the gastroepiploic artery trunk and the anastomotic site was uncommon.

CONCLUSION

The gastroepiploic artery graft can be used effectively for coronary artery bypass for the long term with proper target selection.

Preparation of completely 6-O-desulfated heparin and its ability to enhance activity of basic fibroblast growth factor

Although regioselective removal of 6-O-sulfate groups of heparin has been undertaken by several researchers, complete 6-O-desulfation with little side reaction has not been attained successfully. In this work, a modified method with a certain silylating reagent, N-methyl-N-(trimethylsilyl)trifluoroacetamide, has been established to produce completely 6-O-desulfated heparin with few other chemical changes. The degrees of 6-O-desulfation were estimated by means of chemical disaccharide analyses and/or (13)C NMR spectra. Although the completely 6-O-desulfated heparin lost about 20% of 2-O-sulfate groups, any other chemical changes and depolymerization were not detected. The completely 6-O-desulfated heparin displayed strong inhibition of COS-1 cell adhesion to basic fibroblast growth factor (bFGF)-coated well in a dose-dependent manner, as was clarified by the competitive cell-adhesion assay. Furthermore, the completely 6-O-desulfated heparin was shown to promote in vitro A31 fibroblast proliferation in a dose-dependent manner in the presence of bFGF. These results suggest that signal transduction through bFGF/bFGF receptor in A31 cells occurs in the absence of 6-O-sulfate groups in heparin. The involvement of 6-O-sulfate group(s) of heparin/heparan sulfate in the promotion of bFGF mitogenic activity was reported by several groups. This discrepancy between our results and those of other groups would be due to the differences in molecular size of heparin/heparan sulfate derivatives and/or cell species used for the assay.

[Coronary artery bypass grafting without cardiopulmonary bypass in 200 patients]

OBJECTIVES

To evaluate the efficacy of off pump coronary artery bypass grafting (CABG), results in the initial consecutive 200 patients were reviewed.

METHODS

Between October 1996 and December 1999, 200 patients underwent CABG without cardiopulmonary bypass. There were 146 men and 54 women aged from 27 to 89 years (mean 68 years). Single, double, triple and left main disease were noted in 94, 55, 33 and 18 patients, respectively, with a mean ejection fraction of 51%. Preoperative complications were previous stroke in 34 patients, chronic renal failure in 22 patients, previous CABG in 18 patients, and aortoiliac aneurysm or occlusive disease in 14 patients. Fifty-five patients (28%) were 75 years or older. Surgical approach was made through a midsternal incision including lower half small sternotomy in 105 patients, left anterior small thoracotomy in 92 and small epigastric incision (gastroepiploic-right coronary anastomosis) in 3. Mean number of distal anastomoses was 1.3 (range 1-4). Anastomosis was performed in 189 left anterior descending, 13 diagonal, 27 circumflex and 41 right coronary arteries. The conduits were 174 internal thoracic, 10 internal thoracic-inferior epigastric composite, 22 right gastroepiploic and 5 radial arteries, and 50 saphenous vein grafts. Four patients underwent combined off pump CABG and transmyocardial laser revascularization, and 36 patients underwent hybrid (off pump CABG and angioplasty) revascularization.

RESULTS

Four patients (2.0%) died in the hospital due to intestinal necrosis in 2 patients, postoperative aortic dissection in one, and multiorgan failure with stroke in one. No serious ventricular tachyarrhythmia or use of intraaortic balloon pump occurred. Perioperative myocardial infarction was noted in one patient. Stroke occurred in 4 patients (2.0%) but 3 patients recovered in a short period. Three-year survival and cardiac event free rate were 90.3% and 81.1% by the Kaplan-Meier method. Postoperative angiographic study showed excellent patent graft in 92% of grafts (192/209), stenosed (> or = 50%) graft in 5% (10/209) and occlusion in 3% (7/209).

CONCLUSIONS

Off pump CABG can be performed safely and effectively in both high risk and low risk patients with coronary artery disease. Refinement of surgical technique and equipment will make this procedure more useful.

[Combined valve and coronary artery bypass surgery]

Between January 1997 and November 1999, 31 patients underwent combined valve and coronary artery bypass grafting (CABG) surgery in our institute. There was no hospital death and clinical symptom improved in all patients after surgery. Mean follow-up was 16.3 months. The actuarial survival rate was 96.8% at 1 year. There were 4 late deaths (CHF in 3, arrhythmia in 1). Tepid blood cardioplegia was effective for those operations. Operation of CABG combined with valve surgery or LV surgery could be safely performed. We therefore considered that complete correction of the lesion with not only CABG but also combined valve surgery or LV surgery was the procedures of choice in patients with complicated lesions.

Nontransplant cardiac surgery for end-stage cardiomyopathy

OBJECTIVE

To treat end-stage cardiomyopathy, we evaluated endoventricular circular patch plasty, partial left ventriculectomy, and valvular reconstruction alone in our 2-year experience.

METHODS

Among 86 patients with heart failure evaluated between December 1996 and February 1999, 33 patients with ischemic cardiomyopathy (25 men and 8 women; mean age 61 +/- 7.8 years; New York Heart Association class 3.5 +/- 0.5) were treated with endoventricular circular patch plasty combined with coronary bypass grafting (84%) and mitral reconstruction (36%). The other 53 patients with nonischemic cardiomyopathy (45 men and 8 women; mean age 48 +/- 14.3 years, New York Heart Association class 3.7 +/- 0.5), were treated by left ventricular reduction by partial left ventriculectomy (n = 37) or patch plasty (n = 3) and valve reconstruction alone (n = 13). The first 24 patients (group I) underwent ventriculectomy with or without valve reconstruction; the more recent 29 patients (group II) underwent left ventricular reduction (n = 16) or valve reconstruction alone (n = 13) on the basis of the intraoperative echocardiographic evaluation to observe changes of wall motion and thickness during cardiopulmonary bypass.

RESULTS

Ischemic Group: Hospital mortality in elective (n = 26) and emergency (n = 7) operations was 4% and 43%, and 3 patients died in the late postoperative period. Mean New York Heart Association class and ejection fraction improved from 3.5 +/- 0.5 to 1.5 +/- 0.7 and from 23% +/- 7.7% to 36% +/- 8.6%, respectively. Left ventricular end-diastolic and end-systolic volume indexes decreased from 162 +/- 46 mL/m(2) to 110 +/- 39 mL/m(2) and from 130 +/- 47 mL/m(2) to 70 +/- 32 mL/m(2), respectively. Nonischemic Group: In 40 patients with left ventricular reduction, hospital mortality in elective (n = 33) and emergency (n = 7) operations was 6% and 86%, and 5 patients died in the late postoperative period. Mean New York Heart Association class and ejection fraction improved from 3.7 +/- 0.5 to 1.7 +/- 0.6 and from 18% +/- 6.4% to 31% +/- 5.9%. Left ventricular end-diastolic and end-systolic volume indexes decreased from 203 +/- 45 mL/m(2) to 110 +/- 37 mL/m(2) and from 164 +/- 40 mL/m(2) to 79 +/- 33 mL/m(2), respectively. In 13 patients undergoing valve reconstruction alone (12 mitral with or without tricuspid and 1 tricuspid plus left ventricular assist device), hospital mortality in elective (n = 9) and emergency (n = 4) operations was 0% and 50% with no late deaths. Mean New York Heart Association class and ejection fraction improved from 3.6 +/- 0.5 to 2.0 +/- 0.5 and from 22% +/- 6.0% to 30% +/- 14.5%, respectively. Mean left ventricular end-diastolic and end-systolic volume indexes decreased from 170 +/- 34 mL/m(2) to 150 +/- 50 mL/m(2) and from 140 +/- 38 mL/m(2) to 104 +/- 40 mL/m(2), respectively. Overall mortality decreased from 50% in group I to 10% in group II. The survival estimates at 2 years were 77% (confidence limits 57%-88%) in the ischemic group and 63% (confidence limits 47%-75%) in the nonischemic group (no significant difference). The analysis of our data showed that the factors influencing the surgical results for dilated cardiomyopathy were presence of severe mitral regurgitation, preoperative New York Heart Association functional class IV with emergency operation, and operative procedures with randomly performed partial left ventriculectomy without an intraoperative echo test.

CONCLUSION

Endoventricular circular patch plasty, partial left ventriculectomy, and solo valve reconstruction can be performed with an acceptably low risk as elective operations. The selection of operative procedures in idiopathic dilated cardiomyopathy and avoidance of emergency surgery improved operative mortality and morbidity. Among patients who survived at least 1 year, there were no late deaths up to 30 months' follow-up.

[Aortic valve/root replacement using a stentless bioprosthesis (Medtronic Freestyle valve)]

BACKGROUND

The purpose of the study is to assess the clinical and hemodynamic performance of aortic valve replacement (AVR) with the Freestyle bioprosthesis.

METHODS

Twenty-one patients received AVR with a Freestyle aortic root bio-prosthesis between May 1998 and October 1999. Eighteen patients underwent AVR with subcoronary method and three patients with aortic root (full root) method. Patients were evaluated postoperatively at discharge by clinical examination and color Doppler echocardiography.

RESULTS

There was one death due to multi-organ failure. No patients experienced valve deterioration, paravalvular leak, unacceptable hemodynamic performance, nor thromboembolic event. Excellent function is demonstrated by very low gradient (mean gradient 7.2 +/- 4.7 mmHg) through aortic valve and no significant aortic regurgitation (none: 11, trivial/mild: 10). All patients had been in New York Heart Association Functional Class III and IV preoperatively, and after surgery, 17 patients were in Class I, and 3 were in Class II.

CONCLUSION

The Freestyle bioprosthesis has good clinical and hemodynamic performance without Coumadin. Further follow-up is required to evaluated valve durability.

Lung cancer screening: minimum tube current required for helical CT

PURPOSE

To investigate the minimum tube current required for helical computed tomography (CT) for lung cancer screening.

MATERIALS AND METHODS

Thirty helical scans of the lung were obtained at effective tube currents of 50, 30, 20, 18, 12, 10, and 6 mAs in seven healthy volunteers. Computer-generated nodules 6 mm in diameter that showed ground-glass opacity were superimposed on the images. The image quality and detectability of nodules were evaluated subjectively by six observers. The SDs of measured CT numbers were calculated. The results were analyzed according to location in the lung.

RESULTS

Compared with the subjective quality of images obtained at 50 mAs, the subjective quality of images obtained at 20 mAs was not significantly different. The detectability of nodules was not significantly degraded by reducing the tube current to 20 mAs in the upper zone of the lung, to 12 mAs in the middle zone, or to 18 mAs in the lower zone. The SDs at the apex and base of the lung were larger than those at other levels, and the difference became greater as the dose was reduced.

CONCLUSION

The minimum tube current required for screening helical CT differs for different locations in the lung. An ideal CT protocol for the lung should permit the tube current to be changed during helical scanning.

Partial left ventriculectomy, ventriculoplasty or valvular surgery for idiopathic dilated cardiomyopathy - the role of intra-operative echocardiography

BACKGROUND

The partial left ventriculectomy (PLV) is known to work in some patients with dilated cardiomyopathy (DCM), although this procedure does not work well in all patients and the operative mortality is higher than the other cardiac surgeries. In addition to PLV, left ventriculoplasty to exclude antero-septal wall or valvular surgery without left ventricle (LV) surgery can be also effective in patients with DCM. To improve the surgical results for dilated cardiomyopathy, we introduced echo-guided volume reduction test and evaluated the surgical procedures and the results on the surgery for DCM.

METHODS

Between December 1996 and July 1999, 56 patients with DCM (50 with idiopathic DCM, six with dilated hypertrophic cardiomyopathy) were surgically treated. Under the standard cardiopulmonary bypass, left ventricular motion was determined with color kinesis of echocardiogram and the lesion of akinetic wall was removed or excluded.

RESULTS

After the initial PLV in 18 patients (initial group), operative procedures were selected in 21 with PLV, five with LV plasty, or 12 with valve surgery without LV surgery according to the findings of the LV wall motion by intraoperative echogram (select group). There were six hospital deaths and late follow-up deaths within 1 year in initial group, however, the mortality decreased significantly after the selection of the operative procedures; three hospital deaths and two late deaths in the select-group (P<0.05). Significant decrease of left ventricular diameter, the LV ejection fraction and endosystolic volume index were demonstrated after the LV surgery. The survival rate improved significantly after the selection of the operative procedures; 14 months survival rates was 50.0% in initial group and 73.1% in select group (P<0.05).

CONCLUSION

Operative mortality decreased and late follow-up results improved after the selection of operative procedures according to the intraoperative volume reduction test.

Coronary artery bypass grafting with gastroepiploic artery composite graft

BACKGROUND

To achieve better results after coronary artery bypass grafting (CABG), arterial conduits are the first choice in multiple CABG for younger patients. We present here the early results of CABG with gastroepiploic artery (GEA) composite graft with free radial artery (RA) to revascularize right coronary artery or left circumflex artery in addition to internal thoracic artery to left anterior descending artery.

METHODS

Between July 1997 and June 1998, 13 patients received CABG with GEA (larger caliber than 2.0 mm) composite graft. We have assessed the early results.

RESULTS

There was no postoperative death or major morbidity. Postoperative angiogram was performed in 11 patients and all conduits were patent. Postoperative exercise stress test was done in 13 cases and showed no ischemia.

CONCLUSIONS

Multiple CABG with arterial conduit can be performed by this procedure. The free RA functioned from secondary branches derived from proximal GEA. In conclusion, this procedure seems to be safe and effective, and both long-term patency and better quality of life may be expected.

[Surgery for idiopathic cardiomyopathy]

Among the patients with idiopathic cardiomyopathy, those with dilated cardiomyopathy were surgically treated. Initial 18 patients were treated with partial left ventriculectomy(PLV) and thereafter PLV in 26 patients, septal exclusion technique (EVCPP) in 5 patients, or solo-valvular surgery in 12 patients were applied according to the findings of the intraoperative cardiac echogram. The postoperative morbidity and mortality decreased after the selection of the operative procedures. Conclusively, left ventriculoplasty with PLV or EVCPP is a hope for the patients with dilated cardiomyopathy.

Isolated effect of partial left ventriculectomy for dilated cardiomyopathy: a case report

A 38-year-old man underwent the Batista operation to treat end-stage dilated cardiomyopathy. There was no associated mitral regurgitation, so only partial left ventriculectomy was performed. The patient recovered successfully. His New York Heart Association (NYHA) class improved from IV to I, ejection fraction increased from 8% to 37% and left ventricular diastolic dimension decreased from 89 to 68 mm. Cardiac output and stroke volume increased from 3.8 to 6.7 l/min and from 52 to 85 ml/min, respectively. This case shows the isolated positive effect of partial left ventriculectomy without mitral valve reconstruction.

The Batista operation in patients with dilated cardiomyopathy

Between December 1996 and October 1998, 34 patients with nonischemic dilated cardiomyopathy (DCM) received cardiac volume reduction surgery. The patients' ages ranged from 14 to 67 years (mean = 48 years) and included 28 males and 6 females. Associated mitral regurgitation was present in 31 patients, tricuspid regurgitation in 19 patients, and aortic regurgitation in 4 patients. We performed a partial left ventriculectomy (PLV) using antegrade intermittent warm blood cardioplegia in 15 patients (group A), and in 19 patients (group B) PLV was performed using the on-pump beating heart technique. In group A, the mean aortic clamping time was 79+/-33 minutes and the total cardiopulmonary bypass time was 155+/-58 minutes. In group B the mean cardiopulmonary bypass time was 121+/-43 minutes. There were eight hospital deaths (five in group A and three in group B). Five of 10 survivors of group A required inotropic support for 13.8+/-25.3 days after the operation, while 5 of 12 survivors in group B required inotropes for 4.2+/-3.1 days. Hospital mortality was 86% in 7 emergent cases and 7% in 27 elective cases. Echocardiographic study showed that the left ventricular ejection fraction improved from a mean of 18.7% to 30.3% and the left ventricular diameter decreased from a mean of 80.2 mm to 62.3 mm after the operation. All 26 hospital survivors were followed for 1 to 20 months. Three patients died at early follow-up because of congestive heart failure, thrombosed valve, and hepatic failure, respectively. Nineteen patients were in New York Heart Association (NYHA) Class I or II and four were in NYHA Class III. In conclusion, cardiac volume reduction surgery is effective when the operative technique and proper judgment of patient selection are established, and emergent operation is avoided.

Myocardial inflammatory cell infiltrates in cases of dilated cardiomyopathy: light microscopic, immunohistochemical, and virological analyses of myocardium specimens obtained by partial left ventriculectomy

OBJECTIVE

Partial left ventriculectomy was introduced for the treatment of refractory dilated cardiomyopathy (DCM). To determine the presence and degree of inflammatory cell infiltrates in DCM and the correlation between the underlying myocardial injury and early clinical outcomes after the operation, we performed histopathological, immunohistochemical, and virological studies of the resected myocardium.

METHODS

Posterolateral walls of the left ventricle from 13 idiopathic DCM patients (9 males and 4 females; mean age = 53+/-14 years) were examined. Qualitative and quantitative analyses of the interstitial fibrosis and of the infiltrating inflammatory cells were conducted. For the immunohistochemistry, leukocyte surface markers and antibodies to adhesion molecules and cytokines were used. The histopathological findings were compared with the clinical results, including outcome within 1 year, and pre- and postoperative hemodynamic data. Genomic analysis of the myocardium with polymerase chain reaction was performed for enterovirus, mumps, influenza A, cytomegalovirus, and hepatitis C virus.

RESULTS

(1) The three patients who died of cardiac insufficiency after surgery had a higher count of infiltrating inflammatory cells than the eight survivors (32.1+/-10.4 vs 16.3+/-11.9 cells/mm2, p = 0.07). The severity of interstitial fibrosis (percent fibrosis) did not differ significantly between these two groups (28.3+/-15.0 vs 24.0+/-11.7%). (2) In patients who died of myocardial dysfunction, focal accumulations of lymphocytes were common, in which cytotoxic/suppressor T cells and helper/inducer T cells were observed. (3) Enterovirus genome was detected in the myocardium of two patients, both of them died after surgery.

CONCLUSIONS

Inflammatory cell infiltrates or active myocarditis appear in some cases to play an important role in the etiology and pathophysiology of clinically diagnosed DCM. There is a possibility that those patients with a more severe or ongoing inflammatory process might have poor outcomes after partial left ventriculectomy.

Interactive fusion of three-dimensional images of upper abdominal CT and FDG PET with no body surface markers

The aim of this study was to propose and validate a new method of making fused images from CT and FDG PET images for the upper abdominal area with no body surface marker. PET and CT were carried out in patients with pancreatic cancer (N = 5) and mass-forming pancreatitis (N = 2). First, we determined the midsagittal plane from PET and CT data. From the difference in location of the midsagittal planes, rotations of Y (from back to front) and Z axes (from foot to head) and X translation (from right to left) were calculated. An upper pole of the kidney was determined from PET and CT data. It showed Y and Z translations. The images of the three-dimensional data sets were fused on a workstation. Reproducibility was assessed with randomly misaligned PET and CT data sets. Pancreatic cancer and its lymph node metastases were identified easily on fused images. In reproducibility assessment, the average error of rotation was 0.77 degree. The average errors of translation were 3.43, 4.70, and 9.23 mm on the X, Y, and Z axes, respectively. In conclusion, this PET/CT image registration technique is feasible and practical. It allows precise anatomical assessment of normal and abnormal FDG accumulation.

Efficacy of gastric blood supply redistribution by transarterial embolization: preoperative procedure to prevent postoperative anastomotic leaks following esophagoplasty for esophageal carcinoma

PURPOSE

The aim of this study was to evaluate the effect of preoperative redistribution of gastric blood supply on the prevention of anastomotic leakage following surgical reconstruction of the esophagus.

METHODS

In 37 patients with esophageal carcinoma, transarterial embolization (TAE) of the left gastric, right gastric, and splenic arteries was preoperatively performed with coils so that gastric blood supply was dependent only on the right gastroepiploic artery.

RESULTS

In 34 of 37 patients, preoperative redistribution was successfully performed. The gastric tissue blood flow (TBF) of a gastric tube was higher than in 12 nonredistributed patients. Reduction in the gastric TBF during preparation of a gastric tube was 27.5% in successful patients, in contrast to 68.9% in 12 nonredistributed patients (p < 0.005).

CONCLUSION

Preoperative redistribution by TAE reduced the drop in gastric TBF during preparation of a gastric tube and helped prevent postoperative anastomotic leakage in esophageal reconstruction.

Two-year experience of the Batista operation for non-ischemic cardiomyopathy

The Batista operation was performed in 30 patients (25 men and 5 women, mean age 47 years) to treat cardiac failure due to non-ischemic cardiomyopathy, mostly idiopathic dilated cardiomyopathy, from December 1996 to June 1998. Preoperative New York Heart Association (NYHA) class was IV in 21 patients including 17 receiving inotropic support, and class III in 9 patients. Seven patients required emergency surgery because of on-going shock and 23 patients were operated electively. Combined cardiac procedures were; mitral valve reconstruction in 26 patients (19 replacements, 7 repairs), tricuspid annuloplasty in 15, aortic valve replacement in 3 and one each of maze and coronary artery bypass grafting. All patients successfully weaned from cardiopulmonary bypass. Intraaortic balloon pump was used in 6 patients but no left ventricular assist device was used. Two of 23 patients (8.7%) who underwent elective operation died during hospitalization and 3 patients (13.0%) died in the late period. Six of 7 patients (85.7%) with emergency operation died in the hospital and only one survived. Sixteen of 19 survivors returned to NYHA class I-II, and 3 were in class III. Mean ejection fraction increased from 18 +/- 6% to 31 +/- 5%. Diastolic dimension decreased from 79 +/- 8 to 60 +/- 8 mm. End-diastolic and systolic volume indices decreased from 203 +/- 43 to 103 +/- 25 ml/m2 and from 164 +/- 39 to 70 +/- 25 ml/m2, respectively, at the second postoperative week. Six patients had ventriculography at one year after the operation, and no redilation was noted. Increased thickness of left ventricular wall was observed postoperatively. The Batista operation can be performed with relatively low risk and clinical improvement was obvious in elective operation, wheras risk is very high in emergency cases. Therefore, proper guidelines for patient selection and choice of procedure are critically important to achieve a successful outcome in the Batista operation.